We are familiar with the idea that the psychiatrist’s couch has taken over from the confessional in dealing with mental or spiritual distress. And yet, says says psychiatrist Aaron Kheriaty, his profession has no cure for the greatest psychological malady — a guilty conscience.

In the following article Dr Kheriaty, a professor of psychiatry at the University of California, Irvine, explains why this is so and where the real remedy lies. Although prepared for a group of professionals and much longer than most of our articles, this paper struck MercatorNet’s editors as both accessible for a lay audience and a fascinating read that many will not want to miss.

I am delighted that you have invited a psychiatrist to comment on the question of conscience. I hope that my explorations here can help shed some light on the mystery of man’s conscience – for conscience lies close to the center of the human mind and heart, and to the ultimate concerns that give meaning to people’s lives.

While I am pleased with the opportunity to offer this perspective, I should begin with the frank admission that modern psychiatry and the psychological sciences have paid remarkably scant attention to questions about conscience. With the exceptions of psychoanalytic theory early in the 20th Century, which gave an idiosyncratic but influential account of the formation and workings of conscience, and perhaps a few developmental theorists like Kohlberg, modern psychology and psychiatry seem to have mostly ignored questions about conscience.

How do we account for this neglect? Perhaps it is because any understanding of conscience and its operations must be premised upon human freedom. But the major theories and movements in modern psychology and psychiatry were often prone, in theory if not always in clinical practice, to various forms of psychological (or biological) determinism. This left little room for freedom of the will, and thus, moral conscience was often disregarded as an object of study. The limits of these theories, particularly in their unexamined foundational assumptions, reveal how they need to be corrected and augmented by insights from philosophy and theology. While we critique, we can also learn from modern scientific investigations of human behavior, cognition, and affect. Setting aside the frequent reductionist tendencies of the behavioral sciences, a careful examination of their findings can provide insights into the development, formation, and workings of conscience.

This paper makes no claim to be a comprehensive psychiatric account of our theme; there are several potential avenues of investigation. In the interest of time, I will limit myself to exploring only two. First, I will look at what psychoanalytic theory reveals (and conceals) about conscience. Second, I will highlight some insights from contemporary studies of individuals in whom the formation of conscience has gone radically wrong. Both of these avenues of inquiry may (perhaps ironically or paradoxically) shed some light on our topic.

Conscience in Psychoanalysis

The superego and conscience

Sigmund FreudPsychoanalysis is dead, some will object, so why bother with Freud at all anymore? While it is true that the specific tenets of orthodox psychoanalytic theory no longer have much traction in departments of psychiatry, the continued influence of Freud’s concepts is undeniable. This influence is still strongly felt in areas ranging from popular culture to literary criticism. Even in contemporary psychiatry, which now prides itself on being a “hard” medical science grounded firmly in neurobiology, many unquestioned and unexamined assumptions from psychoanalysis still operate (if you will excuse the term) unconsciously, beneath the glossy scientific surface. We cannot ignore psychoanalysis, nor can we yet consign it to the dustbin of history.

Freud’s theory of the mind, including his account of conscience, can be understood in part as a reaction to earlier rationalist theories, with their one-sided emphasis on reason’s role in determining human experience and behavior. Descartes and his rationalist descendents claimed that we are to give assent only to clear and distinct ideas – only to those ideas most immediately accessible to conscious awareness. Thus, reason was to be our exclusive guide in terms of thinking and behaving.

Along came Freud a few hundred years later to shatter the hard-won Cartesian confidence in reason. Descartes’ extreme position begat Freud’s opposite extreme. Following a trail blazed by Schopenhauer and Nietzsche, Freud claimed that our thoughts, feelings, and behaviors – no matter how clear, distinct, and rational they may appear on the surface – are for the most part controlled by tumultuous unconscious forces, operating relentlessly beneath the tranquil surface. Although the irrational unconscious was inaccessible to all but the psychoanalyst, it nevertheless influenced us in radical and often disturbing ways. In contrast to Descartes’ portrait of “rational man,” operating from the clarity of consciously experienced logical reasoning, Freud introduced us to “psychological man,” operating from unconscious, irrational, and contradictory ideas, affects, fantasies, and wishes.

Freud’s biographer Ernest Jones listed the six most common words Freud used to describe the unconscious: repressed, active, bestial, infantile, alogical, and of course, sexual. Such were the forces bubbling up from the seething cauldron of our unconscious. When the patient (with necessary assistance of the expert psychoanalyst) looked inward, what he saw was not pretty: the “ego” was really a precariously constructed mask, placed tenuously over a deep reservoir of sexual and aggressive drives. How was a person to manage a moral life with the twin forces of unreserved libido and a death instinct pressing up relentlessly from the deep wells of the psyche? Where lies man’s conscience in all of this? How is it formed, and how can the conscience help the ego to manage such primitive drives? Could this grim view of our mental topography leave room for the moral life? We will return to this question shortly.

Freud argued that despite outward appearances we are for the most part controlled by deterministic forces outside of our awareness. Humans are not the freely deliberating, rationally choosing, autonomous beings that the rationalists claimed. With reason so dispensed with, freedom of the will would be the next faculty to go. Indeed, Freudian theory insisted upon a strict psychic determinism – final causes were jettisoned. We may give reasons for our behavior or our moral choices, but these really amount to rationalizations that mask our deeper purposes. For Freud, whatever conscience was, it was not hyper-rational. As he famously quipped, man is not even master of his own house. Freud called his theory a blow to self-love, but it was more than this: it was a blow to any sort of love – for love can only be given and received freely, but freedom was precisely what his theory of the unconscious seemed to exclude.

It is within this rather bleak account of the human person and his psychological makeup that we need to situate Freud’s account of conscience. It is clear that when we perform an act that we judge to be immoral, we typically experience feelings of shame, thoughts of regret, and so on. How did psychoanalytic theory account for this phenomenon? In addition to the unconscious reservoir of sexual and aggressive drives (dubbed the “id”), Freud posited another largely unconscious component of our mental topography, which he termed the “superego”. The superego consisted of two parts: first, the unconsciously internalized prohibitions – the “no’s” and “don’t do that’s” – first experienced from our parents and later from society; and second, the “ego ideal” – the character or behavior that the person consciously wishes to develop or to exhibit.

The superego and its inhibitions, prohibitions, and commandments keeps the id and its impulses in check. Thus, the superego is necessary for all social life; indeed, it is the precondition for civilization itself. A sort of dialectical tension is established between the id (which operates exclusively on the pleasure principle), and the superego (which operates resolutely on the reality principle). The poor pummeled ego – the conscious self – is a bruised and battered synthesis between these two unhappy extremes, pressured by desires from below and subdued by punishments from above.

Morality is thus always a crabbed compromise, a concession. The claims of the subject must forever be restricted by the internalized claims of the social order. The moral life on this account is not ordered to happiness, but only to the social survival of the species. The superego has its way, but always and only at the expense of what the individual really wants. Such desires, when unmasked, are nothing but “primary process” hedonism: “me, mine, now, yes”. The superego represses these drives so that we can live socially; but the resultant neurosis is the price paid for civilization. Freud had no messianic pretentions, and psychoanalysis was no salvific system: he once stated flatly that the goal of therapy was to transform neurotic misery into everyday unhappiness. This, for Freud, is the best that can be hoped for.

The superego is sometimes identified straightforwardly with the conscience; but this simple equation is not entirely accurate. Freud’s account of the formation of superego was partially correct, insofar as he understood relationships and community as essential elements in the formation of a moral individual. Yet the superego, with its inner punishments and strictures, operated almost exclusively outside of the subject’s conscious awareness. It remained, in some sense, extrinsic to the person. The internalized moral norms that constitute one’s superego are not fully understood by the subject or ratified by the subject’s own insight, however much they may be obeyed. Remaining to some degree external to the self, the dictates of the superego are experienced as burdensome. Subjective guilt and the mechanisms of repression (with the resultant neuroses) spring from inner sources over which the person has only dim awareness, limited insight, and little conscious control. This is hardly an account of a healthy conscience at work.

Let us contrast the workings of the superego (with its unconscious source, extrinsic demands, and punitive strategies) with the workings of a healthy conscience, which issues objective moral imperatives of which the person is consciously aware. Drawing on the work of Dietrich von Hildebrand, John Crosby describes the psychological phenomenology of conscience elegantly:

We have to marvel at the “gentle strength” of moral imperatives: they are so demanding, so imperious, invested with divine authority, and yet… they do no least violence to the person, they do not terrorize him or manipulate him, but appeal to him where he is most a being of his own, eliciting his powers of acting through himself. They are also gentle in the sense that they can be ignored, and that it is easy to repress them. (1)

Moral imperatives issued by a healthy conscience (in contrast to the operations of the superego) allow us to act in a fully seeing and understanding way. If we fail to make this distinction, and mistakenly equate conscience with the superego, then we fall into the error of thinking that an ethical or virtuous life is not the path to human happiness, mental health, and human flourishing. The moral life becomes merely a compromise that must be managed as best we can.

What does this compromise look like? In his perceptive book, The Triumph of the Therapeutic, Philip Rieff described the new “therapeutic” character type, which psychoanalysis ushered onto the human scene: he argued that in modern times psychological man replaced political man of ancient Greece, religious man of Christendom, and economic man of the nineteenth century. Psychological man, he writes, “is anti-heroic, shrewd, carefully counting his satisfactions and dissatisfactions, studying unprofitable commitments as the sins most to be avoided…. Psychological man has constituted his own careful economy of the inner life.”(2) It is immediately clear how much psychological man, with his calculating behavior and narcissistic gaze, differs from the character ideal of the virtuous pagan or the Christian saint. Rieff summarized the difference nicely when he quipped, “religious man is born to be saved, psychological man is born to be pleased.”(3)

Psychological defenses and self-deception

After this admittedly critical assessment, one more descendent of the Freudian system deserves brief comment in relation to a study of conscience and its operations. I refer to the psychoanalytic concept of unconscious defenses (of which repression is the prototype) – what in later clunky terminology came to be called “defense mechanisms”. The workings of various unconscious strategies of avoidance, self-justification, distorted perception, and impaired reality testing – which collectively go under this heading of psychological defenses – strikes me as important for our study of conscience and its various deformations. To cite an example: a psychiatric colleague of mine at UC, Irvine, Andre Novac, has studied one such defense, which he terms “depersonification”. This is the defensive process that temporarily makes one unaware of the human and personal characteristics of other individuals, making it possible to victimize such a person as if he was an inanimate object.(4) The mind’s capacity for such depersonifying distortions is astonishing, as illustrated by the now-famous Stanford Prison Experiment conducted in 1971 by Philip Zimbardo, and by the historical example of German soldiers carrying out Nazi orders in World War II.

The detailed psychoanalytic descriptions of these and other psychological defenses are frequently insightful accounts of the vast repertoire of ways and means that we employ to avoid the truth about what we have done, to assuage our guilt, and to manage the awareness our moral imperfections. Unhealthy defenses in response to guilt often constitute what I like to call “the revenge of conscience”. Whatever our conscience is, for most of us, it is not easily quelled. When we attempt to ignore it, it takes its revenge under the guise of all sorts of destructive symptoms and behaviors.(5)
Guilt and its associated emotions of fear, shame, and regret are quite intolerable. If we have not found the true cure for these – that is, the cure effected by contrition and divine forgiveness – then we instead resort to the most astonishing mental gymnastics in order to ward off guilt. Anticipating Freud’s concept of repression as the fundamental psychological defense from a guilty conscience, Nietzsche wrote: “’I have done that,’ says my memory. ‘I cannot have done that’ – says my pride, and remains adamant. At last – memory yields.”(6) But I would add, memory does not yield quietly or complacently. We still pay the price and suffer in other ways.

One of the more common effects, which I have observed in many clinical cases, is a compulsive repetition of the same sin over and over, as the person unconsciously both punishes himself for the sin with the repeated sin, and simultaneously tries in vain to justify himself by willful repetition of the same self-destructive act, as though it became less sinful with repetition. With this sort of habituation, the sin paradoxically becomes a “freely chosen compulsion”.(7) The person who acts thus becomes progressively unaware of what compels him; he grows increasingly hardened and more miserable; and finally, he becomes blind to his own interior state.

These and related forms of self-deception are described in countless carefully documented case histories populating the psychoanalytic literature. A constellation of these unhealthy defenses in Scriptural language is known simply as “hardening of the heart”. One of the chief effects of this hardening is an inability to know ourselves as we truly are. When we ignore or disobey our conscience, our capacity for true and accurate self-knowledge is impaired. Again, I quote Nietzsche, who for all his faults knew well our propensity for self-deception: “We are unknown, we knowers, to ourselves,” he wrote. “Of necessity we remain strangers to ourselves, we understand ourselves not, in our selves we are bound to be mistaken.” In his hilarious parody, Lost in the Cosmos: The Last Self-Help Book, the novelist Walker Percy echoes this with characteristic wit: “Why is it possible to learn more in ten minutes about the Crab Nebula in Taurus, which is 6,000 light years away, than you presently know about yourself, even though you’ve been stuck with yourself all your life?” and, “Why is it that of all the billions and billions of strange objects in the Cosmos—novas, quasars, pulsars, black holes—you are beyond doubt the strangest?”(8) Careful psychological studies confirm that a guilty conscience, perhaps more than any other factor, accounts for our paradoxical inability to know and understand ourselves.

Sociopathy: The absence of conscience

I will now turn from this historical sketch of conscience in Freud’s influential theory to a contemporary area of psychiatric research. If one searches for “conscience” in current psychiatric literature, the most frequent studies that turn up are those that examine individuals who seem to lack a conscience. One way to potentially shed light on the workings of conscience, and to highlight the importance of a healthy conscience, is to study such impaired individuals. These terrifying persons are commonly referred to as sociopaths (or less accurately as “psychopaths”), and designated by psychiatrists as having “antisocial personality disorder”. This extreme condition is characterized above all by the inability to feel guilt or remorse, even after committing heinous acts. With such persons, the “hardening of the heart” is complete: it becomes difficult to discern any traces of conscience beneath the rubble of psychological defenses.

The analogy to a diseased body is apt for understanding this condition: sociopathy is a spiritual disease of the worst sort. Citing psychiatrist Albert Gorres, who argued that the capacity to recognize guilt belongs essentially to the spiritual makeup of man, Joseph Ratzinger explains:

[Guilt] is as necessary for man as the physical pain that signifies disturbances in the normal bodily functioning. Whoever is no longer capable of perceiving guilt is spiritually ill, ‘a living corpse’…. No longer seeing one’s guilt, the falling silent of conscience in so many areas is an even more dangerous sickness of the soul than the guilt that one still recognizes as such. He that no longer notices that killing is a sin has fallen farther than the one who still recognizes the shamefulness of his actions, because the former is further removed from the truth and conversion.(9)

Whatever else it is, conscience is an organ that requires proper development. A full study of the origins of sociopathy would take us too far afield here. Suffice it to say that underlying genetic vulnerabilities, coupled not only with a lack of basic formation and education of conscience, but also typically with severe early childhood trauma, seem to be necessary ingredients in the dark brew that breeds sociopaths. It is a frightful reality: a person’s conscience can indeed become stunted, and even stamped out. Let us now examine this problem by looking at three aspects of sociopathy: the lack of empathy, the lack of inner integration, and a profoundly distorted concept of freedom.

Conscience and empathy

Philosophy has typically examined conscience from the perspective of rational judgment, i.e., applying a universal norm, such as a divine commandment or a categorical imperative, to particular situations or concrete sets of circumstances. Reason or will (or some combination thereof) are given priority. By contrast, contemporary psychiatric literature tends to study moral behavior by examining its affective and relational aspects. In itself, this is an incomplete account of moral behavior and conscience. However, it can help to augment modern philosophical perspectives.

Prior to the separation of passions and virtues from moral thinking effected by the nominalists, philosophical ethics tended to pay much more attention to the role of the passions and appetites (rightly ordered by the requisite virtues) in moral behavior. Much of the work in modern psychiatry and the social sciences can be understood as an attempt to round out our moral picture of man by reintroducing these affective and relational factors, which are often neglected in a deontological or a divine command theory ethics.

Modern psychiatry and the social sciences typically understand conscience (or the absence of conscience in antisocial personality disorder) in terms of the presence (or absence) of the capacity for empathy. This is defined as the ability to “feel one’s way into” the experiences of another person, who is affected by my actions and choices. This focus on empathy, while limited and incomplete as an account of conscience, nonetheless highlights inherent social and relational factors as necessary conditions for acts of virtue or vice. This line of enquiry sometimes mistakenly tends toward a simple equation of conscience with the capacity for empathy – as though I would automatically behave well if only I accurately knew or felt how my actions affected others. While conscience cannot simplistically be said to consist of the capacity for empathy, this capacity does seem to be a necessary condition for a well-formed and well-working conscience. It is clear that sociopaths lack this capacity in many respects (or at least, if they have it, they use it only to manipulate and harm others). Studies of early attachment indicate the importance of healthy bonds between parents and child for the formation of empathic capacities. A more thorough account of healthy and unhealthy attachment would take us too far afield here. But recognizing the essential role of early parental and familial love provides an avenue for further enquiry in understanding the development and formation of conscience.

Conscience and unity of life

In addition to their lack of empathy, another feature of sociopaths that has received some attention in recent years has to do with the lack of inner unity or integration that such people exhibit. Forensic psychiatrists who study criminals with antisocial character traits have carefully examined the personal autobiographical narratives given by such people in structured interviews. These studies have demonstrated that when sociopaths recount their personal life story, their memories and personal histories are fragmented, inconsistent, and full of internal contradictions. In other words, their interior life, particularly their personal narrative history, is incoherent. These cases provide vivid and extreme examples of how ignoring one’s conscience (or never developing one’s conscience in the first place) results in profound inner chaos.

We can contrast this disintegrated person with the person of moral integrity – the person who develops and follows a well-formed conscience. A healthy individual’s interior life is characterized by unity and consistency. The word “integrity,” frequently employed to designate a person of sound character, literally means that one is complete, whole, unbroken, and undivided. Philosophical investigations confirm and complement this clinical insight. Crosby, whom I cited above, describes the profound connection between conscience and psychological integrity:

I know that in deciding whether or not to act in accordance with the dictate of my conscience I will at the same time decide about myself, I will dispose over myself. If I act as my conscience admonishes me, I am aware of affirming myself in a certain way, of willing my deepest human integrity. And if I act against my conscience I am aware of radically compromising myself. That is why persons who are caught up in a moral crisis will sometimes speak as if what binds them to do the right thing is not so much the good that they act to preserve, but rather the integrity of themselves – as if they would split apart as persons by acting against their conscience.(10)

The sociopath who cannot give a coherent or consistent personal narrative account of his acts or experiences is literally split apart – indeed, fragmented into many pieces – in precisely the fashion described here. Crosby goes on to describe how the determination of oneself in conscience is a determination from within – an incommunicable act that springs from the integrity of one’s interior life; it is a determination that I can exercise only toward myself and not toward another. “Thus,” he writes, “the term conscience is often used to mean the innermost center, the inner sanctuary, of the human person.” (11) Sociopaths seem to lack such a center: their inner sanctuary seems inaccessible, or perhaps nonexistent.

The psychological sciences, no matter how refined our techniques become, can no more plumb the depths of this inner sanctuary of a person than a stethoscope can measure one’s imagination. However, these sciences can shed light on the effects of following (or not following, as the case may be) one’s conscience, by examining the unity and integrity (or disunity and disintegration) of one’s psychological life that issues forth from one’s repeated volitional acts. A person’s habitual moral (or immoral) acts will shape that person in such a way that the effects can often be observed, described, and measured externally.

Only a person who is inwardly constituted by repeated acts in accordance with conscience will truly possess the inner unity of life, and the requisite virtues, to be called free. The theme of freedom brings us to the final aspect of sociopathy to be examined here.

Conscience and freedom

As a take off point, I cite a contemporary study of sociopaths by psychologist Robert Hare. In his book, Without Conscience: the Disturbing World of the Psychopaths Among Us, (12) he claims rather implausibly that the sociopathic person actually has more freedom than the rest of us. Hare’s argument runs as follows: the choices of a normal person’s freedom are limited by their conscience, while the sociopath knows no such constraining limits upon his freedom. On this account, it is normal people who have a so-called “freedom deficit”.

This rather flimsy argument rests upon a profoundly confused notion of freedom and its relationship to conscience, and yet it is a confusion than runs rampant today. The reason his conclusion appears (and in fact is) so implausible is that his argument relies on a flawed understanding of freedom. For Hare, as for so many contemporary psychologists, freedom (if it exists at all) is merely the raw power of choice. I would like to contrast this with a notion of freedom as the ability to pursue the good. (13) Hare’s book, and many other examples could be cited, provides evidence of the degree to which voluntarist philosophical notions can creep into the psychological and social sciences and influence the interpretation of clinical and research data, particularly when we are dealing with phenomena or behavior related to the moral order.

We can contrast Hare’s false freedom of indifference with a beautiful account of true freedom for excellence, provided by the Eastern Orthodox theologian David Bentley Hart in his insightful essay, “Freedom and Decency”. Allow me conclude this section by quoting Hart at some length on the topic of freedom:

To be fully free is to be joined to that end for which our natures were originally framed, and for which – in the deepest reaches of our souls – we ceaselessly yearn. And whatever separates us from that end – even if it be our own power of choice within us – is a form of bondage. We are free not because we can choose, but only when we have chosen well. And to choose well we must ever more clearly see the “sun of the Good” (to employ the lovely Platonic metaphor), and yet to see more clearly we must choose well; and the more we are emancipated from illusion and caprice, the more our will is informed by and responds to the Good, the more perfect our vision becomes, and the less there is really to choose. The consummation for which we should long, if we are wise, is that ultimately we shall, in St. Augustine’s language, achieve not only the liberty enjoyed by Adam and Eve – who were merely “able not to sin” – but the truest freedom of all, that of being entirely “unable to sin”, because God’s will works perfectly in ours.(14)

The problem of sin and the limits of the psychological sciences

Freedom as the inability to sin.

Guercino:   	 Guercino Christ and the Woman of Samaria (1647 ) This mention of sin brings me to my closing remarks. Regarding questions of conscience, the psychological and medical sciences clearly have their limits. I want to conclude with a few words on what is perhaps the most significant limit. The language of therapy – of psychiatry and clinical psychology – has often replaced the language of morality and religion in the modern world. Philip Rieff dubbed this, “the triumph of the therapeutic.” But a therapeutic approach to human problems – helpful as it sometimes is – has its limitations. Therapy or medicine cannot cure our deepest disorder, which is the problem of guilt, the problem of sin.

There is a prevalent denial of sin today, a denial often amplified by the triumph of a therapeutic mentality. Rather than liberating us from the guilt of sin by keeping the conscience in a state of invincible ignorance, such widespread denial only serves to augment our anguish and unhappiness. To put it plainly, the therapeutic mentality has often served to obscure, rather than illuminate, the precepts of the natural law written on every human heart.

And so I conclude by turning from psychology to literature – specifically, to drama, which has plumbed the depths of the human psyche more profoundly than any clinician or scientific researcher. T.S. Eliot explored the psychology of conscience in his play, The Cocktail Party.(15) One character, a young woman named Celia Copleston, is having an affair with a married man. When she suddenly realizes emptiness of this relationship, her life is shaken profoundly. One could say that beneath the rubble of her culturally-influenced character deformations, her conscience still operated – veiled and disguised, yet not quiescent. Like many people today, in her distress she turns to physician for advice. There’s something not quite right, she tells him:

“I should really like to think there’s something wrong with me –

Because, if there isn’t, there’s something wrong

Or at least, very different from what it seemed to be,

With the world itself – and that’s so much more frightening!

That would be terrible. So I’d rather believe

There is something wrong with me, that could be put right.”

She tries to name her disorder. It is not simply that she has violated some norm, but that she has failed in something more personal and perhaps more relational. She has an inchoate sense that she has fallen short in regards to something (or someone) outside of her self. These dim intuitions seem to run contrary to the conventional bourgeois ideas and values she was raised with and taught to embrace. And yet, beneath her internalized social conventions, there is a persistent anamnesis – a remembrance or recollection of something or someone else that calls to her. Finally, after floundering, she comes up with the only diagnosis she can think of to explain her symptoms:

Celia: “It sounds ridiculous—but the only word for it

That I can find, is a sense of sin.”

Doctor: “You suffer from a sense of sin, Miss Copleston? That is most unusual.”

Celia: “It seemed to me abnormal…

My bringing up was pretty conventional –

I had always been taught to disbelieve in sin.

Oh, I don’t mean that it was never mentioned!

But anything wrong from our point of view,

Was either bad form, or was psychological.

… And yet I can’t find any other word for it.

It must be some kind of hallucination;

Yet, at the same time, I’m frightened by the fear

That it might be more real than anything I believed in.”

Doctor: “What is more real than anything you believed in?”

Celia: “It’s not the feeling of anything I’ve ever done,

Which I might get away from, or of anything in me I could get rid of –

but of emptiness, of failure

Towards someone, or something, outside of myself;

And I feel I must… atone – is that the word?

Can you treat a patient for such a state of mind?”

The answer of course is no. Freud himself recognized these limits, when he said, “It would be absurd for me to say to a patient, ‘I forgive you your sins’.” The psychotherapist has no power to do this.

According to its Greek root, the word “psychiatrist” literally means, “doctor of the soul”. And yet, the psychiatrist has no cure for this greatest of all psychological maladies – the problem of sin. If he is astute, he can perhaps define and describe guilt; but he can in no way cure the guilty conscience. All of our human attempts to do so, whether by psychological defense strategies, medical ministrations, or therapeutic techniques, ultimately prove insufficient. But we need not despair. For our own failures suggest to us what faith has already revealed: that, in the last analysis, there is only one true and effective Doctor of the soul.

Dr Aaron Kheriaty is assistant clinical professor of psychiatry at the University of California, Irvine, and director of the university’s Psychiatry and Spirituality Forum. He can be contacted at akheriat@uci.edu

1. Crosby, John F, The Selfhood of the Human Person. Washington, DC: CUA Press, 1996, p. 211.

2. Op. Cit.

3. The Triumph of the Therapeutic, Harper & Row, New York: 1966, p. 25.

4. “Depersonification/Dehumanization: A syndrome of neglect in victimization of others. An exploration based on case studies.” Andre Novac, MD. (This is an unpublished paper provided me by the author.)

5. This is not to say, of course, that all neuroses or mental suffering is the result of a guilty conscience – the causes and contributions to mental illness are many and complex, and most typically not the fault of the suffering subject.

6. Beyond Good and Evil
7. Cf. Joseph Pieper, The Concept of Sin. South Bend: ST. Augustine’s Press, 2001, chapter 7

8. New York: Farrar, Strauss & Giroux,1983. These are two of the “subtitles” of the book.

9. On Conscience. San Francisco: Ignatius Press, 2007.

10. Crosby, John F, The Selfhood of the Human Person. Washington, DC: CUA Press, 1996, p. 88.

11. Ibid., p. 89. Cf. Vatican II’s formulation: “His conscience is man’s most secret core, and his sanctuary. There he is alone with God whose voice echoes in his depths.” (Gaudium et spes, n. 16)

12. Guilford Press, 1999.

13. This is a false freedom of indifference, not a true freedom for excellence. Cf. Servais Pinckaers, The Sources of Christian Ethics, Part III, Washington, DC: CUA Press, 1995.

14. In the Aftermath: Provocations and Laments. Grand Rapids, MI: Eerdmans, 2009.

15. Orlando: Harcourt, 1950.

Aaron Kheriaty is Professor of Psychiatry at UCI School of Medicine and Director of the Medical Ethics Program at UCI Health. He serves as chairman of the medical ethics committees at UCI Hospital and...