Geography for Americans: The MicroRepublics of Central Asia

What used to be represented by a blur in our collective consciousness, Central Asia, is now emerging from the geographical fog of the American mind. As our forces have been stomping the kebabs out of Afghans, Tajiks, Uzbeks and all kinds of other folks over there in that craggy and dusty part of the world, they have come home and regaled us with tales of unpronounceable peoples and places. It seems that the stories of our soldier sons and daughters have to some extent ignited the flame of curiosity in us about these ancient cultures. No longer content to live in an isolationist torpor, we at home now yearn to know about all of the inhabitants of these faraway lands, that we might understand them, learn from them and eventually annihilate them, too. The greater countries, like Iraq and Afghanistan, are by now well known to us. But we have come to learn that there are scores of small principalities and regions that are much more obscure. The more we know others, as men of wisdom say, the more we know ourselves, so let us introduce ourselves to the three "MicroRepublics" of Central Asia: Turdistan, Nerdistan and Jerkistan.

Figure 1. The Lands of Gonzonia 

Brief History. This part of the world, Gonzonia, is thought to be one of the places where the Caucasian race first appears beyond the veil of history; this can be determined by the archaeological discovery of khaki pants at the Gongoozle site. It was originally inhabited by a branch of the Hittites called the Borborygms; later the Scythians, Persians and Greeks engulfed the region within their imperial borders. The Mongols as well came through these valleys as they cut their swath through Asia and Eastern Europe, but they left no major settlements or outposts. Turkic peoples left a durable mark, particularly the Tatars and the Seljuks. The British subjugated almost all of Gonzonia in the 19th Century, dividing it into the three great territories largely along ethnic lines. Russia and later the Soviet Union dominated the region until the latter part of the 20th Century.

Although they are distinctive peoples, their cultures, languages and religions bear the mark of almost all of the foreign influences of their conquerors. The Turks brought Islam, for example, but frustrated Muslim scholars complained that the inhabitants could not be made to understand the fundamental beliefs. Anglican and Protestant Christianity fared little better under the British. Orthodox Christianity under the Russian Empire had modest success, as it was not well understood even by the conquering Russians, but the official Atheism of the Communist Party caused what little discernible religion was left to atrophy into almost unrecognizable vestigial beliefs.

With the 21st Century we have seen a resurgence of nationalism and ethnic identity and even a renewed interest in religion. While under the Seljuks Gonzonia was a unified Khanate, and it had retained a sense of geographical identity for several centuries, recent years have seen the three regions, now called "MicroRepublics," devolve into almost continuous conflict.

 I. Turdistan. 

Figure 2. The Flag of the Democratic Republic of Turdistan. The people of Turdistan identify with the camel, as it is a beast of burden in Central Asia. This is somewhat ironic because the Turds are not thought to be very industrious. They excel, however, in telling others what to do, and especially what to think. 

The Westernmost part of Gonzonia is known as "The Democratic Republic of Turdistan." Of the three MicroRepublics, Turdistan was the most influenced by Communism. Although most Turds are atheist or agnostic, those who attend worship generally go the Church of Turdistan, believe it or not a branch of the Church of England. Of interest, a recent poll conducted by UN Committe on Religious NGOs determined that most of the members of the Church of Turdistan were surprised to learn of the existence of a God. Most believed that the purpose of attending church is to receive instructions on social consciousness.

 Figure 3. The Reverend Mohammed Wembish, rector at the Cathedral of St. Ahmet in Berq. 

Demographics, Culture and Geography. Turdistan has a total population of approximately 3 million, about a third of whom live in the capitol, Squirn. There is an official policy of population reduction in Turdistan, which has at its root the strange Turdi belief that human beings are a represent a kind of contamination of the earth; the population was 4 million as recently as 1975. More than 95% of the population is Caucasian, although most of them appear to wish they were not, as there is a cultural mandate that they dye their hair dark colors and spend hours per week tanning themselves. There are important but oppressed minorities from Nerdistan and Jerkistan, despite the official policy of ethnic tolerance.

Figure 4. Turds celebrate Equality Day, a National Holiday. 

Lake Bollox in the southern part of the country is the largest lake in Gonzonia and is home to a fish known as the Gonzonian Crappie.  It is the favorite source of animal protein to the Turds; otherwise the Turdi diet is almost exclusively vegetarian, consisting especially of bitter greens.

The Turds are highly educated, with a literacy rate close to 90%. Of interest, almost all of the universities teach exclusively the humanities, so there has been a gradual decline in technology. Almost half of the population are teachers. National pastimes include reciting poetry, foreign cinema (particularly French), and the consumption of wine.  They also enjoy the theater, and Lacrosse, the national sport.

 Figure 5. Mustafis Furbish, Left Attack Wing and star of the Turdi National Lacrosse Team. 

French culture is very popular in Turdistan. All things French represent, in the Turdi imagination, that which is of the highest quality. Almost no Turds speak French, but many of them pretend to do so, affecting nasal vowels, puckering their lips and brandishing crusty baguettes.

Politics. The Democratic Republic of Turdistan has two legislative houses, the upper house or Gobnob and a lower house, the Karnov. There is a judiciary branch but it functions more like a legislature in that it generates laws and legal standards. The highest court is the Exalted People's Court; it abolished the Constitution in 1988, declaring it "an obstacle to progress." The Executive of the Country since 1993 is the president, Mehmety Govnov; it is anticipated that he will remain president until his death. Term limits exists but they are consistently ignored.

All of the nation's media outlets are strictly controlled by the State. The most important newspaper is The Squirn Post, with a circulation of 500,000. There is only one television network, TurdTV, and programming consists almost exclusively of political orientation, Lacrosse matches, and low-key dramas with indiscernible themes. There is also only one radio corporation, Turd Public Broadcasting.

The ruling class of Turdistan, or the Stroonz (the "Enlightened Ones"), are the most highly educated and wealthiest 1% of the population. They believe it is their burden to hoard the wealth of the nation, so the common people will not be corrupted by its influence. They believe themselves immune to the moral dilemma of wealth by virtue of their high level of education. Virtually all of the politicians, judges and important people of Turdistan are from the Stroonz class.

Officially a pacifist state, Turdistan is nevertheless in an almost constant state of war. Their hatred of Jerkistan is almost without limits and skirmishes and conflicts between the Turds and the Jerks are commonplace. It is widely believed in Turdistan that the Jerks are born literally without brains, that they are greedy and gratuitously violent. Much of the content of the newspapers, television and radio programming is propaganda against Jerkistan.

Turdistan made frequent raids into Nerdistan until the 21st Century to plunder wealth and to capture "technical" slaves. "It is necessary to secure slave labor," wrote President Govnov, "to have sufficient manpower to operate an enlightened, egalitarian society like that of Turdistan. One cannot expect a people like ours to toil, particularly when so many have forgotten how."

Economics. Despite a relatively high educational level, most Turds are relatively poor. Fortunately all social services are free, including healthcare. On the other hand, there are only ten hospitals in Turdistan, and very few doctors, so the healthcare system is run by chiropractors and naturopaths. There are no Magnetic Resonance Imaging (MRI) machines in Turdistan and only one CT scanner. The average life expectancy is 60 for men and 65 for women.

Exports from Turdistan include apples, fish, opium and tobacco (even though tobacco is highly illegal in Turdistan). Turdistan and Jerkistan together produce 85% of the world's bat guano, mined from the extensive mountain ranges.

II. Jerkistan.

Figure 6. The Flag of the Islamic Republic of Jerkistan. The Jerks' symbol is the Asian Rhinoceros, which they believe accurately captures their national spirit of belligerence. It is ironic because the Asian Rhinoceros is actually rather cowardly. 

To the East we find the Islamic Republic of Jerkistan. It is officially a theocracy, although the Jerki sect of Islam is essentially unrecognizable to Sunnis or to Shia Muslims. For example, Jerki Muslims believe that Jesus, Mohammed and Charles Spurgeon were the same person. They abstain from vegetables, subsisting primarily on fatty meats and cornbread; salads and stir-fry dishes are forbidden. Pork is permitted, but only if it is fried (Jerkov Porqi).  Islamic scholars elsewhere in the world have issued a fatwah against Jerki Islam, noting that it is "foolishness."

Figure 7. The Mosque of Jonikash, in Az'holabad. 

Demographics. Culture and Geography. The population of Jerkistan is approximately 4 million. The capitol is Az'holabad, with a population of 500,000, but the largest city is Sqrotoum, population 800,000. The Jerks are a fair-skinned people and they have a suspicious attitude toward other ethnic and religious groups. Therefore almost all of the population of Jerkistan are Jerks. There are small but isolated and oppressed populations of Turds and Nerds, functioning in essentially servile roles.

Jerkistan is the largest of the MicroRepublics, with an area of approximately 3,000 square miles. The second largest lake in Gonzonia is Lake Kraq, considered by the Jerki Muslims to be the holiest body of water in the world. It is precisely at Lake Kraq where the Prophet Mar'jin is said to have relieved himself and the Jerks make pilgrimages there to bathe and be healed of infirmities by the salty warm waters.

The Turds are vehemently hated by the Jerks. It is accepted as fact in Jerkistan that all Turdi men have vaginas and the Turdi women have penises.

The national sport of Jerkistan is rifle marksmanship. Education is despised in Jerkistan; school only goes to the eighth grade and there is only one university: Az'holabad College of Exalted Business Adminstration. Jerks believe that everything they need to know is in their Holy Book, Dianetics.

Figure 8. Bloz Kabela, winner of the 2010 National Jerkistani Marksmanship Medal. 

Politics. As an Islamic Republic, the Supreme Ruler is an Imam named Ali Wakbarov. Wakbarov has been in office since 1988. He must approve all of the legislation of the elected parliament, The Diet of Phat, before it can be enacted as law. The Grand Imam also has the sole power of veto; if he believes the laws do not conform to Sharía they will not be implemented. He may also create laws as he sees fit to support or enforce the Holy Islamic Republic.

Jerk Sharía, then, is the law of the land. For example homosexuality is punishable by death for common people. Of interest, however, it is accepted and widely practiced among the ruling class, or Pedez. Similarly the average citizen of Jerkistan must bathe daily; if they are perceived as having a body odor by the Jerki Kulturi Polizi they are beaten but the Pedez rarely bathe. Making use of a woman of ill-repute, or Snooki, is punishable by stoning but the Pedez have entire paddocks of male and female Snookis at their disposal. 

Jerkistan has effectively been under a state of martial law since 2002. At that time Ali Wakbarov established the Sekuritatni Stat "in order to protect our freedoms." It is ruthlessly enforced by the Sekuritatni Polizi, who can arrest without a warrant, detain indefinitely without charges and torture arrested suspects. Most Jerks have suffered under the current system, but as Prime Minister Kolboz Bobo said in 2010, "It is a small price to pay to be free."

Economics. The Jerki economy is dominated by the three great Korporazi, or dominant industries. The largest is Kakaboli, the company that mines guano in the mountain region. The second largest is Agrinaz, an agribusiness conglomerate and then there is Smerzikon, manufacturer of weapons. The vast majority of Jerks work for one of these organizations. The chairmen of each of these Korporazi are members of the Pedez and have seats in the Parliament. As such they function under the direction of the Supreme Leader. The standard of living is somewhat higher than in Turdistan, a fact that enrages the Turds. The Jerks do not pay taxes, but the state's operating costs come from confiscations by the Sekuritatni Polizi.

The major exports of Jerkistan are weapons, apples, honey and guano. About 30% of the guano produced in Jerkistan is fashioned by artisans into pottery and vessels for food and beverages and most of those are exported.

III. Nerdistan 

Figure 9. The Flag of the Confederation of Nerdistan. The image of the two-headed eagle was imported by the Seljuks, but to the Nerds it represents constant vigilance against the Turds to the West and the Jerks to the East. 

Uncomfortably situated between Turdistan and Jerkistan is Nerdistan, population 3.5 million. The population of Nerdistan has not grown since 2009. This is thought to be for two reasons: The history of the kidnapping of Nerds for technical servant labor by Turdistan and Jerkistan and also because for some reason, the women of Nerdistan prefer to marry Jerks and Turds.

Demographics, Culture and Geography. The population of Nerdistan is more diverse than the other MicroRepublics. Most of the population are Caucasians, but approximately 20% are ethnically Chinese, 10% are ethnically Hindi and 10% are Khazar Jews. A significant number of the population are refugees from Turdistan and Jerkistan. It turns out that the ability to work quadratic equations is grounds for expulsion from those two countries as it is forbidden for citizens, but fortunately it is a qualification for citizenship in Nerdistan.

The capital of Nerdistan is Da'weeb, with 500,000 inhabitants. Other important cities include Dorqov (300,000), Wangi (250,000) and Putzov (100,000). There is no official state religion in Nerdistan, but many are practiced. The largest church is the Church of the Subgenius, with approximately one half million adherents.

Figure 10. The Reverend Ivan Stangolov, Minister of Religion of the Confederation of Nerdistan and Solemn and Serene Patriarch of the Church of the Subgenius. 

Figure 11. The Cathedral of St. Nikolai Tesla in Da'weeb. A significant percentage of the Caucasians in Nerdistan are Slavs, who immigrated here to play chess. The Orthodox Church of Nerdistan has 300,000 adherents. 

Nerds dislike the Turds and the Jerks because of the history of frequent raids by those countries into Jerkistan for the importation of technical servant labor. Science and Mathematics are considered taboo in Jerkistan and Turdistan; nevertheless skilled scientists, mathematicians and engineers are needed in those lands to run factories, machines and utilities. The raids were successfully halted by the Nerds in 1990 by biological warfare. The gene for lactose intolerance was inserted by Nerdi scientists into the chromosome of the highly infectious schizobacillus. The germ was introduced into and spread throughout Turdistan and Jerkistan and those populations were paralyzed by flatus, abdominal pain and severe diarrhea. The Nerds were immune, as they are already lactose intolerant. Since then the Turds and the Jerks are suspicious of and intimidated by the Nerds, fearful of their sorcery, and they have for the most part left them alone.

The national sport of Nerdistan is paintball. The Cup of Nerdistan is held every three years in Putzov and it is a Federal Holiday so everyone might participate. The crowds consume fried lactose-free cheese and kwos (a dark, sweet, carbonated beverage) and advocate for their champions with spirited words of encouragement. The most common pastimes are computer games and board games.

Figure 12. Zorki Borzagis commands a Q-21.2 "Zhukov" Paintball Tank during the championship in Putzov. 

Nerdistan is one of the most tolerant of the Republics of Central Asia. There are Freedom of Speech, Freedom of Religion, and the Right to Bear Electronics. All kinds of lifestyles are sanctioned as long as there is not a lot of noisy moaning and whatnot. The Confederation is libertarian in orientation but not so much philosophically as by a desire not to be bothered with meaningless details.

There are 23 universities of Nerdistan, all awarding degrees exclusively in the sciences, mathematics and history. 18% of the population are physicists. Almost ten percent of the country are doctors, mostly internists and psychiatrists. Nerdistan has more dermatologists and dentists per capita than any other country.

Politics. Nerdistan is a confederation of its fourteen Departments (regions). Each department is headed by a Dean, who reports to the most powerful executive in the country, the Chancellor (Dr. Borb Weebis, an engineer by training, since 2008). The Deans are popularly elected by the Faculty Senates of the Departments, and they in turn form the Council of Da'weeb, also called the Nerdokratia, who elect the Chancellor.

There are over 100 political parties in Nerdistan, but the largest are the Particle Theory Party, the String Theory Party, and the Assembly of Fractals. Anyone with an IQ higher than the averages of those in Turdistan (90) or Jerkistan (89) may vote, regardless of age.

Economics. The economy of Nerdistan is based on the manufacture and exportation of silicone chips. The Nerds were the first to develop the robotic girlfriend prototype J-19 and approximately 5000 are produced at the factory in Dorqov every year. A glitch in the software code was found in the J-16 through 18 models, resulting in the units wandering off into Turdistan and Jerkistan when the owners were at work or at the board game or comic book stores. The latest model, the Kuoko, sells for $10,000 US and while many are sold within the country, most are exported to Japan and the Netherlands.

While the standard of living is high in Nerdistan, there are nevertheless serious problems. None of the Nerds are willing to do manual labor; guest workers from Jerkistan come into the country to perform these functions on two-year visas. There has also been a serious decline in productivity since World of Warcraft was introduced in 2006.

Conclusion. We hope this has been an interesting journey into Central Asia and that you have learned a great deal. It is truly enlightening when we realize that no matter how strange or exotic a culture may be, they are really not so different from us.

(c) Copyright 2011 Robert Albanese

The Defense of Insanity

The Idaho Correctional Institution at Orofino.  It was once a psychiatric hospital.

I learned from a story in the Idaho Statesman yesterday that Idaho has no Insanity Defense.  It seems there is an individual named John Delling who, seized by an acute psychosis due to schizophrenia, shot and killed two men and injured a third.  Although there was agreement across both defense and prosecution that his actions took place under the influence of mental illness, he was apparently tried and convicted as if he were not mentally ill.  According to the article in the Statesman, three other states have eliminated the Insanity Defense:  Utah, Montana and Kansas.   

There will be an impulse from the Northeast Corridor to view the absence of this legal pathway as a flannel-shirt-and-bushy-beard kind of frontier justice.  In the Statesman, a somewhat liberal newspaper trying to bring light to the conservative darkness of Idaho, it is detailed that the insanity defense was "banned" in these four states as a reaction to John Hinckley's use of the insanity legal loophole to avoid accountability for shooting Ronald Reagan.   I believe this issue is being unnecessarily politicized.  It may be that the issue of how mentally ill individuals are found culpable of crimes is not a simple matter of compassion or retribution.   

In my mind at least, I've been an advocate for the mentally ill for twenty years.  I've received a "Helper Friend Award" from a local chapter of the National Alliance on Mental Illness (NAMI), and several years ago I spoke at their national meeting in San Diego.  It may seem inconsistent with advocacy in the minds of some, but over the years I have leaned increasingly in the direction of full accountability of the mentally ill for crimes they may commit.   

My clinical experience is unambiguous.  When mentally ill individuals become dangerous to person and property, at least one of two elements is virtually always present.  The first is a refusal to take medications.  Typically these patients are well-compensated and organized but for whatever reason, and many reasons are given such as side effects, they decide to stop taking their medications and then undergo a marked deterioration.  Paranoia takes hold, and the patient begins to perceive threats all around, leading to what they may see as "preemptive" strikes of violence.  

The second element is use of illegal drugs.  This behavior is astonishingly common among the mentally ill, and although one theory is that these patients are "self-medicating," they virtually always destabilize, even with relatively benign substances like cannabis.  Their internal neurochemical environment is much more prone to disarray than those of people without mental illnesses, and many of these drugs can produce paranoia and violence even in people without a diagnosis of mental illness.  While patients who stop taking their medications do not always use illegal substances, those who use illegal substances virtually always stop taking their medications, either before the drug use starts or after it is under way.   

So while the decision to shoot someone may occur under the impairment of decompensated insanity, the decision to stop taking medications and that to use illegal drugs usually happen while the individual is in a much more stabilized state.  Since the outcome is relatively predictable, especially in patients who have previously become violent, it does not seem reasonable to ignore or soft-peddle the decision not to adhere to treatment. 

With the Insanity Defense, we are teaching individuals with mental illnesses that they are at times not responsible for their behavior.  But what concerns me even more is that we may be conveying to them that, as victims of mental illnesses, they are unable to be in control of their behavior in general.  If that is the case, the consequences will be more decompensation and violence and poorer self esteem and hopelessness in the mentally ill.   

The case of Paul Harrington is instructive in this regard.  He was a Viet Nam combat veteran and heroin abuser who murdered his wife and two daughters in 1975.  Because of his Posttraumatic Stress Disorder diagnosis, he was found Not Guilty by Reason of Insanity in 1977 and spent two months in a psychiatric hospital, then was released.  He later remarried and in 1999 killed his wife and 3 year old son.  This unspeakable tragedy recurred because he was given the rather clear message that he was not responsible for his behavior and probably also that there was no point in trying to control himself.  While the second murders would likely have been prevented had he been held accountable for the first, I wonder if Harrington had already internalized an ambiguous set of standards of responsibility in 1975.   

Experience has also taught me that the connection between mental illness per se and dangerous behavior is not as direct as is portrayed in popular media.  Most of the severely mentally ill people I have known are considerate of the rights of others, and many of them have a completely intact sense of humor.  To say that they are dangerous by virtue of their mental illness is to do them a grave injustice.  Most of them are people who are struggling as best they can against internal strife, social isolation and economic desolation; that we project evil onto them as well may explain why there seems to be so little compassion for them in contemporary society.   

To take the point a bit further, almost every disease state is manifested differently in different people.  Tuberculosis might represent a good analogy.  Most people who contract tuberculosis contain the disease within their immunity; they can eradicate the infection with antibiotics but even without antituberculine drugs they are not infectious.  They pose no threat to anyone.  Other patients, however, have "active" tuberculosis, coughing and spreading the bacilli throughout their contacts.  When these patients do not follow treatment instructions closely, they pose a significant risk to others, and sometimes they have to be quarantined under the authority of the state.  I would argue that mental illnesses are exactly the same in that the character of the affliction varies from individual to individual and it is only the minority who are potentially dangerous. 

Of all the reasons I favor accountability for the mentally ill, however, one far surpasses the rest.  Some years ago I was listening to a story on National Public Radio; it was a feature precisely on this topic.  A nurse who identified himself as having bipolar disorder was interviewed.  "We can't have it both ways," he said.  He observed that if people with mental illnesses demand full integration into society, they will have to assume the same accountability for their behavior as those who do not have mental illnesses.  One cannot demand to be accepted and assimilated into a collective society or culture on one's own strictly individual terms.  That would be kind of like saying:  "Henceforth I shall be considered by all to be a black American, despite the fact that I have no African heritage."   

One fact threatens to obscure my point, though.  It is widely believed that as the state psychiatric hospitals have closed since the 1950s, the mentally ill have streamed into the prisons.  In fact a Department of Justice report from 2006 details that over half of the inmates in state prisons have mental illnesses.  So how can it be true that we do not hold mentally ill people accountable enough, at the same time unfairly holding them too accountable?   

While some people think that the purpose of incarceration is punishment and others think that it is rehabilitation, the fact is that the prisons serve one function:  Quarantine.  Individuals who believe that they are not responsible for their behaviors eventually wind up in prison, generally after an escalating pattern of serious crimes.  In my experience this concept applies to three groups of inmates:  The criminals per se, the nonviolent drug offenders, and the mentally ill.   

The first group, who are sometimes called sociopaths, tend to blame others for the crimes they commit.  They lack compassion for their victims and they have no conscience, so there is almost no psychological obstacle to violence against person and property.  They do not take responsibility for their actions, so they are quarantined.  Similarly, those who become addicted to heroin or crack cocaine come to the realization that their desire to obtain and use drugs surpasses every other drive or instinct, occasionally provoking monstrous behaviors.  Therefore they, too, are quarantined.   

The mentally ill, however, contend with a more complex set of circumstances.  They are frequently homeless, often victims of assault themselves, and sometimes afflicted with superimposed substance use disorders.  They do not always have access to mental health care, let alone general medical care.  Generally it begins with misdemeanors like trespassing, progresses to illegal drugs use and assault, eventually sometimes culminating in violent crimes.  It is possible that because a compassionate court excuses minor crimes on the grounds of mental illness, the perpetrator acquires the sense that he or she is not responsible.  Released therefore from the accountability constraints of civil society, their infractions become progressively more serious, advancing to crimes so violent the jury is no longer inclined toward mercy.  Had we held them accountable at an earlier time and given them access to adequate care, their behaviors might not have progressed to the level of felonies.   

There is a more rational, and in my opinion, less expensive way.  We could build state psychiatric hospitals, as we did a century ago, and make available to patients long-term treatment for substance use and mental illness.  We could make outpatient treatment of mental illness and addiction available in a meaningful way, and in the former case implementation of real case management.  With case managed, when a schizophrenic patient with a history of violence stops coming to his appointments, he is at least in theory quickly located and treatment reinitiated. 

We have closed the mental hospitals and opened the prisons.  It is often said that of all the nations in the world, the U.S. has the highest absolute number, and the greatest percentage of her population in jail or in prison.  If it is true, this statistic is a dramatic challenge to the notion that we are a "free" country.  It might not gratify the emotional need, as Bill Clinton said, to "send a message" to drug users and those who commit crimes.  But we would be safer, freer, and less fiscally strained if we closed the prisons and opened the mental hospitals.   

Everyone, including the mentally ill, should be accountable for his or her behavior.  Reason and compassion dictate, however, that we not expose mentally ill individuals to inhumane conditions; that they not be held accountable under such a different set of circumstances than society at large.  Even those not motivated by moral consciousness will probably concede that since contraction of mental health care was followed by an explosion in homelessness and dramatic increases in prison populations, a reciprocal effect could be induced by investing in mental health care.  If it is true as the NAMI has suggested that the prison system is the new mental health system, it would be cold reason itself to replace it with a more effective and yet also less expensive one.    


Update:   On 12/7/2011 I had a conversation with my colleague Dr. John Hubbard.  We co-authored a textbook some years ago:  "Primary Care Medicine for Specialists and Subspecialists:  A Practitioner's Guide."  We were discussing this topic, that of culpability of the mentally ill.  He made an interesting observation.  He said that people should not be found Not Guilty by Reason of Insanity but rather Guilty by Reason of Insanity.  Such a legal finding would, it seems to me, make it possible to hold patients accountable but also emphasize quarantine and treatment over quarantine and punishment. 

(c) copyright 2011 Robert Albanese

Update:  On 4/20/16 I attended Baylor College of Medicine Grand Rounds.  The speaker, Christina Treece MD, an expert on postpartum psychiatric disorders, noted that Andrea Yates had discontinued her haloperidol (an antipsychotic) without consulting with her psychiatrist not long before the horrific murders of her five children.  

Cui Bono?*

I read in the news today that Russia is sending warships into Syrian waters (Haaretz.com).  This move has been interpreted by the media as a measure  to protect the government of Bashir Assad; the U.S. has played an active role in the lynching of Gaddafi and we played what might be called a "passive-aggressive" role in the downfall of Mubarak in Egypt.  These events are in the context of the shattering of Iraq by the U.S. and the execution of Saddam Hussein.  The U.S. also has left dubious fingerprints in Tunisia, Somalia, Pakistan and Yemen and who knows where else.   

Russia is one of those countries, like France for example, the mention of which causes instant negative emotional reactions in certain groups of Americans.  There are millions in this country who without any sort of reflection attribute nefarious intent to any action Russia takes on the international stage.  That the Hammer and Sickle have been melted down and forged into Crosses is insufficient, despite the tectonic scale of the transformation, to reassure Americans that Russia is not an agent of the Antichrist.   

That Russia is moving to protect secular government of the "mad ophthalmologist" is evidence to many in the U.S. that her motives are far from benign.  After all, it is true that Assad is a ruthless dictator who murders civilians for no more than questioning their lack of political freedom.  What possible motive could Russia have for coming to his aid besides the augmentation of Evil in the world? 

American foreign policy, on the other hand, is much more rational.  At the cost of trillions of dollars (contributing greatly to our economic ruin) and the lives of thousands of Americans, we have overturned secular tyrants and replaced them with religious ones.   

More than anyone else, it is the Christians in the Middle East who have suffered.  Iraq under Hussein was a place where Christians could live in peace alongside their Muslim neighbors, now they are in the process of a gradual flight from their homeland as it becomes increasingly more hostile.  Similarly Mubarak protected the rights of Christians in Egypt, at least for most of his rule; now the Islamic radicals want to make Egypt just as dangerous for Christians as Iraq.  The more the U.S. keeps whacking the Muslim Bee Hive, the more perilous it becomes for a "Christian" bee.   

Despite all the brain-bypassing emotions of the alarmists, what Russia may be doing is protecting secularism and Christianity.  Syria has a large Christian minority who have thrown their support behind Assad; they are well aware of the fact that if his rule is undermined, it will be replaced by an Islamist government and their lives will become very difficult or impossible.  The Syraic Orthodox Church is worth preserving:  The liturgy they celebrate every Sunday was written by James, the brother of Jesus Christ.   

Americans sometimes appear to be so dogmatic about "democracy" that they seem to believe that anything taken to a majority vote must be just and therefore must be followed.  For this reason we high-five each other when we replace a tyrant who wears a necktie with an elected turban-wearing representative body that makes life onerous for women and minorities.  Iran has a functioning legislature, but on close examination there appears to be no political freedom to speak of there.  As Alex Jones has said, "Democracy (as opposed to a Republic) is two wolves and a sheep voting on what's for supper."   

Perhaps Russia is being pragmatic.  The Russians observe America and her lukewarm allies turning the Middle East into a roiling cauldron of Islamic hatred and perhaps they conclude that it is not a rational policy.  If it were in fact possible to replace tyrants like Hussein with democratic republics of peaceful people it might be worth doing; the Russians may well recognize the fact that exchanging one tyranny for another is not worth sacrificing the well-being of minorities and women in those lands.   

American foreign policy in general leaves one bewildered.  In whose interest does our government act?  Take the example of Kossovo.  We determined that Kossovo should be autonomous, perhaps annexed to Albania, since the population in that traditionally Serbian province is overwhelmingly Albanian and Muslim.  Did someone at a boardroom table in Washington think that if we supported the Albanians in this conflict, Muslims around the world would then find us to be a just people?  Well that has not been the outcome.  Albanian Muslims since the Kossovo conflict have been found plotting to attack Fort Dix (2007), and a Kossovar Albanian Muslim named Arid Uka (2011) killed two U.S. military personnel and critically injured a third in Germany.   

The most important aspect of our actions in Kossovo seems to be completely lost on Americans, however.  If we were to use the same reasoning here that we applied there, we would have to turn over vast areas of American land to Mexico.   

It is not surprising that conspiracy theorists all over America profess the belief that some international cabal, pulling the strings of U.S. policies foreign and domestic, is making a conscious effort to bring on a spectacular downfall of the  American titan.    On the other hand, it may be as simple as the ongoing triumph of emotion over reason in the public arena, in my opinion the most consistent character of American political behavior in the 20th and 21st centuries.  The best thing you can say about what looks like such an ill-considered foreign policy is that it is self-defeating.  As Pogo said in 1971, "We have met the enemy and he is us."


*"To Whose Benefit?" A Latin phrase from Ancient Rome.  One hears this question asked more and more frequently about our representative government by those from whom it derives its power. 

(c) Copyright 2011 Robert Albanese

Healing the Veteran: Mind, Body and Soul

Sts. Cosmas and Damian

The following is the text of a speech I gave to a very diverse group of pastors from the Boise area during a conference on Posttraumatic Stress Disorder.  Although I was treated with great kindness, consideration and deference by the audience, it was not as well received as I had hoped it would be.  I think that it challenged the closely held views of some of the participants; others had difficulty placing it into the context of their educations and/or frames of reverence.  Others were apparently bored by the autobiographical content; since my life is admittedly relatively boring, it would be disingenuous to take umbrage.  Nevertheless the lecture contains the philosophical elements of humanology and anthropiatry and the process by which I came to understand them.  Since the reader is not condemned to an hour of listening to a possible doofus in a lecture hall, and can extract from it what he or she desires, I have posted it in the form of a blog.

Keynote Speech:  Conference on Ministry to Veterans

November 9, 2011

It is indeed an honor to address this audience.  It’s an honor for a number of reasons, but one of them is that I have always felt drawn to the ministry.

See, when I was a lad age 7 we moved to a tiny village in coastal North Carolina.  I met this kid my age named Kevin Roughton and we became best friends.  Now even though North Carolina was then the least Catholic state in the US, Kevin just happened to be Catholic (his mom grew up in a Catholic orphanage in Pennsylvania).  “You should come to mass with me,” he declared, “you’re Catholic after all.”

“Am not,” I retorted. 

“Are, too,” he countered.

So I went home and asked my Dad.  “Are we Catholic?”

“I guess so,” said my Dad.  Crestfallen, I started going to mass with Kevin and his mother. 

 Being Catholic in North Carolina at that time was not easy.  I got invited to a lot of church picnics just to get harangued, but it was more than worth it for southern fried chicken and potato salad.  Kevin and I went to mass in Edenton NC 30 miles away but eventually we reopened a tiny mission church in our home town of Columbia.      

By the way Kevin and I are still friends.  He plays music professionally in the beach communities of the Northern North Carolina coast, around Nag’s Head.

In high school I was rather studious, a fact which all but eliminated any possibility of a youthful romance.  Superimposed on that problem was the fact that I had never been incarcerated, and to be popular in the rural south in those days you had to have “fought the law,” and I had not so girls were pretty much out of the picture.  To be fair, I had very little relationship with my mother, and I think a boy’s relationship with his mom contains certain elements that prepare him for the complex system of emotional barter between a young man and a young woman.  I was devoted to my church, and as I had been sitting on the bench in the game of romance, I began to think that perhaps I was meant for the clergy .  

I mentioned to Father Parker, our priest, that I was interested in the priesthood and he gave me information on several seminaries I could apply to, and he walked me through the initial phase of the applications process.  But Father Parker was nothing if not wise, and later he counseled me to wait until after I finished college to apply to the priesthood.  “I had had a bit of life experience before I became a priest,” he advised;  “I was in World War Two and I got to travel, and I think that’s what you should do.  Go to college, and if you still want to be a priest after that, apply again.”  So I went off to Georgetown University, discovered college girls and thought little about the priesthood for a long time thereafter.   After a while in college I reverted to my feral agnosticism. 

Years later I married a Southern Baptist girl from Rocky Mount, NC and we immediately ran into the problem of what church to attend.  We elected to become Anglicans, splitting the difference so to speak and so we went to All Souls’ Anglican Church in the evocatively named town of Ivy, just outside Charlottesville, Va.   The denomination was one of the schismatic branches off of the Episcopal Church and they were aggressively recruiting priests; I felt a resurgence in that old attraction to the clergy and thought that perhaps their choosiness line was on the other side of me.  Although I was still in residency I enrolled in training to become a deacon in that church.  Eventually our bishop, who had recruited me into the ministry and who was our instructor in the classes we were taking for the diaconate, left our parish under something of a cloud so I abandoned my trek toward the Anglican diaconate.  Besides, their standards seemed a little low.

When we moved to Roanoke, Va., we found an Anglican church that did not suit us because there were almost no couples our age there.  I called my wife’s cousin, an Anglican priest who had been our priest in Ivy and who had baptized our firstborn, and asked him what we should do; he suggested we try an Orthodox church.  He said he had gone to liturgy at an Orthodox Church, and quoting the emissaries of St. Vladimir, he said “I did not know if I was in heaven or on earth.”  Intrigued, we went to the only such church in Roanoke: Holy Trinity Greek Orthodox.  The priest, Fr. Bacalis, was one of those spiritually luminous people and despite the uniformly cool reception we got from the laos (the people in the pews), he inspired us to join their congregation.  Some years later in Charleston SC I became interested in being a perpetual deacon in the Greek Orthodox church, and with my wife’s somewhat reluctant blessing I formally applied to the Atlanta Metropolis to begin training.  For reasons I can only speculate about, my application was the beginning of a long period of non-communication from the Atlanta Metropolis.  I concluded that since the Chancellor of the Metropolis had been my parish priest and since he had heard my confessions, there may have been specific reasons why my application had been put “on terminal hold.” 

My point is that I’m the only person I have ever heard of, possibly the only person who ever lived, who has applied to the ministry in all three major branches of Christianity without it resulting in any kind of ordination.  Sometimes I suppose God sends us messages that are both quite clear but also somewhat embarrassing. 

But it is not that I have not been given a vocation and through this business I believe I have discerned the voice of God saying to me:  “Being a doctor is not enough for you?”  And the truth is, Medicine has brought great meaning and challenge to my life.  In retrospect, perhaps God saw that my desire to get involved in some aspect of the ministry was in some ways a lack of gratitude for the meaning he had given my life through Medicine.  It is also possible that he foresaw some untoward outcome of putting me in a pulpit somewhere.  There can be no doubt, however, that the calling to the ministry and the calling to medicine sound very similar, for they are both a calling to service to mankind. 

One of my many motivations for studying Medicine, in retrospect, must have been some psychological need I had to understand what a human being is.  I did a combined residency in Internal Medicine and Psychiatry so I could understand the diseases of the body and the mind and how they interact with each other.  The model of the human being I was using at that time was the same one used by René Descartes in his six essays called Meditationes.   In the model of Cartesian Dualism, a human has a body (“corpus”) and a mind (“mens”).  In the John Veitch English translation (1901), mind and soul are used interchangeably.  For example in one sentence where Descartes uses the word “mens,” Veitch translates “mind and soul.” This is evidence that as the East and the West grew apart, the model in the West became that a human being had two parts:  A physical part or corpus, and an intangible part or spiritus, into which mind and soul have been condensed.

I learned through my own experience and external observations, however, that humans are not quite that simple.  I’ll return to this issue a little later.

Now I mentioned that we became Orthodox Christians on the advice of my wife’s first cousin, an Anglican priest.  But as with any sort of metamorphosis one undergoes, it was not an instantaneous process.  Allison and I had to do a great deal of reading, and we had to attend liturgy frequently and at the end of about a year, we were quite literally anointed or chrismated into the Orthodox Church.  During the process of reading about Orthodoxy I learned a great deal about history and philosophy and one of the things I learned that surprised me the most was that Orthodoxy was in fact my ancestral house of worship.  The name “Albanese” means Albanian, and it was a name applied by Italians to Orthodox and Catholic Albanian (and also Greek) refugees from the Ottoman conquest of the Albanian homeland.  A number of my family members in New York have made this same journey back to their ancestral Christianity.

Of the most compelling things I learned during our journey to Orthodoxy was that there once existed a magnificent Christian empire in the eastern Mediterranean.  I knew very little about it, but learned that it lasted for a thousand years almost to the day.   They called themselves the Roméos, and they called their empire Romanía.  It is the historical spiritual homeland of all Eastern Orthodox Christians, much as Palestine was for so many centuries that of the Jews. 

How could it be that one of the most important empires in history is little more than empty space on the map of historical consciousness of Westerners, especially Americans?  One reason is that Edward Gibbon, the British historian whose magnum opus was The Decline and Fall of the Roman Empire, the traditional lens through which we perceive ancient Europe, felt that one of the worst events in world history was the Christianization of Rome.  I will quote E.J. Oliver [1958]:  “Although Gibbon judges events in the history of Rome with the serenity, detachment, and seeming objectivity of an English scholar, it is important to note that as the author of his History, he feels as a Roman, thinks as a Roman, and writes as a Roman. His Rome is neither Italian nor Christian, but simply Roman, or more precisely, Republican Roman. It is specifically for this reason that he expresses the strongest opposition to Christianity and the Byzantine Empire (I believe he called them a race of degenerate princes), since he considers the morals and manners of both institutions to be debilitating in nature, and therefore in exact opposition to those of Republican Rome.”  Julius Norwich is another historian who blames the Western lack of interest in Byzantium on the scorn directed at the empire by Gibbon. 

Another reason for the rather startling ignorance of the Eastern Roman Empire in the West is that Byzantium was Orthodox, and for the last five hundred years the religious consciousness of the West has been almost exclusively Protestant and Catholic.  Orthodoxy could only be perceived dimly behind the turbans and keffiyehs of the Muslims of Asia and North Africa, having been engulfed by an Islamic tide.  A hard example of this phenomenon is the book by one of our greatest contemporary historians, Paul Johnson, called “A History of Christianity.” He makes virtually no mention of the Orthodox East in this book. 

The Byzantine Empire’s first ruler was named Constantine the First and it’s last was Constantine the Second.  During most of its existence, it remained one of the most powerful economic, cultural and military forces in Europe.  It was the most stable power of the Medieval period and for much of its history the wealthiest place on earth.  Their culture was a blend of Roman, Greek and Arabic but their language was Greek.  It has also been said that the Byzantine Empire had a Roman body, a Greek mind and an Eastern, mystical soul. 

Come with me back there on the Orient Express to Istanbul, formerly called Constantinople (even by the Ottomans) and before that called Byzantium.  We will dial back the time gauge to approximately 1000 AD, the time of Basil the Second.  The extent of the Empire at that time was Asia Minor (Turkey), all of the Balkans and southern Italy and Sicily.  On this journey we will open the doors of the Hagia Sophia  and look upon Orthodox Christianity; we have a strong ethic in Orthodoxy against proselytism but we are always eager to share the riches of our faith and traditions with others.  We view ourselves as the keepers of an ancient version of Christianity, and although for a lot of reasons we do not encourage conversion from other Trinitarian communities, we believe all have something to gain from knowledge of our way.  Perhaps an analogy would be that in your seminaries, most of you study Greek to enhance your understanding of the Scriptures.  You may have seen the Idaho Statesman Sunday, where there was a front page article about an Orthodox iconographer here in Boise.  While he is devout, as are all iconographers, he sees no conflict with sharing his gift with the non-Orthodox, and he paints these sacred images for churches of all kinds. 

Now the Byzantines had universal literacy when in England, France and Germany it was only the monks who could read and write.  They had female physicians, and a tolerance for Catholics, Muslims and Jews that was unusual in the Medieval period.  While it would be unfair to say that the Jews fared as well under the Byzantines as they do in America today, their lot worsened terribly when the Crusaders and the Latin Kings invaded Byzantine territory.  Byzantine citizens practiced good hygiene when people in France and England smelled like barnyard animals. Much to the dismay of the Franks and Germans who visited there, they drizzled olive oil over their food.  Barbarity!

The West owes a tremendous debt to the Byzantine Empire.  First, for many centuries the Byzantines formed a strategic buffer between the West and the surge of Islam.  The continuity of Western European Civilization exists because of the valiant warfare of the Byzantine cataphract; had they not prevailed for so long this might well be a meeting of imams and mullahs as opposed to Christian ministers.  Second, Byzantine scholars brought the embers of classical thought with them to Italy as the hour approached of the final Turkish assault on Constantinople.  Lars Brownworth, contemporary historian and author of the book Lost to the West:  The Forgotten Byzantine Empire that Rescued Western Civilization,  has noted that of the some 50,000 original manuscripts we have from the Classical Age, 40,000 were brought to the West by these Byzantine scholars.  This was precisely the spark, argues Brownworth, that ignited the flame of the Renaissance. 

The Byzantines had a huge advantage over other civilizations that came before and those that came after.  They spoke and read and wrote in Greek, the language of Plato and Aristotle, but also the language of the Septuagint and the New Testament.  Therefore they understood the Scriptures with the discernment of classical wisdom, patterns of thought that have never been improved upon.  In the West, mind you, classical Greek thought had been largely discarded, for it was pagan and therefore unlikely to be of any value.  In Byzantium the writings of the Greek Fathers were on the bookshelf next to the Holy Bible. 

This is important because not only did the knowledge of the classics affect the way the Byzantines saw their faith, it also had an influence on the way they viewed the world around them.  Medicine, for example, was secular and essentially pagan (Hippocratic).  This fact had significant implications for the way mental illnesses were treated.  For Hippocrates wrote one of the most important essays in the history of Medicine, perhaps of civilization itself:  “On Spiritual Illness.” In this essay he says “I know you Greeks out there all think that when someone develops insanity, it was done to them by the Gods (here he articulates the concept portrayed in the story of Hercules).  But I tell you that insanity represents diseases of the brain.”  Hippocrates had skipped ahead many centuries of medical understanding.  Now in the West during the Middle Ages, as noted by Andrew White in his classic book “A History of the Warfare of Science with Theology in Christendom,” all too often were the mentally ill tortured to death because of the confusion between the mental and the spiritual.  In the Malleus Maleficarum, the infamous treatise on witchcraft, the authors say that one of the ways witches cause harm to mankind is to “deprive them of reason,” in other words, mental illness is evidence of demonic influence. 

The confusion between the mental and the spiritual is found in many places and it always has terrible consequences.  One example is this.  When I was in Charleston SC I was part of the chaplain’s corps of the Citadel (The Military College of South Carolina—you may be familiar with it from Pat Conroy’s The Lords of Discipline).  I was the leader of the Orthodox Christian Fellowship, and once a week I met with the cadets and we would study the Scriptures and the writings of the Holy Fathers of the Church.  When the Commandant of the Chaplain’s Corps, learned that I was a psychiatrist, he puffed out his chest and proclaimed “Doc, I believe that all psychiatric illnesses are basically spiritual.”   He was professing the belief, like the authors of the Malleus Maleficarum, that the signs of mental illness are evidence of a spiritual defect. The implication is that if someone with autism or schizophrenia were to make a heartfelt conversion to Christianity, his or her mental illness would resolve.  This error in thinking is what I call the spiritualization of mental illness.  As I said it was specifically refuted by Hippocrates 2400 years ago. 

This ran directly against my experience.  I said earlier that the body/sprit model of the human being started to run counter to what I was seeing in my professional life.  I knew many severely mentally ill people who were basically kind and while you can’t read hearts or minds, many of them appeared to have very deep faith.  They seemed to be taking in their faiths the only refuge they could find against a lifetime of isolation and torment. 

Let’s do a thought experiment.  We are going to go looking for a spiritual disease.  Could diabetes and sleep apnea be spiritual diseases?  Well, they are both the products of the two of the “seven deadly sins:” Gluttony and sloth.  If the symptoms of mental illness are due to a spiritual defect, why does God supposedly have such an easy time healing depression but a difficult time healing diabetes? 

In the ivory towers of academia, a similar problem exists.  Here, however, because atheism is so firmly rooted in the culture of academics, we see the reciprocal of the problem of people like the chaplain at the Citadel. The university professor perceives concepts like good and evil, spirituality and religion as fundamentally superstitious, and moral issues (for want of a better term) becomes subjugated to psychiatry.  Monstrous behavior is attributed to mental illness alone, and mental illness always predisposes to monstrous behavior.  This is what I call the psychologization of evil, and it is why many psychiatrists resent having to be custodians of pedophiles in psychiatric hospitals when in the opinion of many mental health professionals, they are not mentally ill.  In my experience, mentally ill individuals are rarely dangerous, and those who are usually have chemical addictions.  Many dangerous people who are not mentally ill also have chemical addictions. 

Scientology has very few adherents, but it has a disproportionate impact because it aggressively recruits from within the Brahman class of entertainers.  Its views, dimly perceived in much of the elements popular culture, that the symptoms of mental illness are caused by inhabitation from evil entities, is just as harmful to the mentally ill as the Malleus Malleficarum.

Is it any wonder, since the mentally ill have to contend with some ignorant people within Christianity, academics and Scientologists that we have closed the Mental Hospitals and turned the patients out into the streets?  This society, which perceives itself to be the most compassionate in history, has, I would argue, some very 17^th Century ideas about how we should treat the mentally ill.  Patients with major mental illness have a reduction in life expectancy of approximately 10-25 years, most of the mortality coming from cardiovascular disease.  Available data also suggest that there is a significant reduction in life expectancy from PTSD as well; PTSD is not usually included in these data indexed above but in an article by Op Den Velde et al (2011) in Psychological Reports, PTSD among Dutch survivors of World War II led directly to decreased quality of life and a 42% increase in mortality. Were this another category of illness, the CDC would have declared a state of emergency I think. 

St. Paul, who although a Jew was schooled in Greek, writes in  I Thessalonians chapter 5:  “Now may the God of Peace himself sanctify you completely; and may your whole spirit (psyche), soul (pneuma) and (soma) body be preserved blameless at the coming of our Lord and Savior Jesus Christ.”  He makes unmistakable use of the classic Greek model of the human being. 

When I was a young man I had the unparalleled opportunity to study for a year in France.  I call it studying; it was mostly chasing girls.  The most durable part of that experience is the memories of all the people I met there:  French people, international students from almost every country, and a number of expatriate Americans of all descriptions.  One guy was quite a bit older than the rest of us students, he was a Presbyterian missionary.  He told me about his conversion.  Under the guidance of what we Orthodox would call his “spiritual father,” he accepted Christ as his savior.  “I don’t feel any different,” he protested to his mentor.  “It’s not in your feelings,” he replied, “it’s in your faith.” He was saying, the way I interpreted it, that faith is not a psychological experience. 

For Trinitarian Christians, the tripartite model of the human being has a certain significance.  Here are a couple of concepts from Oriented Leadership, a book written by Ben Williams and Mike McKibben as a kind of a guidebook based in Orthodox Theology for lay parish leaders.  “The understanding of God as Trinity was the direct result of experience, of revelation—that God is somehow Three-in-One and One-in-Three.  We human beings have this same image and likeness.”  Also:  “The Church Fathers affirm a Trinitarian nature in our mind, word and breath.”  Mind, word and breath correspond closely to mind, body and soul. 

So there is this view in Orthodoxy that in some sense Man is a kind of a Metaphor for God, and that we are made in God’s image in that we are trinities like Him.  It is important to recognize the limitations of any metaphor; if Christ is fully Human and fully Divine (Chalcedon 451), for example, is his Human Nature also Trinitarian like ours?  The concept of Man being made in the Image of God in this manner is a hypostasis (in mathematics, a hypostatic union is like honey has sweetness as opposed to honey is sweet) like the doctrine of the Trinity.  In other words, you believe it to a point but recognize that it is a concept limited by language and human cognition. 

The three systems of mind, body and soul are distinct from one another but they have hazy frontiers, and each can influence the other two.   Let us examine how the pneumopsychosomatic model of the human being might improve our understanding of various sorts of diseases and how to manage them.  We will do so by examining the relationships between the three systems. 

1.       Psychosomatics.  This is the study of the relationship between mind and body.  I am board certified in psychosomatic medicine, so it must exist.  The perfect example of psychosomatics is the cycle between depression and myocardial infarction, as demonstrated by Frasure-Smith.  We know that if someone has a heart attack, he is four times as likely to develop depression as he would if he had never had a heart attack.  And if a person who has had a heart attack develops depression, he is four times as likely to die of a heart attack during the next year as someone who has a heart attack and does not develop depression.  We already saw how major mental illness yields a reduction in life expectancy, in that case the imaginary arrow goes from the mind to the body.  In the reciprocal of that, a patient with liver failure develops confusion and disorientation, a case of the body affecting the mind. 

2.       Pneumosomatics.  This is the relationship between soul and body.  This relationship can be illustrated by the fact that those who go to church regularly live longer than those who do not.  Scientific articles in scholarly journals have demonstrated the health effects of various religious practices; one study demonstrated significant benefit from being an Adventist.  Of course that study was done at Loma Linda University, but it only proved what we already know.  Moreover Viktor Frankl, the Viennese psychiatrist who spent World War II in the concentration camps, concluded that it was those who had faith who were able to survive the horror, because it gave meaning to their suffering.  But how does the body affect spirituality?  Perhaps the most important way is the manner in which various biological imperatives, like the cravings for food and sex and sleep create distractions for us, and this is why so many traditions (especially perhaps the Orthodox) make use of asceticism as a way to open the nous, the eye of the soul, which we will again look at a bit further on.  Ascetic disciplines in the form of fasting and vigils make the body healthier as well.  As Chrysostom said, “The body tolerates hunger much better than it does gluttony.”  There is an ethic in Orthodoxy that one way to evaluate an ascetic practice is whether or not it is helpful or harmful.  The Orthodox Church disapproves of flagellation, for example, because although it serves the purpose of subjugating the body to the soul by conquering pain in a sense, ultimately it is harmful to the body. 

3.       Psychopneumatics.  This is the relationship between mind and soul.  This one is in some ways the hardest to characterize, because it is a relationship between two immaterial entities.  We know, however, that although faith does not prevent or treat mental illness, it can be an important part of recovery and it can have a mitigating effect.  There are data that show that religious experience decreases the effects of depression, anxiety and substance use on populations who participate (Wink et al., Research on Aging 2005).  In the other direction, when one is striving to improve the health of the soul, one turns one’s mind to the sacred, by reading Holy Books, meditating on holy things and so on.  The mind, when exposed to or turned toward the horrific, can have an impact on spiritual health.  Posttraumatic Stress Disorder is adumbrated by St. John Chrysostom thus:  “…there are those who are under an inner compulsion to sin:  their hearts and minds have become so twisted and distorted, possibly through bitter experiences in the past, so that they can barely prevent themselves from sinning.  This type of sin is really a spiritual disease; we must try to heal such sinners with the same combination of compassion and determination which we apply to bodily diseases.”  Of the six mature ego defense mechanisms described by George Vaillant, five are experienced by most people in a spiritual context including, get this, asceticism.  

Now let us examine the way in which all three systems work together.  We will look at two patients, patient A and patient B. 

Patient A has depression and diabetes.  She is taking an antidepressant and a medication to lower her blood sugar.  She feels like her health is slipping away.  She struggles to balance a 50 hour a week job and managing her relationships with her husband and her children.  She responds to stress by overeating and her blood sugar control is not satisfactory.  She feels she is too busy to go to Church. 

She struggles to fill an emptiness.  An Orthodox Christian, she talks to her priest, who recommends reading the Bible and the Philokalia, he recommends prayer and meditation, observance of the fasts, frequent attendance at liturgy and taking communion. 

Now we return to the concept of the nous, the eye of the soul.  In Orthodox tradition, the nous is normally closed because of the distracting cares and activities of this world.  By reading the holy books, meditating, fasting, consulting with a spiritual mentor, going to church and to communion the eye of the soul gradually opens and the divine light can enter, cleansing and healing mind, body and soul. 

While she had improved significantly on her antidepressant medication, her residual depression eventually subsided.  She gained control of her appetite and her blood sugars decreased.  She felt a calming and an inner peace she had not had in many years.  Patient A has experienced what is properly called noetic healing.  She also evidences what is called metanoia, a recognizable transformation in thought and behavior as caused by faith. 

Patient B is a Viet Nam combat veteran.  While in theater, he participated in the killings of numbers of civilians; he was acting under orders but was deeply conflicted about it, and he wondered for many years later if he could have prevented it.  This is the spiritual injury mentioned by Chaplain Holt a moment ago.  Gory images filled his mind without his consent, and he was plagued by nightmares of these events.  The spiritual conflict over killing affects his mind, such that he is debilitated by Posttraumatic Stress Disorder.  He cannot tolerate going to church because his hypervigilance makes it impossible for him to focus on the service.  He begins abusing drugs and alcohol, including intravenous heroin in an effort to find some kind of peaceful state.  He accidently inoculates himself with hepatitis C, goes on to develop cirrhosis and liver failure, and from there dementia and delirium.  So a spiritual conflict leads to a psychiatric disorder and from there to a substance use disorder and then disease of the body, affecting the function of the mind.  The challenge here may be to find a spiritual way to approach this patient, for the original lesion was a spiritual one, and it is difficult to imagine a durable recovery without spiritual intervention.  As St. John Chrysostom wrote:  “But only when we truly open our souls to the transforming grace of God will the symptoms of spiritual disease begin to disappear.”

To me, these cases are compelling evidence for the reality of the pneumopsychosomatic (anthropiatry or humanology) approach to disease.  One of the greatest problems with it is that not everyone perceives in him- or herself a spiritual dimension.   Once I had a chronic pain patient who was referred to me for psychotherapy, perhaps medication.  He spent the hour talking about how great was his suffering, and the only thing that would help would be escalating doses of opioid narcotics.  His provider, alas, was unwilling to increase the dose of the oxycodone, so the patient felt that life was not worth living.  I had just read Man’s Search for Meaning, so I shared with the patient that faith can give perspective to one’s suffering and perhaps he should explore the possibility of a spiritual answer to his dilemma.  Even though I took care not to recommend any specific spiritual pathway, I later learned that the patient had complained about me to the Patient Representative, noting that I had been “pushing religion” on him.  Physicians have to be very careful about the manner in which they make contact with their patients’ spirituality and in that case I must not have been careful enough.  I for one do not know how to address spiritual issues in such patients. 

Another problem if you want to look at it that way is that we live in a diverse and secular society.  When I was visiting Russia a few years ago, my hosts took me on a tour of a psychiatric hospital.  The hospital was full of Orthodox icons for the patients to venerate.  Presumably the patients were all Orthodox.  The benefits of living in a diverse, secular society are many but among the disadvantages is that you have to tread carefully on spiritual matters and it’s difficult to meet the needs of a large number of patients in one approach.  Nevertheless the Department of Veterans Affairs, even though we a part of a secular organization, recognizes the role of spirituality in the health of the veteran. 

Once some years ago I heard an anecdote about a woman who complained to her gynecologist about being depressed.  She had every reason to consult her gynecologist about depression because most gynecologists are pretty good with depression psychopharmacology.   He surprised her though, by telling her that if she were to accept Christ as her personal savior, she would no longer be depressed.  The gynecologist had violated a Hippocratic principle:  sacerdotalism.  Hippocrates warned that physicians should not get too deeply involved in the spiritual lives of their patients; there are professionals whose job that is and that is not what the patient is paying you for.  There are exceptions to this rule; when I was a student at Georgetown I met physicians who were Jesuits, but you knew right away they were trained priests by the way they dressed.  Most of us, however, know better than to do any more than facilitate interaction between our patients and their professional clergy. 

That’s why at the Boise VA the Chaplains are so important.  I know their value from personal experience.  Last January I was diagnosed with cancer, and the person who was the most important support to me through that terrible ordeal was Chaplain Bramhall.  There were important spiritual elements in my journey to feeling well again and Chaplain Bramhall, and I cannot forget my priest Father Nektarios, made it possible for me to get through that experience.  I had three great catastrophes going on in my life at the same time, and the only way I could rest was to believe that God was taking me apart, destroying me utterly so he could take my component parts and put them together into something more useful than me.  Father Nektarios asked me to read Job, which seemed too obvious.  But I read it with new eyes, closed my Bible and said, “Blessed be the name of the Lord.” 

As Chaplain Holt said in the video, there is a complex interaction between the biology, psychology and spirituality of the patient, and at our VA Hospital we recognize every element of the care of the Veteran.  The role of the minister or priest or rabbi is viewed with great importance on inpatient mental health, medical surgical wards, in Hospice and Palliative Care.  The challenge for me is to figure out how best to integrate the Chaplain’s Service into our activities in Medicine Service; our frontline providers are residents and they are focused on acquiring the knowledge and skills necessary to manage the biological needs of their patients.  But at the Boise VA, we recognize our patients not just as pancreases or dopamine receptors, but as human beings with biological, psychological and spiritual dimensions and we bring healing to them in all three systems.  In my opinion, that's how you care for a human being.   

Sources:

1.       The Byzantine Empire, by Julius Norwich. 

2.       Lost to the West, by Lars Brownworth. 

3.       Decline and Fall of the Roman Empire, by Edward Gibbon. 

4.       Man’s Search for Meaning, by Viktor Frankl. 

5.       The Orthodox Study Bible. 

6.       The Encyclopedia Albanica (theencyclopediaalbanica.blogspot.com).

7.       Greek Orthodox Archdiocese (goarch.org).

8.       On Living Simply, by St. John Chrysostom.

9.       On Wealth and Poverty, by St. John Chrysostom. 

(c) Copyright 2011 Robert Albanese