Paul Kymissis, MD I am deeply honored, and very pleased to be here this evening for the 12th Conference of OCAMPR. Under the leadership of its first President, Dr. Chirban, OCAMPR has served to open new horizons in our thinking about the relationship between medicine, psychology and religion. The late Professor John Meyendorff, a friend of OCAMPR, saw it as a catalyst for dialogue between behavioral scientists, physicians and the Church. This dialogue is desperately needed in our time. I want to thank Steve Muse for his kind invitation to speak tonight about the new developments in the field of neuroscience, and their relationship with Orthodox spirituality. Once when I was a psychiatric resident, I met with Dr. Kaufman, a visiting Professor and the former chairman of Psychiatry at Mt. Sinai School of Medicine, and asked him to summarize the current mode of thinking in psychiatry. He replied that the older he became the more he realized the importance of genetics in understanding human behavior. Indeed, genetic research has contributed enormously throughout the past few decades to our understanding of psychiatric syndromes. The first director of Child Psychiatry at New York Medical College, Dr Stella Chess, studied 300 children from birth up to 30 years of age. She discovered that the early behavioral characteristics she was able to observe in a person in the first few weeks and months of life, were in fact the dominant characteristics of that person throughout the thirty years of the study. These characteristics, which she labels the ‘temperament’, seem to be closely related to the genetic endowment of each person. There is much evidence for this in studies of identical twins reared apart. The similarities are sometimes striking, down to the level of identical twins giving their dogs the same name or choosing the same brand of toothpaste. During the last half of the nineteenth century, psychiatry, with leaders like Kraeplin, Werwicke, Lombroso, and others, placed most emphasis on the biological basis of mental illness. In the first half of the twentieth century, with the introduction of psychoanalytic theory by Freud, there was much emphasis placed on the psychology of the individual. During the last thirty years, with the new discoveries from the field of neuroscience, a new interactive model has been emerging. Biological and psychological factors play important roles in the etiology of mental illness. In certain conditions like bipolar disorder or schizophrenia, biology plays a major role, whereas in other conditions like depression, psychological factors are more prominent. The discovery of certain neurotransmitters and their role in human behavior opened new avenues of thinking about many psychiatric disorders. Neurotransmitters are the chemicals used to communicate across synapses (the junctions between brain cells). These communications are related to several brain functions like perception, memory, emotions and thinking. So now we can study the mind, not only through observable behavior, but by looking at parallel and simultaneous, neuropsychological functions. There are specific synapses that participate in the formation of memory, co-ordination and numerous other functions. Obsessive-compulsive disorder, for example, seems to be related to a neurotransmitter called serotonin. The use of medication that selectively inhibits serotonin reuptake (SSRIs), such as fluoxetine, has resulted in a dramatic improvement in many patients with this disorder. Another example is that genetics has been found to play an important role in some alcoholics. Epidemiological studies have shown that the risk of alcoholism is about seven times greater in persons with a first degree alcoholic relative, than those without such familial associations. In addition to the genetic factors, there are a number of environmental factors that play an important role, such as parental modeling, cultural patterns of alcohol use, and stressful events of life. Findings from the field of neuroscience have also demonstrated the importance of biological factors in many psychiatric syndromes. It is well documented that dopamine receptors in the brain play an important role in schizophrenia. These patients may also present with hypofrontality and a host of other neuroanatomical abnormalities. Further, young children at risk of schizophrenia have a lower degree of neuronal migration to the periphery of the brain’s cortex. Head and brain trauma has often resulted in personality changes, including oppressive and violent behaviors. Other syndromes like depression, panic disorder, post-traumatic stress disorder, and personality disorders may also have biological correlates. A fascinating discovery in the quest to understand the connection between the mind and the brain has come from using the latest brain imaging technology. New studies have demonstrated that the neuropsychological milieu of the brain is influenced by psychological interventions, not only chemical ones. These physiological changes were detected using SPECT (single photon emission tomography), PET (positron emission tomography), MRI (magnetic resonance imaging), and three-dimensional PET/MRI scanning. Using this equipment, the studies could detect functional changes in the brain, in addition to the already known structural changes. Patients with obsessive-compulsive disorder (OCD) were discovered to have an elevated level of activity in the frontal lobe and caudate nucleus using PET. The over-activity in these segments of the brain could be overcome using medication or through a psychotherapeutic intervention (in this case, cognitive-behavioral therapy). One should not underestimate the capacity of psychotherapy to restore ‘normal’ brain functioning. Depressed patients who were randomized to treatment with either psychotherapy or antidepressant medication in a number of studies, were shown to have largely the same outcome success. Paroxetine, an antidepressant, was found to produce identical functional changes in the brain as interpersonal therapy in a recent study by Dr. A. Brody from UCLA. Dr. Eric Kandel, a Nobel Prize winning psychiatrist and neurobiologist proved that the process of learning in fact changes the structure and function of the brain. Cognitive therapies and learning have become popular in modern psychotherapy. Many people have said that their lives had changed after they read a book, heard a lecture, or were made to think of alternatives they had never considered. Other popular therapeutic methods include the utilization of relaxation and exercise to enhance the emotional state of a person. There is some evidence that physical exercise could be an effective method of treating depression. Another important factor which could have an important influence on the psycho-biological system is suggestion. Many of the so-called ‘treatments’ of the past (of the pre-scientific era of psychiatry) have been forms of suggestion. Jerome Frank, in his book ‘Persuasion and Healing’ describes the power of the placebo effect in psychobiological processes. One study involved randomizing anxiety patients to either a placebo or anti-anxiety medication group. The first experiment of the study used a young, unconvincing and apparently inexperienced therapist. In this experiment the patients on medication fared better than those on placebo. When the experiment was repeated with a more mature, convincing and apparently experienced doctor, the group on placebo fared better than the group on anti-anxiety medication. Suggestion plays a major role in the doctor-patient relationship, but also in many other phenomena of life. Suggestion and hypnosis can induce anaesthesia, paresthesias, and even olfactory hallucinations. How are these findings, and the great wealth of other research data not presented here, connected with the healing process and our understanding of Orthodox spirituality? The phenomena observed in the above-mentioned studies extend the frontier of our understanding of the natural realm. It is our Christian duty to offer to our brothers and sisters the medical treatments developed using modern scientific discoveries. This capacity to learn more about the natural order of the universe is given to us by God. According to the Wisdom of Serach, “God gave science”. Further, it says that one ought to “give honor to the physician, because God created him”, and in fact that “medication was created by God”. Surely it is ridiculous to demand miracles from God if we do not use the medical means available to us to tackle a medical problem. It is the temptation of “charismatics” to expect miracles, where God has provided a means of resolving a medical problem. It would be absurd for a person to demand that God heal his tooth instead of going to the dentist. In a similar way, where there is a clear genetic and biological component to a psychiatric disease, then the available medical and pharmacological interventions are indicated. However, there are a number of conditions where cognitive changes, a healthy lifestyle, and alternative complementary non-medical interventions could play a role. The cognitive and belief structure of an individual has a direct relationship with his emotional or affective state. The way a person perceives him or herself, others, and the world may generate feelings of hope, contentment, frustration or despair. In the Bible there are a number of references to temptation and despair. In chapter 14 and 22 of the Acts to the Apostle we read that we must go through many tribulations to enter the kingdom of God. Paul writes to the Corinthians (2 Cor 4:8) that “we are hard pressed on every side, yet not crushed” and that we are “perplexed, but not in despair” (aporoumenoi al'ouh exaporoumenoi). Freud, in his work on mourning and melancholia, described how the usual process of mourning may end up in the stage of despair he called melancholia. There are conditions where the boundaries between biological and psychological factors are blurred, and hence require not only medical and pharmacological interventions, but a spiritual process, for true healing to come about. This especially applies when the stressors include: sin, guilt, an irrational fear, hate, and holding a grudge. A recent study demonstrated the power of forgiveness, that is, being able to forgive, in bringing about personal healing. When we talk of “Orthodox spirituality” we should be sure of what we are speaking. Orthodox spirituality is not the result of some suggestive experience; nor is it the end result of an artificial state of well-being achieved through the process of relaxation and meditation; nor is it related to the excitement and enthusiasm created by inspirational speakers of so-called “charismatic” groups; nor is it guided by man-made means like art, music and other human devices. St. Seraphim said that the purpose of life was the acquisition of the Holy Spirit. St. Silouan exclaims that he “asked for forgiveness and (he got) not only forgiveness but the grace of the Holy Spirit, and then (he) knew God.” Our desire for communion with God cannot be filled with man-made artificial substitutes. During the 14th century there was a major debate in the Church about the ability of man to experience God. Varlaam, a western philosopher, insisted that what the “hesychasts” were experiencing was a product of their imagination. He mockingly labeled them as ‘omfaloskopoi’ (men with their soul in the navel). To their defense came St. Gregory Palamas, who suggested that a distinction should be made between the essence and energies of God. Both are uncreated. While the essence of God cannot be communicated, humans can experience God as He is revealed through His Divine uncreated energies. Prayer is not a movement of the spirit only, but also of the body. St. Gregory Palamas writes: “What pain or joy or movement of the body is there which is not shared by the soul and the body?” He affirms that in spiritual men, the grace of the Spirit is transmitted to the body through the soul as an intermediary. The Spirit gives to the body an experience of divine things, it grants it the capacity to feel the same passion as the soul. In this way Palamas rejected Varlaam’s dualistic mysticism, where the body and soul are seen as separate to one another. St. Gregory suggested that the experience of the uncreated Light by the body was not the product of a suggestion, but the action of the uncreated energies of God. The divine energies cannot be examined scientifically, because they are beyond the laws of physics or nature. Therefore there should be a clear distinction between what is natural and subject to the laws of nature, and what is supernatural; a distinction between what can be achieved through human effort and research, and what is revealed or given as a gift. The Greek word for gift is “charisma”. Charisma is not the product of human effort, but by definition is a gift, which is given at the discretion of the giver. Palamas’ contribution to our understanding of the Divine substance and energies, is pertinent understanding the role of psychiatry as a scientific method, as distinguished from the pursuit of spirituality, which is to participate in Christ’s life. It is important to keep this distinction in mind when addressing psychopathological phenomena, particularly phenomena which are evidently subject to the laws of nature, and can be alleviated by human intervention. Whenever God gives us the knowledge to understand and treat a disorder, we have the responsibility to use this knowledge to treat the suffering person. It is also true that stress is a major factor in precipitating psychiatric symptoms like anxiety, panic, depression etc. In treating psychiatric patients it is important to address factors like sin, guilt, shame, narcissism, a preoccupation with oneself (selfishness), and an inability to delay gratification or control sexual and aggressive impulses. St. Mark the Ascetic said that there are two major reasons for a man’s unhappiness: love for himself and a love for pleasure. People who have been suffering from anxiety are able to find comfort when they understand the meaning of life. Anxiety is defined as the fear of something going wrong. Hope is the opposing emotion to fear. Therefore St. Paul writes that through hope you will find peace. An existential vacuum is another potential source of anxiety. This is where an individual who is created in the image of God, fails to understand himself because he doesn’t know God. Orthodox spirituality could be a major source of healing for many of these people. “Spirituality” is one of the most abused and ambiguous words of our time. “Spirituality” without God has become the new religion of our Days. In the name of Pluralism, tolerance and cultural sensitivity, people are willing to talk about spirituality without even mentioning the Holy Spirit. “Spirituality”, emptied of its power, is taught at college, presented in workshops at conferences, and becomes a new dimension of psychological care. These “spiritual” pursuits are in fact anthropocentric. They begin and end with man. “Man is the measure of everything”, as one Greek philosopher wrote. Orthodox spirituality is summed up in St. Silouan’s statement, “I asked for forgiveness, and I was given not only forgiveness, but also the gift of the Holy Spirit, and then I knew God.” This kind of experience of God is called by St. Gregory “theoptia” (a vision of God). There is a difference between talking about God and from being with God. This charisma ‘harisma’ is not an experience produced by suggestion, art, music, or powerful oratory, but by the presence of God, a Divine Visitation, a response to the request for forgiveness, as St. Silouan had put it. Psychotherapy is a scientific method of healing the whole human being (body and mind). It is based on what is known and understood at any given moment in history. Orthodox spirituality transcends scientific barriers. It cannot be manipulated by human effort or scientific research because it is primarily the work of God. It is a gift, a charisma, which represents God’s response to a humble and contrite heart. Lecture presented as key- note address at the Annual Meeting of the Orthodox Christian Association for Medicine, Psychology and Religion (OCAMPR) at the Hellenic College, Brookline, MA, in October 2002