Spiritual accompaniment in illness

Spiritual accompaniment in illness

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Understanding the meaning of physical and psychological suffering

The spiritual accompaniment of the sick is an art, like all spiritual direction, with major challenges. In this article or script, different themes are developed to better understand depression, anxiety, psychiatric illnesses, but also the normal ailments that affect us until the end of our days.

Table of contents

1. Christians and illness

Illnesses raises many questions, the most immediate and most usual being “Why me?” and “Why now?” These can easily be followed by questions about the deeper meaning of the illness. Therefore the first aim of spiritual direction offered to a ill person will be to help them find meaning in their suffering. It is not something that can be imposed from outside; it is something that the ill person has to find and make their own in a very personal journey.

For Christians suffering does have a meaning even when it is not fully understood. The starting-point is our Lord’s Passion and Death, since by his suffering he took our suffering upon himself and filled it with light. The meaning of suffering is rooted in the Cross, “a stumbling-block to Jews and folly to Gentiles” (I Cor 1:23), and in the conviction that suffering makes us co-redeemers and benefits the whole Church, as St Paul says: “Now I rejoice in my sufferings for your sake, and in my flesh I complete what is lacking in Christ’s afflictions for the sake of his body, that is, the Church” (Col 1:24).

Illnesses are permitted by God as a consequence of the frailty contracted by human nature after sin. They are not, therefore, good in themselves, and hence they are to be avoided when possible. All too often, however, there is no way of avoiding illness. Unavoidable illness offers us the opportunity to say “Yes” to God’s will, to increase our love, and to become more mature both humanly and spiritually. Suffering continues to be a mystery, but an “open mystery” that brings us face to face with the limitation and mortality of our earthly life, and opens the door in some way to our future life, eternal life.

Job’s life in the face of suffering and sickness

Job, who was blessed by God with possessions and children and then suddenly deprived of everything, is a paradigm of the acceptance of suffering. The friends who came to comfort him tried to convince him that all his sufferings were the result of his past sins (cf. Job 4:8-10). Job, who was aware of his own innocence, kept his faith alive and said, “Naked I came from my mother’s womb, and naked shall I return; the Lord gave, and the Lord has taken away; blessed be the name of the Lord” (Job 1:21). In his bitter trial, resisting his own wife when she urged him to curse God, he remained faithful (cf. Job 2:10).

God’s response, coming at the end of the book, is an invitation to patience. He shows Job that he cannot understand all reasons, and in reward for his humility he returns all that he had lost, many times over (cf. Job 48-52). Pope John Paul II, making plentiful references to this Old Testament text, sums up its argument as follows: “This is the meaning of suffering, which is truly supernatural and at the same time human. It is supernatural because it is rooted in the divine mystery of the Redemption of the world, and it is likewise deeply human, because in it the person discovers himself, his own humanity, his own dignity, his own mission.”[1]

Being moved, even to tears, by the suffering or death of someone we love, is such a human experience that Jesus Christ wanted to leave us his experience of it (cf. Jn 11:33-39). In offering spiritual direction to someone who is suffering, a basic attitude is compassion and empathy, taking upon oneself what the person is undergoing. To do that, we have to listen to them. A simple gesture can do more good than hundreds of words.

The aim is to help the ill person to look at God and other people, since this is the path to discovering the meaning of suffering. Suffering can only be understood if it is apprehended as sacrifice, gift, trial or “touchstone of Love”.[2] This understanding of it can transform it into a “good”, in a certain sense, for the sufferer and for others.

Discovering the meaning of pain

St Josemaría Escrivá said, “The great Christian revolution has been to convert pain into fruitful suffering, and to turn a bad thing into something good. We have deprived the devil of this weapon; and with it we conquer eternity.”[3]

The World Health Organization defines health as a “state of complete physical, mental and social well-being.” It considers these three dimensions as being closely interlinked. Any defect in one has repercussions on the other two. Organic problems can be the cause of mental disorders; mental illness can cause organic illness; spiritual difficulties (not mentioned by the WHO) can also cause mental and physical problems. It is always the whole person who suffers.

This conviction of the unity of the human person, and of the primacy of the spiritual dimension, enables us to understand that all sick persons are unique, and to treat them accordingly. What we are faced with is never a problem, but a unique person who has a problem. That is the way to read the suggestions contained in this article, which refers mainly to the spiritual care of the ill. Some of them will be useful to the sick person’s family members, who share in the suffering of someone they love and may be affected by tiredness and suffering themselves.

Physical and Mental illness

This article distinguishes between physical and mental illness, although there are many interconnections between the two, and what is said in one part of the article complements what is said in the other. I will talk about the person who is looking for the meaning of their suffering and for someone to share it with. This is a basic task for spiritual direction. Illness reminds all of us that we do not live forever, and reminds Christians that we are on our way to Heaven. “By permitting illness, God teaches us to deplore the unhappiness of this life and to desire the happiness of the next.”[4]

I will spend longer on the psychological aspects of illness, because they are closely linked to the spiritual dimension,[5] and because in physical illnesses, especially chronic ones, there are often psychiatric symptoms, which may be disconcerting for the patient and for those who know him or her. The descriptions and suggestions are intended to help understand the ill persons better, so that one may guide them appropriately. Health is not the aim or object of spiritual direction, but spiritual direction does contribute to the person’s well being.

See also: Improving one’s way of being with the help of the saints

Spiritual resources can forestall problems and favor good health. Christians know that good health is not the ultimate value, but they should cultivate it in order to be able to serve God and others better and for longer. The doctor, the spiritual director, and all those looking after the ill person, should work together for his or her improvement, ensuring that they don’t make contradictory suggestions.

The goal of this article is to offer some basic tools and information that may be useful for spiritual direction. Accordingly, the medical or scientific explanations are general and secondary, not offering detailed analysis of pathologies or methods of treatment, which vary according to different medical or psychological pathways and the circumstances of the individual patient.

Anyone who is in contact with people who suffer will benefit from the words in which Benedict XVI sums up the ability to “heal every disease and every infirmity” (Mt 10:1) which Jesus gave to his Apostles. The Pope writes: “Whoever truly wishes to heal man must see him in his wholeness and must know that his ultimate healing can only be God’s love.”[6]

2. Physical illness

In physical illness, a malfunction is initially caused by, or else provokes, a defect in the organs or in a physiological process: for example, diabetes, cancer, or meningitis.

The sick require special care. They need to be treated with the greatest possible affection, since their illnesses can sometimes cause them to react badly to advice or suggestions. This is the experience of masters of spirituality: “When we are ill we can get very tiresome: ‘They aren’t looking after me properly, nobody cares about me, I’m not getting the attention I deserve, nobody understands me…’

The devil, who is always on the lookout, can attack from any angle. When people are ill his tactics consist in stirring up a kind of psychosis in them so as to draw them away from God and fill the atmosphere with bitterness, or destroy that treasure of merits earned (on behalf of souls everywhere) by pain – that is, when it is borne with supernatural optimism, when it is loved!”[7]

Obviously, the first thing to do is ensure that they have the medical care that they need, to end or reduce their suffering as far as possible.

Their rule of life, or plan of devout practices, should be modified according to their individual circumstances, depending on whether they are confined to bed, whether or not they can get out of the house, and so on. They should be offered the opportunity to receive the sacraments, if they so desire, especially confession and Holy Communion, and, where appropriate, anointing of the sick and viaticum.

The feeling of guilt in illness

In the case of physical illness feelings of guilt can arise, (which, as we shall see, are very frequent in the case of mental illness). The spiritual director should guide or channel these feelings, and should nurture in the ill person the peace and joy that comes from knowing that they are children of God. In some cases the guilt may be imaginary. In others it may be real, such as where the illness is the result of morally wrong behavior – infections in drug addicts, AIDS contracted through sexual promiscuity, serious accidents while under the influence of alcohol, and so on. In such cases, without denying the sick person’s responsibility, the spiritual director should help them to recover grace, if they have lost it, and love for God.

Such people will gain great peace of mind by receiving and accepting suffering as atonement and penance, in union with Jesus Christ’s redeeming Passion, while continuing to pray for recovery. Our Lord, who can undoubtedly grant them a physical cure, is still more concerned, so to speak, for their conversion and spiritual health. They can hear, joyfully, the words of the Son of God who became man: “See, you are well! Sin no more” (Jn 5:14).

Types of illness are arranged below in four general groups. In each of them there are countless differing factors, the key one being age. Young people normally think that they will recover, even if suffering from serious illnesses. Older people, although they may hope for recovery, will face their situation differently. The way the spiritual director speaks to each, while always full of hope, should be appropriate to their situation.

2.1 Acute illnesses and minor accidents

When a health problem arises unexpectedly, even though it is a simple one, if it causes a change of plan it can lead to the questions “Why me?” and “Why now?” being asked quite vehemently. This is true even in the case of a sprained ankle or attack of influenza that keeps someone in bed for a week: it is always just the week when so many events were coming up – a daughter’s wedding, an exam, holidays, etc.

In more difficult and risky circumstances – for instance, an operation under general anesthetic to deal with appendicitis or set a fracture – the person gains a greater awareness of life’s limited nature.
From the spiritual point of view, these unexpected illnesses are also important. They are an opportunity to renew self-abandonment into God’s hands, and accept his will. To offer up to God the changes of plans and difficulties, accept them and endure them well and joyfully, is to be “faithful over little things” (cf. Mt 25:14-28), even in the matter of one’s health.

2.2 Chronic and incurable illness

The diagnosis of a chronic, incurable illness brings many new concerns, which increases with the seriousness of the symptoms. Life will not be the same as before, even if only because of changes in the daily pattern: regular exercises, diet, medication, etc. A person diagnosed with diabetes will have to keep to a careful diet, perhaps use insulin, and have frequent blood tests. People with high blood pressure, high cholesterol, renal or cardiac insufficiency, will have to cut down on salt, fats, etc.

A proper understanding of the illness will dispel unjustified fears and enable the right preventive steps or treatment to be applied. People in this situation need to be given optimism. They need to try and see their situation as a sign of God’s love for them. They should try to be constant in offering up the pain, discomfort, tests, etc.; and even offer up the fear or uncertainty when the prognosis is not clear.

There are usually periods when the illness suddenly becomes more severe or more apparent, and at such times the virtue of patience becomes more necessary. When time goes by and the functioning of some organs deteriorates, or the regular treatment becomes a burden, the sick person needs to exercise perseverance, and rejoice in the cross. It should be stressed that the way they bear their illness is an opportunity to help others with their good example, and especially to be united to Christ’s Passion.

To accompany the sick person spiritually with practical tips

They can use daily actions such as taking medicines, measuring their blood-sugar levels, etc., to remind themselves to raise their hearts to Heaven with an aspiration or short prayer, an act of self-abandonment, an act of atonement, or a prayer for the Church, the Pope, all souls, etc. Sick people, especially the chronically ill, have in their hands a great treasure of prayer and sanctification that they can distribute generously.

If a stage comes when these patients can perform very few activities, or their advancing illness reduces their independence, they may experience feelings of uselessness, being burdensome, and being a nuisance to others. Such feelings should be forestalled by reminding them, when offering them the care they need, that they would do the same for the people they love; that they are an opportunity of growth for the people looking after them; and that, by following our Lord in his suffering, they have even greater effectiveness than when they were in full possession of all their faculties. At the same time it is important to recognize the first symptoms of depression or anxiety, which require specific care that will be discussed in the third section below.

They should be helped to set a high value on the Mass, and where possible their family members should be asked to help them to get to Mass. Many old and sick people suffer greatly because they cannot go to Mass. Obviously, if it is impossible for them to get to Sunday Mass, it should be made clear that they are not culpable, and when possible, they can be advised at least to follow it on television. They should be encouraged to let themselves be looked after humbly, which is a privileged way of being united to our Lord.

2.3 Incapacity and dementia

Under the broad heading of chronic illness is a special group of diseases in which the malfunctioning of physical or cognitive faculties brings about a high degree of incapacity. Many people of all ages go through years of dependency on others for their feeding, personal hygiene, movement, etc. This is frequently the case – not always, since the prognosis and clinical outcome varies – of neurological illnesses such as multiple sclerosis (MS), and similar diseases. As always, each patient is different and should be given affection and encouragement in accordance with his or her situation.

The testimony of the sick

Understandably, these patients will experience times of greater discouragement and find it hard to see any meaning in what is happening to them. An extreme case is that of those who have an accident and, from one day to the next, pass from an active life to one of almost total paralysis. To provide spiritual help for someone in this position it is very useful to become thoroughly acquainted with what they are actually experiencing, and the best way to do that is to listen to them. A very valuable resource is the first-person testimony of a Spanish priest, Fr. Luis de Moya, who describes how he tackles the challenge of being left quadriplegic (with total loss of sensation and movement in the limbs) after a car accident; and he tells how, for someone in that situation, “the most painful thing is to feel useless or unloved.”[8]

There is also a set of diseases that involve progressive cognitive or mental deterioration, impeding or preventing normal activity. These are what are known as dementias, which affect up to 15 per cent of people over 65 and up to 40 per cent of those over 80.[9] They become apparent through one or more of the following symptoms: memory loss, impoverishment of language, difficulty in remembering the names of objects or in recalling words (anomia), inability to concentrate, temporal or spatial disorientation, agitation, or loss of capacity for judgment. Initially dementia is only detected by family members, who notice a loss of short-term memory in the person, or that he or she forgets a lot, undergoes character, mood or behavioral changes, and loses interest in things that previously mattered a lot to him or her.

Spiritual accompaniment in Alzheimer’s disease

The most frequent form of dementia is Alzheimer’s disease, produced by degeneration of the neurons. Alzheimer’s alone accounts for between 50 and 60 per cent of all dementias. The life expectancy following diagnosis is very variable, with an average of seven years. The next most common form is that caused by vascular factors (multiple cerebral infarctions). The subjective suffering of dementia patients is greatest in the early stages, especially after diagnosis. Afterwards, suffering increases on the part of their family members, because they often find that their loved one undergoes disconcerting changes in their behavior and reactions, such as feeling persecuted and other delusional notions and psychotic symptoms.

Spiritual help for a dementia sufferer will depend on their state. Especially at the beginning, it is important to transmit hope, foster self-abandonment, and help them to think about the good that their illness can represent for themselves and for the people looking after them.

From the medical viewpoint there are useful strategies and exercises that can slow down the process of cognitive deterioration in some cases. With time, if patients lose the use of reason completely, recourse should be had to the faculties they still possess. It will be helpful to remind them of prayers they learned as children. Even in advanced stages of the disease, they often have periods of greater lucidity. It is possible to pray with them, even though they may not seem to understand.[10] It is always important to treat them with respect, extreme consideration and affection, among other reasons because the capacity to perceive these things, to feel and to express emotions, lasts longer than others.[11]

Parkinson’s disease

Another chronic progressive illness is Parkinson’s disease. It is a syndrome or set of signs and symptoms, including, particularly, tremors when at rest, stiffness, slowness of movement and unsteadiness when standing upright. It affects adults in middle age and beyond. About 30 per cent of patients report symptoms before the age of 50. Between 20 and 60 per cent of Parkinson’s disease sufferers develop dementia in advanced stages of the disease. In many cases, even in very early stages, patients undergo depression, which it is important to recognize in order to deal with it appropriately. Although there is currently no cure for Parkinson’s disease, there are significant medical advances in managing it, and new treatments are being tried. As with other illnesses, family members should be aware of the details of the condition so that they can understand and help the patient better.

Accompanying the elderly in their frailty

Finally, it is worth mentioning debilitating states in old age, bearing in mind that age itself is not the cause of them. Therefore when an elderly person shows signs of deterioration it should not be simply put down to “old age”. Debility in old people can be considered as a syndrome, characterized by a reduction in physical strength and general activity, increased fatigue, slowness and unsteadiness in walking, fear and risk of falling, lack of appetite, and weight loss, to which can be added cognitive loss and depression. It is advisable for them to have a medical check-up and geriatric examination to find the causes of these things. If no specific cause is found, there are various steps that can be taken to improve the person’s overall health: a plan of weekly exercise to improve their resilience, balance and flexibility (going up and down stairs, walking, aerobic exercises, etc.); vitamin supplements, especially Vitamin D, calcium supplements via fat-free milk products, as well as a vegetable- and fruit-rich diet.[12]

Attentive, affectionate care of these patients’ physical and psychological side also helps improve their spiritual health. A more specific prescription for the spiritual dimension is that they should renew their love for God and their efforts to bring him to others through apostolate and Christian example. It is surprising how many older people seem to recover their strength when presented with new opportunities for apostolate and service,[13] and perhaps in this way even their physical and mental health improves, or at least the process of deterioration is slowed down. There are other aspects to be considered in people with these chronic diseases or significant age-related health deterioration, but space does not permit enlarging on them here.[14]

Accompanying those who accompany sick people

People who care for ill people with major limitations or dementia need a lot of support, because it is tiring work that can wear them down, however great their love and supernatural outlook. It is not unusual for them to suffer from insomnia, anxiety, etc. If they are family members, they can be advised to take it in turns to do the caring, or, if feasible, employ a home healthcare assistant or private nurse. In most developed countries there are care homes which are able to look after patients with chronic illnesses or elderly people in need of more attention.

The decision to put a loved one into a care home, whether for day care or permanently, can be a difficult one, about which people often ask for advice in spiritual direction. It is worth pointing out that some care homes are very good, with specialized staff, who can help with the physical and spiritual care and treatment of the ill person, establishing daily routines, looking after feeding, hygiene, medication and many other small tasks that reduce or slow up the process of deterioration.

2.4 Serious illness and the approach of death

When a diagnosis includes the danger of death, questions about the meaning of life and death are crucial. For Christians, death means moving to a new house: it is the door that leads to Heaven. The advice given in spiritual direction should be still more intensely imbued with hope.

Sick people ought to be told about their situation with sufficient time for them to prepare as thoroughly as possible and receive the anointing of the sick and viaticum while they are still fully conscious. However, it is not usually necessary for them to know every detail of the prognosis too far in advance. It should be family members, or doctors in agreement with them, who explain the situation to the sick person, gently, but not employing so many euphemisms that the message doesn’t get through. They should also, obviously, talk about the possibility of recovery, if it is God’s will, and encourage the patient to keep praying for a cure, as a valuable exercise of faith.

For many people the diagnosis will impel them to put their affairs in order. They will want to take leave of their friends, sort out unfinished business, be reconciled with someone, think about their dependants, make or update their will, etc. But above all they should want to prepare as well as possible for their definitive meeting with God.

The spiritual director should foster serenity in the patient’s spiritual life. At the same time they will find it helpful to keep up their normal work and activities for as long as they are able. Children of God who trust in eternal life will be happy to be able to give themselves right up to the end, even though they will not live to see their projects accomplished or to enjoy here on earth the fruits of their last efforts; they know that they will see them, from a better place and forever.[15]

“Terminal illness” is the term applied to the final phase of many chronic diseases, where life expectancy is less than six months. Medically speaking, this diagnosis is given in the case of a progressive illness when all the conventional treatments have been tried and medication is ineffective, and when there is irreparable insufficiency in one or several organs, or irreversible complications such as one or various system failures.[16]

The spiritual director may be consulted, by the sick person or, more usually, by family members, on questions such as “Which means to preserve life are ordinary and which are extraordinary?” “Is it licit to give sedation in the final stages, or use medication that may have the effect of shortening the patient’s life?” “When should we agree to organ donation?” “Is it right to make a living will?” and so on. The spiritual director needs to have made a study and acquired in-depth knowledge on these questions, so that he can reply in accordance with the teaching of the Magisterium of the Church, and obtain expert advice where necessary. In this way he will avoid giving hasty, ill-considered answers.[17]

A fundamental task of those looking after patients in the terminal stages of a disease is to alleviate their suffering and other physical ailments (such as severe breathing difficulties, nausea and other digestive problems), which is often possible through medication, and to keep them company to reduce their anxiety or feeling of powerlessness. This kind of medical attention, known as palliative care, requires specialist staff and therefore it is often the case, and sometimes recommendable, that such patients die in a hospital or hospice. However, it is sometimes possible to arrange for expert palliative care in the home; there are unquestionable advantages in a patient’s being able to spend their final moments in their own home, if they have appropriate medical support. In any case, wherever they are, they need to be provided with a calm, loving environment in which to receive the sacraments and meditate peacefully, in the company of their loved ones, on the love of God who awaits them. “Helping a person to make a good death means helping them to live intensely through the final experience of their life.”[18] If family prayers have been customary, it is naturally good to continue them, as this supports people in their devout practices at a time when they are coming to the end of one stage of existence and on the point of beginning a new adventure – “moving house”.[19]

3. Mental illness

Mental illness manifests itself especially in activity at the psycho-spiritual level, such as feelings, thought-processes, attitudes and behavior. It may be caused by biological, environmental, social, psychological or other factors.

As mentioned above, there is a close relationship between the physical, mental and spiritual dimensions of the human being. In some physical ailments, mental factors may contribute directly or indirectly. Asthma, certain skin diseases, gastric ulcers, and even infections, can be brought on by stress. Psychological symptoms, in turn, may be the result of damage to the nervous system or endocrine system, or reaction to a physical disorder.

On the other hand, there are mental illnesses, such as some forms of depression, which do not appear clearly but are masked by physical symptoms: pain, bowel disorders, etc., may be evidence of a background of depression.

It is not always easy to distinguish between the physical and the mental sphere. When doctors suggest the possibility that some symptom may have a psychological cause, they often get the response, “I’m not crazy, doctor!” This makes some doctors reluctant to enquire further or look more deeply, limiting themselves to prescribing medications that may well have little effect.

It is likewise not easy to determine whether a mental problem has ascetical or spiritual causes. If a spiritual director perceives a possible mental problem, he should point it out to the person concerned, delicately and prudently, without letting the problem drag on indefinitely. If it is necessary to consult a psychiatrist, it is important that the person should look for a reputable psychiatrist with reliable criteria – if possible, a practicing Christian.

There is a broad classification of mental illnesses, but there is generally no laboratory test or obvious physical symptoms for them. Diagnosis is made according to criteria drawn up by medical consensus. The most commonly used classifications are the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), and the International Classification of Diseases (ICD-10) of the World Health Organization.

The distinction between psychosis and neurosis is no longer in use[20]. However, it is vital to recognize psychotic symptoms, because they indicate the most serious kinds of disorder.
Psychosis designates a state in which the capacity to perceive, evaluate and interpret reality is seriously damaged (rupture or loss of contact with reality), impeding a correct view of the world. The main psychotic symptom is the impairment of the capacity to understand or judge reality, shown in strange thoughts, statements or behaviors that are obviously out of keeping with the judgment of a sane person. Speech may be illogical, impoverished or disconnected. Other psychotic symptoms are: delusions, or firmly-held, illogical, erroneous convictions that stubbornly resist reason; and hallucinations or unreal perceptions. Insight into having an illness is often lacking: such people do not recognize that they are ill or that they need any kind of treatment.

The most characteristic thing about people with these symptoms is the incomprehensibility of their behavior, which may have bizarre elements. The observer is up against a brick wall: attempts at persuasion are often ineffective.

Neurosis was the name previously given to non-psychotic illnesses that had no demonstrable physical cause. Neurotics were thought to have a heightened capacity for self-observation, and insight to a greater or lesser extent into the pathological nature of their symptoms. They manage to act, work and behave acceptably. Neurosis is a sort of anomalous, but generally understandable, reaction suffered by the patient to certain situations, whether internal or external. Any of us can respond neurotically to a certain type of stimulus, perhaps because of its intensity or its long duration. Neurosis can take on different pathological forms: phobias, obsessions, insomnia, etc.

Anxiety is part of the response to stress or danger. It produces physiological reactions in a person’s organism: tachycardia, sweating, raised blood pressure and rapid breathing, etc. It is a defense mechanism that anticipates danger and prepares to face it. Everyone has experienced this directly, so we can all understand our own anxiety and other people’s.

If it is not a response to anything real, the anxiety is unjustified. The anxiety could be also disproportionate to the danger. These two situations can lead to what are known as anxiety disorders.

There are also many organic factors that can cause anxiety attacks: hyperthyroidism, hypoglycemia, cardiac irregularities, arrhythmia, lung diseases, intoxication, alcohol or drug withdrawal syndromes, adverse reaction to medication, etc.

Here we will look at just a few disorders. (Obsessive-compulsive disorder will be dealt with separately.) We will begin with panic attacks since they are common, and they show what happens with extreme anxiety. They start with an unexpected and intense sensation of fear and anguish, even without the presence of any real danger. They are manifested in extreme physical signs and symptoms: palpitations, sweating, trembling, suffocation or asphyxia, oppressive pain in the chest, like that of a heart attack; nausea, giddiness, and fear of losing control, going mad or dying. Their onset is sudden and usually reaches maximum intensity in ten minutes; they do not normally last longer than half an hour. They cause great suffering and, obviously, a desire to get away from whatever gave rise to them.

Manifestations of phobias are similar to those of panic attacks, occurring in certain situations. There are many types. Social phobia consists of avoiding situations where the person may be judged by others; there is an irrational fear of ridicule or of behaving inappropriately. Agoraphobia, or fear of open spaces, in case something bad happens and one is unable to get to a place of refuge or find help, can occur in crowded places, when using some means of transport, etc. There are all sorts of specific phobias: fear of animals, of enclosed places, etc.

Post-traumatic disorders are the consequence of life threatening events: accidents, assaults, wars, earthquakes, etc. In addition to anxiety, there are often disturbances of consciousness and memory.
Generalized anxiety disorder begins in the third decade of a person’s life and can be complicated with symptoms of depression. Anxiety and excessive worrying are present almost all day, in many circumstances, for at least six months. It is different from normal worrying in that the person is unable to control it and it leads to continuous tension, irritability, tiredness, difficulties in concentration and memory, sleeping problems, etc. This does not mean that there is a clear line between the normal and the pathological condition, as if there were two types of worrying. The worries themselves are not different in normal and pathological cases; the conditions differ only in the frequency and the effects of worry.

When we experience anxiety personally or see it in others, the first thing to do is try to identify the cause. If no external or internal problem (an objective or subjective reason to be worried) or physiological explanation can be found, the anxiety is probably more related to mental health. There are a series of simple measures to take first:

  • Physiological support: proper care of sleep, regular exercise, preferably with other people, walking for 30-40 minutes every day, relaxation exercises such as diaphragmatic breathing, etc.
  • Cut down on alcohol, caffeine and stimulants; tobacco is used by many people to help calm down, but it can have effects that are prejudicial to health.
  • If the anxiety persists and impedes normal life, consult a doctor. A short course of tranquillizers may be sufficient.

These are real illnesses and, thank God, many of them can be cured. They are not a sign of weakness or the result of personal faults. Early diagnosis and treatment are important to obtain the best results.
The first line of treatment is the cognitive behavioral therapy. Then antidepressants and tranquilizers may be useful. Psychotherapy could also explore possible hidden conflicts that are conditioning the pathological fear, find ways of counteracting the fear, and identify ways of facing life that generate less anxiety. Psychotherapists normally propose progressively more challenging exposure exercises, experiencing anxiety and controlling it by way of small steps forward.

The spiritual director needs to realize that patients with anxiety disorders put a great strain on their family relationships, because their behavior seems incomprehensible and forces others to change their plans, or because of their tension in everyday life. The spiritual director needs to be understanding and patient. Still more than in the case of other kinds of suffering, he needs to remain calm and speak serenely, without entering into arguments about the patients’ illogical fears. He should suggest that patients put all their trust in God who is their Father and brings everything about for the good of those who love him. They should try to “rest in the Lord”, who is our peace and the supreme source of serenity.

The spiritual director must also counsel fortitude, and help people fulfill the duties of their state in life, according to the order of charity, even though they have anxiety while doing it (gradually, they will have less). He must counsel patience, so that the person accepts their anxiety as part of the present moment; they must be helped to embrace it as the Cross for them, rather than running from it by avoiding activities that life requires of them. He must help them live a life guided by their true ideals, and not from the desire to escape unpleasant emotions. A life that consists in one long effort to avoid all anxiety – which effort is the generator, and the essence, of all anxiety disorders – is not a life worthy of a child of God; we are called to so much more. He must also help them live in the present moment, in God’s presence, fulfilling the little duty of each moment with charity; when they notice they are worrying excessively, they need to put their attention back into little things, embracing the Cross of the moment, offered with love: perfect love casts out fear. They should ask for the Gift of Fear from the Holy Spirit, which has the effect of leading them to only be afraid of one thing, the one that really matters – being separated from God.

Obsessions and compulsions can present in several different illnesses. Obsessive-compulsive disorder is included in the anxiety disorders discussed above, but these symptoms can also be present in personality disorders. There also exists an “obsessive tendency” which is not actually a disease but a personality trait or characteristic. We will now look at the most typical illness, Obsessive-compulsive disorder (OCD) within anxiety disorders.[21] It affects approximately 0.5 per cent of the general population.

“Obsession”, from the Latin obsessio, meaning siege, consists of ideas, thoughts, impulses or images which the subject is unable to get rid of. They take hold of the mind and are perceived as something irrational, uncontrollable, absurd and producing anguish. (This is different from the sort of undesired thoughts that many people experience, and that disappear by themselves in the end, frequently occurring in states of tension, worry, lack of sleep or fatigue that tend to make one go over ideas repeatedly.) Moreover, it sometimes happens that if a person tries to get rid of an involuntary thought too forcefully and directly, that very effort intensifies the anxiety and makes it more difficult to get rid of the thought.

“Compulsion” indicates impetuous behaviors or thoughts that accompany an obsession, and are pursued as a way of reducing the anxiety generated by the obsession. It is a powerful impulse to act in a certain way in order to check that a particular thought is not true, or to avoid an imagined danger. The most typical example is to keep washing one’s hands because one is obsessed with the idea of contamination. Such acts only reduce the anguish momentarily[22].

In OCD, the person experiences involuntary and absurd obsessions that they cannot get rid of, and that cause so much worry that they cannot perform their ordinary activities. In most cases, OCD develops before 25 years of age and rarely after 40. The most frequent themes are the fear of being contaminated with germs, doubts such as “Did I turn off the light?” “Did I lock the door?,” tidiness or symmetry, aggressive impulses (e.g. shouting obscenities, absence of control of sexuality), etc.
It is a chronic disease that becomes more intense in situations of stress. It may be complicated by depression, and be linked to other illnesses. There are proven genetic factors in its cause. This illness can also occur in children, because of the body’s response to certain germs that cause tonsillitis.

In dealing with OCD the same measures should be applied as with other anxiety disorders. Not everyone who goes through a period of greater obsessiveness is ill, but if the symptoms do not disappear soon and the anxiety increases, or compulsions appear, the person will need treatment. There are some medications that are effective in reducing obsession and compulsion. Cognitive behavioral therapy is effective, offering ways of channeling and modifying the obsessive ideas and compulsive rituals through exposure and response prevention.

It is important not to encourage the ill person’s compulsions, e.g. by a family member opening doors for them so that they don’t pick up germs, or making it easier for them to keep washing their hands, etc. In response to compulsive and continuous questions, which may also be asked in spiritual direction, such as “Am I doing this right?” “Have I explained this matter in sufficient detail?” “Did I lock the door?” “Did I give the correct telephone number?” etc., the listener should not get annoyed or become sarcastic; nor should they try to soothe them by pretending nothing is wrong. They should say, calmly, that that question has already been answered, and little by little help the ill person to realize their own pathological symptoms. The listener should always behave and answer calmly and smilingly, so that the sufferer can begin to understand their own way of acting and learn how to be patient with themselves and with other people. The spiritual director should help them with the same advice given above for the anxiety disorders.

Mood disorders refer to a disturbance of the state of mind by excess or by defect. They may be unipolar (depression) or bipolar (manic depression).[23]

Depression and mania are two opposite poles. Depression presents as sadness, loss of interest and initiative, slowness in mental processes and physical movement, pessimism, indecisiveness and exaggerated feelings of guilt. Mania, by contrast, presents as irritability or euphoria, psychological excitement and rapidity of movement, uninhibitedness, causeless optimism, an exaggeratedly high estimation of one’s own capacity, multiple ill-thought-out projects and activities, etc. In a milder form, it is “hypomania”: these are people who frequently live at an excessively high level of irritability or euphoria and are hyperactive and impulsive.

Mania has an adverse effect on the capacity for judgment and social behavior. It leads people to make snap decisions with disastrous results in family or money matters, and leads to wrong acts, for example in the area of sexuality. A manic episode causes great surprise, comes on within the space of a few hours, and may be accompanied by delusions. People suffering from mania are noticeably excited, with multiple plans and projects, enormous physical energy, and little need of sleep. This kind of extreme pathology should be distinguished from sadness and joy, although there is no hard and fast line between them. In the pathological state, there is no proportion between the stimulus and the reaction, and there is dysfunction in the person’s personal, professional or relational life.

There are many conditions that affect mood. There are temporary depressions, in reaction to festivities when a member of one’s close family is missing; anniversaries of sad or painful events; or, in women, of premenstrual dysphoria. They can also occur in situations of prolonged work-related stress, such as the “burnout” experienced by people whose work is helping others (health workers, social workers, teachers, etc.) and are subject to constant emotional tension because of their contact with physical or mental suffering. Fatigue can be normal, or it can be a sign of mental or physical illnesses, such as anemia, hypothyroidism, diabetes, infections, etc. In attention deficit disorder with hyperactivity (ADDH) in adults, occurring as the prolongation of the childhood condition, anxiety and depression are frequently present.

There are certain critical periods of life that tend to favor the appearance of symptoms of depression, such as adolescence, the midlife crisis (the 40s), or old age. The process of menopause, which represents the end of the woman’s hormonal cycles, is a biological factor that can affect mood and trigger depression. It occurs around the age of 50 and includes numerous symptoms of varying frequency and intensity: hot flushes and sweats, difficulties in sleeping, dizziness, tachycardia, tingling sensations, joint and muscle pain, intestinal problems, etc. Hormone replacement therapy may be efficient but has adverse effects that must be evaluated by the physician.

The exact cause of mood disorders is unknown. There is an interaction between various factors – biological (hormonal changes and cerebral neurotransmitters), genetic, psychosocial (stressful situations in the areas of emotions, work, or relationships), and personality factors. The genetic factor is significant, especially in bipolar disorder. Some personality traits known to favor depression are emotional instability, pessimism, and perfectionism. There are also certain pharmaceutical drugs that may produce depression, such as some used for treating high blood pressure, Parkinson’s disease, cancer chemotherapy, contraceptives, etc. Sometimes depression is associated with organic diseases such as Parkinson’s, Huntington’s disease, and some cancers.

Before going on to describe mood disorders, it will be useful to clarify the terminology. “Major depression” refers to the classic depressive episodes, which will be discussed further. (The term does not indicate much greater severity, but the number of symptoms.) “Dysthymia” is a less severe but chronic form of depression (formerly called neurotic depression), which appears to be connected with personality disorders and this association complicates treatment and prognosis, as there are two problems to be solved. There are “reactive depressions”, triggered by an intensely emotive event such as the loss of a loved one, the break-up of an emotional relationship (engagement or friendship), loss of work, diagnosis of a serious illness, etc. This is sometimes contrasted with “endogenous depression”, in which no external cause is found, and therefore is due to cerebral biological alterations.. Reactive depressions are also related to “complicated bereavement” – depression originating with the death of a loved one, which is prolonged excessively or of unusual intensity, with guilt or bizarre ideas that may be delusions. There is also a fluctuating form of sadness and euphoria that lasts hours or days and does not reach the severity of depression or mania: this is called cyclothymia.

Depression

After anxiety disorders, this is the most common mental illness. In one form or another it affects up to 15 per cent of the population at some stage of their lives. The key symptom is persistent sadness, with loss of interest and loss of the capacity to enjoy any or almost any activity. A common sign is the inability to experience joy or “feel things like before”. Other symptoms are: slowed thinking and movements, insomnia – sufferers frequently wake up very early – loss of appetite and weight loss, difficulty in concentrating, diminished libido, and suicidal thoughts. There are often ideas of guilt, ruin, damnation and death, which may reach delusional intensity. There are also somatic manifestations such as headache, pain, tingling, dizziness, intestinal disorders and cardiovascular diseases. When these symptoms have lasted more than two weeks, a depressive episode is established.

The German psychiatrist H. Tellenbach defined Typus melancholicus in a large number of these patients, which consists of an excessive desire for order in relation to the world and a high demand for themselves, which affects their professional lives and their relationships, and can cause scruples and intolerance for the slightest sense of guilt. It is common to find the following characteristics exaggerated: perfectionism and desire for order, responsibility and honesty, sensitivity, self-imposed intolerance, sense of duty and inflexibility, search for optimum performance, self-esteem dependent on the opinion of others, changing mood, and obsessiveness. This way of being, similar to what today is known as obsessive-compulsive personality or anankastic personality makes a person live under great mental strain and, with age, can cause depression.

The spiritual director must channel these traits in order to develop their positive aspects. This contributes to prevention, although depression is not a sign of weakness nor a condition that depends on the will of the person. Depressed people do not feel better by making more effort, nor by showing goodwill, nor by their struggle against being depressed. Vulnerable or fragile personalities can be modified by changing their way of life.

Bipolar disorder

Bipolar disorder used to be called manic-depressive psychosis, underlining the presence of psychotic symptoms. It consists of alternating periods of depression like those described above, periods of mania, and periods with no symptoms. Both phases usually appear at a young age. A single clear episode of mania is sufficient to make the diagnosis and distinguish it from unipolar depression.

Bipolar disorder sufferers may have frequent relapses and require lifelong treatment with mood stabilizers (such as Depakote or lithium). Mania requires urgent medical attention.

How to deal with mood disorders

Ways of helping someone with a mood disorder will depend on the situation or phase they are in. For mania, as with psychotic symptoms, words are not much use; medication is required. In depressive phases, the support of spiritual direction is useful in enabling them to understand the problem. But they also require medication. Between crises, or after recovery, it is useful to identify, with the help of experts, the character features that predispose the person to depression.

During therapy family members, friends or the spiritual director can back up the advice of the therapist, and reassure the patient that good results will be obtained through the medication, which begins to take effect after two to four weeks of treatment. Depression is a treatable disease: two-thirds of patients respond well to the first medication prescribed. Complete remission is achieved in over 80 per cent of cases. In the most serious cases, as when suicidal thoughts or delusions occur, hospitalization may be necessary.

There are no general rules about how to help these people: each person is different, and needs to be treated differently. They will be helped by something that takes them out of themselves and brings them to look at God and other people, as cheerfully – with the joy that comes from being a child of God – as they are able. They need to try and control their imagination and live each day as it comes. The spiritual director should listen to them calmly, and let them come and talk as often as they need to. They will not be helped by comparisons such as “there are plenty of people who are worse off than you”.

If people with these disorders refuse medication, they should be told something that the doctor will probably have said to them already: that the medications in use today do not alter one’s personality, change the way one thinks, or interfere notably with one’s work or social life. Nor are they addictive, even when used for months or years. What they do is help the person out of the depression.

People with these disorders should be helped to stand back from the way they feel, not identifying themselves with their state of mind or mood. They should be given reasons for hope, and should be asked for trust and patience. It is worth putting forward positive arguments such as the fact that they will gain experience, and greater self-knowledge, and so be in a position to help others. They should be helped to avoid constantly looking for a cause or reason to explain their situation, because that increases the tendency to self-criticism and produces feelings of guilt and powerlessness.

They can offer their sadness up to God – and can also do this in retrospect, when they have recovered and view things more objectively – with the joy of faith, which is neither physiological nor psychological. They need to be helped to understand that God permits these illnesses, which we have to learn to sanctify, because we know that all things work together for the good of those who love God (cf. Romans 8:28). They should try to understand that what they have is a illness like any other: a treasure from which they can bring forth many good things. In no way is it to be considered a punishment. And so, omnia in bonum! Everything is for the best! They should also bear in mind that the fact of offering up their illness does not mean it will suddenly vanish.

It is essential that they should feel understood. The area of feelings and affections is distorted in these ill people, so they need proof that they are understood, loved and supported. Sometimes it is more important for them to talk freely than to receive advice. There is the risk that they will take simple suggestions made in spiritual direction as though they were orders or rebukes.

In so far as is possible, they should be helped to rely trustingly on God, our Blessed Lady and the intercession of the saints. They should be encouraged to pray before the Tabernacle, take care of their mental and vocal prayer, their filial conversation with their Father God, self-abandonment, and spiritual childhood. It is worth recommending texts and topics for their personal prayer; sometimes simply looking at photographs can enable them to turn to God in acts of thanksgiving, praise, etc.

They should be encouraged to make abundant prayer of petition and given intentions to make petition for: the Church, souls, etc. Suggestions and goals need to be easy and specific, achievable and stimulating; and proposed in a way that takes the individual into account, fostering his or her autonomy and freedom of spirit.

Ruminations on their feelings or problems, if they occur, can be used to help them to pray. Rather than trying to block them directly, they should try not to give them any importance, but use them as calls to attention, or reminders, for their devotional life. That can be the very best sign of faith. The spiritual director should suggest little things they can do to increase their awareness of being in God’s presence and that they can look forward to doing, or at least feel able to do. In all of this they need to seek conversation and friendship with the Holy Spirit.

If they have the custom of making a daily examination of conscience, it should be short. It is enough for them to consider a few points and make a small resolution, such as saying a brief invocation the next day. An excessive desire for self-examination would not be good for them.

Most sufferers from mood disorders, with treatment, can carry on with their work, family life and devotional practices almost from the onset of symptoms or very soon afterwards. There are not usually sufficient reasons for them to miss Mass or drop other devotions they may have, such as saying the rosary or spending some time in mental prayer. In general it is beneficial for them to follow a timetable, getting up and going to bed at a fixed time. Care should be taken so that they do not sleep more than is necessary, as excess sleep could turn into negative sleep, in which the brain is being more taxed than restored. The doctor can help decide on the details of their daily regimen.

They should try and keep their time occupied and not be idle. They should make a point of not being lonely or shutting themselves off from others, and should be given practical ways to avoid doing so. It is not a good thing for them to be habitually alone, or to get away from others for instance on weekends. Family members should take the initiative and suggest things to do, ask what they would like to do, and sort out who could go for a walk or go shopping with them, etc., though without insisting if they are reluctant.

If they fall into acts contrary to the virtues, by way of lack of sobriety, sensuality, etc., they should be helped to see that when one feels unable to behave well, behaving badly is never the answer. Illness can never be an excuse for consenting to acts contrary to the moral law. Notwithstanding, there are pathologies that diminish the moral responsibility of some choices and even, in extreme cases such as psychosis, destroy the patient’s freedom. God’s love and his grace, which is never lacking, enable us to nurture our spiritual health.

In periods of depression, it may be more difficult to fight temptation, among other reasons because one’s defenses are weaker and one has fewer mental resources available to combat them with. The sick will be given renewed peace of mind by being reminded of the difference between feeling and consenting, the importance of acts of contrition and acts of thanksgiving.

During a period of depression, or when taking stock after the most severe phase has been overcome, people may feel they want to break away from their previous life: their marriage, their vocation, their occupation, their profession, etc. They should be helped to see that a time of mental illness is not a good time for taking important decisions. They should wait until they have properly recovered and then think about it carefully. In any case, they need to realize that there are some obligations to which they have freely committed themselves, and which therefore they cannot simply walk away from. To leave such duties unfulfilled would harm not only themselves but also other people, such as their spouse and children. God will not abandon them, and will give them the strength to continue faithfully along the path to which he has called them.

Thoughts such as these offer an opportunity to help them see things that need to be changed. Rather than destroy, perhaps irremediably, something that they formerly valued, they will need to sort out, with help from their doctor, aspects in which they were not living as they should have: where there was perfectionism, sterile activism, a “double life”, a problematic relationship to authority, personality problems such as those dealt with under the next heading, etc. Sometimes cases of exhaustion due to overwork, which also occurs in people who dedicate themselves to Christian apostolic undertakings, can be prevented by sufficient rest, a change of activity to pursue a range of interests, exercise, support from family members, good self-knowledge, help with improving personal relationships, and a realistic view of things: work is a means and not an end. God wants to make use of Christians in spite of our personal limitations, which we should accept without either denying them or exaggerating them. What is done for love of God always has a good effect, even though we may not see it straight away.

Anyone who is going through situations like these needs to be spoken to with great kindness, including references to the virtues they possess, the good that they have done and can continue to do. “Physical collapse. You are worn out. Rest. Stop that exterior activity. Consult a doctor. Obey, and don’t worry. You will soon return to your normal life and, if you are faithful, to new intensity in your apostolate.”[24]

The personality is formed throughout a person’s lifetime. It is a dynamic (meaning changing and modifying over time) organization, of the whole psycho-physical system that affects a person’s way of thinking and behaving.[25] It is the result of interactions between constitutional, environmental, social etc. factors, in which religion plays an important role.

Two elements are usually distinguished in the make-up of a personality. The first is temperament or “nature”, with the physiological substratum of the functioning of the psyche: the set of inherited characteristics that grow and develop from birth. The second is character, or “nurture”: aspects of the personality that are acquired through external influences, such as upbringing, education and training, social interaction, socio-cultural conditioning, etc.

There are many ways of classifying people according to temperament or character, and still more attempts to define what a mature personality is. Without going into details, it could be said that for a Christian, a mature personality is one that comes closest to our model. “(…) You need to have your own personality, agreed. But you should try to make it conform exactly to Christ’s.”[26]
Both good, virtuous acts and bad ones affect the personality, enriching or impoverishing it respectively. There are some character traits that are considered dangerous, because they impede maturity and adaptation to one’s environment, and can generate some type of mental pathology.
Examples of such traits are perfectionism, activism, impulsivity, insecurity, narcissism, and obsessiveness.

When these traits or characteristics go beyond a certain limit is when illnesses or personality disorders start. These are negative or pathological features that are constant, rigid, and influence the subject’s whole life and way of living it. They present as structured, particular ways of thinking, perceiving reality, and/or relating to the world and other people, which are clearly different from what is to be expected in that culture or environment. They manifest themselves in all areas: knowledge, feelings and emotions, control of impulses, and personal, social and professional relations. They give rise to a strong sense of existential emptiness and much suffering.

Personality disorders begin to cause problems in adolescence or in the first years of adulthood. To be diagnosed as disorders, the features have to be completely inflexible, not just momentary, and not just adaptations to particular situations. They also have to significantly impede the person from functioning normally, or cause subjective suffering. Although they are usually stable in time, with appropriate psychotherapy they can improve notably.

An understanding of these disorders enables one to help many people as well as to know oneself better. These disorders should be distinguished from ordinary defects, although some ways of dealing with them will be similar. The exact cause of personality illnesses is not known. A part is played by genetic factors and the person’s developmental process: family problems, especially lack of affection or abuse in childhood, upbringing, interpersonal relations and negative experiences. People with an intense spiritual life possess an added weapon to overcome anomalous traits.

The Manual of Mental Disorders (DSM-IV-TR) groups them under three headings, with a lot of overlapping.

  • Group A: paranoid, schizoid and schizotypal personality disorders. These people seem odd or eccentric.
  • Group B: antisocial, borderline, histrionic and narcissistic personality disorders. These people are very emotional, dramatic and erratic.
  • Group C: avoidant, dependent and obsessive-compulsive personality disorders. These are people with deep-rooted fears and anxiety.

We can take a brief look at the characteristics of each of these personality types.[27] Schizoid: cold and distant, with little emotional experience, solitary, reject social relations. Schizotypal: Extravagantly eccentric thoughts and behaviors; formerly diagnosed simply as schizophrenic; often have a family history of schizophrenia and in stress situations can suffer psychotic episodes similar to schizophrenia. Paranoid: cold and distant in social relations, constantly suspicious of others, harbor many grievances.

Antisocial: do not obey moral or social rules; lack empathy and guilt; frequently fall into drug use and other addictions. Borderline: about 75% of sufferers are women; very impulsive, anxious and irritable; sudden mood swings between anger and happiness; unstable in social relations; paranoid ideas and often self-harm, attempting to neutralize their mental suffering with physical pain.

Histrionic: dramatic; intensely emotional; react badly if they are not the center of attention; seductive or provocative. Narcissistic: unreal ideas of grandeur; feelings of superiority; believe they are special or unique; use others for their own ends; envious; lack empathy or any capacity for realizing what is happening around them or the needs of others.

Avoidant: avoid any risk situation, and interpersonal contact – even though they would like it – for fear of rejection, embarrassment, ridicule or humiliation; see themselves as inferior to others; afraid to speak in public or be the center of attention; suffer isolation. Dependent: pathological dependence on others; incapable of deciding for themselves; overwhelming fear of being abandoned due to their great insecurity, leading to a totally submissive attitude. Obsessive-compulsive (or Anankastic personality disorder): perfectionist, inflexible and excessively concerned with order and tidiness; hate errors and find it difficult to take decisions for fear of being wrong, which leads them to lose other people’s respect and produces a deep sense of inferiority; exaggerated care for details, rules, list of things to be done, which make them feel useful and valued; workaholic; inability to delegate, out of distrust and a desire to control; frequently fall into scruples.

Prevention seems possible by fostering a healthy family atmosphere and identifying danger-signals early; it is easier to remedy these things in young people since their personality is more pliable. This is the parents’ responsibility in the first place, but it also falls to teachers and to a certain degree to spiritual directors. Personality disorders are formed over years, so recovery will likewise take time. The anxiety and depression that often accompany these disorders need to be reduced, and interpersonal relations need to be redirected. Medication is less useful with these disorders than with others.

Contact and dialogue with these patients is hard work and demanding, so patience is key. Calmly and serenely, the spiritual director should tell them how their way of behaving looks from the outside. He needs to be extremely gentle and sensitive, to avoid hurting them or reinforcing their conviction that “people do all they can to annoy me”. It is important to avoid sarcasm, in word, attitude or expression. If the person is angry or upset, as they often are, it is all the more important to maintain one’s calmness and self-control. A calm and peaceful speaker normally gains the upper hand over one who is upset and troubled; the exchange needs to be peaceful and conciliatory.

People with these personality disorders often do not consider themselves ill, so it is hard to get them to seek medical advice. They need to be given the hope that they can do a lot, with professional help, to change their own behavior and the way they relate to themselves and others, and to give their life a new direction. Accepting the difficulty is the first step to changing. Obviously, it is beneficial for them to go to the Sacrament of Reconciliation as often as necessary: they will receive effective help from God’s grace, which leads them to discover faults and sins that they may or may not have been aware of; and from the forgiveness they receive. Sometimes it is vital for them to learn to forgive and forget past grievances themselves. If they have ideas of self-harming or psychotic symptoms, they should seek medical help urgently.

In practice, it is common to meet people with some negative traits – everyone has one or two – that are not at the level of a personality disorder, because they are not sufficiently intense and because they do not seriously impede the person’s normal functioning. It is not always easy to distinguish between a personality disorder, a pathological character trait, a simple passing defect, and psychological immaturity[28]

When there is significant or lasting subjective unhappiness or negative external consequences such as family conflict or difficulties in socializing, there is probably a personality problem and it is advisable to consult an experienced doctor. Although it may not be an illness per se, medical or psychological help may be beneficial. It is risky to leave such things alone, since this may delay a diagnosis or enable dangerous traits to become more pronounced and rooted.

People who have marked character defects should also recognize their problem for what it is. They should be encouraged to confide in people who know them and want to help them. Recognizing what they themselves are like is closely linked to accepting what other people are like, and this lies at the basis of the virtue of humility, which regulates our self-esteem and the esteem we have for other people. That self-recognition has to go together with the effort to overcome a difficulty or correct a defect, relying on God’s grace. We can look at some examples.

It is worth paying particular attention to people who are excessively centered on themselves, and are incapable of seeing anything good in other people or the world around them; people who constantly get irritated or upset by events and other people’s behavior – “I just can’t stand the way they dress/eat/speak”; people who are quick to judge and condemn – “Why must they do things like that?” which simply means “Why don’t they do things the way I do?”; people who see everything in self-referential and pessimistic terms. Many serious character faults cover up a common factor, a sort of “culture medium” for the growth of various dangerous features: egocentrism.[29] However, people should never be labeled – “That’s just the way they are.” It is always possible to change, even though the struggle, or the serene and constant effort, may last one’s whole life.

A first negative feature that should be pointed out is perfectionism, which at a pathological level is observed in the obsessive-compulsive personality disorder and in some people suffering from depression. It may be related to pride: trying to do things well for love of oneself and not for love of God. But it is also possible that its roots lie not so much in pride as in the person’s character. These are people who live focused on the future, with little tolerance of things left undone, and strongly dependent on other people’s opinion. It frequently goes together with fear of uncertainty, hyper-responsibility, and activism.

St Josemaria wrote in The Way: “Hurrying, hurrying! Working, working! Feverish activity, anxiety to be up and doing. Marvelous material structures… Where spiritual things are concerned: broken up boxes, cheap cotton, painted cardboard, hurrying, working! And many people running here and there. It is because in their work they think only of ‘today’; their vision is limited to what is ‘present’. You must see things with the eyes of eternity, ‘keeping present’ what has passed and what has yet to come… Calmness. Peace. Intense life within you. Without that wild hurry, without that frenzy for change, you can work from your proper place in life. And, like a powerful generator of spiritual electricity, you will give light and energy to very many, without losing your own vigor and light.”[30]

The goal that should be proposed to some perfectionists is to keep their eyes spiritually on Heaven, so as not to make tidiness, order, punctuality or any other virtue into an end in itself. They need to try and accept, serenely, the fact of being human, i.e. by definition imperfect, living in an imperfect world and surrounded by other people who are also imperfect. An indispensable step is for them to have the humility to recognize that they are merely “hurrying” meaninglessly and need help.

They have to “see things with the eyes of eternity”: discover the meaning of human and divine love, and the fact that God is waiting for us. They need to begin again and again, without getting tired of it, exercising patience towards themselves as well as others. They need to be helped to realize that what matters is not doing things, but doing them for love of God and other people, with “intense life within” that overflows to “give light and energy to very many”, learning to listen to them and forgive them. They need to learn to open up to other people, to enjoy being with their family and friends, even though they think they are “wasting time”.

The goal for them is to do things out of inner conviction, “because I want to”. They have to accept that it is not possible to manage everything. The desire for a healthy and virtuous life is not the “I want” of a child determined to get what he likes – an ice-cream, a treat – but an “I want” that is rooted in maturity: “I want because I make my own the thing I am aiming for”, because through my commitment I share the same goal, for love of the person who gives me the job, piece of work, etc.
They need to be convinced that God does not ask us to “hurry” to do more things, or more difficult things, every day, like performing animals in a circus.

God normally asks us to do the same things every day, but with ever-growing love. What is useful is to make small resolutions, and to remember that Christian life is something joyful. In practice, it will help these people to have a pastime, hobby or activity that will help them learn to enjoy everyday things. They should practice being flexible, accepting changes of timetable or changes of plan, and offering small setbacks to God with a smile.

The spiritual director should help them to develop a positive attitude, looking for the good points in other people and in themselves; learning to laugh and accept that they make mistakes. They should not feel called upon to solve the whole world’s problems. Simplicity and self-abandonment to God are of great importance.

In an appropriate context they can be set “exercises” aimed at diminishing the negative aspects of their character. For instance, if someone is overwhelmed by the feeling that they have to correct instantly something they see as wrong, it is worth advising them to wait for a day or two before saying anything. Someone who never finishes a job because they don’t think it is perfect can be reminded that “the best is the enemy of the good”, or advised to do something “less than good” on purpose. Someone who never has time to have fun or rest should draw up a timetable that includes leisure activities, and follow it. Someone who thinks that they are in the right, or they are the only ones who can do things properly, may be told to let other people act, and learn to seek help and ask for advice. If someone tends to judge others harshly, they could be asked to make a daily effort to speak and think well of everything and everyone, without snap judgments that are often wrong.

A second negative character feature is emotional instability. People’s moods normally change for all sorts of different reasons, but some people are subject to continual abnormal fluctuations of mood. All their feelings, emotions and passions are amplified or flattened. These people tend to be very sensitive or sentimental and to hold on to real or imagined grievances for a long time. This susceptibility flares up at times in disproportionate reactions to minor stimuli. They often have a negative self-image: “I’m no use”, “Nobody loves me”. They create strong dependencies and are very selective in the way they treat others. They go in for jealousy and comparisons: “Why them and not me?”, etc.

It is good to talk to them, and get them to talk, about the certainty of being God’s children, the need for self-forgetfulness and humility. They should be helped to speak about their emotional life, any envy they feel and comparisons they make. They should be shown the meaning of the Cross, so that they can their fortitude and temperance. They should develop their autonomy so as to take responsibility for their decisions, ways of acting and opinions, which is compatible with a healthy mistrust of their own feelings.

By following this route they will learn to act out of love, without paying too close attention to their own moods. They will learn to forgive offences and be honestly happy about other people’s good things and virtues. Something they can pray for is the gift of seeing through Christ’s eyes, making their own St John the Baptist’s desire: “He must increase and I must decrease” (Jn 3:30).

A third trait that predisposes to illness is the tendency to pessimism and sadness. This is sometimes found in people who are complicated and introverted and do not react well to difficulties. They are usually insecure and irritable. They tend to isolate themselves, shut themselves up in their inner world, and feel misunderstood. They may have suffered experiences in the past that they have not assimilated; perhaps some that they are ashamed of and have never talked about or confessed in the Sacrament of Reconciliation. Sometimes these things are small matters that they have blown up in their imagination. Externally they are formal in their behavior and tend to act out of duty rather than for love of God.

These people may be helped by talking to them about cheerfulness as a virtue, and how to practice it. They should be encouraged to practice smiling, and having an expression that radiates peace, like Christ’s. They need to learn to de-dramatize external or internal situations, including defects. They should be helped to get to know their own feelings and perceive other people’s; and to understand how feelings are formed, so that they are not afraid to show them and talk about them. It will help them to get involved in activities with other people, sharing time, joys, setbacks and interests together. They should leave behind self-pity and self-isolation and learn to work in a group, without relying exclusively on their own abilities.

As practical exercises, they can be recommended to try and do things well for love of God and others, including when they don’t feel like it or don’t initially enjoy it; they should believe that others understand them, even when they imagine they don’t. They should act peacefully, convinced that they are doing things well, except if they are told otherwise on some specific point: in that case they should ask for help in putting the thing right.

A distinction should be made between the foregoing cases and that of people who experience situations of sadness and abandonment as trials sent by God. A discussion of this phenomenon would be outside the scope of this article, but it is one that has been experienced by many saints. Their advice may be useful to anyone who is going through times of discouragement or even depression. St Theresa of Lisieux, in the middle of such an experience, exclaimed, “Despite this trial, which takes away all my happiness, I can say nevertheless: ‘Lord, you fill me with joy by all that you do!’ (Psalm 94: 4) Is there any greater happiness than to suffer for love of you? The deeper the suffering, the more hidden from others’ eyes, the more joy it brings, O my God!”[31]

This is how St Josemaría put it: “Grant me, Jesus, the Cross with no Simon of Cyrene to help me. No, that’s not right; I need your grace, I need your help here as in everything. You must be my Simon of Cyrene. With you, my God, no trial can daunt me… But what if my Cross should consist of boredom or sadness? — In that case I say to you, Lord, with you I would happily be sad.”[32] If the depression or sadness does not go away, at least the subject’s attitude towards it changes, and that itself facilitates recovery.

Another trait appearing in people with a tendency to depression is insecurity. The advice they need is similar to that recommended for perfectionists and for what will be discussed below for the scrupulous. Insecurity can increase when they come up against their own limitations: someone who thought that they knew everything and were the best at everything, realizes that they were mistaken, that there are many things they haven’t learned or that they cannot change at will. Sometimes trauma over physical or mental defects, whether real or imaginary, can intensify the problem.

Sufferers from insecurity tend to look for thanks and acceptance from others. They fall into making comparisons, and are dependent on “what people will think”. For fear of failing or looking stupid, they may opt to do nothing at all, stop taking decisions, and not even ask for help. They may end up in sadness and isolation, and not infrequently behave brusquely in self-defense. They are usually rigid in their personal opinions and on specific topics. As adolescents they are inclined to be competitive, especially in their work. As young professionals they embrace activism.

They need to be convinced that God’s children take decisions in the knowledge that they may be mistaken. They have to realize that one-hundred-per-cent certainty is not possible on this earth. They should practice making acts of contrition, as joyfully as children returning to their father’s arms. They can change if they discover that our security is in God, and learn to act in his presence; and if they accept that “It is true that life, which by its nature is already rather narrow and uncertain, sometimes becomes difficult. But that will help you to become more supernatural and to see the hand of God. Then you will be more human and understanding towards those around you.”[33]

To forestall the development of insecurity, when raising or forming young people, it is better not to give them everything ready-sorted in advance, but to foster their personal initiative. They should set themselves achievable goals and realistic objectives. They need to be given a sense of genuine security and helped to discover the immense value each individual has as a son or daughter of God, redeemed by Jesus Christ. Like that they learn to tackle life here and now, without dreaming of unreal scenarios, and they learn to practice and develop their capacity for taking decisions. “Man’s freedom is always new and he must always make his decisions anew.”[34]

A final feature to mention is the victim complex. The connotations of this term are worth looking at, as they highlight some of its characteristics: self-pity, laments, protests, complaints, and narcissism. People who are inclined to have a victim complex normally see themselves as martyrs or as being sacrificed, in whatever happens to them. They have great difficulty in accepting God’s will, but equally in accepting ordinary everyday events, such as when something doesn’t turn out as expected, or when illness comes.

In a way they are like sufferers from paranoia: everything is against them. They don’t actually have delusions, except when paranoia itself sets in. The victim complex is part of narcissism, with the same fixation on the self. Such people constantly find reasons for lamenting and feeling oppressed, undervalued or incapable of doing anything. They have a distorted self-image that fluctuates between self-admiration and self-contempt. They are over-sensitive and easily hurt by the slightest thing. They interpret other people’s words and actions, never taking what is said to them at face value.

The spiritual director should help them to meditate on the passion of our Lord, who is the only real Victim. If that is accepted, they are basically out of danger. The thought that Jesus Christ suffered for mankind although totally innocent, opens up horizons of self-giving and makes the false idea of being a victim vanish or at least diminishes it. It makes room for happiness and enables a person to overcome any suffering, real or imaginary.

The etymology of the word “scruples” reflects the type of discomfort it causes: it comes from the Latin scrupulus, a small sharp stone, the type that gets in one’s shoe and causes acute discomfort until one can get rid of it. That is like the anguish and fear aroused by the obsessive ideas of people suffering from scruples.

Scruples usually do not last long. If they do not disappear quickly – as in young people or in those who are starting out on a spiritual path –, then they could be a sign of a mental illness that requires medical diagnosis and treatment: these are common in obsessive-compulsive disorders and in perfectionists and insecure personalities.

Scruples are of different kinds: immoral thoughts in specific places or situations, ideas of being damned, continuing worry about sins that have already been confessed, etc. They may be accompanied by compulsions, such as repeatedly going to confession,repeating prayers, running to exhaustion, or beating oneself to flee from temptation. If the signs were striking and did not yield to the usual advice then the need for medical assistance would be clear.

It is important to distinguish scruples from a delicate or sensitive conscience, which many people have. In such cases, the person sees their defects and faults serenely, and is hurt by them out of love for God. The person concerned is discovering that grace is making a greater demand on them, or that God is asking them for increased self-giving.

When young people say they “have scruples”, it may simply be that they have a problem with a badly-formed conscience or as a result of not speaking sincerely. Obviously, they should not be contradicted, but they should be helped to get things clearly sorted out, in case there are unresolved matters of conscience. The spiritual director should be gentle, without forcing their confidence or being overbearing, to encourage the person to open their soul wide, with a supernatural view and with the sorrow that comes of love.

In helping people who are scrupulous the first thing to do is use the supernatural means, praying that they will recover sufficient serenity of conscience. The next thing is to explain to them the psychological mechanism which sometimes produces scruples:  “anticipatory anxiety”. It consists of building up a vicious circle in which persons are afraid of having certain thoughts, and then keep having them because they fear having them; they then fear what it means that they keep having the thoughts, and the cycle continues. This phenomenon is cut short if such thoughts are shown to be unimportant, if possible with the right kind of humor, and if the person understands that their thoughts are distinct from themselves. This means distancing oneself from those thoughts. The spiritual director could say, for example: God is more pleased with you accepting that you may be wrong and that you have doubts, than if you were sure that you hadn´t offended Him.

They have to be convinced that the happiness and peace of the saints, their sense of security amidst all trials, comes from God: “His mercy I never doubted; myself, often.”[35] They need to be helped to laugh at themselves, not to be afraid but to love. A properly formed conscience leads one to serenity and enables one to put to good use even things that can harm the soul – an indecent picture, a provocative advertisement, the bad example of people in public office – to turn one’s mind to our Lord and our Lady, to pray more intensely.

It is useful to remind them of some basic principles of moral theology. For instance, when someone habitually practices a virtue, and that person has doubts over whether a particular act contrary to that virtue was a mortal or a venial sin, the assumption is that it was venial. By contrast, if someone is not generally in the habit of practicing that virtue, in case of doubt the presumption would be that it was a mortal sin. What a soul in love wants is never to offend God in anything, and such people hate deliberate venial sins as well, but there is a radical difference between venial sins and mortal ones. It should be stressed that venial sins can be forgiven with an act of contrition, the use of holy water, receiving Holy Communion, and, obviously, through regular Confession; but they should not bring their normal Confession forward out of scruples, only if they are certain that they are in a state of mortal sin. To want to define the exact degree of sin, with the precise percentage of goodness and badness, is usually of concern to those with scruples.

It is useful to keep stressing the love of God, who seeks us as the best of fathers, and the divine filiation that enables us to respond trustingly to his call as much-loved children. They need a proper understanding of virtue (and to learn to live accordingly), law, conscience, and above all the action of the Holy Spirit in souls through grace and the sacraments; and in practice, they need to understand that there are many ways of pleasing God and that each person has their own way, in Jesus Christ, guided by the Holy Spirit, of reaching him.

When resolving their concerns, the spiritual director should, while taking the person seriously, show that their problems are not major ones. This can restore their peace of mind and give them serenity. They will be helped by being asked quite firmly to follow the advice they are given. It may be useful to explain to them how to make better use of the Sacrament of Reconciliation, by limiting themselves to stating the facts, and recalling that the priest, and not the penitent, is the judge; and that obedience to the confessor’s advice is the best way to develop a properly formed conscience and get rid of scruples.

It is necessary to simplify the person’s interior life and encourage them to increase their trust in God. They should learn to make a simple examination of conscience, with just a few questions; what matters is God’s light, not the introspection which they tend to indulge in. It is recommendable that they limit their examination of conscience to a few specific questions. The value of self-forgetfulness should be stressed, and they should be encouraged to work hard and be concerned for other people, because this is a splendid resource both humanly and supernaturally, and God will give them light as a reward for their good will.

Paradoxically, and counter-culturally, scruples diminish when people have a healthy sense of guilt. In other words, when people accept the possibility of being guilty, with all its consequences, and are able to say sorry and ask for forgiveness. When this path is followed, remorse turns into repentance.

Eating disorders are characterized by faulty behavior in eating and a deformed perception of one’s weight and body image. Before symptoms become apparent there is usually a personal identity problem. The causes may be genetic, biological and psychological. There may be perfectionism, unbalanced emotions and feelings, fear, a history of abuse, emotional and cognitive deprivation, depression, anxiety and personality disorders.[36]

Other influences are family factors such as obesity of one or both parents, conflicts or excessive concern about weight. Eating disorders may be triggered by parental separation, having to leave one’s family temporarily, physical illness, an accident or traumatic experience. There are two major eating disorders.

Anorexia nervosa: faulty perception of body image and pathological fear of obesity, which leads to not eating and loss of weight that puts one’s health in serious danger. 95% of cases occur in women, normally beginning in adolescence. Although the literal meaning of anorexia is lack of appetite, the appetite is not lost except in an advanced stage of this disorder. It often happens that people who begin with anorexia go on to present isolated symptoms of bulimia nervosa or the complete disorder itself.

Bulimia nervosa: manifested in recurrent (at least twice a week) episodes of compulsive eating, when the person “binges” or eats large amounts of food and feels unable to stop eating. This is followed by “purging” or efforts to avoid putting on weight by self-induced vomiting, abuse of diuretics and laxatives, or extreme physical exercise. Like anorexia, this condition occurs most frequently in women.

Where either of these illnesses is suspected medical advice must be sought. Treatment includes some forms of psychotherapy and medication, directed especially at preventing recurrence and reducing anxiety or depression. For families and friends of sufferers, patience is important. A person who suffers from anorexia should have the danger of their attitude explained to them, and be assured that even the perception they have of themselves will improve when they recover some weight. Spiritual direction should nurture the healthy self-esteem that comes from being a child of God, and should not fail to highlight the many good qualities the person possesses. As with similar disorders, they should be helped towards interests and hobbies that are far removed from the area of their obsession – food, weight, etc. Bulimia should be tackled in a similar way.

3.9 Problems related to sexuality

There are numerous disorders in the field of sexuality.[37] Uncontrolled sexual activity becomes addictive, and when it is begun too early in life, before the normal age for marriage, it can lead to mental disorders. There are people who are excessively centered on the most physical and animal aspect of sexuality; many become incapable of seeing the relationship between sexuality and love or self-giving, the procreation of children, etc. Some use sexuality in a clearly pathological way and consider others simply as an object for pleasure.

Many simple difficulties can be sorted out by clarifying the person’s conscience or with the advice of a doctor. The spiritual director should know the moral aspects in order to provide formation and restore the person’s peace of mind. When something pathological is suspected, it is appropriate to suggest, prudently, consulting a specialist who has a proper knowledge of human beings and their sexuality.

Unfortunately, some psychiatrists advise sexuality without any rules. If they retain any common sense they do not state that all sexual behavior is normal, but in practice they do not see any limits.
The main types of mental aberrations related to sexuality are dysfunctions which affect the exercise of this faculty. These are common, and may be psychological or physical in origin. For many of them effective treatments exist, for which expert medical advice should be sought. As well as these, there is gender identity disorder, or the firm conviction of belonging to the opposite sex; and paraphilias, in which the sexual appetite is wrongly directed (e.g. pedophilia).

Masturbation is not in itself an illness but may indicate mental problems when it is used as a way of combating anxiety. Specialists note that masturbation leaves a sense of inner emptiness, even in people who have never heard of the Sixth Commandment. It cannot be said to be harmless or indifferent. As a false use of sexuality it affects the entire person.

In the spiritual life the disruption produced by masturbation is considerable. The fact that it is widespread during adolescence does not mean that it is healthy. Parents, teachers and spiritual directors should help young people to acquire a correct understanding in this area and to fight serenely, without fears or phobias, which would be counter-productive, but knowing that it is possible to win the battle with God’s grace and the normal means described under previous headings. In that way they can ensure that a bad habit does not become a vice that would be progressively more difficult to eradicate, even after marriage.

Homosexual activity is not considered an illness by many psychiatrists and it is obvious that in some cases it is the result of a choice, with some degree of freedom, on the part of the subject. However, there are people who, without wishing it, discover in themselves a homosexual tendency which has been formed by circumstances connected with their family upbringing, childhood and adolescence; they are often able to overcome this tendency.[38]

As the Catechism of the Catholic Church explains, the moral order requires that the sexual faculty should be used only in normal marital relations, in a “context of true love”.[39]

A good anthropology of sexuality, understood in relation to love, is fundamental for prevention and help in such situations, which often reflect a more deep-rooted existential problem. Teaching children how to love, nurturing their capacity to love, as part of their family upbringing, lays the foundations for healthy development. Pleasure should be seen as an effect, not as a goal. Otherwise a person could reach the point of excluding satisfaction, even sensual satisfaction. The specific place for the expression of sexual love is marriage: only in marriage do the positive characteristics of self-giving exist; this is what leads to relations that are specifically human.

Young people should be warned against the danger, not only moral but health-related, of early sexual activity. This is a psychological fact: “a young person who enters an exclusively sexual relationship prematurely, will never find the path that leads to a harmonious synthesis between what is sexual and what is erotic”.[40] Such people will not come out of themselves towards the other, they will not be in a position to love truly. They reduce the possibility of a stable future marriage, harm the development of other aptitudes, their study and their profession; and increase the risk of mental illnesses and sexually transmitted diseases.

When people come with this type of problem, the spiritual director must listen, knowing how difficult the person may find it to speak, out of shame or embarrassment. The goal is for the person to learn to love, which is the best way of assuring a sexual life that is worthy of a human being. If topics related to sexuality are always put in the first place, there is something that is not right: many other interests, ideals and values should come before this subject. A person with uncontrolled acts contrary to the virtue of chastity will benefit from medical or psychological help.

It is always necessary to look for the causes of recurrent difficulties and apply the remedy. If the person concerned really does have good will in wanting to tackle the problem but it does not disappear when they follow the normal advice, the possibility of illness must be considered. Anxiety, depression, obsessiveness, and other personality disorders or character traits such as a victim complex, can contribute to intensifying problems in this area.

At a more general level, good upbringing and formation should lead to people becoming more mature in their impulses, i.e. integrating them into their character as a whole, which includes the capacity for self-transcendence. Young people should be taught to develop a true idea of their own intimacy; to defend their personal privacy, modesty and decency; to dress appropriately for their family and social surroundings, respecting other people and themselves. Sometimes scanty, provocative clothes reflect insecurity and a low self-image. Advice on this matter should make it clear that it is not merely a question of obeying a set of rules or being rigid. Young people should be helped to understand the Christian and anthropological reasons for behaving in a particular way, so that each individual can act with full inner freedom.

3.10 Alcoholism and drug addiction

Alcoholism and drug addiction are problems that have a huge social impact, especially because they have escalated in many countries and affect more and more young people. It is not possible to give an exhaustive treatment of this subject here, because it is a very broad one with many different aspects.[41] Nor does this article aim to speak of all the moral conditions applying to the use of alcohol, which may be excessive and harmful, without actually being an addiction properly speaking; or may be legitimate and good in moderation. Drug addiction, by contrast, is never morally acceptable as even in low doses it harms mental, physical and spiritual health. There is, in truth, no such thing as merely “recreational” drug use.

This discussion will focus on the medical condition known as substance dependence, which is frequently the result of alcohol and drug use and is related to other mental problems. It is similar to obsessive-compulsive conditions. The person is almost incapable of controlling their impulses, and this ends up by generating a habit, which, as it is in some way pleasurable, they find hard to break, although they realize that it is harming them or is dangerous. The pleasure may be perceived as pleasing psychophysical sensations: disinhibition, hallucinations, sensual arousal, etc.; or as forgetfulness and escape from burdens, worries and responsibilities. In some cases the main thing is for them to realize that what they crave is harming them. Spiritual direction has an important role to play, adding supernatural motives to the need to drop the vice.

People with pathological dependencies need a lot of support and accompaniment. They need to be helped to discover the negative aspects of their dependency and the features in their character that are negative and harmful. When they realize that a drug, or alcohol, like other dangerous tastes, is not a source of genuine pleasure but a problem that robs them of their autonomy, they are in a position to remedy the situation. The mental mechanisms involved are similar to other conditions that diminish a person’s freedom – any kind of obsession, gambling addiction, obsession with sex, obsession with food, and even more innocent activities that reduce one’s control over oneself such as nicotine addiction (the possible immorality of smoking relates not to its use but to its abuse), and uncontrolled reading or looking at the Internet (today known as Internet addiction disorder: IAD).

An important objective for alcoholics and drug addicts, and people with other dependencies, is to discover the meaning of life, recover their confidence in everyday living, in the possibility of working, having ideals, and being useful. For treatment to produce results they must find strong motivations for breaking with a harmful lifestyle. A rich spiritual life, love for God, the beauty of creation if we look at the Creator and other people, are powerful motivators.

As well as advising medical help, which is indispensable in cases of dependency, the spiritual director should make clear what the moral danger of the dependency is, the offense against God caused by drug use or excessive alcohol; and should point out that these things often lead to other evils such as robbery to support the habit, attacks on others when under the influence of the substance in question, sins against different virtues, etc. The spiritual director should get the person to talk about who their friends are, and if this is part of the problem, should encourage them to stop going to certain places which will be likely to cause them to fall into the same behavior again; and should explain the moral obligation of avoiding occasions of sin.[42]

Support from the family is crucial. As well as helping the person to recognize the problem, they can learn to identify times when the craving for alcohol or a drug is strongest and offer them special support. These are normally times of loneliness, tiredness, boredom, anxiety or anger, and if they are discovered early on it is possible to forestall relapses. When someone has overcome a pathological dependency, continued vigilance is necessary to avoid returning to what caused them pleasure or euphoria (their artificial paradise). They should keep their time fully occupied and fill their lives with meaning: a stable job, volunteer work, family entertainment, spending their leisure time with good friends, or helping those in need. The escalating incidence of harmful dependencies today is related to the current crisis of values in society, together with frenzied activism, exaggerated competitiveness, and superficiality in social relationships.[43]

4. Suitability and health

The spiritual director may be presented with the need to discern whether a person is suitable or not for a particular spiritual pathway with specific obligations, e.g. celibacy, in its various circumstances or situations. It is sometimes the person concerned who asks about this.

The following is a discussion of some general aspects and other practical elements in discerning suitability from the viewpoint of health. It must not be forgotten, however, that what matters is the interior life of the person whose function it is to act as spiritual guide, and recourse to prayer; and that God’s grace helps people to overcome major deficiencies. The starting-point is the Christian perception that people are capable of taking final, permanent decisions, of giving themselves forever out of love, without losing the smallest part of their freedom.[44]

4.1 General aspects

The particular demands of a given lifestyle – politics, army, art, sport, research, etc. – require a state of health that measures up to those specific circumstances. If this is not borne in mind, a person runs the risk of failing or falling ill because they have undertaken something that is beyond their capacity. The same is true of specific Christian vocations.

With regard to physical illness, it is not too difficult to come to a decision on a person’s suitability. With character problems or mental health problems, there are more difficulties, because the diagnosis is often not obvious. There is no test or laboratory procedure to arrive at a precise statement of what a person is like.

In general, in order to follow a Christian vocational path that makes specific demands, determining in a particular way, for that person, the obligations of all the baptized, what is needed is normal intelligence, a balanced emotional life, and the absence of mental or physical illnesses that would impede them from fulfilling the duties they are thinking of undertaking. Obviously, as previously stated, someone suffering from mental symptoms can have a deep spiritual life, even though it would not be right for them to burden themselves with new responsibilities.[45] Moreover, there is always the possibility that as they grow older they may achieve greater stability or entirely overcome the health or character problem which afflicts them.

In discernment it can be useful to consult experts, as advised by the Congregation for Catholic Education, in the case of seminarians;[46] but the ultimate responsibility does not lie with external specialists. Those who have the duty to discern have to know the candidates personally. It is this knowledge which, provided the time of discernment or trial period is sufficient, offers, humanly speaking, an acceptable degree of moral certainty.

4.2 Some elements for the discernment of a vocation

In deciding whether a person is or is not suitable for a specific vocational path there are certain characteristics that have to be taken into account. Here I am not going to discuss the main point – spiritual qualities – but only one aspect of the human qualities that they need: mental health. The first thing is to establish whether the basic personality is normal. The spiritual director should consider the dangerous character features that have been described above. Exaggerated emotionality or pessimism should be carefully weighed. When the person’s emotions, passions or desires impair the use of reason, when everything is done on the basis of feeling, and they are motivated by sheer enthusiasm, then there is a risk of frustration and failure to persevere.

The person’s past experiences and history are of capital importance, because it is this that has shaped them as they now are. God calls whomever he chooses, and today, as in the Gospel, there are plenty of vocations that come from backgrounds and situations contrary to faith and morality. However, a past that is full of conflicts and moral failings, even though these have been resolved, may leave an indelible mark on someone and make certain commitments, such as celibacy, extremely arduous or, in practice, impossible.

Persistence in aberrant sexual behavior may indicate psychological unbalance and for this reason too may be a sign of unsuitability.[47]

Anyone who has abnormal difficulties with a virtue is not a good candidate if they do not improve. A defect in chastity can reflect immaturity or pathology. Those who desire to live in apostolic celibacy, giving their heart totally to God, and continue to have serious problems with purity, may suffer a mental crisis when they realize that their actions are incompatible with the way of life they have chosen to commit themselves to. Something similar could be said of extreme sensitivity, a strong tendency to compare oneself with others, excessive concern for one’s health or with eating, or a notable difficulty in the practice of sincerity.

Maturity is fundamental in taking final, permanent decisions. Defects may indicate delayed character development, may be signs of illness, or may be simple faults. Some are more important when they occur after childhood is over: never being satisfied, the feeling of being misunderstood, making marked distinctions in the way they treat people, having many fads, stubbornness, habitual absence of common sense, difficulty in planning activities and resting, the habit of making one’s past an excuse, unhealthy touchiness, jealousy, envy, vanity, excessive dependence on what others will think, attachment to superficial things such as fashion or music, exaggerated emotions and disproportionate reactions, being overwhelmed by life’s everyday difficulties, going over and over ideas or corrections received, difficulty in opening up, untruthfulness, distortions of reality, wrong use of money or time, low tolerance of frustration, frequent pronounced mood changes, rigidity or inflexibility.
In vocational discernment each case has to be evaluated on its own; it would be difficult for someone who was good but immature, or had notable character weaknesses, to be in a position to live in celibacy. Before anyone takes on this commitment there must be the assurance that they possess the necessary balance; this will also be necessary so as not to impact negatively on a possible process of growth or cure.

Serious mental illnesses indicate unsuitability – especially schizophrenia, other psychotic disorders, bipolar disorder, recurrent depression, obsessive-compulsive disorder, drug addiction, etc. Personality disorders also suggest a person will not be suitable, at least until they have permanently overcome them, which will be a matter of years. The prognosis for these states, as has been seen above, is uncertain, especially in cases of early onset.

It is important to identify such cases and find out about family antecedents, although it should be realized that these do not totally determine a personality. In general, special prudence should be used in the case of candidates who are very excitable, or whose ideas or reactions surpass normal bounds. When dangerous characteristics are noticed, it is still more important to know the person’s family antecedents.

Many mental illnesses become manifest before the age of 25, or at least there are symptoms that point to them, but sometimes symptoms do not appear until after that age. For this reason it is worth recalling some character traits that predispose people to mental illness: extreme timidity, complexes or traumas, excessive insecurity, tendency to isolate themselves, social or other phobias, absence of self-control, obsessive thoughts, compulsive or impulsive reactions, perfectionism, and strong willfulness.

When the spiritual director has to evaluate a person’s suitability he should have the certainty – at least a moral certainty – that they are fit for the step they wish to take. To entertain a hope that they may improve is not sufficient. Nor is it advisable to keep them in a provisional situation for a long time without coming to a decision on them, especially if the whole direction of their life is at stake.

To seek the help of doctors or psychologists in the task of discernment should be something exceptional. Normally the opinion of those who know and live with the candidate is more than sufficient. However, consulting a doctor or psychologist may be useful when, after a sufficient length of time and despite a deep knowledge of the candidate on the part of those whose task it is to judge, doubt still remains: “Is this something transitory?” “Will they be able to alter such-and-such a harmful habit with medication and the passage of time?” Naturally, the explicit consent of the candidate must be obtained, and patient confidentiality must be borne in mind. The information obtained belongs to the person concerned, who can share it with whoever they consider appropriate.

Psychological testing is a very useful tool for a doctor who has to arrive at a precise diagnosis in a short space of time, but it is neither indispensable nor reliable when it comes to deciding on a person’s suitability. It normally takes the form of a questionnaire. If a personality problem is so acute as to fall into the categories of illness or disorder in psychological testing, obviously the people responsible for the decision on the person’s suitability would already have noticed it; ultimately, the psychological test could at most only confirm information gained from the experience of living with the candidate.

This section would be incomplete without a reference to those people who, having taken on a definitive vocational commitment, realize that they are in circumstances such as those outlined above: they have been diagnosed with mental illness, they have continuing difficulties with chastity despite having committed themselves to celibacy, they discover severe personality defects, etc. Perhaps they might be inclined to conclude, “It is clear that I was unsuitable, so that’s the end of it.” A supernatural way of reasoning, which is not so far from straightforward human reasoning, would lead to the opposite conclusion: “God, who knows me perfectly, has wanted me to be with him where I am.” The ideal of preserving their vocation and renewing their assent to God’s call can enable them to confront problems more resolutely and reaffirm the meaning of their lives, which is always positive and will itself have a beneficial effect on their health. In spiritual direction they need to be helped not to be hasty, to apply all the means to improve, and to go to the doctor if necessary.[48]

With light from the Holy Spirit, the opinion of an experienced priest and a prudent, competent doctor who is a good Christian, the most appropriate advice for the individual case can be given. When years go by, those who let themselves be guided by grace, those who are even more concerned with praying than thinking so as to be able to act rightly, experience the serenity of realizing that God, unlike us men, does not make mistakes.

Conclusion

It is hoped that this article has helped to clarify how spiritual direction offered in a climate of openness, naturalness, simplicity, affection and understanding, helps ill people to face up to their afflictions supernaturally; and is also effective in forestalling some symptoms, improving character, and nurturing a healthy way of life with our Lord for its model.

The article has looked at the value that physical and mental suffering have in God’s eyes, and has aimed to give a better understanding of the relationship between the dimensions of the human being and how the spirit is capable of drawing the whole human organism upwards. This same human organism needs to be taken care of, through means of orderly work, rest, sleep, cheerfulness, etc., so that it can continue being a good instrument of evangelization for a long time.

Every spiritual director needs to be able to discover or at least intuit, with common sense, when certain symptoms point to a illness and not merely a failure to struggle, carelessness, laziness, lukewarmness, etc.; while bearing in mind that both elements may be present simultaneously. Certain anxieties and imbalances are brought about by a person’s not wanting to reject something that separates them from God but trying, perhaps subconsciously, to lead a double life, if only on the level of thought.

However, the spiritual director should be prudent so as not to attribute certain behaviors to mental illness prematurely, when they really fall within the normal difficulties encountered by any normal person, which, if they overcome them, will greatly contribute to their maturity as a person. As has been said, people should never be labeled.[49] The spiritual director should always give hopes of being cured or at least that certain negative character traits can improve. Although it may not be possible to get rid of the illness entirely, the attitude with which it is borne can always be modified, so as to see it in more optimistic terms, as God’s children should.

Any Christian, healthy or ill, should make the effort to go beyond themselves and direct themselves towards God and other people. This capacity is called “self-transcendence” and is a sign of spiritual and mental health. The opposite, egocentrism, is very harmful.

Self-transcendence is essentially and exclusively human. It is already present in children, and impels one to go beyond oneself, enables one to integrate natural tendencies and other conditioning factors into a higher plane that could be called that of the “person”, beyond that of the ego. St Augustine says: “Infants are even feebler in the use and movement of their limbs, and more infirm to choose and refuse, than the most tender offspring of other animals; as if the force that dwells in human nature were destined to surpass all other living things so much the more eminently, as its energy has been longer restrained, and the time of its exercise delayed, just as an arrow flies the higher the further back it has been drawn.”[50]

Spiritual direction should strengthen this capacity. No one should center themselves too much on their own ego, its needs or difficulties, but should make the effort to make life and the path to Heaven pleasanter for those around them. People should learn to put conflicts, suffering, and illness to good use: the limitation will be transformed into greater strength to launch oneself upwards and forwards, like the arrow. John Paul II recalled that “no adequate assessment of the nature of the human person or the requirements for human fulfillment and psycho-social well-being can be made without respect for man’s spiritual dimension and capacity for self-transcendence.”[51]

A soul who is seeking to become more like Jesus Christ every day, with the grace of the Holy Spirit, travels a path of serene, self-sacrificing self-giving; and this is how to face one’s own and other people’s illness, for love: “But no one can live out this love unless they are taught in the school of the heart of Jesus. Only if we watch and contemplate the heart of Jesus will we ensure that our heart is freed from hatred and indifference. Only in this way will we know how to react as Christians to the pain and sufferings of others.”[52]

© CRIS, 2010
© Wenceslao Vial, 2010

[1] John Paul II, Apostolic Letter Salvifici Doloris, 11 February 1984, no. 31. A full discussion of this document is outside the scope of the present article. Some of the ideas covered in it are: suffering promotes interior maturity and spiritual greatness (nos. 21-22 and 26); the hard trial of suffering contains a call to persevere in bearing whatever disturbs and causes harm; it leads us to find the meaning of life (no. 23); with regard to the suffering of others, compassion is sometimes our only resource; man cannot fully find himself except through a sincere gift of self (no. 28), which leads to the discovery of another meaning of suffering – to spread love (no. 29).
[2] Cf. St Josemaria Escriva, The Way, no. 439.
[3] Furrow, no. 887.
[4] St Augustine, The City of God, 12, 22, 3.
[5] For a deeper study of theory and practice in this area, and the pathologies mentioned in the present article, see the relevant chapters in La salud mental y sus cuidados, Javier Cabanyes and Miguel Angel Monge (eds), Pamplona: Eunsa, 2010.
[6] Benedict XVI, Jesus of Nazareth (I), London: Bloomsbury, 2007; Chapter 6, p. 177.
[7] St Josemaria Escriva, Friends of God, no. 124.
[8] Luis de Moya, Sobre la marcha. Un tetrapléjico que ama la vida, Madrid: Edibesa 1997 (3rd edition), p. 197. (For information about Fr Luis de Moya in English, see: http://youniv.wordpress.com/category/blog20-luis-de-moya/.)
[9] Forms of dementia may occasionally occur in younger people, even under 40. In these cases it is usually related to head injuries, infections such as AIDS, or hereditary degenerative factors.
[10] This also applies to people in profound coma or in a persistent vegetative state, who give no observable response to stimuli; it is advisable to pray aloud with them, fostering their union with God and their hope of Heaven.
[11] Cf. Manuel Martin Carrasco, “Atención a enfermos con demencia”, in Cabanyes and Monge, op. cit., pp. 431-439.
[12] Cf. Claus Hamann and Kenneth L. Minaker, “Approach to frailty in older adults”, in Allan H. Goroll and Albert Mulley (eds), Primary Care Medicine, Wolters Kluwer and Lippincott, Philadelphia 2009, pp. 1550-1553.
[13] Interior life and apostolate rejuvenate people: cf. St Josemaria Escriva, Furrow, no. 79.
[14] See M. Cornelia Cremens, “Management of Alzheimer’s disease and related dementias”, in Goroll and Mulley, op. cit., pp. 1207-1219; and Miguel Angel Monge, “Enfermedad y vejez”, in M. A. Monge (ed.), Medicina Pastoral, Navarre: Eunsa, 2001, pp. 183-186.
[15] For more on this topic, see Miguel Angel Monge and Purificacion de Castro, “La muerte, final de la vida humana”, in Monge, Medicina Pastoral, op. cit., pp. 190-222.
[16] Cf. Monge and De Castro, op. cit., pp. 190-201.
[17] For specific cases see Maurizio Calipari, Curarse y hacerse curar, Buenos Aires: Editorial de la Pontificia Universidad Católica Argentina, 2007; Lino Ciccone, Bioética. Historia, principios y cuestiones, Madrid: Palabra, 2006; www.eticaepolitica.net; and other web-pages on bioethics at www.almudi.org.
[18] Pontifical Council for Pastoral Assistance to Health Care Workers, Charter for Health Care Workers, Vatican City, 1995, no. 16.
[19] Cf. St Josemaria Escriva, The Way, no. 744: “You, if you are an apostle, will not have to die. You will move house, that’s all.”
[20] The term neurotic has become pejorative (albeit not always), and so it has been dropped from clinical usage. Now the assumption is that a person with a mental disorder is not psychotic unless specifically said otherwise.
[21] Cf. Ernesto Avino Navarro, “Trastorno obsesivo compulsivo” in Cabanyes and Monge, op. cit., pp. 369-376.
[22] The first line treatment for OCD consists in having people resist the compulsions while simultaneously provoking the obsessions (“exposure and response prevention”).
[23] For more on this topic and the ways sufferers can be helped, cf. Salvador Cervera Enguix, “Trastornos depresivos”, in Cabanyes and Monge, op. cit., pp. 333-343.
[24] The Way, 706; and cf. The Way 723: “So you couldn’t care less? Don’t try to fool yourself. This very moment, if I were to ask you about certain people and undertakings in which for God’s love you put your soul, I know that you would answer me eagerly, with the interest of one speaking of what is his own. It’s not true that you don’t care. It’s just that you’re not tireless, and that you need more time for yourself: time that will also be for your activities since, after all, you are the instrument.”
[25] Cf. Gordon W. Allport, Pattern and Growth in Personality, Holt, Rinehart and Winston, 1961.
[26] The Forge, 468. The whole point reads: “My son, where is the Christ that people look for in you? In your pride? In your desire to impose yourself on others? In those defects of character which you don’t wish to overcome? In your stubbornness?… Is Christ to be found there? No, he is not! You need to have your own personality, agreed. But you should try to make it conform exactly to Christ’s.”
[27] It is not easy to draw a clear line between normal and abnormal personalities; the diagnosis is based on statistical and social criteria. Cf. Jose Luis Besteiro Gonzalez and Angel Garcia Prieto, “Trastornos de la personalidad”, in Cabanyes and Monge, op. cit., pp. 297-309.
[28] See further: Javier Cabanyes Truffino, “Personalidad”, in Cabanyes and Monge, op. cit., pp. 85-98.
[29] A useful analysis of egocentrism may be found in Joan Baptista Torello, Psicología y vida spiritual, Madrid: Rialp, 2008, pp. 110-127.
[30] St Josemaria Escriva, The Way, no. 837.
[31] St Theresa of Lisieux, The Story of a Soul, Manuscript C, Folio 7r.
[32] St Josemaria Escriva, The Forge, no. 252.
[33] St Josemaria Escriva, Furrow, no. 762.
[34] Benedict XVI, Spe Salvi, no. 24.
[35] St Teresa of Avila, Vida, chapter 9, in Obras completas, Madrid: Aguilar, p. 86.
[36] See: Pilar Gual and Francisca Lahortiga Ramos, “Trastornos de la conducta alimentaria”, in Cabanyes and Monge, op. cit., pp. 407-413.
[37] Cf. Ricardo Zapata and Jorge Pla, “Trastornos psicosexuales”, in Cabanyes and Monge, op. cit., pp. 345-356.
[38] Cf. Javier Schlatter Navarro and Juan Carlos Garcia de Vicente, “Dificultades en la orientación sexual”, in Cabanyes and Monge, op. cit., pp. 357-368.
[39] Catechism of the Catholic Church, no. 2352.
[40] Viktor Frankl, Psychotherapy and Existentialism. Selected Papers on Logotherapy, New York: Simon & Schuster, 1967, 1985. (Psicoanálisis y existencialismo, Fondo de Cultura Económica, México D.F., 1967, p. 209.)
[41] See Pedro Anton Fructuoso, “Conductas adictivas”, in Cabanyes and Monge, op. cit., pp. 387-394; and José Ramón Varo, “Adicción al alcohol y a drogas”, ibid., pp. 395-405.
[42] Cf. Miguel Angel Monge, “Pastoral terapéutica”, in Monge, Medicina pastoral, op. cit., pp. 449-477.
[43] Cf. Pontifical Council for Pastoral Assistance to Health Care Workers, Charter for Health Care Workers, op. cit., nos. 92-103.
[44] There are mistaken ideas of freedom around which hold that it is not possible to make a final, permanent decision or any lasting commitment. This way of thinking is the obvious consequence of not believing in ideals or values; it has negative repercussions on the spiritual life and the person’s general health. Cf. Jose Angel Garcia Cuadrado, “Libertad y compromiso”, in Cabanyes and Monge, op. cit., pp. 55-65.
[45] Cf. Miguel Angel Monge Sanchez, “Vida espiritual y enfermedad psíquica”, in Cabanyes and Monge, op. cit., pp. 201-212.
[46] Congregation for Catholic Education, “Guidelines for the Use of Psychology in the Admission and Formation of Candidates for the Priesthood”, 29 June 2008.
[47] Congregation for Catholic Education, “Instruction Concerning the Criteria for the discernment of Vocations with regard to Persons with Homosexual Tendencies in view of their Admission to the Seminary and to Holy Orders,” 4 November 2005.
[48] See what is said above on how to tackle mood disorders, section 3.5.
[49] There are also many psychiatrists who prefer not to categorize ill people according to their mental symptoms, because they are aware of the great variety of illnesses that exist and how complex they are.
[50] St Augustine, The City of God, 13, 3.
[51] Address of His Holiness John Paul II to the Members of the American Psychiatric Association and the World Psychiatric Association, Monday, 4 January 1993.
[52] St Josemaria Escriva, Christ is Passing By, no. 166.

Wenceslao Vial
Wenceslao Vial

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