September.11, 2001, Riverdale ,New York, 6.30 a.m. I go to vote in the Democratic electoral primary. I had listened to the numerous candidates for mayor and decided that we need administrative experience in a city that caters to the corporations and their need for a cheap workforce, often under? or over?represented in the state and city budgets, according to political expediency.9:15 a.m. My telephone rings while I am having breakfast. It is Eliot, who was coming to see me from Brooklyn at 10. "Do you have your radio or TV on?" he asks. "I cannot get over the Brooklyn bridge. The Trade Towers have just been hit by terrorist planes, and they are closing off access to the city." Stunned, I rush to the television set just in time to witness the image of the first tower billowing out in a mushroom of fire and smoke, and the second tower being hit by a plane from the right. My TV is in front of my bed, and I collapse onto it immobilized. I do not feel like myself. I am both fascinated observer and wounded soul. It occurs to me that I have never liked those towers much as seen from the ground, but I remember eating and dancing at "Windows" and the "Brasserie." I remember the Statue of Liberty seen from the observation deck on a glittery gold afternoon and the open vision of the horizon whence those immigrants came and still come to the piers and airports of New York. I wonder if the Museum of Jewish heritage is safe, housing our donated historical memorabilia brought to a safe rest and fruition here as nowhere else.
News comes of the Pentagon attack and the plane in Pennsylvania. My mind cannot hold or process what I am hearing. Filmed shots of people waving and jumping from the windows of the towers, followed people running away. Chaos. I am simultaneously numb and guilty for being so safe in my bed. It occurs to me that my patients may not be safe either. Even if I cannot cross the bridge into the office, I can make phone calls. Telephones are disrupted. It feels like an eternity before I reach anyone, some not at all. I have to contain my anxiety about them. A woman calls for a prescription of Klonopin. She has just returned from the site of the towers and fears she will not sleep tonight. It takes four hours to reach her pharmacy.
I watch the beginning of the attempt to clear the rubble at what is now called "ground zero." My admiration goes out to the brave souls doing it. The sight of the twisted steel ribs of the huge towers sears itself into my retina. I see it whatever I try to do ?? which is not much. I too am immobilized. My sense of who I am has crumbled. How can this be, I wonder? I was never this identified with corporate America. Or was I? I feel stony, and I do not feel normal. I cannot eat. I do not want to go out of the house. All I want to do is lie in my bed and watch the horror unfold It occurs to me that I am an addict to grief. It occurs to me that most of the people in those towers were young, raised in a blue?collar world and moving into the lower echelons of the white?collar world. They believed in their futures.
It is night. I am exhausted from disbelief and detachment. I go to sleep by 10. having heard that the Democratic primary was a tie, and we have to have a run?off. What would have been important news now hardly seems to matter.
Septempber.12, 6.30a.m. I slept better than expected with no nightmares. I woke feeling more like myself with the thought that I needed to do something to contribute. The bridges are still mostly closed, and requests for donations of blood and money are not what I feel I can or want to respond to right now. Pictures of families seeking their loved ones in the rubble float by on the screen, tragic and repetitious. They too are numb and disbelieving. It will be weeks before the full impact of the horror hits us and them.
An irrational thought enters my mind. "There is going to be a war! Join the medical corps. Join the army." I remind myself that I am a senior citizen and not eligible. This is not WWII, this is terrorism 2001. So what to do? I remember that the pharmacies were unreachable yesterday. People still need their medications. So I call a friendly drug representative and suggest that she and her colleagues from other drug companies deposit their samples at the Red Cross stations where people can get them. Later she tells me they gave out over 2700 of them. After doing this I feel better and more energetic.
I call the local police volunteer number and offer trauma counseling over the phone, but no one calls. They are not ready yet to deal with feelings. I call a patient who is a police officer on his cell phone. He tells me he is at the site on 24?hour duty sorting body parts. He says, "It's awful. The families are in shock, and the smell is terrible." Hearing this, I go back to bed. I still cannot go to work. Later I check my e?mail. Concerned friends from Poland, Israel, and Australia are asking if I am OK. My children and grandchildren have had difficulty reaching me by phone. I go to the supermarket to pick up groceries. People are mumbling and shaking their heads as they push their carts along. It is as if each person is in a bubble, processing what has happened alone. The bridges into New York are still on "restricted access" so it occurs to me to ask the check?out clerk if they are experiencing shortages of food. "Some," she says without much concern. I remind myself again that this is not WWII. At home I turn on the radio and cook up a large pot of home?made soup, my comfort food in emergencies. I listen for further news, give up and go back to bed to watch the World Trade Towers go down over and over on the TV screen.
By evening I have managed to contact my patients and know they are all right. One or two are a concern, but I decide to wait till they reach me and they do. It is a great relief to know no one is lost. I am reminded of my emotional exhaustion only by the tension in my body. Usual remedies for this feeling like stretching or movement do not seem to work. Mind and body seem to be on hold. I remember a picture of a gopher someone once showed me, standing upright and vigilantly scanning the distance for danger. Right now, I think I am that gopher.
September 13 through November 25.
I do not know why I did not continue the daily documentation of this experience for all this time, maybe because I have felt so depersonalized and emptied of my life's meaning. For about a month nothing has felt worthwhile or real. All goals and identifications seem to be on hold. I have had to keep reminding myself that I am a professional with obligations, that I have children and grandchildren who matter to me, that I must document what is happening. That life is important. Two days after the events I called a Muslim colleague in another town to express my sympathy about the anti Muslim riots in parts of Brooklyn. At the same time, my rage was unbounded when I saw pictures of Palestinians celebrating the event on TV.
My colleagues seem to be doing a lot of posturing and paperwork, organizing trauma centers which may or may not be useful. The emergency work was done by those brave souls at the hospitals who went down to "ground zero" and to the hospital pier immediately. My contribution to their effort was to hold two group sessions with some residents at a hospital I am affiliated with. They are all in the United States on temporary visas, from Rumania, Bulgaria, Israel, Singapore, Belgrade, India, and Australia. Concern about their own visa status was among their first reactions. Some had already lived through violent disruptive events and resented having their careers interrupted once more. Others missed the presence of loved ones and immediate family. One stressed her fear that she and her child would be mistaken for Arabs since they are brown?skinned. We shared their own reactions to patients from Islamic cultures as well as some of my own overreactions to what I perceived to be "Arabs" in the street. Some of the group were Islamic by birth and expressed discomfort about the extremist elements within their faith and about their differences from the rest of the group.
There is a poem by Mallarme' written about WWI, called "Polpes," French for "Octopi." Mallarme' speaks of the octopi at the bottom of the sea watching fearfully as aeroplanes fly overhead dropping bombs which the creatures experience as deadly eggs. The poet repeats a compassionate refrain while the octopi, confused, wonder about the boundaries of the sea and the edge of the land. I have felt exactly like those octopi. I did not want to spend time with anyone. I did not want to enjoy anything. I have needed a lot of sleep. Physical activity has been hard to initiate but routine tasks became almost a sacred duty and kept me from becoming totally paralysed. I realized that I had reverted to what I remembered to be my WWII mode. Slogans from that time surfaced in my mind. "Loose lips sink ships." "Is your trip really necessary?" Needless to say, flying was out of the question.
The Jewish Holidays came and went. Many of us including myself were afraid to go to synagogue. I found myself angry at God, not wanting to observe the rituals. Reminding myself that personal spirituality was as important as ritual or temple religion helped, and I could restore my faith and hope that this too would find a resolution.
There is a story circulating around New York about a kindergarten child who said after the loss of the Towers, "It's so sad. New York has lost its two front teeth." Every time I look at images of the shore front I feel like that child. You cannot be pretty or social without front teeth. It's also hard to feed yourself without them. Will our two front teeth ever grow back? I doubt it.
And then came the anthrax scare. People began to panic, buy gas masks, stock up on Cipro and to leave the city as much as possible. Going to the post office to buy stamps as well as opening letters became a hazard. I have faith that we will overcome and indeed we are doing better in Afghanistan and with the anthrax. However the silence from Iraq and bin Ladin feels ominous to me. I am prepared for more nasty surprises.
I am reviewing my life and documenting events as if my life is ending. I want to re?experience it all. I suffer from survivor guilt that manifests as anhedonia and procrastination on creative projects which might give me pleasure and satisfaction. I see this also now in patients as a delayed effect of PTSD. This must be fought against at all costs. Fortunately, some of my projects involve Holocaust memorial work, so two survivor guilt trigger factors come together in what I hope will be a final cure for a life?long misery of mine. There is a silver lining to every cloud they say. I hope so.
November 25 through December 16.
On December 11, New York celebrated the three?month anniversary of the attack. It was also Chanukah, a celebration of victory over oppression, also fought in the mountains. It is ironic that both wars were fought over religious issues, one about the freedom to worship as one believes, the other about the imposition of faith on others. Guilt is beginning to surface everywhere now. Patients have dreams about being and not being at the World Trade center to help. Those who were there have nightmares, flashbacks, anxiety, and depression. For many the recollections are so painful that they can not maintain themselves in therapy.
My housekeeper told me of a dream of her husband's. He has been working on plumbing at "ground zero." While she was out shopping he dreamt that "I came home from work, but you and the children are not there. The house is empty, and I am afraid. I choke with fear and pain." At that moment their budgerigar began to sing and woke him. He saw this as an affirmation of life and love and went to feed the bird. A dream of my own mirrors his. I am on the observation deck of the World Trade Center, but instead of telescopes there are parking meters with large slots for money on the top and running scanners in the front. I put ten cents into the slot three times hoping to see the "outlook" in the scanner, but it is running by fast and blurred. I get more anxious with each insertion of the money. Then I become aware that there are people behind me waiting to do the same thing , so I give up and leave the line relieved. It is clear from this dream that I know there is no answer to our anxieties and that no one is clairvoyant, but I am not alone and I share these concerns with my community.
Patients bring me pins of jeweled American flags and glittering New York City apples with flags inside them as symbols of hope and renewal. I wear them proudly. Memories of 1976, when we celebrated our first 200 years as a nation come back to me. Memories of sitting at a concert in Central Park with the smell of dozens of ethnic foods all around me, and people of many different colors moving up to make room for one another happily, peacefully on the grass. Shared joy. Right now we share our vulnerabilities, our mourning, and a restrained enjoyment of life as it goes on quietly for each of us in the recesses of our souls. We are concerned for each other, and we are contained in our attitudes to one another. A brash, busy city has shown the world that we have a tender humanistic heart. We are praised for our politeness to each other right now. Many tell me to move out of the city, that it is too stressful, too economically vulnerable. I am not going anywhere. This is my city. I am proud to be a New Yorker. A time will come for fireworks, for celebrations, and for dancing. New York will rise again to glitter and shine like Joseph's coat of many colors. I want to be there to see it and rejoice.
In the fall of 1998 four senior psychiatry residents in the Columbia University Department of Psychiatry founded a charitable organization devoted to providing voluntary psychiatric services to all people affected by disasters. Disaster Psychiatry Outreach (DPO) grew out of their experiences responding to the crash of Swissair Flight 111 as part of a team of psychiatrists hastily assembled by the Office of the Mayor of New York. Struck by the work they did but unable to find an organization through which they could provide such psychiatric services in the future, they developed DPO in consultation with various experts, the New York City of Department of Mental Health (DMH), and the American Red Cross (ARC).DPO has spent the last three years inching towards its ultimate goal of being able to respond to disasters at any time and in any place in the world. The September 11, 2001, terrorist attack on the World Trade Center struck on a scale, in a place, and a time always feared but never wholly envisioned by its founders and current directors - affecting many thousands if not millions of people in the organization's own city when the organization itself still consisted of a devoted but small band of volunteers. DPO has since struggled mightily and seen much along the way of fulfilling its mission in its own backyard.
DPO previously grappled with a shortage of psychiatrists on its clinical staff. In the wake of September 11, however, close to two hundred psychiatrists have volunteered or offered to volunteer with the organization (up from a dozen). The clinical need and the inspired outpouring of volunteerism among our colleagues required the organization to expeditiously credential, orient, train, and coordinate an unprecedented number of staff in a uniquely brief time. To accomplish this and despite a shortage of funds adequate to the task, DPO's half-time program administrator was upgraded to full time (really overtime), a full-time associate administrator was hired, and dozens of volunteer medical students and other non-psychiatrists from the Mount Sinai Medical School as well as other medical centers were recruited to work for DPO in the role of support staff.
Disaster psychiatry is unique in many respects, requiring close and easy relationships between psychiatrists and other relief agencies. DPO was able to deploy its psychiatrists into the community because of its collaborations with both the New York City Department of Mental Health and the American Red Cross, which permitted access to what were felt to be the primary sites for psychiatric outreach, the Family Assistance Center and so-called "Ground Zero." These have been the central focus of DPO's work, but other locales have included corporate settings, schools, and medical centers around the city, where both clinical and educational work was accomplished.
The Family Assistance Center (FAC) has been the central location for families to receive and provide information about missing loved ones. DPO was operating there within a day of the terrorist attack, making it possible for psychiatrists to participate in non-psychiatric roles where they could offer support, psycho-education, and psychiatry "on the fly" - reviewing hospital lists with families searching for loved ones in the days immediately after the disaster and initially assisting in the gruesome task of DNA collections. Many hundreds of people were seen in this informal capacity, with varying levels of emotional depth having been explored. DPO psychiatrists also provided individual consultations and group interventions and "de-briefings" from the outset. Up to forty such consultations have been done per day along with many more additional so-called "brief encounters." A bustling "Children's Corner" was also set up and supervised by DPO's child and adolescent psychiatrists, working along with para-professionals to serve dozens of children and parents each day.
A sizable portion of what has been seen at the FAC is "normal" reactions to grief and trauma, including indifference, sadness, anxiety, inattentiveness, loss of appetite, nightmares, and insomnia. Similarly, among children, normal reactions on the order of regressive behaviors have been common. On the other hand, a considerable number of individuals have been seen who are experiencing depressive syndromes, of either recurrent or incipient nature. Some cases associated with suicidality were referred for hospitalization. A few individuals, mainly relief workers, have presented with hypomania and mania. Rarer cases of catatonia (mutism), new onset psychosis, and exacerbations of psychotic disorders have been assessed and treated.
The basis for DPO's interventions has been a literature review conducted and written by its board over the last one and a half years entitled, "Disasters and Psychiatry" (submitted for publication, August, 2001). This review of the literature on trauma and disasters has established whatever empiric basis there is for acute interventions post-disaster. This academic work and DPO's prior experience in responding to disasters was in the midst of being translated into a 17-page "Clinical Protocol" when the World Trade Center attack occurred. None-the-less the protocol has been reproduced with a notation that it is being revised and distributed widely in order to structure the practice of DPO psychiatrists in response to the events of September 11.
Talking treatments have varied from psycho-education to cognitive-behavioral and supportive psychotherapies. Basic but crucial interventions included advising families and workers alike to be sure to eat, sleep, and adhere to some measure of a routine. Perhaps the most needed and common intervention has been normalizing reactions and reassuring people that they are not "going crazy," all the while educating them about what constitute "abnormal" reactions. Psychoeducational handouts have been helpful in supplementing this effort. An equally important role for psychiatrists has been one of advising parents about how to talk with and otherwise respond to their children in the face of the recent atrocities. Direct work with children has centered on drawings and play therapy. DPO psychiatrists were frequently asked to "de-brief" workers, an intervention which was practiced with the formal model of Critical Incident Stress De-briefing (CISD) in mind but tempered by a much broader model of psychoeducation and support. Massive donations of lorazepam and zaleplon have made it possible to provide these medications in either one-time only fashion or small supplies to people excessively burdened by their symptomatology, normal or otherwise.
Both full and brief encounter forms are available for recording all contacts with family members, children, and workers.
Medication logs and an on-site lock-box for the medications have ensured the safety and security of medication dispensation at the FAC.
Wherever possible, the FAC has been staffed with a mix of trainees and attendings, making it possible for supervision and teaching to be part of their experience (although everyone has learned something from their involvement, irrespective of their level of experience). Relationships with patients seen in these settings are not intended to extend beyond a single meeting or perhaps one follow-up meeting at the FAC; practitioners may see these patients in private follow-up only if no fee is charged. The National Alliance for the Mentally Ill has generously provided a continually revised list of local outpatient referrals for DPO psychiatrists to give to patients they have seen at the FAC or to use to provide them with a specific referral.
Work of an entirely different nature was begun with the workers at the site of the bombing in lower Manhattan, the so-called "secure zone." Concern for the well-being of the thousands of law enforcement, fire, military, construction, and volunteers involved in the often grim work of search and rescue/recovery led to the eventual establishment of a team of DPO psychiatrists within that zone. This took over a week after the bombing to even begin to operationalize for a multitude of reasons. Initiation of this effort was especially hampered by the tight security at the site, which necessitated many discussions between DPO and government officials to work out a viable, sometimes convoluted, system for clearance of its psychiatrists to obtain the all-important red security passes needed to enter and move around in the zone. At the time of this writing, this clearance system has changed once again.
Once cleared to work at the site, DPO psychiatrists, outfitted with hard hats and respirator masks, could begin their work amid a scene that seemed like a horror movie come alive - the "pit" of mangled buildings, pungent odors, bright lights, and frantic activity surrounded by a perimeter of burnt-out storefronts occupied to support the operation with supplies and food. An initial team of psychiatrists from New York, Milwaukee, and St. Louis spent several days "scouting" the site in order to establish key locations at which to base operations. These were found to be several medical aid stations that lacked mental health support, a private gym that became a 24-hour rest stop for the workers, a Red Cross operated respite center for the workers, and "staging" areas at which workers congregated, watched the operation, and took brief breaks. Equally important during this phase was being visible and friendly so that workers could become familiar with the psychiatrists and the idea of their being there to talk and assist them.
The often roaming clinical work within the security zone has consisted of informal encounters begun over a meal, a cigarette, or even a security check that invariably lead to an outpouring of talk and some emotion from the rescue workers. Joking about being a "shrink" has been a creative and successful entry point as well. Sometimes a brief initial encounter has lead to a more intensive and frank discussion when the psychiatrist later re-visits a worker. These interactions have numbered in the hundreds already and center on themes such as the brutal conditions under which the work is being done, the horrific sights and smells, longings for missing co-workers, anger at the perpetrators of the atrocity, and the well-being of families not seen in days. No medications have been utilized as yet despite their availability. Currently these operations are being formalized through collaboration with federal medical teams dispatched to the site.
In brief, the days since the World Trade Center bombing have provided an unfortunate opportunity for psychiatrists to make a difference in a very profound way. DPO's tireless and devoted psychiatrists have banded together in a special relief effort that transcends departmental affiliations and the walls of consultation rooms to be part of the greater outpouring of good that has followed the unparalleled bad of September 11. It is hoped that this work will bring some good to others' lives now and even more so down the road of recovery. By being a part of the story from its outset, DPO's psychiatrists and other mental health professionals can hope to be part of the many chapters certain to follow in the difficult emotional timeline of this event.
Psychiatrists who are interested in more information about the Disaster Psychiatry Outreach program may consult the website at www.Disaster-Psychiatry.org or call 212-659-8733.
Dr. Katz is President, Disaster Psychiatry Outreach; Director, Psychiatric Emergency Services, Mount Sinai Hospital; and Clinical Assistant Professor in Psychiatry, Mount Sinai School of MedicineCorrespondence to: Dr. Katz at the Department of Psychiatry, Mount Sinai Medical School, One Gustave L. Levy Place, Box 1230, New York, NY 10029
Japanese society has a peculiar nature in terms of religion. The majority of Japanese do not seem to take any specific interest in it. In an investigation of public opinion, about 70 percent replied that they did not believe in any particular religion. However, another statistic shows that about 80 percent of the Japanese population belongs to the religious organizations of Shinto and about 70 percent to those of Buddhism, suggesting that a large number of Japanese people belong to at least two religious organizations although most have no faith in them. This data reveals a truth about Japanese attitudes toward religion. They are indifferent to religion and very lenient about having different religious beliefs or customs at the same time.In my own case, my family's religion is Soto?shu, a sect of Zen Buddhism. If a family member dies, we ask a monk of that sect to direct worship at the funeral, and memorial services will be held every fixed number of years by a monk from the same sect. My parents' home has a Buddhist altar, and I am supposed to pray before it at certain opportunities, such as New Year's Day, during the Obon festival, or the first time I visit their house after a long time. It might sound as if I am very religious, and my religious life is organized in a Buddhist way. However, strangely enough, I have never learned Buddhism systematically, i.e., the teachings of the Buddha, and so on.
A further contradiction is the fact that I was occasionally taken to a Shinto shrine, for example, to celebrate a gala day for three? and five?year?old boys. New Year's day is a popular occasion for going to Shinto shrines. We would stand in a long line waiting to come to a place where we would offer a ten?second prayer. If we have any special wish, such as health for our family, no car accidents, passing a difficult exam, or having a baby with an easy delivery, we would usually go to a shrine. Again, I don't know what Shinto is and what Shinto teaches us.
Buddhism and Shinto are two traditional religious systems which are deeply rooted in Japanese ways of life. After World War Two Christian customs came to be widely accepted, although the number of adherents remains few. Celebrating Christmas by eating cake and giving presents to children and having a marriage ceremony at a Christian church have become a part of Japanese culture.
My academic background also reflects this polytheism. My parents sent me to a kindergarten run by another sect of Buddhism. They did not care that the sect was different from our family's. My parents adopted a family custom of saying Namuamidabutsu before mealtime, which I learned at that school, even though none of us knew exactly what it meant. Upon finishing a public elementary school, I entered a Jesuit missionary junior high and high school. My parents seemed happy and satisfied with the school's good reputation for academic teaching skill. They naively thought the religious atmosphere would be good for their adolescent son. Ironically, my soul started responding to the religious atmosphere. I joined a religious study group in school and started reading the bible. At one point a father teacher asked us to convert. I took this invitation seriously and asked myself whether I could make a commitment to Christianity. It was so appealing that I came close to converting, but I could not understand what the real existence of God meant. I thought it must be a kind of metaphor and asked the father teacher if it meant that God exists exactly in the same way a chair or a desk exists in front of me. He said, "Yes." Then I gave up the idea of converting. I asked him whether I would go to hell. He said, "Yes."
Since then, at the cost of being destined to go to hell, I have been content with the Japanese polytheistic secularism. My marriage celebration was held in Shinto style. I got a job in the university which was founded by Tenri?kyo, one of the new religions started about a hundred and forty years ago. Nothing appears contradictory, at least not on a surface level.
Historical Background:
The climate of Japanese polytheism is a historical product built up over a long period. Shinto is a naturalistic religion that developed out of the daily life of the Japanese people in a primitive era. Primitive Shinto centered on the animistic worship of natural phenomena, such as the sun, mountains, trees, water, rocks, and the whole process of fertility. Its mythology is concerned with many deities, reminiscent of early Greek mythology. Buddhism, which originated in India, was introduced into Japan in the sixth century. In contrast to Shinto, Buddhism is concerned with the afterlife and salvation and more concerned with theology. After its introduction Japanese Buddhism went through cultural transformations.
Amazingly, an imported foreign religion was accepted and harmoniously integrated with a religion indigenous to the country. Two religions came to coexist, making a two?layered structure. Neither Shinto nor Buddhism in Japan insisted on getting rid of the other, and they chose to live together in the same society. The two religions influenced, partially merged with, and adhered to each other. This fusion of two religions is called Shinbutsu?shugo.
In the 8th century, Shinto shrines started building Buddhist temples in their own precincts or remote places. They are called Jinguji, i.e. Shintoistic Buddhist temples. Some of them were built with the support of the dynasty along with a prayer for protection of the nation. Other temples were generated on a local level, independent of the central dynasty. In these cases many temples were set up on the basis of a prophecy made by Kami, a Shinto deity. For example, an ancient record about the foundation of Tado Jinguji in Ise district relates that in 763 the deity of Mt. Tado decided to convert to Buddhism in order to be delivered from karma of the deity of Kami. While reigning over the district for a long time, he had come to bear the burden of the sins, and he wished to escape from his position as Kami. Based on this prophesy, the Kami of Tado was renamed Tado Bodhisattva, and Tado Jinguji temple dedicated to him.
Another key concept to the fusion of Shinto and Buddhism is Honji?suijaku (True Nature manifestation) theory, in which Shinto deities are seen as incarnations of Buddha who came to this world to be the salvation of the people. This is an approach from the Buddhist side to incorporate Shintoism into it. It started in the 11th century, when Buddhism had been consolidated in Japan. There was a doctrine that Amaterasu, the central deity in dynastic mythology, is an incarnation of Dainichi Nyorai (Mahavairocana). These theories continued to have a strong influence until the end of Edo period. This type of fusion of two religions is unique in the world. In contrast to the strict repression of other religions, as when Christianity conquered the Germanic-Celtic religions and prohibited people from even reciting the names of indigenous dieties, Japanese Buddhism and Shinto chose a way to a peaceful coexistence.
Confucian philosophy has also had a great impact on Japanese secular ways of thinking. Beginning with Confucius, who lived around 500 BC, Confucianism accumulated the teachings of other scholars and took final shape in China during the twelfth century. Its religious aspect was not outstanding; rather it stressed a rational natural order, of which man was a harmonious element, and a social order based on strict ethical rules. The Confucian classics and system entered Japan between the sixth and ninth centuries but tended to be overshadowed by Buddhism until the seventeenth century. During the Edo period, its philosophy and attitudes pervaded society and contributed to the secularization of society along with the religious policies of the centralized Tokugawa system, such as the prohibition against Christianity, and the registry of all persons as parishioners of some Buddhist temple. In this period, Buddhism and Shinto became mere names, and Japanese rationalism was spread across the nation.
Polytheism and Japanese Mentality :
A Japanese religious scholar, Matsumoto, posited two ideal types of religion: paternal and maternal. In his view, a monotheistic religion, which has strict precepts and requires complete devotion, is categorized as paternal. For example, in Christianity, the contents of faith are defined ideologically, and each person's faith must be examined consciously. Severance of affective bonds to secular people is a prerequisite for establishing the supremacy of the relationship to the monotheistic God. This kind of commitment seems to be consistent with the independent and autonomous ego of Western individuals. In contrast to paternal religion, the Japanese religious climate is striking in its tender, merciful, and lenient characteristics. Polytheistic Shinto does not have clear doctrines and does not require any conscious commitment to Kami. Widespread sects of Buddhism, like Jodo sects, emphasize salvation of all people. For example, in Jodo?shu (Pure Land sect), only reciting the name of Buddha is enough to be born in a pure land or heaven after worldly life. A founder of Jodoshin?shu (True Pure Land sect) advocated, "If even a good man can be born in a pure land, more so an evil man." These doctrines were generated through the assiduous attempts of monks to find ways in which all human beings might be relieved.
This strong contrast between western religion and Japanese religion seems compatible with the psychoanalytic discussion of unique features of the Japanese mentality. A Japanese colloquial word, tutumu, which means to wrap or to envelop, is a key word for understanding self?image and interpersonal relationships in Japan. In the interpersonal situation, a person has to wrap up his individual thought or feeling and either conceal it or express it, if needed, tenderly and covertly. Another connotation of this word is to wrap up things and not make distinctions among them. Differential treatment of members of the group according to ability and merit tends to be seen as cold-hearted, sometimes even unfair.
Two types of ethics can be distinguished in Japanese culture, those based on the group or field (Ba no Rinri) and those based on the individual (Ko no Rinri). The former represents the predominance of the maternal principle in Japan. The Japanese word "ba" means "place" on the most concrete level but it also connotes a situation or relations among the people who are there. Ethics based on the field is usually not noticed explicitly but is shared implicitly or unconsciously by a group. If we assume that this ethic is rooted in a substratum of Japanese mentality and that it has supremacy over any other ethical elements, it is understandable that different religious beliefs and rituals coexist harmoniously in Japanese society. Differences among various religions and religious sects are not emphasized. Various Kami, Buddha, and God must keep equilibrium in a field. They all exist for people. Why should they fight each other?
Identity Formation of Japanese Christian Youth:
Sixteen years ago, I researched Japanese identity formation, comparing Christian and non?Christian youth and examining the characteristics of Japanese identity formation. I focused on Japanese Christian youth, who adhere to a paternal religion in a maternalistic society.
According to Erikson, psychosocial identity formation is a process by which one accepts a value system shared by the members of group and thus reorganizes one's inner world. In this process, an ideology or an ideological image of the world is eagerly sought by young people. He emphasized the importance of selecting an ideology and committing oneself to it subjectively. We can see a prototype of this ideological commitment in the example of Christian faith, but it seems quite in discordance with Japanese mentality. The Japanese religious scholar Yoshida, himself a Christian, contrasted Japanese ego structure with that of a Christian. He designated a Christian who has a Japanese mentality as a marginal man, not only because he believes in a religion which is culturally different but also because in Japan it is unusual to believe in one particular religion.
In my study, 83 Christian and 177 non? Christian students were asked to fill out questionnaires such as the Ego Identity Scale, Ethics Scale, Commitment Scale, and Object Relation Scale.
Christian students were divided into three subgroups: those who were baptized as children; those who had Christian parents; and those who had non?Christian parents. The first group consisted of students baptized in childhood, at least one of whose parents are Catholic. Those belonging to the second group also had at least one Christian parent but were baptized after adolescence; in this case, the Christian parents were Protestant. The third group consisted of students who were baptized by their own decision without having a Christian parent. They encountered Christianity during adolescence, through a mission School, YMCA activities, or friends.
There were no differences in the Ethics scales between the second and third groups, but significant differences were found in one of Ethics subscales among subgroups of students with Christian parents. The third group (those with non-Christian parents) showed a significantly lower score in ethics based on the field than other two groups. This result is understandable if we take into account that the students in that group chose their position as the one and only believer in Christianity in their families. This study was originally derived from my interest in the difference in natures of religions, especially between paternal and maternal religions. Believers in paternal religions, like Christianity, have been supposed to show higher respect for individuality?based ethics than ordinary Japanese. It seems that the relevant factor here is not what they believe in, but how they come to believe in it. Above all, how the person is connected or disconnected to his family members seems to play a significant role.
Disruptive nature of religious conversion:
The religious scholar Lewis Rambo (Understanding Religions Conversion, Yale University Press, 1993) pointed out that the issue of conversion is controversial because quite often it does in fact disrupt people's lives, and it does disrupt families. If we consider the secular character of Japanese society, this disruptive aspect of conversion can be a most salient issue. The magnitude of the disruption is dependent on the degree to which the religion is accepted in the society. The more the religion is radical or subversive to the society, the more conversion to it would be disruptive. However, whatever religion the person converts to, the process of conversion includes disconnection in two ways, internally and externally. Internally, the convert is disconnected from the old identity, and externally, from various human relationships in the secular world.
Dramatic examples of external disconnection include the seclusion from the secular world by many virtuous Buddhist monks. They are sometimes strongly idealized because of their success in religious life and their heroic appearances, but we must not forget the shadow entailed by light. The negative aspect of this type of behavior is clearly seen in the story of Sangi Saito, a modern Japanese haiku poet. He determined in his middle years to become a poet, having felt being touched by the elegant spirit of haiku. He deserted his family, who clung to him in tears, and started a vagabond life. For his family, even the most successful haiku poet was an irresponsible fugitive. More subtle and internal disruption can be seen in the Japanese Christian as a marginal man. In the process of becoming a Christian, the person has to acquire a new identity, and to lose some part of Japanese identity.
Here, we need to think about what kind of psychological meaning this disruption has to each individual. The adolescent period coincides with the time of the youngster's identity formation. Religious commitment may play a critical role in this process. It may facilitate the second individuation process by providing these young people with extra?familial social networks and new relationships with a transcendental authority. However, these perspectives seem to have a missing part, which has to do with the development of continuity. Gaines (Detachment and continuity: The two tasks of mourning, Contemporary Psychoanalysis 33:549-571, 1997) in a discussion of the mourning process of children who lost a parent, says,
Emphasis on the need to detach from the lost object has obscured another aspect of the work of mourning, which is to repair the disruption to the inner self?other relationship caused by the actual loss. The individual needs to reconnect the severed bond, now on an exclusively internal basis, and to maintain the availability of a sustaining inner relationship. This is the task I call "creating continuity". (p. 549)
The same task could be posited in the process of conversion. How the convert creates continuity for the former unreligious self and his human relationships in the secular world has not been given enough attention. On the contrary, these attachments to the old relationships and identity are regarded as a hindrance to religious commitment. Contemporary religious studies point out that converting is a complex process rather than a one?time event. Rambo breaks down the conversion process into seven steps: context, crisis, quest, encounter, interaction, commitment, and consequences. In this process, the converter creates new identities and consolidates a new spiritual orientation. This model, however, lacks a complementary part of transition, that is, the re?creation of the old connections. In order to shed some light on this aspect of conversion, we might examine the life course that Japanese Shinto Kami chose, becoming Buddhist while remaining Shinto Kami. This unique way of conversion might tell us something important about the conversion process, something that has been neglected in Western culture, and which may become more meaningful in our time of religious globalization.
Dr. Kawabata is a graduate of the William Alanson White Institute and will be teaching at the Kyoto Bunkyo University in Japan.Correspondence to: Dr. Naoto Kawabata, Nanbu-cho 43-1-701, Fushimi-ku, Kyoto 601-8059, Japan.
Psychosis and conversion are closely related, as the following abbreviated case study illustrates. A seventeen-year-old youth loses all interest in doing his schoolwork. He is unable to concentrate. For the last two or three months he becomes withdrawn, indifferent to family and friends. Family members grow worried and angry. Teachers give extra homework assignments to discipline him. One Sunday afternoon he is trying to do a lesson, but his mind wanders. His older brother walks in, sees his inattentiveness, and scolds him. The next morning the boy runs away from home. Immediately, previous habits of sleeping and eating go by the wayside. He sleeps rarely and erratically. He eats only if fed by concerned strangers. He stops speaking. In fact, he talks to no one for the next four years. He becomes disheveled, oblivious. He never bathes. Insects bite him, leaving pus-filled sores on his back and legs. He hardly notices. This process in its most acute form continues for about a year.What has happened here? Perhaps it would help to know that the boy's father died when he was twelve years old, and that one day around the time his schoolwork began slipping he suddenly felt gripped by a fear of death and a sense of certainty that he himself would die imminently. Even with only this information, there can be little doubt that we are dealing here with a severe psychotic break. What kind of treatment would be indicated? Supportive psychotherapy? Antipsychotic medication, perhaps mood stabilizers? Adjunctive family therapy, perhaps?
This boy never received professional help. He never returned home. When an uncle and then his mother and brother first found him years later, he all but entirely ignored them. In his subsequent long life he never worked at a job, never married, never developed normal relationships. Instead, this young man, born Venkaturamana Iyer, grew older, settled down considerably, and came to be known as Sri Ramana Maharshi, one of the most deeply and universally admired saints in the history of India. For almost anyone looking to the East for inspiration, Maharshi represents a phenomenal pinnacle of spirituality and wisdom. While he lived all his life, from 1879 to 1950, in or around two small villages in southern India, he attracted an international following. Among Western visitors to his cave were the author W. Somerset Maugham, who later wrote The Razor's Edge. The psychiatrist C.G. Jung, wrote of the sage: "In India he is the whitest spot in a white space. What we find in the life and teachings of Sri Ramana is the purest of India" (Forward, in The Spiritual Teaching of Ramana Maharshi, Shambhala: Boston, 1972).
Without the case's unexpected end -- "the rest of the story" -- it is simply a sad glimpse at the life of a teenager with a major mental illness. With its conclusion, however, it is a challenge to basic assumptions about psychosis and conversion. Are they separate entities? Is it possible to distinguish between a profound mystical conversion experience and a psychotic episode? Sri Ramana's transformation is one type of conversion, in which a person "converts" to a deeper form of his or her own tradition rather than turning to another sect or religion. In any conversion experience, as in a psychotic episode, the world is suddenly seen with different eyes -- through a rearranged belief system.
Henri Ellenberger's idea of creative illness may be useful here, which is one way of talking about "regression in the service of the ego." Stanislav Grof provided a recent version of this concept with his diagnostic category of "spiritual emergency." Yet both thinkers run the risk of over-romanticizing and prematurely clarifying a gray area. This same risk applies to Ken Wilber's important work. At the core of his efforts (in books like The Spectrum of Consciousness and The Atman Project) is his simple yet brilliant explication of the distinction between regression and transcendence -- between pre-egoic psychopathology and trans-egoic spirituality. Wilber has indicated that true spiritual practice transcends the ego; it is a mistake to dismiss it as narcissistic withdrawal or oceanic regression. Genuine spirituality lies above and beyond and builds upon a healthy ego; don't reduce it to regression or equate it with emotional disturbance. (See Walsh, R., and Vaughan, F, Eds., Paths Beyond Ego, Jeremy P. Tarcher: Putnam, NY, 1993, and Wilber, K., Engler, J., and Brown, D.P., Transformations of Consciousness, Shambhala: Boston, 1986)
In this light, how shall we understand Ramana Maharshi? Was he disturbed or inspired? Was he pulled into his flight from home by regressive tendencies? Or was he pushed from home by a divine process? My own answer to these questions is "yes" and "yes;" both are true. One can discern a mixture of pre-egoic and trans-egoic elements in the unfolding of his early life, but more importantly either interpretation becomes compelling depending on how one views the story. Seen from a psychiatric standpoint, Maharshi was clearly regressed and obviously ill, at least in his late teen-age and early adult years. Seen from a spiritual orientation, he was undergoing a salutary transformation -- extreme in its manifestations yet tremendously positive in its end result.
However one might clarify and understand Maharshi's transitional period, it poses a challenge to any vision of spirituality as supreme or higher psychologic health and of development as proceeding from the stage of childhood conflicts to normal mature functioning and then ascending into spiritual realization and mastery. It is helpful to re-consider the situation without the benefit of historical hindsight. Forget "the rest of the story" and all the spiritual definitions and categories (samadhi, kundalini, or the like) that go with it. If you saw a patient with the behaviors described above, what would you think? What should your way of looking at it and responding to it be? Despite the possibility of distortion, imaginative reconstruction with oneself in the picture is necessary. To explore the interface between spiritual realization and madness and shed light on both, highlighting the hidden story of madness in the saint is a vital task, and it carries with it the requirement to intentionally forget and then remember again that the person under consideration was a religious pioneer and a spiritual giant. Equally important, though beyond the focus of this article, is uncovering the urge toward transcendence in madness. Of course, in the sketch of the saint's adolescent years above, I have purposely been selective. I have given a thumbnail history close to what would probably be culled at the average mental health clinic or psychiatric hospital. Most of the recorded details we have left unmentioned would be summarily characterized as "hyper-religiosity" and therefore further evidence of a psychotic illness at any conventional treatment facility. Our protagonist had religious longings beginning rather suddenly at age sixteen. A year or so before his departure from home he read a devotional book that stirred him to his depths. Thereafter he visited the local temple every day for hours at a time, tears in his eyes, fervently praying to be made a true devotee of God. Upon fleeing home he left a note that read, "I have started from this place in search of my Father in accordance with His command...."
A further issue should be touched upon, though it is beyond the scope of the present discussion. In describing the young Maharshi, I mentioned in passing that he had an experience of abruptly feeling certain of his own imminent death. This occurred about two months before he left home. I neglected to add that he then lay down for a half hour and calmly and rather spontaneously inquired into the matter of who was dying. According to the spiritually oriented biographical sources about the sage, at the end of that half hour he had fully awakened to That which is deathless, That which can never die. The Absolute. From that time on he was, they say, completely liberated. All this occurred some weeks before the saint's rapid downslide into months and years of a shockingly deteriorated level of functioning!
Sri Ramana's story is one of those instances where life eludes our best efforts at categorization. More specifically, he exemplifies the reality that psychosis and conversion cannot always be cleanly separated, nor can psychopathology and transcendence. Differentiation between regression (pre-egoic experience) and spirituality (trans-egoic existence) remains a preliminary and useful theoretical construct, but it does not seem to hold up terribly well in many real life situations. It is tempting to resolve the problem of explaining Maharshi's behavior by saying that the human struggle and perhaps the spiritual journey in particular contains a mixture of regressive and transcendent elements. After all, even spiritual teachers have their human side. While this may shed some light, it does not come to grips with the important finding that in this story and similar ones the times that are most worrisome psychologically are the very transitions of deepest spiritual unfolding. It is no accident that Maharshi recalled the period of apparent psychosis as the transformative turning point of his life. Such paradoxical logic applies to the specific behaviors under scrutiny as well. For instance, is a person's sudden and dramatic drop of interest in his customary routine a sign of illness or of health? In terms of current psychiatric diagnosis, it can only be appreciated as an expression of illness. From the spiritual perspective, however, it sometimes implies an upsurge of profound health.
Ramana Maharshi may be an exception in some important ways, but the difficulty his story presents is encountered to one degree or another in the histories of most individuals of significant spiritual realization about whom there is adequate personal data. The people in this category whose biographical or autobiographical writings I know include Ramakrishna, who along with Sri Ramana has been generally considered one of the brightest spiritual lights of modern Hinduism; the great Zen Buddhist teacher Hakuin; the well-known philosopher J. Krishnamurti; the 19th-century Hasidic rabbis Nahman of Bratzlav and Mendel of Kotzk; many of the Catholic saints, including St. Anthony, the third-century Christian recluse known as "the father of monks," and St. Francis of Assisi; and George Fox, the founder of Quakerism, who was scrutinized by William James in The Varieties of Religious Experience. This list is incomplete, but perhaps it gives some sense of the range of individuals under view. The figures who have led to major religious traditions might also be mentioned in this connection, even though much less is clearly known about their lives. For instance, according to Christian scripture, in the early days of Jesus's mission his own family thought he was "out of his mind" (Mark 3:21).
Let us return to Ramana Maharshi and the central unresolved question we have been asking about him. How are his flight from home and subsequent disruption of previous functioning to be best understood? Psychosis or conversion? Regression or transcendence? Was it an expression of sickness or a part of a process of realization? The conventional psychologic view would see Maharshi as an example of unhealthy regression, whereas an Eastern vantage point would essentially claim that his apparent psychosis was a pseudo-psychosis involving the adjustment of his physical body to the profound spiritual energies released by awakening. Fortunately, spiritual heroes like Ramana Maharshi save us by defying the categories we have decided are real. Was he regressed or not? The idea of regression (or for that matter suppression or repression) does not make quite so much sense in this case, however, as something we might call compression. The magnitude of Sri Ramana's spiritual life compressed other aspects of his life to the periphery for a period of years. Our psychiatric and spiritual categories soften in the face of a phenomenon like this. Any good solution to the dilemma posed by this saint will be found not through maintaining our old logic but through seeing how it has misled us. The dilemma remains, and as we walk a fine line into the ambiguity here, as reductionism and romanticism both fall away, the dilemma heightens.
One of the issues here is the never-ceasing challenge of selectivity in constructing a "history of present illness." Inevitably a multitude of suggestive data presents itself, each bit clamoring for recognition as "significant" or "central." For example, was Maharshi's brother's scolding him important? What if that two-minute incident had been bypassed in the narrative? Suddenly the seeker leaving home now seems a little less like an average teenager or a troubled youth, and therefore a touch more like a newly converted religious man off to meet his destiny. Psychoanalysis today offers a meaningful starting point for moving more fully into the dilemma. As a fundamental psychoanalytic view, all human experience and behavior is adaptation. Psychosis and conversion are both adaptations to the realities of loss, separation, change, and death -- and these realities surely affected the young Ramana deeply. This is only a starting point. It leaves much unresolved, but it is a good place to begin. It is also where Buddha's First Noble Truth (the central fact of suffering) and the living symbol of Christ on the cross join modern psychotherapeutic thought.
(I am indebted to Jeffrey Rubin, Ph.D., who co-authored an earlier version of this paper.)
Tony Stern, M.D. is in private practice and on the faculty of New York Medical College. He is also an attending psychiatriston the Westchester Medical Center's mobile crisis team and at Abbott House,a foster care agency."Correspondence to: Dr. Tony Stern, 7 Ravine Drive, Hastings-on-Hudson, NY 10706