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ORIGINAL ARTICLE
SheDoesNotNeedaMedicalorPsychiatricDiagnosis
JamesPhillips,MD,*BrianFallon,MD,† SalmanMajeed,MD,‡ KeithMeador,MD,§
JosephMerlino,MD,||HunterNeely,MD,¶JeniferNields,MD,* DavidSaunders,MD,PhD,† andMichaelNorko,MD*
Abstract: ThisarticletracesthehistoryofJoanofArcthroughherbrieflifethat includesleadinganarmyindefenseofFranceattheageof17andendingwith herdeathatthestakeattheageof19.Inheractivities,StJoanreportedthat shewasguidedbyvoicesandvisionsinwhichshecommunicatedwithvenerated spiritualfiguressuchasStMichaelandStMargaret.Questionshavearisenabout thenatureoftheseexperiences,andvariousmedicalandpsychiatricdiagnoses havebeenofferedbycontemporaryexperts.Inourefforttoevaluatethediagnosticproposals,wehaveexaminedtheincidenceofvoicesandvisionsintheMiddle Ages,andwehavefollowedthatwithareviewofnonpathologicvoice-hearingin ourownera.Wethenmoveontoananalysisofsomeproposedmedicalandpsychiatricdiagnoses,allofwhichwefindunconvincing.Withthisbackground,we arguethatStJoandoesnotwarrantamedicalorpsychiatricdiagnosis.Sucha conclusion,however,leavesuswithanotherissue,thatofJoan'sachievements. Howdoweunderstandanadolescentbeingabletoleadanarmy?Addressingthis questionprovesmoredifficultthandecidingwhetherStJoanwarrantsadiagnosis.InadditiontoherachievementsinthewaragainstBritain,JoanofArcstands outasboththemostdocumentedpersoninWesterncivilizationupuntilherera, andastheonlypersonwhohasbeenbothcondemnedandcanonizedbythe CatholicChurch.
KeyWords: Psychiatry,JoanofArc,diagnosis,history,medieval,voices (JNervMentDis 2023;211:559–565)
METHODS
TheprincipalsourceofinformationaboutStJoan'slifeisthevoluminousdocumentationofhertrials:theTrialofCondemnationin 1431andtheTrialofRehabilitationin1456,allfoundinthearchives ofFrance.Ournarrativeofherlifeandexperiencesisbasedoninformationfromthetwotrials.Forthisarticle,wehavereliedmainlyonthree documents:thetrialreportsthemselves,foundinT.DouglasMurray, JeanneD’Arc,MaidofOrléans,DelivererofFrance (1902);theWeb site,www.Jeanne-darc.info,foundedin1997bySørenBieasafree WebsitecontainingallavailableinformationaboutStJoan;and,finally, ReginePernoudandMarie-VeroniqueClin, JoanofArc:HerStory (1998).InFrancePernoudwasconsideredthegrandedameofMedievalandStJoan–relatedhistory.
TheofficialLatintextofthetrialswasdiscoveredintheofficial archivesofFranceandbroughttolightandtranslatedintomodern FrenchbyJulesQuicheratinthe1840s.Theworkwastranslatedinto EnglishandeditedbyT.DouglasMurrayin1902.
*YaleUniversitySchoolofMedicine,NewHaven,Connecticut; †ColumbiaUniversity SchoolofMedicine,NewYork,NewYork; ‡PennStateHersheyMedicalCenter, Hershey,Pennsylvania;§VanderbiltUniversity,Nashville,Tennessee;||Downstate CollegeofMedicine,Brooklyn,NewYork;and¶UCDavisMedicalCenter, Sacramento,California.
SendreprintrequeststoJamesPhillips,MD,YaleUniversitySchoolofMedicine;88 NobleAvenue,Milford,CT06460.E‐mail:james.phillips@yale.edu.
Copyright©2023WoltersKluwerHealth,Inc.Allrightsreserved.
ISSN:0022-3018/23/21108–0559
DOI:10.1097/NMD.0000000000001654
Finally,wehavebenefitedfromMarkTwain's JoanofArc (Twain,1896),forwhichhedidextensiveresearchinFranceandwhich heconsideredthebestofhisbooksandtheonethataffordedhimthe mostsatisfaction.
Introduction
LetusbeginbyturningthisintroductionovertoMarkTwain, whooffersusastarkdescriptionofStJoan'sbeginning:
InJoanofArcattheageofsixteentherewasnopromiseofromance.Shelivedinadulllittlevillageonthefrontiersofcivilization:shehadbeennowhereandhadseennothing;sheknewnone butsimpleshepherdfolk;shehadneverseenapersonofnote;she hardlyknewwhatasoldierlookedlike;shehadneverriddena horse,norhadawarlikeweaponinherhand;shecouldneither readnorwrite;shecouldspinandsew;sheknewhercatechism andherprayersandthefabuloushistoriesofthesaints,andthis wasallherlearning.ThatwasJoanatsixteen(pp441–442).
HowStJoanofArcemergedfromthismodestbeginningwewill leaveforfurtherconsideration.WebeginthisessayonStJoanbyplacingherinthehistoricalcontextinwhichherextraordinaryexperiences occurred.TheywerebothlikeandunlikeotherMedieval,mysticalphenomena,andcorrespondingly,herfellowcountrymenandherChurch bothpraisedherandcondemnedher.Amongherotherachievements, shestandsasboththemostdocumentedpersoninWesterncivilization upuntilherera,andastheonlypersonwhohasbeenbothcondemned andcanonizedbytheCatholicChurch.
HistoricalBackground
JoanofArc's(Jeanned'Arc's)storytookplaceinthecontextof theHundredYearsWar,datedsomewhatarbitrarilybetween1337and 1453andconsistingofaseriesofconflictsandwarsbetweenthePlantagenetrulersofEnglandandtheValoisrulersofFrance.Beginning withtheNormanconquestofEnglandbyWilliamtheConquerorin 1066,FranceandEnglanddisputedtheroleofeachinFranceover theensuingcenturies,involvingbothpropertyandtitles.Duringthisperiod,Franceitselfwasalooseconfederationofprincipalities,oftenwith unclearboundaries.
Intheearly15thcentury,afteraperiodofminimalwartimeactivity,HenryVofEnglandwonimportantvictoriesatAgincourt(1415) andNormandy(1417–1418).Thosevictoriesawardedhimashiswife, Catherine,daughteroftheFrenchCharlesVI.Hedeclaredthattheirson wouldbecomeHenryVIandwouldbekingofthedualmonarchy,EnglandandFrance.ThatgesturedisinheritedCatherine'sbrotherCharles, thedauphin,whowastobecomeCharlesVIIofFrance.
AftertheEnglishvictories,theyoccupiedalmostallofnorthern France,includingParis.DirectlysouthofParis,ontheLoireRiver,the cityofOrléanswasthelaststrongholdbetweenEnglandandsouthern France.TheconquestofOrléanswasHenryV'snextgoal.Itwasat theEnglishsiegeofOrléansthatJoan'sstorybegins.
JoanofArc,whowasalwaysreferredtoastheMaid(laPucelle), wasborninDomremy,intheprovinceofLorraine,in1412.Although LorrainewastechnicallynotpartofFrance,Domremyconsidereditself partoftheFrenchkingdomandstronglyonthesideoftheDauphin (Charles,heirtothethrone)andthenationalparty.Joan'sparentsowned about50acresofland,whichherfatherfarmedalongwithraisinganimals.Joanspentherearlylifetendingtohouseholdaffairs,caringfor thefamilyanimals,andmasteringherskillsasaseamstress.
Attheageof13,shebeganexperiencingmysticalvisionsurging hertopiety,andthenmorespecificvisionsofStMichaelandStCatherinedesignatingherasthesaviorofFrance.AstheEnglishwereatthis timelayingsiegetoOrléans,thesaintsencouragedhertoseekanaudiencewiththeDauphintorequestthatheallowhertoraisethesiegeof Orléans,installhimastherightfulking,andbanishtheEnglishfrom France.In1428,attheageof16,thevisionsinstructedhertogoto VaucouleursandcontactRobertdeBaudricourt,thegarrisoncommanderandasupporterofCharles,theDauphin.Hewouldbeableto leadhertoChinon,southwestofOrléans,wheretheDauphinwasresiding.ShearrivedinVaucouleursonMay13,1428.Baudricourtfound herprogramridiculousandrefusedherrequest.Shereturnedtoher homeinDomremybutreturned2monthslatertoVaucouleurswith herparents,littlesister,andthreebrothers.Afterherparentsreturned home,JoantookupresidenceinVaucouleurs,tryingtomeetagainwith Baudricourt.Inthefollowingyear,atthetimeofLent,shemetwith him,andheagainrejectedherrequestforpassagetoChinon.Whena squireinthehouseholdofBaudricourtteasedandquestionedher,she responded:
Icameheretotheking'schamber[thatis,intoroyalterritory]to speaktoRobertdeBaudricourtsothathewouldeitherbringme orhavemebroughttotheking,buthepaysnoattentiontome ortomywords;nevertheless,itisimportantthatIbeattheking's sidebeforemid-Lentarrives,evenifitmeansIhavetowalkuntil myfeetareworndowntomyknees;thereisinfactnooneelse, neitherakingnoradukenorthedaughterofthekingofScotland, noranyotherwhocanrecoverthekingdomofFrance,andhewill havenohelp,ifnotthroughme,eventhoughIwouldprefertostay homeandspinwoolwithmypoormother,forthisisnotmystation,butImustdoit,becausemyLordwillsthatIdoso (Pernoud,1955,p19).
Whenaskedbythesquire, “butwhoisyourLord?” themaidanswered, “God.” Andhecontinued, “AndsoIpromisedtheMaid,by placingmyhandsinhersasasignofgoodfaith,thatIwouldwithGod's aidleadhertotheking;andIbeggedhertotellmewhenshewantedto leave;andshesaid, ‘Bettertodaythantomorrow,bettertomorrowthan later’” (p19).
Inthemeantime,thepeopleofVaucouleurswerebecomingincreasinglysympatheticwithJoan'scause,andBaudricourt,encouraged bythesquireandthepeopleofVaucouleurs,finallyrelentedtogether toChinon,thesiteofCharles'court.Hegaveherahorseandanescort ofseveralsoldiers.Shecroppedherhairanddressedinmen'sclothes forthe11-dayjourneyacrossenemyterritorytoChinon.Theytraveled mostlyatnighttoavoidhighwaymen,theEnglish,orBurgundians(the FrenchofBurgundy,whosidedwiththeEnglish).HermalefellowtravelersreportedthatJoansleptnexttothem,buttightlybound,sothat therewasnoissueof “carnalimpulse.” Theyfoundher “withoutfault orweakness,exemplaryinpietyandcharity,inflexibleinresolve” (PernoudandClin,1998,p21).
Atfirst,Charleswasnotcertainwhattomakeofthispeasantgirl whoaskedforanaudienceandprofessedshecouldsaveFrance. Charleswashimselfonly26yearsoldandhadneverlivedinParis,as itwasoccupiedbytheEnglish.Hewasfullofdoubtabouthimself andhisroleintheroyalstructure,andhedidnotunderstandwhyhe hadnotbeenanointedking.Joan,however,wonhimoverwhenshecorrectlyidentifiedhim,dressedincognito,inacrowdofmembersofhis
court.Thetwohadaprivateconversationduringwhichitissaidthat JoanrevealeddetailsofasolemnprayerCharleshadmadetoGodto saveFrance.Heremaineduncertain;someofhiscounselorswere impressedbyJoan,othersconsideredhermad.Joanhadalreadydemonstratedtohimherskillsinwieldingalanceandridingahorse.In hisuncertaintyandnotwantingtobemadeafoolof,Charlessenther andherentouragetoPoitiers,acenteroftheologicallearning,foranintensive,3-weekevaluation.Poitierswasonlyday'sjourney(35miles) fromChinon.Hereisanexampleofherevaluationbythetheologians ofPoitiers aclearinstanceofthe17-year-old'switinthefaceofher inquisitors.
Iaskedherwhatlanguagehervoicespoke.Sheanswered, “Better thanyours.” Me,IspokethedialectofLimoges;andthenIasked herifshebelievedinGod;sheanswered, “yes,betterthanyou.” AndIthensaidtoherthatGodwouldn'twantustobelievein herunlesssomethingmadeusthinkthatweshoulddoso.Icould notadvisethekingsimplyonherassertionthatheshouldentrust men-at-armstohersothatshemightleadthemintoperil,unless shecouldatleasttellhimsomethingfurther.Andsheanswered, “InGod'sname,IdidnotcometoPoiterstoproducesigns.But leadmetoOrléans,andIwillshowyouthesignforwhichIwas sent” (p29).
Joanwasalsosubjectedtoaphysicalexaminationinwhichit wasdeterminedthatshewas “awoman,avirgin,andamaid.” Theclergymenandtheologiansreportedtheyfoundnothingimproperwith Joan,onlypiety,chastity,andhumility.TheyrecommendedtotheDauphinthatheacceptheraidandsendhertoOrléans.
Charlesthenrelentedandgavethe17-year-oldJoanofArcarmorandahorseandallowedhertoaccompanythearmytoOrléans, thesiteoftheEnglishsiege.Wordhadtraveledfast,andbythetime shereachedOrléans,shewasalreadyheraldedastheMaidwhowould raisethesiege.ShetraveledwithJohn,CountofOrléans,alsocalledthe BastardofOrléans,whowastechnicallytheCommanderoftheFrench forces.JoanhadbroughtaseparateFrenchforce,andthetwoindividualswerefrequentlyinconflict,theBastardpreferringtoliebackand wait,whileJoanarguedfordirectlyconfrontingtheEnglish.Hereisa sampleoftheirconversation:
“IsityouwhosaidthatIwastocomeonthisside[oftheriver]and thatIshouldnotgodirecttotheothersidewhereTalbotandthe Englishare?”“Yes,andthosemorewisethanIareofthesame opinion,forourgreatersuccessandsafety?”“InGod'sname,” shethensaid, “thecounselofmyLordissaferandwiserthanyours. Youthoughttodeceiveme,anditisyourselveswhoaredeceived, forIbringyoubettersuccorthanhasevercometoanygeneralor townwhatsoever – thesuccoroftheKingofHeaven.Thesuccor comesnotfrommebutfromGodHimself ” (Murray,1902,p234).
ThisstatementisasuperbexampleofJoan'sstyle:afirmconvictionthatshespeaksforGod,andthatanyonewhodisagreesmustbow tothevoiceofGod.Sometookreliefinhercertainty,andothers questionedtheauthorityofthis17-year-oldgirl.Inviewofthisarticle's questionastowhetherJoanwarrantsamedicalorpsychiatricdiagnosis, thisstatementandtheeventsthatensueddemonstrateadegreeofintelligenceandcompetencethatspeakagainstattributingherbehaviorto eitherformofpathology.
Joan'scommandingstylemotivatedthehesitanttroopstomove aggressivelyforward,andinaseriesofbattlesbetweenMay4and May7,1429,theFrenchtroopstookcontroloftheEnglishfortifications.Joanwaswoundedbutlaterreturnedtothefronttoencouragea finalassault.Bymid-June,theFrenchhadroutedtheEnglishand,in doingso,crushedtheirperceivedinvincibilityaswell.
AlthoughitseemedthatCharleshadacceptedJoan'smission,he didnotdisplayfulltrustinherjudgmentoradvice.Afterthevictoryat Orléans,shekeptencouraginghimtohurrytoReimstobecrowned
king,butheandhisadvisorsweremorecautious.Inthemeantime,the EnglishwereregroupinginPatay,notfarfromOrléans.Asthetwo forcesweredrawingneartooneanotherinanopenfield,theBastard ofOrléans,alongwiththeDukeofAlecon,bothleadersoftheFrench, questionedJoan,andsherespondedthateveryoneshouldhave “good spurs.” Askedifthatmeantthattheywererunningawayfromthebattle, JoanrespondedthattheyneededthespurstochaseafterthefleeingEnglish.Shewasright,theEnglishtookflightand4000ofthemwere takenprisoners.TheBattleofPatayonJune18,1429,isconsidered Joan'sgreatestvictory.
Afterthebattleandalittlemoredithering,theDauphinagreedto gotoReimsforhiscoronation.TheyleftonJune29,1429,onwhatwas technicallyafoolhardymission,asReimswasfarawayinnorthern FranceandinBurgundianterritory.OnJuly17theyenteredReims, andonthefollowingday,theDauphinwascrownedCharlesVII.Joan wasathisside,occupyingavisibleplaceattheceremonies.
Intheaftermathofthecoronation,JoantheMaidbeganher downhillcourse.Thisbeganwithresentmentamongtheotherleaders thattheyhadnotbeenputonequalfootingwithJoanatthecoronation. OnlyshestoodwiththeKing,andonlyshebroughtherbannertothe ceremony.
Therewas,however,alargerissueatplayinJoan'sfate. NorthernFranceandPariswerealreadyoccupiedbytheEnglish andtheEngland-supportingBurgundians,andtheyhadnointerest ingivinguptheirpossessions.ThisputthemindramaticdisagreementwithJoan'sgoaltoliberateFrancefromtheEnglish.Simply put,theywantedJoanoutoftheway.Charles,asalways,weak,evasive,andsuspicious,sidedwithJ oan'senemies.Wantingtomake peacewiththeEnglishandtheBurgundians,hegaveupthegoal ofbanishingtheEnglishfromFranceandorderedJoantoabandon hereffortstotakeParis.
HegaveJoanonlyminorassignmentsand,inthatcontext,orderedherinthespringof1430toproceedtothesmalltownof CompiègnetoconfronttheBurgundians.Duringthebattle,she wasthrownoffherhorseandleftoutsidethetown'sgates.The Burgundianstookhercaptiveandheldherforseveralmonths,negotiatingwiththeEnglish,whosawherasavaluablepropagandaprize. Finally,theBurgundiansexchangedJoanfor10,000francs.Charles VIIwasunsurewhattodo.StillnotconvincedofJoan'sdivineinspiration,hedistancedhimselfandmadenoattempttohaveherreleased.TheEnglishoccupationarmyturnedherovertochurchofficials,whoinsistedthatshebetriedasaheretic.Shewascharged with70counts,includingwitchcraft,heresy,anddressinglikea man.Initially,thetrialwasheldinpublic,butitwentprivatewhen Joanbetteredheraccusers.BetweenFebruary21andMarch24, 1431,shewasinterrogatednearlyadozentimesbyatribunal,always keepingherhumilityandsteadfastclaimofinnocence.Insteadof beingheldinachurchprisonwithnunsasguards,shewasheldin amilitaryprison,whereshewasthreatenedwithrapeandtorture,althoughthereisnorecordthateitheractuallyoccurred.Sheprotected herselfbytyinghersoldiers'clothestightlytogetherwithanumber ofcords.Frustratedthattheycouldnotbreakher,thetribunaleventuallyusedhermilitarydressagainsther,chargingthatshedressed likeaman.
Hertrialisrecordedinvoluminouscourtrecords,consideredauthenticbecausetheregistrarrecordingtheproceedingswasnotunder theauthorityofthetribunal.ThetrialrecordreportedJoan'sdescription ofhervoices,suchasthis: “Itinstructedmetobegoodandtogooften toChurch;ittoldmeitwasnecessaryformetocomeintoFrance….It saidtome: ‘Go,raisethesiegewhichisbeingmadebeforetheCityof Orléans.Go!’” (Murray,1902,pp10–11).
Inthetrial,Joan'sbehaviorwasremarkable.Constantlypressuredby theviciousinquisitorsofthetribunal,theilliterate19-year-oldrespondedwiththecalmassertivenessandintelligencewehavealready recognizedinher.Herearesamplesfromthebeginningofthetrial:
Askedtoplaceherhandonthebibleandsweartotellthetruthto allquestionsaskedofher:Towhichshedidreply:
“Iknownotuponwhatyouwishtoquestionme:perhapsyoumay askmeofwhichIoughtnottotellyou.”
“Swear,’ wedidsaytoher,tospeaktruthonthethingswhichshall beaskedyouconcerningtheFaith,andofwhichyouknow.”
“OfmyfatherandmymotherandofwhatIdidaftertakingthe roadtoFrance,willinglywillIswear;butoftherevelationswhich havecometomefromGod,tonoonewillIspeakorrevealthem, saveonlytoCharlesmyKing;andtoyouIwillnotrevealthem, evenifitcostmemyhead;becauseIhavereceivedtheminvisions andbysecretcounsel,andamforbiddentorevealthem.Before eightdaysaregone,IshallknowifImayrevealthemtoyou” (PernoudandClin,1998,p109).
OnMay29,1431,thetribunalannouncedthatJoantheMaidwasguilty ofheresy.OnthemorningofMay30,shewastakentothemarketplace inRouenandburnedatthestakebeforeanestimatedcrowdof10,000 people.Shewas19yearsold.Onelegendsurroundingtheeventtellsof howherheartsurvivedthefireunaffected.Herashesweregatheredand scatteredintheSeine.
AfterJoan'sdeath,therequicklydevelopedanegativereactionto whathadtakenplaceinRouen.Inamoodofdefensiveanxiety,Bishop PierreCauchon,whohaddirectedthetrial,orderedallthoseinvolvedin thecasetoissuestatementsaccusingJoanofheresy,thusaffirmingher guiltandrelievingthestateandChurchofresponsibility.
TheHundredYearsWarcontinuedforanother22years.France slowlybeganrecapturingmoreofthelandoccupiedbytheEnglish,includingallofNormandy,ofwhichRouenwasthecapital.Atthesame time,sympathyforJoanwasgrowing.Charleshadbeencrownedking andwasfeelingmoresecureinhisposition.Whenhelearnedthatthe townspeopleofRouenwereattemptingtoretakethecity,hemarched therequicklyonNovember10,1449,toleadtheFrenchforcestovictoryovertheEnglish.WhenheheardthepeopleofRouendescribe theexecutionofJoanin1431,hehadtherecordsofthetrialandexecutionbroughttohimandonFebruary15,orderedthefollowingletterto bedistributedtothecountry:
AsheretoforeJoantheMaidwastakenandseizedbyourancient enemiesandbroughttothecityofRouen,againstwhomthey causedtotakeplaceacertaintrialbycertainpersonswhohadbeen chosenandgiventhistaskbythem,intheprocessofwhichthey madeandcommittedmanyfalsificationsandabuses,somuch that,bymeansofthistrialandthegreathatredourenemieshave againsther,theycausedherdeathiniquitouslyandagainstreason, verycruellyindeed;forthisreasonwewishtoknowthetruthof theaforesaidtrial,andthemanneraccordingtowhichitwascarriedout.Wecommandyou,instructyou,andexpresslyenjoin youtoinquireandinformyourselfwellanddiligentlyonwhat wassaid;andthatyoubringbeforeusandthemenofourcouncil theinformationthatyouwillhavegatheredonthiseventundera closedseal forwegiveyoupower,commission,andspecialinstructionbythesepresentstocarrythisout.GivenatRouen,the 15th dayofFebruary,theYearofGrace1449[[2],p149].
Averyactiveinquestfollowedthisletter.Itwasdecidedthat, sinceJoan'sfirsttrialhadbeenconductedbytheChurch,withafinal convictionforheresy,anyfurtherinquestortrialshouldalsobeconductedbytheChurch.Asafirstgesture,thepapaldelegatesdeveloped alistof27articles,thefirst12ofwhichcorrespondedtothe12articles onwhichJoanhadbeencondemned.Theformaltrial,calledthenullificationtrial,tookplaceduring1455and1456.Atotalof115individualswereinterrogated,someofwhomhadbeenwitnessesintheearlier
inquest,andmosthavingbeeninvolvedintheabusescarriedouton Joan.Allweregivenimmunity.
AnothergroupofdelegatesweresenttoJoan'shometown, Domremy,toinquireaboutherchildhood.Thesewitnessesprovideda pictureofJoanasyounggirllikeanyotherinthevillage:afriendly childwhoenjoyedplayingwiththeotherchildren,whohelpedwith familychoressuchastendingtheanimals,helpingaroundthehouse, developingherskillsasaseamstress,andquiteobservantinchurchservices.Thestarkquestionposedbythesereportsofherchildhood,and probablynevertobeanswered,is,howdidthisordinaryyounggirlbecomeJoanofArc?
TheresultofthenullificationtrialwasthatJoanwasfoundinnocentofallchargesanddesignatedasamartyr.Shewascanonizedasa saintonMay16,1920,andisthepatronsaintofFrance.
VoicesandVisionsintheMiddleAges
Withthishistoricalbackground,wecanwonderaboutJoan's voicesandvisionsandplacethemintheirhistoricalcontext.Inthefirst trial,theprosecutorspressedJoanrepeatedlyaboutherexperiences. Sherefusedmanyoftheirquestionsaboutdetailsofthevoicesbut didoffersomedescriptionofthem,includingthisstatementthatends inthewordsquotedearlier.
IwasthirteenwhenIhadaVoicefromGodformyhelpandguidance.ThefirsttimeIheardthisVoice,Iwasverymuchfrightened; itwasmid-day,inthesummer,inmyfather'sgarden.Ihadnot fastedthedaybefore.IheardtheVoicetomyright,towardthe Church;rarelydoIhearitwithoutitsbeingaccompaniedalso byalight.ThislightcomesfromthesamesideastheVoice.Generallyitisagreatlight.SinceIcameintoFranceIhaveoftenheard thisVoice .IbelieveitwassentmefromGod.WhenIheardit forthethirdtime,IrecognizedthatitwastheVoiceofanAngel. Thisvoicehasalwaysguardedmewell,andIhavealwaysunderstoodit;itinstructedmetobegoodandtogooftentoChurch;it toldmeitwasnecessaryformetocomeintoFrance.Youask meunderwhatformthisVoiceappearedtome?Youwillhear nomoreofitfrommethistime.Itsaidtometwoorthreetimes aweek: ‘YoumustgointoFrance.’ Myfatherknewnothingof mygoing.TheVoicesaidtome: ‘GointoFrance!’ Icouldstay nolonger.Itsaidtome: ‘Go,raisethesiegewhichisbeingmade beforetheCityofOrléans’ (Murray,1902,pp10–11).
SuchexperienceswereverylikelymorecommoninJoan'sera thaninthemodernworld,althoughwewillquestionthatinthefollowingsection.
CorinneSaundershassummarizedMedievalexperiencesina comprehensivemanner.Shewrites: “Themedievalperiodisofspecial interestbecauseitsthought-worldtakesforgrantedthepossibilityof thesupernaturalanditstheoriesofmedicineandpsychologyofferpowerful explanatorymodesforhallucinatoryexperience.Someofthegreatestreligiouswritingintheperiodisinspiredbyhearingvoices,whileitsfictionsalsoplaycreativelywithvoice-hearing” (Saunders,2016,p2136).
Regardingthelatter,SaundersinvokesGeoffreyChaucer,writinginthelate14thcentury,forwhomtheemotionexcitingsuchexperiencesisoftenlove.He “depictsthephysiologyoflovewithprecisedetail.Inhis Knight'sTale,theloverArcite,struckintheheartbylove,is transformedbothphysically,becomingpale,cold,andhollow-eyed,and mentally,sothathis ‘cellfantastic’,hisimagination,obsessivelybrings forththeimagesofhislady” (p2136).Inaddition,inhisepicromance TroilusandCriseyde,Troilus, “thearchetypalbetrayedlover,isliterally unmadebylove,hisillnesssoextremethathewastesawaytoatypeof melancholy-emaciated,swooning,withdrawn,sufferingfromnightmares.Hismemoryrepeatedlycirclesbacktoimagesbutalsotothe voiceofhisbeloved,whosemelodioussingingheseemstohear ‘in hissoul’” (p2136).
Addressingthereligiouscontext,Saunderscallsonthe11thcenturyabbessandtheologian,HildegardofBingen,aswellastwoEnglish mystics,JulianofNorwich,ananchorite,andMargeryKempe,amarriedmotherof12,toillustratethemedieval,mysticalpracticeofvoices andvisions.AsSaundersdescribesthesewomen,eachinherownway, theyenjoyedlivesthatwerepeopledbyvoicesandconversations. Margery,forinstance,vividlydescribesherconversationswithGod andwithJesus.DameJulian's RevelationsofDivineLove isthefirst bookwritteninEnglishbyawomanandistheoldestbookinEnglish writtenbyamystic.
HearingVoicesinContemporaryTimes
HowdoesourcontemporaryworldcomparewiththeMiddle Agesinthemannerofvoicesandvisions?Theyarenotpartofour commonplaceworld,astheywereinJoan's,butthereisinfactalarge literatureassertingthathearingvoicesisarathercommonexperience thatdoesnotnecessarilyimplymedicalillnessorpsychopathology. OnemainwitnesstothisrealityistheHearingVoicesNetwork (HVN)anditsassociatedHearingVoicesMovement,bothlocatedat DurhamUniversityintheUnitedKingdom.TheHearingVoicesMovementisavast,peer-supportundertakingthatgathersvoicehearersofall sorts,somewithpsychiatricdisorders,othersnot.Theexperiencesare asvariedanddifferentastheindividualsreportingthem.AsAngela Woods,oftheHearingtheVoiceprojectatDurhamUniversity,Durham,UK,putsit: “…peoplehearvoicesinawiderangeofcircumstances:forsomeitisanunremarkablefeatureofeverydayexperience, forothersitispartofreligiousandspiritualdevotion,anaspectofbereavement,orasourceofintensecreativity.Studieshaveshownthat voice-hearinginthegeneralpopulationismorecommonthanisusually thoughtandthatupto13%ofpeoplewillhearvoicesatsomepointduringtheiradultlives” (Woods,2015,p.2386).
Inathoroughreviewoftheliteratureofvoice-hearing,Beavan andcolleaguesreportthatinstudiesofvoice-hearing,theprevalence inthegeneralpopulationrangedfrom0.6%to84%,withaninterquartilerangeof3.2%to19.5%.Theysuggestattheendofthearticlethat wecanthinkoftheprevalenceas3%to15%.Thedifferencesamong studiesareduetodefinitionsandmethodologies,aswellasvariations insex,ethnicity,andenvironmentalfactors(Beavanetal.,2011;see alsoFernyhough,2014,andHartiganetal.,2014).
Anumberofstudieshaveemergedfromresearchersworking withintheHVN.Inoneofthem,Corstensandcolleaguesreviewed thehistoryofHVNandrecommendtheinvolvementofvoicehearers inresearch,aswellasagreateruseofnarrativeandqualitativeapproaches(Corstensetal.,2014).
AmongtheHVN-relatedstudies,severalinvolvethebenefitsof self-helpgroups.DillonandHomsteir(2013)foundthatself-help groupscanbemoreeffectivethanconventionaltreatment.Ininterviews ofself-helpgroupparticipants,OaklandandBerry(2015)foundthat thefeelingofhopewasanimportant,commonexperience.Longden etal.(2018)describethebenefitsofself-helpgroupsas “theopportunitiestomeetothervoicehearers,provisionofsupportthatwasunavailableelsewhere,andconfidentialplacetodiscussdifficultissues.”
Daalmanetal.(2011)comparedagroupofindividualswithpsychoticdiagnoseswithanothergroupofindividualswithnopsychotic history.Theyfoundthat “Theperceivedlocationofvoices(inside/ outsidethehead),thenumberofvoices,loudness,andpersonification didnotdifferentiatebetweenpsychoticandhealthyindividuals.” Featuresthatdiddifferentiatethegroupswereemotionalvalenceofthe content,frequencyofAVHs,degreeofcontrolovertheAHVs,and youngerageofmanynonpsychotics. “Inoursample,thenegativeemotionalvalenceofthecontentofAVHscouldaccuratelypredictthepresenceofapsychoticdisorderin88%oftheparticipants.” Thelatterpoint maybeimportantinjudgingtheputativepathologyofStJoan'svoices.
OutsidetheHVN,Powers3rdetal.(2017)foundthehallucinatoryexperiencesofpsychiatricvoicehearerstobeverysimilartothose ofpatientswithpsychiatricdiagnoses(seealsoPierre2010).
Inthissectionwehavereviewedvariousanalysesofdifferences (andlackofdifferences)betweenthosevoicehearerswhocarryapsychiatric(psychotic)diagnosisandthosewhodonot.Whatwehavenot heardenoughaboutiscontemporaryexperienceslikethoseofJoan voicesthatarepositive,inspiring,andeffective.AngelaWoods,from theHearingtheVoicemovementinDurham,UK,quotedaboveinadifferentarticle,addressesthisphenomenon:
Ifwelisten,reallylisten,thestatement “Iamavoice-hearer” issues atwofoldinvitation:itasksthatwebracketanyassumptionsabout thenatureofauditoryverbalhallucinationsandtheirstatusas symptom,anditopensupaspaceforconversation,aspacein whichitisnotonlypossiblebutimportanttoaskaboutwhoor whatthevoicesare,whattheysay,andwhatmeaningtheyhave inthecontextofaperson'ssenseofselfandworld(Woods etal.,2015).
Finally,St.Joanandcontemporaryvoicehearershavebothhad tocontendwiththepossibilityofnegativeoutcomes.ForJoan,therisk wasbeingdeclaredawitchandbeingputtodeath;forlatter-dayvoice hearers,theriskisbeingsubjectedtoapsychiatricdiagnosis.Regarding thelatter,wedonothowmanywomenhidetheirvoice-hearingormysticalexperiencesforfearofbeinglabeledpsychoticorcrazy.
ProposedMedicalandPsychiatricDiagnoses
InattemptingtounderstandJoan'svisions,psychiatristsand othershaveofferedavarietyofdiagnosticpossibilities.Wewillreview afewoftheprominentones.
ThemostfrequentmedicalexplanationofJoan'svoiceshasbeen someformofepilepsy.AstudybyFoote-SmithandBayne(1991) reflectedtheefforttounderstandthevoicesasanauraofanepileptic seizure.Amorerecentstudybyd'OrsiandTinuper(2006a)challenges earlierexplanationsofthevoicesasauras,and,recognizingthatJoan lacksthestandardsignsofepilepsy,proposeanewerdiagnosticentity calledIdiopathicPartialEpilepsywithAuditoryFeatures(IPEAF). TheymakethisdiagnosisthroughasemioticanalysisofJoan'sstatements,focusingonsymptomsandpossibletriggerfactors,andforthis, theyrelyontheextensivedocumentationofJoan'strials.Inafurtherlettertotheeditor,theywrite:
Joan'sspellswerecharacterizedbyaconstantauditorycomponent, complex,spontaneous,orevokedbysudden auditorystimuli,that couldbeassociatedwithaninconstantvisualcomponent,sometimessimpleand,moreoften,complex,andverbaldisturbance. Thesespellsdifferfromecstaticepilepsywithrespecttoclinical featuresandinvolvementofcerebralregions.Thenegativefamily history,the ictal semiology,andthepossibilitythatthespellswere triggeredbyacousticstimulisuggestIPEAF,andthesearchforthe epitempin/LGI1geneorothernew genemutations onahairofthe MaidofOrléansmayenhanceourknowledgeaboutherpresumed epilepsy(d'OrsiandTinuper,2006b,p281).
AsJoanwasilliterate,herwrittendocumentsweredictated.All herstatementsinthetrialswerereportedbythecourtclerks.Anysemiotic(orsemantic)analysisofhervocalstatementswouldbeananalysis ofdictatedstatements,andthesewouldbeofquestionablevalue.Asfor heractualvoice,weofcoursedonothavearecording.Evenifwedid, sinceshespokeaFrenchdialect,evaluatingitwouldrequireknowledge ofthedialect oragain,theuseofatranslation.WeconsiderthesuggestionofIPEAFasaseriousexplanationforhervisionsandbehavior tobeofinterestbuthardtosupportwiththecurrentevidence,giventhat thesedocumentsdonotoffermuchmaterialforasemioticanalysis.
Anotherpopulardiagnosishasbeenthatofsomeformoftuberculosis.Ratnasuriya(1986)arguesofJoanthat “[m]anyofthesefacts canbeexplainedbythehypothesisthatJoanofArcsufferedfromtuberculosiswithatemporallobetuberculomaandtuberculouspericarditis” (p234).Asshewasinvolvedintendingherfather'scattle,Ratnasuriya speculatesthatJoanhadabovineformofthetuberculouscondition, whichheargueswasprevalentinJoan'sera.
Thetubercularhypothesispresentsadifferentkindofchallengeto theimaginationofthereaderthantheepileptichypothesis.Althoughthe epilepticproposalprovidednoevidenceofepilepticbehavior,thetubercularhypothesisoffersaplethoraofsuchbehavior,butwithnoevidence forassertingsuchsymptoms.Hedescribescachecticappearance,amenorrhea,psychoticdisturbanceswithaudioandvisualhallucinations,and disturbancesofsexualfunction.Asidefromlackofevidencefortheputativesymptoms,thesymptomsdonotseemtofitJoanverywell.Regardingcachexia,didJoanhaveacachecticappearancewhilebattling troopsinfullarmor?Wehavenowayofknowingwhethershewasamenorrheic,butifshewas,wouldthatbesurprisinginhercircumstances? Suggestingpsychosisisalittleodd,giventhattheonlyevidenceforthat isthevoicesthatareinquestion?Disturbancesofsexualfunction?What sexualfunction?Thefactsthatshecutherhairanddressedlikeaman wereinfactveryprotectivewhenwearingarmorandinprotectingherself fromrape.
Itisnotdifficulttodismisstheepilepticandtubercularhypotheses.Wenowneedtoexaminethepsychiatricalternatives.Wewillfocus ontheeffortofHenker(1984)tosortoutwhereJoanfitsinthe DiagnosticandStatisticalManualofMentalDisorders,3rdEdition (DSM-III) classificatorystructure.Willthe DSM certifyherwithadiagnosis? Henkerrecognizestheveryunusualnatureofthisyoungwomanandsuggeststhreegeneraldiagnosticcategories:psychoses,psychosexualdisorders,andpersonalitydisorders.
Intheareaofpsychoses,Henker(1984)considersthediagnostic criteriaforschizophreniaandbipolarmania,andhefindsthatineach case,Joan'sthoughtandbehaviordonotmeetthecriteria.Hethentakes uppsychosexualdisordersandwrites:
Wecomenowtopsychosexualdisorders,agroupmuchmore broadlycoveredinthecurrentthaninthepreviousclassifications. Cross-dressingandadoptionofthemasculinemilitaryrolesuggestsomeproblem.Shewasexaminedtwiceandfoundtobeindisputablyfemale.Foratranssexualclassification,the DSM-III criteriarequireasenseofdiscomfortandinappropriatenessabout one'sanatomicsexandawishtoberidofone'sowngenitalsandto liveasamemberoftheothersex.ThereisnorecordofJoan's complainingabouthersex;rather,sheproudlyreferredtoherself as “themaid.” Transvestismmightbeconsidered,exceptthat DSM-III presentsitentirelyasamasculinedisorder.Thus,wefind nofirmbasisforadiagnosisofpsychosexualdisorder.Joan seemedtotranscendphysicalsexuality,beingzealouslydevoted tohermission(p1489).
Finally,Henkeraddressespersonalitydisorders.ThisisaveryinterestingdiscussionbecauseJoanissuchanunusualperson.Henker breaksdownpersonalitydisordersintothethreeclusters.Herecognizes thatshedoesnotbelongintheodd,eccentricclusterofparanoid,schizoid,andschizoptypaldisorders. “Sheattractedtheloyaltyofanarmy, andsheeasilymetothers – evenroyalty.” Shealsodoesnotfitthefearful,anxious,avoidantgroup. “Joanwastoooutwardlyaggressive,confident,andsecureforanyofthese.” Itisfinallythedramatic,emotional, orerraticgroupofhistrionic,narcissistic,antisocial,andborderlinedisordersthatcapturesHenker'sattention.Hefocusesonhistrionicand narcissisticdisorders,findingthatnoneofthemreallyappliestoJoan. Andheconcludes:
Inconclusion,weareleftwithaspectacularlydifferentindividual whoapproximatesbutdoesnotmeetcompletelythediagnostic
criteriasetforthin DSMIII foranyofthepsychiatricentities. Joan'sbehaviorwaslikelytheproductofamessianicidentificationproducedbyintensereligiousindoctrinationcoupledwithrepeatedexposurestothefrustrationsandcrueltyofmilitaryactions uponahighlysuggestibleandsomewhatobsessiveadolescent. Thevoicesandvisionswerelikewiseinfluencedbythereligious patternofhertimeandwouldincurrenttermsbeattributedtoeideticimagery.ItismostunfortunatethatJoan'slifewasterminated beforemoreofitcouldhavebeenfollowedandrecordedfora morecompletestudy(Henker,1984,p1490).
Thelastsentenceisalittlechilling,regrettingJoan'sexecution becauseitdeprivedusofthetimeneededtocompletethediagnostic evaluation!(Using DSM-5 ratherthan DSM-III wouldnotalterHenker's discussion,withoneexception: DSM-5 includesadiagnosisofgender dysphoria.StJoan,however,nomorequalifiesforthisdiagnosisthan fortheotherpsychosexualdisorders.)
DiagnosingStJoan
Inthisarticle,wehavereviewedStJoan'spersonalhistoryinthe contextof15thcenturyFrance.Wehaveexaminedthephenomenonof voice-hearinginbothMedievallifeandcontemporarytimes.Wehave takenupwell-knownmedicalandpsychiatricspeculationsregarding whatdiseaseentitiesmighthavecausedthevoices.Itisnowtimeto drawconclusionsaboutherdiagnosis.
InpursuingthediagnostictrajectoryofJoan,weshouldbearin mindthatwhatweseeintheaccountofherbrieflifeisanastonishing degreeofcharacterstrength,fortitude,leadership,courage,loyalty,toleranceofsuffering eventorture andfaith.Allthisina17-year-old adolescent,anadolescentwhospendsmuchofherwakinglifeinaconversationwithherGod.Whatarewetomakeofthis?Itdoesnot, prima facie,seemtobethepictureofamentallyafflictedadolescentwho “hears” voices.Anyefforttodiagnoseherwillhavetofacethisobstacle ofherapparentlackofmentalaffliction.
Indeed,whenviewedinthelightofthesewell-documentedcharacterstrengths,thediagnosticproposalsreviewedaboveseemrather unlikely.WhenHenker(1984),forinstance,writesthat “Joan'sbehaviorwaslikelytheproductofamessianicidentification uponahighly suggestibleandsomewhatobsessiveadolescent” (p1490),thisdoesnot seemtofittheJoanwehavegottentoknowfromherhistory.
InviewofJoan'sobviouscharacterstrengths,thefrequencyof nonpathologicvoice-hearingandvisionsinMedievalEurope,andthe implausibilityofproposedmedicalandpsychiatricdiagnoses,wetake thepositioninthisarticlethatJoan'svoicesandvisionsdonotwarrant adiagnosis.
Thisconclusion,ofcourse,fliesinthefaceofthemedicalliteratureinsistingonamedicalorpsychiatricdiagnosis.Itis,infact,strikingthatnoneofthemedicalexpertswhohavestudiedJoanhaveargued forabsenceofdiagnosis.WecouldlocatenostudycontendingthatJoan doesnotrequireadiagnosis.Henkertakesastepinthatdirectioninstatingthatshedoesnotfitintothe DSM-III diagnosticgrid,butintheend, heseemstofeelaneedtooffersomekindofdiagnosis.
Ifthevoiceswerenottheproductofdisease,whatthenwere they?Ouransweristhattheywere, toutcourt,Medievalexperiences thevoicesandvisionsofanextraordinaryadolescentinacontext wheresuchexperienceswerenotunusual.
Iftheconclusionofnodiagnosisiscorrect,wecanwonderwhy themedicalfieldbeensoinsistentthatJoanhadamedicalormentaldisease?Partoftheanswertothisquestionisthegreatreluctanceofthe medicalprofessionalstoconsider voicesandvisionsasnonpathologic behavior.Suchreluctancemustinvolveafailuretoacknowledgeboth thecommonexperienceofvoicesandvisionsintheMiddleAges,aswell asthefrequencyofvoice-hearinginourowntime.Italsoreflectsahesitancytothinkbeyondthe DSM andbiomedicalmodel.
Dismissingthediagnosticissue,however,doesnotrelieveusof theburdenofexplainingStJoan.Weare,infact,leftwithanotherquestion.Joan'svoicesandvisionsmayhavebeenatypicalMedievalexperience,butthatdoesnotexplainherachievements howanadolescent couldhaveledanarmy.OtherMedievalmysticshavenotdemonstrated suchachievements,especiallyasadolescents.
WecannowrecognizethatJoanpresentsustwobigquestionsrather thanone.Thefirstofcourseisthediagnosticquestion doessheneed adiagnosis?Thesecondistheachievementquestion howcouldanilliterateadolescentleadanarmy?Wehavestatedourconclusionregardingthefirst thatshedoesnotwarrantadiagnosis.However,wenow havetoaddressthesecond.
Inattemptingtoanswertheachievementquestion,weendupwith asurpriseconclusion wedonothaveananswer.Althoughithasnot beendifficulttodismissthemedical andpsychiatricdiagnosticclaims, theachievementquestionhasleftuswithemptyhands.Alleffortstofind anexplanationhavefailed.
Thisconclusionmayaddanotherdimensiontothedoctors'insistenceondiagnosingJoan.Theymayshareourownmystificationatthe notionofanadolescentleadinganarmy.Howmucheasier,then,say,to writeitoffasthepsychoticbehaviorofaderangedadolescent.
Ratherthanacceptthisasadefeat,weinvokephilosopherslike KarlJaspers,SørenKierkegaard,JohnDewey,andotherswhoassertthat thereisanunknowndimensiontoanyhumanbeing adimensionthat defeatsalleffortsto “explain” it.DoesthismeanthatJoanwithheraccomplishmentsremainssomethingofamystery?Yes,aswithallofus.
CONCLUSION
Inthisarticle,wehavearguedthatStJoan'svoicesandvisions donotrequireamedicalorpsychiatricdiagnosis,butthatherextraordinarybehaviorcallsforanexplanationthatwedonothave.Wecanassociatethisconclusionwithtwoothercurrentculturalphenomena. Ontheonehand, DSM-5 hasbeenaccusedofdiagnosticexpansionandatendencytoimposeadiagnosisonanyunusualbehavior. Thiscertainlyputsthe DSM systemonthesideofintolerancetoward differenceanddivergence.Inaddition,inthatway,wemightunderstand the DSM-orienteddoctors'tendencytopathologizeStJoan'sbehavior. Ontheotherhand,popularculturehasbeenmovingtowardmore acceptanceofdifferenceanddivergence,easilyexemplifiedbytheacceptanceoftheLGBTQcommunity.Inmoregeneralterms,weoften seeinyoungerpeopleatoleranceofdifferencethatexceedsthatof theirelders.
Weare,ofcourse,treatingStJoan'sdivergenceasabehaviorthat cannotbeexplainedbutshouldnotbepathologized.
WebeganthisarticlebyinvitingMarkTwaintojoininthe Introduction.Itisperhapsfittingthatweinvitehimtojoinusin theConclusion.
TheevidencefurnishedattheTrialsandRehabilitationsetsforth JoanofArc'sstrangeandbeautifulhistoryinclearandminutedetail…Itgivesusavividpictureofacareerandapersonalityofso extraordinaryacharacterthatwearehelpedtoacceptthemasactualitiesbytheveryfactthatbotharebeyondtheinventivereachof fiction.Thepublicpartofthecareeroccupiedonlyamerebreath oftime – itcoveredbuttwoyears;butwhatacareeritwas!The personalitywhichmadeitpossibleisonetobereverentlystudied, loved,andmarveledat,butnottobewhollyunderstoodand accountedforbyeventhemostsearchinganalysis…Takinginto account,asIhavesuggestedbefore,allthecircumstances – herorigin,youth,sex,illiteracy,earlyenvironment,andtheobstructing conditionsunderwhichsheexploitedherhighgiftsandmade herconquestsinthefieldandbeforethecourtsthattriedherfor herlife – sheiseasilyandbyfarthemostextraordinaryperson thehumanracehaseverproduced(Twain,1896,p.452).
Downloaded from http://journals.lww.com/jonmd by
DISCLOSURES
Ethicalconsiderations:Therearenohumanparticipantsinthisstudy.
Authorcontributions:TheprimaryauthorofthisarticleisJames Phillips.TheauthorshipincludestheReligionandPsychiatryCommitteeofGAP(GroupfortheAdvancementofPsychiatry),whosenames arelistedabove.Allmembersparticipatedinthecompositionofthisarticle,readingthroughseveraldrafts,suggestingchanges(e.g.,Jenifer Nieldssuggestedchangingthetitlefrom “DiagnosingStJoan” to “UndiagnosingStJoan”)andcorrections.MichaelNorko,chairofthe committee,orchestratedcommunicationswiththeGAPPublications Committee,inadditiontomakinghisownsuggestionsandmanaging otheradministrativetasks.
Thereauthorsdeclarenoconflictofinterest.
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