Chapter 1: From the Ancient World to Father Amorth Chapter 1 FROM THE ANCIENT WORLD TO FATHER AMORTH
There are more things in heaven and earth, Horatio,

Than are dreamt of in your philosophy.

—William Shakespeare, Hamlet
A FRAMEWORK FOR REALITY
On the afternoon of July 7, 2016, I received a call from William Friedkin, director of the 1973 supernatural thriller The Exorcist. The critically acclaimed film earned ten Academy Award nominations and won two, including Best Screenplay. It seemed that Billy, as he insisted I call him, had retained an interest in spiritual possession since working on the movie, in which the young daughter of a film star becomes ill and undergoes all manner of medical and psychiatric tests and procedures to diagnose her condition. When all medical science’s tests and treatments fail to reveal the reason for her increasingly bizarre and aggressive behavior, including some bodily maneuvers that defy the natural laws of physics and biology, the desperate mother appeals to the Catholic Church and a wizened exorcist is summoned, pitting the forces of evil against a mortal agent of God. In May of 2016, Billy told me, he had traveled to Rome, where the Vatican’s ninety-one-year-old chief exorcist, Father Gabriele Amorth, had allowed him to witness his first real exorcism—a woman named Rosa. Not only had Billy attended the event, he had filmed it. He was planning to produce a documentary sequel to The Exorcist.

Billy had already shown the footage to two physicians at UCLA Medical Center. Neil Martin, the chief of neurosurgery, didn’t think it looked like schizophrenia or epilepsy, though it could be some form of delirium. He had performed thousands of brain surgeries—on tumors, traumatic injuries, ruptured aneurysms, none of which had produced symptoms like Rosa’s. Itzhak Fried, an epilepsy specialist, was equally mystified, though he regarded what he was seeing as authentic: Rosa wasn’t fabricating her symptoms. He’d mentioned hyper-religiosity and said he doubted you would see such behavior in someone with no religious background. “It’s a physiological state… Can I characterize it? Maybe. Can I treat it? No.”

Their reactions had surprised Billy. He’d expected these doctors to dismiss Rosa’s behavior as insanity or fraud, but they were genuinely baffled. They left open the possibility of something that couldn’t be explained medically or cured by medical treatment. Now Billy wanted psychiatrists to weigh in and asked if I’d review the case. But first he had to find out if I believed in the possibility of such things: spirits, demons, the supernatural. I thought for a moment and then offered, in a professorial tone, what I thought was a diplomatic answer. As a physician and scientist, I said, I always sought empirical evidence by which to understand clinical phenomena. On the other hand, I added, I tried to keep an open mind and didn’t discount the existence of a spiritual plane or the possibility of its incursion into the natural world.

This was good enough for Billy. “When can I come see you?” he asked excitedly.

Billy arrived at the New York State Psychiatric Institute, part of Columbia University, around noon on a sunny September day. I had asked three members of my faculty who were experts in psychiatric diagnoses to join us. Dr. Michael First had played a key role in the development of the fourth and fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)—the bible of psychiatric diagnoses—and was the most knowledgeable person I knew on the diagnosis of mental disorders. Dr. Roberto Lewis-Fernández, president of the World Association of Cultural Psychiatry, was an expert in transcultural psychiatry. And Dr. Ryan Lawrence had studied philosophy and religion at the University of Chicago before his medical training and thus straddled, epistemologically, the scientific and spiritual disciplines.

We settled in to watch the video. Rosa was a tall, dark-haired young woman who had traveled from her home in Alatri, a small and deeply religious mountain village about sixty miles from Rome, seeking relief from what she called “attacks,” which tended to happen on dates related to Jesus’ life (such as his birth, transfiguration, Passion Week, resurrection). She seemed certain she was in the grip of demonic possession. On Father Amorth’s team were four middle-aged priests and two burly assistants. Ten or so relatives of Rosa’s were crowded into the small room to watch. As the exorcism began, Rosa started to thrash. At various points during the exorcism, she appeared to lose consciousness. She foamed at the lips. It took all of Father Amorth’s men to restrain her.

Father Amorth spoke to her throughout. “Infer tibi libera,” he would say, stroking her hair. “Set yourself free.” “Recede in nomini patris!” “Leave in the name of the Father!”

“Mai!” Rosa would growl. “Never!”

“Cede! Cede!” “Surrender! Surrender!”

“Io sono Satana!” Rosa screamed. “I am Satan!”

Eventually, after much back-and-forth, and following Father Amorth’s command “Requie creatue Dei” (“Rest, creature of God”), Rosa emerged from her trancelike state. She was briefly at ease, though when Father Amorth blessed her parents, she began to writhe and growl, before finally calming down again. After nearly an hour, the video ended, and Billy asked what we thought.


A photo of a priest performing an exorcism of a man believed to be possessed.

Rosa was clearly suffering—none of us believed we were looking at a fraud—but nothing we saw in the video required the supernatural to explain it. Rosa’s behavior didn’t go beyond what we had all seen and treated in our mentally ill patients who were agitated, dissociated, or psychotic. We agreed that Rosa was most likely suffering from dissociative trance disorder, a variant of dissociative identity disorder (known previously as multiple personality disorder), a complex psychological condition that usually occurs in reaction to extreme or repeated physical, sexual, or emotional trauma in early life. The memory of this emotionally charged experience is so noxious that it cannot be processed neurobiologically or psychologically or stored in the usual way.

In adults, the effects manifest as post-traumatic stress disorder, or PTSD, but in children the cognitive and emotional residues of the experience are encapsulated and pushed out of conscious awareness. This compartmentalized experience is more than a painful memory; it is a segment of someone’s life that is too hurtful and frightening to even acknowledge, and that he or she cannot assimilate into the conscious self. In the dissociation from the usual modes of behavior and sense of self, the sufferer has literally shut off, or dissociated from, the traumatic experience. This psychological coping mechanism suffices until the person matures into adulthood, when the repressed experience begins to seek expression through some new form of dissociation, including an emulation of psychosis or demon possession. In dissociative trance disorder, the particular form the dissociation takes is that of being possessed, usually by a demon, the devil, or a spiritual being.

Roberto remarked on the importance of culturally shared meanings in the scenario we’d just witnessed, saying, “What may work particularly well for some people in that setting is that everybody in the room actually believes that this is the framework for reality.” Michael likened the situation and treatment to a kind of collective placebo response, with everyone “participating in a ritual that they all agree is the right way to look at the world.” Ryan said that at that very moment, he had a patient who believed herself to be possessed by the devil. The woman came from a religious background and had a history of trauma. She was being treated with medications and psychotherapy. Ryan and his colleagues had seen her on the unit before: her “possession” would run its course, and she would get better and be discharged.

The most common antecedent to dissociative disorders is early-life trauma in the form of childhood abuse. These findings are highly consistent. We didn’t have enough information about Rosa’s background to know definitively, but based on what we had seen and been told, we believed that some psychological disturbance was at work, and speculated that, in order to cope, Rosa may have resorted to the only culturally acceptable expression of and way of seeking relief from her psychic trauma—religion, possession, and exorcism.

Medicine and religion have been intimately connected throughout history. In preliterate societies, there were few distinctions between religion, medicine, and magic. Illness was seen as the product of demons or spiritual forces that entered the person, and treatments were directed at these “causes,” just as today’s medical treatments address the germs or tumors that we believe produce the symptoms. For Rosa, the treatment of choice was exorcism. We subsequently learned that this was not Rosa’s first exorcism; it was her ninth. She had been receiving “exorcism therapy.”

I expected Billy to question our diagnosis or at least express some disagreement, but he didn’t protest. He asked several clarifying questions, then packed his gear, thanked us, and left.

I knew that Billy intended to make a documentary of the Vatican exorcism and interviews, including ours. Since our comments hadn’t conformed to the script I assumed Billy might have envisioned, I wasn’t sure how he would spin the story and represent our views. I didn’t have long to wait. He wrote an article for Vanity Fair, published in November 2016, and the documentary premiered the following August. I was relieved and gratified that both reflected my views faithfully. Billy stuck to his word, but at the same time, the dramatic endings of the article and film shrewdly left open the possibility of spiritual possession.
MADNESS IMAGINED
Over the course of my career, I have become intimately familiar with the clinical manifestations of schizophrenia and their treatment. However, to those afflicted, the people around them, and the lay public, they remain as distressing and frightening as in the ancient past. Throughout human history, schizophrenia has been defined and redefined by a succession of pagan, religious, cultural, and secular environments. From ancient epochs governed by irrational beliefs and emotional reactions, to the modern age of rational thought and scientific enlightenment, schizophrenia has served as a behavioral totem straddling the boundaries between mysticism and madness, genius and insanity. Its victims have been viewed as diabolic or divine; cursed or blessed; miscreants, degenerates, and, finally, invalids.

Throughout history, our attitudes toward sickness have largely been shaped by what we understand of a given disease and our ability to treat it: that is, the less we know about the causes of an illness and the fewer treatments we have for it, the more our cultural attitudes and prejudices fill the gap in knowledge. This has been true of many of the most dreaded diseases. In her 1978 book, Illness as Metaphor, Susan Sontag explored how cultural distortions have framed various illnesses, and drew an analogy between the romanticized views of tuberculosis and insanity. “The melancholy character—or the tubercular—was a superior one: sensitive, creative, a being apart.” But the myth of TB, Sontag writes, provided more than an account of creativity; it supplied a model of bohemian life, whether or not one had the artistic vocation. “The TB sufferer was a dropout, a wanderer in endless search of the healthy place.”

The TB myth validated subversive longings and turned them into cultural pieties, which is what allowed it to survive both human experience and two centuries of accumulating medical knowledge. The power of the myth was dispelled only when the tubercle bacillus was isolated and effective treatments for TB were developed, in the form of antibiotics (streptomycin in 1944 and isoniazid in 1952).

Sontag then goes on to write, “If it is still difficult to imagine how the reality of such a dreadful disease could be transformed so preposterously, it may help to consider our own era’s comparable act of distortion, under the pressure of the need to express romantic attitudes about the self…. In the twentieth century, the repellent, harrowing disease that is made the index of a superior sensitivity, the vehicle of ‘spiritual’ feelings and ‘critical’ discontent, is insanity.”

A disease that suffered in a different way from culturally based attributions is HIV/AIDS. When the AIDS epidemic began in 1980, it was a mysterious, deadly illness for which we had no treatments, and which became an epidemic. Its victims were regarded as modern-day lepers. In the absence of information, and with the hardest-hit groups—homosexual men and intravenous drug users—being among society’s most stigmatized, some people chose to attribute the illness to divine punishment for sinful behavior—a view that would have been right at home in the ancient world. It was only when LGBT activists exhorted the federal government, universities, and pharmaceutical companies to address the AIDS crisis that scientific research was mobilized, leading to breakthrough discoveries: isolation of the human immunodeficiency virus that caused the illness in 1984; AZT, the first medication for HIV, in 1987; and, subsequently, the invention of antiretroviral and protease inhibitor drugs, culminating in the pragmatic innovation of combining drugs, or triple therapy, in 1995. Eventually, the stigma surrounding the gay population lessened, and the hysteria that had greeted this plague-like illness in those early years abated. Now it is commonplace to see advertisements for its treatments on television.

Over the centuries, we have traced this arc from ignorance to knowledge for innumerable diseases. But progress in understanding schizophrenia has lagged behind, and false beliefs still linger. The scientific revolution that informed medicine and deepened our understanding of health and disease in the 1800s did not begin to impact mental illness until more than a century later. The suffering that accompanies madness was compounded by misunderstanding and mistreatment. Only in the last several decades have technological advances in pharmacology, biochemistry, brain imaging, molecular biology, and genetics enabled us to elucidate the biological underpinnings of many mental disorders that in the past were attributed to demons, social deviance, or bad parenting.

This revelatory knowledge has been a long time coming and only recently come to light. While we need to be cautious about applying modern diagnoses to ancient figures and case histories, nevertheless we can recognize descriptions of behaviors in historical texts from as far back as 1550 BC that reflect symptoms characteristic of what we now associate with psychotic disorders, including schizophrenia. The “Book of Hearts” (contained in the ancient Egyptian medical text known as the Ebers Papyrus) describes a condition resembling schizophrenia, postulating that demons, fecal matter, poisons in the heart or uterus, or blood abnormalities caused madness. The Hindu Vedas, in about 1400 BC, contain descriptions of illnesses marked by bizarre behavior, absence of self-control, filthiness, and nudity. One of the earliest biographical descriptions we have of madness is that of Saul, first king of the Israelites, who reigned in the late eleventh century BC. According to the Old Testament’s first book of Samuel, Saul was struck with insanity after disobeying the Lord. His torments included violent mood swings, rampant paranoia, fits of raving, and crushing despair. On one occasion, Saul stripped off his clothes and prophesied before Samuel, then lay naked all through the day and night. (In Hebrew, “prophesying” can mean “to rave” as well as “to behave like a prophet.”) If Saul were alive today, he would mostly likely be diagnosed with psychotic depression or schizoaffective disorder. Interestingly, the story of Saul also contains an early depiction of “treatment.” Saul suffers, and is soothed by music:

But the Spirit of the LORD departed from Saul, and an evil spirit from the LORD troubled him…. And it came to pass, when the evil spirit from God was upon Saul, that David took a harp, and played with his hand: so Saul was refreshed, and was well, and the evil spirit departed from him.

A few centuries later, King Nebuchadnezzar of Babylon suffered a fate similar to Saul’s. Nebuchadnezzar is described in the Book of Daniel as one who was punished by God for his pride and impiety, and compelled to “eat grass as oxen, and his body was wet with the dew of heaven, till his hairs were grown like eagles’ feathers, and his nails like birds’ claws.”

In ancient societies, disease was understood as the result of divine displeasure at human conduct and indicated a state of disharmony. Given this link between religion and disease, it was logical that healers were priests who employed prayer, ritual, sacrifice, and magic as treatments.

As medical historian Andrew Scull puts it, in a world ordered by the divine, where God spoke routinely through human instruments and imposed severe penalties on those who defied him, misfortunes were invested with religious or supernatural meaning, and the transformations occasioned by madness were readily attributed to divine displeasure, spells, or possession by evil spirits.
HUNTING IN THE EMPTY AIR
Greek myth, drama, and poetry all drew frequent links between the machinations of the gods and human madness. Hera punished Heracles, the offspring of Zeus’s adulterous affair, by “sending madness upon him.” Agamemnon complained that “Zeus robbed me of my wits.” The Iliad and the Odyssey—and the subsequent plays of Aeschylus, Sophocles, and Euripides—displayed a fascination with madness. The Greeks saw the gods everywhere, with their hands in all aspects of the natural world. Why should madness have been any different?

But Classical Greece’s views of mental disturbances evolved beyond the cultural domains of myth and drama largely due to the influence of Hippocrates (c. 460–357 BC). Hippocrates, widely considered the father of medicine, and his followers produced a corpus of descriptive and theoretical knowledge and clinical practices based on his teachings that didn’t rely on gods or supernatural explanations of diseases—including psychological disturbances. Hippocrates’s practice of medicine was based on concepts developed through empirical observations and inference. He encouraged practitioners to obtain complete and detailed medical histories of patients. These thorough workups included patients’ immediate environments—where they lived and what the climate was like—as well as age, diet, mood swings, sleep habits, menstruation patterns, dreams, and appetite; any symptom of physical illness was carefully assessed. A diagnosis was then made and a treatment devised. By declaring that the practice of medicine depended on detailed observation, inference of cause and effect, and reason rather than metaphysical explanations or religious beliefs, Hippocrates established the foundations of clinical medicine as it is now constructed and practiced. Numerous terms that we use today come directly from the Hippocratic corpus, such as symptom, diagnosis, therapy, trauma, and sepsis, as well as the physician’s oath.

The Hippocratics were emphatically clear that even manic or melancholic troubles had naturalistic explanations, both due to social circumstances and physical ailments, and no more resulted from the whims of the gods than did physical ills: “Men ought to know that from the brain, and from the brain only, arise our pleasures, joys, laughter, and jests, as well as our sorrows, pains, griefs, and tears…. It is the same thing which makes us mad or delirious, inspires us with dread and fear.”

Hippocratic physicians made sport of the beliefs of the temple healers who, with their notions of spiritual possession and arcane rituals, they regarded as little better than snake-oil salesmen. A key Hippocratic text, On the Sacred Disease (a title either ironic or just badly chosen, given its central argument that epilepsy results from pathological conditions of the body and not from the gods’ displeasure), accuses these “charlatans and quacks” of having no treatment to offer and thus hiding behind the divine: “[They] called this illness sacred, in order that their utter ignorance might not be manifest.”

So, what did madness look like to the ancients? And how can we relate the deluded thoughts and hallucinations of ancient figures to our contemporary notions of schizophrenia?

Hippocratic physicians were clearly familiar with hallucinations, in one instance attributing them to a brain illness in which “reason is disturbed and the victim goes about thinking and seeing alien things; one bears this kind of disease with grinning laughter and grotesque visions.” And elsewhere: they “hunt in the empty air… snatch chaff from the walls—all these signs are bad, in fact, deadly.” These symptoms were thought to indicate mental disorders with underlying physical causes. The Hippocratics also recognized what we might now call a predisposition or vulnerability to mental illness: The category of “half mad” was used to describe people regarded as susceptible to madness if stress or intoxicants came into play.

Medical explanations of what we now view as mental illnesses continued to be naturalistic into the first two centuries AD. Aulus Cornelius Celsus (25 BC–AD 50), an encyclopedist whose On Medicine (De Medicina) remains a key source of information in the Roman world, differentiated between acute and chronic psychosis. Celsus describes a form of insanity that was chronic and prolonged, in which patients remained physically healthy but mentally ill for the duration of their lives. This type of madness, in which patients were “duped… by phantoms,” was very disabling and relatively resistant to treatment. Unfortunately, some of the treatments Celsus recommended were barbaric: these patients were “best treated by certain tortures” such as starvation, fetters (leg shackles), and flogging, while “untimely laughter” should be treated with “reproof and threats.”

Celsus also held that an episode of insanity could be detected as it approached, with a patient becoming suddenly more talkative or speaking more quickly—almost certainly a description of what we now call “pressured speech” resulting from “flights of ideas” that can indicate the onset of a manic episode and may also be a feature of schizophrenia.

The prominent Roman physician Galen (AD 129–216) was influenced by the Hippocratics. He believed that all mental disorders arose not from demons or gods but were “the result of some lesion, some damage to the brain… that prevents it from functioning properly.” As a child, he had high fevers, during which he experienced hallucinations; years later, he would deduce that mental disturbances can occur as temporary aspects of other medical conditions. When he served as physician to Roman gladiators, he saw injuries up close, giving him valuable knowledge about anatomy and physiology as well as experience in treatment.

Galen describes a patient named Theophilus, whose insanity took the form of hallucinating flute players who played in his house all through the day and night. Another patient of his was stricken by fear that the Titan Atlas, cursed to hold the world on his shoulders, would grow tired and drop the world. The man suffered insomnia, anguish, and melancholy because of this belief and was exhausted by his anxiety. Though it isn’t clear how Galen treated him, we know that Galen was a creative physician. When faced with a delusional patient who believed she had a snake in her stomach, he “cured” her by inducing her to throw up and sneaking a snake into the vomit to convince her that she had expelled the creature.

While the Hippocratic school of medicine was conceptually advanced in its attempt to demystify disease, including attributing mental disturbances to natural rather than supernatural causes, the explanations and treatments that derived from its astute observations were grossly inaccurate. The Hippocratics believed that mental illnesses were the result of an imbalance of the body’s four fluids, or humors, a theory extended by Galen that survived well into the eighteenth century. According to the humoral theory, the body contains blood, phlegm, yellow bile, and black bile. Health was the state in which these substances were in balance, and ill health, or pain, the state in which one of the humors was either excessive or deficient. Melancholy, for instance, arose from too much black bile (balance was restored through treatments such as special diets and bloodlettings), but the theory covered a range of mental disturbances, which went by the names of mania, melancholy, phrenitis, insanity, paranoia, panic, and epilepsy.

Apart from Galen, the Romans did little to advance medical science and the understanding of mental illness. However, they did leave behind an insightful legal text that touches on madness and presents practical approaches for dealing with it. The Digest (AD 530) focused on defining proper treatment under the law, rather than on identifying the causes of madness; “passive” conditions such as depression were thus of less concern than conditions that gave rise to violent acts. Romans understood that madness could come and go, and the law distinguished between a crime committed during a period of insanity and one committed when a formerly insane person was lucid—a distinction we still struggle with today. For the Romans, madness was principally a legal matter. The mad also had rights. They were entitled to be cared for by a “curator” and to retain their property and status. We can compare this pragmatic legalistic view to that of the seventeenth and eighteenth centuries, when madness was seen as a moral or social problem, and to the nineteenth and twentieth centuries and into the present, when we mostly view madness through a medical lens—a view that coexists and often conflicts with complex legal and social questions, and which science is still trying to free from the age-old vestiges of stigma.