ROMAN CATHOLIC PERSPECTIVES ON PSYCHIATRIC ETHICS - Chapter 42_Mordini

Chapter 42
Roman Catholic
Perspectives on
Psychiatric Ethics
Emilio Mordini
Introduction
The Roman Catholic Church is the largest Christian community in the world. It includes
more than 1.2 billion believers worldwide, around 1.2 million clerics, and consecrated people
(monks, nuns, etc.).1
Roman Catholics call themselves just “Catholic,” which comes from a
Greek word that means “universal.” The denomination Roman Catholic originated during
the seventeenth century within English speaking countries to differentiate Roman Catholic
from reformed Christian churches and, notably, from Anglicans.
Theologically speaking, Roman Catholics share with most other Christian communi-
ties and churches the so-called “Nicene Creed,”2
which is the profession of faith adopted at
the First Council of Nicaea (325 AD) by Christian clerics convened in Nicene, in Northern
Anatolia, by the Roman Emperor Constantine (Ratzinger 1968). The Nicene Creed includes
1
<http://www.pewforum.org/2013/02/13/the-global-catholic-population/>.
2
The Creed includes seven original statements: (1) We believe in one God, the Father Almighty,
Maker of all things visible and invisible; (2) And in one Lord Jesus Christ, the Son of God, the only
begotten of the Father; that is, of the essence of the Father, God of God, Light of Light, very God of very
God, begotten, not made, being of one substance with the Father; (3) By whom all things were made
both in heaven and on earth; (4) Who for us men, and for our salvation, came down and was incarnate
and was made man; (5) He suffered, and the third day he rose again, ascended into heaven; (6) From
thence he shall come to judge the quick and the dead; (7) And in the Holy Ghost. In the First Council of
Constantinople (381 AD), this Creed was further modified, notably statement 7, and two new statements
(6bis and 8) were added. Consequently the Creed final statements read now: (6bis) Whose kingdom shall
have no end; (7) And in the Holy Ghost, the Lord and Giver of life, who proceedeth from the Father, who
with the Father and the Son together is worshiped and glorified, who spake by the prophets; (8) In one
holy catholic and apostolic Church; we acknowledge one baptism for the remission of sins; we look for
the resurrection of the dead, and the life of the world to come. Amen.
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540 Roman Catholic Perspectives on Psychiatric Ethics
the central profession of Faith of all Christians, say, that (1) there is only one God, the Father;
that (2) Jesus Christ, a young Hebrew master, who lived in Palestine around two thousand
years ago, is the son of God, and that He is God himself, together with (3) the Holy Ghost
who is the Spirit of God. The three—God Father, Jesus Son, and the Holy Ghost—are three
and, the same time, they are one, as the three leaves of a clover.3
God Father is the maker of
the universe; Jesus is his “logos,”4
who once came into a historical dimension, became a true
man, was crucified5
because of an accusation of blasphemy, died, and resurrected; the Holy
Ghost is the wisdom of God, who inspired prophets6
and drives human history.
The essential theological features the Roman Catholic Church are: (1) the Roman Catholic
Church claims to be a human institution, but also a supernatural society, which was founded
by Jesus Christ; (2) the Church is made up by a visible and an invisible Church. The invisible
Church includes all individuals who are saved and live forever in communion with God. The
visible Church is the institution on the earth; (3) Catholic priesthood is an order, the Holy
Order, which derives from a sacrament, which has been transmitted along centuries from
the first Jesus’ apostles to current clergy. The clergy includes deacons, priests, and bishops.
The bishop of Rome, called “Pope,” is the successor of Peter, one of the twelve apostles, he
who was bestowed by Jesus with the responsibility to head the Church7
; (4) the main mission
of the visible Church is to administer sacraments, preach the Gospels, and transmit through
generation the Sacred Tradition,8
which is—together with Sacred Scripture—the way in
which Jesus’ teaching is transmitted; (5) the Gospels are written records of Jesus’ words and
actions. The Church recognizes four books,9
traditionally ascribed to four Jesus’ disciples,
Matthew, Mark, Luke, and John; together with some other writings of Jesus’ disciples, they
constitute the “New Testament;” the “Old Testament” (Hebrew Bible) is also regarded as a
holy book; (6) sacraments are seven10
and were instituted by Christ. Sacraments are signs
of the new11
covenant between God and human beings. They are vehicles of grace12
and are
necessary for salvation.13
From a sociological view point, the main features of the Roman Catholic Church are: (1) it
is the oldest Western institution and has shaped Western identity, ranging from philosophy,
3
Other monotheistic religions have sometimes accused Christianity not to be truly monotheistic. In
fact the Christian God “is neither one (a substance) nor three (three Gods). God is the ultimate reality
and infinite correlative of reality” (Panikkar 2006, pp. 111–112).
4
Logos is a Greek noun which derives from the verb lego, which originally meant “to count,” “to
choose,” and subsequently came to mean, “to tell,” “to state.” Logos means “word,” “verb,” “action,”
“reason,” “rationale,” “argument,” In John’s Gospel it is used to speak of Jesus. Jesus is the Logos of God.
5
“Crucifixion,” from Latin crucifigere “to fasten to a cross,” was an ignominious capital punishment.
6
Prophet comes from the Greek verb pro-phemi, which means “to speak using words that produce
effects.”
7
Matthew 16:13–20; Mark 7:27–30; Luke 9:18–21.
8
The distinction between written Revelation and Tradition originates in Phariseean Judaism.
9
There many other gospels, which are not recognized by the Church as inspired by God. These
narratives—apocryphal gospels—are interesting historical sources but are not considered holy books.
10
Baptism, Confirmation, Eucharist, Penance, Anointing of the Sick, Matrimony, and Holy Orders.
11
Say, the one established by Jesus by his sacrifice.
12
Grace is a gift of God, which redeems human beings by restoring a status of just relationship with
God (justification), which was antecedent to human corruption (original sin).
13
Whether the believer receives a grace from the sacrament depends also on her inner disposition.
Approaching a sacrament as a mere formality, or even worse, as a magic, does not produce any grace.

Roman Catholic Moral Teaching 541
to politics, economics, art, music, architecture, and so; (2) since the moment in which it
became the official religion of the Roman Empire (395 AD), the Roman Catholic Church has
been variously involved in the political history of the West, in some periods even becoming
one of the most powerful Western institutions; (3) it is a hierarchical organization, which
has been shaped initially on the model of the Roman Empire, subsequently on the model of
European absolute monarchies, although it has never had a dynastic structure; (4) its cul-
tural and ritual roots include significant elements from Judaism before the destruction of
the second temple (70 AD), and important contributions from Greek and Latin ancient civi-
lizations; (5) from the Roman Empire, it has also taken an inclusive attitude towards diverse
cultures and religions; because of this reason it has been even accused of religious syncre-
tism; (6) women participate to Church’s life, they could consecrate themselves (nuns), and
are highly valued by all official documents, yet the Roman Catholic Church is chiefly a male
organization. Ordered priesthood is reserved to bachelor males14
and the whole hierarchical
organization is made up only by unmarried males.
Roman Catholic Moral Teaching
The Creed has been the earliest summary of Christian doctrine, used in teaching religious
instructions. Since the Reformation period, Western Christianity used also doctrinal man-
uals called “catechisms,” from Greek katekhismos, which means manual for oral teaching.
The idea of a religious manual was first developed by Reformed Christian churches, which
focused on religious teaching within the family. In 1556, also the Roman Catholic Church
published its catechism (the Roman Catechism, known as the Catechism of Pius V). This
catechism was a reference book for clerics, rather than a manual for family men, and its
main goal was to defend Roman Catholic orthodoxy against Reformed Christian churches.
In 1997, the Catholic Church issued a new Catechism (Catechism of the Catholic Church
1997). Apart from some theological and liturgical questions, the main difference from the
1556 Catechism relies on the fact that the current Catechism is not only a reference book for
clerics, but it “is offered to every individual … who wants to know what the Catholic Church
believes.” (John Paul II 1992). The Catechism also summarizes the Church’s official teach-
ing on matters of morals. According to the Catechism there are “different expressions of the
moral law, all of them interrelated: eternal law—the source, in God, of all law; natural law;
revealed law, comprising the Old Law and the New Law, or Law of the Gospel; finally, civil
and ecclesiastical laws” (art.1952). The notions of “eternal law” and “revealed law” are easily
understandable, but what is the “natural law?”
The Catechism defines the natural law as “the original moral sense which enables man to
discern by reason the good and the evil, the truth and the lie” (art. 1954) and specifies “in the
diversity of cultures, the natural law remains as a rule that binds men among themselves and
imposes on them, beyond the inevitable differences, common principles” (art. 1957), “the
natural law is immutable and permanent throughout the variations of history” (art. 1958).
14
Prohibition to marriage for Catholic priests is only customary. On the contrary, bishops cannot
marry because of doctrinal reasons.

The concept of natural law derives from Stoic philosophy,15
was transmitted to Western
Christianity through Cicero and Roman lawyers, became the mainstream Roman Catholic
doctrine with Aquinas, and finally was included in the 1997 Catechism:
Unlike other great religions, Christianity has never proposed a revealed law to the State and to
society, that is to say a juridical order derived from revelation. Instead, it has pointed to nature
and reason as the true sources of law ( … ) Christian theologians ( … ) acknowledged reason
and nature in their interrelation as the universally valid source of law.
Benedict XVI 2011
This creates a bizarre situation. On one hand Christian ethics is definitely an “ethics of striv-
ing” rather than an “ethics of ought” (Kramer 1992). The core of Jesus’ teaching, “As I have
loved you, so you must love one another”16 could be hardly considered a precept. On other
hand, the notion of “natural law” provides Catholicism with a strong normative framework.
The tension between these two poles is unavoidable. The notion of “natural law” includes,
however, at least two different concepts. First, the natural law could be understood as “law of
nature,” say, moral order grounded in the very nature of things. This approach has been often
mainstream in Roman Catholic moral teaching, at least from XIX century on. Yet the natural
law could be also understood as “practical reason,” say, as human capacity to conform to
God’s mind and cooperate to divine providence. In other words, moral norms could be said
“natural” either because they can be found in “nature” or because they are consistent with
human practical reason (Rhonheimer 2000). Ultimately, the idea that ethical norms could,
and should, be rationally justified (say, they are not God’s arbitrary commands and there is a
deep harmony between reason and revelation) is thus integral to Roman Catholic teaching,
but this does not imply that the moral law is written in the “book of nature.”17
Although the
physicalist doctrine of “natural law” may be prevalent, one could be Roman Catholic with-
out sharing it (Antiseri 2003).18
15
Stoicism was a philosophical current, born in the Hellenistic milieu around 300 BC, which became
one of the most influential schools of thought of the Roman Empire. According to Stoics, the universe is
governed by rationale laws. The goal of a rational agent is to live in accordance with these laws.
16
John 13:34–35.
17
The Catechism define the natural law as “the light of understanding placed in us by God; through
it we know what we must do and what we must avoid” (art.1955), and John Paul II’s encyclical letter
“Veritatis Splendor” reads “the light of natural reason (is) the reflection in man of the splendour of God’s
countenance … this law is called the natural law: it receives this name not because it refers to the nature
of irrational beings but because the reason which promulgates it is proper to human nature” (John Paul II
1993, n. 42).
18
Roman Catholic teaching in matter of faith and morals obliges the believer to assent only when
it is “extraordinary”, say, when: (1) it is a specific, solemn, Pope’s declaration called ex cathedra; (2) it
is a doctrine formally endorsed by a General Council of the Church; (3) it is considered definitive and
absolute by all bishops, all over the world, without exceptions. In all other cases, Church’s teaching is
called “ordinary,” which is authoritative and demands hierarchic submission, but it is not a truth that one
should believe in order to define herself Roman Catholic. Finally, disagreement is always possible with
theologians’ teachings (magisterium cathedrae magistralis) no matter if it is the prevalent doctrine.

Scriptural Sources 543
Scriptural Sources
“14When they came back to the disciples, they saw a large crowd around them,
and some scribes arguing with them. 15Immediately, when the entire crowd saw
Him, they were amazed and began running up to greet Him. 16And He asked
them, “What are you discussing with them?” 17And one of the crowd answered
Him, “Teacher, I brought You my son, possessed with a spirit which makes him
mute; 18and whenever it seizes him, it slams him to the ground and he foams at the
mouth, and grinds his teeth and stiffens out. I told Your disciples to cast it out, and
they could not do it.” 19And He answered them and said, “O unbelieving genera-
tion, how long shall I be with you? How long shall I put up with you? Bring him to
Me!” 20They brought the boy to Him. When he saw Him, immediately the spirit
threw him into a convulsion, and falling to the ground, he began rolling around
and foaming at the mouth. 21And He asked his father, “How long has this been
happening to him?” And he said, “From childhood. 22”It has often thrown him
both into the fire and into the water to destroy him. But if You can do anything,
take pity on us and help us!” 23And Jesus said to him, “`If You can?’ All things are
possible to him who believes.” 24Immediately the boy’s father cried out and said, “I
do believe; help my unbelief.” 25When Jesus saw that a crowd was rapidly gather-
ing, He rebuked the unclean spirit, saying to it, “You deaf and mute spirit, I com-
mand you, come out of him and do not enter him again.” 26After crying out and
throwing him into terrible convulsions, it came out; and the boy became so much
like a corpse that most of them said, “He is dead!” 27But Jesus took him by the
hand and raised him; and he got up. 28When He came into the house, His disciples
began questioning Him privately, “Why could we not drive it out?” 29And He said
to them, “This kind cannot come out by anything but prayer.”
New American Standard Version—Mark 9:14
The episode of the exorcism of a boy possessed by a demon, which is extensively reported
by Mark but is also reported by Matthew (17:14–21) and Luke (9:37–49), is one of the mira-
cles of Jesus in the Gospels. The scene was vividly represented by Raphael in his last paint-
ing, “The Transfiguration.”19
The episode reported by Mark has always drawn attention of
scholars. On one hand the tale follows the standard plot of all Jesus’ exorcisms (Twelftree
2011), on other hand there are some significant particularities that make this exorcism rather
peculiar (Meier 1994). First, the whole episode is included between two explicit references
to Jesus’ disciple helplessness to heal the boy, which is uncommon in the Gospels. Second,
Jesus’ interlocutor is not the demon, as in all other exorcisms, but the distressed boy’s father.
Third, it is the sole instance in the Gospels in which Jesus conditions an exorcism to faith
and mentions his own faith as the source of his miracles. Fourth, the clinical description of
the boy possessed by a demon is an accurate picture of a neuropsychiatric disturbance, say,
epilepsy.20
Because of all these elements, and a textual analysis of Mark’s lexicon, most New
19
Intriguingly enough, this painting is mentioned by Friedrich Nietzsche (Nietzsche 1872) as the
highest plastic representation of the tension between the two primordial holy follies, Apollonian
possession and Dionysian frenzy.
20
Moreover, Mark uses a Greek word that literally means “lunatic,” which was often used in his epoch
to describe epilepsy.

Testament scholars think that behind this tale there is the memory of a historic event of Jesus’
life (Meier 1994, p. 778), say, the healing of a boy suffering from epilepsy.21
This makes this
tale particularly intriguing to psychiatrists, because it is the sole example of a well-defined
neuropsychiatric disorder treated by Jesus in the Gospels, and it could even be an episode
occurred to the historical Jesus.22
There is an important lesson that one could elicit from this episode. Although in Jesus’
Palestinian culture, madness and demonic possession largely overlapped, in the episode
there is no explicit reference to evil. The expression “possessed by a demon” is used here
without any moral nuance, it is purely descriptive. Not even it is mentioned any moral fault
that could explain the possession (it is only said that the boy suffered from childhood). Jesus’
doctrine on disease was quite different from the common wisdom of his cultural milieu,
which assumed that diseases could be always explained by a moral fault, or a ritual sin.
Jesus—at least the Jesus of the Gospels—believes that diseases are not a God’s punishment
and that they are not ethically relevant per se, but only because they challenge human beings
and their faith. In Mark’s episode, Jesus does not attribute any special moral relevance to
epilepsy, which is actually treated as any other extremely severe23
medical disease. Jesus rec-
ognizes the special difficulty to treat epilepsy, which cannot be healed by “exorcisms”—as
those performed by disciples—but chiefly demands faith. It is noteworthy that in Mark’s tale,
faith is somehow contrasted with ritual exorcisms and mysterious healing powers (which
was probably what the crowd was searching for). Jesus makes appeal to a sort of pious, faith-
ful in God, “suspension of disbelief”24
rather than in any kind of magic. In such a sense, he
implicitly rejects any explanatory theory of epilepsy based on the notion of moral evil.
The concepts that (1) mentally disturbed people deserve the same care and attention of any
other patient, or even more because of the severity of their conditions, (2) that it is a moral
duty for Christians to take care of mentally disturbed people; and that (3) neuropsychiatric
and psychiatric diseases are not due to any moral fault, and do not represent a moral fault
by themselves; are thus integral to Jesus’ teaching as it has been transmitted by the Gospels.
These three concepts are complemented by a fourth concept, which does not belong to the
Gospels, but it is new testamentary, say, the concept of God’s foolishness. “For Jews demand
signs and Greeks desire wisdom, but we proclaim Christ crucified, a stumbling block to
Jews and foolishness to Gentiles ( … ) For God’s foolishness is wiser than human wisdom,
and God’s weakness is stronger than human strength” (Corinthians 1:18–31). Paul25
cancels
any preconception in favor of the Greek, philosophic, notion of rationality, and affirms the
supremacy of God’s wisdom, which is definitely beyond human rationality, till to the point to
seem pure nonsense to humans. If Jesus is the new Adam, the archetypal human being, then
21
Of course recognizing the likely historical authenticity of an episode does not imply to accept also
its nature of miracle.
22
The notion of “historical Jesus” refers to the reconstruction of Jesus’ life based on historical
methods.
23
Some scholars have thought to find in this episode many elements that usually characterize
resurrection miracles in the Gospels (Meier 1994).
24
The expression “suspension of disbelief” was coined by Samuel T. Coleridge in the context of poetry
(Cattorini 2007).
25
Paul was a Hebrew Pharisee who converted to Christianity, and played a pivotal role both in the
theological systematization of Jesus’ teaching and in its diffusion in the Hellenistic and Roman world.

Mental Diseases According to the Church Fathers and Aquinas 545
Paul is telling us that the human essence is not philosophical rationality. From the psychiat-
ric ethics perspective, this is intriguing because it does justice of any conception of human
value based on mental capacities. A human being values independently from being men-
tally competent. An idiot could value even more than a genius, because—taking it to the
extreme—also God would be considered mental incompetent according to human, rational,
parameters.26
A non-magical model of mental diseases; refusal of moral explanatory theories of psy-
chiatric disturbances; duty to care for mentally disturbed people; and intrinsic value of any
human being independently from her mental capacity; are the scriptural anchorage of the
Christian approach to psychiatric ethics.
Mental Diseases According to the Church
Fathers and Aquinas
The Church Fathers27
were not particularly interested in mental diseases. Somehow depart-
ing from the lesson taught by Mark 9:14, they accepted the notions of their cultural envi-
ronment (Larchet 1992) and started introducing into the Christian perspective a partial
overlap between medical and moral categories, which was remote from Jesus’ teaching. On
the contrary, Augustin,28
who adopted Galen’s29
conception of mental diseases, espoused a
reductionist approach, and he hardly ever refers to mental disorders as spiritual, or moral,
disturbances.
Thomas Aquinas30
distinguishes between mental conditions generated by bodily dys-
functions, which affect the mind only contingently; and mental disturbances, which affect
directly the mind,31
but do not have any moral relevance per se. Aquinas speaks also of
“aegritudo corporali” and “aegritudo animalis” (bodily and mental infirmities).32
Mental
infirmities (aegritudo animalis) are moral vices, he calls them “beastly or pathological vices,”
they include sexual sadism, paraphilia, and some psychopathic behaviors. The Barcelona
University Professor Martín F. Echavarría (Echavarría 2006) has recently argued that this
category would capture the core Aquinas’ teaching on psychiatric diseases.
26
This concept is echoed by Dostoevsky “The more stupid one is, the closer one is to reality. The more
stupid one is, the clearer one is” (Dostoevsky 2007, p. 258).
27
With the term “Church Fathers,” one usually refers to ancient Christian theologians who variously
contributed to the definition of Christian religion.
28
Augustine of Hippo (354–430 AD) was a Latin philosopher and Christian theologian, who played a
pivotal role in the development of Western Christianity and philosophy.
29
Galen (129–216 AD) was a Greek physician and philosopher in the Roman Empire. Galen
argued that the mental and the physical were the same and mental diseases had a physiological basis
(Hankinson 1991).
30
Thomas Aquinas, (1225–1274) has probably been the most influential philosopher and Christian
theologian. In his encyclical of 4 August 1879, Pope Leo XIII stated that Thomas’s theology was a
definitive exposition of Catholic doctrine.
31
Sum III, q. 15, a. 4.
32
Sententia Ethic., lib. 7 l. 1 n. 4–5.

Psychiatry, Psychoanalysis, and
Papal Teachings
During Middle Age and Renaissance, priests and religious authorities, together with medical
doctors, shared, and contributed to generate, abusive practices and confusion between insan-
ity, social deviance, and moral evil. The most known, and over cited, example is the interpre-
tation of mental diseases as a form of demonic possession. The belief in demonic possession,
and its use as an explanatory category for mental diseases, was not specific to the Roman
Catholic Church, on the contrary it spread across the whole of Christianity for centuries, pro-
voking major atrocities also in the Protestant world. Yet—apart from “outbreaks” of witch
hunting—the social condition of mental disturbed people was probably better in pre-modern
societies than in early industrial society, as it has been argued by Foucault (Foucault 2001).
With the industrial revolution, “deviant” people were increasingly institutionalized in pris-
ons for the insane. The birth of modern psychiatry occurred as a reaction to the awful con-
ditions in which these people were guarded (Weiner 2008) and it was hallmarked by two
major events, (1) the transformation of asylums into hospitals and (2) the introduction of
more humane treatments. The psychiatric reform was initially regarded with suspicion by
Catholic hierarchies, although there was no reason why it should evoke negative reactions
in the Church (Schorter 1998). In fact, the problem was political. Psychiatric reformers were
often engaged in the Enlightenment movement and consequently suspected of anti-Catholic
feelings. Moreover, the establishment of psychiatry as a discrete branch of medicine, and the
birth of psychiatric clinics, implied some diminution of religious expertise and authority in
this field. Yet, religious institutions soon understood that opportunities provided by psychi-
atric reform could largely balance the transfer of power. In Europe, the private psychiatric
system was chiefly managed by charities and religious institutions and, in Catholic countries,
religious congregations often staffed public and private psychiatric hospitals.
After the psychiatric reform of the late eighteenth century, another important moment of
ethical tension between the development of psychiatric practices, and the Roman Catholic
hierarchy, was probably the tumultuous development of psychoanalysis and psychothera-
pies during the second half of the twentieth century (Elia 2010). Although psychoanalysis’
diffusion in European and American cultures dates back to the period between World War
I and II, it was only in 1952 that the Catholic Church took a stance on psychoanalysis. In his
speech to “To the participants in the International Congress of Histopathology of the Nervous
System” (Pius XII 1952), Pope Pius XII stated that pansexuality advocated by “a given psycho-
analytic school” was hardly compatible with Christian anthropology and natural morality.
The Pope did not deny the importance of sexual drivers in human psychology, but criticized
that they might be unraveled and represented to the patient. In a further speech delivered in
1953 (Pius XII 1953) Pius XII’s addressed the core of Christian religion and Freudian theories,
say, the place and function of love in mental life. Could psychoanalysis accept the central
Christian tenet “Love your neighbor as yourself?” According to Pius XII, this is the real ethi-
cal challenge between Catholic moral teaching and psychoanalysis. An answer to the Pope
will arrive four years later through the words of one of the most influential psychoanalysts,
and scholars, of his age, Jacques Lacan. In a 1960 lecture, Lacan argues that the center of the
whole Freudian reflection is anything but the human (im)possibility of altruistic love (Lacan

Psychiatry, Psychoanalysis, and Papal Teachings 547
2005a). The problem, argues Lacan, is that the subject, who should love his fellow as himself,
does not exist, and is empty. In other words, he who should love his fellow is anything but
the internalization of his fellow’s desires and fantasies. In Lacan’s words, he is “the speech of
the other.” Who loves whom? As in a mirror play, the subject looks into the looking glass but
he sees reflected the other. Where is himself, where are the subject and the object of love?
Only looking into God—argues Lacan33
—the subject could see himself and his own fellow.
Lacan, who was a Roman Catholic,34
captures here something extremely important, which
has variously crossed the most interesting developments of contemporary psychoanalysis
(Bion 1965; Matte Blanco 1975; Lear 1990; Stoller 1991).
In 1962, Pope John XXIII convened the Second Vatican Council, a plenary meeting of
the highest Roman Catholic officials and theologians with the goal to meet the challenges
of modernity. Nothing was the same in the Roman Catholic Church after this Council and
also the Catholic teaching on psychoanalysis smoothed, and formal bans were removed.
A good example of this new wave is 1963 Paul VI’s speech “To the participants of the meeting
Psychiatry and Spiritual Problems” (Paul VI 1963).
During his long papacy, also John Paul II addressed the relationship between Catholicism
and psychiatric disciplines. In line with the Catholic tradition, John Paul II greatly valued
medical and biological approaches. For instance, in a 1990 speech (John Paul II 1990), he
emphasized the contribution of neuroscience to the knowledge of human person, which
could arrive—he argued—up to the “threshold of the mystery of man.” He was much more
cautious, even distrustful, towards psychological, notably psychoanalytic, approaches. John
Paul II identifies—as Pius XII did—in the analysis of the structure of human desire the real,
irreconcilable, tension between Catholic moral teaching and psychoanalysis (John Paul II
1980). The Pope recognizes that psychoanalysis deserves the merit to have drawn the atten-
tion on the centrality of longing in human actions, but he argues that longing can be over-
come. The Pope uses the word “concupiscence,” which is a term directly, derived from Latin,
which points at “the selfish human desire for an object, person, or experience.” Concupiscence
is a central concept in Roman Catholic teaching, and it has been one of the main points of
friction between Roman Catholic and Reformed churches. What is finally concupiscence? It
is the original sin, say, the innate human will to power and long for owning (objects, persons,
experiences). While most Reformed churches see in the selfish nature of human desire the
hallmark of evil, say, the unequivocal sign of human corruption, Roman Catholic Church
teaches that concupiscence is not a sin, but a challenge. In other words, selfish desire and
will to possess may cause sin if the person consents to them, but if the person does not, they
are instead a great opportunity for freedom. John Paul II argues that self-overcoming and
repression of selfish desires are not only possible, and morally laudable, but they are the way
in which humans fulfill their humanity.
After John Paul II, Benedict XVI was particularly challenged by the issue of discrimina-
tion against mentally disturbed people. He met this theme various times (Benedict XVI
33
« ‘Mais en Dieu, Frére, sache aimer comme toi-même ton frère, et, quel qu’il soit, qu’il soit comme
toi-même’ Tel est le commandement de l’amour du prochain. Freud a raison de s’arrêter là » (Lacan 2005b,
p. 62).
34
« La vrai religion, c’est la romaine … Il y a une vrai religion, c’est la religion chrétienne » (Lacan 2005b,
p. 81).

2005, 2009), but his more touching speech is likely to be the one that he delivered when
he was still cardinal (Ratzinger 1996). In that speech, Joseph Ratzinger, the future Pope
Benedict XVI, dramatically recalls his youngness in Traunstein, a small town in the Bavarian
Alps, and the way in which people suffering from mental illness silently disappeared from
the town, victims of the Nazi program to eliminate “life unworthy of life.”
Until today Pope Francis has never addressed the issue of mental health and psychiatric
practice, however his recent stance on homosexuality could have some repercussions also on
psychiatric ethics (see below).
Psychiatric Clinical Ethics
The last part of this article will be devoted to Roman Catholic perspectives on some ethical
issues related to psychiatric clinics. In most cases, there are neither Catholic official state-
ments nor established moral practices. The Roman Catholic teaching on mental health is
rather limited (Kehoe 1998) and the institutional Church tends to espouse traditional
medical deontological approaches to psychiatric ethics (Vanderveldt and Odenwald 1957,
pp. 123–155). There are, however, some cases in which ethical conflicts between Catholic faith
and psychiatric professional practices may occur. I will focus only on these occurrences,
while I will not discuss ethical conflicts that would not challenge a Catholic psychiatrist
as a believer. I will also mention some ethical problems that could arise when a patient is
Catholic and her psychiatrist is not.
Psychiatric Diagnosis
The main ethical issues raised by psychiatric diagnosis are related to stigmatization and
“psychiatrization.”
Stigmatization: stigmatization refers to the process of attributing to an individual a stereo-
typical description, a behavior, or reputation which is socially demeaning (Goffman 1963).
This has been one of the main theoretical tools used by 1960s anti-psychiatric movements
to criticize official psychiatric theories and practices (Dain 1995). From a Catholic perspec-
tive, promoting, or not preventing enough, psychiatric stigma is one of the major unethical
behavior which a psychiatrist could incur, because it threatens the inherent human dignity
of the patient.
Psychiatrization: with this neologism, one refers to the process of labeling a behavior, or a
social fact, as an occurrence that pertains to psychiatrists. Although this process is habitually
justified by alleging a new scientific discovery, this is rarely—if ever—the case. Usually the
process of changing label to a behavior is due to reasons that are more mundane and some-
times it is even used as a diagnostic cover for the introduction of, or new indications for,
drugs and treatments. Psychiatrization is always ethically questionable and it could become
a source of specific ethical conflicts for Catholic psychiatrists when it is used to justify serious
disregards of responsibility. If school teachers use the diagnosis of “learning disability” as an
alibi for neglecting problematic children; if public authorities use the label “psychopathic”
to avoid confronting social problems that they are unable to handle; if families delegate the

Psychiatric Clinical Ethics 549
management of rebellious adolescents to psychiatric agencies; in all these cases Catholic psy-
chiatrists should refuse to participate into a collective system for discharge of responsibility,
which is definitely in contrast with Jesus’ teaching35
and the Church’s teaching on individual,
and professional, responsibility (Pontifical Council for Pastoral Assistance to Health Care
Workers 1994, n. 57).
“Abnormal” Sexual Behaviors
The sources of Catholic sexual morality could be hardly traced back in the Gospels, which
almost ignore sexual matters as causes of ethical conflicts (Fuchs 1979). Jesus’ teachings on
sexuality are definitely less numerous than those which concern power, violence, money,
hypocrisy.36
The (almost) sole explicit reference to sexual morality is actually a warning
against lust.37
Indeed the main sources of Catholic sexual morality are Rabbinic Judaism,
chiefly through Paul the Apostle, and the doctrine of “natural law.” This does not change the
fact that sexual abstinence and heterosexual intercourse, in a religiously married couple, are
the sole moral standards accepted by Roman Catholic teaching. The Catechism (Catechism
of the Catholic Church 1997) reads, “the deliberate use of the sexual faculty, for whatever
reason, outside of marriage is essentially contrary to its purpose” (art. 2352). Ethical conflicts
may arise about three main areas, paraphilia, sexual dysfunctions, and sexual orientation.
(1) Paraphilia: paraphilias are “atypical sexual interests.” According to DSM-5 they can
be classified as disorders only when “people with these interests: (i) feel personal dis-
tress about their interest, not merely distress resulting from society’s disapproval; or
(ii) have a sexual desire or behavior that involves another person’s psychological dis-
tress, injury, or death, or a desire for sexual behaviors involving unwilling persons
or persons unable to give legal consent” (American Psychiatric Association 2013a).
From a “natural law” perspective, paraphilias subvert the (alleged) natural order. This
implies that the goal of the treatment should be to achieve a “normal” (viz. in accord-
ance with natural law) sexual life. Yet not only this goal is often unrealistic, but it
is also ethically questionable. The non-Catholic psychiatrist could find it difficult to
explain to a Catholic patient that the ideal of “conjugal chastity” (Catechism of the
Catholic Church 1997, art. 2349) does not correspond to any mental health standard
and does not concern a physician, at most a spiritual director or a pastoral counselor.
A self-imposed “conjugal chastity” would even risk perpetuating forever a paraphilic
disorder by turning it into an “underground river,” which could emerge again in any
moment. For the same reason, the Catholic psychiatrist should think twice before
setting “conjugal chastity” as the end point of the treatment. Here there is, however, a
further complication. While any psychiatrist would agree that imposing on a patient
one’s own morals would not be in line with professional ethics, in the case of para-
philia a Catholic psychiatrist could argue that the notion of “normal sexual life” is
35
Matthew 22:34–40, Mark 12:28–31, Luke 10:25–37.
36
John 8, 3–11.
37
Matthew 5, 27.

not dictated by any moral perspective. This depends on the inherent ambiguity of the
physicalist notion of “natural law,” which aims to be at the same time scientifically
and ethically normative. This situation admits only one ethical solution, “the Sabbath
was made for man, not man for the Sabbath,”38
the good of the patient should always
prevail. The belief on the existence of a moral order grounded in human biology is
not a truth of faith, but it is a philosophical perspective. If the psychiatrist privileged
her philosophical perspective at the expense of the patient, she would behave as those
scribes and Pharisees hypocrites, who “tie up burdens that are heavy and unbearable
and lay them on people’s shoulders.”39
(2) Sexual dysfunctions: they include a vast array of disturbances, ranging from sexual
interest/arousal disorders, to delayed and premature ejaculation, erectile disorders,
and so. Working with patients with these disorders could cause ethical distress in the
Catholic psychiatrist because of two reasons. First, it could happen that the patient
who is seeking help is not engaged in a Catholic marital situation. Think for instance
a patient who is suffering from premature ejaculation within the context of a “free
union” or a civil marriage, or with occasional sexual partners, or with a homosexual
partner. From a Catholic standpoint, is the psychiatrist entitled to meet the request of
these patients? The Catechism reads “carnal union between an unmarried man and
an unmarried woman … is gravely contrary to the dignity of persons and of human
sexuality” (art. 2353). Yet the question is badly formed. When sexual dysfunctions are
not due to an organic cause, they are often symptoms of more complex and nuanced
mental conditions. A psychiatrist—no matter whether she is Catholic—should
always investigate on these reasons and make clear to the patient that a sexual dys-
function is not a “mechanical” problem that just need a technical fix. In other words,
any good clinician would explore the reasons behind a sexual dysfunction. Moreover,
a good clinician would not prescribe for instance drug to treat erectile dysfunction
without a careful psychological assessment. If the patient accepts such a perspective,
I don’t see any major ethical problem to the Catholic psychiatrist. On the contrary, if
the patient demands only a rapid and technical fix to her sexual dysfunction, I think
that the ethical option would be to gently decline, and refer the patient to a colleague.
It could also happen that a patient, who seeks for a rapid and technical fix to her
sexual dysfunction, is engaged in a Catholic marriage. The Catholic psychiatrist
could erroneously think—given that the sexual dysfunction threatens the marital
union—that her duty is to fix as soon as possible the dysfunction, without investigat-
ing too much on psychological and relational causes. The psychiatrist could be even
concerned that a deeper investigation could lead to a crisis, or a dissolution, of the
marriage (think of case in which the sexual dysfunction masks unconscious homo-
sexual fantasies). Although this behavior would apparently meet both professional
standards and patient’s expectations, it would be hardly ethical. The “ideological”
concern to cement a religious marriage would risk indeed prevailing on the good of
the patient. Sexual dysfunctions can be symptoms of deep relational uneasiness, even
severe mental disturbances, overlooking an accurate diagnosis in order to preserve a
38
Mark 2:27.
39
Matthew 23:4.

religious marriage would be definitely unethical (American Psychiatric Association
2013b, sect. 2 and 8).
(3) Sexual orientation: both gender dysphoria (former “gender identity disorders”)
and homosexuality are usually expected to raise ethical problems to the Catholic
psychiatrist.
The main ethical conflict in the case of gender dysphoria is when a patient is seeking sex
reassignment therapy; because a Catholic psychiatrist could legitimately think that
individual sexual constitution is part of the whole God’s design40
and should be
respected by humans.41
The problem is very close to the one we have met discuss-
ing the notion of natural law, say, a misunderstanding between moral and scientific
norms. Ultimately, the concept of sex reassignment therapy is grounded on gender
theories. All gender theories—although varied—share the conviction that gender
and sex are two different things (Butler 1990). This is a legitimate and interesting
point of view, which is not however a scientific theory, rather it is a philosophical
perspective. For the same reason, in clinical practice, a Catholic psychiatrist should
not confuse the natural law doctrine with scientific evidence; she (or any other psy-
chiatrist) should not feel obliged to espouse gender theories, as they were the medi-
cal state-of-the-art. If a Catholic psychiatrist thinks that sex reassignment therapy is
unethical, she could simply refer the patient to a colleague. What is paramount is that
the psychiatrist always avoids criticizing or stigmatizing the patient, which is never
ethically tenable (American Psychiatric Association 2014, N.1.J).
Homosexuality is an over-debated issue. The Catechism reads “homosexual acts are intrinsi-
cally disordered. They are contrary to the natural law” (art. 2357). Once more, the physicalist
notion of natural law makes things, in my opinion, pointlessly complicated. Not only is it
highly debatable that homosexuality could be considered out from the “natural order,”42
but
any clinical psychiatrist knows that homosexual fantasies and desires (if not behaviors) are
part of “normal” human sexuality. A Catholic psychiatrist—based on Paul’s writings,43
the
Old Testament,44
and the Church’s moral teaching—could legitimately argue that homosex-
ual acts are an execrable moral fault, but this does not make them abnormal or psychiatric
symptoms. When a patient asks to be helped to change sexual orientation, from homosex-
uality to heterosexuality, the psychiatrist (also the Catholic psychiatrist) should reject this
request, not only because this is the professional ethical standard (American Psychiatric
Association 2014, N.1.J), but also because for a Catholic physician it would be unethical to
treat conditions “as medical when, in fact, they are not medical-health in nature. In this case
the person is not helped to perceive the exact nature of their problem, thus misleading them”
(Pontifical Council for Pastoral Assistance to Health Care Workers 1994, n. 57).
40
Genesis 1, 27.
41
Matthew 19, 4–6; Mark 10, 6–9.
42
There are as many examples of homosexual behaviors among animals (Bagemihl 1999) as it is
ridiculous to say that it is a behavior contrary to the natural order.
43
Romans 1:26–27, 1 Corinthians 6:9–10, Timothy 1:9–10.
44
Genesis 19; Leviticus 18 and 20.

What should a Catholic psychiatrist do when she is asked to treat a psychiatric patient who
is actively engaged in homosexual activities and relations? The answer is easy and straight-
forward, she should treat this patient as any other patient, not only because refusing treat-
ment because of patient’s sexual orientation would be against professional ethical principles,
but also on the basis of Catholic moral standards. Better than any scholarly argument, one
could simply quote Pope Francis: “During the return flight from Rio de Janeiro I said that if
a homosexual person is of good will and is in search of God, I am no one to judge. By saying
this, I said what the catechism says. Religion has the right to express its opinion in the ser-
vice of the people, but God in creation has set us free: it is not possible to interfere spiritually
in the life of a person. A person once asked me, in a provocative manner, if I approved of
homosexuality. I replied with another question: ‘Tell me: when God looks at a gay person,
does he endorse the existence of this person with love, or reject and condemn this person?’ ”
(Spadaro 2013).
Right to Life
“The intrinsic finality of (physicians) profession is the affirmation of the right of the human
being to his life” (Pontifical Council for Pastoral Assistance to Health Care Workers 1994,
n. 48). Right to life is a well-established principle in Roman Catholic ethical teaching. It
is rooted in the Old45
and New46
Testaments, and in the Tradition. The Catechism reads
“Human life is sacred because from its beginning it involves the creative action of God and
it remains forever in a special relationship with the Creator, who is its sole end. God alone is
the Lord of life from its beginning until its end: no one can under any circumstance claim for
himself the right directly to destroy an innocent human being” (Catechism of the Catholic
Church 1997, art. 2258). Although non-violence appears to be almost an absolute principle in
Jesus’ teaching47
, the Catholic Tradition has always accepted three exceptions, say, legitimate
defense, just (defense) war, and capital punishment, which is considered as a societal “legiti-
mate defense,” whose necessity today is however “very rare, if not practically non-existent”
(Catechism of the Catholic Church 1997, n. 2267). The Right to Life is relevant to psychiatric
clinical ethics mainly in three contexts:
(1) Capital punishment: the WPA Ethical Standards for Psychiatric Practice reads,
“Under no circumstances should psychiatrists participate in legally authorized
executions nor participate in assessments of competency to be executed” (World
Psychiatric Association 2011, p. 3). This is definitely in line with Roman Catholic
moral standards. A Catholic psychiatrist should refuse to participate not only in the
execution but also in assessment of competency, notwithstanding the different opin-
ion of the Ethics Committee of the American Psychiatric Association, which argues
that “it is ethical to provide a competency examination” (American Psychiatric
Association 2014, G.1.c).
45
Exodus 20:13; Deuteronomy 5:17.
46
Matthew 5:21, Matthew 15:19, Matthew 19:19, Matthew 22:7, Mark 10:19, Luke 18:20, Romans 13:9, 1
Timothy 1:9, James 2:11, Revelation 21:8.
47
Matthew 5:21, Matthew 19:19, Mark 10:19, Luke 18:20.

(2) Euthanasia: Catholic moral teaching affirms that euthanasia, as well as medical
assisted suicide, is always unethical, while psychiatric professional ethical standards
are a bit more nuanced (World Psychiatric Association 2011, p. 1). A Catholic psy-
chiatrist should refuse to participate in, and actively oppose, any procedure, which
may lead to the decision to suppress the life of mentally incapacitated people, and
people suffering from mental disorders, who are unable to express a valid informed
consent. In addition, when a competent patient asks to be assisted to commit suicide,
a Catholic psychiatrist should refuse, as she should refuse to participate in any related
procedure. However, in the situation where a psychiatrist is requested to provide a
pharmacological treatment to a dying person in order to mitigate physical sufferance,
psychological distress, and make less painful the event of death, this kind of assis-
tance is permissible. “In so far as the procedures do not aim directly at the loss of
consciousness and freedom but at dulling sensitivity to pain, and are limited to the
clinical need alone, they are to be considered ethically legitimate” (Pontifical Council
for Pastoral Assistance to Health Care Workers 1994, p. 71).
(3) Abortion: The Catechism (Catechism of the Catholic Church 1997) reads “Life must
be protected with the utmost care from the moment of conception: abortion and
infanticide are abominable crimes” (art. 2271). Catholic psychiatrists are requested
not to perform abortion, which would be, however, outside their professional com-
petence. The Catechism also specifies “formal cooperation in an abortion constitutes
a grave offense. The Church attaches the canonical penalty of excommunication48
to this crime against human life.” (art. 2272). This means that a Catholic psychiatrist
should also avoid providing her expertise to medical teams that perform abortion.
This leads to a question, would a Catholic psychiatrist be morally allowed assess-
ing mental conditions of a woman, in those jurisdictions where such an assessment
is legally mandated in order to terminate a pregnancy? When this procedure is a
mere legal formality, a bureaucratic green light before pregnancy termination—as
it often occurs—I think that the psychiatrist should decline. On the contrary, when
pre-abortion psychological assessment is a sincere social effort to assure that the
decision for an abortion is intellectually robust, I think that professional duties pre-
vail and the psychiatrist should accept to visit the patient. The psychiatric interview
could also be one of the last opportunities offered to a woman to change her mind.
A difficult question concerns the way in which a Catholic psychiatrist should respond to a
non-Catholic patient who raises elective abortion in the context of therapy. From a Catholic
perspective, this is almost a Tarasoff-type49
situation. If abortion were (or is) a murder, one
would be (or is) confronted with same dilemma that arises when a patient shows homicidal
intentions, or acts out behaviors that could seriously damage other people. This ethical
dilemma is made still more complex by the fact that abortion is legal in most western juris-
dictions, and this prevents the psychiatrist from relying upon a legal escape hatch. Actually
the psychiatrist is trapped in a Catch 22 situation; either she becomes morally responsible
48
Excommunication is a censure, which prevents a person participating in the liturgy in a ministerial
capacity and receiving Sacraments.
49
Tarasoff vs Regents 551 P. 2d 334 (1976).

to allow a murder (or what she thinks it is a murder); or she tries to prevent the abortion
by using persuasion, psychological pressure, soft coercion, and so, disregarding her pro-
fessional duty to respect the patient’s value system and freedom (not to mention that very
often these pressures fail to achieve their goal). There are neither easy solutions, nor estab-
lished guidelines. Catholic psychiatrists deal with this dilemma in different ways, accord-
ing to different social contexts, and different cultural environments. However, there are a
few ethical caveats that need to be considered. First, the psychiatrist should avoid feeling
herself endowed with any salvific mission, which would be only a way to gratify herself by
emotionally exploiting the patient’s situation. Second, the psychiatrist should be self-honest.
Too many Catholics, included physicians, follow a double moral standard about termina-
tion of pregnancy; one for personal matters and one for professional business, becoming
like “whitewashed tombs, which look beautiful on the outside but on the inside are full of
the bones of the dead.”50
Third, the psychiatrist should give up the arrogance of wanting to
find the just solution. Taking care of other human beings always means having “dirty hands.”
A Catholic psychiatrist is ethical not because she respects the Catechism, but because she
respects (and care for) her patient51
.
Psychotherapy
Ethical conflicts between Catholic faith and psychiatric professional practices could also
occur in psychotherapies. In the previous sections, I have briefly enlightened those issues
that are specifically related to psychodynamic psychotherapies and psychoanalysis. As per
ethical issues related to other kinds of psychotherapies, either they have been already dis-
cussed under sections 6.1, 6.2, 6.3, or they are not directly related to any specific conflict
between Catholic morals and psychiatric practice. There is probably only one issue missed
in ethical discussions raised by the situation in which a non-Catholic psychiatrist takes in
therapy a Catholic cleric. For instance, a priest could seek a treatment because of the occur-
rence of panic attacks or a monk, or a nun, could suffer from serious depressive disorders.
These symptoms could mask, or be related to, various psychological conditions, e.g. panic
attacks are often related to unconscious homoerotic phantasies, and depressive disorders
could hide deep, inhibited, aggressive feelings. The psychiatrist should respect patients,
notably she should avoid confronting them violently with their mental contents, particularly
when they explicitly contrast with patients’ moral and religious beliefs. 52
Of course respect-
ing does not mean that one could not discuss psychological meanings, but this should never
be done in derogatory ways, or hurting feelings of modesty, or humiliating the patient. If
during the psychotherapy the patient experiences a priestly crisis, the psychiatrist should
become over-vigilant about her countertransference. Actually, this is a very delicate situa-
tion, both clinically and ethically, and it is paramount that the psychiatrist avoids either miti-
gating or intensifying the crisis, as it could happen if the psychiatrist is not fully aware of the
50
Matthew 23, 27.
51
Luke 7, 44–47.
52
When I was a young psychoanalyst in training, my supervisor used to teach that disturbing mental
contents are like champagne corks, they must be eased out very slowly, with a gentle, almost silent thud.
He used to add that this was not only a technical rule but also an ethical norm.

Conclusions 555
anxiety that the patient’s religious crisis could generate in her.53
Moreover the non-Catholic
psychiatrist should respect confessional secrecy (a priest cannot divulge for any reason what
he has learned during a confession) although this could be problematic, notably in a psycho-
dynamic psychotherapy (Gemelli 1955, pp. 139–140).
Cognitive Enhancers and Cosmetic Psychiatry
According to the Charter for Health Care Workers (Pontifical Council for Pastoral Assistance
to Health Care Workers 1994) a Catholic psychiatrist should not prescribe psychoactive
medications to increase performance or to enhance cognitive capacities in her patients (n.
103). The reason of this principle would be that, used in such a way, psycho-pharmaceuticals
become similar to narcotics, whose usage is morally illicit because “it implies an unjustified
and irrational refusal to think, will and act as free persons” (n. 94).
Conclusions
Religions are complex phenomena, which include doctrines, philosophies, ritual, structures,
communities, narratives, popular beliefs, power relationships, and so. By examining Roman
Catholic perspectives on psychiatric ethics, I have focused on official teachings, statements,
and scholarly debate. Is this enough? Probably it is not. Catholic culture (or cultures) is not
the same as Roman Catholic institutions and official documents. One should study, for
instance, Catholic popular piety and the role of popular practices in the traditional under-
standing of mental diseases. It would be interesting, for instance, to investigate the patron
saints related to mental illnesses in popular culture (Tomić and Salopek 2012) and the narra-
tives that surround these saints, as in the case of Simeon the Holy Fool, a monk and hermit
lived in Syria in the sixth century AD, who is traditionally considered the patron saint of
fools and, with an intriguing association, of puppeteers as well (Krueger 1996). One could
also investigate healing miracles concerning mental diseases. Narratives about miraculous
healings very rarely concern mental diseases—why? What different religious traditions have
been incorporated by regional Catholic subcultures? How did these different, and oldest,
religions contribute to shape Catholic perspectives on mental health? Briefly, one should
face the richness and complexity, which characterize any religious phenomenon. Cultural
analysis is essential to understand the way in which ethical themes are presented in the real
world, notably addressing mental health issues. Unfortunately, this was not possible in a
short chapter of a book.
53
Behind a psychotherapy between a non-religious psychiatrist and a religious patient, there is
sometime a silent fight about him who will first convert the other. If this fight is not analyzed, and the
patient experiences a religious crisis, this could cause either guilty feelings or omnipotent fantasies in the
psychiatrist.

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