The Persecuting God and the Crucified Self: The Case of Olav and the Transformation of His Pathological Self-Image

Abstract

This case study describes the treatment of "Olav," a divorced lawyer in his mid-30's, who, at the time of treatment, had been continuously hospitalized in closed, short-term psychiatric wards for more than seven years with severe treatment-resistant depression, transient psychotic episodes, self-destructive behavior, suicide attempts, and Axis II diagnoses of Borderline and Paranoid Personality Disorders, with narcissistic traits. He was about to be admitted to a long-term ward for chronic schizophrenics. A great deal of his psychopathology revolved around his feeling tortured from condemning inner voices of what he called "The Committee," which he believed were the sacred voices of God. Olav's treatment took place in our institution's "VITA" unit, a 12-week, group-based, residential day-treatment program that explicitly concentrates on existential and religious issues, and is based on principles drawn from existential, narrative, object relations, and affect theories. The VITA program includes diary-writing, affect consciousness exploration, individual therapy, and regular group sessions with such activities as mindfulness training; art therapy focusing on drawing or painting internal representations of self, father, mother, and God; reflection on existential issues; "here-and-now-oriented" psychodynamic group therapy; and physical exercise. An assessment battery of standardized, quantitative, clinical questionnaires documents Olav's dramatic improvement over the course of treatment and at one-year follow-up. CASE CONTEXT AND METHODHistorically, religious belief as a part of a patient's mental health treatment has not been given the attention it deserves, and the patient's relationship to God is often a neglected issue in psychotherapy (e.g., Rizzuto, 1979;Shafranske, 1992). Rizzuto's (1979) research 30 years ago demonstrated the psychological significance of the individual's representations of God for psychic health and sickness. Many patients state that religious belief is an important part of their life (Bergin, 1991). Recently a journal, Psychology of Religion and Spirituality, has been established by the American Psychological Association, and other developments in the field have shown a gradually increasing focus on religious issues in psychotherapy (e.g., Rizzuto, 1979;Meissner, 1984;Shafranske, 1992; Sperry & Shafranske, 2005;Silverstein, 2008). Nevertheless, there is a long way to go in learning how to address systematically religious belief and related affects in psychiatric treatment. The present case is intended as a contribution to this ongoing development. A. The Rationale for Selecting This Particular Patient for StudyA patient we will call "Olav" had a severe, long-standing, treatment-resistant depression linked to religious pathology, with psychotic episodes and suicidal behavior. This case was chosen to demonstrate how our institution's "VITA" model (Austad & Folleso, 2003; see below) could impact on severe pathology as well as personality structure, affect organization, and inner r...

The Role of Religion and Spirituality in Olav's Treatment and Recovery: Commentary on an Exemplary Case Report

“…The VITA treatment model described by the authors was grounded in four main theoretical orientations, including existential theory, narrative theory, object relations theory, and affect theory (Stålsett et al, 2010). At the heart of the treatment team's conceptualization of Olav was the idea that "patients' inner representations of God originate in the relationship with their parents" and that "in order to change an impaired sense of self, the affects and beliefs associated with inner representations of mother, father, and God must be transformed from rigidly held, harsh and punitive images to more differentiated images" (Stålsett et al, 2010, p. 52).…”

“…Individuals may experience God as a compensatory figure because God really did help fill in the gaps left by inadequate parenting (O'Grady & Richards, 2007, p. 190). Stålsett et al (2010) wrote that "Olav continually expressed the need for a God representation that could be available as an object of faith" (p. 78) and that Olav's "fear, guilt, and rage towards God were replaced by closeness and tenderness to a benevolent God whom Olav felt received by and who loved the real Olav" (p. 78). They concluded that "One could say that he learned to use God as a soothing object rather than a persecutory one" (p. 78).…”

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ABSTRACTThe Case of Olav (Stålsett, Engedal, & Austad, 2010) offers in-depth insight from a spiritually and existentially informed psychodynamic perspective of how religious and spiritual issues may be intertwined with psychopathology. This case report also shows how psychological and spiritual interventions can be used in an integrative manner to help patients with severe longterm psychopathology.

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Psychotherapeutic Change and Spiritual Transformation: The Interaction Effect

“…His case study by Stålsett, Engedal, and Austad (2010) is used here to illustrate the VITA treatment program at the Modum Bad Hospital in Norway. This program uniquely combines contemporary psychoanalytic therapy and a focus on religious and spiritual concerns to produce a remarkably intense 12-week inpatient treatment process.…”

Reflections on Olav's Therapy: The Roles of Religious Experience, Self Psychology, and Mentalization

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ABSTRACTCommentaries on the case study of Olav (Stålsett, Engedal & Austad, 2010) by Richards (2010), Jones (2010, and Malitzky (2010) identify and discuss a number of key issues associated with the case study, including the study's scientific value, the importance of religious experience in relation to psychopathology and psychotherapy, and the roles of selfpsychology, attachment, and mentalization in the therapy change process. In our response to the commentaries, we address these issues.

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