Scruples and Psychology
Ad artis pastoralis essentiam spectat profunda et omnimoda hominis cognitio, quae studio sui ipsius et aliorum observatione obtinetur.-- Bishop Hartmann
The perennial problem of scruples is still with us. The zealous pastor and confessor, conversant with those sections of moral and ascetical theology which have a bearing on the problem, realizes that even with the best of effort he often makes little headway in curing scruples. The repeated explaining away of the anxieties does not eradicate them, and the encouragement and consolation offered seem to fail of their purpose. When the chronic scrupulant approaches, what is the confessor to do? Shall he brace himself to listen patiently and without interruption to the long story that is imminent? Or shall he ruthlessly cut short the hesitating recital of doubts and fears, and dismiss the scrupulant? The confessor realizes that such a procedure is at best merely a toleration of the evil. But what further aids are there? Or is the case of the scrupulant entirely hopeless?
Psychologists claim for their science great progress within the last few decades. If these claims be but partly true, we should expect psychology to throw some light on this mental state we know as scrupulosity. Now a number of priests have tested out various theories offered by psychologists to explain the phenomenon, and their efforts have not been entirely in vain. While no one theory alone seems to cover all cases of scruples, it has been found that several theories contribute something toward the solution of this difficult problem. We propose to discuss these theories here, and to state briefly the synthesis to which they have led. There was no deliberate a priori attempt to harmonize the various theories. Whatever unification there may be has resulted from actual practice over a considerable period of time.
It should be borne in mind that we discuss here only the psychological aspect of scruples. This consideration of purely natural causes in no way implies a denial of the supernatural. In a similar way typhoid fever, for instance, could be discussed from the medical standpoint, without for a moment denying that there are supernatural causes--the purposes of Divine Providence in allowing the disease. We are simply seeking aids to theology, not a substitute for that science. It is held that psychology can assist--not replace--theology in what has been aptly called the cura afflictorum.
I.
Nature Of Scruples, And Some Theories
We like to start with definitions. But in the matter of scruples this presents serious difficulties. Many of the former definitions are given from the theological viewpoint, and hence are unsatisfactory here.1 The psychological definitions are equally unsatisfactory, in that they often include theoretical implications regarding the causes and growth of this malady. Thus Gemelli, putting off the definition of scruples until the last chapter of his book, says: "Scruples are a form of psychasthenia, etc." 2
If we cannot readily give a definition at this point, we are at least familiar with the characteristics of scruples. Because of our acquaintance with them, it may even seem superfluous to mention these symptoms. But our purpose is simply to recall the principal stigmata of the scrupulous state, which must be borne in mind in any examination of theories. If a theory is to be at all adequate, it must explain not merely some of the characteristics, but all of them.
We know the scrupulous state principally by that condition which has been described by the terms " fixed ideas ", " irrepressible thoughts", Zwangsideen, etc., and which is now called by psychologists the state of "obsession ". This latter term is rather wide, and includes not only irrepressible thoughts, but irrepressible fears and impulses as well.
Obsessions are defined as " psychic elements which lack the normal faculty of disappearing under the influence of the will, and for that reason upset the normal course of the psychic processes."3 When some particular thought, fear, or impulse is constantly in the mind, we have an obsession. A melody, a poem, a problem may stick in the mind and refuse to be dislodged; that is a species of obsession. For no apparent cause thoughts and anxieties will thus persist, thoughts of friends or business, anxieties about health or success. The thought may take any one of numberless forms, but whatever its form or content, the persistency is the same. Though the victim may realize that the obsession is very foolish and without foundation, he cannot get rid of it. If he is distracted for a moment, it is only to return again to the obsession, which has all the time apparently been lurking in the background, ready to spring again into full consciousness.
Every scruple is such an obsession, but not every obsession is a scruple. For one may have obsessions about anything, whereas one is properly said to have scruples only when the obsession turns about a matter of faith or morals.
There are varying degrees of scrupulosity. At one end of the scale there is the rather temporary scruple, which is apt to come at times of physical or mental exhaustion, and occurs in more or less isolated and less persistent form. At the other end there is the chronic state of scrupulosity with all its lasting and serious disturbances. Between the two there are varying degrees of the evil. Hence not everything that is said of the extreme form will hold for the lesser disturbances.
Gemelli 4 has pointed out the peculiar complex of thought contained in an obsession. Analyzed, the scruple appears as a sort of loose syllogism, which contains a general principle totally beyond reproach, as "One must strive for perfection" or "All mortal sins must be confessed", and another particular judgment: "Perhaps I do not strive for perfection", "Perhaps I did not confess all mortal sins". The defect lies in that fatal "perhaps". The agony of doubt and anxiety that fastens itself on the victim, because of that "perhaps", is terrible. The obsession constantly returns. All manner of odd associations are set up, and any one of them readily calls up the obsession. Even the fear of its recurrence works toward the recall, and direct resistance usually only strengthens the obsession. (We observe a similar condition is some temptations.)
At times the patient seems to deceive himself. To the confessor it appears that the scrupulant actually recalls the obsession of his own accord. He clings to it; he seems to offer some kind of resistance to cure. Yet the patient usually sees that his fear is foolish, while he vainly tries to rid himself of it.
That terrible "perhaps" is the cause of the scrupulant's attempts to acquire certitude. When reasoning proves useless, he goes to all sorts of extreme measures, especially in severe cases. He resorts to vows and auguries, develops irresistible impulses and unreasonable fears. Such impulses are called manias, while the fears are known as phobias.5
There is another peculiar characteristic found in some cases of scruples. The patient at times readily changes the content of the scruple. When there seems to be some progress toward the solution of one anxiety or doubt, he promptly arrives with an obsession having another content, that is, turning on an entirely different point of faith or morals.
Much has been said too, in the literature on the subject, about this content of the scruple, and the writers often classify obsessions according to their content.6 Now the content, as we shall see, may prove very useful in diagnosis, and may indeed in itself be very important. But any classification of scruples on the basis of content is practically valueless.
Theories Of Scruples
It would be impossible to enter into a discussion of all the theories that have been advanced to explain the obsessive states. We propose to consider only those rather recent theories, which have apparently contributed something toward the final solution of the problem. Accordingly we have the:
- Theory of "Psychasthenia";
- Theory of "Neurasthenia ";
- Theory of "Parataxis of Anxiety".
We do not propose to enter into the theories of the psychoanalysts. The different psychoanalysts and schools of psychoanalysis hold such divergent views that it is almost impossible to give the psychoanalytic theory in all its variations. Moreover, there are grave objections to these theories. Quite apart from the repulsive "pansexual" character of their explanations, serious difficulties have been raised on many points.7 The principal value of psychoanalysis seems to have been the calling into prominence of factors which were formerly too often disregarded, and any contributions of real value made by this method have been taken over by other authors.
The Theory of "Psychasthenia"--This is the theory of Janet, Eymieu, and Gemelli.8 According to them, scrupulosity is a manifestation of psychasthenia, which is a distinct disease entity. It is classed among the psychoneuroses, states of ill health whose symptoms are produced psychologically. Psychasthenia rests on two concepts, viz: the "hierarchy or gradation of psychological phenomena", and the "tension of the vital force ". Psychological phenomena are graded according to difficulty, ranging from mere daydreaming, as least difficult, to such things as are involved in speaking before an audience or performing other important duties in public. Eymieu adds at the top of the list, as most difficult of all, "moral actions", or the practices of religion. Their difficulty is determined by the degree in which these processes bring the subject in touch with reality; that is, the more attention one must pay to one's surroundings when performing some action, the more difficult does that action become. This contact with reality, however, is not absolute, but relative and subject to change. "Vital force" is the force that brings into being vital acts, that is, "life understood as having a certain intensity, and in a certain state of tension".
When the tension of the vital force is not adequate to meet the difficulty of establishing the contact with reality, mental processes are no longer energized in a normal way, and the subject is unable to perform the acts at the top of the scale.
He loses contact with reality, and develops obsessions. It must be noted that the lack of equilibrium between vital tension and difficulty may be either because the difficulty is too great, or because the tension is sunk too low. Even though the vital tension may be normal, the same disproportion will hold if the needs or difficulties be too much increased. However, the various circumstances that augment the difficulty or lower the tension are not the causes, but only the occasions for the manifestation of psychasthenia. The real cause of the disease is unknown. While it is not hereditary in the strict sense, heredity is a principal factor.
Such is, briefly, the theory of psychasthenia. This account of the cause of obsessions has not failed to meet with serious objections, which go to show that it alone is not an adequate explanation. Binet and Simon9 object that the contact with reality cannot be the measure of difficulty in psychological processes; otherwise abstract thought would be far easier than mere looking into a show-window, whereas as a matter of fact the former is far more difficult. Bergmann10 does not think that the state of obsession can be considered a separate disease entity, inasmuch as obsessions occur in other diseases, neurasthenia, hysteria, paranoia, etc. Jos. Frobes11 points out that the theory of psychasthenia fails to explain some obsessions which demand just as much energy as the carrying out of the actions they are said to replace. Then there is the objection of E. Boyd Barrett12 that the theory does not explain the source of energy of the obsession--"Why should this particular idea become more active than others?" He adds that the trouble does not seem to be so much a lack of energy as rather a maldirection of energy, since much of it goes to keep aflame the worry.
But there are still further difficulties, which have been revealed in practice. Even Eymieu's adding of activities of the moral order to the "hierarchy of phenomena" does not free the concept from objection. For we see that individual scrupulants find different things difficult, while performing with ease such as are higher in Janet's and Eymieu's scale. Nor do we get over the difficulty by saying that it is not something absolute, but relative. If we are to make a separate list to fit each person, we frustrate the purpose of the list. For then we are simply pointing out which things are more difficult for such a person, without giving the cause.
The theory, moreover, does not explain the peculiar resistance met in the patient, nor the shifting from one scruple to another. As these are facts we meet in the handling of scrupulants, we expect of an adequate theory that it will explain them satisfactorily.
The theory of psychasthenia, then, is not of itself adequate. But it gives us the concept of at least a psychasthenic factor in the problem, and this is a real contribution, as we shall see later.
Somewhat akin to Janet's theory is that of Dr. Vittoz,13 although it also resembles slightly the next theory, that of "neurasthenia". According to Vittoz, the obsession is due to "loss of cerebral control", which permits ideas from the unconscious to invade the sphere of conscious life. Vittoz claims that the content of the scruple is of no consequence.
This form of the theory meets with objections. While claiming to disregard the content of the scruple, it yet indicates that some important thought with much emotional energy breaks loose from the unconscious and finds its way into consciousness. In other words, the theory admits what is known to psychologists as a complex, or at least a pathological association. To this we shall return later. Here it is sufficient to point out that Vittoz's theory is close to contradiction. For if the content of the scruple has any such significance, it cannot possibly be ignored.
The Theory of "Neurasthenia"--W. Bergmann14 says that obsessions should not be labeled psychasthenia. The obsessive states are not separate disease entities, but appear in hysteria, neurasthenia, epilepsy, etc. While agreeing that there is a psychasthenic factor in the trouble, Bergmann maintains that this is in turn caused by the weakness of the organism, that is, of the nervous system of the person affected. Neurasthenia, according to him, is the ultimate cause of the trouble, though fright and worry, as well as lack of sleep, effeminacy, dissipation, etc., may weaken physical and mental power. Neurasthenia is a functional nervous disturbance, that is, there is no organic defect, but the nervous system does not function properly. The scruple arises when the will power and the intellectual processes, weakened by this disturbance, cannot control the instinctive movements, which have their peculiar force because they were, at the time of their origin, thrust into the unconscious.
Bergmann's contribution is not to be overlooked. His insistence on the element of nerve fatigue, and his description of the vicious cycle by which body acts on mind and mind on body indicates an important point.
On the other hand this description of the cycle does not prove that the beginning is the corporal rather than the mental condition. The theory, moreover, does not explain the peculiar resistance met in the patient, nor yet the shifting from one scruple to another with a different content. It might be noted too that Bergmann, while refusing to class obsessions as a separate disease entity called psychasthenia, practically falls into the same error by classing them, in the last analysis, under neurasthenia. When he says that obsessions occur in many diseases, he indicates that the true explanation must be more fundamental than that which he himself gives.
The Theory of "Parataxis of Anxiety"--This is the theory of Dr. T. V. Moore, explained in his book Dynamic Psychology.15 As the title indicates, this work does not treat exclusively of the obsessive states, but is an introduction to modern psychological theory and practice. It would be unfair to see in the few paragraphs on scruples a full explanation of the malady. These paragraphs must be viewed in the context of the entire volume.
According to Dr. Moore there are many ways of reacting to a difficulty. A normal impulsive drive to react to a mental difficulty in some definite way he calls a "psychotaxis". If the impulse becomes abnormal, or its execution shows such abnormality, it is a "parataxis". In all these tendencies, whether normal or abnormal, there are mechanisms that are partly conscious, partly unconscious, with all shades of transition between the two. Over and above all these there is, of course, the rational readjustment: a voluntary effort made under the influence of intellectual insight and ideals of conduct.
One of the abnormal reactions is the parataxis of anxiety, an impulse to consider over and over again unpleasant possibilities, which is abnormal because of its intensity and excess. A factor of these states of anxiety is an apparently irreconcilable conflict between incompatible desires. If neither side is chosen, the anxiety is likely to attach itself to things in which the patient can freely admit his interest. If one or the other desire is more or less indulged, the anxiety often remains associated with that desire. It must be borne in mind that desire is not used here in the same limited sense as in moral theology; it does not here necessarily imply an act of the will. Desire is defined as "a craving that we experience to seek or produce a situation in which impulsive tendencies may be satisfied, or natural wants may be supplied."16 It is only when we are both conscious of the desire and will it that we have desire as used in moral theology.
Scrupulosity is the form that the anxiety type of reaction sometimes takes. The mechanism of this condition is probably not uniform. One mechanism is a modification of a crude form of exhibitionism, that is, of a perverse sexual tendency toward exposing the person. The modification consists in this, that it takes the form of rehashing sexual offenses over and over again, or more often in simply repeating confessions. The tendency to persevere in anxiety may be due to hereditary factors, and may be further strengthened by abnormal conditions of will-functioning.
This is but a very brief outline of the doctrine. The theory offers an advantage over the previous ones noted, in that it gives the basis of an explanation of the shifting from one scruple to another. Such a shifting can be understood in the light of a present conflict, to which the anxiety is a reaction. As long as the conflict continues, the patient will react, and if there be occasion he will simply shift to a scruple with another content.
This theory, however, does not expressly give a total explanation. It is stated that the mechanism of scruples is not uniform, and only one mechanism is given, whereas a full explanation would demand a discussion of other mechanisms. It should also explain why, in the presence of a conflict, the patient reacts by the parataxis of anxiety rather than by another parataxis. But the deficiency is due to the fact that scruples are not treated ex professo. Consequently no full explanation is intended, as would be the case in a monograph on the subject.
Relation Between These Theories
At first sight these theories seem widely divergent. This is partly due to the fact that they are stated here in the barest outline, and have been rather arbitrarily named according to the factor on which they place the principal stress. Actually the theories have some things in common, but with varying emphasis on different points. Thus the theory of psychasthenia admits as secondary factors excessive work and sickness (neurasthenia?) and the difficulties of life (mental conflict?). The theory of neurasthenia admits a psychasthenic personality, and factors in the unconscious. Dr. Moore too indicates, as contributing causes, will defects (psychasthenia?) and abnormality of mental life (neurasthenia?). This already points the way to the synthesis, which has grown out of their application in practice--the composite theory, which will be the subject of the next part.
II.
An Attempt At Explanation
It seems doubtful whether scrupulosity should be considered as a separate disease entity. For scruples manifest all the marks of obsessions, and these occur in various disturbances. Moreover, the desire to fit all the details into one general disorder rules out many points of the complex matter under discussion, and tends to suppress points that will not fit. Consequently the fixing and labeling of a disease entity entails the danger of making individual cases fit previous standards, so that there may indeed be classification, but no real explanation, and no treatment of real value. Thus it comes that those who have attempted such isolation of obsessions as a separate disease entity have really failed to give a complete explanation.
More likely the matter should be looked upon rather as (a) a type of individual, (b) reacting in a characteristic way (c) in the face of certain conditions. This point of view was introduced in regard to mental disturbances by Adolf Meyer,17 and was taken up by Dr. Hoch18 and Dr. MacCurdy.19
The various theories have given us several factors or elements in scrupulosity. How will these fit into this point of view?
The Element Of Psychasthenia
While the theory of psychasthenia does not give an adequate explanation of the scrupulous state, we cannot deny that it offers something in explanation. Though we must reject, as being inadequate, the concept of psychasthenia in the sense of Janet, it seems necessary to retain the idea of "a person of psychasthenic type". For we find that scrupulants very often show defects in volition, and further inquiry frequently reveals that such defects had manifested themselves long before the obsessions began. Thus we find disinclination to effort, proneness to discouragement, no ability to make decisions, no carrying out of resolutions made, extreme sensitiveness, hesitation) lack of courage. All these marks go to make up a picture of a personality which Meyer calls the "psychasthenic personality". He gives a vivid description of this type: "These persons are aboulic, undecided, hesitating, timid, not combative, not able to take the world as it is, idealistic, longing for love and kindness, and correspondingly, with ways that solicit a kindly and just attitude; they are misunderstood and meek; easily led and misled; they need stimulation and are apt to yield without decision, notwithstanding their usually superior intelligence and vivid imagination. This leads to a life given to avoiding troubles, decision and action. The child avoids active plays and is perhaps encouraged by solicitous parents; the choice of occupation is away from the trying struggle. The young man or woman shirks responsibilities, is passive in questions of marriage and choice of work. New situations, a threat, or a joke, examinations, new religious duties, or some emotional shock prove too much, and bring forth the symptom-complexes so well described by Janet."20
This may seem a grave accusation against the character of the scrupulant. Indeed, it is a description of the extreme type of the psychasthenic personality, a degree, which is not found in every case of scruples. But in severe and chronic cases of scrupulosity this type has actually been found.
What produces such a personality? Probably heredity is a factor, but unfortunately a rather unknown and immeasurable factor. In addition there are other causes, especially lack of training or faulty training. Abnormality of the intellectual life, the lack of an adequate life-plan, must be included.
Disturbances in emotional life also tend to intensify this defect of personality. For the lack of affect lessens the desirability of any act and does not furnish the will with a strong motive, whereas excessive emotion may interfere with the normal exercise of will-power.
These latter factors indicate that the various elements causing the scrupulous state influence one another. But over and above such influence, and by all accounts chronologically prior to it, there seems to be this defect, which is called the psychasthenic personality. In a well-developed and serious case of scrupulosity this factor is usually present.
The Element Of Neurasthenia
While Bergmann's explanation of scruples is hardly adequate, it serves to point out an important element in the difficulty. We find in scrupulosity disturbances in the intellectual processes, especially abnormal speed in the formation of associations. This is seen in the speech of the patient, which often seems rather disconnected, due to the fact that the intervening associations are not expressed, and do not even seem to have come into full consciousness. We find too the abnormal irritability and tendency to exhaustion which are the marks of the functional nervous disturbance known as neurasthenia.21
It is not always clear that this condition preceded the state of obsession. Even when it seems to have preceded, the influence of the other elements certainly augments it. This need not be surprising, since we know that emotional states have a very marked effect on the organism) due to the greater activity of various glands. The stimulation of the adrenal glands in violent emotion, for instance, secretes adrenalin into the blood) with consequent increase in the amount of blood sugar. A prolonged disturbance of emotional life, such as accompanies the doubts and fears of the scrupulous state, cannot be without its unhappy effect.
The ultimate causes of neurasthenia are many.22 Various diseases, disturbances in metabolism (that is, in the building-up and breaking-down processes within the body), dissipation, soft living, overwork or monotonous work, and the influence of the obsessions themselves, are all listed as causes.
In the case of more or less isolated scruples this element of neurasthenia may be the whole explanation. These are the cases in which a person, normally free of scruples, falls into them in times of exhaustion, etc. There is much truth in the observation of O'Malley: "When nervousness takes the form of religious scrupulosity in school children and novices, do not immediately apply a moral theology to them; call in a physician who has common sense, because there is a nervous scrupulosity which is more frequently met with than the purely spiritual form."23
In the chronic state of scruples some nervous disturbance usually occurs, whether it have preceded the malady or be really the result of the other factors in the trouble.
The Element Of The Conflict
The theory of the parataxis of anxiety, outlined previously, calls attention to the element of the conflict as a factor in obsessive states. This conflict, if it exist, is understood to be a conflict between apparently irreconcilable desires, that is, the fulfilment of one desire would apparently rule out the possibility of having the other fulfilled. Actually the desires may not be irreconcilable; it is sufficient that to the subject they appear so. It must be well understood that "desire" here is not desire in the theological sense--actus voluntatis quo quis deliberate intendit opus patrare. Desire here is practically synonymous with tendency or inclination.
There is evidence that such a conflict exists in cases of scrupulosity. The patient usually sees the folly of the obsession, but still he cannot throw it off. This would indicate the presence of some factor of which he is not fully conscious. But the strongest reason, from the side of theory, is the fact that the patient actually seems to resist cure. If there is such a conflict, and the scrupulosity is a parataxis, an attempt out of the difficulty, why should the patient not resist cure? Even though his reaction is not an adequate solution of the difficulty, it is that attempt at solution in which the patient has taken refuge. Were even this denied him, he would be thrown back again to the original conflict. Therefore the scrupulant clings to his reaction. Inasmuch as these reactions, according to Dr. Moore,24 have mechanisms that are partly conscious and partly unconscious, it would seem that the resistance too is not fully conscious.
In point of fact, actual conflicts have been found in many cases of scruples. When the conflicts were satisfactorily solved, the patients recovered.
But is the conflict a factor in every case of scruples? It may be urged that these conflicts are not always found. But the failure to find the conflict does not prove it non-existent. The process of uncovering such a conflict is difficult, and even an expert may fail when dealing with these mental processes.
It may be urged too that before such conflicts were ever heard of people were cured of scruples, and that even now they sometimes recover though no such disturbance be found. The fact of such cures is certain. But the cure may be due to any one of a number of things. Instruction has often effected the solution of a conflict that remained hidden throughout, by taking away one side of the apparent conflict. This is particularly true where lack of knowledge has led the patient to consider something sinful which actually is no sin. Again, training of the will may bring about a cure. If the will be sufficiently strengthened, the patient is sometimes able to solve the conflict for himself. Finally, the changing conditions of life may effect a solution, by removing one side of the dilemma. A young man who is torn between the inclination toward matrimony and what seems to him to be a duty to enter religion is relieved of the dilemma when he is declared unfitted for the religious state. There is no certain evidence that no conflict existed in such cases, though it may not have been uncovered.
The Reaction
So far we have three elements or factors: the psychasthenic personality, the nervous disturbance, and the conflict. We have moreover three elements, which are not independent, but mutually influence each other, so that with the continuation of the trouble they are still more intensified.
But does this give a complete explanation? In other words, granted that a person of psychasthenic type, with a disturbance in the nervous system, finds himself confronted by a conflict, does it follow that he reacts with the parataxis of anxiety? If so, why does this parataxis, this mode of reaction, follow rather than some other?
Such a person falls into this particular parataxis of anxiety because practically that is the only reaction open to him, principally on account of his very personality. A rational adjustment, a voluntary effort at solution, is ruled out. For if the conflict appears absolutely as a dilemma, either side is undesirable; if the choice supposes only the giving up of one desire or inclination, the psychasthenic has not enough willpower to make the choice. Compensatory reactions, the seeking of compensation for the desire denied, supposes the choice already made, while the patient is unable to make that choice. The same thing holds for the reaction known as sublimation, the seeking, in pleasures of a higher order, of satisfaction for desires denied. Alone the patient can hardly make a choice between the original inclinations and then seek compensation for that inclination which he has given up.
There are other reactions known as defence reactions. Thus we have the reactions of forgetting, of excitement, of transfer of blame. We readily forget such people or events, as we do not care to remember; we plunge into excitement to forget, if possible; we blame others for our failures, to divert the blame from ourselves. Against external difficulties there is the defence reaction of incapacitation, the developing of disabilities, which will excuse from what is difficult. There is also what is known as negativism, cutting oneself off from contacts with fellow men, and as it were shutting oneself in with one's own thoughts.
Now these defence reactions result from some unpleasant situation, whether internal or external. Incapacitation and negativism are reactions to difficulties from without, while the conflict is within. But why not the other defence reactions? Inasmuch as the difficulty in the case under discussion is not merely a single unpleasant situation but a conflict between two tendencies or desires, these defence reactions offer even less, by way of solution, than does the reaction of anxiety. To plunge into excitement may drown an unpleasant single situation, but hardly a constant conflict and even if it could, the patient's own personality, his defective volition, is hardly sufficient for him to make the effort. He can hardly forget a present conflict permanently, and he cannot well transfer blame when he himself has not been blamed, whether openly or by mere insinuation. Sometimes indeed such a defence reaction may follow, and then there is no scrupulant. But usually these reactions are passed by in the situation we are here discussing.
So the only reactions left are those of depression and anxiety. But since depression usually results from something in the past, whereas the conflict is in the present, the only reaction finally left to the psychasthenic is that of anxiety. That this anxiety then take the excessive form called the parataxis is not surprising. A more normal reaction of anxiety, which would be called a psychotaxis, supposes that the impulse to consider the matter over and over again be kept within normal bounds. Unless a solution is found within a short time, the anxiety becomes abnormal, and so we have that form which is the parataxis--the state of obsessions and scruples.
But now what of the content of the scruple? Granted that the reaction is one of anxiety, why anxiety on any particular point? Dr. Moore 25 has pointed out that, in case of a conflict, if neither desire is indulged, the patient is apt to attach the anxiety to something in which he need not be ashamed of his interest; but if one or the other desire is indulged to some extent, the anxiety remains associated with that desire. This needs further elaboration.
The content of the scruple, that point about which the doubt and anxiety turn, has been found to be usually one of the following:
1. Something in which the person confesses great interest, and in which he need not fear to show his interest, as for instance the preservation of chastity. This was usually the case in those patients who readily shifted from one scruple to another.
2. That impulse to which the patient thinks he has consented. This is particularly true in the case of those who cannot distinguish between impulse or temptation and actual consent to such temptation.
3. That impulse to which the patient has actually at times consented.
4. A modification of an impulse. Dr. Moore 26 says that the impulse to exhibitionism (the perverse tendency to expose the person), if it be repressed, may seek outlet in a sort of sublimated exhibitionism, the rehashing of sexual offences or simply the repetition of confessions. It is important to note that such alleged offences may be only imaginary. Moreover it has sometimes been found that the content was a disguised expression of some other impulse, and that the patient was not even aware of the impulse and certainly did not recognize it in its disguised or "symbolic" form. Thus an impulse to appear humble sometimes shows up as an abnormal anxiety about pride. In some cases the connexion was not so obvious, as the content was connected with one of the desires by a more or less logical sequence through a whole series of intermediate steps. Hence at first sight the anxiety may seem to have absolutely no connexion with the conflict.
5. The matter of the scruple has sometimes proved to be something with which there is, as psychologists say, a pathological association. The patient has an abnormal fear of something or other. He may even know the event, which was actually the beginning of that fear, but not the connexion between that event and the present fear or phobia. When both the past event and the connexion are unknown to the subject, the affair is often called a complex. But when the connexion only is unknown, it is called a pathological association. A man may fear abnormally any enclosed space, such as the confessional, and the cause may be the fact that he was as a boy shut up in a dark closet. He may remember that event of his youth, but not realize that it causes his present fear. There is no normal reason for associating the two in the mind, so the abnormal connexion is called a pathological association.
Though these are the main mechanisms that seem to determine the content of the scruple, there sometimes occur variations and combinations. It follows that the content may or may not be significant. Whether it is of significance or is such that it can safely be neglected, can be determined only by that analysis which is part of the treatment.
Now how much of all this is in the consciousness of the scrupulant? Of course individual cases vary. But it was found that the patient was hardly ever aware of the connexion between his scrupulosity and the conflict, that is, he rarely realized the anxiety was a reaction to a conflict. In some cases the opposing tendencies, which made up the conflict were apparently known to the scrupulant, although even then they were not always thought of as conflicting. In some cases there was no evidence whatsoever that the conflict could be considered as falling within the consciousness of the individual. It was only after long probing that the conflict was brought to light, to the surprise of the scrupulant, who gave all evidence of being in good faith when he protested that it had all been unknown to him.
From all this we may evolve a sort of formula, which must of course be understood in the light of what has already been said.
Obsession arises when a person of psychasthenic type, especially in the presence of nervous disturbance, reacts by the parataxis of anxiety to an apparent conflict between mutually incompatible impulses or desires.
The scrupulous state arises in the same manner; but the content of the obsession is something related to faith or the moral law.
In cases of more or less isolated and less severe scruples, one or the other factor may be lacking.
III.
Treatment Of Scrupulosity
In order to proceed properly and safely with the treatment, it is necessary to diagnose accurately the patient's condition. Gemelli27 calls attention to the fact that scrupulants often seek a new confessor and simply lay bare their doubts and anxieties without really showing the scrupulosity, perhaps with the hope of finding someone who will consider those anxieties justified. For this reason rapid and accurate diagnosis is the first step in the treatment.
Diagnosis
It is of prime importance to distinguish between scrupulosity and other things with which it might be confused. Some of these distinctions can be readily made, but others present considerable difficulty.
Scrupulosity is of course not delicacy of conscience. The latter is that fear of offending God, which is a virtue; it does not show the perturbation and anxiety of the scrupulous state. Nor is the scruple simply an error of judgment, though a conscientia erronea, especially if it errs by being unduly severe, is sometimes loosely called a scruple. An error of judgment does not show the same grave disturbances, and when the error is corrected the matter is adjusted. Again, it is not difficult for the confessor to distinguish between scruples and temptations. The important thing is that the decision be made by the confessor or director, and be not left to the penitent.
Another important distinction to be made is that between scrupulosity and hysteria. 28 Hysteria shows itself by mental capriciousness, rapid change of moods, excessive emotional reactions. There is a sort of splitting-off of part of the patient's experience, a restriction of the field of consciousness. This shows itself in a sort of splitting of the personality. But this "double personality", which is complete in hysteria, is only partially evinced in obsession. Lewandowsky 29 maintains that in obsessions the irrepressible thought is in constant conflict with sound judgment, whereas in hysteria the product of the splitting-off process has a tendency to submerge the other. The line of demarcation between hysteria and obsession, he says, is that at which the patient is able to pass judgment on his symptoms. In the more severe forms of mental disturbance, the psychoses, the patient likewise no longer retains insight into his condition. The patient with obsessions regards them as something foolish or abnormal, whereas one who has a psychosis does not have such insight. In the matter of hysteria and the psychoses the help of a good psychiatrist is indispensable. To this point we shall return later.
There is one other abnormality against which the confessor must be on his guard. In rare cases he may find that scruples are actually assumed, more or less consciously, as a sort of compensatory reaction to difficulties, a bid for sympathy. These fictitious scruples do not show the disturbances characteristic of real scrupulosity. They do not ring true, and the craving for sympathy, rather than for certainty in the doubts, is soon evident to a careful observer. When the expected sympathy is denied, the reaction has failed of its object, and is then usually given up quite readily.
Further diagnosis of the trouble includes inquiry as to whether the scruple appears in more or less isolated form, the determining of the degree in which the different factors seem to be present, and the establishing, if possible, of the ultimate causes of the factors in the individual case. But this is all bound up with the treatment itself.
General Procedure
The success of the treatment will depend largely upon the ability of the confessor or director in these matters, upon his knowledge of mental functioning, his powers of observation, his sympathetic insight. It will depend too upon the authority of the director, such exercise of authority as will command confidence and trust, and above all obedience. Haste, impatience, lack of sympathy--these will be fatal to this authority. The cooperation of the patient will have to be enlisted, and because of his defect in volition this becomes at times rather difficult. If obedience is not obtained, it may help to point out that this is actual lack of the necessary cooperation. But to dismiss a scrupulant flatly for want of obedience would be too harsh, since what the confessor demands may appear to the scrupulant to be contrary to the dictates of conscience. Tact and sympathy, united with firmness, will go a long way to obtaining the required obedience.
The scrupulant is only too ready to tell his difficulties in detail, and the permission to do so, or even to make a general confession once, may prove invaluable as a means of mental exploration. Naturally, the recital that goes too far astray must be brought back to the subject from time to time. This can be done by inserting a few words now and then to show that the patient is understood, which will encourage the scrupulant. For his further consolation it seems he should be informed that the whole matter is really a question of sickness. But on no account must the patient conclude that the confessor thinks him insane. According to the account of scruples as so far given, there is absolutely no accusation of insanity. But an incautious statement may lead the patient to believe that he is looked upon as "crazy", and then his confidence is lost, and his hope shattered.
As for the scrupulant's confession, it is evident that the condition to be dealt with here makes it admissible to restrict him to formal integrity. Eymieu 30 and Gemelli 31 maintain that the scrupulant should be told there is no sin "unless he has certain evidence". But this meets with practical difficulties. Evidence is the one thing the patient would like to have, to settle his doubts, but which he cannot obtain. Therefore he sometimes, to make a certainty of the doubt for his own peace of mind, actually manufactures evidence where there is none. Gemelli 32 himself admits that this advice is not always effective, and he thinks the patient should in extreme cases be allowed to give up the difficult religious practices. But he is forced to admit that this is evasion, not a cure, so he warns that this should not continue too long. It seems better in all cases to lead the penitent to receive the sacraments without anxiety, and this can be furthered by the restriction to formal integrity in confession.
As for the "temptations" of the scrupulant, he should be induced to ignore them rather than to oppose them by active resistance. Resistance only serves to fix some temptations more firmly in the mind. Therefore the procedure ought to be that which seems advisable in bona fide temptations, especially if they concern purity. There is a right and a wrong way of treating such temptations. If the tempted one continually thinks: "Now this would be a sin", "I must not think of that", he is actually each time focusing his attention on the temptation. The proper procedure, to use a figure of speech, is not to back away from the danger while still keeping it in sight, but to turn one's back to the temptation and look elsewhere.
If it is at all possible, the scrupulant should be sent to a physician who is both competent and reliable, that is, to one who is both able to deal with such cases and willing to help without suggesting any infringement of the moral law. "Some doctors," says Dr. Moore, "do not scruple at an attempt to bring the conflict to an end by sacrificing the moral law . . . But duty and moral obligations cannot be sacrificed in order to overcome anxiety, however great. The task of psychology is the finding of a real solution which will do away with the anxiety, and, at the same time, not deprive the patient of the safeguards of the moral law." 33 The help of a competent reliable psychiatrist is invaluable for insuring a correct diagnosis, as well as for aiding in those conditions of the patient that fall within the scope of medical practice.
These observations are general, and for the most part obvious. But they cannot be neglected in the application of the special treatment. The diagnosis, mental exploration, and special treatment should be begun as soon as possible.
Special Treatment
As the factors in scrupulosity, at least in severe cases, are three in number, the special treatment is likewise threefold. Since these factors moreover mutually influence each other, the treatment of one will help others. It is for this reason too that all three lines of treatment should be begun simultaneously.
Treatment of Nervous Factor--This factor is nearly always found in chronic cases, and in more or less isolated and temporary scruples it may furnish the total explanation. It is here that the help of a physician is desirable. The confessor, however, may help to remove the causes by seeing to it that the patient does not overwork, and has work which is not monotonous, but varied and congenial. The positive treatment consists in building up the patient physically. The patient must have proper food in reasonable quantities, sufficient sleep, exercise, and recreation. While rest is indicated, absolute inactivity is certainly not desirable, as it only affords further opportunity for brooding over the difficulties. The exercises must not be too strenuous; just what is to be advised will depend on the individual. All that enters into the treatment of this factor is indicated by the one phrase--a rational and hygienic mode of life.34 This can be looked after in great part by the confessor or director; other treatment must be left to the physician.
Treatment of the Will-Element--One of the main causes of improper will-action seems to be the lack of a definite plan of life. The psychasthenic easily drifts along, never definitely choosing anything, sometimes not even a state of life. Again the patient may err by excess of planning, by making all sorts of impossible plans, spending the time in day dreaming and building air castles. In either case the patient needs to be induced to make a definite and practical plan of life. Of this Dr. Moore says: "Human life is so complicated and our abilities are so manifold and our opportunities are so numerous that it is a physical impossibility for anyone to realize all his desires . . . All desires are not equally worth while satisfying, and the criterion of worth in evaluating them is not pleasure but accomplishment . . . It is, therefore, necessary for us to establish a hierarchy of desires in which there shall be one supreme end of life to which everything else must conform. The establishment of this hierarchy of desires is what we have termed the formulation of a plan of life . . . One should pick out some walk in life in which occupation will not only give him a livelihood but also pleasure and happiness." 35 Previously he had pointed out that, "One must not think that in order to have a successful plan of life it must be highly idealistic." 36
In addition, there should be a further treatment in the strengthening of the will. 37 Lindworsky has called attention to the fact that a strong, indomitable, persistent will-power can be made to appear as something worthy of attainment, as a goal in itself, which later becomes detached from the content of the acts and can be attached to other acts. The affective mental states, the feelings and emotions, should be called upon to help. If the patient's confidence in his own powers is awakened, if his courage is sustained, and patience and cheerfulness encouraged, he is more disposed to effort. Then the will must be actually exercised. The acts carried out should be of some value in themselves, so that their fulfilment brings the realization of something accomplished, and is an encouragement to further effort. The individual exercises must of course be prescribed to fit the particular case. But whatever the exercises chosen, they should be carried out at a definite time, and persistently over a definite period.
The will-exercises described by Vittoz,38 and such as are designed in accord with the plan of E. Boyd Barrett,39 were found rather unsatisfactory in cases of scruples. These exercises may indeed be of use in other disorders; but in cases of scrupulosity they were tried and found wanting, as one of several unpleasant results usually followed. In the more severe cases, these exercises at times only furnished one more opportunity for manias, since they were used "to obtain certainty". In other cases the exercises were looked upon as "silly" by the scrupulant, with a consequent weakening of the authority of the director. Worst of all perhaps, they frequently caused the scrupulant to suspect that the director doubted his sanity, and as a result there was discouragement and no cooperation. Whatever the value of these exercises of Vittoz and Barrett in other disorders, they failed of their purpose in cases of scrupulosity.
Treatment of the Conflict--Three things are here involved: the finding, explaining, and solution of the conflict.
Now the finding of the conflict is frequently no easy matter. Inasmuch as even the conflict is sometimes not consciously perceived, and generally at least the connexion between conflict and scruple is unknown to the patient, the finding of the conflict involves considerable mental exploration. Such exploration resolves itself into the investigating of those processes, which are not in the conscious mind. The methods usually given are indeed very useful, but they are of such a nature that they are better adapted for use in the clinic, or at least limited to those rare cases in which the scrupulant comes, not to the confessional, but to the rectory. These methods are those of free association, of dream analysis, of controlled association, of the galvanopsychic reaction.40
For practical purposes, especially in the confessional, the following procedure was found most useful. After listening carefully to all parts of the patient's recital, including such parts as seem to have no bearing on the scruple, the confessor gives considerable thought to the whole matter at his leisure. A good beginning is to ask oneself (not the scrupulant!): What would the scrupulant have to gain if that were true which he fears? Then what? And then what? Thus he carries the investigation as far back as possible. This will depend considerably not only on the confessor's original ability, but on the skill developed in practice with these cases. In cases where the scruple actually has some connexion with the conflict, no matter how remote, this procedure is often productive of good results.
But if this fails, the only alternative is to take any part of the recital that seems significant as indicating a possible conflict, and formulating some kind of hypothesis. It goes without saying that one must not be so much prejudiced by this hypothesis as to attempt to fit a conflict to the theory when actually no conflict exists. The theory, advanced temporarily, stands or falls by the results of further inquiry. In those cases in which the patient knows of the desires or inclinations, but not of the conflict as a cause of the scruple, this procedure often reveals the underlying trouble. Sometimes too the confession or conference itself shows a dissatisfaction with existing conditions of life, and further inquiry reveals there a conflict.
Much time is saved by careful thought about the matter at times when the patient is not present. But even so the procedure takes considerable time in the confessional. It will, however, consume no more time than that which would be lost in vain re-explaining that there is no sin, etc., and what is of greater importance, it is more likely to produce the desired results.
In the investigation one may find not only a conflict, real or apparent, between incompatible tendencies, but also some peculiar fear connected with a past event, some pathological association. Therefore in any case of scrupulosity a double element may be found, the conflict, which causes the reaction and the pathological association, which determines the content of the scruple.
A pathological association with past events may be found to produce a condition that bears all the earmarks of the scrupulous state, and yet on analysis proves to be actually a fear, not of sins or the confession of sins, but of the place of confession. A harsh word, an uncalled-for diatribe on some former occasion, especially if the patient was already then under some emotional strain, may cause the penitent to fear the place or act of confession, and later transfer the fear to the matter of confession.
A pathological association may often be cured by analysis and explanation of the mental mechanism. But unless care is taken to point out expressly that such connexion must have been entirely unknown to the patient, he may conclude the confessor suspects him of shamming, or accuses him of guilt.
The cure of a conflict, however, demands more than explanation. The dilemma must be solved. If the conflict is only apparent, instruction will remove it; but if the conflict is actual one side or the other must be chosen. To aid the patient it may be necessary to suggest ways of compensation or sublimation. Compensation is the making good of one loss by finding an equivalent substitute, while sublimation is compensation for a disappointment by substituting something of a higher order, e.g. by doing something of value for others. Art, music, science, literature, and especially religion, may be drawn upon for means of compensation, and the patient who can be led to do something for others will find therein forgetfulness of his own loss, and even a greater joy than that he must forego in giving up one of his inclinations or desires. In advising, or rather suggesting these, the patient's personality and conditions of life must of course be taken into account. Moreover, the patient should be led to make the choice himself. For it is only when these compensations are freely chosen that they actually give satisfaction. But after all a rational adjustment, a voluntary molding of the life made in accord with the dictates of reason, is the only complete and adequate solution.
Finally, even if the conflict cannot be discovered, the treatment of the other factors may still bring results, since a hygienic mode of life and training of the will may so strengthen the patient that he can make his own adjustment. Everyone has conflicts, but not everyone reacts, as does the psychasthenic. If the psychasthenic factor be lessened, there is a strong possibility that the patient will act in a normal manner by a rational adjustment--a consummation devoutly to be wished.
Jos. G. Kempf
Endnotes
1 See, e.g. St. Alphonsus, Theol. Mor., lib. I, n.11; St. Ignatius, Spir. Exercises, Chap. on Scruples; Abbe Grimes, Traite des scrupules, 2 ed„ Paris, 1910.
2 Aug. Gemelli, De Scrupulis, Lat, trans. by C. Badii, Florence, 1913, P. 343. Germ. trans. of same, Skrupulositat und Psychasthenie, by B, Linderbauer, Regensburg, 1915.--References in these pages are to the Latin version.
3 L. Lowenfeld, Die psychischen Zwangserscheinungen, Wiesbaden, 1904, p. 69.
4 Op. cit., pp. 33-37.
5 For description of these, see Gemelli, op. cit., ch. 2-4.
6 Gemelli, op. cit., pp. 20-32; W. Bergmann, Die Seelenleiden der Nervosen, Freiburg, 3 ed., 1922, pp. 177-204.
7 See, e.g. T. V, Moore, Dynamic Psychology, 2 ed., Philadelphia, 1926; Wm. McDougall, Outline of Abnormal Psychology, N. Y., 1926; W. H. R. Rivers, Conflict and Dream, N. Y., 1923; J. T. MacCurdy, Problems in Dynamic Psychology, N. Y., 1922.
8 Pierre Janet, Les obsessions et la psychasthenie, 2 ed., Paris, 1908; also Nevroses et idees fixes, Paris, 1908.
Ant. Eymieu, Le gouvernement de soi-meme, II: L'obsession et le scrupule, 27 ed„ Paris, 1922.
Gemelli, op. cit.--Eymieu builds on Janet's theory; Gemelli follows Eymieu very closely.
9 Series of articles on mental disorders, in L'annee psychologique, Vols. 16 and 17 (1910-11).
10 Op. cit., page 21.
11 Lehrbuch der experimentellen Psychologie, Vol. II, Freiburg, 1920, p. 452.
12 The New Psychology, N. Y., 1925, pp. 217-218.
13 R. Vittoz, Treatment of Neurasthenia, Eng. trans. by H. B. Brooke, N. Y., 1911. See also Abbe D'Agnel and Dr. Espiney, Psychotherapie des troubles nerveux et direction de conscience, Paris, 1922.
14 Op. cit.; also, Selbstbefreiung aus nervosen Leiden, 5 ed., Freiburg, 1922.
15 Second edition, Philadelphia, 1926.
16 Op. cit., p. 152.
17. Meyer, "An Attempt at Analysis of the Neurotic Constitution", Amer. Journ. of Psych., XIV (1903), p. 96 ff.; "Fundamental Conceptions of Dementia Praecox ", Brit. Med. Journ., Sept. 26, 1906; "The Problems of Mental Reaction Types, Mental Causes and Diseases", Psychol. Bulletin, Vol. V (1908), p. 259 ff.
18 Aug. Hoch, "The Psychogenic Factors in the Development of Psychoses", Psychol. Bulletin, Vol. IV (1906), no. 6.
19 Jno. T. MacCurdy, Problems in Dynamic Psychology, N. Y., 1922; The Psychology of Emotion, N. Y„ 1925.
20 Amer. Journ. Psych., XIV (1903), pp. 363-4.
21 Neurasthenia in scientific, not popular sense. Cf. A. C. Buckley, The Basis of Psychiatry, Philadelphia, 1920, p. 375 ff.
22 W. Bergmann, Selbstbefreiung aus nervosen Leiden, p. 36 ff; Buckley, loc. cit.
23 O'Malley-Walsh, Essays in Pastoral Medicine, p. 208.
24 Dynamic Psychology, p. 184.
25 Op. cit., p. 208.
26 Op. cit., p. 202.
27 De Scrupulis, pp. 238-9.
28 Hysteria in scientific sense, not popular acceptation.
29 Lewandowsky, Die Hysterie, 1914.
30 Ant. Eymieu, Le gouvernement de soi-meme, II--L'obsession et le scrupule, P. 251 ff.
31 Aug. Gemelli, De Scrupulis, p. 301 ff.
32 Op. cit., pp. 310-11.
33 Dynamic Psychology, p. 210.
34 See W. Bergmann, Selbstbefreiung aus nervosen Leiden; A. C. Buckley, The Basis of Psychiatry.
35 Op. cit., pp. 157-8.
36 P. 156.
37 Cf. Moritz Meschler, "Bildung des Willens", Stimmen aus Maria-Laach, LXXI (1906), no. 9; T. V. Moore, Dynamic Psychology, Part VI; J. Lindworsky, Der Wille, seine Erscheinung und seine Beherrschung, 1919; M. Faszbender, Wollen eine konigliche Kunst, 20 ed., Freiburg, 1923.
38 R. Vittoz, Treatment of Neurasthenia, Eng. trans., N. Y., 1911.
39 E. Boyd Barrett, Strength of Will, N. Y., 1911.
40 See Moore, op. cit., Part I, ch. 5, C. G. Jung, "The Association Method", Collected Papers on Analytic Psychology, Eng, trans., London, 1916; also L. Dooley, "A Study in the Correlation of Normal Complexes", Amer. Journ. of Pysch., XXVII (1916), p. 119 ff.
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