Religion and Psychiatry
Religion and Psychiatry: Beyond Boundaries Editors
Peter J. Verhagen Meerkanten GGZ, Harderwijk, The Netherlands
Herman M. van Praag University of Maastricht, Maastricht, The Netherlands
Juan J. Lo´pez-Ibor Jr. Complutense University, Madrid, Spain
John L. Cox University of Gloucestershire, United Kingdom
Driss Moussaoui Ibn Rushd University, Casablanca, Morocco
This edition first published 2010 Ó 2010, John Wiley & Sons Ltd. Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing. Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Other Editorial Offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data Religion and psychiatry / editors, Peter J. Verhagen ... [et al.]. p. cm. Includes bibliographical references and index. ISBN 978-0-470-69471-8 (alk. paper) 1. Psychiatry and religion. I. Verhagen, Peter J., 1957RC455.4.R4R4525 2010 616.89–dc22 2009023908 ISBN: 978-0-470-69471-8 A catalogue record for this book is available from the British Library. Set in 10/12 Pt Times by Thomson Digital, Noida, India. Printed in Singapore by Markono Print Media Pte Ltd. First Impression 2009
Contents List of Contributors Foreword
xiii
Preface
xv
General Introduction: Religion and Science Peter J. Verhagen PART 1
1.1
1.2
1.3
1.4
ix
PROLEGOMENA (FIRST ISSUES): HISTORY, PHILOSOPHY, SCIENCE AND CULTURE
1
11
Introduction
11
Evil in Historical Perspective: At the Intersection of Religion and Psychiatry Michael H. Stone
13
Linguistic Analysis and Values-Based Practice: One Way of Getting Started with Some Kinds of Philosophical Problems at the Interface Between Psychiatry and Religion Bill (K.W.M.) Fulford
39
Science and Transcendence in Psychopathology; Lessons from Existentialism Juan J. Lo´pez-Ibor Jr. & Marı´a Ines Lo´pez-Ibor Alcocer
63
Psychiatry of the Whole Person – Contribution of Spirituality in form of Mystic (Sufi) Thinking Ahmad Mohit
73
PART 2
MAIN ISSUES: THE INTERFACE BETWEEN PSYCHIATRY, MENTAL HEALTH AND MAJOR RELIGIOUS TRADITIONS
Introduction
87 87
vi
CONTENTS
2.1
Judaism and Psychiatry Ayala Uri, Noa Navot & Alan Apter
2.2
Christianity and Psychiatry John R. Peteet
105
2.3
Religion and Mental Health in Islam Ahmed Okasha
119
2.4
Psychiatry and African Religion Frank G. Njenga, Anna Nguithi & Sam G. Gatere
143
2.5
Hinduism and Mental Health R. Srinivasa Murthy
159
2.6
Buddhism and Psychotherapy in Japan Naotaka Shinfuku & Kenji Kitanishi
181
2.7
Psychiatry and Theravada Buddhism Pichet Udomratn
193
PART 3
CORE ISSUES: RELIGION AND PSYCHOPATHOLOGY
89
209
Introduction
209
3.1
Religious Experience and Psychopathology Juan J. Lo´pez-Ibor Jr. & Marı´a Ine´s Lo´pez-Ibor Alcocer
211
3.2
God’s Champions and Adversaries: About the Borders between Normal and Abnormal Religiosity Herman M. van Praag
235
3.3
Religion and Psychopathology: Psychosis and Depression Andrew C. P. Sims
253
3.4
Obsessive Compulsive Disorder and Religion: A Reconnaissance Harold J. G. M. van Megen, Dianne A. den Boer-Wolters & Peter J. Verhagen
271
3.5
Religion and Psychoanalysis: Past and Present Allan M. Josephson, Armand Nicholi Jr. & Allan Tasman
283
3.6
On the Psychology of Religious Fundamentalism John, Lord Alderdice
305
3.7
Measurement at the Interface of Psychiatry and Religion: Issues and Existing Measures Peter C. Hill & Carissa Dwiwardani
319
CONTENTS
PART 4
4.1
4.2
4.3
4.4
4.5
4.6
RESEARCH ISSUES
341
Religion and Mental Health: What Do You Mean When You Say ‘Religion’? What Do You Mean When You Say ‘Mental Health’? Charles H. Hackney
343
A Moment of Anger, a Lifetime of Favor: Image of God, Personality, and Orthodox Religiosity Elisabeth H.M. Eurelings-Bontekoe & Hanneke Schaap-Jonker
361
The Relationship Between an Orthodox Protestant Upbringing and Current Orthodox Protestant Adherence, DSM-IV Axis II B Cluster Personality Disorders and Structural Borderline Personality Organization Elisabeth H.M. Eurelings-Bontekoe & Patrick Luyten When Religion Goes Awry: Religious Risk Factors for Poorer Health and Well-Being Hisham Abu Raiya, Kenneth I. Pargament & Gina Magyar-Russell Religious Practice and Mental Health: a Moroccan Experience Driss Moussaoui & Nadia Kadri Religious and Spiritual Considerations in Psychiatric Diagnosis: Considerations for the DSM-V David Lukoff, C. Robert Cloninger, Marc Galanter, David M. Gellerman, Linda Glickman, Harold G. Koenig, Francis G. Lu, William E. Narrow, John R. Peteet, Samuel B. Thielman & C. Paul Yang INTERDISCIPLINARY ISSUES: PSYCHOTHERAPY, PASTORAL CARE AND MEANING GIVING
Introduction
5.2
341
Introduction
PART 5
5.1
vii
Gods of the Horizon: The Therapist’s and the Patient’s Religious Representations and the Inevitability of Countertransference Moshe Halevi Spero Assumptions About Pastoral Care, Spirituality and Mental Health Peter J. Verhagen & Adamantios G. Avgoustidis
373
389
413
423
445 445
447
479
viii
5.3
CONTENTS
Coming to Terms with Loss in Schizophrenia – The Search for Meaning Hanneke (J.K.) Muthert
PART 6
6.1
CONTROVERSIAL ISSUES: RELIGION AND THE BRAIN
497
513
Introduction
513
The Limits of Scientific Understanding and their Relevance for the Role of Religion in Psychiatry Robert H. Belmaker
515
6.2
Seat of the Divine: A Biological ‘Proof of God’s Existence’? Herman M. van Praag
523
6.3
Neuro-Theology: Demasque of Religions Dick F. Swaab & Wilma T.P. Verweij
541
PART 7
TRAINING ISSUES: RESIDENCY TRAINING AND CONTINUOUS EDUCATION
569
Introduction
569
7.1
Religion and the Training of Psychotherapists Allan M. Josephson, John R. Peteet & Allan Tasman
571
7.2
Multicultural Education and Training in Religion and Spirituality Peter J. Verhagen & John L. Cox
587
Epilogue:
Proposal for a World Psychiatric Association Consensus or Position Statement on Spirituality and Religion in Psychiatry Peter J. Verhagen & Christopher C.H. Cook
615
Notes on Contributors
633
Index of Names
647
Index of Subjects
651
List of Contributors Hisham Abu Raiya Psychology Fellow United States of America
Carissa Dwiwardani Doctoral Graduate Student United States of America
John, Lord Alderdice House of Lords (London), Psychiatrist United Kingdom
Elisabeth H.M. Eurelings-Bontekoe Associate Professor of Clinical Psychology The Netherlands
Alan Apter Professor of Psychiatry Israel
Bill (K.W.M.) Fulford Professor of Philosophy and Mental Health United Kingdom
Adamantios Avgoustidis Psychiatrist, Priest and Associate Professor of Pastoral Theology and Psychology Greece
Marc Galanter Professor of Psychiatry United States of America
Robert H. Belmaker Professor of Psychiatry Israel
Samuel G. Gatere Psychiatrist Kenya
Dianne A. den Boer-Wolters Junior Doctor The Netherlands
David M. Gellerman Assistant Clinical Professor of Psychiatry and Behavioral Sciences United States of America
C. Robert Cloninger Professor of Psychiatry, Psychology and Genetics United States of America
Linda Glickman Research Assistant Professor in Psychiatry United States of America
Christopher C.H. Cook Consultant Psychiatrist, Theologian and Anglican Priest United Kingdom
Charles H. Hackney Professor of Psychology Canada
John L. Cox Emeritus Professor of Psychiatry United Kingdom
Peter C. Hill Professor of Psychology United States of America
x
LIST OF CONTRIBUTORS
Allan M. Josephson Professor of Child and Adolescent Psychiatry United States of America Nadia Kadri Professor of Psychiatry Morocco
Ahmad Mohit Professor of Psychiatry Iran Driss Moussaoui Professor of Psychiatry Morocco
Kenji Kitanishi Professor of Psychiatry Japan
R. Srinivasa Murthy Emeritus Professor of Psychiatry India
Harold G. Koenig Professor of Psychiatry and Behavioral Science United States of America
Hanneke (J.K.) Muthert Spiritual Caregiver and Assistant professor of Spiritual Care The Netherlands
Marı´a Ine´s Lo´pez-Ibor Alcocer Professor of Psychiatry Spain
William E. Narrow Psychiatrist, Research Director DSM-V Task Force United States of America
Juan J. Lo´pez-Ibor Jr. Professor of Psychiatry Spain Francis G. Lu Professor of Clinical Psychiatry United States of America David Lukoff Professor of Psychology United States of America Patrick Luyten Assistant Professor of Psychology Belgium Gina Magyar-Russell Psychologist, Instructor of Psychiatry and Behavioral Sciences United States of America Harold J.G.M. van Megen Psychiatrist and Director of the Psychiatric Residency Training Program The Netherlands
Noa Navot Child Psychiatry Fellow Israel Anna Nguithi Consultant Psychiatrist Kenya Arman Nicholi, Jr. Associate Clinical Professor of Psychiatry United States of America Frank G. Njenga Consultant Psychiatrist Kenya Ahmed Okasha Professor for Research and Training in Mental Health Egypt Kenneth I. Pargament Professor of Psychology United States of America
LIST OF CONTRIBUTORS
John R. Peteet Associate Professor of Psychiatry United States of America Herman M. van Praag Emeritus Professor of Psychiatry The Netherlands Hanneke Schaap-Jonker Lecturer in Psychology of Religion The Netherlands Naotaka Shinfuku Professor of Psychiatry and Mental Health Japan Andrew C.P. Sims Emeritus Professor of Psychiatry United Kingdom Moshe Halevi Spero Professor of Clinical Psychology, Social Work, and Psychoanalysis Israel Michael H. Stone Professor of Clinical Psychiatry United States of America Dick F. Swaab Professor of Neurobiology The Netherlands
xi
Allan Tasman Professor of Psychiatry and Behavioral Sciences United States of America Samuel B. Thielman Adjunct Assistant Professor of Psychiatry and Behavioral Sciences United States of America Pichet Udomratn Professor of Psychiatry Thailand Ayala Uri Child Psychiatry Fellow Israel Peter J. Verhagen Psychiatrist and Theologian The Netherlands Wilma Verweij Scientific Secretary The Netherlands C. Paul Yang Associate Clinical Professor of Psychiatry United States of America
Foreword Religion is a major activity of human beings including those suffering from a mental disorder. Psychiatric patients often raise for themselves the kind of questions that everybody has considered and which religion tries to answer. Where do we come from? Is there life after death? What is the origin of the universe? Why are we confronted with evil? Are we free or ruled by our instincts and brain mechanisms? Religion is an important component of life. Anthropologists have recognized that the Neanderthals already had some sense of transcendence and of spirituality, a fact that is more striking in the remnants of archeological excavations of Homo sapiens sapiens settlements. The history of religions as we know them today begins in the Near East with the invention of writing about 3000 BCE, with the written record of human religious experiences and ideas. The middle of the first millennium BCE has been considered by Karl Jaspers, in his The Origin and Goal of History, as a key Axial Age of thinkers having had a profound influence on future philosophy and religion. In this context, Rudolf Otto’s famous book, The Idea of the Holy (1917), defines the essence of religious awareness as awe, a unique blend of fear and fascination before the divine. The Encyclopedia of Religion defines religion as a “push, whether ill-defined or conscious, toward some sort of ultimacy and transcendence that can provide norms and power for the rest of life. When more or less distinct patterns of behaviour are built around this depth dimension in a culture, this structure constitutes religion in its historically recognizable form. Religion is the organization of life around the depth dimensions of experience, varied in form, completeness, and clarity in accordance with the environing culture.” A religion is an organized approach to human spirituality which usually encompasses a set of narratives, symbols, beliefs and practices, often with a supernatural or transcendent quality, that give meaning to the practitioner’s experiences of life through reference to a higher power or truth. Religion includes three components: 1) a notion of the transcendent or numinous, often, but not always, in the form of theism; 2) a cultural or behavioural aspect of ritual, liturgy and organized worship, often involving priesthood, and societal norms; and 3) a set of myths (sacred truths) held in reverence or believed by adherents. Spirituality shares with religion the personal belief in ideas of religious significance, such as God, the Soul, or Heaven, but rejects the administrative, often bureaucratic and hierarchical, structure and creeds of a particular organized religion. Based on census or public opinion data, a person is considered to be of a particular religion if they say that they are of that faith. According to David Barrett et al, editors of the World Christian Encyclopedia: A comparative survey of churches and religions - AD 30 to 2200, there are 19 major world religions which are subdivided into 270 large religious groups, and many smaller ones. There are about 2.1 billion Christians (32% of the world population); 1.3 billion Muslims (19%); 0.8 billion Hindus (13%); 0.4 billion practise Chinese folk religion (6%) and 0.36 billion are
xiv
FOREWORD
Buddhist (6%). The remaining religions are practised by the other 10% of the global population. Another 775 million people (12%) have no religion (they consider themselves agnostics, freethinkers, humanists, secularists, etc.) and 150 million (2%) are atheists. Religion plays an important role in the ceremonies attached to the stages of life, such as birth, becoming adult, marriage and death. It is also important when confronted with illness and misfortune. The case of mental disorders is special. Severe depression uncovers what Kurt Schneider called the primordial fears of human beings: the fear of poverty, the fear of becoming ill and the fear of damnation, which were respectively at the origin of the delusion of being ruined, the hypochondriacal and the guilt delusions. Delusional patients are preoccupied with delusions on the origin of the universe, good and evil and so on and delusions of religious content have been recognized for centuries. In spite of all of this, psychiatrists have not paid sufficient attention to the examination of religiosity in their patients. Even fewer include religiosity and spiritualism in psychotherapy, which is strange as both religion and psychotherapy try to bring meaning to experience. The separation of religion and science in general parallels the separation of Church and State and this has been sometimes taken too far. As an example, an English nurse was reprimanded by The National Health Service for having asked an elderly lady if she would like the nurse to pray for her. In Western civilization, there is a division of the world into two comprehensive domains, one sacred, the other profane. Religion is often described as a communal system for the coherence of belief focusing on a system of thought, unseen being, person, or object, that is considered to be supernatural, sacred, divine, or of the highest truth. Moral codes, practices, values, institutions, traditions, rituals and scriptures are often traditionally associated with the core belief, and these may have some overlap with concepts in secular philosophy. Religion is also often described as a “way of life” or a life stance. The scientific method gains knowledge by testing hypotheses to develop theories through elucidation of facts or evaluation by experiments and thus only answers cosmological questions about the physical universe. It develops theories of the world which best fit physically observed evidence. All scientific knowledge is subject to later refinement in the face of additional evidence. Modern science and laicism often go together. Whether religion has a positive or a negative impact on personal growth and mental health is a controversial issue. It is easy to quote in this respect Sigmund Freud, who wrote that religion is a “universal obsessional neurosis of humankind”, representing an infantile stage of mental development which prevents human beings from facing the reality of their life. Furthermore, it is easy to argue that religion – or an aberrant way to understand religion – has been a source of conflicts and mass violence in recent years, which have had an enormous negative impact on the mental health of thousands of people. However, there is also abundant research evidence that religion, or spirituality (defined as the individual religious experience as opposed to ritualistic religious practices), is associated with higher levels of subjective well-being and lower levels of depression, and may promote both emotional and cognitive growth. The issue is complex, is made even more complex by problems with definition and assessment, but is very topical and attractive. The WPA, therefore, welcomes this comprehensive and multifaceted volume, produced by one of its most active Scientific Sections, hoping that this effort will contribute to clarify the issue and stimulate further reflection and research. Mario Maj President, World Psychiatric Association
Preface CROSSING BOUNDARIES The boundary between religious belief and the practice of psychiatry is becoming increasingly porous. No longer can psychiatrists in a multi-faith, multi-cultural globalized world hide behind the dismissal of religious belief as pathological, or behind a biomedical scientism, as they are more frequently confronted by distressed patients for whom religious belief may determine their choice of symptoms and their compliance with treatment. There is inevitably a tension in any such boundary crossing. Religious belief, for example, can be harmful to mental health and be a trigger for mental illness. Spirituality may not have the safeguards and structures of established Faith Communities; and the political abuse of religion has left an indelible scar on the world. The destructive manipulation of behaviour and belief by cult leaders is also well known to be disastrous. Crossing the boundary, or breaking the psychiatry and religion taboo, may therefore be complex for an atheist psychiatrist, challenged by a patient with a religious problem, or when the values espoused by the patient are at variance with their own values and beliefs. Boundary violations and unrecognized counter transference when treating religious patients from a similar faith background to the psychiatrist are other pitfalls for the unwary. Yet, as the authors of this book illustrate, the evidence is cogent that mainstream religiosity is an enabler of health and a protection against mental illness – through, for example, the provision of social support, or by enabling contact with a forgiving creator God. The religiosity gap, we would maintain, therefore needs to be reduced; and the religious source of the values that are instrumental to compassion, and which can unleash altruism, needs to be more fully recognized and utilized. The World Health Organization (WHO) has rightly regarded spiritual values as a component of Quality of Life. After the publication of The World Health Report 2001. Mental Health: New Understanding, New Hope by WHO, the World Council of Churches showed its partnership and identified mental health as a key issue for the churches’ role in the mission of the church in the twenty-first century1 [1, 2]. The World Psychiatric Association (WPA) was also correct to establish greater links with user organisations and to explore the provision of a more person-centred psychiatry.
1
The World Council of Churches formulated its view on mental health in an ambitious Strategic Plan of the Mental Health & Faith Communities Initiative: “Mental health is a life-long dynamic process which allows the whole person to develop psychologically, emotionally, and spiritually within society, whilst integrating personal and interpersonal joy and distress, leading towards the experience of well-being and harmony with oneself, others, the environment, and God” [3].
xvi
PREFACE
FOUR GREAT STREAMS OF RELIGIONS This volume is about psychiatry and the interface between psychiatry and religion. In other words, this is not a book on religion(s). However, it is concerned, especially Part 2, with the views religions have on psychopathology, disordered behaviour and treatment. We are just at the beginning of exploring, understanding and comparing these views. Although we were used to the more or less pronounced influence of Judeo-Christian traditions and doctrines in the Western world, together with Islam, as the Semite, prophetic or Abrahamic religions, the monotheistic religions do not have exclusive rights. They share prophetic faith, faith in a transcendent being, consciousness of time and history, and a community based on justice [4–6]. What do these characteristics mean for an understanding of psychopathology and disordered behaviour in comparison with the other two main streams of religions? The mystic religions that emerged out of India have a completely different view on human nature and the ultimate reality of the universe [5]. It can be expected that these characteristics mean an original take on psychiatry. The third stream, the wisdom religions, emerged out of China. Not the prophet, not the mystic, but the sage, the wise man, is honoured as the ideal human person in his religious context [5]. There is a fourth stream of religions, often called tribal or indigenous religions [4]. Australian and African religion is typical of this fourth stream. It is inevitable that this world seems confused and confusing. But at the same time, despite this enormous diversity, great questions are universal, such as how to cope with suffering, serious illness and death. And despite the differences, religions of all times and places offer a message and a way of salvation. What did and still does that mean for the understanding of psychopathology, treatment and human welfare?
A LONG AND TENSE HISTORY For many centuries religiosity and spirituality played a major role in speculations about the origin of mental disorders. They were thought to be the works of demons, able to penetrate body and mind of an individual because he had sinned. Exorcism was the treatment of choice. In the nineteenth century, demons lost their dominant position. The pioneers of American moral treatment started to view mental illness as a physical illness. In many cases “moral treatment”, a child of humanism [7, 8], seemed to be far more appropriate than the dire treatments that had preceded it. In the twentieth century, psychoanalysis became the dominant philosophy of psychiatry. Though sin in a religious sense faded into the background, it returned in a different shape. Friction between unacceptable strivings (secular “sins”) versus demands of the super ego played an important role in psychoanalytical theorising. Religiosity proper, however, was anathema to psychoanalysis. It was considered to be an anachronism, a remnant from an infantile past; if anything, to be treated rather than to be cherished. The influence of those ideas has been tremendous, including beyond the boundaries of psychiatry. They probably have contributed substantially to secularisation of the Western world. They certainly buttressed the inclination of many, if not most, psychiatrists of the twentieth century to exclude religiosity from their purview. For biological and social psychiatry – focusing
PREFACE
xvii
predominantly on brain functions and living circumstances – religiosity was not a factor generally to reckon with. Transcultural psychiatry, with its roots in social anthropology, has always taken the religious beliefs and practices of individuals and their communities more seriously as they may relate to the understanding of mental disorder. That psychiatry in the twentieth century was largely a “Godless” period was not to the advantage of the psychiatric patient. Religiosity can be considered a normal personality trait and cannot be disregarded by psychiatrists, whatever their own ideas on religiosity might be. The entire soul/psyche, after all, belongs to their sphere of work. This point of view is the raison d’^etre of the WPA’s section on Religion, Spirituality and Psychiatry, and the main reason why this book was conceptualised under the section’s auspices. We hope that this volume will indeed stir up curiosity and interest in the interface between psychiatry and man’s tendency to provide life with a vertical transcendental dimension. Peter J. Verhagen Herman M. van Praag Juan J. Lo´pez-Ibor John L. Cox Driss Moussaoui
REFERENCES 1. World Health Organization (WHO) (2001) The World Health Report 2001. Mental Health: New Understanding, New Hope. World Health Organization, Geneva. 2. Tharyan, P, Braganza, D, Jebaraj, P (2006) Mental health as a key issue in the future of global health developments. International Review of Mission 95, 36–49. 3. World Council of Churches (2008) WCC Strategic Plan Mental Health & Faith Communities Initiative. Available at: http://www.oikoumene.org/fileadmin/files/wcc-main/documents/p4/ health/WCC_strategic_plan_Mental_health.pdf. 4. K€ung, H (2002) Tracing the Way. Spiritual dimensions of the world religions. Continuum, London. 5. Kyoung-Jae, K (2007) Christianity and Culture. A hermeneutic of mission theology in an East Asian context. In: Chung, PS, K€arkk€ainen, VM and Kyoung-Jae, K (eds.) Asian Contextual Theology for the Third Millennium. Theology of Minjung in fourth-eye formation. Pickwick Publications, Eugene, OR, pp. 147–163. 6. Pridmore, S, Pasha, MI (2004) Psychiatry and Islam. Australasian Psychiatry 12, 380–385. 7. Taubes, T (1998) “Healthy Avenues of the Mind”: Psychological theory building and the influence of religion during the ea of moral treatment. American Journal of Psychiatry 155, 1001–1008. 8. Van Praag, HM (2007) Psychiatry and religion: an unconsummated marriage. In: Glas, G, Spero, MH, Verhagen, PJ and Van Praag, HM (eds.) Hearing Visions and Seeing Voices. Psychological aspects of biblical concepts and personalities. Springer, Dordrecht, pp. 9–19.
World Psychiatric Association Evidence and Experience in Psychiatry Series Series Editor: Helen Herrman (2005 - ) WPA Secretary for Publications, University of Melbourne, Australia The Evidence & Experience in Psychiatry series, launched in 1999, offers unique insights into both investigation and practice in mental health. Developed and commissioned by the World Psychiatric Association, the books address controversial issues in clinical psychiatry and integrate research evidence and clinical experience to provide a stimulating overview of the field. Focused on common psychiatric disorders, each volume follows the same format: systematic review of the available research evidence followed by multiple commentaries written by clinicians of different orientations and from different countries. Each includes coverage of diagnosis, management, pharmaco- and psycho- therapies, and social and economic issues. The series provides insights that will prove invaluable to psychiatrists, psychologists, mental health nurses and policy makers.
Depressive Disorders, 3e Edited by Helen Herrman, Mario Maj and Norman Sartorius ISBN: 9780470987209
Bipolar Disorders Edited by Mario Maj, Hagop S. Akiskal, Juan Jose´ Lo´pez-Ibor, Norman Sartorius ISBN: 9780471560371
Substance Abuse Edited by Hamid Ghodse, Helen Herrman, Mario Maj and Norman Sartorius ISBN: 9780470745106
Eating Disorders Edited by Mario Maj, Kathrine Halmi, Juan Jose´ Lo´pez-Ibor, Norman Sartorius ISBN: 9780470848654
Schizophrenia 2e Edited by Mario Maj, Norman Sartorius ISBN: 9780470849644
Phobias Edited by Mario Maj, Hagop S. Akiskal, Juan Jose´ Lo´pez-Ibor, Ahmed Okasha ISBN: 9780470858332
Dementia 2e Edited by Mario Maj, Norman Sartorius ISBN: 9780470849637
Personality Disorders Edited by Mario Maj, Hagop S. Akiskal, Juan E. Mezzich ISBN: 9780470090367
Obsessive-Compulsive Disorders 2e Edited by Mario Maj, Norman Sartorius, Ahmed Okasha, Joseph Zohar ISBN: 9780470849668
Somatoform Disorders Edited by Mario Maj, Hagop S. Akiskal, Juan E. Mezzich, Ahmed Okasha ISBN: 9780470016121
Other World Psychiatric Association titles Special Populations Contemporary Topics in Women’s Mental Health: global perspectives in a changing society Edited by Prabha S. Chandra, Helen Herrman, Jane Fisher, Marianne Kastrup, Unaiza Niaz, Marta B. Rondo´n and Ahmed Okasha ISBN: 9780470754115 The Mental Health of Children and Adolescents: an area of global neglect Edited by Helmut Remschmidt, Barry Nurcombe, Myron L. Belfer, Norman Sartorius and Ahmed Okasha ISBN: 9780470512456 Approaches to Practice and Research Psychiatric Diagnosis: challenges and prospects Edited by Ihsan M. Salloum and Juan E. Mezzich ISBN: 9780470725696 Recovery in Mental Health: reshaping scientific and clinical responsibilities By Michaela Amering and Margit Schmolke ISBN: 9780470997963 Handbook of Service User Involvement in Mental Health Research Edited by Jan Wallcraft, Beate Schrank and Michaela Amering ISBN: 9780470997956
Families and Mental Disorders Edited by Norman Sartorius, Julian Leff, Juan Jose´ Lo´pez-Ibor, Mario Maj, Ahmed Okasha ISBN: 9780470023822 Disasters and Mental Health Edited by Juan Jose´ Lo´pez-Ibor, George Christodoulou, Mario Maj, Norman Sartorius, Ahmed Okasha ISBN: 9780470021231
Psychiatry in Society Edited by Norman Sartorius, Wolfgang Gaebel, Juan Jose´ Lo´pez-Ibor, Mario Maj ISBN: 9780471496823 Psychiatry as a Neuroscience Edited by Juan Jose´ Lo´pez-Ibor, Mario Maj, Norman Sartorius ISBN: 9780471496564 Early Detection and Management of Mental Disorders Edited by Mario Maj, Juan Jose´ Lo´pez-Ibor, Norman Sartorius, Mitsumoto Sato, Ahmed Okasha ISBN: 9780470010839 Also available in electronic editions only:
Psychiatrists and Traditional Healers: unwitting partners in global mental health Edited by Mario Incayawar, Ronald Wintrob and Lise Bouchard, ISBN: 9780470516836 Psychiatric Diagnosis and Classification Edited by Mario Maj, Wolfgang Gaebel, Juan Jose´ Lo´pez-Ibor, Norman Sartorius ISBN: 9780471496816
WPA Anthology of Italian Language Psychiatric Texts WPA Anthology of Spanish Language Psychiatric Texts WPA Anthology of French Language Psychiatric Texts WPA Anthology of German Language Psychiatric Texts
General Introduction: Religion and Science Peter J. Verhagen Psychiatrist and Theologian, The Netherlands
I.1
PSYCHIATRY AND RELIGION
The World Psychiatric Association (WPA) Section on Religion, Spirituality and Psychiatry (SRSP) took the initiative to start a project that would lead to the publication of a handbook like volume that would serve several purposes. First of all the editors were convinced, and still are, (of the fact) that the study of interface between Psychiatry and Religion offers a lot of helpful and at the same time critical tools for psychiatric thinking and practice. Religion and spirituality play their role in the lives of many, many people in a personal and/or socially meaningful, be it salient way. In that sense religiosity and spirituality belong to the domains of quality of life. In fact it is not imaginable how religion or spirituality could not be of influence on the way of life, the well being and psychic and social functioning of people in general, psychiatric patients in particular. It took psychiatry a lot of time to rediscover this simple and at the same time complicated fact. For a long time psychiatry had not been aware of the fact that a more or less silent antipathy against religion influenced her thinking and practice fundamentally, even in her classificatory systems like the DSM. Although Freud is frequently mentioned as the father of this anti-religious stance, its roots go further back. Was it not psychiatry, according to the well-known hagiography, that liberated those poor living creatures who had been captured for so many years, chained in irons, as a triumph of human care and humanism? The real story is slightly different. In western society God was replaced by nature and by the end of the eighteenth century the physician who knew the order of nature, including the structure of the body, could replace the priest who claimed his authority in the name of God. The start of psychiatry is an illustration of that development. Religion lost its leading position, and the physician became the new guide in life with scientific and moral authority. Since then the relationship between psychiatry and religion has been strained to a greater or lesser extent. The words ‘mad’ and ‘madness’ are complex terms and, as has been illustrated in several ways, these and other terms we are used to in (descriptive) psychopathology and the underlying way of thinking contain these tensions.
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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GENERAL INTRODUCTION: RELIGION AND SCIENCE
This book is about the interface between psychiatry and religion and spirituality. It is a book mainly written by and aimed at psychiatrists all over the world. At the same time it is a multidisciplinary book and we welcome the contributions of many experts in the field of inquiry of religion, spirituality, psychiatry and mental health. The discussion and debates are complex and span a number of disciplines: psychology, psychology of religion, psychotherapy, psychoanalysis, cognitive sciences, neurosciences, philosophy of mind, of science and of religion, history, and theology. No single discipline can do full justice to the complexity of the issues at hand. Any opposed claim would raise troublesome barriers; it is the intention of the editors of this volume to get beyond such barriers.
I.2
NO APOLOGETICS
In order for progress to occur in this interdisciplinary field of inquiry a minimum consensus concerning the meaning of core constructs is needed. Now, here the discussion becomes exciting, because, as one thing is very clear from the perspective of religion and spirituality, one cannot settle any kind of consensus as intended here on purely objective grounds. As soon as one starts to discuss such core constructs as disease, mental health, religiousness and spirituality all kinds of background issues, assumptions and convictions, mindsets come about. One of these assumptions, to name just one, is the rather typical Western idea that illness is secular [1, p. 271]. Somatic and/or psychic, illnesses have to do with biomedical, causal-mechanical patterns that are in no way spiritual or religious. However, Islamic understanding of health and illness cannot be understood otherwise than in the context of religious conceptualization. Within a totally different discourse the anti-Semitic image of ‘the dirty Jew’ was repudiated in the nineteenth and twentieth centuries with the Jewish model of preventive medicine based on the interpretive tradition of Moses and hygiene [2]. Anyhow, it means that from a global perspective it becomes very clear that a discussion like the one we are thinking of here has much of an interreligious and interspiritual dialogue. Greater awareness of religious and spiritual plurality has heightened the need for such an interreligious and interspiritual dialogue, even with regard to psychiatry, or better: from within the profession itself. In connection with this need, there is overwhelming agreement that training and permanent education should include instruction and guidance on how to handle religious and spiritual issues in assessment and therapy. In the meantime such a dialogue asks for a new kind of spirituality itself in order not to fall back into any form of outdated exclusivism [3]. Psychiatry is not helped forwards by any form of religious apologetics or expansionism! That is a very difficult but nevertheless worthwhile task, beyond usually very tough barriers.
I.3
OVERVIEW
Many colleagues from all around the world, among them many WPA officials, started working on this project which reflects their commitment to study the interface of psychiatry and religion. ‘Beyond boundaries’ is felt as a challenging task and formulated as the general theme.
GENERAL INTRODUCTION: RELIGION AND SCIENCE
3
Table I.1 This List Includes Only Organized Religions and Excludes More Loosely Defined Groups Such as Chinese or African Traditional Religions Religion
Members
Percentage
Christianity Islam Hinduism Buddhism Sikhism Judaism Baha’ism Confucianism Jainism Shintoism
2.1 billion 1.3 billion 851 million 375 million 25 million 15 million 7.5 million 6.4 million 4.5 million 2.8 million
33.0% 20.1 13.3 5.9 0.4 0.2% 0.1 0.1 0.1 0.0
Source: Encyclopaedia Britannica [4]
The central part of the book, Section II, offers a description and analysis of how major world religions look at psychiatry, its practice and psychiatric disorders. We posed several questions to the authors. How do the religious and spiritual traditions they represent look at mental or psychic functioning and how do they evaluate and interpret psychic disorders? These are rather general formulations and questions. What does it mean in concreto, in daily practice? Mahayana Buddhism is widely and profoundly immersed in the mental life of East Asian people. Muslims attribute all events in life to God’s will and thus the concept of mental illness is influenced by religious aspects. What do these influences mean to psychiatric thinking and practice and to (the development of) therapy? Table I.1 shows the top 10 organized world religions. Necessarily, we had to confine ourselves. The project will cover Christianity, Islam, and Hinduism, Buddhism in East and South Asia, and Judaism. We are also able to include a chapter on African Religions. Of course, this is a very ambitious program. The authors have enough room to elaborate to the best of their knowledge/with their own expertise on psychiatry and the religious tradition they represent. Statistics of the world’s religions are only very rough approximations. Aside from Christianity, few religions, if any, attempt to keep statistical records; and even Protestants and Catholics employ different methods of counting members. This central part, including seven chapters, is meant to be the fundamental part of this book. It is preceded by what could be called the prolegomena, about issues that have to be explored first or that cannot be missed without great detriment. When entering an unfamiliar or unknown field or subject one needs to know (something like) where to begin. There are so many approaches and confusion is inevitable. Why should we (as psychiatrists) think and write about religion, spirituality and psychiatry anyway? What has psychiatry to do with religion or spirituality? Why care? On the one hand, it could be said that such an idea, prolegomena I mean, is a rather typical Western post-enlightenment idea. On the other hand, our claim could be that Western psychiatry has omitted an important realm of human experience [1, p. 182] ‘The constraint of ontological space’). So in this section it needs to become clear that there are plausible reasons for doing what we
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GENERAL INTRODUCTION: RELIGION AND SCIENCE
are going to do, and for exploring the hindrances, or for explaining why it should be evident that we care. In the twentieth century the encounter and interaction of religion and science took many forms. New discoveries in science have challenged many classical religious ideas. In response some people have defended their tradition, others have abandoned their tradition, and still others have reformulated long-held concepts in the light of science. This first section contains historical, philosophical, theological and aesthetic viewpoints. Concepts of evil are dealt with in various religious traditions throughout the ages and also how these concepts affect(ed) psychiatric thinking from a historical point of view. The theme will also be approached from a philosophical point of view. This is an important aspect, because we need a tool to approach the theme. In order to find such a tool, philosophical fieldwork needs to be done. Chapters are included on science and transcendence, and on religion and spirituality as (not just as) human endeavor, in a very sensitive and open-minded way. So, this first section is about (world)views, assumptions, concepts and (ontological) values, and about relevance! Is it still clear that religious believers and spiritually minded people live by religious and spiritual stories and statements which they interpret their (even pathological) experiences with accordingly and which enable them to express meanings of a profound and transcendent kind? Is a human propensity for transcendence facultative, or is there a fundamental shortfall, and does man need to learn to cope with emptiness? Do we think exclusively in medical psychiatric categories, hiding or masking existential layers? After this first part follows the announced central part on religions and psychiatry; again too ambitious, nevertheless full of starting points for future discussion and research. The third section is on religion, spirituality and psychopathology. In this part the core business of psychiatry, assessment/diagnosis and psychopathology is at stake. Discussions, explorations, research data and the like will not be restricted wherever possible to Western thinking or Western populations only, although data from elsewhere might not be available or insufficient. Since Sigmund Freud published his first article on religion more than a century ago a number of developments have taken place in psychoanalysis and psychoanalytic psychology of religion. A review of these developments is included in this part of the book. A chapter on the psychology of fundamentalism and religion (‘Violence of the Sacred’) is necessarily included. The fourth section is on empirical research, exploring the relation between spirituality/ religion and mental health. These chapters should inform the readers, if possible and relevant, about phenomenology, epidemiology, research data, explanatory models and theories, wherever evidence based data are available. It is important to refer to these data whenever necessary opinion based points of view are presented, explained and discussed, and that credulity based material should be detected. However, also attention will be paid to a more conceptual approach. How do these psychopathological phenomena relate to existential themes? What does that mean? Are we looking at epiphenomena or what else? In addition, what are the effects of religious practices of fasting and circumcision? Furthermore it is important to give an account of discussions towards the development of new classification and diagnostic systems, e.g. DSM-Vand WPA Program on Psychiatry for the Person [5, 6]. Three other parts are added to the foregoing: one with regard to (psycho) therapy and pastoral care, one concerning Religion and the Brain and a third one on religion, spirituality, and training and permanent education.
GENERAL INTRODUCTION: RELIGION AND SCIENCE
5
How to approach the religiously committed patient? This question is thoroughly discussed and illustrated from both a psychotherapeutic and a spiritual care-giving angle. A chapter on the relationship between pastoral care an mental health completes the fifth part. Recent brain research has revealed changes in brain functions concomitant with religious and spiritual experiences. This is anything but surprising. Experiences of whatever nature are predicated upon activation of certain brain circuits. Atheists have taken the neurotheological data as the ultimate triumph of their viewpoint: religiosity is but a brain state, nothing more. This is a misconception. Religious needs orginate on a psychological level, not in the brain. The brain enables one to generate the corresponding religious feelings. As an analogy: aesthetical feelings are made possible by the brain, they are not caused by the brain but by external stimuli. Neuro-theological data show that man has the capacity to conceive of a transcendental realm and communicate with it. These data do not have to mean the death blow to the deistic idea at all. And although a ‘God spot’, or ‘God gene’ has been discovered, no conclusions can be drawn whatsoever about the existence of God, or any supreme being or reality. In the meantime that does not mean, despite the fact that repeated emperical arguments can not prove the existence or non-existence of God, that the claim that God exists is meaningless. It just means that we have to argue on anothere level of knowledge for or against the existence of God. In connection with this type of reasoning more can be said on brain, soul, self and freedom [7, 8]. With regard to training and education, a curriculum should offer sufficient opportunity for teaching trainees to address the existential, religious and spiritual needs of our patients, including: Knowledge: basic knowledge of major belief systems; knowledge about the developmental, experiential, and mental health; consequences of religious experiences. Skills: improvement of interviewing skills; improvement of diagnostic skills with respect to people having all kinds of religious backgrounds; therapeutic skills. Attitudes: systematic reflection on the professional’s own belief system (atheism included) and the influence of it on their functioning; analysis of transference and countertransference issues; empathy. All contributors were asked to look at how (if at all) their own faith perspectives influence the way they think about psychiatry and human nature, about the phenomena they are writing about and the way they study and write about these phenomena. What are some of the starting, fundamental premises of their perspective? What are some of their chief concerns within their religious/cultural perspective that would point the reader to certain aspects that should have priority? What aspects of religiousness or spirituality are likely to influence directly the phenomena they are describing for better or for worse?
I.4
RELATION BETWEEN SCIENCE AND RELIGION
Ken Wilber called the relation of science and religion in today’s world ‘a deadly dance’ [9, p. 15]. He warns the reader of several stances toward this relation, that still influence and even dominate our thinking [9, p. 15–24]: 1. Science denies any validity to religion; 2. Religion denies any validity to science;
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GENERAL INTRODUCTION: RELIGION AND SCIENCE
3. Science is but one of several valid modes of knowledge, and thus can peacefully coexist with spiritual modes; 4. Science can offer “plausible arguments” for the existence of Spirit; 5. Science is itself not knowledge of the world but merely an interpretation of the world, and therefore it has the same validity – no more, no less – a poetry and the arts. The author argues that none of these five stances are acceptable. They are not powerful enough in a way that both parties would find agreeable. I take just one element from his line of thinking that is worthwhile keeping in mind. The third statement would be properly called ‘epistemological pluralism’. However, what is meant by that? The traditional view on this pluralism goes back to the Middle Ages: ‘every human being has the eye of flesh, the eye of mind, and the eye of contemplation’ [9, p. 18]. These three eyes are three eyes of knowledge: empiricism, rationalism, and mysticism. It would make a great difference with regard to our view on the relation between science and religion if the existence of this epistemological pluralism was an accepted fact. However, that is not the case according to modernity. Science and religion have often been seen as enemies locked in mortal combat. Some people in both camps are even aggressively continuing the warfare, for instance on the topic of evolution. But conflict can be avoided if science and religion are seen as strangers, occupying separate domains at a safe distance from each other. Science and religion, for instance, represent two kinds of inquiry and so they offer two complementary perspectives on the world. However, many people are seeking a more constructive partnership. Science raises questions it cannot answer itself. So many participants are looking for a constructive dialogue, because they are aware of the limitations of their own field of inquiry, and because both partners do not claim to have all the answers. Still other scientists and theologians even go a step further. They seek a closer integration of science and religion. We will use a well known influential fourfold typology, originally formulated by Ian Barbour, who is a pre-eminent figure in the field of science and religion [10, 11]. This fourfold typology is in fact the standard manner to present the relationship between science and religion and for that reason it can help us to sort out the great variety of ways in which people have related science and religion, and neurosciences and theology in particular. Barbour uses four key words to typify the four relationships: conflict, independence, dialogue and integration; Table I.2 illustrates the way Barbour relates certain scientific disciplines and their way of thinking, and religious assertions about human nature.
Table I.2
Genetics, Neuroscience, and Human Nature [10]
Conflict
Independence
Dialogue
Integration
Reductive materialism
Body/soul dualism
Neuroscience and the embodied self
Sociobiology and human morality
Body and soul: complementary perspectives Sin and redemption
Anthropology and the social self
Biological organism and responsible self Mind and brain: Two aspects of one process Process philosophy
Genetic determinism and human freedom
The computer and the brain
GENERAL INTRODUCTION: RELIGION AND SCIENCE
I.4.1
7
Conflict?
Scientific materialism makes two assertions: matter is the fundamental reality in the universe, and, the scientific method is the only reliable path to knowledge. Religion is not acceptable because religion lacks public data, lacks experimental testing and so on. Science is objective, open-minded, and universal; religion is none of these. In neuroscience we can find this same reductionistic materialism. In principle, we are told, we can account for every mental phenomenon using the same physical laws that suffice to explain radioactivity, or nutrition, or growth. The same reductive point of view holds true for the sociobiology: the only demonstrated function of religious beliefs and human morality is to keep the genes intact. Another illustration of the conflictual relationship between the neurosciences and theology would certainly be genetic determinism. It has sometimes been claimed that our fate is determined by our genes. But although nature and nurture impose severe constraints upon us, we are free selves who envision possibilities and can decide deliberately and responsibly among alternative actions. So here the conflict is between determinism and human freedom. Dean Hamer, who is a pre-eminent geneticist, recognizes the limitations of his scientific treatise and acknowledges that his approach is not a complete explanation of spirituality; genes explain only a relatively small percentage of variance at best. Hamer shows that new discoveries in genetics and neurobiology might indicate that humans inherit a set of predispositions that make their brains ready and eager to embrace a higher power [12]. He calls the specific gene he identified the ‘God gene’ that appears to influence spirituality. Elaborating on his findings he argues that spiritual belief may offer an evolutionary advantage by providing us with a sense of meaning and purpose, and the courage and will to overcome hardship and loss. In fact in that way Hamer tried to bridge the gap between science and religion instead of stirring up the conflict. (For a critical discussion of religion as ‘adaptation or evolutionary by-product’ and genetics, see [13]).
I.4.2
Independence?
What is the meaning of independence regarding science and religion? One way to avoid conflict or any problem is to keep neuroscience and religion separated in watertight compartments (demarcation theory). One can distinguish the two according to the questions they ask, the domains to which they refer, the claims they make, and the methods they employ. Science asks how matters work, and about causal relations. Religion asks why and asks for meaning and purpose. From another point of view: scientific and religious languages have distinctive functions and so science and religion offer complementary perspectives, for instance the complimentary perspectives of brain and mind. Body and soul used to be two separate compartments. But nowadays it is clear from the neurosciences that such a dualism can no longer be maintained. The dependence of mental status on biochemical processes, for instance in moral dilemmas [14, 15] or during religious practices as meditation or prayer, is clearly shown. So we are getting used to the concept of the embodied self, that goes beyond the body/soul dualism, and that goes beyond this second type of relationship between science and religion called independence. Religious concepts like sin and redemption seem far removed from any scientific data. Even that, however, is highly questionable from an evolutionary and ethological point of view.
8
I.4.3
GENERAL INTRODUCTION: RELIGION AND SCIENCE
Dialogue?
Contrary to the independency point of view the dialogue looks at the presuppositions and tries to explore similarities between methods and concepts. Independence emphasizes the differences. Many theologians today try to reclaim a religious or spiritual view of the self as a unified activity of thinking, willing and acting. Neuroscience seems to be consistent with theological affirmations of embodiment. Embodiment is very clear when we look at our affectivity. When I am moved by an emotion, it is clear that being emotional, for instance being afraid, is not possible without feeling a bodily tension or beating of the heart. So here religious thinking and the neurosciences, and also the behavioral sciences join in asserting the embodied self with special importance of emotions.
I.4.4
Integration?
In integration scientists and theologians go even further. Exponents of dialogue may sometimes reformulate traditional ideas. Integration is more far-reaching in articulating theological reconstruction more extensively and systematically. For instance, reconstruction of a religious concept like original sin as a biologically based disposition from the past that is not adaptive in the modern world. So according to this approach new knowledge from the neurosciences will affect religious thinking! It is up to the reader to look at his or her position, regarding one’s own religious, spiritual and scientific background. It is one of the aims of the WPA section on Religion, Spirituality and Psychiatry to help clear up these kinds of important discussions.
I.4.5
Neuro-theology
Neuro-theology is an example of a new emerging scientific discipline, based on neurosciences, that presents strong challenges to traditional religious beliefs concerning human nature. Neuroscience is the study of the physical structures of and causal interactions between neurons and neuronal assemblies [16]. It studies religious and spiritual concepts in relation to neurological and neuropsychological findings and analyses. There is much to tell about interesting data and recent discoveries in this particular field regarding religion and spirituality [12, 17]. At the same time, if one looks carefully, it is not difficult to recognize the fourfold typology in the way participants in neuro-theology handle and evaluate their findings.
I.5
REFINEMENTS
Barbour’s typology had been the starting point for the study of religion and science relationships for many years. Stenmark [11] offered a new searching exploration based on the premise that science and religion are social and dynamic practices and no static entities. His study offers a refinement of the Barbour typology. How do these relationships between science and religion evolve? According to Stenmark we need four parameters or dimensions to take into account in order to understand how and why science and religion relate to each
GENERAL INTRODUCTION: RELIGION AND SCIENCE
9
other as they do. His approach helps us to get a more differentiated picture of the interactions between science and religion. Stenmark’s approach is based on the idea that science and religion are both social practices. He calls it the social level of science and religion, and it is about the social interactions between practitioners of both science and religion. Such practices can be distinguished by the aims the practitioners have in mind (teleological dimension) by the methods that are used (epistemological dimension), and by the subject matter and content of science and religion (theoretical dimension). The independence view would mean that these two practices are completely different with regard to these parameters. The conflict view would mean that the parameters should be the same. The dialogue and integration views mean that there is a more or less overlap between one or more parameters. With regard to psychiatry and religion we would have to look at these parameters and to search for areas of overlap, or areas of total difference. What would be the overlap and the difference between psychiatry and religion in a teleological sense? If it would be appropriate to say that both practices aim at ‘healing’ or at helping relationships, there still would be a great difference between mental health and welfare (salvation) as a goal. However, despite the difference in ‘healing’ methods (e.g. medication versus prayer) the relationship between ‘the healer’ and ‘the healed’ is fundamental for employing the method. On a theoretical level the question would be how much overlap or difference there is in theoretical output. Could both psychiatry and religion offer us explanations of concepts like disease, illness and health, and also of experiencing illness and health? Would these explanations be complementary or opposite? However, if we look at the historical development of science and religion as social practices it is clear that at different times and places human nature has been differently experienced, behavior has been differently regarded, and claims to knowledge have been adjudicated in different ways.
I.6
CROSSING BOUNDARIES
The boundary between religion and spirituality and the practice of psychiatry is becoming increasingly porous, as the contributors to this book amply illustrate. No longer can psychiatrists in a multi-faith, multi-cultural globalized world hide behind the dismissal of religious belief as pathological, or behind biomedical scientism. During the last two or three decades religion and spirituality have become more prominent in mainstream psychiatry, not least because of the increased migration [18]. Globalization affects psychiatry, as it affects religion and spirituality. According to Kale [19] globalization exhibits five main trends in spirituality and religion: * * * * *
the use of religion and spirituality in reterritorialization; a worldwide quest to integrate spirituality in all aspects of day-to-day life; the increasing individualization of spirituality; the enhanced manifestation of spirituality in cyberspace; the syncretization of spirituality.
Religion and spirituality are on the move, so to say. This asks from psychiatrists to be more knowledgeable. Religion, spirituality and globalization have a vital impact on wellness and
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GENERAL INTRODUCTION: RELIGION AND SCIENCE
quality of life for a growing number of people worldwide. The World Health Organization (WHO) has rightly regarded religious, spiritual and personal beliefs as a component of quality of life. This growing awareness may enhance the study of religion and spirituality in psychiatric training, research and practice. In their review Fulford and Sadler stated: ‘There is a renewed cross-disciplinary contact (between religion and psychiatry, PJV) after nearly a century of mutual neglect’ [20]. We really hope that this book may stimulate WPA, as a global organization, to take an active stance in this renewed and promising contact.
REFERENCES 1. Sadler JZ (2005) Values and Psychiatric Diagnosis. Oxford University Press, Oxford. 2. Hart MB (2007) The Healthy Jew. The symbiosis of Judaism and Modern Medicine. Cambridge University Press, Cambridge. 3. Schmidt-Leukel P (2004) A New Spirituality for a Religiously Plural World. Concilium 40, 62–68. 4. Information Please Almanac: Top Ten Organized Religions of the World. Available at http:// www.infoplease.com/ipa/A0904108.html. Accessed February 21, 2008 5. WPA Report from the London Conference on Person-centered Integrative Diagnosis and Psychiatry for the Person. Electronic Bulletin. 2008; 59. Available at http://www.wpanet.org/ bulletin/eb59.html. Accessed February 23, 2008. 6. Cox J, Campbell AV, Fulford KWM (2007) Medicine of the person. Faith, Science and Values in Health Care Provision. Jessica Kingsley Publishers, London. 7. Oomen PMF (2003) On brain, soul, self, and freedom: an essay in bridging neuroscience and faith. Zygon 38, 377–392. 8. Verhagen PJ Sanctifying Personhood; beyond roles, functions, schemas and traits. Spirituality and Psychiatry Special Interest Group Newsletter. 2007; 24. Available at http://www.rcpsych.ac.uk/ college/specialinterestgroups/spirituality/publications/newsletter24.aspx. Accessed February 23, 2008. 9. Wilber K (1998) The marriage of sense and soul. Integrating science and religion. Broadway Books, New York. 10. Barbour IG (2000) When science meets religion. HarperSanFrancisco, New York. 11. Stenmark M (2004) How to relate science and religion. A multidimensional model. Eerdmans Publishing Co, Grand Rapids. 12. Hamer D (2004) The God gene. How faith is hardwired into our genes. Doubleday, New York. 13. Kirkpatrick LA (2005) Attachment, evolution, and the psychology of religion. The Guilford Press, New York. 14. Casebeer WD (2003) Moral cognition and its neural constituents. Nature Reviews Neuroscience 4, 840–847. 15. Greene J (2003) From neural ‘is’ to moral ‘ought’: what are the moral implications of neuroscientific moral psychology? Nature Reviews Neuroscience 4, 847–850. 16. McConnell D, Pickering N (2005) Clinical Practice, Science, and the Unconscious. Editorial. Philosophy, Psychiatry, & Psychology 12, 1–7. 17. Newberg AB, Iversen J (2002) On the “neuro” in neurotheology. In: Joseph R (ed.) NeuroTheology. Brain, science, spirituality, religious experience. San University Press, San Jose. 18. Boehnlein JK (2006) Religion and spirituality in psychiatric care: looking back, looking ahead. Transcultural Psychiatry 43, 634–651. 19. Kale SH (2004) Spirituality, Religion, and Globalization. Journal of Macromarketing 24, 92–107. 20. Fulford KWM, Sadler JZ (2002) Imaging the soul. Current Opinion in Psychiatry 15, 515–518.
Part 1 Prolegomena (First Issues): History, Philosophy, Science and Culture INTRODUCTION Where to begin? This first part fulfils an introductory function. It starts with an exploratory survey of concepts of evil and psychiatric thinking from a historical point of view. Does psychiatry have anything to say about the nature of evil? Evil causes suffering (harm) due to or without wrongdoing. Does DSM-IV’s definition of dysfunction and impairment imply suffering or harm? Does psychiatry have anything to contribute to the debate about moral evil? History shows that concepts of evil strongly influenced psychiatric thinking. This first part proceeds with a full account of the value-ladenness of medical/psychiatric practice and values-based medicine. There is more at stake here than just a ‘new’ approach complementary to evidence-based medicine. In fact this approach offers an important tool for conceptual fieldwork in psychiatry. One should not undervalue the meaning of such a tool. It is followed by a thorough discussion of science and transcendence. Transcendence is about otherness or distinctness of (a) being beyond the limits and limitations of our universe. Such limits and limitations pose boundaries to science and confront human beings with boundary experiences. Both facts give food for thought. And that is what one would expect. Part 1 is concluded by a sensitive discourse on spirituality and wholeness of the person from a spiritual perspective. Apparently it is felt as a necessity to draw attention to the idea of the person as a whole person. It introduces a first exploratory description of spirituality, including religion, as any experience or way of life, religious or otherwise, which can help the person to detach from the trivia, transcend and reach a calming and reassuring level of connectedness, meaning and purpose (p. 75).
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PROLEGOMENA (FIRST ISSUES)
1.1 Evil in Historical Perspective: At the Intersection of Religion and Psychiatry Michael H. Stone 1.2 Linguistic Analysis and Values-Based Practice: One Way of Getting Started with Some Kinds of Philosophical Problems at the Interface Between Psychiatry and Religion Bill (K.W.M.) Fulford 1.3 Science and Transcendence in Psychopathology; Lessons from Existentialism Juan J. Lo´pez-Ibor Jr. & Marıa Ines Lo´pez-Ibor Alcocer 1.4 Psychiatry of the Whole Person – Contribution of Spirituality in form of Mystic (Sufi) Thinking Ahmad Mohit
CHAPTER 1.1
Evil in Historical Perspective: At the Intersection of Religion and Psychiatry Michael H. Stone Professor of Clinical Psychiatry, United States of America
1.1.1
INTRODUCTORY REMARKS
Mankind has struggled since remotest antiquity, and presumably long before recorded history, to comprehend and to deal with – the manifold sources of challenge and threat to our earthly existence. Precisely because the threats to our survival are so numerous, compared with the comforting and healing actions that aid our survival, we have evolved over the millennia with a heightened awareness of the things that can harm or kill us, lower our social status, adversely affect our loved ones, or otherwise rob us of the necessities of life. This has led to the broad distinctions in our language between the positive and the (altogether more numerous) negative influences – captured under the headings Good and Bad, or in a manner more freighted with religious overtones, Good and Evil. Originally, the concept of Evil covered a large territory on our mental map: natural disasters such as droughts, floods, earthquakes, plagues, and extremes of temperature; animals that could endanger our lives; and finally – the most dangerous of all our enemies: other humans with hostile intentions. The inescapable death of ourselves and of all living species was often itself regarded as an evil. Natural disasters, in particular, could be so overwhelming, wiping out great numbers of people, even whole populations, at one stroke, that they cried out for explanation and, if possible, for being brought under our control. But war and violent acts even in peacetime could also reach devastating proportions. These phenomena also cried out for explanation and control. The religious impulse, which has sprung up spontaneously in all cultures from the beginning of recorded time (if not from the time of our emergence as a separate species), has acquired pride of place among the attempts our ancestors made to explain evil. Mankind has found it both comforting and necessary to invoke the concept of the divine, whether compartmentalized into many deities (as in the pantheons of the ancient Greeks, the Hindus, Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright 2010 John Wiley & Sons, Ltd
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the early Egyptians, etc.) or, as in the Abrahamic religions of Judaism, Christianity, and Islam, manifest in the existence of one God. Many believe that God created us in His image; others, regarding this as an anthropomorphic conceit, assert that we created (the concept of) God in our image. Be this as it may, religion assigns to God (whether in the singular or the plural) supernal powers over our lives and over all Nature. Related ideas include heavenly reward for doing well; heavenly retribution for doing evil. As we shall see, in earlier times the natural disasters were themselves understood as punishment writ large – for violating God’s laws about proper conduct by whole groups of people, even at times by whole nations. The belief in life after death, adhered to by religious persons of many faiths, brings with it the accompanying notions that those whose lives have been (mostly) good will reap the reward of life-everlasting in Heaven; those whose lives have been (mostly) bad, devoted repeatedly to acts regarded as evil – will earn only a place in eternal damnation, Hell, or its equivalent. The appeal of these beliefs is easy to grasp, given the unhappiness endured by most well-meaning and well-behaved people, and given the outrageous success to the very day of their death, whether in fame, power, or money, of certain undeserving people who, in the estimation of society, were evil. One of the functions acquired by religion, in other words, was the promise of at least belated justice via the punishment of bad people, even if it could only be carried out in the hereafter – that the good people had been unable to effect within the lifetime of the offenders. Looking at the world’s timetable, it is clear that religion antedated philosophy, and that philosophy came before psychiatry. It is not surprising, then, that in seeking an explanation as to how the mysterious and embarrassing existence of evil arose amongst their own kind, men turned first to religion. The first persons to offer explanations about evil were men of religion: either founders of a new religion, or else men schooled in-, and strongly identified with, an already developed religion. Many of these men were of what we would now call a ‘philosophical turn of mind’ – in the sense that they grappled with the larger issues of good and evil, morality, how life should be lived, how death should be confronted, our place in Nature, and our relation to Deity. The next group of men to ponder these issues and to offer explanations, steeped as they were in both religion and philosophy – were the religious philosophers. Only within the past three centuries have we witnessed the emergence of a few philosophers – often raised in deeply religious families – whose approach to the subject of evil is nevertheless more secular in construction and less tied to the tenets of this or that religion. Until very recently the topic of evil was felt to be the exclusive province of religion, or perhaps of religious philosophy; explanations of evil partook of the metaphysical or the supernatural. To that extent, only for religious adepts: priests, ministers, rabbis, imams, was it permissible to make pronouncements about evil. Philosophers whose thoughts and writings were imbued with religion might also address the subject. But for the vast majority of people – to speak about evil, especially to categorize certain others as evil, was felt as an intrusion on sacred ground, and would often enough invite adverse criticism. In the twentieth century, however, discussion of evil underwent a sea-change. Many important philosophers were less attached to conventional religion than heretofore. And in the last half of the century, particularly following the Holocaust, but also in recognition of the genocides in Armenia earlier, and in Cambodia, Rwanda, Nigeria, Yugoslavia and elsewhere, along with the Nanking Massacre of 1937, and the mass murders of its own citizenry in Russia and China – the topic of evil could no longer be confined to the
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sanctuaries of religious leaders or to the university halls of the philosophers. Two significant developments have, in recent years, brought about a reshaping of our attitudes towards evil. First, we have begun to pay more attention to how the word evil is used by the public and by the media. There are certain classes of crime, for example, that predictably elicit the word, whether from people in ordinary life or from writers and journalists. Evil is no longer ‘offlimits’ except to men of the cloth. Second, evil has become an acceptable subject for study by the mental health professions, including general psychiatry, forensic psychiatry, and neuroscience. Rather than relying only on the Bible (of whatever religion) for explanations about the nature and roots of evil, we now look where we should have been looking all along: the human brain. There has been an inchoate recognition for a long time that evil is a purely human phenomenon. For an action on the part of one creature toward another creature to be considered evil, there must be consciousness and also an awareness of death. The consciousness, in this case, would involve the awareness of the suffering that one is inflicting upon another. Awareness of death is a special case of consciousness, the implication being that an aggressor realizes consciously (a) that the death of the victim may be the result of aggressive action, and (b) that the victim would have been vehemently opposed to this result. There is also the matter of attitude. Acts that we regard as evil are often preceded by powerful emotions of hatred (whether in the form of contempt, envy, jealousy, outrage over being humiliated, and the like). Born of such hatred are such acts as murder, rape, grievous assault, public humiliation, the depletion or ruin of another’s possessions, etc. All these manifestations are unique to our human species (with perhaps a few analogous acts among some of the higher apes). The cat bears no malice toward the mouse, nor the walrus to the fish it devours for its sustenance. For all intents and purposes we are the only members of the animal kingdom of whom it is meaningful to apply the word evil. In reviewing how the concept of evil has evolved over the centuries, we turn our attention first to the men of religion in ancient times, some of whom also became the founders of new religions. We then see how the concept was reworked and understood by men who were at once professional philosophers and deeply religious persons. In the more recent centuries the main commentators on evil were philosophers, often with a strongly religious background and upbringing, but who were not also clergymen. Still more recently, we confront professors of philosophy of a more secular orientation. Finally, commentary on evil is divided between philosophers who are less strongly identified with a particular religion – and persons in the disciplines of psychology and psychiatry.
1.1.2
EVIL AS VIEWED BY MEN OF RELIGION IN ANTIQUITY
One of the earliest ideas about evil is to be found in the writings of Yajnavalkya, a Hindu religious adept and ascetic of the eighth century BCE. He spoke of an ‘inner person’ who existed in two states: one of this world, one in the Other. When we are born and acquire a body, we are joined with evils; when we die, we abandon evils. In the intermediate situation of the dream state we see both the evils of this world and the joys of the Other world – an idea that is incorporated in a religious text: the Brhadaranyaka Upanishad [1]. As for ‘evils,’ Indian and Buddhist countries believe in the notion of karma, according to which all our deeds, whether good or evil, are rewarded or punished; our ultimate fate is determined by the accumulation of our deeds, extending over our lifetime ([1], p. 40).
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A near-contemporary of Yajnavalkya, the Old Testament prophet Isaiah spoke in the tradition of Jewish monotheism, referring to the fallen angel Lucifer (lit.: the bearer of light) as one who had claimed that he would ascend into Heaven and exalt his throne above the stars of God. . . I will be like the Most High [Isaiah 14:12–15]. The prophet asserts that no, Lucifer (called also Satan: Hebr. for ‘adversary’) will be brought down to Hell. Lucifer’s sins were those of pride and covetousness – akin to our modern concept of narcissism. But there is a hint in Isaiah’s remarks that the good and evil observed among men is related in some way to the supernatural, celestial battle waged between God and His adversary – Lucifer/Satan. Prince Gautama Siddharta (623–543 BCE) as he neared 30 gave up a life of riches, wandering in northern India as a poor man, and developing a philosophy that emphasized the renunciation of earthly desires and the state of non-attachment. Having achieved enlightenment, he became known as the Buddha (from the Sanskrit verb to awaken). Though he never claimed divine status, rather that of a teacher and guide, he has now become the object of veneration by those who claim Buddhism (and its offshoots) as their religion. Buddha taught that to escape suffering one needed to eliminate desire and to follow the noble Eightfold Path (right view, right speech, right thought, etc). To be avoided were the chief sins – all related to lust or desire; namely, anger, greed, and foolishness. These constitute the same triad of sins embodied in Japanese Zen-Buddhism: ikari (anger), musabori (greed) and orokasa (foolishness). The religious teacher and prophet of ancient Persia, Zoroaster, was probably a contemporary of the Buddha, though some have suggested he may have lived much earlier, even before 1000 BCE [2]. The religion he founded – Zoroastrianism – postulated the twin brother-Gods, Ahura-Mazda (the God of Light and Good), and Ahriman (the God of Darkness and Evil). There is a close parallel here to the Old Testament story of the twin brothers, the virtuous Abel and the murderous Cain. Ahriman is said to have chosen of his free will to behave in an evil way, creating in the process the phenomena of sin, death, and evil. The Jewish prophet of the Old Testament, Ezekiel (622–570 BCE), a contemporary of the Buddha, wrote of Lucifer in this way: ‘Thou wast perfect in thy ways from the day that thou wast created, till iniquity was found in thee. . .. Thou hast sinned: therefore. . . I will destroy thee, o coveting cherub. . . and never shalt thou be anymore’ [28:12–19]. Centuries later, Christian theology could not accept that God created Lucifer/Satan as a wicked creature, since this would amount to God creating an evil. Instead, St. Augustine’s idea (built upon Ezekiel’s understanding) found preference, according to which God had not created Lucifer as evil. Rather: Lucifer, now as Ha-Satan [the adversary] via an exercise of his own free will – chose an evil path, and was cast out of Heaven (cf. [3]).
1.1.3
EARLY PHILOSOPHERS
Kong Fu-zi [Kong, the Master], whom we know as Confucius [551–479 BCE], albeit a religious man, rarely discussed supernatural phenomena, emphasizing instead a humanistic approach – one that recognized the free will of all people [4]. Confucius taught that the superior man is one who has learned to overcome his innately evil nature, through the practice of jen [acknowledgment, knowledge]. He also advocated
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moderation as a transcendent virtue, akin to the emphasis on the ‘middle way’ in the philosophy of Aristotle. Evil, for Confucius, was not seen as a supernatural force implanted in us, and against which we must constantly struggle, but as an inborn human tendency – against which we must constantly struggle. Mencius [372–289 BCE], who may have been taught by Confucius’ grandson, Zi Si, was an idealist after the manner of Plato, in agreement with the latter that he believed in man’s innate moral goodness, in contradistinction to Confucius’ belief in man’s originally evil nature. The comments of Plato [427-347 BCE] on evil have a resonance with those of Confucius. For Plato, God was not the cause of evil; instead, God guarantees the inevitable decree of Fate; namely, that the man who will make the wrong or immoral decision will pay for it, itio&). The ‘evil becoming tormented, perverted, and unhappy. God is without blame (ana soul,’ meanwhile, is that part of the soul where evil naturally resides; that is, the irrational part of the soul which is receptive to evil and to ‘unmeasuredness’ – i.e., excess and defect, the sources of unrestrained wickedness and cowardice. One effect of this irrational soul is to make the soul think that whatever it avoids or shuns is ‘evil,’ and whatever it seeks is ‘good’ ([5], Phaedrus 256B 2–3). Plato’s pupil, Aristotle (384–322 BCE), expressed similar views concerning evil: evil was a form of the ‘unlimited’; good, of the limited. Excess and deficiency are failings; virtue lies in the (golden) mean. As Aristotle mentioned: Men are bad in countless ways; good, only in one ([6], II vi). The mark of virtue was to have the right feelings at the right times on the right grounds toward the right people for the right motive and in the right way. In this regard, Aristotle’s ideas harmonize with those of the Buddha’s Eightfold Path. Epicurus, a Greek philosopher [341–270 BCE] from the generation after Aristotle, held that the purpose of philosophy was to attain a happy, tranquil life, adding that pleasure is the measure of what is good; pain, of what is bad. He held that the gods neither reward nor punish people, but also counseled against hedonism – remarking that restraint and temperance were prime virtues, much as was emphasized by Plato and Aristotle ([3], 1:20). The philosophical school he founded (Epicureanism) was one of the three then dominant schools of thought, alongside Stoicism and Skepticism. Epicurus is noted for his effort to explain the world without recourse to myth or religion, but through reference to material principles – testable in what we would call a scientific way via direct observation. Moral reasoning for Epicurus involved a cost/benefit analysis of pleasure versus pain (the latter included both physical and mental suffering). Mirrored in his philosophy is the Jeffersonian credo, embedded in the American Declaration of Independence, asserting that human beings have the inalienable rights to life, liberty, and the pursuit of happiness. In one of his writings, preserved by the early Christian rhetorician, Lactantius [240-ca. 320 CE], Epicurus casts doubt on God’s responsibility for evil via a method of careful reasoning that we will confront only much later in the works of Pierre Bayle. As Epicurus phrased it: God either wishes to take away evils, and is unable, or He is able and unwilling, or He is neither willing nor able – or He is both willing and able. If He is willing but unable, He is feeble, but this is not in accord with the character of God. If He is able and unwilling, He is envious, which is equally at variance with God. If He is neither willing nor able, He is both envious and feeble – and therefore not God. If He is both willing and able (which alone is suitable of God), where then does evil arise? And why does God not remove evils? It will be many centuries before this dilemma is resolved satisfactorily.
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1.1.4 COMMENTARY ON EVIL IN THE 1ST MILLENIUM OF THE COMMON ERA The word evil, once the New Testament was organized in its final form by Bishop Irenaeus in the late second century CE, occurs some 106 times (as against 446 times in the Old Testament). The Greek word kako´n is used much as was the Hebrew [ra] of the OT– in a variety of ways: wickedness, hurt, mischief, bad, affliction, adversity, harm, wrong, etc: that is, both to designate the deed and also its consequence. There is not so much comment on the primal source of evil (as in Zoroaster’s Ahriman), as there is an implicit recognition that men are strongly inclined to commit acts which others define as evil – particularly if there is a weakness in their link to God. In this sense, God plays a role more in the center stage of human conflict than is apparent in the philosophy of Plato, where God (or the ‘gods’) are at a greater remove from human affairs, operating more as observer or final judge. Thus the New Testament speaks of the ungodly man: one whose life-course is an injury to himself and to everyone around him; he is morally evil and hurtful. Saul of Tarsus [? to ca. 67 CE], who became St. Paul, famously wrote in the first epistle to Timothy: ‘the love of money [jilargura] is the root of all evil’ – referring especially to ‘. . .they that will be rich fall into temptation and a snare, and into many foolish [lit. ano´hto& ’mindless’] and hurtful lusts, which drown men in destruction and perdition’ [1 Tim. 6:9 & 10]. Paul here inveighs against the same evils of greed and foolishness that the Buddha underscored. Elsewhere, Paul gives us a brief catalog of evils: adultery, fornication, uncleanness, lasciviousness, idolatry [lit.: heresy], witchcraft, hatred, strife, envy, drunkenness, revellings, and such like’ [Paul’s Epistle to the Galatians 5: 16–24]. Oddly, the King James version also mentions ‘murder’ [Gal. 5:21] – which would be jo´no& /phonos, whereas the original Greek of the Septuagint only reads jqo´no&/phthonos – which signifies envy or malice. Paul does not present these evils in a hierarchical manner; certain ones nevertheless appear to us more malign (such as ecqra: hatred, enmity) than others (such as drunkenness). Plotinus [205–270 CE] is believed to have been a Hellenized Egyptian, the developer of neo-Platonic philosophy. He himself was not Christian nor did he refer to Christianity in his works. Plotinus’ cosmology influenced subsequent philosophers from many backgrounds, including Jewish, Christian, and Muslim. One aspect of his cosmology centers around his belief that the soul is composed of a higher and a lower part: the higher part – divine, and imparting life to the lower part, which in turn is the seat of the personality with its passions and vices. Evil is linked with matter, in contrast to the Intellect, which is always pure – and which turns away from matter. For Plotinus evil was not irremediable, since it came about through privation: through the soul becoming disconnected from the higher part because of forgetfulness. In this latter state, the soul loses its ability to rule over its inferior part and comes under the influence of matter. The remedy for the soul, by which it can free itself from evil – is through the experience of love. In contrast to the mind-set of Plato or Mencius, the early Christian philosophers tended toward a pessimistic view of humanity, picturing man as sinful, evil as inescapable, salvation as difficult to achieve. This gloomy view was not universal among them, but was characteristic of the most influential thinkers. Consider, for example, the ideas of St. Augustine as contrasted with those of Pelagius. Both were born in the same year [354 CE]: Pelagius in Britain; St. Augustine, in North Africa. St. Augustine, before his conversion to Christianity at age 31, struggled with sexual feelings that overwhelmed him and which he strove to ‘conquer’ after coming under the influence of St. Ambrose in Milan. In his effort to
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understand evil, St. Augustine argued that God was good and the things He made were good. Evil, not being attributable to God, came from the sin committed by Adam and Eve in violating God’s prohibition against eating the forbidden fruit (which conferred knowledge, including, by the way, knowledge about sex and procreation). Because of this hubris, we became corrupted by our own free will – the Original Sin of these first two humans being passed down the generations. For St. Augustine this vitium (flaw) lay in our passions and desires of the flesh, summed up under the heading of concupiscentia (which includes all desires – for wealth, admiration, power, not just for sex), the root being Pride (the craving for self-exaltation). In one of his more dour comments, he wrote Sub Deo justo, nemo miser nisi mereatur: Under a just God, no one is miserable who has not deserved misery. Yet St. Augustine disagreed with Plotinus, claiming instead that whatever exists on earth (including matter) is good, because it came from God. The one curative that could free our will from its inherited and otherwise irremediable predisposition to sin – was the elusive (and for St. Augustine, not very liberally dispensed) force of God’s grace [7]. Pelagius’ views were diametrically opposed to those of St. Augustine, rejecting the latter’s fatalistic and rigid conceptions. Opposing the doctrine of Original Sin, Pelagius proposed instead that Adam was created susceptible of death – whether or not he had sinned; his sin was his alone and not that of all mankind; infants are in the same state as Adam before the Fall; and even before Christ there were some men who were sinless. Each person, furthermore, was free to choose between good and evil. Though Pelagius regarded his contemporary as nearly Manichaean (and thus heretical) in his picture of Good and Evil as akin to two separate forces, it was St. Augustine who won the day and set the tone for much of Christian philosophy in the years to come. Pelagius emerged, despite his (as we would see it) humanistic philosophy, as the ‘heretic.’ In fairness to his rival, St. Augustine did recognize (in a manner at variance with Manichaeism) that ’. . . I once thought that it is not we who sin but some other nature that sins within us (mihi videbatur non esse nos qui peccamus, sed nescio quam aliam in nobis peccare naturam). . . The truth, of course, was that it was all within my own self, and that my own impiety had divided me against myself’ ([8], V, 10).
1.1.5 ARABIC PHILOSOPHERS IN THE TIME OF THE FIRST MILLENNIUM A number of important Arabic philosophers bookended the first millennium, having flourished in the century-and-a-half just before, or just after 1000 CE. The first philosopher of major significance during this era was Abu Yusuf al-Kindı (ca. 801–873), who was born into an aristocratic family in Kufa (in what is now Iraq). A polymath learned in many academic subjects, Al-Kindı is credited with having introduced Indian numerals (that we now refer to as Arabic numerals) into the Islamic and Christian worlds. In the field of psychology he wrote a treatise on sleep and dream interpretation. As to his philosophic thought, he was influenced by Aristotle and by such neo-Platonic writers as Plotinus and Proclus. In his treatise The Eradication of Sorrow, Al-Kindı touches on the broad topic of good and evil, insofar as he speaks of grief as related either to the loss of loved ones or to the loss of personal possessions. Yet one cannot live without sustaining the loss of loved ones nor can one acquire all he may desire. As Butterworth [9] mentions, ‘the only way to escape sorrow is to be free from these attachments’ (p. 269). In this sense
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Al-Kindı argues for the kind of asceticism urged by the Buddha long before him, and by the neo-Platonic philosophers as well – who equated evil with the material world – and with the inordinate quest for material wealth; good – with philosophic contemplation and the pursuit of virtue. Implicit in his recommendation for the virtuous life is something akin to life according to an Aristotelian Golden Mean – where, regarding possessions, one strives to get along with the low side of average; to be satisfied, that is, with ‘just enough.’ This would be the optimal antidote to greed (recall the Buddha’s triune conception of evil: anger, greed, and foolishness) – that was still compatible with a tolerable human existence. The philosopher/polymath whom we know as Rhazes was born in Persia, in the city of Rayy (whence his name: ‘from the city of Rayy’) in about 854. He became physician in charge of the Royal Hospital in Rayy, eventually moving to a similar post in Baghdad. Among his medical accomplishments were the discovery of sulfuric acid and the medical use of alcohol. Though a prolific writer (one year he is said to have written 20,000 pages, or 55 a day), little has come down to us of his original works. A freethinker whose philosophic ideas were more in keeping with Platonic than with Aristotelian thought, Rhazes did not see creation as a gift or an act of grace bestowed on us by a benevolent deity. Rather, he felt that ‘. . . in this life, evils outweigh goods,’ in sympathy with the Epicurean view, and also with his physicianly observation that there was a ‘prevalence of pain and suffering over peace and pleasure in all sensate beings’ [10]. Akin to the Judaeo-Christian notion of expulsion from the Garden of Eden because of sin, Rhazes pictured our bodily existence as representing a fall from the life-giving principle of the Soul – a fall that can be broken by the gift of intelligence. The fall was not so much imposed on us by God as permitted by a tolerant and all-seeing Wisdom [10]. There is a hint here of man having free will, despite the omnipotence of an all-knowing God – leaving us free to pursue good or to descend into evil. In a manner analogous to Pelagius’ departure from orthodox Christian belief, the Persianborn Islamic philosopher, Ab u Nas¸r al-Farabi [870–950], the founder of Islamic NeoPlatonism, questioned the authority of the Qur’an and rejected the notion of predestination. He felt reason was superior to revelation – a heretical idea for a Muslim [11]. Al-Farabi may have been influenced in this direction by his (heretical) teacher ‘Isa al-Warraq (died 909 CE). Dividing the cosmos into three worlds: the First (independent of matter; the realm of intelligible forms and higher spirits); the Second (the heavenly spheres); and the Third (material entities), Farabi posited that evil was excluded from the first two, and could exist only in the third realm. Even there, in the domain of willful action, good and evil can be found, and depend on either the proper use, or else the misuse, of material means. Voluntary evil is associated with wrong choice, as when, for example, the rational faculty is oblivious to the supreme good and is directed instead toward an inferior good such as pleasure or profit ([11], p. 97). There is no simple correspondence, in other words, between Pleasure and Good versus Pain and Evil, since certain pleasures are obviously associated with vice and with harm to others. Rhazes before him had cautioned that pleasure is to be pursued only in a manner that brings on no greater pain or harm ([9], p 271). As with Pelagius, and in opposition to St. Augustine, God and the supernatural are no longer primary elements in Al Farabi’s conceptualization of evil and its origins. Even though he invokes God as the ‘Lord of the Worlds,’ God, in Al Farabi’s view, does not act directly on the sublunary world (Rhazes would agree with this postulate), and is thus more remote than the God of St. Augustine.
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Ab u ’Ali al-Husayn ibn Sina, whom we know as Avicenna, was born near Bukhara (in Central Asia) in 980. He died in 1037 CE. A polymath like the previously mentioned Islamic philosophers, Avicenna is better known today for his voluminous medical writings than for his essays on other topics. In his philosophical work, he was interested primarily in creating a coherent system that dealt with man’s place in the world in a way harmonious with Islamic religious doctrine. His earliest works were influenced by Al-Farabi, and include his Maqala fi’l Nafs (Compendium on the Soul) in which he argues for the incorporeality of the soul, though without adopting the Neo-Platonic notion of its pre-existence [12]. As with medieval philosophers in general, Avicenna used the philosophical mind-set in the service of religion, positing that God, as one pure Good could produce only a cosmos that was orderly and good. But this raises the vexatious question: if God is pure Good, whence Evil? Avicenna’s answer was that there was no Pure Evil (like the Zoroastrian Ahriman) on the other side of the balance. Rather: in our world there are particular evils, best understood as ‘accidental consequences of good’ ([12], section 5). Still to be explained: moral evils among human beings, as opposed to natural evils such as earthquakes and floods. Here Avicenna posited that God knows the things that exist, but not individuals. This drew fire from a later Islamic philosopher, Al Ghazali (1058–1111 CE), for whom Avicenna’s denial that God had knowledge of particulars, as well, was heretical. In the area of psychology Avicenna’s religion-inspired views existed side by side with his practical medical knowledge. In a prelibation of Descartes’ seventeenth-century theory, he believed that the soul is independent of the body, even going so far as to enunciate an argument, similar to Descartes’ cogito ergo sum, that a blind man, were he suspended in the air, would be unaware of his body, yet still possessed of self-awareness – because he could still think ([12], section 7). But in his great compendium, the Canons of Medicine, Avicenna described various ‘down-to-earth’ psychological (we would say psychiatric) conditions, such as melancholy and mania – along with recommendations for their treatment. Avicenna’s views on the temperaments (Sanguineous, Phlegmatic, Bilious, Melancholic or ‘Atrabilious’), and their connections to the four elements: air, water, fire, and earth, respectively, derive from ancient Greek sources (particularly, Galen). We still use the corresponding temperament terms manic, phlegmatic, melancholic//depressive, and irritable even today, as did Kraepelin in the early 1900s. But Avicenna hardly confined himself to psychological issues, and though he touched on psychiatric conditions, he cannot in any meaningful sense be called a psychiatrist. The most prominent successor to Avicenna, Ab u’l Walıd ibn Rushd (our Averrho€es), born in Islam’s western-most area, in Cordoba (1126–1198), is famous for his commentaries on Aristotle. Ibn Rushd was in touch with Christian and Jewish philosophers in Islamic Spain, including Maimonides (also from Cordoba), who greatly admired him. As with many philosophers, from the Greeks to the time of ibn Rushd, the attainment of intellectual excellence was considered a ’prerogative of the privileged few’ ([13], p. 301). The masses, in contrast, could aspire at best to a level of moral excellence through leading a life of virtue (according to the wisdom and recommendations of the philosophers). Moral uprightness was a potential for them, even though a comprehension of the essential truth lay beyond their grasp. A philosophical posture vis-a-vis good and evil is implicit in this view, though ibn Rushd focuses less on the topic of evil than did some of his Islamic predecessors. Dante knew of both Avicenna and ibn Rushd, whom he situated in the limbo of Inferno – where lay the unbaptized and the virtuous pagans (whereas another prominent Aristotelian, St. Thomas Aquinas, was in Paradiso). Toward the end of Canto IV (ll. 142–144) of the
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Inferno, Dante wrote: Euclide geometra e Tolomeo, Euclid the geometer and Ptolemy, Ipocrate, Avicenna e Gali€eno, Avicenna and Galen, Averoı`s che ’l gran comento feo. Averro€es who made the great Commentary. [14]
1.1.6
RELIGIOUS PHILOSOPHERS OF THE MEDIEVAL PERIOD
The humanist Jewish philosopher Maimonides [1135–1204] transmitted Aristotelian rationalism, which had been kept alive through the Arabic sources of the previous four centuries, to later Christian theologians like Albertus Magnus and St. Thomas Aquinas. Maimonides accepted the Platonic view that earthly matter was the source of evil and saw the Imitatio Dei of St. Augustine as a way of freeing oneself from the ties of matter [15]. He also saw the imagination as tied to material things, one manifestation of which was the anthropomorphism and belief in a corporeal, as opposed to an abstract, God [16]. He advocated, in a manner akin to asceticism, minimizing one’s attention to bodily functions and impulses (food, drink, sex. . .), recognizing how they underlay the ‘evil impulse’ yetzer ha-ra]. Yet his realism was such that he understood that the evil impulse [ was not irredeemably evil: later rabbis would argue, in fact, that without a measure of the impulse, one would not marry, have children, build a house, or engage in business. What was crucial in Maimonides’ argument was that the impulses that govern sex and the desire for mastery can go overboard (beyond, in effect, the Aristotelian mean) and end up as evil actions. For St. Thomas Aquinas [1225–1274?] the main theological struggle was that of theodicy: how to explain the existence of evil, given an omnipotent God who was thoroughly benign and good – an echo here of the earlier lament of Bo€ethius: ‘If there be a God, from whence so many evils?’ ([17], xix). The resolution lay for him in the concept of free will. Only God had a free will that was at the same time incapable of sin. But St. Thomas considered it impossible for God to create human beings having both a rational nature and free will – who would always choose what was right and never commit a fault or a sin. As to why it should be that God could not have gone the extra distance and engineered our free will in such a way that we too could not commit sins – St. Thomas does not hazard an explanation. He does conclude, however, that the root of all vices lay in the inordinate love of self [Question VIII, art. 2, reply 19] – a comment in line with our modern conception of narcissism (Aquinas St. Thomas [71]. For further explication of the views of St. Augustine and St. Thomas, the reader should consult the excellent summary of Carlos Steel [72]. Count Giovanni Pico della Mirandola [1463–94] hoped to put to rest, as had Pelagius before him, the belief still held by some – that evil was born of two distinct sources, one representing the Good; the other, Evil, as posited by Zoroaster and the similar-minded thirdcentury prophet, Mani – from whose name the Manichaean heresy derives. Writing in the early Renaissance period, St. Ignatius Loyola [1491–1556], the founder of the Jesuit order, expressed a mixture of views: some that pay homage to traditional Christian theology; others that have a more modern ring. He mentions (in the traditional vein) that the Devil, studying the nature and traits of each man, suggests splendor to the ambitious, gain to the covetous, delight to the sensuous, etc. But he avoids the trap of theodicy in stating that one cannot define Good and Evil in absolute terms, and that evil is an emergent property that grows out of a particular context, dependent also on the mind-state of the person(s) in question [18]. Stressing the important role played by our free will – by which we may choose to turn away from God’s loving desire (and thus commit evil acts), Loyola lays less emphasis
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on God as omnipotent and all-good, which so bedeviled, or rather confounded, those who grappled with theodicy. Similar views were expressed by Loyola’s contemporary, Juan Luis Vives [19]. As a Jew who converted to Catholicism under the impact of the Spanish Inquisition, Vives was perhaps more ready to think along less conventional paths, contending that the Will is essentially spontaneous (and not always subject to Reason), and is at liberty to choose to do evil things as well as good things, God notwithstanding.
1.1.7 THEOLOGIANS AND PHILOSOPHERS OF THE RENAISSANCE AND ENLIGHTENMENT Among the prominent theologians and philosophers of the sixteenth through the nineteenth centuries, the subject of evil is treated more and more as a human affair, with God or the Devil playing less active roles from the standpoint of causation. There is an increasing tendency to picture God in a more abstract, less anthropomorphic, manner. Most of the philosophers are believers; many come from families where the father was a clergyman. But the dominant explanation concerning the origin of evil relies on concept of free will, albeit a free will that was granted us by the deity. The German Protestant religious mystic, Jacob Boehme [1575–1624] argued, in a way that would have been considered quite heretical earlier, that God was ‘underneath’ rather than ‘above.’ In what amounts to a prelibation of Spinoza’s philosophy, Boehme stated that Nature rises out of God, and that we ‘sink into him’ [20]. He also posited two triads of forces, one of which was composed of the elements: Soul, Body & Spirit – corresponding to which are Good, Evil, and Free Will. In his later writings Boehme envisioned evil as the direct outcome of the wrathful side of God, adding that the object of the world’s life and history was to exhibit the eternal victory of Good over Evil; Love over Wrath. For Thomas Hobbes [1588–1679], the son of a Protestant vicar, God was one Substance, of which there could be more than one Persons (or Representatives), such as Moses, or later, His own Son, Christ ([21], p. 520). But Hobbes’ comments on Good and Evil reflect his sociological/political understanding of these attributes. Portraying human life as involving a universal desire for self-preservation, Hobbes argued that because Man is in the state of nature anarchic and greedy, a social or civil order soon evolves – as a means of avoiding a war of all against all. In his famous comment about our life as ‘solitary, poore, nasty, brutish and short’ ([21], p. 186), Hobbes states that the remedy for this is the appointment of a sovereign, who saw to it that men exchanged a degree of personal freedom in return for personal safety. Good, Evil, and Justice had no meaning, in Hobbes’ schema, until men curbed their desires and entered into a social pact ([21], Ch. XIII). The comments on evil of Descartes [1596–1650] resemble those of Vives: in his De Passionibus he asserted that ‘All good and evil in this life depend on the Passions alone’ [CCXII] . For Descartes the passions (we would call them the emotions) are the products of Nature; their use is to contribute to actions that preserve or improve the body. Yet the Will must at times oppose the Passions with ‘. . .firm and determined judgments touching the knowledge of Good and Evil, according to which the Soul has resolved to conduct its actions’ [CXXXVII]. What Descartes does not make clear is how we know what is Good and what is Evil to begin with. Sometimes called the last of the medievalists, Baruch Spinoza [1632–77] had a conception of evil as identified, in neo-Platonic language, with privation or ‘absences
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which express no essence.’ He also thought of God in a way reminiscent of Boehme: God is ‘immanent in the world’ and individual things are themselves modes or modifications of God. The one reality is ‘God or Nature’ [23, 24]. This equation of God with Nature earned for Spinoza an excommunication from his Jewish coreligionists, but also later even from the Calvinists – both groups regarding such an unexalted view of God as heretical. Spinoza argued, in regard to evil, that there is no evil in the nature of things: the same object may be good in one set of circumstances and evil in another. Whatever advances man toward a more perfect nature is a true good; evil could be seen as a criticism of God’s goodness. A` propos free will, we may know a thing to be (good or) bad, yet not find in ourselves the power either to do the good or to abstain from the bad. In the same way that Spinoza’s family fled to Holland to avoid religious persecution, Pierre Bayle [1647–1706], the son of an impoverished Calvinist minister in southern France, fled to Holland – because of his unconventional ideas that ran counter to the Catholicism of Louis XIV. Picking up where Epicurus left off two millennia before, Bayle contended that it cannot be the case that Evil exists and that God is both omnipotent and benevolent [25], for if God were both willing and able to remove Evil, then where does Evil come from? To strengthen his point (meanwhile alienating the religious orthodoxy of his day), Bayle challenged the accepted wisdom that belief in divine reward promotes morality – given that many religious believers are not deterred from evil acts, including cruel and destructive behaviors, whereas many atheists are not immoral, even though they stand in no fear of divine retribution for their non-belief. Instead, as Bayle emphasized, people’s conduct is determined primarily by secular sanction and by character structure: those who are cruel will act cruelly, whether or not they believe in God or the Hereafter. People who are kind will distance themselves from cruelty, even if they do not believe in divine punishment [26]. Bayle’s contemporary, the Baron Gottfried von Leibniz [1646–1716] is known more for his co-invention of the calculus than for his theodicy [27]. Bayle, the incurable pessimist, viewed a God who could have made a world where there were fewer crimes and sufferings – yet chose not to do so – as something of a criminal on a grand scale. Leibniz, the incurable optimist, argued that, au contraire, this was the best world that could have been created; any alternative world would have been worse – a view savaged by Voltaire in his famous parody, Candide. Leibniz did define three categories of Evil; namely, the metaphysical, the physical, and the moral. The ‘metaphysical’ related to the degeneration inherent in the substance of which the world was made (since only God is perfect). The ‘physical’ concerned the pain and suffering we experience in the world, whilst ‘moral’ evil amounts to the crime – for which physical (or ‘natural’) evil is the punishment. It was this latter notion that came in for Voltaire’s ridicule: how, for example, were the 60,000 victims in Lisbon on that fateful day in November, 1755 – any more ‘deserving’ of the earthquake than were the citizens of some other city? The Lisbon earthquake was in fact a turning point, much as the Holocaust or 9/11 in our day, that forced men to rethink the concept of evil, and to rid themselves of the idea that natural disasters were somehow or another ’God’s punishment’ for our sins. As Voltaire wrote, with timeless eloquence: What crime, what sin, had those young hearts conceived That lie, bleeding and torn, on mother’s breast? Did fallen Lisbon deeper drink of vice Than London, Paris, or sunlit Madrid? — (from Poem on the Lisbon Disaster [28])
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In Bayle and Leibniz we have the paradox of two men, both Protestant, both born within a year of each other: one still wedded (though not exclusively) to the metaphysical view of evil; the other, rejecting the metaphysical in favor of a more down-to-earth (and down to the individual person) conception. Perhaps the answer lay in the fact that Bayle was poor and was exiled; Leibniz was rich and honored in his own country. The empiricist Scottish philosopher, David Hume [1711–76], though raised in a Calvinist background, removed God from the equation concerning good and evil, claiming that what ought, and what ought not, to be the case cannot legitimately be derived from the ideas of a deity. He argued against the notion that Reason alone enables us to make moral distinctions. Rather: morality is concerned with such non-ideational entities as Passions, Volitions, and Actions. It is only when we are able to attend to our own feelings that we are able to distinguish Virtue and Vice; between moral good and evil [29]. In the same way that Bayle and Leibniz emerge at the conceptual antipodes regarding the origins of evil, the postulates of Jean-Jacques Rousseau [1712–88] are diametrically opposite, regarding the original state of man, to those of Thomas Hobbes. In his Second Discourse (1762) Rousseau claimed that the human condition derives from society, whereas in the ‘state of Nature’ Man was free and independent, healthy, happy, and innocent. Once a social condition develops, there was, Rousseau supposed, a fall from Nature, and with it a corruption of the once ‘noble savage.’ Here Rousseau was mistaken, for there is not a shred of anthropological evidence to support his claim. But there was certain grandeur to his error: scientifically mistaken, but politically correct – for his time. It was not hard to see evils (social evils, in this case) in Rousseau’s France, on the cusp of the up-coming revolution – if one contrasted the lot of the common man with that of the aristocracy. Hobbes may have been right about society in general, but Rousseau was right about the society in particular with which he was familiar. At all events, Rousseau deserved great credit, as Susan Neiman pointed out ([30], p. 41), for being the first to treat the problem of evil as a philosophical (one might even say, sociological), as opposed to a theological problem. Rousseau took the problem out of God’s hands and ‘put it squarely in ours’ ([30], p. 43). Evil did not require reference to supernatural forces, which meant in effect that evil is not a metaphysical problem; it is a human problem. Immanuel Kant [1724–1804] also rejected the notion of Original Sin –as an affront to our moral freedom [31], but retained a place for religion, given that religion underlines our duty to uphold moral values as divine commands. Christianity focuses on pride as the primary sin, which Kant regarded as ineradicable by human means. Kant distinguishes between selfconceit (Eigendunkel) and Self-Love (Eigenliebe), as the latter can be good insofar as it is controlled by ‘practical reason.’ He understood the evil that arises in the human heart as stemming from the subordination of what he called the Objective Law of Duty to (mere) happiness. Evil becomes one of the choices open to us via our free will. Man has a propensity [Hang] to evil (akin to Maimonides’ yetzer ha-ra), which must be combated through our ¨ bel becoming our own ‘moral sentries.’ Kant made a distinction between B€ose [evil] and U [bad, though it is the cognate for the English word evil]: evil actions are those which aim at the violation of the humanity of another person (such as murder, rape, torture). Whereas bad actions are those that might be harmful or disagreeable to one’s general well-being (e.g., delayed payment of a debt or failure to honor some other type of promise). While neither Kant nor other philosophers give detailed descriptions of individual case-histories embodying evil actions, he was aware that terrible crimes occurred, and remarked that ’great crimes are paroxysms, the sight of which makes one whose soul is healthy to shudder’ [32].
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Here is a comment that presages our contemporary, more emotional, use of the word evil, as pertaining to acts that are (to those who witness or experience them) breathtakingly inhuman. Georg Hegel [1770–1831] became famous for his dialectic triad of thesis, antithesis, and synthesis – inspired in part by the French Revolution. Hegel felt the latter movement could be understood as a burst into freedom for the masses (thesis), that then ushered in a reign of terror (antithesis) that led finally to a better post-revolutionary form of government based on freedom and equality (synthesis). As for his comments on evil, these are mostly to be found in his Philosophie des Rechts [33] – the German word conveying the meanings both of ‘right’ and ‘law.’ Hegel sought to establish a groundwork for morality centered on each person’s free will and humanity – within the context of our life as members, inevitably, of a social entity. The social entity, in turn, needed to be regulated by a superordinate morality, which for Kant (more so than for Hegel) necessitated the acceptance of God as the embodiment of that higher morality. What makes a person evil in Hegel’s view is the choosing of natural desires in opposition to the good ([33], section 40). Though Hegel does not give ‘case histories’ of evil, he does assert that there is an important distinction between crimes that attack the entire manifestation of one’s Will (i.e., of another person’s freedom and humanity), as in the instance of murder, slavery, or religious compulsion – in contrast to lesser crimes that invade less of the life-space of another person [34]. As for the matter of ‘free will,’ it is noteworthy that Hegel felt that the success of America (along with England and France) in the nineteenth century related in large part to the large numbers of Protestant dissenters who ‘created a tradition for a people who aspired to create libertarian societies’ ([35], p. 172). The point here is that the dissenters exercised greater freedom to think for themselves and to stress their individuality – in contrast to those who adhered to monolithic systems of thought and belief, like the Catholics and Muslims. For Arthur Schopenhauer [1788–1860], irritable, embittered, pessimistic, this was, in his 180 turn from Leibniz, the worst of all possible worlds – where pleasure was the exception in human life; pain, the rule. As he concluded in his most important work, Die Welt als Wille und Vorstellung ([36] The World as Will and Representation), the Will is equated with effort and desire, which is ultimately painful and ‘evil.’ Pain arises from the desire to have – and then not having. After a brief satisfaction with one’s desire there is momentary pleasure – and then the emergence of new desire and new pain. Selfishness or egoism (narcissism, in our language) was for Schopenhauer, universal: the egoist seeks his own advantage and is ready to strike down those who oppose him. His Weltanschauung resonates in this way with Hobbes’ ‘war of all against all.’ Schopenhauer recognized that the attachment to life that characterizes all living forms makes understandable our horror in reaction to murder – as the maximal violation of our inherent will-to-live. Toward the end of life Schopenhauer embraced Buddhism, by virtue of its preaching deliverance from Self – unlike the egoist: the malicious man who thinks only of himself. The year before Schopenhauer’s death coincided with the publication of Darwin’s Origin of Species. Darwin, though of course not a philosopher, gave new meaning to the kind of existential struggle for survival alluded to by Hobbes and Schopenhauer. Putting this struggle on a scientific footing for the first time, Darwin drew attention to natural selection. Herbert Spencer five years later used the term ‘survival of the fittest.’ Some took this to mean that brute force triumphed over weakness, applying the idea to our species as well as to the other animals. But Darwin was not arguing that evil won out over the good, particularly as he held that the ethical life (among men) is different from the life in (the rest of) Nature. It is the
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ethical life that brings us out of the state of all-against-all warfare and leads us to peace. In our own generation it has become clear through the work of evolutionary psychiatry – that as a group species we also harbor genes that promote compassion and altruistic behavior. As James Wilson has put forward [37], we would not have survived as a species if we did not possess, alongside our aggressive tendencies, other innate, gene-driven tendencies that promote moral sentiments: sympathy, fairness, self-control, and (here, James cited Kant) duty. Viewed in this light, evil can be seen as an exaggeration of our aggressive tendencies; good – as a manifestation of our adherence to the moral sentiments outlined by Wilson. In this schema religion no longer has any explanatory value vis-a-vis evil, though it retains its value as a promulgator and advocate of the moral sentiments by which our lives should be guided. Darwin’s new theory did not sweep away all at once the religion-based explanation for evil. Søren Kierkegaard [1813–55], for example, though born after Darwin, died before the Origin was published. Still ensconced within traditional Christianity, he understood sin as rooted in Willing. Sin (and hence evil) occur when a person refrains from doing what is right even though he understands what is right [38]. For Friedrich Nietzsche [1844–1900] God played no role in the causation of evil, which, he argued, was to be understood in purely human terms. ‘Being evil’ was ‘being not moral,’ practicing immorality, resisting tradition – however reasonable or stupid tradition might be. Nietzsche recognized that ‘harming the neighbor,’ however, was felt to be preeminently harmful in all the moral laws of different ages ([39], #96). Though Nietzsche endorsed the idea of the will to power as the basis of human nature (a view in sympathy with that of Schopenhauer), he also spoke of ‘resentment’ as a key emotion in those whose quest for power was denied them. This resentment, Nietzsche saw as resulting from the ‘corruption of human nature’ that was encouraged by religion in general, specifically by Christianity ([40], p. 262) – a pretty radical departure from beliefs of Nietzsche’s Lutheran father, grand¨ bermensch fathers, and great-grandfather. His much-misunderstood concept of the U [‘Superman,’ or ‘Overman’) was totally unrelated to the notion, as hijacked by the Nazis, ¨ bermensch was the creative artist who lives ‘beyond good of a superior race. Nietzsche’s U and evil’ (as popularly conceived): the powerful man, that is, who has mastered his passions and risen above the mediocrity of everyday existence [41]. At all events, Nietzsche took the concept of evil far away from the religion-based explanations (the theodicies of Leibniz and others), adopting a much more relativistic notion of what constituted evil. Apart from harming one’s neighbor, that is, certain acts or tendencies might be regarded as evil in one culture or one context, but not so in another culture or context.
1.1.8 MODERN CONCEPTIONS OF EVIL. THE INFLUENCE OF PSYCHIATRY & NEUROSCIENCE During the last century the ways of defining and understanding evil have been left less in the hands of theologians and philosophers; much more, in the hands of experts in psychology and psychiatry, including those in the field of neuroscience. There has been increasing recognition that evil is a purely human phenomenon, and that the place to look for its site and origins is not in the heavens but in the human brain. Even the question ‘what is evil?’ is recognized as an erroneous question, since it presupposes there is some ineffable substance that corresponds to the substantive [i.e., the noun] ‘evil,’ or that there is some one-size-fits-
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all definition that is universally acceptable. Instead, a more meaningful approach is to adopt the standard proposed by the Austrian philosopher Wittgenstein [1889–1951], who took the position that the meaning of a word is its usage [42]. Viewed in this light, we look to the way in which people in ordinary life, as well as the ways in which journalists and others in the media, employ this term. It turns out that we reserve the word ‘evil’ in everyday life for actions that evoke the emotion of horror: acts that are breathtakingly horrible because of the intense suffering to which the victims are subjected, the outrageousness of the acts, their heinousness or depravity – especially if the acts were prompted by scheming (malice aforethought) of a ‘diabolical’ nature (implying the intention to hurt in a particularly cruel and sadistic manner). Thus, a man who kidnaps a child, whom he then violates sexually, and afterwards strangles and dismembers – is readily identified as having committed an evil act. And if he has committed a string of such acts over time, with every intention of repeating such behavior if given the opportunity – people will often apply the word evil to the man himself: he is an evil person. Perhaps the only philosopher to draw attention to this way of thinking about evil: as that which is breathtakingly awful – is Susan Neiman [30]. Persons who are apprehended by the authorities for having committed acts of these kinds will usually be incarcerated in prisons or, if mental illness had been a key factor in the commission of the act, will be mandated to a forensic hospital for observation and treatment. In either situation, a forensic psychiatrist may be summoned to evaluate the offender – as to whether he or she is mentally ill, or is instead in the grips of a personality disorder, such as antisocial or psychopathic personality. It is uncommon for people to use the word evil in reference to crimes (such as financial swindles) that do not involve violence or intense psychological harm (as by extreme humiliation, subjugation, or unlawful imprisonment). Furthermore, one seldom refers to a person as evil (in contrast to particular acts of violence), unless the person has engaged habitually and for an extended period of time in acts of unusual cruelty. Many men committing serial sexual homicide, and some repeat-rapists, fall into this category, especially where there is an element of torture of the victim(s). Descriptions of such persons can be found in numerous books and articles by forensic psychiatrists and psychologists [43–46]. Buss, writing from the perspective of evolutionary psychiatry, focuses on those brain mechanisms that subserve aggression and defense against threats to one’s survival: mechanisms that under certain circumstances can operate in a grossly exaggerated manner – leading to extreme acts of violence of the sort to which the public will apply the label ‘evil.’ Egger, Stone, and Ward et al. enumerate the background factors in men committing serial sexual homicide, some of whom subject their victims to prolonged periods of torture, earning thereby the label of ‘evil person.’ The background factors conducing to violence in general: genetic predisposition to psychopathy, parental neglect or cruelty, hormonal factors, head injury with unconsciousness, drug abuse, etc. – have been discussed in detail by Debra Niehoff [47]. In an outstanding book written by a survivor of an attempted murder by an axe-wielding psychopath, Terri Jentz [48] defined as an act of evil: ‘when an act ruptures all categories of comprehension’ (p. 516), elsewhere describing her ‘belief in the existence of utter evil as a modern revision of Manicheanism,’ based on her study of gratuitous cruelty in the twentieth century (p. 512). Even more poignantly is her comment about her would-be assassin, whose sadism was in no way confined just to her and her friend (who was blinded by this axe wielder): ‘I was astonished at the many searing memories this one man had ignited in so many people. . . Was this evil’s strategy, to perform breathtakingly brutal acts that so shocked the nervous system and
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overwhelmed the brain that these traumatic events were not integrated into consciousness, but left disturbing, damaged mosaics of unassimilated memories?’ (p. 509). The inadvertent spokesman for the general public and its use of the word, Jentz has left us with as accurate a depiction of evil as we are likely to find in the lay literature. In the psychiatric literature the term evil occurs very seldom. Freud, when writing of his celebrated case, the Wolf Man [49], mentions the patient’s dissatisfaction with God, leading to his own strange theodicy, according to which: ’If He were almighty, then it was His fault that men were evil, wicked and [that they] tormented others. . . He ought to have made them good; He was responsible for all the wickedness’ (p. 62). In his Introductory Lectures [50] Freud speaks of our dream-life – in which the Ego, freed from all ethical bonds, finds itself at one with all the demands of sexual desire, even those which have been condemned by our ethical upbringing; lusts we think of as remote from human nature show themselves. . .. These censored wishes appear to rise up out of a positive Hell’ (p. 142). A` propos Freud, the interconnections between religious thought and the development of his psychoanalytic theories are discernible, albeit subtle and complex. Among his ancestors were rabbis and Hasids, but his father, Jakob, broke away from the stricter practices and traditions of his forebears, while retaining great pride in his Jewish heritage and his familiarity with Yiddish and Hebrew. Sigmund grew up still less familiar with Jewish observance, though retaining throughout his life a ‘Judaism without religion’ ([51], p. 6). Toward the end of his life, Freud wrote his controversial Moses and Monotheism – which angered both observant Jews and Christians (as Spinoza had managed to do, years before, with his equation of God with Nature). Freud likened Moses to the first Messiah, and saw Christ as reborn as a resurrected Moses – transfigured as the Son in the place of his Father ([52], p. 114). Freud’s biographer, Peter Gay, tells us that Freud spoke with his friend, Lou Andreas Salome in 1935, mentioning that ‘The figure of Moses . . . had haunted him all his life,’ adding that Freud had compared Jung to Joshua – ‘who would take possession of the promised land of psychiatry while he, Freud, the Moses, was destined to glimpse it only from afar’ ([52], p. 605). So far we have commented on Freud’s complex relationship to his Jewish origins. But the impact of his religious background upon his practice of psychiatry is less readily detectable. There is some fairly compelling evidence for a more direct influence, however, in two related areas. Two of the ’pillars’ of psychoanalysis are free association and dream analysis, both crystallizing in Freud’s mind in the 1890s. David Bakan [53] makes the case that Freud’s exposure to the Hasidic and Kabbalistic background of his grandparents’ generation set the stage for his discovering the value of ‘free association’ as a method of gaining access to deeper layers of reality. Freud may well have been aware, for example, of his thirteenth-century coreligionist – the Spanish-Jewish mystic philosopher from Saragossa: Abraham Abulafia. As part of his method of achieving a trance-like state in which he felt in closer touch with God, by unsealing the soul and untying the knots which ] – which meant jumping or bind it (Bakan, p. 76) was through the practice of k’fitsah [ skipping from one thought to another, till he was able to escape the quotidian, and reach ever more lofty and spiritual levels. Abulafia induced this state in himself in the quest of a religious goal. Freud appears to have transformed this method in the quest of a psychiatric goal; namely, that of gaining access to hidden layers in the psyche of his patients, with the ultimate goal of liberating them from their neurotic conflicts. The second pillar – dream analysis – represents an interest of long-standing in Jewish tradition, as noted in the Old Testament story of Joseph (Genesis 41: 1–37), and in the Moreh Nevuchim (Guide to the Perplexed) of Maimonides. But dream-interpretation before Freud tended, with a few
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exceptions, to stereotyped and sterile; the results, unconvincing. Dream dictionaries were popular, in which common dream elements were said to have certain specific meanings. Aside from the genius of the poet, Pushkin, who gave his heroine, Tatyana, a dream which had the effect of warning her against marrying the ‘gloomy and dangerous crank,’ Evgeny Onegin (a full 60 years before Freud’s Traumdeutung/The Interpretation of Dreams) – there was almost nothing in the earlier dream literature that hit upon the psychological meaning of the dream, unique to each dreamer. It was Freud’s genius that paved the way to unlock these highly individual meanings – via his patients’ own free associations to their dreams. Granted there are culturally determined, rather common symbols: bottles are often female genitals; snakes are often penises – but not always. In the dreams of one of my analytic patients from many years ago snakes kept cropping up. From her associations it became clear the snakes did not represent her boyfriend’s organ; instead, they led her to think about his sister – an intrusive and highly critical woman who kept trying to interfere in their relationship. None of the old dream-dictionaries would have led one to this conclusion. The relationship of Carl Gustav Jung (1875–1961) to religion was quite different from that of his erstwhile mentor, Freud. Jung’s father was a Swiss pastor; Jung himself throughout his life was preoccupied with mystical themes, astrology, and spiritism (the latter prompted by the spiritistic trances he witnessed in his 15-year-old maternal cousin, Helene, when he was a young man). During his youth, Jung once saw an eighteenth-century carriage, and imagined that he had a memory of it in a previous life ([54], p. 664). During the period of the Great War, Jung became intrigued with Gnosticism, not only for its emphasis on knowing, but on its interest in the problem of evil ([54], p. 719). Equally interested in dreams as Freud was, Jung, once he became a psychiatrist, developed a different technique. He took to writing his dreams down, then telling himself stories stimulated by the dream images, and encouraging fantasies to arise in his mind, as an outgrowth of these mental pictures. Next, Jung would draw the resulting images on paper. He began this practice in 1913. It was out of these exercises that his theory of archetypes emerged. He believed that there existed a set of universal, primordial images – the archetypes – embedded in the unconscious of every person. Various coincidences convinced Jung of this proposition, such as the similarity of a hallucination (of a phallus suspended from the sun, that produced the wind) mentioned to him by a schizophrenic patient – to an early Greek text that spoke of a tube hanging from the sun that set the winds in motion ([54], p. 705). These impressions led Jung to speak of a ’collective unconscious.’ He later used the terms collective subconscious and then the objective psyche, by which he referred to what he believed was a reservoir of the experiences of human beings as a species – by virtue of its being common to everyone. Practitioners in contemporary psychoanalysis and psychiatry, apart from those who are adherents to Jung’s psychology, do not accept the notion of a collective unconscious. There is another concept that Jung developed that relates to the subject of evil. The set of personal characteristics that a person wishes to conceal from others, even from himself, Jung called the ‘shadow.’ Jung further postulated that the more someone tried to keep this shadow hidden, the more the shadow becomes active, predisposing to evil actions. Further, Jung imagined that the shadow could, especially under the influence of alcohol or other mindaltering agents, become the predominant force in the individual, leading to hitherto unsuspected levels of evil. Robert Louis Stevenson’s 1886 classic, Dr. Jekyll and Mr. Hyde, may be understood as a parallel in novel-form to Jung’s shadow. Consistent with Jung’s beliefs in archetypes, collective unconscious, shadows, and the like – is his religious faith. Toward the end of his life, in a 1955 interview with a journalist, Jung stated that ‘God is
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the voice of conscience speaking within us,’ adding that he had an ‘unshakable conviction of the existence of God. . . I do not take His existence on belief – I know that He exists’ ([54], p. 726). It is easy to see why Freud and Jung eventually parted ways, given that the religionbased views of Jung, expressed rather in poetic than in scientific language, were quite alien to Freud, who retained his biological foundation and his antipathy to organized religion to the end, even while pursuing similar psychoanalytic pathways as did his younger counterpart. Jung’s psychology, in this respect, offers analogies to whatever it is in us that leads to evil action, but does not have the kind of explanatory value that would give it purchase in the field of science, including in the domain of forensic psychiatry. What contemporary psychiatry can now provide by way of explaining the phenomenon of evil, as defined in popular usage – is the following: (a) commonalities can be discovered when one looks at a large number of detailed case histories of persons whose acts have been described as ‘evil,’ (b) study of the brain, via functional magnetic resonance imaging and other techniques, can reveal differences in the brains of such persons, when compared with the brains of ordinary persons. I refer here only to evil acts committed in peacetime, since it is well known that in wartime many ordinary men suddenly find themselves capable of cruelties which would be most foreign to their lives before and after their participation in warfare. As for the commonalities among persons with a penchant for committing evil acts, there are two in particular that stand out. One group consists of serial killers intent upon torturing their victims. From a diagnostic standpoint these persons (the vast majority of whom will be men) exemplify the confluence of psychopathy and sadistic personality. The main personality traits of the psychopath, as defined by Robert Hare and his colleagues [55] are glib speech (insincerity), grandiosity, lying, manipulativeness, callousness, lack of empathy and remorse, and inability to take responsibility for one’s actions. The main traits of sadistic personality as outlined in DSM-III-R [56] consist in the enjoyment of another’s suffering, humiliation, and subjugation of others [57]. Another group consists of persons, outside the domain of serial homicide, who scheme (‘with malice aforethought’) to subject another to extreme pain and/or death – as witnessed in the cases of certain men who stage the death of their wives in order to make their deaths appear accidental, or who make plans to hide their bodies in hopes of rendering their death an uncertainty (as in the case of Scott Peterson, who killed his pregnant wife and threw her body into the ocean [58]). Neuroscientists do not use the word evil in their reports, but considerable research has recently been carried out on brain activity in persons whose violent crimes have inspired the word evil in everyday discourse. Much of this research has been summarized in the book about psychopathy of James Blair and his colleagues [59]. One common underlying factor concerns brain-differences in psychopaths that diminish their capacity for empathy; specifically, for feeling compassion for the suffering of others. Absent this capacity, the possibility of inflicting torturous suffering on others becomes greatly enhanced. This is reflected in the commission of acts that the public experiences as ‘evil.’ Specific regions of the brain that communicate with one another in determining what behaviors emerge in response to particular urges or stresses have been outlined by Kalivas and Volkow [60] in their paper on pathways relevant to addiction. Their model is pertinent as well to other maladaptive behaviors, including those related to violent crime. The key regions in this schema involve a memory system, subserved by the amygdala, in touch with prior experiences (including those of harm done to the individual by early caretakers). This region communicates with another – the dopamine-dependent nucleus accumbens – that
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weighs the salience (degree of desirability) of various behavioral options. Both these regions are important parts of what is often called the ‘bottom-up’ brain mechanisms, and concern our basic drives [61]. Final decisions regarding action (that is, what we actually end up doing in any given situation) are the function of the ‘top-down’ mechanisms. A controlmechanism mediated by the anterior cingulate gyrus exerts either a weak or a strong control upon the various options being considered. Finally the orbitofrontal cortex, integrating all this information, either allows the most favored option to go forward into actual behavior – or decides against it, thwarting the behavior. A man struggling with the temptation to kidnap and rape a child (which would end up as an evil act, if consummated) may think of how that child might feel, or might think about the consequences of getting caught and arrested – and then decide against this ‘desired’ behavior. Or his desire may be so strong as to override the ’braking’ mechanisms; his impulse-control may be so weak as to fail to inhibit the behavior. In these scenarios, the crime (the ‘evil’ act) will occur. As I mentioned at the beginning of the chapter, judgments about which acts are considered evil are made more easily in peacetime – by individuals and by the public – than is the case in situations of group conflict (as in riots or between gangs) or of full-scale war. The witness of inter-group strife, so characteristic of our species, reminds us of our origins as members of small tribes numbering perhaps 100 or 150 persons. Our brains have evolved over the approximately four million years since we split off from bonobos and chimpanzees to become hominids, gradually emerging as what Carl Zimmer has cleverly called (because we can talk and read) the gossiping ape [62]. To meet the multitudinous threats to survival in our early days, our brains became ‘wired’ for group affiliation and for aggressive defense against those who would harm us—whether the predators were sabertooth tigers or (more commonly) other people. Religion sprung up in every human society, presumably answering to vital needs and impulses peculiar to a distinctly social species such as our own. We cannot do without each other, and (all too often) we cannot get along with one another – especially when goods necessary to survival are scarce and when the conditions that make life secure and comfortable are seriously compromised. During times of adversity religion can play contrary roles: religion unifies and strengthens the bonds among members of a religious group, offering hope, and emboldening group action that fosters survival. But therein lay the rub. For at such times, religion may be used by one group to rally forces against a competing group, fomenting a war that is justified (in the eyes of the adherents of the warring group) against those who do not believe in the ‘true God’ of the group that has taken up arms. This conceit – that God stands behind only our group – helps explain the paradoxical situation in which the monotheistic Abrahamic religions, quickly separate into tribes (albeit large ones) in times of trouble. The followers of Jehovah, Christ, and Allah are suddenly at each other’s throats. This phenomenon becomes particularly acute during times of drastic change or drastic shortage. If the crisis is local, we see the emergence of religious cults, some of which are led by fanatics of remarkable cruelty. The Reverend Jim Jones in Guyana, David Koresh in Waco, Texas, and Jeff Lundgren, the breakaway Mormon leader in Kirtland, Ohio are examples. If the crisis involves whole nations or religious memberships, we see the emergence of religious armies, with a charismatic leader at the helm, poised to conquer another group or nation. If the army is strong, there will be war; if it is too weak to conquer outright, there will be terrorism. The red thread running through all these religion-inspired actions is fundamentalism. Two chief characteristics of such fundamentalism, as mentioned by Vamik Volkan in a recent address on psychoanalysis and religion [63], are a list of unchangeable doctrines adhered to by the believers, and their
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opposition to non-believers or to ‘lukewarm’ believers. By no means is fundamentalism regularly associated with violence. But under particular circumstances a group of believers may be energized by a charismatic and hate-filled leader, such that religious fundamentalism becomes the force by which violence is unleashed. Kernberg [64] made the point, in the immediate aftermath of 9/11, that the internal tensions of the jihadists (bemoaning the decline of Islam since the defeat in 1683 at the gates of Vienna, and the relative impoverishment in Dar al-Islam (the countries where Islam is the dominant religion) compared with the Western industrialist countries – are now displaced toward the outside, toward, that is, the ‘infidel’ West. Volkan has striven to create a bridge between the psychology of the individual, as emphasized in traditional psychoanalysis, and the psychology of the group – stressing how children are raised as fledgling members of a social group – with which they strongly identify, at the same time they develop, during the same formative years, a sense of personal identity. The admonitions and information imparted to children in their first half dozen years, creating both the individual and the group identities, become ‘hard-wired’ into brain circuitry, fostering automatic, unconscious responses. In certain groups, these responses may include such convictions as we the faithful of religion X are better than you people of religion Y and we are thus, through God’s favor, more deserving of the good things of the world than you. . . Like all thought-habits of long standing, these automatic responses are not easily overturned. The topic of religious fundamentalism and its psychology has been previously explored by Rene Girard [65] and summarized recently in the admirable article by Lord Alderdice of Northern Ireland [66]. Alderdice makes the point that the jihadist terrorists that figure so prominently in the current geopolitical scene are heavily indoctrinated, but are not mentally ill. The fundamentalist environment in which they were enveloped was one that predisposed to violent solutions. Many were educated in madrassas, memorizing the Qur’an, with its many references to the infidel and to the dire fate that awaited them (as in the long passage in Sura 5: 35–66). Saturated in a Good/Believer versus Evil/Infidel atmosphere, the step toward violence, when under the influence of a paranoid leader during socially disruptive times – is not a long one. One may note in contrast that in the Old Testament ‘infidel’ does not occur; the word is used in the New Testament just twice (2 Corinthians 6:15, and 1 Timothy 5:8). In neither reference is the (Christian) believer abjured to harm or to kill the infidel; merely to avoid association with the infidel. Psychiatry, as it turns out, has much of value in helping us to understand the mind-set of fundamentalists, as well as of those who become terrorists. But psychiatrists at the vanguard in this arena, such as Jerrold Post [67], Vamik Volkan, Otto Kernberg, John Alderdice, and also the historian-philosopher, Rene Girard, convey their excellent points to like-minded audiences; in effect, they preach to the converted. The fundamentalists, and the terrorists among them, do not listen. The most militant and disaffected among them continue to regard those who disagree with them as infidels and evil-doers. We are then apt to see a perversion of religion: religious leaders sanction actions that, ironically, the rest of the world regard as evil. Examples are legion: the Protestants and Catholics in Northern Ireland bombing each other’s houses, the Sunnis and the Shiites in Iraq bombing each other’s mosques, Hindus and Moslems in India destroying each other’s holy places, the jihadists bombing the Twin Towers and cafes in Tel-Aviv, or slitting the throat of journalist Daniel Pearl in Karachi (February 1st, 2002) – because he was a Jew. The date is of interest to me: I was in Karachi 20 years earlier to the day, living as a Jewish psychiatrist in the home of Moslem psychiatrist colleagues, lecturing on my topic of ’borderline personality,’
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and attending many Moslem weddings. It was a different time. When religion is hijacked and made into a pretext for war and atrocities, we may, as psychiatrists, correctly diagnose that calamity as a sign that a large group of people has come to feel humiliated, disenfranchised, dealt out of the chance to have the good things of life: dignity, adequate food, satisfactory work, the pursuit of happiness. Military action may be necessary as an unfortunate first step. Ultimately the excesses of fundamentalism, and the terrorism it may spawn, can be corrected only politically: by helping in whatever way possible to improve the lives of the group whose cause was spearheaded (literally) in the first place by the fundamentalists and their terrorist cohorts. In this great task, psychiatry can play only an advisory role, helping to educate political leaders as to what the social ‘disease’ had been, and what might be its most likely cure. Equally important as an antidote to religious fundamentalism, when it has gotten out of hand, is the voice of the ‘lukewarm’ believers, the moderates, who show, instead of paranoid hatred and fanaticism, tolerance and the warm acceptance of others. More such voices are beginning to be heard. An outstanding example is that of the Moslem writer, Irshad Manji. She has shown the courage to criticize the jihadists within Islam in her widely read The Trouble with Islam Today [68]. And Salman Rushdie has outlived the fatwa leveled against him by Ayatollah Khomeini. I was privileged to hear Rushdie address a large audience two years ago, where he could speak freely, and where it was not even necessary for the public to pass through metal detectors. There is hope. In summary, religion and philosophy no longer have a meaningful role in explaining the causes of evil, though they of course retain an important role in setting forth the guidelines for appropriate moral values and acceptable behaviors. For clues concerning causation, we must turn instead to psychiatry, psychology, and neuroscience. Age-old conundrums as to whether humans are inherently good or inherently evil fall by the wayside, as we become aware that our genetic givens and our brains are equipped with the mechanisms for both altruistic/ cooperative interactions – and for narcissistic or aggressive interactions. This position was already championed long ago by the Moslem empiricist historian of culture – ibn Khaldun [1332–1406]. Unhappy with the abstract and metaphysical arguments of theologians and philosophers, ibn Khaldun relied on what he could actually observe in societies. He recognized that ‘evil qualities’ existed in man – such as injustice and aggression, which were ’natural’ to human beings, yet compassion and affection were also part of our human nature – in such measure that we were more inclined to the good than to the bad [69, 70]. Which behaviors are favored, as we now realize, are dependent upon a host of factors: heredity, constitution, gender, early rearing, culture, brain damage, involvement with drugs that lower impulse-control, etc. When aggressive actions pass a certain socially-acknowledged boundary-line and pass into the grotesque and the heinous, we have entered the realm of evil. As one of their functions, religion and philosophy deplore such actions. To understand evil actions – is the domain of sciences that explore the workings of the human brain.
REFERENCES 1. Scharfstein B-A (1998) A Comparative History of World Philosophy. Albany, NY: State University of New York Press. 2. Boyce M (1984). Textual Sources for the Study of Zoroastrianism. Chicago: Chicago University Press.
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3. Forsyth N (2002). The Origin of Evil. Perspectives on Evil 1: 17–52. 4. Williams JN (1988) Confucius, Mencius, and the notion of the true succession. Philosophy East & West 38, 157. 5. Plato (1973) Phædrus & Letters VII and VIII. Walter Hamilton, tr. London: Penguin Books. 6. Aristotle (1955) Nicomachean Ethics. JAK Thomson, tr. London: Penguin Books. 7. Mendelson M (2000) St. Augustine. The Stanford Encyclopedia of Philosophy. 8. Augustine St Aurelius (2007) Confessions. AC Outler & M Vessey, trs. New York: Barnes & Noble Classics. 9. Butterworth CE (2007) Ethical and political philosophy. In The Cambridge Companion to Arabic Philosophy. P Adamson & RC Taylor (editors), 4th edit. New York: Cambridge University Press, pp. 266–286. 10. Goodman LE www.muslimphilosophy.com/ei2/razi.htm. 11. Fakhry M (2002) Al-Farabi: Founders of Islamic Neoplatonism. Oxford: One World. 12. Rizvi SH (2006) Avicenna/IbnSina. www.iep.utm.edu/a/avicenna.htm. 13. Fakhry M (2004) A History of Islamic Philosophy. 3rd edn. New York: Columbia University Press. 14. Durling RM Translator & Editor (1996): The Divine Comedy of Dante Alighieri: vol. I: The Inferno. New York: Oxford University Press. 15. Seeskin K (2000) Searching for a Distant God: The Legacy of Maimonides. New York: Oxford University Press. 16. Maimonides (1956) A Guide for the Perplexed. M Friedlander, tr. New York: Dover Press. 17. Oesterle JA & JT (1995) On Evil: St. Thomas Aquinas. Notre Dame, Indiana: Univ of Notre Dame Press. 18. Loyola St. Ignatius (1997) Personal Writings. JA Munitiz, ed. & tr. New York: Penguin Books. 19. Vives JL (1538/1553) De Anima et Vita. Basel: Johann Oporinus. 20. Boehme J (1648) Concerning the Three Principles of the Divine Essence. J Sparrow, tr. London: H. Blunden [reprinted: KessingerPublishing]. 21. Hobbes T (1651/1968) Leviathan. CB Macpherson, editor. London: Penguin Books. 22. Descartes R (1650) De Passionibus. Amsterdam: Elsevier. 23. Spinoza B (1989) Tractatus Theologico-Politicus. S Shirley, tr. Leiden: Brill. 24. Spinoza B (2000) Ethics. G. H. R. Parkinson, ed. & tr. New York: Oxford University Press. 25. Bayle P (1697/1991) Historical and Critical Dictionary. RH Popkin, tr. Indianapolis, Indiana: Hackett Publishing Company. 26. Edwards P (2003) Pierre Bayle: 1647-1706. Free Inquiry 23 (summer issue): 55ff. 27. Leibniz GW (1988). Theodicy. AM Farrar, ed.; EM Huggard, tr. Chicago, Illinois: Open Court Publishing. 28. Voltaire FMA (1756/1994) Poem on the Lisbon Disaster. In – A Treatise on Toleration and Other Essays. Amherst, New York: Prometheus Press. 29. Hume D (1740/2000) A Treatise on Human Nature. DF & MJ Norton, eds. Oxford, UK: Oxford University Press. 30. Neiman S (2002) Evil in Modern Thought. Princeton, New Jersey: University of Princeton Press. 31. Lilla M (1998). Kant’s theological-political revolution. Review of Metaphysics 52: 397ff. 32. Garcis EV (2002). A Kantian theory of evil. The Monist 85: 194ff. 33. Hegel GWF (1821/1952) The Philosophy of Right. TM Knox, tr. New York: Oxford University Press. 34. Rayburn HA (1921) The Ethical Theory of Hegel: A Study of the Philosophy of Right. Oxford, UK: Clarendon Press. 35. Harris L (2007) The Suicide of Reason: Radical Islam’s Threat to the West. New York: Basic Books. 36. Schopenhauer A (1819–1859/1966) The World as Will and Representation. 2 vols. EFJ Payne, tr. New York: Dover Publications.
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37. Wilson JQ (1993) The Moral Sense. New York: The Free Press/Macmillan. 38. Kierkegaard S (1849/1980) Sygdommen til Døden (Sickness unto Death). A Hanny, tr. London: Penguin Books. 39. Nietzsche FW (1878) Human, All Too Human. RJ Hollingdale, tr. Cambridge: Cambridge University Press. 40. Blackburn S (1994) The Oxford Dictionary of Philosophy. New York: Oxford University Press. 41. Nietzsche FW (1887/1966) Jenseits von Gut und B€ ose (Beyond Good and Evil). W Kaufman, tr. New York: Randon House/Vintage Books. 42. Wittgenstein L (1953) Philosophical Investigations. GEM Anscombe, tr. Oxford, UK: Basil Blackwell. 43. Buss D (2005) The Murderer Next Door: Why the Mind is Designed to Kill. New York: Penguin Books. 44. Egger SA (2002) The Killers Among Us: An Examination of Serial Murder and its Investigation. Upper Saddle River, New Jersey: Prentice Hall. 45. Stone MH (2001) Serial sexual homicide: Biological, psychological and sociological aspects. Journal of Personality Disorders 15, 1–18. 46. Ward T, Polaschek DLL, & Beech AR (2006) Theories of Sexual Offending. Chichester, UK: John Wiley & Sons. 47. Niehoff D (1998) The Biology of Violence. New York: The Free Press. 48. Jentz T (2006) Strange Piece of Paradise. New York: Farrar, Straus & Giroux. 49. Freud S (1918). From the History of an Infantile Neurosis. S. E. XVII, pp. 3–122. London: The Hogarth Press. 50. Freud S (1916). Introductory Lectures on Psychoanalysis. S. E. XV. London: Hogarth Press. 51. Gay P (1988) Freud: A Life for Our Time. New York: W.W. Norton. 52. Freud S (1938) Moses and Monotheism. S. E. XXIII, pp. 3–137. 53. Bakan, D. (1990) Sigmund Freud and the Jewish Mystical Tradition. London: Free Association Books. 54. Ellenberger HF (1970) The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry. New York: Basic Books. 55. Hare RD, Harpur TJ, Hakstian AR, Forth AE & Hart SD (1990). The Revised Psychopathy Checklist: Reliability and factor structure. Psychol. Assessment 2: 338–341. 56. Diagnostic & Statistical Manual of Psychiatric Disorders, 3rd edn., revised [DSM-III-R] (1987). Washington, DC: American Psychiatric Press. 57. Stone MH, Butler J & Young K (2009) Sadistic Personality. In: Blaney PH & Millon T (eds.) Oxford Textbook of Psychopathology, 2nd edn. Oxford University Press, New York, pp. 651–670. 58. Linedecker C (2003) The Murder of Laci Peterson. DesMoines, Iowa: America Media Inc. 59. Blair J, Mitchell D & Blair K (2006). The Psychopath: Emotion and the Brain. Malden, Massachusetts: Blackwell Publishing. 60. Kalivas PW & Volkow ND (2005). The neural basis of addiction: A pathology of motivation and choice. Amer J Psychiatry 162: 1403–1413. 61. Siever LJ (2008) Neurobiology of aggression and violence. American Journal of Psychiatry 165, 429–442. 62. Zimmer C (2001) Evolution: The Triumph of an Idea. New York: Harper Collins. 63. Volkan V Psychoanalysis and Religion. (Power-Point presentation: www.acopsa.org/acopsa_ assets/ReligiousFundamentalismandViolenceDD.pdf). 64. Kernberg OF (2001) The psychology of religious fundamentalist ideologies. Presented at the New York Academy of Medicine, October 30th. 65. Girard R (1972). Violence and the Sacred. Baltimore: The Johns Hopkins Press. 66. Alderdice John Lord (2008) On the psychology of religious fundamentalism. www. medicalnewstoday.com/articles/113876.php.
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67. Post JM (2007) The Mind of a Terrorist: The Psychology of Terrorism from the IRA to al-Qaeda. New York: Palgrave Macmillan. 68. Manji I (2005) The Trouble with Islam Today. New York: St. Martin’s Press. 69. Ibn Khaldun (1967) The Muqaddimah: An Introduction to History. F Rosenthal, tr.; NJ Dawood, ed. Princeton, New Jersey: Bollinger Series/Princeton University Press. 70. Baali F (1988) Society, State, and Urbanism: Ibn Khaldun’s Sociological Thought. Albany, New York: State University of New York Press. 71. Aquinas St. Thomas (2002) Summa Theloogica [shorter version]. C Vollert, tr. Manchester, New Hampshire: Sophia Institute Press. 72. Steel C (1994) Does evil have a cause? Augustine’s perplexity and Thomas’s answer. The Review of Metaphysics 48, 251–273.
CHAPTER 1.2
Linguistic Analysis and ValuesBased Practice: One Way of Getting Started with Some Kinds of Philosophical Problems at the Interface Between Psychiatry and Religion Bill (K.W.M.) Fulford Professor of Philosophy and Mental Health, United Kingdom
1.2.1
INTRODUCTION
The sub-title of this chapter borrows from a note that a former White’s Professor of Moral Philosophy, J. L. Austin, wrote to himself on the papers for one of his Saturday morning seminars in 1950s Oxford. The note, as cited by one of Austin’s literary executors, the late Sir Geoffrey Warnock, spelled out that linguistic analysis should be understood at most as ‘just one way of getting started with some kinds of philosophical problem’ [1, p. 6]. As the master of aphorisms, Austin’s words capture everything that I want to say in this chapter. First, linguistic analysis. As a way of ‘getting started’ with philosophical problems, linguistic analysis, as developed by Austin and others in what has become known as the ‘Oxford School,’ focuses particularly on conceptual problems. This is what makes it relevant to a wide range of conceptual problems in medicine, including, as I will illustrate with a detailed case history in the first part of the chapter, conceptual problems arising at the interface between psychiatry and religion. Second, values-based practice. The second part of the chapter moves from theory to practice by exploring the role, specifically, of a new skills-based approach to working with complex and conflicting values that builds directly on the work of Austin and others in the Oxford School. As we will see, values-based practice, as this skills-based approach has come to be called, takes us a little beyond just ‘getting started’ at least at the level of practice: Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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it offers well-developed policy, training and research resources to support more effective practical engagement with the problems at the interface between psychiatry and religion. Third, the caveats. The motivation for Austin’s note to himself was the persistent attempts, by critics and supporters of linguistic analysis alike, to try to make too much of the approach. Hence it is with the caveats that we will be concerned in the third part of the chapter. Certainly, linguistic analysis and values-based practice together offer rich resources (theoretical and practical) for tackling the problems arising at the interface between psychiatry and religion. But as we will see, these resources, echoing Austin’s words, amount to only one way of tackling these problems (many other disciplines, philosophical and empirical, may also be relevant); they offer, at most, only a way of getting started with these problems (they leave much else to be done); and, in all this, the resources of linguistic analysis and values-based practice are relevant only to some kinds of philosophical problem (namely, those conceptual problems that arise from the impact on practice of complex and conflicting values). We should not be too modest here, however. Psychiatry may have done little more than ‘get started’ with the philosophical problems at the interface between psychiatry and religion. But in this, as I will indicate in the conclusions to the chapter, psychiatry is leading the way towards a model of healthcare that is not only firmly science-based but also fully responsive to the values, including the religious and spiritual values, of individual patients and their families.
1.2.2 LINGUISTIC ANALYSIS AND PHILOSOPHICAL PROBLEMS AT THE INTERFACE BETWEEN PSYCHIATRY AND RELIGION As a way of exploring conceptual difficulties, linguistic analysis involves, in another of Austin’s aphorisms, ‘philosophical field work’ [1, p. 25]. As its name implies, philosophical field work is a quasi-empirical approach to exploring meanings. Standardly, philosophers have worked largely by reflecting directly (albeit deeply and rigorously) on the meanings of words. Austin and others in the Oxford School, argued that at least with some kinds of philosophical problem, it would be more effective if philosophers went out and looked at how the concepts with which they were concerned are actually used in real life situations. The focus on use of concepts is one of the reasons why linguistic analysis is particularly relevant to philosophical problems arising in practical disciplines like psychiatry: the conceptual difficulties we face, including difficulties arising from the concept of mental disorder itself, far from being matters merely of theoretical interest, are right at the heart of our day-to-day practice with individual patients and their families. Hence linguistic analysis, in focusing on the use of concepts in everyday discourse, engages with these problems at precisely the right practical level. Linguistic analysis is also patient-focused. Thus, in his most explicitly methodological paper, ‘A Plea for Excuses’ [2], Austin explored legal cases drawing on the transcripts of court reports. Towards the end of this paper, however, he pointed philosophers to the importance of psychiatric case histories, saying of psychopathology that ‘there is gold in them thar hills!’ [2, p. 24]. Sadly Austin died relatively young, and it was left to others in the Oxford School such as Jonathan Glover [3] and Kathleen Wilkes [4], anticipating the emergence of the interdisciplinary field of philosophy and psychiatry in the 1990s [5], to take his ideas forward.
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We turn, then, with Austin’s emphasis on the importance of case histories for philosophical research in mind, to a case example, The Story of Simon. I will set Simon’s story out in some detail. As Austin would have anticipated, this will take us directly not only to the conceptual problems arising at the interface between psychiatry and religion, but also, in the next part of the chapter, to some of the ways of getting started with tackling these problems in practice.
1.2.2.1
The story of Simon
Simon (40) was a senior, black, American professional, from a middle-class, Baptist family. Before the onset of his symptoms, he reported sporadic, relatively unremarkable, psychic experiences. These had led him to seek the guidance of a professional ‘seer,’ with whom he occasionally consulted on major life events and decisions. Around four years before the first interview, his hitherto successful career was threatened by legal action from his colleagues. Although he claimed to be innocent, mounting a defense would be expensive and hazardous. He responded to this crisis by praying at a small altar which he set up in his front room. After an emotional evening’s ‘outpouring,’ he discovered that the candle wax had left a ‘seal’ (or ‘sun’) on several consecutive pages of his bible, covering certain letters and words. He described his experiences thus. ‘I got up and I saw the seal that was in my father’s bible and I called X and I said, you know, ‘something remarkable is going on over here.’ I think the beauty of it was the specificity by which the sun burned through. It was . . . in my mind, a clever play on words.’ Although the marked words and letters had no explicit meaning, Simon interpreted this event as a direct communication from God, which signified that he had a special purpose or mission. From this time on, Simon received a complex series of ‘revelations’ largely conveyed through the images left in melted candle wax. He carried photos of these, which left most observers unimpressed, but were, for him, clearly representations of biblical symbols, particularly from the book of Revelation (the bull, the 24 elders, the arc of the covenant, etc). They signified that ‘I am the living son of David . . . and I’m also a relative of Ishmael, and . . . of Joseph.’ He was also the ‘captain of the guard of Israel.’ He found this role carried awesome responsibilities: ‘Sometimes I’m saying - O my God, why did you choose me, and there’s no answer to that’. His special status had the effect of ‘Increasing my own inward sense, wisdom, understanding, and endurance’ which would ‘allow me to do whatever is required in terms of bringing whatever message it is that God wants me to bring’. He expressed these beliefs with full conviction, ‘The truths that are up in that room are the truths that have been spoken of for 4000 years’. His experiences were incomprehensible to other people, including his own family and close friends. But when confronted with skepticism, he commented: ‘I don’t get upset, because I know within myself, what I know’.
The practical problem presented by Simon’s story Simon’s story is one from a number of such case histories (all stories of real people) first published by the British psychologist, Mike Jackson [6]. When Jackson collected these stories, he was working for a doctorate with Gordon Claridge at Magdalen College, Oxford, on the differences between delusion and spiritual experience.
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Using the currently available gold standard diagnostic instruments, such as the Present State Examination [7], Jackson found a surprising degree of overlap between these two very different areas of human experience. Thus, in the present case, Simon had a diagnostically significant symptom, namely a delusional perception, in the revelations he received from his ‘suns’ or wax seals. This was confirmed by blind ratings from people trained in the use of the PSE. Correspondingly, according to traditional psychiatric diagnostic criteria, as in the International Classification of Diseases [8], Simon had schizophrenia or some related psychotic illness. The difficulty, though, was that far from being ill, let alone suffering from a severe psychotic illness, Simon (along with many others in Jackson’s study) was much empowered by his experiences. Moreover, the information he received from these experiences, despite meaning nothing to his family and friends, guided him so effectively in the conduct of his court case that he won it! His stock as a lawyer (which was his own profession) then rose considerably, he made a great deal of money, and when last heard of, he was planning to set up a trust fund to support research on spiritual experience. Jackson was thus faced with a problem. His doctoral research depended on using the best of the currently available empirical diagnostic tools; but these tools, far from improving the distinction between delusion and spiritual experience, seemed, in a number of cases like Simon’s at least, actually to bring them closer together. One option was to sharpen the definitions of the relevant diagnostic concepts, notably the concept of delusion. But the nature of delusion was and remains obscure [9]; the broader concepts of ‘psychosis’ and ‘insight’, were still more contested [10], to the point indeed that both ICD and DSM have done their best to exclude them [11]; and falling back on the concept of ‘mental disorder’ itself, led straight into the highly polarised debate between psychiatrists and a variety of ‘anti-psychiatrists’ about whether the concept of mental disorder had any validity at all [12, 13].
Embedded conceptual difficulties To this point, then, Simon’s story illustrates a series of conceptual difficulties – involving the concepts of delusion, insight, psychosis, and mental disorder itself – embedded in the differential diagnosis of delusion and spiritual experience. On first inspection, however, a way round these difficulties is offered by the main alternative to ICD internationally, the American Psychiatric Association’s Diagnostic and Statistical Manual [14]. This is because the DSM includes, in addition to traditional symptom-based diagnostic criteria, a number of ‘criteria of clinical significance’. In the case of schizophrenia, the relevant criterion of clinical significance is Criterion B, a criterion of ‘social/occupational dysfunction’. And in Simon’s case, Criterion B turns out to be the key to distinguishing his spiritual experience from a psychotic illness. For Criterion B requires a deterioration in social and/or occupation functioning [14, p. 285]; and to the extent at least that Simon’s occupational functioning as a lawyer was actually enhanced by his experiences, he failed to satisfy Criterion B and hence did not, despite satisfying Criterion A (the symptom-based criterion), have schizophrenia at all according to the DSM, but a spiritual experience. The success of the DSM in this respect, however, far from resolving the conceptual problems at the interface between psychiatry and religion, actually deepens them [13]. This is because Criterion B itself opens up a further series of conceptual difficulties. The DSM indeed rightly acknowledges these difficulties. The use of its categories, including by
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implication its criteria of clinical significance such as Criterion B, requires ‘clinical judgement’ [14, p. xxiii] which, DSM recognizes, is inherently difficulty; but beyond this acknowledgement, DSM offers neither a definition of clinical judgement nor guidelines on how it should be deployed. The DSM, it is true, suggests a definition of ‘mental disorder’; but again, this is unhelpful in the present case because the definition turns on the presence of ‘dysfunction’, and, beyond the exclusion condition that mental disorder should not be attributed on the basis of social value judgements alone (p. xxi), the DSM offers no clarification of how ‘dysfunction’ itself, the concept at the heart of Criterion B and other criteria of clinical significance, should be judged. The DSM definition of mental disorder, indeed, actually takes us deeper into the conceptual difficulties, by stipulating that the requisite dysfunction should be ‘in the individual’ (p. xxi-xxii), a phrase opening up all the deep metaphysical issues arising from how ‘individuals’ should be defined [15].
1.2.2.2 Values as a (relatively) tractable element in these difficulties The conceptual difficulties embedded in DSM – clinical significance, clinical judgement, mental disorder, dysfunction, individual - show the extent of the practical task of distinguishing between delusion and spiritual experience, as in cases like Simon’s. Clarifying these difficulties may in itself be helpful: Austin noted the critical importance of making conceptual problems explicit as the first step in conceptual research [2, p. 23]. As to ‘next steps’, there are a number of possible ways forward so far as research methods are concerned and I will return to some of these in Part III. First, though, in anticipation of the practical interventions to be outlined in Part II, I want to draw out a particular component of the conceptual difficulties presented by Criterion B, namely the extent to which applying Criterion B involves a series of (potentially contested) value judgements. The importance of value judgements in applying Criterion B can be brought out in Simon’s case by imagining alternative outcomes. Thus, as just noted, it is clear from the way his story actually turned out that he did not satisfy Criterion B: he won his court case, after all, so could hardly be said to show impaired occupational functioning. But suppose he had lost his case. Or what if he had won his case but the messages from his ‘suns’ (the wax marks on his bible) had led to him abandoning or abusing his family and friends. How, then, should we balance different aspects of his social and occupational functioning in coming to a diagnostic judgement about whether or not he satisfies Criterion B? The required ‘balancing’, surely, involves balancing different values. Again, there are aspects of his functioning that might be regarded as good functioning from some perspectives but as impaired functioning from others, for example if his experience had led him to abandon his legal practice and to become a hermit. Such contingencies raise matters not only of individual but also of cultural values: in some cultures, working very long hours at the expense of your family life is a good thing; similarly, someone who leaves his home and work and goes off to meditate in the desert might be thought to be functioning well in a society that values religious retreat, but to be functioning badly in a society that is more work-oriented. The DSM, it is important to say straight away, is strongly evidence-based (see in particular, the Introduction to DSM, [14, p. xv]); and there will be some for whom the claim that values are involved in applying some of its key criteria will seem to conflict with this: see for example, and as described further below, a number of commentaries in
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World Psychiatry critical of the claim that diagnosis involves values as well as evidence [16]. But whatever the theoretical considerations, Simon’s story, and others like it, show that at a practical level at least, the clinical judgements involved in applying Criterion B include value judgements. And indeed, once we start looking for values in the DSM, as the American psychiatrist and philosopher John Sadler [17] has shown, they turn up everywhere! Other examples include: i) the use of overtly value terms like ‘bizarre’, for instance in relation to one kind of delusion that is characteristic of schizophrenia (DSM, p. 299 and 312). ii) the inclusion in DSM of criteria that are evaluative rather than descriptive in form: Criterion A for conduct disorder, for example, covers ’. . . behaviour in which the basic rights of others or major age-appropriate norms or rules are violated’ (DSM, p. 93 and 98). iii) the inclusion by implication in DSM’s definition of mental disorder conditions defined in part by social value judgements. DSM expresses this as an exclusion condition: the definition states that ‘Neither deviant behaviour (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual . . .’ (DSM, pxxxi, emphasis added). The DSM of course makes it clear that its definition of mental disorder requires that there be ‘clinically significant distress or impairment’ (DSM, p. 8, emphasis added). But this leads back to all the problems, including problems of contested value judgements, raised by the DSM criteria of clinical significance (such as Criterion B). The observation that DSM, and by extension the ICD and other psychiatric classification include, explicitly or implicitly, key diagnostic value judgements, may be taken by some to be prejudicial to the scientific status of psychiatry. Different interpretations of the value-ladenness of psychiatric diagnostic concepts were at the heart of the psychiatry/anti-psychiatry debate [18]. It is to these different interpretations, and in particular the work of one of Austin’s pupils, R. M. Hare, that we turn next. As we will see it is Hare’s work in moral theory, a branch of linguistic analytic philosophy focusing on the meanings and implications of value terms, that provides the theoretical basis for the practical tools of values-based practice; and it is these practical tools that can help us to make progress with the problems arising at the interface between psychiatry and religion, to the extent at least that these problems reflect complex and conflicting values.
1.2.3 VALUES-BASED PRACTICE AND CONCEPTUAL PROBLEMS AT THE INTERFACE BETWEEN PSYCHIATRY AND RELIGION In this section, then, I will be describing the theoretical basis and practical tools of valuesbased practice. First, though, we need to start from the broader question of just what are values. This is an important preliminary because ‘values’ is a term that means different things to different people and this can lead to many misunderstandings. In medicine, indeed, it is perhaps fair to say there is some resistance to the idea that values (at any rate other than ethical values) should come into clinical decision-making; and there is perhaps an especially
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deep-rooted view, noted above, that diagnosis, in particular, should be somehow exclusively scientific and, hence, on this view, value-free (see, for example, the commentary by Robert Spitzer [19], who was Chair of the DSM-III task force, on a discussion article in World Psychiatry on this issue [16]).
1.2.3.1
What are values and how do they come into medicine?
So, what are values? First, values are wider than ethics: they include ethical values but also values of many other kinds – preferences, needs, hopes, expectations, and so forth. A helpful definition of values in this broad sense is given by Sackett et al., in, perhaps surprisingly, their training manual on evidence-based medicine: ‘By patient values’, they write, ‘we mean the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient.’ [20, page 1; emphasis in the original]. There are thus many different kinds of values. This raises the question, what is it that makes values in general relevant to medicine? The nature of values is one of those topics that has been widely debated by philosophers for over 2,000 years! But an important feature of values, and one by which they are at least partly defined, is that, as Hare put it, they are ‘prescriptive’ or ‘action guiding’ [21, 22]. Values are of course explicitly present in some areas of medicine, for example in the cost-benefit analyses of health economics [23] and in other areas of medical decision-making [24]. But Hare’s point was the more general one that, whether explicit or not, values as well as evidence underpin all decisions, including therefore all medical decisions, and including therefore all medical decisions about diagnosis.
1.2.3.2
Values visible and invisible
But if values are everywhere in medicine, as Hare’s work suggests, why should they be clearly visible in some areas, such as psychiatric diagnosis, but (relatively) invisible in others, including diagnosis in most areas of bodily medicine? Or to put the question another way, why is it that there is no equivalent of Criterion B, for example, in the diagnostic concepts used in areas such as cardiology and gastroenterology? It is this contrast, between value-laden psychiatric diagnostic concepts and (apparently) value-free diagnostic concepts in most areas of bodily medicine, that as noted earlier, lay behind much of the debate about the concept of mental disorder in the 1960s and 1970s. Many of those involved in this debate, as I have shown elsewhere [18], approached it from opposite points of view about the significance of the value-ladenness of the concepts of mental disorder. Thus, the American psychiatrist, Thomas Szasz, notoriously claimed that mental illness was ‘a myth’ essentially on the grounds that where ‘genuine’ medical diagnostic concepts were scientific and value-free, concepts of mental disorder were defined by ‘social, ethical and legal norms’ [25, p. 114]. Conversely, authors such as R. E. Kendell [26], argued that the value-laden nature of mental disorder reflected the (as he saw it) primitive stage of development of psychiatric science. Thus, Kendell accepted that in the present state of our knowledge, mental disorder is more value-laden than bodily disorder;
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but he believed that with developments in the sciences, mental disorder would eventually come to look like bodily disorder, i.e. value-free. I examine the moves in this debate, which are clearly important to the way we should understand the boundary between psychiatry and religion, in Chapter 1 of my Moral Theory and Medical Practice [27]. Linguistic analysis, though, as I set out fully in Chapters 2 to 6 of that book, offers us a very different way of understanding the relative value-ladenness of the concept of mental disorder. The key point, that is derived particularly from Hare’s work, can be summed up in the slogan ‘visibility of values equals diversity of values’. Hare’s argument is illustrated diagrammatically by Figure 1.2.1. Hare showed that all value terms, including such general value terms as ‘good’ and ‘bad’, may
Figure 1.2.1
Good strawberry versus good picture.
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come to look like factual terms (and hence appear value-free) where the values they express are largely agreed or settled upon. Hare’s example, as in the left-hand side of the illustration in Figure 1.2.1, was of ‘good strawberry’, this being a use of the value term ‘good’ in which it carries largely factual or descriptive connotations (that the strawberry in question is red, sweet and grub-free, etc). Conversely, ‘good’ used of pictures, as in the right-hand side of Figure 1.2.1, retains clearly evaluative connotations because there are no widely agreed or settled criteria for what is a good picture. As Figure 1.2.1 also shows, therefore, applying Hare’s point about value terms in general to the medical concepts, suggests that psychiatric diagnostic concepts are relatively value-laden, not because psychiatry is somehow outwith medicine (as Szasz suggested), nor because psychiatric science is primitive and under-developed (as Kendell argued), but because the values involved in diagnostic judgements in psychiatry, in contrast with such areas as cardiology and gastroenterology, are particularly diverse [27]. Again, I do have space here to go into the arguments for and against this interpretation. At the level of theory, it falls within a 200-year debate about the logical relationship between descriptive (or factual) and evaluative terms, a debate that continues to this day (see for example, [28]). At a practical level, however, Hare’s interpretation leads directly to the skills-based approach of values-based practice.
1.2.3.3
What is values-based practice?
A wide variety of disciplines are already contributing to more effective ways of working with values in medicine. In addition to ethics and law, these include: health economics, decision analysis, the history of medicine, medical humanities, and the social and anthropological sciences. However, important as the contributions of these disciplines have been, when it comes to clinical decision-making in day-to-day practice, it often seems that we are not being as responsive as we should be to the diversity of individual human values [29]. This is where values-based practice has a role to play in strengthening the practical resources for working with values in medicine. Based on work in analytic philosophy (in particular, [27 and [11], together with a number of empirical studies (notably, [3]), values-based practice offers a new and primarily skills-based approach to working with complex and conflicting values in medicine. And a particular feature of values-based practice, furthermore, and one that makes it particularly relevant to tackling the problems at the interface between religion and psychiatry, as illustrated by the story of Simon, is that it starts from and celebrates the diversity of individual human values, relying on ‘good process’ rather than pre-set ‘right outcomes’ as a basis for balanced decision-making where values conflict. Figure 1.2.2 gives ten key elements of the process of values-based practice in the form of an arrow diagram. As just noted, values-based practice is primarily skills-based, and I return to the four main areas of values-based clinical skills, represented by arrows 1 to 4, below. But an appropriate service model is also important (arrows 5 and 6), as are the strong links between values-based and evidence-based approaches (arrows 7–9), and the objective
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of full partnership between service user and service provider in clinical decision-making (arrow 10). I give a full account of these ten elements illustrated with a detailed case history, of ‘The Artist Who Couldn’t See Colours’, in my Ten Principles of Values-Based Medicine [31].
Practice Skill 1. AWARENESS: of the values present in a given situation. Careful attention to language is one way of raising awareness of values.
2. REASONING: using a clear reasoning process to explore the values present when making decisions
3. KNOWLEDGE: of the values and facts relevant to the specific situation
4. COMMUNICATION: combined with the previous three skills, this is central to the resolution of conflicts and the decision making process
Models of service delivery 5. USER-CENTRED: the first source for information on values in any situation is the perspective of the service user concerned
6. MULTIDISCIPLINARY: conflicts of values are resolved in VBP not by applying a ‘pre-prescribed rule’ but by working towards a balance of different perspectives (e.g. multidisciplinary team working)
Figure 1.2.2
Ten key elements of values-based practice.
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VBP and EBP 7. THE ‘TWO-FEET’ PRINCIPLE: All decisions are based
on facts and values (EBP and VBP thus work together).
8. THE ‘SQUEAKY WHEEL’ PRINCIPLE: We only notice values when there is a problem
9. SCIENCE AND VALUES: Increasing scientific
knowledge creates choices in health care, which introduces wide differences in values
Partnership
10. PARTNERSHIP: In VBP decisions are taken by service users and the providers of care working in partnership
Figure 1.2.2
1.2.3.4
(Continued).
The development of values-based practice in mental health
Values-based practice in mental health has been developed through a number of initiatives involving national and international partner organisations representing three key stakeholder groups, namely patients, professionals and policy makers. Partner organisations have included, in particular, two major mental health NGOs in London, The Sainsbury Centre for Mental Health and the Mental Health Foundation and the United Kingdom government’s Department of Health. There have also been important developments internationally. The World Psychiatric Association, through its Institutional Program on Psychiatry for the Person (IPPP) [32], has been particularly active in this area with a number of key initiatives, including important innovations in person-centred diagnosis [33]; and there have been significant contributions from both Continental Europe and North America (see, for example, respectively, [34, and 17]) and from South Africa ([35]). Building on all these initiatives, there are now significant resources to support valuesbased practice through policy and service development, through training and through research.
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Policy and service development A national framework setting out a number of key principles of values-based practice has been developed by the National Institute for Mental Health in England (NIMHE – www. nimhe.org.uk). The framework was developed and piloted originally by a group representing different service provider and service user perspectives, the NIMHE Values Project Group. NIMHE is the section of the United Kingdom government’s Department of Health with responsibility for implementing policy in mental health. As such, the NIMHE Values Framework has subsequently become the basis for a series of policy and service development initiatives concerned with improving multidisciplinary and multi-agency teamwork as the basis of more effective person-centred care (see for example, [36 and [37]). The NIMHE Values Framework is given in full in Figure 1.2.3. This illustrates directly the way in which, as noted above, values-based practice is all about good process rather than prescribing right values. Emphasising process over outcomes is sometimes thought to lead to a laissez faire culture of ‘anything goes’: and it is true that as already noted, values-based practice starts from, as it were, a meta-value of respect for differences of values [31]: as indicated earlier, this is one reason why values-based practice may be helpful in relation to problems arising from the diversity of religious and spiritual values as these impact on clinical practice. But in starting from respect for differences of values, values-based practice certainly does not lead to ‘anything goes’. On the contrary, valuesbased practice is in this respect somewhat like a political democracy. Democracies differ from totalitarian regimes in relying on good process (starting from ‘one person one vote’) and far from resulting in anything goes, the processes of political democracy lead to clear and strong principles of law and practice. Some of the corresponding clear and strong principles of law and practice that can be derived from the values democracy of values-based practice, are illustrated by Figure 1.2.3. The most important of these in relation to religious and spiritual values, is that in the words of the NIMHE Values Framework, the values of ‘each individual service user/client and their communities must be the starting point and key determinant for all actions by professionals’. This key phrase, which was drafted by Simon Allard, as the service user member of the NIMHE Values Project Group, makes clear the importance of ‘walking the talk’ on person-centred care. Person-centred care, after all, is nothing if it is not fully responsive to the unique values of the individual persons concerned [38]. The framework goes on to spell out a whole series of further positive constraints from valuesbased practice, that it should be multidisciplinary, recovery oriented, dynamic, reflexive and so forth.
Training A detailed training manual for values-based practice, ‘Whose Values?’ [39], originally developed and piloted with front-line mental health and social care staff, was launched by the Minister of State in the Department of Health, Rosie Winterton, at a conference in London in 2005. The training manual, which is based on a series of practical exercises, has subsequently been used successfully in a wide variety of clinical contexts and parts of it have been developed in the form of a CD-Rom resource to support the above policy initiatives [40].
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The National Framework of Values for Mental Health The work of the National Institute for Mental Health in England (NIMHE) on values in mental healthcare is guided by three principles of values-based practice: 1) Recognition – NIMHE recognizes the role of values alongside evidence in all areas of mental health policy and practice. 2) Raising Awareness – NIMHE is committed to raising awareness of the values involved in different contexts, the role/s they play and their impact on practice in mental health. 3) Respect – NIMHE respects diversity of values and will support ways of working with such diversity that makes the principle of service-user centrality a unifying focus for practice. This means that the values of each individual service user/client and their communities must be the starting point and key determinant for all actions by professionals. Respect for diversity of values encompasses a number of specific policies and principles concerned with equality of citizenship. In particular, it is anti-discriminatory because discrimination in all its forms is intolerant of diversity. Thus respect for diversity of values has the consequence that it is unacceptable (and unlawful in some instances) to discriminate on grounds such as gender, sexual orientation, class, age, abilities, religion, race, culture or language. Respect for diversity within mental health is also: *
*
*
* * * *
user-centred – it puts respect for the values of individual users at the centre of policy and practice; recovery oriented – it recognizes that building on the personal strengths and resiliencies of individual users, and on their cultural and racial characteristics, there are many diverse routes to recovery; multidisciplinary – it requires that respect be reciprocal, at a personal level (between service users, their family members, friends, communities and providers), between different provider disciplines (such as nursing, psychology, psychiatry, medicine, social work), and between different organizations (including health, social care, local authority housing, voluntary organizations, community groups, faith communities and other social support services); dynamic – it is open and responsive to change; reflective – it combines self monitoring and self management with positive self regard; balanced – it emphasizes positive as well as negative values; relational – it puts positive working relationships supported by good communication skills at the heart of practice.
NIMHE will encourage educational and research initiatives aimed at developing the capabilities (the awareness, attitudes, knowledge and skills) needed to deliver mental health services that will give effect to the principles of values-based practice. Figure 1.2.3
The NIMHE values framework.
As Figure 1.2.2 (above) indicates, there are four main skills areas of values-based practice each of which is built up in part from philosophical sources: *
Awareness – improved awareness of values and of the often surprising diversity of values, is the foundation of the good process of values-based practice: training resources for developing clinical skills here draw directly on work in the Oxford tradition of linguistic analytic philosophy, including that of Hare [21 and 22] but also Austin [2]. The training
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*
*
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exercises are not presented as exercises in philosophy! But this philosophical tradition lends itself readily to the development of skills training exercises for front-line staff. Reasoning – in addition to raising awareness, the ability to reason about values is essential to effective clinical decision-making. Again, skills development in this area draws on established philosophical sources. These include all the reasoning skills that have been well-developed in ethics, such as principles reasoning, casuistry, utilitarianism and deontology, but with a distinctive twist – values-based reasoning is used primarily not to reach or support a particular ethical position but rather to explore the range of often very different values that may be present in a given clinical situation [41]. Knowledge – one of the key links between values-based and evidence-based approaches is simply that values-based practice itself should be as far as possible evidence-based! It is often thought that values can just be taken for granted, being perceived and understood intuitively. But it is just as important to ‘listen to the evidence’ in values-based practice, rather than relying solely on intuition, as it is in more obvious areas of evidence-based practice such as deciding on the effectiveness of different treatment options. In addition to directly empirical methods [30], other sources of knowledge of values include, for example, personal narratives of patients and family carers, and a number of powerful philosophical methods, such as phenomenology [34], hermeneutics [42] and discursive philosophy [43, 44]. Communication skills – communication skills are central to values-based practice: in addition to exploring values and differences of values, good communication skills are vital when it comes to bringing values and evidence together in individual cases [45]. As well as the more familiar medical communication skills, this is an area in which methods and resources derived from management theory, which has a long tradition of working with values, may be particularly helpful both for exploring differences of values and for resolving conflicts between them [46].
Although set out above separately, and capable of being learned individually, the skills of values-based practice have to work together in a fully integrated way when it comes to applying them in practice. The ‘good process’ of values-based practice, furthermore, depends on these skills being employed in an appropriate policy and service development context. A recent example from the United Kingdom that illustrates how policy, law, and values-based approaches can be successfully combined, is the package of values-based materials that have been developed to support implementation of a new Mental Health Act. The new Act covers the use of involuntary treatment in psychiatry. This is a particularly key area for values-based practice because involuntary treatment by definition involves a direct conflict of values between the patient concerned and everyone else [47, 48]. The development of the training materials to support the new Act, which is being led by Malcolm King, one of those who contributed to the development of the original training manual, ‘Whose Values?’ [39], builds on the Guiding Principles behind the Act to support how the Act is applied in practice. This is because as Figure 1.2.4 illustrates, the Guiding Principles represent a set of key values (such as respect, good communication, assessment of risk, etc.) that provide a framework of values for balanced decisions about involuntary treatment in individual cases. The basic approach is this: the law is the starting point – it is the law that tells us ‘what’ to do; and the law is supplemented by a Code of Practice – this tells us how to apply the law in general (the Code of Practice is a guide for clinicians and other non-lawyers); but it is the Guiding Principle, as a framework of values, that, literally, guides us in applying the law and the Code of Practice in individual cases.
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ect Resp le ip Princ
L Alte east rna Res tive trict Pri ive nci ple
Purpose Principle
Values Based Practice
es rc e ou ipl es c R Prin
Figure 1.2.4
n tio pa le i c r ti cip Pa Prin
The guiding principles as a framework of values.
Research As a quasi-empirical method, linguistic analysis, on the model of Austin’s philosophical fieldwork, is a natural partner to more traditional empirical methods of enquiry. Colombo et al.’s [30] study, cited above, illustrates the importance of this. Essentially, the study employed a combination of analytic philosophical and empirical social science methods [49] to show that, although different members of multidisciplinary teams (psychiatrists, social workers, nurses, etc) believed that they all had the same shared values, in practice they were often being driven by very different values: for example, doctors were more concerned about medication and social workers were more concerned about risk. So long as they remained unaware of them, these differences of values were a source of failures of communication and of associated difficulties in teamwork and shared decision-making. By contrast, however, once team members became aware of their differences of values, these became a positive resource for a personcentred approach that is fully responsive to each patient’s or client’s individual values. The research frontier, however, for values-based practice is diagnosis. This brings us back directly to the heart of the philosophical problems at the interface between psychiatry and religion as illustrated by the Story of Simon.
1.2.3.5 Values-based diagnostic assessment and problems at the interface between psychiatry and religion NIMHE (as above), following a model developed by John Sadler in Dallas [50], has supported a series of international research meetings that have brought together clinicians, patients and policy makers to explore the role of values in psychiatric assessment and diagnosis. The
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meetings were run in partnership with a number of international organisations, including both the World Psychiatric Association and the Mental Health and Substance Abuse Section of the World Health Organization. They culminated in a national consultation, launched by the minister, Rosie Winterton, aimed at bringing together a Shared Vision of how a mental health assessment should be carried out, that draws on the different approaches of different members of the multidisciplinary team as a resource for understanding the perspective of the individual service user concerned (see www.3keys.org.uk/downloads/3keys.pdf). Building on established values-based principles, the development of this work has been co-led by myself with Laurie Bryant and Lu Duhig, respectively the Service User and Carer Leads for the Care Services Improvement Partnership in the Department of Health; it has been supported by a steering group co-chaired by Sheila Hollins for mental health (as President of the Royal College of Psychiatrists) and Lord Adebowale for social care (as Chief Executive of a major social care NGO in the United Kingdom, Turning Point); and it has been developed with input from an extended development group including representatives not only of each of the major mental health and social care professional groups (psychiatrists, psychologists, social workers, nurses, etc), but also representatives of non-professionally trained staff and of a range of voluntary organizations. From these diverse sources, we have developed what is at this stage a rather highlevel statement of our Shared Vision of how the assessment of a mental health issue should be carried out. The Shared Vision has three key elements, namely that assessment should be, 1. Based on active and full partnership with the service user concerned and (where appropriate) with their carers. 2. Include more than one disciplinary perspective so that no one perspective dominates: if possible, this should include perspectives from outside health and social care, such as housing, employment and, importantly for the relationship between psychiatry and religion, faith-based organisations. 3. Focus on individual strengths, resiliences, and aspirations, as well as exploring needs and difficulties, as a basis for recovery and development of the skills of self-management. We have subsequently collected examples of good practice from a wide range of different groups, again representing both statutory and voluntary sectors, illustrating how these three elements can be made to work effectively in a practical context. As these examples illustrate, a values-based approach to diagnostic assessment, while not engaging with the deep philosophical problems at the interface between psychiatry and religion, nonetheless provides the practical tools for tackling these problems more effectively on a case-by-case basis, at least and to the extent that, as in the story of Simon, values are integral to the clinical judgements on which the application of the (diagnostically crucial) criteria of clinical significance directly depend.
1.2.4 CAVEATS: OTHER WAYS OF DOING MORE THAN JUST GETTING STARTED WITH FURTHER KINDS OF PHILOSOPHICAL PROBLEMS AT THE INTERFACE BETWEEN PSYCHIATRY AND RELIGION As set out in the last two sections, linguistic analysis and its practical spin-off in valuesbased practice, together provide well-developed resources of theory and practice for
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tackling some of the philosophical problems arising at the interface between psychiatry and religion. It is important, however, as Austin’s cautionary note to himself cited at the start of this chapter reminds us, to recognize the limitations of the approach. In this final section, therefore, I will look at a number of examples of other resources available, to paraphrase Austin, for supporting other ways of doing more than just getting started with further kinds of philosophical problems at the interface between psychiatry and religion. I will consider, first, other methods besides linguistic analysis for tackling conceptual problems; second, other resources besides values-based practice for going beyond just getting started; and, third, other philosophical problems besides conceptual problems and the resources of non-Western as well as Western philosophical traditions for tackling them.
1.2.4.1 Other ways of tackling conceptual problems at the interface between psychiatry and religion Philosophical field work as has several times been noted, is a natural philosophical partner to empirical research methods. Indeed, Austin, as reported by Warnock, argued that linguistic analytic field work should be combined with other methods relevant to particular research problems [1, pp. 9–10]. Warnock also reports (personal communication) that Austin, influenced by his experience as an intelligence officer in World War II, argued that complex philosophical problems could be broken down into smaller and more manageable parts and then distributed across a team of researchers [1, p. 9], much as the new philosophy of psychiatry is developing currently [5]. The combined outputs from this distributed approach, again pursuing the parallels with empirical science, would not be once-and-for-all solutions, but step-wise advances in understanding, that, as in the case of values-based practice, might contribute, along with other resources, to improving clinical care. The work of Anthony Colombo, noted above [30], combining empirical social science with linguistic analytic philosophical methods, illustrates the relevance of Austin’s ideas at least in the practical arena of psychiatry. This study was supported by a research ‘board’ that included Peter Campbell, a founder of the early service user empowerment group ‘Survivors Speak Out’, who has written of his own psychosis in terms of spiritual experience rather than psychopathology [51]: and a pilot study extending Colombo’s work to issues of race and spirituality, which is being led by Dr Colin King, who has direct personal experience of being misdiagnosed as suffering from schizophrenia [52], is currently under way with a mental health NGO in London. A number of other philosophical methods have clear potential for improving our understanding of the conceptual problems arising at the interface between psychiatry and religion, and, thereby, for improving practice. First, and directly relevant to exploring the boundary between psychiatry and religion, is contemporary phenomenology: the Italian psychiatrist and phenomenologist, Giovanni Stanghellini, for example, has produced a detailed phenomenology of schizophrenia with many deep insights into the value structures of the people concerned [34]. Other examples include Heidegger’s phenomenology and work on trauma [53 and 54]; Merleau-Ponty’s phenomenology and new understanding of how the experience of time is structured for people with dyslexia [55]; and the use of Sartre’s detailed phenomenology of the body to characterise different forms of body dysmorphophobia [56]. Hermeneutics is also providing a powerful tool for exploring the experience of people with Alzheimer’s disease [42]. And, again in old age psychiatry, discursive
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philosophy and psychology (concerned with how meaning is created through discourse), are proving to be powerful resources not only for theory [43] but also for improving practice [44].
1.2.4.2
Other resources for doing more than just getting started
If the skills of values-based practice have a contribution to make to tackling the problems at the interface between psychiatry and religion, they are certainly not in themselves a sufficient resource for improving practice. In the first place, as the story of Simon shows, recognising the importance of the value judgements involved in applying Criterion B, actually enhances rather than reduces the need for the more traditional clinical skills involved in the examination of a person’s mental state. Judgements of clinical significance depend on bringing together both kinds of skill: the skills of traditional descriptive psychopathology and the new skills of values-based practice. It is a similar case with the resources of clinical psychology. The British Psychological Society, building on the work of Jackson and others, now takes the line that psychotic experiences should be understood, not as pathological in themselves, but rather as being one among a number of problem-solving strategies that people have available to them [57]: sometimes the strategy goes seriously wrong (this is psychotic illness); but sometimes, as in Simon’s case, it goes well; and in many cases, precisely how an individual’s experiences develop, whether in a positive or negative direction, may be much influenced by their interactions with others, including, crucially, professionals. Religious and spiritual traditions offer further important resources for practice that, properly understood, are complementary to those of mental health and social care professionals. It is often thought that religious and spiritual traditions will be ideologically driven. But this is very far from always being the case. The Christian tradition of spiritual direction, for example, dating back to the Desert Fathers of the early church, and exemplified in current practice by the Benedictine monks, combines personal convictions with a total openness to and respect for the perspectives of others. Like values-based practice, then, respect for the values and the beliefs of others is at the very heart of the approach of spiritual direction. Spiritual direction, furthermore, again like values-based practice, relies for its effectiveness on a number of well-defined elements of ‘good process’ rather than ideologically driven preassigned right outcomes. These include deep understanding of such apparently familiar ideas as ‘friendship’ (a ‘meeting of souls’) and self-knowledge; but also of the less familiar though no less practically relevant concepts of a ‘word of life’ (sparking life and hope), ‘compunction’ (the gift of tears), and discernment (right judgment) (see [58], for a detailed illustrative case history). The resources of other monastic traditions, similarly, are directly relevant to understanding stories like those of Simon [59] and in ways that are complementary to those of valuesbased practice [60]. There are also open and inclusive approaches to be found within all the great faith traditions. The Sikh commitment to tolerance and inter-faith dialogue, for example, derived from the teaching of the fifteenth-century Guru Nanak, is a fundamental part of Sikh life today. Judaism captures the concepts of both charity and justice in the same word, tzedakah [61, p. 32]. Muslims speak of the qalb salim – the healthy heart (see [62, pp. 30–32]). Zoroastrians are strongly committed to social action and to improving the local community and society in general (see [63]).
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Each of these faith traditions, therefore, offers resources of both theory and practice for supporting, in different ways, the development of positive person-centred practice at the interface between psychiatry and religion that is aimed, not at promoting this or that ideology, but rather at meeting the wide range of very diverse needs presented by individual service users and their families.
1.2.4.3 Other kinds of philosophical problems at the interface between psychiatry and religion The final part of Austin’s note to himself reminds us of what is perhaps the most important of his caveats: that linguistic analysis, in so far as it has a place in philosophy, is appropriate as an approach only to certain kinds of philosophical problems, namely conceptual problems, or problems of meaning. As we have seen, such problems are clearly part of the difficulty we face in negotiating the boundary between religion and psychiatry. But as Austin’s note anticipates, there are many other kinds of philosophical problems here as well. First, there are problems of the kind recognised within what may broadly be called ‘Western’ philosophy, i.e. the philosophical traditions of Europe and North America. These traditions are already proving important for psychiatry: the importance of modern phenomenology has already been emphasised [64] and Jaspers’ phenomenology of course underpins modern descriptive psychopathology [65]. Less well known, but still a key contribution to the emergence of modern classifications, is the work of the American philosopher of science, Carl Hempel [66, 67], as interpreted and developed by the British psychiatrist, Sir Aubrey Lewis, working with Norman Sartorius at the WHO [68, ch 13, Section 2.2]. A more recent example is the work of the British philosopher of psychiatry, Tim Thornton [69, 70], on the irreducibility of individual judgement in clinical decision-making; hence in ‘clinical judgement’; hence in clinical judgement as used in the DSM in relation to Criterion B; and hence in the crucial diagnostic role of Criterion B at the interface between psychiatry and religion, as illustrated by the Story of Simon. There has also been important work in political philosophy [53 and 54; 71] leading to the development of organisations, mostly service user-led, affirming the non-pathological and often life enhancing effects of some forms, particularly, of hallucinatory experiences (see for example, www.hearing-voices.org). The philosophy of mind, too, has been an area of active research: examples include innovative work on delusion [72, 73]; and studies exploring the changes in the structure and content of consciousness experienced by people with schizophrenia (see several articles in a double special issue of PPP edited by Christoph Hoerl [74]). Yet Western philosophy itself, so defined, represents only 25% of the great traditions of thought and practice across the world as a whole. These traditions, furthermore, offer additional important resources for tackling the philosophical problems at the interface between psychiatry and religion. For example, the British psychiatrist, Dinesh Bhugra [75] has shown how Hindu concepts of the person challenge the taken-for-granted unity of the person in Western thinking. Then again, the meditative practices of Asian philosophy [76] are directly relevant to current work in mental health on ‘mindedness’ [77]. And directly relevant to understanding stories such as those of Simon, are the overtly spiritual traditions of African philosophy [35].
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CONCLUSIONS
Starting with the story of a real person, Simon, this chapter has explored how one particular approach to tackling philosophical problems, Austin’s linguistic analysis, combined with its skills-based off-shoot in values-based practice, can help us, in Austin’s words, to get started with at least some of the conceptual problems at the interface between psychiatry and religion. Linguistic analysis is no sinecure, however: again echoing Austin’s words, we have seen that there are other methods for tackling conceptual problems, that there are other resources for improving practice, and that there are other relevant philosophical resources available from both Western and non-Western traditions. There will be some, as I indicated in Part II of the chapter, for whom the very idea that philosophy, let alone the philosophy of values, should be relevant to tackling problems of the kind raised by the Story of Simon, will be taken as a reflection of the (supposed) limitations of psychiatric science. Nothing could be further from the truth. The need for conceptual alongside empirical research is a mark, as in theoretical physics, of a science at the very cutting edge of understanding [68, Chapter 13]. Austin would have approved! In another famous, if politically unreformed aphorism, he pointed out that in conceptual research it is often the negative concept that may ‘wear the trousers’ [1, p. 32]. What he meant was that it is where our concepts cause difficulty (as in mental health), not where they work well enough (as in most areas of bodily medicine), that we are most likely to make progress in understanding them. Psychiatry, therefore, in tackling the conceptual problems at the interface between psychiatry and religion, and in identifying the need for values-based as well as evidence-based approaches, should be understood, not as lagging behind bodily medicine scientifically, but rather as leading the development of a model of twenty-first century healthcare that is not only firmly science based, but also, and essentially, person-centred.
ACKNOWLEDGMENTS As indicated in the text, the Story of Simon was first published by Mike Jackson as part of his DPhil thesis and subsequently in Jackson 1997. The analysis of this and similar case histories outlined here was first published in Jackson and Fulford 1997.
REFERENCES 1. Warnock GJ (1989) J. L. Austin. Routledge, London. 2. Austin JL (1956-7) A plea for excuses. Proceedings of the Aristotelian Society 57:1–30. Reprinted in: White AR (ed.) (1968). The Philosophy of Action. Oxford University Press, Oxford, pp. 19–42. 3. Glover J (1970) Responsibility. Routledge & Kegan Paul, London. 4. Wilkes KV (1988) Real People: Personal Identity Without Thought Experiments. Clarendon Press, Oxford. 5. Fulford KWM, Morris KJ, Sadler JZ, and Stanghellini G (2003) Past Improbable, Future Possible: the renaissance in philosophy and psychiatry. In: Fulford KWM, Morris KJ, Sadler JZ, and Stanghellini G (eds.) Nature and Narrative: an Introduction to the New Philosophy of Psychiatry. Oxford University Press, Oxford, pp. 1–41.
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6. Jackson MC (1997) Benign schizotypy? The Case of Spiritual Experience. In: Claridge GS (ed.) Schizotypy: relations to illness and health. Oxford University Press, Oxford, pp. 227–250. 7. Wing JK, Cooper JE, Sartorius N (1974) Measurement and Classification of Psychiatric Symptoms. Cambridge University Press, Cambridge. 8. World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization, Geneva. 9. Garety PA and Freeman D (1999) Cognitive approaches to delusions: A critical review of theories and evidence. British Journal of Clinical Psychology 38, 113–154. 10. Markova IS, Berrios GE (1992) The meaning of insight in clinical psychiatry. British Journal of Psychiatry 160, 850–860. 11. Fulford KWM (1998) Dissent and dissensus: the limits of consensus formation in psychiatry. In: ten Have HAMJ and Saas HM (eds.) Consensus Formation in Health Care Ethics. Kluwer, Philosophy and Medicine Series, Dordrecht, pp. 175–192. 12. Fulford KWM (2003) Mental Illness: Definition, Use and Meaning. In: Post StG (ed.) Encyclopedia of Bioethics 3rd edn. Macmillan, New York, pp. 1789–1800. 13. Fulford KWM, Sadler J.(forthcoming) Mapping the Logical Geography of Delusion and Spiritual Experience: A Linguistic-analytic Research Agenda covering Problems, Methods and Outputs. In: Peteet J & Lu F (eds.) Religious and Spiritual Issues in Psychiatric Diagnosis and Classification. American Psychiatric Publishing Inc., Arlington. 14. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (fourth edition, DSM-IV). American Psychiatric Association, Washington, DC. 15. Strawson PF (1977) Individuals: An Essay in Descriptive Metaphysics. Oxford University Press, Oxford. 16. Fulford KWM, Broome M, Stanghellini G, Thornton T (2005) Looking With Both Eyes Open: Fact and Value in Psychiatric Diagnosis? World Psychiatry 4, 78–86. 17. Sadler JZ (2005) Values and Psychiatric Diagnosis. Oxford University Press, Oxford. 18. Fulford KWM (2000) Teleology without Tears: Naturalism, Neo-Naturalism and Evaluationism in the Analysis of Function Statements in Biology (and a Bet on the Twenty-first Century). Philosophy, Psychiatry, & Psychology, 7, 77–94. 19. Spitzer RL (2005) Recipe for disaster: professional and patient equally sharing responsibility for developing psychiatric diagnosis. World Psychiatry 4, 89. 20. Sackett DL, Straus SE, Scott Richardson W, Rosenberg W, Haynes RB (2000) Evidence-Based Medicine: How to Practice and Teach EBM, 2nd edn. Churchill Livingstone, Edinburgh and London. 21. Hare RM (1952) The Language of Morals. Oxford University Press, Oxford. 22. Hare RM (1963) Descriptivism. Proceedings of the British Academy 49, 115–134.(Reprinted in: Hare RM (1972) Essays on the Moral Concepts. The Macmillan Press Ltd., London). 23. Brown MM, Brown GC, Sharma S (2005) Evidence-Based to Value-Based Medicine. American Medical Association Press, Chicago. 24. Hunink MGM, Glasziou PP (2001) Decision Making in Health and Medicine: Integrating evidence and values. Cambridge University Press, Cambridge. 25. Szasz TS (1960) ‘The myth of mental illness’, American Psychologist 15, pp. 113–118. 26. Kendell RE (1975) The concept of disease and its implications for psychiatry. British Journal of Psychiatry 127, pp. 305–315. 27. Fulford KWM (1989, reprinted 1995 and 1999) Moral Theory and Medical Practice. Cambridge University Press, Cambridge. 28. Putnam H (2002) The Collapse of the Fact/Value Dichotomy and other Essays. Harvard University Press, Cambridge, Mass., and London, England. 29. Petrova M, Dale J, Fulford KWM (2006) Values-Based Practice in primary care: easing the tensions between individual values, ethical principles and best evidence. British Journal of General Practice 56, 703–709.
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30. Colombo A, Bendelow G, Fulford KWM & Williams S (2003) Evaluating the influence of implicit models of mental disorder on processes of shared decision making within communitybased multi-disciplinary teams. Social Science & Medicine 56, 1557–1570. 31. Fulford KWM (2004) Ten Principles of Values-Based Medicine. In: Radden J (ed.) The Philosophy of Psychiatry: A Companion. Oxford University Press, New York, pp. 205–234. 32. Mezzich JE, Salloum IM (2007) Towards innovative international classification and diagnostic systems: ICD-11 and person-centered integrative diagnosis. Guest Editorial. Acta Psychiatrica Scandinavica 116, 1–5. 33. Mezzich JE (2007) Psychiatry for the Person: articulating medicine’s science and humanism. Editorial. World Psychiatry 6, 1–3. 34. Stanghellini G (2004) Deanimated bodies and disembodied spirits. Essays on the psychopathology of common sense. Oxford University Press, Oxford. 35. Van Staden CW, Fulford KWM (2007) Hypotheses, neuroscience and real persons: The theme of the 10th International Conference on Philosophy, Psychiatry and Psychology. Lead Guest Editorial. South African Journal of Psychiatry 13, 68–71. 36. Department of Health (2007) New Ways of Working for Everyone. A best practice implementation guide. Department of Health, London. 37. Department of Health (2008) Refocusing the Care Programme Approach: Policy and Positive Practice Guidance. Department of Health, London. 38. Allott P, Loganathan L and Fulford KWM (Bill) (2002) Discovering Hope For Recovery. In: Innovation in Community Mental Health: International Perspectives. Special issue of the Canadian Journal of Community Mental Health, 21, pp. 13–33. 39. Woodbridge K, Fulford KWM (2004) Whose Values? A workbook for values-based practice in mental health care. Sainsbury Centre for Mental Health, London. 40. Woodbridge K, Fulford KWM (2005) Values-Based Practice. Module 4. In: Basset T & Lindley L (eds.) The Ten Essential Shared Capabilities Learning Pack for Mental Health Practice. The National Health Service University (NHSU) and the National Institute for Mental Health in England (NIMHE), London. 41. Fulford KWM, Dickenson D and Murray TH (2002) Introduction: Many Voices: Human Values in Healthcare Ethics. Introductory chapter. In: Fulford KWM, Dickenson D and Murray TH (eds.) Healthcare Ethics and Human Values: An Introductory Text with Readings and Case Studies. Blackwell, Malden, USA, and Oxford, UK, pp. 1–19. 42. Widdershoven G and Widdershoven-Heerding I (2003) Understanding Dementia: a Hermeneutic Perspective. Chapter 6 In: Fulford KWM, Morris KJ, Sadler JZ and Stanghellini G (eds.) Nature and Narrative: An Introduction to the New Philosophy of Psychiatry. Oxford University Press, Oxford, pp. 103–112. 43. Sabat SR and Harre R (1997) The Alzheimer’s Disease Sufferer as Semiotic Subject. Philosophy, Psychiatry, and Psychology 4, 145–160. 44. Sabat SR (2001) The Experience of Alzheimer’s Disease: Life Through a Tangled Veil. Blackwell Publishers, Oxford. 45. Hope T, Fulford KWM and Yates A (1996) The Oxford Practice Skills Course: Ethics, Law and Communication Skills in Health Care Education. The Oxford University Press, Oxford. 46. Fulford KW and Benington J (2004) VBM: A Collaborative Values-Based Model of Healthcare Decision-Making Combining Medical and Management Perspectives. In: Williams R & Kerfoot M (eds.) Child and Adolescent Mental Health Services: Strategy, planning, delivery, and evaluation. Oxford University Press, Oxford, pp. 89–102. 47. Fulford KWM and King M (2008) A values-based perspective on good practice in compulsion. Commentary on Roberts G, Dorkins E, Wooldridge J and Hewis E ‘Detained - What’s my choice? A discussion paper’, 14:172–180. Advances in Psychiatric Treatment 14, 183–184.
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48. Fulford KWM, King M and Dewey S (forthcoming) Values Based Practice and Involuntary Treatment: A new training programme in the UK. Advances in Psychiatric Treatment. World Psychiatric Association, Geneva. 49. Fulford KWM and Colombo A (2004) Six Models of Mental Disorder: A Study Combining Linguistic-Analytic and Empirical Methods. Philosophy, Psychiatry, & Psychology 11, 129–144. 50. Sadler JZ (ed.) (2002) Descriptions & Prescriptions: Values, Mental Disorders, and the DSMs. The Johns Hopkins University Press, Baltimore. 51. Campbell P (1996) What We Want From Crisis Services. In: Read J and Reynolds J (eds.) Speaking Our Minds: An Anthology. The Macmillan Press Ltd for The Open University, Basingstoke, England, pp. 180–183. 52. King C (2007) They Diagnosed Me a Schizophrenic When I Was Just a Gemini: The Other Side of Madness. In: Chung M, Fulford KWM and Graham G (eds.) Reconceiving Schizophrenia. Oxford University Press, Oxford, pp. 11–28. 53. Bracken P (2001) Post modernity and post traumatic stress disorder. Social Science and Medicine 53, 733–743. 54. Bracken P (2002) Meaning, culture and mental illness. Openmind 117, 14–15. 55. Philpott MJ (1998) A Phenomenology of Dyslexia: The Lived-Body, Ambiguity, and the Breakdown of Expression. Philosophy, Psychiatry, & Psychology 5, 1–20; with commentaries by Komesaroff PA and Wiltshire J, pp. 21–24, Rippon G, pp. 25-28, and Widdershoven GAM, pp. 29–32; and author’s response to the commentaries, pp. 33–36. 56. Morris KJ (2003) The phenomenology of body dysmorphic disorder: a Sartrean analysis. In: Fulford KWM, Morris KJ, Sadler JZ and Stanghellini G (eds.) Nature and Narrative: An Introduction to the New Philosophy of Psychiatry. Oxford University Press, Oxford, pp. 270–274. 57. The British Psychological Society (2000) Recent advances in understanding mental illness and psychotic experiences. The British Psychological Society, Division of Clinical Psychology, Leicester. 58. Atwell R and Fulford KWM (2006) The Christian Tradition of Spiritual Direction as a Sketch for a Strong Theology of Diversity. In: Cox J, Campbell AV and Fulford KWM (eds.) Medicine of the Person: Faith, Science and Values in Health Care Provision. Jessica Kingsley Publishers, London, pp. 83–95. 59. Marzanski M and Bratton M (2002) Psychopathological Symptoms and Religious Experience A Critique of Jackson and Fulford. Philosophy, Psychiatry, & Psychology 9, 359–372. 60. Jackson MC and Fulford KWM (2002) Commentary ‘Psychosis Good and Bad: Values-Based Practice and the Distinction Between Pathological and Nonpathological Forms of Psychotic Experience’. Philosophy, Psychiatry, & Psychology 9, 387–394. 61. Sacks J (2005) To Heal a Fractured World: The Ethics of Responsibility. Continuum, London. 62. Sheikh A and Gatrad AR (eds.) (2000) Caring for Muslim Patients. Radcliffe Medical Press, Oxford. 63. Gilbert P and Kalaga H (eds.) (2007) Nurturing Heart and Spirit: Symposium Papers. University of Staffordshire Monograph, Stafford. 64. Gupta M and Kay LR (2002) The Impact of ‘Phenomenology’ on North American Psychiatric Assessment. Philosophy, Psychiatry, & Psychology 9, 73–86. 65. Jaspers K (1913) Allgemeine Psychopathologie. Springer, Berlin.English edition, Hoenig J and Hamilton MW (1963) General Psychopathology. Manchester University Press, Manchester. 66. Zubin J (ed.) (1961) Field Studies in the Mental Disorders. Grune and Stratton, New York. 67. Kendell RE (1975) The Role of Diagnosis in Psychiatry. Blackwell Scientific Publications, Oxford. 68. Fulford KWM, Thornton T, Graham G (2006) Natural Classifications, Realism and Psychiatric Science. In: Fulford KWM, Thornton T, Graham G (eds.) The Oxford Textbook of Philosophy and Psychiatry. Oxford: Oxford University Press, pp. 316–383. 69. Thornton T (2007) Essential Philosophy of Psychiatry. Oxford University Press, Oxford.
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70. Thornton T (2006) Tacit knowledge as the unifying factor in EBM and clinical judgement. Philosophy, Ethics, and Humanities of Medicine, 1:2doi:10.1186/1747-5341-1-2 at http://www. peh-med.com/content/1/1/2. BioMed Central Ltd. An Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0). 71. Bracken P and Thomas P (2005) Postpsychiatry. Oxford University Press, Oxford. 72. Davies M and Coltheart M (2000) Introduction: Pathologies of Belief. In: Coltheart M and Davies M (eds.) Pathologies of Belief. Blackwell Publishers, Oxford, pp. 1–46. 73. Gipps RGT, and Fulford KWM (2004) Understanding the Clinical Concept of Delusion: From an Estranged to an Engaged Epistemology. In: Broome MR and Bebbington P (Special Issue eds.) International Review of Psychiatry: Special Issue on the Philosophy of Psychiatry 16, 225–235. 74. Hoerl C (2001) Understanding, Explaining, and Intersubjectivity in Schizophrenia: Introduction. In: Hoerl C (ed.) On Understanding and Explaining Schizophrenia. A double Special Issue of Philosophy, Psychiatry, & Psychology 8/2 and 8/3, 83–88. 75. Bhugra D (2006) Hindu and Ayurvedic Understandings of the Person. In: Cox J, Campbell AVand Fulford KWM (eds.) Medicine of the Person: Faith, Science and Values in Health Care Provision. Jessica Kingsley Publishers, London, pp. 125–138. 76. Depraz N (2003) Putting the epoche into practice: schizophrenic experience as illustrating the phenomenological exploration of consciousness. In: Fulford KWM, Morris KJ, Sadler JZ and Stanghellini G (eds.) Nature and Narrative: An Introduction to the New Philosophy of Psychiatry. Oxford University Press, Oxford, pp. 187–198. 77. Gilbert P (2006) Spirituality and Mental Health: Practical Proposals for Action. In: Cox J, Campbell AV and Fulford KWM (eds.) Medicine of the Person: Faith, Science and Values in Health Care Provision. Jessica Kingsley Publishers, London, pp. 141–155.
GUIDE TO FURTHER READING Warwick Medical School website for values-based practice http://www2.warwick.ac.uk/fac/med/ study/cpd/subject_index/pemh/vbp_introduction
CHAPTER 1.3
Science and Transcendence in Psychopathology; Lessons from Existentialism Juan J. Lo´pez-Ibor Jr. and Marı´a In es Lo´pez-Ibor Alcocer Professors of Psychiatry, Spain
1.3.1
SCIENCE AND HUMANISM
The dilemma between science and transcendence is a subject that characterizes the intellectual concerns of the Modern Age. The problem was not raised before and in post-modern times it is becoming of less and less concern. Science is not the single pathway to understanding. Scientific knowledge has limits and therefore other perspectives should be accepted. The clinician is constantly confronting situations for which science still lacks an answer, and may never have one. Consequently a humanistic attitude is essential for every doctor. In pre-modern times, knowledge was single and included all that, today, we would assign to faith, beliefs and science. Modernism introduced a gap in the ways of reaching knowledge, separating science from non scientific approaches. Another modern split, parallel to it, is the separation between the Church and the State. Science and transcendence should be independent and the boundaries between them clearly defined. When they are confused, the risk of fundamentalism emerges, but if they are drastically separated, then the risk of abuses of science and technology turn up, such as during the Nazi regime in Germany. The lesson from these abuses is clear: science must be carried out in agreement with ethical principles, as manifested through the advances in bioethics.
1.3.1.1
Humanism and rationalism
The word humanism is commonly applied to any discipline where human beings are the core element. In this context word man means both, a concrete human being and the whole of
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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humankind as the philosopher Dilthey [1] pointed out, and therefore no individual is any more or any less than the whole of mankind. Consequently the humanistic perspective aims not only to enhance the wellbeing of humanity but also the dignity of each individual person. Humanism appeared during the Renaissance as a reaction to the Middle Age view of the world as a place of transit, without value in itself and where human beings were abandoned to a supreme unquestioned and indisputable order. The new geographical discoveries (America, new routes to the East Indies), the new scientific successes (such as the finding of new planets and the rings of Saturn) and the new inventions (such as printing) brought fresh feelings of self-reliance, the drive to know more about the universe (‘the Creation’ in Medieval terms) and the place of man in it. This change of perspective was driven by two facts: 1) The reading of Greek and Latin classics and 2) The teachings of scholars from the Byzantine Empire that scattered all over the world after the fall of Constantinople. Humanism is the consequence of the confrontation to a new situation, to a new order and to a new social contract. Humanism represents a spirit of liberation from old ties. Humanism is an attitude of the mind which gives pre-eminence to man and to human values. From a philosophical perspective, humanism considers man as the measure of everything. By revisiting Antique times, Renaissance humanism found inspiration for the personal search of truth and goodness and as a consequence philosophical systems, religious dogmas and speculative thinking locked in them, were abandoned in favor of more human values.
1.3.1.2
Dualism
Dualism is attributed to Descartes (‘Cartesian dualism’), although it is older than him since it pervaded Gnosticism. Descartes [2] described two natures in human beings: *
*
Res extensa (lit., the substance that has dimensions) or material substance, our material nature, that is measurable and that is accessible to be studied by the positive sciences. Res cogitans (lit., the substance that is able to think) or the reasoning or thinking nature that is accessible to hermeneutics.
These two natures lead to types of sciences as described by Dilthey [3]: 1) natural sciences (Naturwissenschaften), and 2) spiritual sciences (Geisteswissenschaften). In natural science everything is ruled by the principle of cause and effect. The prototype of natural science is classical mechanics. Everything here is linked in a determined way, to the point that knowing the first links of the chain, the end can be foreseen. The forecast is carried out even according to the principles of mathematics, that’s to say, with an absolute accuracy. Every cause has its effect, when the causes are known the effects are also known. Therefore for example it is possible to predict the place a billiard ball will reach after its impact with another ball, once the speed, the direction, the dimensions, the mass of each ball and the friction with the card table are known. Natural sciences search for general laws. In the last years science has been trying to overcome postulates of lineal casualty and tried to expand its field to sciences considered as weak, for example meteorology, economy or psychology based on models of complex systems. The traditional ideal of science is to reduce phenomena of nature and nature itself to very simple notions or formulations such as Einstein’s equation that relates matter with energy (E ¼ mc2) or the trial to unite the four elemental forces of physics. Science operates like the brain, parting from a series of
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extraordinarily complex environmental stimuli; it creates a reality, a world, a subjectivity which is coherent and astonishingly simple. Dilthey aimed to give the status of science to the ‘sciences of the spirit’ (Geisteswissenschaften). The prototype is history where reasons (not causes) can be investigated. Reasons enlighten the meaning of events but they cannot predict them mathematically. Between reasons and consequences there is a gap. Even if the history of a nation is known very well up to a given moment, and even if the knowledge is very good, it is not possible to foresee what is going to happen in the future. Let’s consider as an example psycho-history which applies the knowledge of deep psychology to the study of biographies of individuals that have had a great repercussion on the history of people. The most important conclusion of almost all studies is that brilliant individuals are persons that have been able to find individual solutions to a personal conflict, which at the same time was a conflict of the society they were living in. This way anxiety, personal concerns and their individual solutions have been the reflection and solution for a critical situation of a community. It provides interesting but never deciding data. Erikson [4] described in his Young Man Luther how the conflicts of a young, tormented, intelligent and righteous adolescent found an answer, the renewal of his spirituality beyond the traditions of the Church of Rome. His personal answer was at the same time an answer to the identity conflicts of the German society he was living in. All this paved the way to the Protestant Reformation, with great repercussions on German distinctiveness and language. However, many other adolescents had the same conflicts of the nature and importance, without any consequences, as in the case of the Augustinian monk. Another well studied character is Gandhi [5] who suffered a crisis in his identity during his youth in South Africa, conditioned because he was neither black nor white. The search for his own identity marked the beginning for his country’s search for its own identity and definitely its independence from the British Empire. Anatomy, physiology and pathology are sciences of nature. On the other hand, even if the pathogenic of an illness is perfectly known, the physician may feel insecure and unable to foresee accurately its course in a concrete patient. This uncertainty is due to lack of sufficient knowledge and also to the occurrence of the singularity of the person versus the generality of the law. This dualism, the dichotomy between the physical and the spiritual nature, and between their respective sciences, makes the position of the scientist difficult. The difficulty is even greater if the step is taken to achieve transcendental knowledge. As a consequence, the researcher who simultaneously wants to be a humanist, and even more the one who is a believer, is forced to live in two worlds: the world of research and the world of belief. In one world the enigmas of nature are disentangled by scientific research, in the other world the mysteries are approached by faith. Enigma and mystery are, therefore, different concepts which share the eagerness of human beings to know and the recognition of the limits of what knowledge is able to reach.
1.3.1.3
The two classes of logic
Logic is the science of Logos, and since Aristotle [6] two types of logic are considered. First the analytic, translated into Latin as ratio, that is the perspective of the modern sciences and mathematics (with some exceptions in Leibniz and Hegel), and that is interested in logical
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and rigorous deductions. Logic and rationality need to be analyzed beyond any doubt as syllogism and mathematics do. The goal is to find general laws. This implies autonomy of the rationality, independent from feelings, the body, and the world. At some point cool rationality has been abused by the bureaucratic state as in totalitarian regimens, in which human beings can be exchanged one for another. The synthetic logic precedes Aristotle, and was disliked by him. Is the logic of the Logos of Heraclitus and of the Nous (cosmic mind) of Anaxagoras. Its concern is the meaning of the structure of human mind and nature. If human beings are rational it is because we are able to structure the word in order to give a meaning to it. In order to do so, mathematics and syllogisms are not needed, as this task can be completed by using words and meanings in a grammatical way and communicating them to other people. In the synthetic logic there is a traditional theory, passive, according to which God or a divinity is responsible for the order of the World. Human beings should try to rebuild this Logos according to the holy texts. Therefore religion is re-legere ‘reading again’ There is another synthetic logic, active, that is modern or a post-modern phenomenon. According to this perspective God is a human need. It is also the way in which non occidental cultures accept and interpret irrationality. For Hegel it is the way of exploring and integrating irrationality in an expanded form of rationality, that can respect variety and singularity on the individual consciousness or ways of thinking without rejecting their own truth. Synthetic logic is more interested in an aesthetic order: singularity of the person and the work (i.e., a piece of art), and is therefore the whole is more important than the parts, as Confucius stated. Synthetic logic creates and lives in a physiognomic world, in which the perceived is revealed. It is the phenomenological perspective that rejects the Cartesian dichotomy between the external and the internal – Wittgenstein named it physiognomy.
1.3.1.4
Modernism and rationalism
The philosopher Descartes advocated for an extreme rationalism, Je pense donc je suis (‘I think, therefore I am’), is the postulate of his philosophical system. However, are those who still do not think yet (children) or those who stopped thinking (mentally ill patients, demented persons, and patients in a coma) less human? If the answer to this question is no, as it obviously is, then we have to look elsewhere. Not everything in human beings is rational. Pascal [7] refuted extreme rationalism in his Thoughts (Les Pensees). In a concise way it can be said that until Pascal emotions were considered as mirages of rational thinking. For Descartes, emotions were rudimentary thoughts. With Pascal sentimental life gained a leading role in human nature: M. de Roannez said: ‘Reasons come to me afterwards, but at first a thing pleases or shocks me without my knowing the reason, and yet it shocks me for that reason which I only discover afterwards.’ But I believe, not that it shocked him for the reasons which were found afterwards, but that these reasons were only found because it shocks him. All reasoning is reduced to the fact yielding to feelings. The heart has its reasons, which reason does not know.
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Pascal initiates a tradition in which Schopenhauer, Nietzsche and Freud speak out. All of them were able to recover the importance of sentimental non-rational aspects of human nature. This movement culminates with a series of philosophical (existentialist) and social (contra cultural) movements after World War II, as a reaction to the disasters of national socialism because of which, in the name of reason, unimaginable abuses were committed, with the active collaboration, it must be remembered, of some scientists and physicians.
1.3.1.5
Medical ethics
These changes have important and deep consequences in the way physicians took care of patients, although it took time to fully develop. Traditional medicine was based on a paternalistic ethics of welfare, where the doctor took all the decisions and the patient was considered as a minor. The paternalistic role of the doctor increased and achieved its highest expansion as medicine became more scientific because his knowledge grew enormously and as a consequence, his power to decide. However, since the beginning of the 1970s, the pressure of consumer associations in the United States led to the rapid implementation of an ethics of autonomy, in which the patient became the protagonist in the process of decision taking and therefore the physician, instead of being the one who decides, became the one who had to inform so that the patient was able to give his/her consent to the different options. In the ethics of welfare the patient was initially the object of charity and later on of scientific knowledge; in an ethics of autonomy, the patient is a subject to rights. Nowadays, a new phase has emerged, the ethics of equity, because the physician is no longer the clinician in charge of a patient, but a piece in a healthcare structure that has to achieve increased levels of health for all citizens. The adequate distribution and use of resources (material, human and of time) is basic and therefore also the introduction of management procedures [8]. Healthcare is an essential component of humanism, and humanism is an essential component of medicine. It allows the physician to lean on the human element of the illness. Human means in this sense, the ill human being the physician has to treat, and simultaneously, it is the manifestation of a commitment to society, to health and to human condition in general. Paraphrasing Sir Martin Roth, medicine is the more human of the sciences and the most scientific of humanities [9].
1.3.2
TRANSCENDENCE
Transcendence has philosophical as well as religious implications. The theme was introduced by Aristotle although he never used the term transcendence. Aristotle described the categories that stand by with a subject as predicates. For instance, Socrates is a man, Socrates has a pale skin, Socrates is taller than Alcibiades, he is married, and so on. Everything that describes Socrates is a predicate. But there are also concepts that prevail over predicates like the one, the good, the beautiful, the real, among others. Duns Scoto, Albert Magnus and the majority of scholastic philosophers considered this kind of concept as the methodological principles to gaining knowledge. Their aim was to find a principle
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obvious by itself, valid for everyone, and able to give an answer to every single preoccupation of human beings. Furthermore, such a principle could explain the nature of God or the immortality of the soul. Such principles would be: ‘Every cause has its effect’ or ‘I think therefore I am’. Kant [10] went beyond the scholastic structure of knowledge and introduced a philosophy called transcendental, which became the core of German idealism. What is essential for Kant is not the knowledge of things, but to know in which way we can get to know things considering the abilities we have a priori for knowledge. From this perspective, modern science has not yielded all what can be expected from it. In a sense it has disappeared because it has been divided in many particular sciences and, with the exception of some aspects of physics, there is not a single science that aims at a global knowledge. All of them aspire to specific areas of knowledge and to their own paradigm, as Kuhn [11] stated. Another fact is the supremacy of technique over science. The struggle between science and technology was an important intellectual topic during the 1940s and 1950s. The decade that followed the end of World War II was called the Age of Anxiety, paraphrasing the title of the eclogue by Auden [12], for which Bernstein composed music. Then the supremacy of science over technology was proclaimed. It was said that the abuses during World War II, the use of science and of technology for massive destruction of human beings were not abuses of science but the product of technology in the hands of abhorrent beings and that science was above all that. It was the modern version of the myth of Prometheus. However, as a result of these abuses, the movement that gave way to the birth of scientific ethics was aroused, and as a consequence, so too the moral delimitation of science and the limits of the pursuit of knowledge. The Helsinki Declaration limits experimentation with human beings. Science is no longer be considered as the supreme form of knowledge, since ethics and bioethics have imposed restrictions on it. On the other hand, sciences have become resigned to defining their object (i.e., biology is not able to define what life is) and science has been substituted by scientific research. Biology will never lead us to discover what life is but it will lead us along a path that will allow us to acquire knowledge over things. Kant’s efforts crystallized in post-modern times. Brain research explains how the brain is able to know about objects, as much as this knowledge is possible beforehand. Nowadays we know how the brain grabs hold of stimuli, how those are selected and how they are ascribed the quality of salience, which refers to relevance. The brain is able to create a world in which we live and survive with only a few stimuli, it is a world that has physical dimensions and it is also a world full of meanings and feelings. We also respond to this world. The research of how the filtering process of stimuli is carried out, the question of why we act in response to some of them and not to others and the way we respond is fascinating. When we carry out the most minimal action the brain acts, creating virtual maps of reality which are constantly being compared with reality. For example, during the act of taking a glass a map of the successive positions of the hand to reach out for this glass appears and each 20 ms they are being compared. If the hand is diverted from the goal, a so called Error Related Negativity (ERN) appears. Recently it has been seen that this phenomenon is double. There are two potentials: one that happens when the hand does not follow the right path and another one which appears shortly after if suddenly two valid options appear, and a decision between the two of them has to be taken [13]. These maps allow us to approach knowledge and the creation of the world, which is what Kant was writing about.
1.3
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HUMAN BEINGS, THE WORLD AND THE NOTHINGNESS
The psychological reaction to a stressful situation is anxiety. Anxiety is the emotional experience which appears when confronting a non-identified threat [14] and that sets in motion unspecific coping mechanisms. Emotions are always accompanied by bodily phenomena. For the philosopher Sartre [15] these vegetative correlates are the serious side of emotions, since without them they would be a fraud. The vegetative correlate of anxiety is stress. Both represent unspecific reactions of the individual organism when its internal balance (homeostasis) is endangered by potentially insuperable variations of the environment, challenging the adaptation capacity of the individual. When confronting external threats, the organism sets in motion specific mechanisms (increased blood flow through the muscles, a reaction of alert and inhibition of functions not immediately necessary for survival) to face up to any type of danger. After some time, when the threat has been identified, these unspecific reactions, anxiety and stress, are substituted by other much more specific ones like fight, escape, adaptation or immunological mechanisms. Under some circumstances these essential mechanisms for the survival of the individual, become threats themselves and the reaction is considered pathological. This is the case when they are unchained by trivial stimuli, when they are of an exaggerated intensity or when they persist longer than needed. In fact physicians do more often treat the response to an external threat than the threat itself. Corticoids, which slow down the reaction of adaptation to stress, act as ‘cellular tranquilizers’ and anxiolytics have been described as ‘corticoids’ for the mind. Both drug groups raise the same problems of long term dependence, precisely by interfering in important physiological mechanisms for the survival of the individual. These same phenomena also exist at a collective level that turn up in situations of disasters [16]. On the other hand, creative persons have frequently expressed the presence of anxiety and further, some of them, like the poet Rilke, have recognized that the origin of their creativity precisely lies in his anxiety [17]. Nonetheless there is a great difference with the patients we see at the clinic, who are very frequently anxious. In these patients anxiety is inhibition and those who suffer anxiety constantly refer to those things they are not able to do: ‘Doctor, I can’t go out on the street’,. . .‘I cannot work’,. . .‘I’m not able to enjoy things I enjoyed before’, concluding that they cannot love nor work. For the creative person, on the contrary, anxiety is an impulse to find an explanation and a way out from the experience of threat. Saint Augustine described it as a restlessness that would not cease until dormant with the Lord [18]. Anxiety is the radical of human condition and has been analyzed and studied from the most diverse philosophical, religious, psychological and social perspectives. But anxiety is also an important symptom in medicine and moreover a clinical entity. The first one who spoke about anxiety, raising it to a psychological and philosophical category, was Kierkegaard [19], the Danish philosopher of the first half of the nineteenth century who contradicted Hegel’s philosophy which represented the end point of rationalism. Later on philosophers like Heidegger, Jaspers and Sartre made anxiety the turning point of their anthropological considerations. Existentialist philosophy considers human beings from a different perspective to the classical concept of rational animal, since they also possess many other things (instincts, feelings, etc). Therefore it is necessary to approach the problem with a wider range parting from existence itself. Existence is to be in the world (in der-Welt-sein) [20]. Human beings
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are located among things, in a determined space, in a concrete world. The first obvious fact is that human beings are in this world without having chosen it. From a psychological point of view human beings are thrown into this world. Anyhow, of all the ways of being-in-theworld, Heidegger chose anxiety since it was the one which most genuinely revealed the structure of existence. Spinoza wrote [21]: No better remedy against affects can be found than real knowledge about them. There is no other power of the spirit than the thought and formation of adequate ideas. . .
Anxiety has been defined as the experience of nothingness. What is nothingness? Can we have an idea of it? The sole fact of having an idea of it would mean that nothingness is something; therefore the question lacks any sense. From the point of view of the thought it cannot be explained; there is a premonition of it and during anxiety it is experienced as a sort of anticipation, of a dark prediction of something which is going to happen and which still is not.
1.3.4
DEATH ANXIETY
Human beings positively know they are going to die, a knowledge animals do not have. Usually it is said to be a knowledge based on experience. There are two forms of living: one, the everyday form, in which events follow one another without noticing them, without stopping to think over them. It is a life on a vegetative, animal level. Another one is when life itself is perceived deep inside, through each crisis, of which the most revealing is anxiety. From this crisis experience we start to know what human beings are. The same happens with death. There is an external death, ignored in a certain way, that comes from the outside, striking without any preparation. There is another death, conscious, existential death, which we know through events experienced intimately. Anxiety is only felt in the face of death if death is experienced as a premonition, as anxiety facing the nothingness, a premonition that can be reached through certain situations. All beliefs about survival are based upon the premonition of nothingness, therefore survival is a mental architecture with which to defend oneself against death anxiety in front of the nothing. In those situations in which the unity of the Ego is threatened with falling apart, individuals have the experience of losing control over all their actions, which leads them to say they are afraid of getting mad. Because getting mad for the common individual means precisely that: to lose control over one’s actions. Tillich described, from a theological point of view, three basic topics of anxiety: death, lack of sense and condemnation guilt [22]. Anxiety is a feeling and as such, it is not a pure psychological phenomenon. It consists also of bodily manifestations, the so called physiological correlates of emotions (blood pressure modifications, tachycardia, sweating, and so on). Therefore, we will face words and meanings concerning not only psychological states but also parts of the body attached to the feelings (i.e., constriction) or involved in a particular activity (i.e., in vomiting). On the other hand, anxiety (Angst in German) is, for Kierkegaard, Heidegger and other philosophers, the basic radical of the human condition. For Heidegger Angst is the expression of the authentic existence of the Dasein confronted with the fact of being thrown into the World.
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Delusions in depressed patients are the manifestation of the primitive anxieties (Ur-€angste) of humankind: 1) the loss of health as a threat to physical integrity and survival (hypochondrial delusion); 2) economic losses as the menace to subsistence (delusion of poverty) and 3) the loss of the opportunity to access paradise due to a sinful existence (delusion of guilt) [23]. In most Roman languages anguish is a deeper feeling than anxiety and is experienced as a constriction of the throat or the chest that inhibits and hinders the activity. This shade is beautifully expressed in Spanish by the word sobrecogimiento (lit., to be shocked and paralyzed). The bodily expression of anxiety leans more towards the respiratory system, to the act of inspiration and not, like anguish, to the heart.. Anxiety conveys the impulse to liberate oneself from the threat. For that reason, the feeling of relief when anxiety has ended is a sigh. This nuance is expressed by the Spanish word sobresalto (lit., to jump out). The philosopher Zubiri [24] on the same line has put the emphasis on the concept of expectancy. According to Lo´pez Ibor [25, 26] the words sobrecogimiento and sobresalto are related to two primitive defence reflexes when facing a danger: the Totstellung reflex (death feigning reflex, death feint) manifested in the mimesis of the animal which tries to disappear from the sight of a predator and the Bewegungssturm (movement storm or tempest, instinct flurry) of the poultry in the henhouse when they fly about madly, frightened by some danger. Both were described by Ernst Kretschmer as reflexes underlying hysterical symptoms [27] and Lo´pez Ibor extended the allegory to all neurotic manifestations.
REFERENCES 1. Dilthey W (1991) Selected Works. In: Makkreel RA and Frithjof Rodi F (eds.) Volume I: Introduction to the Human Sciences. Princeton University Press, Princeton NJ. 2. Descartes R (1637) Discours de la methode. In: Oeuvres philosophiques. Volume I. Garnier, Paris (re-ed. 1963). 3. Dilthey W (2002) Selected Works In: Makkreel RA and Rodi F (eds.) Volume III: The Formation of the Historical World in the Human Sciences. Princeton University Press, Princeton NJ. 4. Erikson EH (1962) Young Man Luther: A Study in Psychoanalysis and History. W. W. Norton and Company, New York. 5. Erikson EH (1970) Gandhi’s Truth on the origins of militant nonviolence. W. W. Norton & Co, New York. 6. Aristotle (written 350 B.C.E) Metaphysics. Translated by WD Ross. http://classics.mit.edu/ Aristotle/metaphysics.html. 7. Pascal B (1670) Œuvres completes. Bibliotheque de la Pleiade. Gallimard, Paris. 1998–1999. 8. Lo´pez-Ibor JJ Jr. and Crespo Hervas MD (2000) A West Mediterranean Perspective. In: Ocaza A, Arboleda-Florez J & Sartorius N (eds.) Ethics, Culture and Psychiatry. International Perspectives. American Psychiatric Press, Washington, DC. 9. Roth M (1973) Psychiatry and its critics. British Journal of Psychiatry 122, 373–378. 10. Garcı´a Morente M (1975) La filosofı´a de Kant. Espasa-Calpe, Madrid. 11. Kuhn TS (1962) The Structure of Scientific Revolutions. Chicago University Press, Chicago. 12. Auden WH (1948) The Age of Anxiety. A Baroque Eclogue. Faber & Faber, London. 13. Olvet DM & Hajcak G (2008) The error-related negativity (ERN) and psychopathology: Toward an endophenotype. Clinical Psychology Review Jul 9. [Epub ahead of print] 14. Baeyer W von (1984) Angst als erlebtes Bedrohtsein. Hinweis auf die Angst-Lehre des Jakob Boehme. Nervenarzt 55, 349–357. 15. Sartre JP (1939) Esquisse d’une theorie des emotions. Hermann, Paris.
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16. Lo´pez-Ibor JJ (1985) Psychopathological aspects of the Toxic Oil Syndrome Catastrophe. British Journal of Psychiatry, 147, 352–365. 17. Rilke RM (1978) Letters to a Young Poet. W.W. Norton, New York. 18. Augustine (1909-14) The Confessions. Harvard Classics. P. F. Collier & Son Company, New York (also in Bartleby, New York, 2001). 19. Kierkegaard S (1957) Concept of Dread (translator: Walter Lowrie). Princeton University Press. Princeton, NJ. 20. Heidegger M (1966) Being and Time (translated by Joan Stambaugh). State University of New York Press, Albany NY. 21. Spinoza B (1996) The Way to Wisdom. Purdue University Press, Lafayette IN. 22. Tillich P (1992) The Courage To Be. Yale University Press, New Haven Co. 23. Schneider K (1959) Clinical Psychopathology. Grune and Stratton, New York. 24. Zubiri X (1991) Las fuentes espirituales de la angustia y la esperanza. Revista latinoamericana de teologı´a 22, 91–97. 25. Lo´pez Ibor JJ (1950) La angustia vital. Paz Montalvo, Madrid. 26. Lo´pez Ibor JJ (1966) Las neurosis como enfermedades del animo. Gredos, Madrid. 27. Kretschmer E (1958) Hysterie, Reflex und Instinkt. Thieme, Stuttgart. English translation: Hysteria, Reflex, and Instinct. Philosophical Library, New York.
CHAPTER 1.4
Psychiatry of the Whole Person – Contribution of Spirituality in form of Mystic (Sufi) Thinking Ahmad Mohit Professor of Psychiatry, Iran
I died as an inanimate To be borne a plant I died as a plant To be borne an animal I died as an animal To be borne a man And. . .later on I shall be flying like an angel And turn into what doesn’t even approach imagination – Rumi [1] Cytoarchitectronics of the cerebral cortex are sculpted by input from the social environment because socialization shapes the essential human attributes of our species. – Leon Eisenberg [2]
1.4.1
THE WHOLE PERSON (BEYOND BIO-PSYCHO-SOCIAL)
Before discussing the ‘Psychiatry of the Whole Person’ and relating it to one aspect of this whole, meaning ‘Spirituality’, we need to have an understanding of the ‘Whole Person’. The super system of the whole person is the product of the combination of many different, but dynamically interactive systems. Another way of looking at the whole person is to consider it as a system with different levels constantly and dynamically interacting. As shall be seen, the systems (or levels) that a whole person is composed of are more than what we customarily call Bio-psycho-social in psychiatry. All these levels are at the same time independent and connected. For instance the fact that a human embryo has certain genetic endowments (a purely biological ability) that enables him to attain the faculty of language Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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cannot help us understand ‘the creative aspect of language use’ [3], which has so much to do with numerous non-biological aspects. The first of such systems is the biological system or level of functioning. In the beginning there was the chaos of the earth that was gradually cooling off. In this chaos, there was no life and needless to say, no brain and mind. Looking back to that billions of years old history, the first and the most basic question with much relevance to the discussion of ‘The whole person’ is how life started, how organisms were formed and started to interact internally and with the outside world. Putting the theories aside, as Fredric Gowland Hopkins said about 80 years ago ‘life is a dynamic equilibrium in a polyphasic system’ [4], an equilibrium that is the product of chaos, out of which, order is borne. Biological information is transmitted by different languages. There are phylogenic languages in the form of DNA sequencing and genes that transmit the information across generations, and there are onthogenic languages in the form of hormones, nerve impulses and transmitters that transmit information internally and with the organism’s environment. Biological systems also have different levels which start from a unimolecular virus and become as complicated as the human brain. All of these systems interact in a human body and the working of a human depends on this interaction. From the very moment of inception, the human fetus, which already carries the genetic information; is under the influence of countless types of information. At the unicellular stage, it carries the general ability to react to the information in the form of Irritability. A cell shows this reaction to some types of stimuli, but its reaction to all kinds of stimuli are similar. With cell division comes differentiation of cells in relation to functions. The evolution of irritability gives rise to Sensation. With sensation the organism becomes able to read different languages (types of information) existing in the world. These are the languages of, touch, sounds and so on. When the organism becomes aware of sensing something Perception starts and here this is another level of function which can no longer be understood by pure biological laws. Up to the level of pure and separate sensation and isolated perceptions; the working of an organism is both understandable and explainable at the biological level. In reality though, ‘mental experience is not composed of separate bits but forms a unity, and the fact that this unity involves a constructive activity of the mind itself rather than a passive reflection of external events’ [5]. Therefore, when we need to find explanations for forming a whole picture, a gestalt or unity; biology alone is no longer sufficient. Forming a whole picture of what is there in the world, is done through combining the senses and perceptions and relating them to each other. This is apperception, the first prerequisite for ‘Cognition’. And this is the beginning of the psychological system. The percepts combine with each other; they get meanings and attach to emotions. Now the organism is ready for a qualitative leap forward and the human language emerges. Many animals communicate with members of their own species, but communication of humans through the ability of human language is unique. It is through such a level of communication that humans become the only true social animals and the social system or level becomes a part of the definition of human functioning. It is through language that humans relate to each other inside one generation and also beyond their generation. It is through language that humans register their verbal history and deliver it to the future. And . . .‘nothing makes sense in biology except in the context of history . . . which includes evolution, development, social, cultural and technological history’ [6]. Therefore, the next system or level is the social system, including family, which is an important system in its own right, and school, working place, society at large, community and neighborhood, area and nation and the whole humanity. With the advent of information technology, the social
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systems of humans include a new and very influential formation named Virtual Environment. And the systems that contribute to the ‘Whole Person’ do not stop here. There are other aspects to humans with highly important effects on health and disease and particularly mental health. The following are the most important of these aspects. 1. As has been mentioned humans are ‘Historical’ creatures. The origins of a person becomes a part of his identity. We not only judge ourselves and others based on identities like belonging to a family, profession, neighborhood, city, a nation and its history; our concept of wellness are also affected by the traditions and thought patterns of the people we belong to. 2. People also belong to their pre-historical past through their myths. Myths are the oldest and most profound remnants of human interaction with nature. Identity, including sexual identity, which determines how a person feels about his (her) own gender and self, is to a large extent determined by the way genders are presented in a people’s myths. Certain myths like the myths about creation play a profound role in people’s inner sense of life and love. The myths and archetypes are also related to the common and non ending anxiety of all humans at all ages; namely death. The fact is all living creatures have the instinct to preserve their own life, and also, the continuation of their species through reproduction. However, the only creature on earth that is conscious of the inevitability of death is human kind. This is associated with fear of death, uncertainty about the future and need for explanation. Death also functions as a strong leveling force. Many poets, philosophers and thinkers have pointed out that ‘Death is the only thing that makes everybody equal.’ Considering all these aspects of myths, Karl Gustav Jung was the great psychiatrist who introduced myths, archetypes and our deeply rooted mythology as another system of the whole person, mythological system [7]. 3. And the whole person is not all memories of the past and realities of the present time. The whole person has an eye on the future as well. Imagination, vision, speculation, planning, hope and despair are all related to this ‘ability to construct the future’ in the mind, which in its developed form is uniquely human. 4. And being composed of all these various systems and having so many unanswered questions, humans need something to calm them, detach them from the trivia and explain their endless questions, particularly the ones about origin and destiny. And that brings another system and dimension to the whole person, the one called spirituality.
1.4.2
WHAT IS SPIRITUALITY?
Many meanings can be attached to the word ‘spirituality.’ These range from belonging or inner devotion to a religion or an ecclesiastic, to having a predominantly spiritual character as shown in thoughts and life. Here this word is selected to refer to any experience or way of life, religious or otherwise, which can help the person to detach from the trivia, transcend and reach a calming and reassuring level of connectedness, meaning and purpose. Understanding the spiritual experiences may vary with cultures, individuals, and different stages of life. Such understanding may also be affected by the prevailing modes of conceptualizing health and disease in general and mental health and illness in particular. A clear example is understanding mental illnesses based on a purely ‘biomedical’ model in which a living organism is basically seen as a biological machine and diseases are viewed as
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very specific entities as compared to a mainly ‘integrative, holistic’ model, which takes all aspects of human life including spirituality and culture into consideration. In relation to psychiatry, one can consider issues related to spirituality as a part of cultural psychiatry. Cultural psychiatry deals with the definition of culture, interactions between it and the individual, culture specific syndromes, and cross-cultural differences in definition of health, illness and healing [8]. It is an expanding and at the same time disputed area of today’s psychiatry. Lewis and Kleinman state that this is now a matured discipline that holds great promise for understanding the ways social relations cause body experiences. They consider cultural aspects of treatment modalities, including pharmacotherapy, as relevant points for patient care and health policy. They also point out that in spite of all evidence pointing to the importance of cultural factors in mental health, a general inattention to these factors can be judged in many areas. Examples are: lack of cultural validation of classifications, widespread misdiagnosis of ethnic minorities and racial bias in treatment recommendations. They conclude, ‘psychiatry needs new ways of delivering culturally appropriate care to the disenfranchised and the destitute.’ For the present author, whose responsibility is to think, plan and assist in the development of such systems of care for a region, nothing is closer to the truth.
1.4.3 SOME HISTORICAL OBSERVATIONS ON DIFFERENT DOMAINS OF THE SPIRITUAL EXPERIENCE 1.4.3.1
Greek, Middle East and Mesopotamia
The need for spiritual attachments, feelings and practices is probably as old as humans’ earliest societies and our ancient ancestors’ bewilderment and unanswered questions in confronting the nature that Karen Armstrong refers to as this ‘beautiful and horrifying world’. Humans created religion at the same time as they started to create works of art. According to Wilhelm Schmidt, as quoted by Karen Armstrong [9], ‘in the beginning and before men and women started to worship a number of gods “there was a primitive monotheism”. This primal God was a Supreme Deity, who had created the world and governed human affairs from afar.’ This very early God was the Sky God. Later on and with the advent of agricultural societies in the Paleolithic period the concept of Mother Goddess appeared and took different forms and names like, Inana in ancient Sumeria, Ishtar in Babylon, Anat in Canaan, Isis in Egypt and Aphrodite in Greece [10]. It is interesting that in those early days too, all aspects of spirituality including art were influenced by this image of a kind of god-like figure in peoples’ minds. Sumerians who lived in Mesopotamia 4000 years ago built the temple-like structures of Ziggurats. Babylonians who replaced them many centuries later attributed their cultural achievements to gods and believed Babylon to be an image of heaven. They attributed their power to gods who had brought order out of primordial chaos and created mankind from their own essence. In this, one can find one of the first origins of holistic thinking: All that exist are from the same essence and the aim is to bring order out of chaos. It was upon this background that Abraham, the father of Jewish, Christian and Muslim monotheism should be seen. In recent times, a small number of studies related to historical, cultural and spiritual aspects of psychiatry have been undertaken in the countries of the Middle East. Most of these studies are in the form of literature review or monographs. The present author is aware
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of the following studies. Basher has done a major overview on the history of Arab psychiatry [11]. Saa’edi [12], has done a monograph on the practice of Zar in southern Iran. Davidian [13] has written on Iranian mythology and psychiatric symptomatology in Iran and is working on a major work on the history of psychiatry in Iran. Okasha [14] has studied the roots of psychiatry in ancient Egypt. Moharrery [15] has done a study on psychiatric symptomatology in the writings of the tenth-century Iranian physician Jorjani. El Haddad [16] is doing a study on the history of psychiatry in Bahrain. Moussaoui in Morocco and El Ammar in Tunisia have also worked in this area. Studies on cultural similarities between different countries of the region are rare. Perhaps the most comprehensive ones are still Dr. Taha Baashar’s chapter on the Arab world in the book World History of Psychiatry [17] and Dr. John Racy’s [18] contribution to the book Religious Systems and Psychotherapy under the title of Islam. These two articles are very informative, but are almost completely limited to Arab countries. They do not represent the rest of the region. The present chapter aims at being an introduction to the understanding of the origins of common cultural notions, thoughts and beliefs in different people and cultures of this region that make them cohesive enough to form a cultural system.
1.4.3.2
Indian-Buddhist
Although the very ancient religion of Indians expressed in the odes known as Rig-Veda is consistent with the existence of many gods; later on the belief in a holy power called Brahman which was believed to be present in each individual in the form of an eternal principle called Atman. It was believed Brahman was present in everything in the world. An idea which was taken on later by the mystics of all disciplines [19]. The concept of God in the Indian mind is not an ever observing, regulating and ordering power. It is an ever existing spiritual presence in everything [20]. The number of studies done on Indian-Buddhist spiritual values and their effect on psychiatry are numerous. This is particularly true for the practice of yoga as it relates to relaxation. The author admits that the present paragraph does not do justice to the vast area of this domain of spirituality. It is less than a drop in an ocean.
1.4.3.3
Ancient Persian (Iranian)
Ancient Iranians believed that every single person or object in the mundane world (getik) was held to have its counterpart in the archetypal world of sacred reality (menok). Of interest is the myth of creation in ancient Iranian thoughts according to which, the sperm of the first man on earth was cleaned by the sun, impregnated an angel and remained inside the earth for 40 years and then ‘Mashi,e’ and ‘Mashianeh’, representing man and woman, were born from it in the form of one plant. The two (man and woman) then were joined in the form of one plant and the soul (psyche) was between them [21]. It was believed that the psyche was created innocent and clean, but became sinful under the influence of evil (Ahriman.) Iranians also had their own monotheistic religion called Zoroastrianism. It was a religion that praised productivity in cultivating the land and raising livestock and was quite opposed to austere and ascetic practices common in some Hindu, Christian and Muslim Sufi sects. Later on, other Iranian spiritual trends like Gnostisists and Manicheists appeared and had more in common with the post Islamic Sufi trends.
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Examples of non-religious spiritual experiences
The spiritual experience associated with art is known to anybody who just walks through the halls of an art museum and observes the behavior of the visitors. The deep silence of a concert hall and the sense of separation from trivia that is associated with the appreciation of a piece of good music are well known. Listening to a good poem rehearsed in an appropriate way and writing poetry can both be a source of spiritual satisfaction. These are just a few examples that are by no means enough. Spirituality associated with art deserves separate attention. Nature can be a source of deep spiritual experience. Having a humanitarian or altruistic cause and dedicating oneself to it, is a great source of spiritual experience.
1.4.4 1.4.4.1
WORLDVIEW IN MIDDLE EASTERN THOUGHT Philosophical trends
The greatest root of Western philosophy is in ancient Greek thoughts. Islamic philosophy also has some roots in Greek philosophy, however, it has roots in holistic Indian thoughts coming from Ghazni and Iran, Zoroastrian and Judaist thoughts about the afterworld, standing to answer for goodness and transgressions, Christian thoughts about the attributes of God, the nature of Christ and the word of God, determinism versus free will [22]. Islamic philosophy started to shape up with the development of the discussion about the verse of the Holy Koran being Pre-existent or Created. In the Old Testament man and his qualities were modeled after God: ‘Then God said, “let us make man in Our image, according to our likeness. . .” [23] as such, Word and speaking that is among the most human qualities of mankind is a part of the image of God, based on which, man is created’. In the Holy Koran, the role of Word, as discourse and commandment is described in ‘It is (God) Who has taught the Qur’an. He has created man: He has taught him speech (and intelligence)’ [24]. Whereas in Judaism and Christianity man is the representation of God on earth in general; in Islam God teaches the word to man. This leads to a kind of esoteric hermeneutics which seeks to comprehend the position of the prophet of Islam by mediating on the modality of his relationship, not with his own time, but with the eternal source from which his message emanates. This view contrasts with the historical critique of some scholars who attempt to understand the prophet through his circumstances, education and type of genius. As has already been mentioned, in addition to the main teachings and the way of life in Islam, as the main common denominator of the vast majority of the people in the Middle East, Islamic Mysticism (Sufi schools of thought) and the traditions, beliefs and practices related to them deserve attention. It is particularly true when we discuss the cultural aspects and their relation to mental health and illness. The cultural influence of Sufi trends in this part of the world is beyond their official recognition. It is sufficient to say that a major annual Sufi festival in the city of Tanta in Egypt attracts hundreds of thousands of people. It is also interesting to note that the book in second greatest demand in Iran, right after the Holy Koran, is The Divan (collected works) of the famous lyric poet Hafiz’, a renowned Sufi (or Arif, as Iranians like to say.) As has been mentioned, Sufi teachings are shared by all Islamic denominations in one way or another and are deeply integrated into culture, language,
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poetry and prose, music and all other products of intellectual and spiritual life. Many different people in the Middle East regard Hallaj, who was one of the Sufi saints, as a martyr. In summary, these thoughts and teachings are an essential part of common wisdom and their effect is beyond belonging to a certain religious denomination. The words mystic and mysticism that are adopted in the English language for the equivalent of the words Sufi and Sufism are hardly adequate. The same is true for the word Sufi itself. The Oxford Dictionary’s definition of the word mystic puts the emphasis on ecstatic contemplation and reliance on spiritual intuition. This, being to some extent true is just one aspect of the way these thoughts are perceived in the East. The word itself may have a negative connotation meaning irrationality, self-deluding attitude and hidden, supernatural practices related to certain sects [25]. Sufi on the other hand, is a name based on the appearance of the people who believed in these thoughts. In Arabic it means a person who wears wool. Both these terms miss the concept of Gnosis of one’s self and the whole that is the essence of these teachings. A better word seems to be Irfan (Erfan), an Arabic word used more in this sense in Iran, meaning ‘Gnosis’, ‘Knowing’ or ‘Wisdom.’ The knowledge it refers to, is inner knowledge of a more intuitive type and not only empirical knowing. As has already been mentioned, mystic thoughts do not only belong to Muslims. There is an immense current of spiritual understanding passing through all religions. Christian Mysticism is a great part of Christian history and practice. Mystic thoughts in Judaism and the practice of Kabala is an important trend in that religion. Practically speaking, however, it is in the Far East, the Indian subcontinent and the Middle East that they have affected the culture and meaning of life most. Describing all aspects of Middle East mystic thoughts is beyond the scope of this chapter and the ability of the present author; but it is necessary to point to the main teachings that have greatest influence on cultures. An effort is also made to show the foundation of holistic worldviews in these thoughts. Some of the relevant points are as follows: *
God is an ever present ‘Ultimate Truth’, in unity with every existence. It is ‘Unity’ and not ‘Polarity’ and ‘Love’ and not ‘Fear’ that characterize human being’s relationship with the Divine. In one of his many symbolic stories, the great thirteenth-century mystic poet and philosopher Rumi [26], talks of a simple shepherd who was praying to God using the friendly, down to earth, kind words of a friend or one family member to another. A prophet who was passing by saw the man talking to God in such a simple, informal way. He got angry and condemned the man. Soon the prophet hears the condemning voice of God requesting him to offer his apologies to the simple man who was so correctly and sincerely addressing his god. Such an example of relating to the ultimate authority, when put in the context of cultural behavior provides a trend which indicates the individual’s unique place and esteem in the authority’s eye. Since, within the historical perspective of the region, authority and power are mainly associated with the exercise of tyranny, cruelty and bloodshed, an easy and open relationship with authorities is the best antidote for fear and insecurity. Examples of this type can be seen in people’s relationship with their natural community leaders (not necessarily political), which is at the same time respectful, but informal and down to earth. Such relationships exist in many communities in the Middle East. The author has observed it at its best in a village in the Sudan, where the religious leader (Sheikh) also functions as a traditional healer. The natural confidence of people in such a community leader is unlimited. This has major mental health
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*
*
*
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significance, hence these healers can be trained to offer some level of modern mental health services, as it has actually been done in the Sudan [27]. Life is seen as an evolutionary continuum. Man is at the same time a part of nature and God’s hire and substitute on earth. Nothing exists that is unrelated to other existing creatures. Nothing can be understood in isolation. Understanding can only be gained by examining the Undivided Whole, that is, parts, plus their interaction. Here, again, one of Rumi’s symbolic stories comes to mind. It is the famous story of the people who were touching an elephant in the dark, each thinking of something, according to the part of the body they had touched. They were in the darkness of their reduced perception and missing the whole. This is a clear example of the depth of holistic approach taken by Rumi and other mystic thinkers [28]. Believing in the existence of Shohood [29], which is an intuitive knowledge gift. The word ‘Shohood’ means vision or seeing with an inner eye. The sudden enlightening of a poet when the first line of a poem sparks in his or her mind, is a good example of such an occurrence. Such intuitive knowledge has been the genesis of much philosophical, scientific and particularly artistic creativity. It has been as valid, important and useful as empirical knowledge. Ironically, what artists see and describe in abstract forms, science discovers in concrete forms many years later. As an example, the scientific equivalents of the holistic view of the world in the form of the laws of modern physics are a product of the twentieth century. However, the truth about the holistic nature of the world and mind was appreciated centuries ago in the concepts of Indian mythology and thought and later on in the works of some poets, and to a certain extent, philosophers. Can the knowledge of such a history of thought behind us help in understanding the mind as a system in modern times? The formulation of the concept of (Vahdat e Wojood) meaning Pantheism (Unity of all in Existence) as a principle of Sufi thought is owed to two great thinkers Bayazid e Bastami from Iran and Ibn e Arabi [30] from Andalucia. The origin of this concept which sees the ultimate truth everywhere and within one’s self is Indian and needs a detailed discussion [31]. Put simply, one can say that this concept refers to the unity of the creature with the creator. As such, the whole world is seen as a super-system of systems which is all a reflection of the divine, and is all connected in oneness. This is also another version of a model that tries to gain knowledge in the unity of a living, interactive whole and not the reduced, dead parts of it. In psychological terms, being a part of this belief system gives the person the security of belonging and being connected to a cosmic network of knowledge and love.
1.4.5 HOLISM AND REDUCTIONISM IN MODERN PHILOSOPHY AND SCIENCE. A COMPARISON WITH MYSTIC THOUGHTS [32] Like modern medicine, modern psychiatry started as a product of Positivism [33], industrial revolution and Newtonian scientific methodology. These scientific disciplines were empirical and the dominant philosophical and methodological tendencies governing them, were, and to a large extent remain reductionist, laboratory and experimental based, all relying on simple cause and effect relationship. Undoubtedly these methods have made tremendous contributions to the advancement of medical and non-medical sciences including some aspects of the human mind. They are preferred methods of research when the subject is hierarchically simple and belongs to one scientific discipline. However the efficacy of these
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methods comes under question from two sides: dealing with complex, multifaceted issues like the human mind, and confronting scientific questions related to modern causality like the ones in Quantum Physics. The first decades of this century witnessed revolutionary advances in science and theories like Einstein’s ‘Relativity’ and Heisenberg’s ‘Principle of Uncertainty’, which shook the very basis of Cartesian thoughts and the Newtonian and Pascalian worldview of a predictable clock, which up to that time were non disputable principles of modern science. From then on, it was not enough to look at the parts or details of what was being studied. The inter-relatedness and constantly changing condition of these parts were even more important. Furthermore, it was ‘the fundamental inter-relatedness and inter-dependence of all phenomena and the intrinsically dynamic nature of reality’ that was important. In other words, it was the Whole and not the reduced parts of it that were becoming the subject of science and knowledge. The impact of these theories did not remain limited to the world of physics and particles. Biology, neuroscience, psychology and sociology were also affected. However, resistance was also strong. The main reason for such resistance was that it was much easier to work and do research in the accustomed, predictable laboratories. The reader, particularly if Western, may rightfully ask: What is in common between these advanced scientific and methodological developments in quantum physics with ideas in Indian mythology or the philosophical beliefs of some ancient Indian thinker or twelfthcentury oriental, and seemingly eccentric poets or thinkers? I would answer Attention to the whole and the inter-relatedness of the events. Behaviour of a particle, time in which it exists and space in which it moves and changes are so interconnected that they are just one whole. This is so similar to the opening invocation to the famous Isa-Upanishad the Sanskrit translation of which is: ‘That is whole. This is whole. From the whole emerges the whole. The whole is taken from the whole but the whole remains. And the similarity ends here. But there is one difference that makes the whole issue an important one from a historical, socialpsychological and cultural point of view. Holistic thinking in the East is the natural way of looking at the world, and that poet or philosopher has just put it in words. In the West, man reached this concept not as a natural inclination, but as a consequence of a scientific necessity. The natural inclination in the West is to dissect, reduce, experiment and the result is taken as the truth. In the East, on the other hand, the truth is seen in the whole, and in the unity of all the elements that make the whole, and the means that keep these elements together. The reduced part (separated organ) is not considered to be the same, when connected to the whole. How this can be applied to psychiatry is a question to be tackled. The fact is that psychiatry cannot afford to be only dependent on one area of its vast basic sciences, namely biology. Psychiatry is the science and the art of healing the whole man, whose definition goes even beyond the bio-psycho-social. Each person comes from a culture, belongs to a set of beliefs and responds to certain beauty in art and nature. Each person gets hope from a certain spiritual experience and belief. Psychiatry cannot afford to neglect these important aspects of human life in health and disease.
1.4.6
CONCLUSION AND SOME LESSONS FOR THE FUTURE
This chapter was intended to introduce some of the prevailing thoughts and attitudes in some schools of thought, like mysticism, that are, generally, more holistic. Historically, a great
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number of such cultures and ways of thinking and the practices related to them originated, flourished and continue to be practiced in the Middle East. On the other hand, this area of the world is one of the cradles of civilization and some of the most important cultures and religions that continue to inspire the world were born here. But the truth is that such trends of thought and even practices are not limited to this part of the world and exist in all parts of the world. And, it is quite interesting that more recently, these ideas are rapidly becoming a part of Western curiosities and in some circles popular culture as well. Different notions regarding the working of the human mind can be traced back to old mythological, philosophical and general trends of ideas of the people with such holistic ideas. Some are the different beliefs and rituals about the origin and treatment of mental illnesses. In general, reasons were given in favor of the presence of a more holistic view of the human mind in the oriental (mystic) way of thinking. The author feels these issues are quite relevant to today’s psychiatry, which is in some way, struggling for a new identity. This chapter started with two quotations: The first one is from one of the most eminent Eastern Sufi thinkers of the twelfth century about the origin of man and our common heritage with nature and our connection to a spiritual future. The second is from an eminent psychiatrist of our time about the relationship between the cytoarchitectronics of the human brain and inputs from his social environment. These are the type of holistic ideas, based on which the real discipline of psychiatry can be built. This is where psychiatry can find its place, connected to, but independent of either pure neurology and neuroscience, or pure social sciences. Psychiatry deals with the translation (transduction) of social and personal (psychological) experiences to biological (i.e. synaptic) changes and vice versa. Problems, dysfunctions or imbalances in each level of this system can cause psychiatric disorders. Social inputs have many different origins. They may originate in the mythological, cultural, historical or contemporary events. They reach a nervous system that is made of a genetic structure, a certain level of biological integrity and at any given moment, the effects of all the information it has received. Pathology is always the result of a continuous, dynamic interaction between all these factors that are incessantly being translated to each other. Although the task of each branch of science is to dissect its respective subjects and reduce them to understandable mathematics, the result of their work is not always the truth about the whole. This idea that is so clearly described by Leon Eisenberg originated in the East and is the natural way of looking at the world there. Later, it was elaborated in the works of many Middle East thinkers and found new dimensions. We live at a time when the practice of psychiatry and the future of our patients and the increasing number of people who need our help, are at a very crucial stage. None of our famous theories of this century, from pure behaviorist reflexology to elaborate psychodynamic formulations, have proved sufficient to describe the human mind in health and disease. Our new hopes on synapse, as the biological answer to the complexities of the mind, pragmatic and convenient as they can be, are too simplistic to provide all the answers and solutions. It is time for reflection and perhaps our diverse cultural heritages can help. There is a wealth of wisdom in this diversity. There is another reason to look more carefully at the contributions of different cultures, beliefs and practices including different aspects of spirituality. We need to know the realities of other cultures. Each culture has the potential for some contribution to the advancement of our complex and multi-dimensional discipline. Knowing other culture’s contributions can also help by decreasing some of the misunderstandings we may have regarding other
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cultures. It also helps us to become more humble and distance ourselves from the dangerous attitudes of ‘we know it all.’ Or ‘one discipline embodies all the truth.’ The new developments in molecular biology and mapping of the human genome and the like are all good news. We are now, for the first time, hopeful when regarding probable solutions for medical and psychiatric problems of a very complex nature. But are these the keys to enter the temple of truth? Some try to make us think this way. However, the wisest among us caution that it is the beginning of the road and not the end. In a recent landmark article S. E. Hyman [34] tells us that these new developments have now given us the opportunity to come up with a legitimate series of questions that are to be answered. Questions like: ‘How is the human brain built? How does it change over a life span/what are the precise genetic and environmental risk factors for mental illnesses? What are the pathophysiological processes that produce the symptoms and disabilities? How do our treatments including psychotherapy work?’ He then observes that ‘although genes will provide critically important ‘bottom-up’ tools to investigate mechanisms leading to illness, sophisticated ‘top-down’ tools provided by integrative neuroscience and behavioral science will be no less crucial.’ Then he proceeds to make what I feel is the most important statement in his paper. ‘Neither do our brains simply reflect the deterministic unfolding of complex genetic programs, nor are we the victims of environmental determinism inscribing indelibly on a tabual rasa. Throughout development and maturity, genes and environment are involved in a set of complex and almost inextricable interactions. Everything we learn . . .. Physically changes the brain.’ This is a clear call for the need for a more holistic look at the human mind in health and disease. It is a welcome call coming from one of the most influential places in our discipline. Culture, mythology and contribution of schools of thought are undoubtedly an important partner in this pursuit of truth and in our effort to help our patients to the best of our ability. Many voices from many corners of the world call us for such an approach. Call us for a more holistic approach [35, 36]. Finally, for those of us in charge of provision of models for services, knowledge of cultural contributions is of great importance. It gives us clues as to the existing potentials we may otherwise be unaware of. It provides opportunities for designing services that are more acceptable to users. It helps in decreasing the stigma and provision of more humane services. I would like to finish with a quotation from another prominent psychiatrist of our time, Aubrey Lewis [37] who in 1962 wrote: ‘The philosophers thought it proper to put not one but two mottoes on The temple of Delphi: one, the better remembered, was ‘know thyself’: But the second, equally imperative, enjoined ‘nothing in Excess’. It might be worth inscribing that over the Temple of Psychiatry.
REFERENCES 1. Rumi Mawlana Jalaleddin (Mawlavi) (1990) “Mathnavi e Ma’enai” a book of philosophical and mystic teachings in Persian language poetry. Etesami M (ed.) Zowwar Publishers, Tehran. (Translation of the quoted lines to English is from the author of this article.) 2. Eisenberg L (1995) The Social Construct of the Human Brain. American Journal of Psychiatry 152, 1563–1567. 3. Chomsky N (1998) On Language. The New Press, New York, pp. 137–138. 4. Rose S (2005) The Future of the Brain. The promise and perils of tomorrow’s neuroscience. Oxford University Press, New York, p. 12.
84 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.
27. 28. 29. 30. 31. 32.
PROLEGOMENA (FIRST ISSUES) Richard LG (ed.) (1987) The Oxford Companion to the Mind. Oxford, pp, 33–34. Same as Ref. No.4. Jung CG (1964) Man and His Symbols Laurel, New York. Lewis Fernandez R, Kleinman A (1995) Cultural Psychiatry. Theoretical, clinical and research issues. Psychiatric Clinics of North America 18, 433–448. Armstrong K (1999) A History of God, Vintage, The Random House Publishing Group, London, pp. 9–11. Ref. No 7 Page 11. Taha Ba’ashar (1975) The Arab countries. In: Howells JG (ed.) World History of Psychiatry. Balliere, Tindall, London, pp. 402–410. Saa’edi Gh (1967) Ahl e Hava, (Inhabitants of Air), a monography on Zar in southern Iran (1346, Iranian year). Daneshkadeh e Adabyiat, Tehran (In Persian). Davidian H (1965) Ahamiat e Bar rasi e Asaatir e Irani (The importance of evaluation of Iranian mythology) (1344 Iranian year). Sokhan 15, pp. 2–19 (in Persian). Okasha AOur Heritage: A Perspective of Mental Disorders in Pharaonic Egypt. Proceedings of Thematic Conference of the Eastern Mediterranean Region, World Psychiatric Association, Kaslik, Lebanon, 14–17 April 1998. First published in Egyptian Journal of Psychiatry 1978, 1, 3–12. Moharreri RPsychiatric symptomatology in Zakhireh e Kharazmshahi, Tenth century medical book by Jorjani. Personal communication. Personal communication. Ref 11 above. Racy J (1973) Islam. In: Cox RH (ed.) Religious Systems and Psychotherapy. Thomas Publishers, Springfield, pp. 156–167. Capra F (1989) The Uncommon Wisdom. Conversations with remarkable people, 2nd edn. Flamingo, London, pp. 43–46. Taken by meaning from ‘The Upanishads’ translated by Robert Ernest Hume, Continuum Publishers, New York, London, 1984. Bahar Mehrdad (1996), Pazhooheshi dar asatir e Iran (An Essay on Iranian Mythology) (1375, Iranian Year). Agah Publishers, Tehran, Iran (in Farsi). Durant W (1980) The Age of Faith. The story of civilization Part IV, chapter 12/4 (philosophy). Simon and Schuster. Inc, New York, pp. 163–177. Holy Bible (The New King James Translation), verse 1. Book 1. American Bible Society, New York, 1994. Holy Koran, Verse 1 Sourah Al Rahman (From Original Arabic). Bothamley J (2002) Dictionary of Theories. Visible Publishers, Detroit, p. 358. Maulana Jalal e din (Maulavi), Mathnavi e Ma’enavi’ (a book of symbolic philosophy and mystic teachings in Persian language poetry, M. Este’lami ed. Zowwar publishers, Tehran, 1369 (Sh) 1990. Baashar T (1962) Some aspects of the history of the treatment of mental disorder in the Sudan. Sudan Medical Journal 1, 44. Ref. 23. Schimmel A (1978) Mystical Dimensions of Islam. The University of North Carolina Press, Chapel Hill, NC. Ibn e Arabi, Muhyiuddin in Sufis of Andolusia translated by R.W.J. Austin. London, 1971. Wig NN (1999) Mental Health and Spiritual Values. AView from the East International Review of Psychiatry 11, 92–96. The views presented in these paragraphs are combined by the author who has used three main resources: * Heizenberg W (1962) Physics and Philosophy, Harper and Row, New York. * Capra F (1989) The Uncommon Wisdom. Conversations with remarkable people, 2nd edn. Flamingo, London.
1.4 *
33. 34. 35.
36. 37.
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Bunge M (1980) From Neuron to Behaviour and Mentation, an Exercise in Levelmanship. In: Pinsker HM & Willis WD (eds.) Information Processing in the Nervous System. Raven Press, New York. Chung MC, Nola P (1994) The influence of positivistic thought in nineteenth century asylum nursing. Journal of Advanced Nursing 19, 226–232. Steven E Hyman, MD (2000) The Millennium of Mind, Brain, and Behavior, Archives of General Psychiatry 57, 88–89 Robert M Young The Moral and the Molecular in the Future of Psychiatry. Paper presented to the Conference on the bi-centerary of the founding of the York retreat, The Retreat, York, UK, 4 October 1996. Paper on the internet. Wig NN (1998) Mind and Medicine. Annals of National Academy of Medical Sciences (India) 34, 191–202. Quoted from Eisenberg L (1997) A very British kind of social psychiatry. British Journal of Psychiatry 171, 309–313.
Part 2 Main Issues: The Interface Between Psychiatry, Mental Health and Major Religious Traditions INTRODUCTION We are in search of the relationship between (medical) science, psychiatry in particular, and worldview and practical religious beliefs. Throughout this volume authors will remind the reader of the barriers that stand between religion and psychiatry (and psychotherapy). In fact we were accustomed, and still are, to a kind of dissociation, to a split of religion and psychiatry. This split can also be seen in the field of psychiatry itself. It is the split between psychopathology that is the real problem, defined by classificatory schemes, and the life history and psychosocial context in which psychopathology unfolds. Religion and spirituality belong to that context and are no part of the ‘real’ problem. In this second part the contributors explore a diversity of aspects of the interface between psychiatry and religion. Of course they were free to do so in their own way. However, we wanted to see how they would (try to) overcome the split. So they inform the reader in various ways how (their own) religious traditions and spirituality influence (their) thinking about psychiatry, human nature, mental health, psychopathological phenomena and mental illness. To put it in epistemological terms, how naturalistic, or realistic, or reductionistic are they in their approach? Or, in ontological terms, is their view on the interface between psychiatry and religion qualified by realism, or idealism, or essentialism? Terms like these, one by one, refer to as many hindrances and boundaries.
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The reader is invited to investigate questions like: What is his view on the issue of human nature and agency? In what ways do the reader’s religiousness, spirituality and worldview influence thinking about mental health and illness? What aspects of religion and spirituality are most likely to influence (physical and) mental health? What are the boundaries like? How best to overcome these? 2.1 Judaism and Psychiatry Ayala Uri, Noa Navot & Alan Apter 2.2 Christianity and Psychiatry John R. Peteet 2.3 Religion and Mental Health in Islam Ahmed Okasha 2.4 Psychiatry and African Religion Frank G. Njenga, Anna Nguithi & Sam G. Gatere 2.5 Hinduism and Mental Health R. Srinivasa Murthy 2.6 Buddhism and Psychotherapy in Japan Naotaka Shinfuku & Kenji Kitanishi 2.7 Psychiatry and Theravada Buddhism Pichet Udomratn
CHAPTER 2.1
Judaism and Psychiatry Ayala Uri and Noa Navot Child Psychiatry Fellows, Israel
Alan Apter Professor of Psychiatry, Israel
2.1.1
INTRODUCTION
The basic question which the authors of this chapter had to ask themselves is whether or not there is a Jewish approach to psychiatry which is different from that of other religions and if a Jewish understanding of psychology and psychiatry has anything which is unique or specific to offer to the field of psychiatry and religion as discussed in this volume. Even more problematic is the effort to explain what is meant by Judaism and how Jewish psychiatrists see their Judaism as affecting their professional lives and practice. What is Judaism? What does it mean to be a Jew? Most people, both Jewish and gentile, would instinctively say that Judaism is a religion. And yet, there are militant atheists who insist that they are Jews! Clearly, there is a religion called Judaism, a set of ideas about the world and the way we should live our lives that is called ‘Judaism.’ There is a lot of flexibility about certain aspects of those beliefs, and a lot of disagreement about specifics, but that flexibility is built into the organized system of belief that is Judaism. However, many people who call themselves Jews do not believe in that religion at all. More than half of all Jews in Israel today call themselves ‘secular,’ and don’t believe in God or any of the religious beliefs of Judaism. Most Jews in Israel and the United States don’t belong to any synagogue. They may practice some of the rituals of Judaism and celebrate some of the holidays, but they do not think of these actions as religious activities. Other possibilities include regarding Jews as a race, nation or culture, however none of these definitions is satisfactory and a full discussion of this matter is beyond the scope of this chapter. Judaism is not a static entity, but an evolving culture which has continually developed and changed over the last 3000–4000 years. The Judaism of the Old Testament is very different from the Judaism of the Talmud and of Hassidism which are in turn very different from the Judaism of the Holocaust and from the Judaism of modern Israel and the Diaspora.
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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Our postulate is that Judaism has made specific contributions to psychiatry over the ages and that each period of Jewish history has in some way influenced the way the psychiatry is practiced. It is beyond the scope of this chapter to catalogue all these influences therefore we have chosen examples from four periods of time. These examples are somewhat arbitrary and reflect the authors’ own prejudices and interests and should not in any way be taken as representative of any official view of Judaism. None of the three authors of this chapter are practicing religious Jews, but all are Jews living in Israel and all think of themselves as Jewish psychiatrists. Two (AU and NN) were born in Israel, one on a Kibbutz and one in an urban area, and are at the beginning of their careers, while the other (AA) came to Israel in the late 1960s inspired by the Zionist movement. In this chapter we did not aspire to define the relation between Judaism and psychiatry but to attempt to enlighten a few perspectives, guided purely by our own views and personal choices. Any discussion of the influence of Judaism must of course begin with the Old Testament. Many examples of the close interaction between what would now be termed psychotic symptoms and the development of human history can be found here. We feel, however, that the major contribution of the Bible to psychiatry can be found in the rich psychological descriptions of some of the major characters appearing in its pages. We have chosen the example of Saul as just one representative story which is of major psychological importance. Although Orthodox Judaism is not a central part of our lives and even in Israel it is not a major influence on psychiatry we felt that we should devote a section to this approach. In general the ultra-orthodox are suspicious of psychiatry and attach major stigma to mental illness. One major exception is the tradition of the ‘Mussar’ and its adaptation to modern psychiatry by Rabbi Dr. Twersky who is a major figure in the translation of psychiatric concepts for the Orthodox Jew. We then turn to the complex question of psychoanalysis. Terming psychoanalysis as a Jewish profession is controversial and perhaps even has antiSemitic connotations. Psychoanalysis, however, arose out of the anti-Semitism of the preholocaust era and was initially a profession practiced mainly by Jews. Although Freud did not like the idea that his views were in any way Jewish, recent scholarship has challenged this and has brought into focus the ‘Judaic’ nature of this school whose tremendous influence on psychiatry, controversial though it may be, cannot be denied. Finally, being Israeli we must see how modern Israeli literature sees psychiatry. Undoubtedly Shmuel Yosef Agnon is the most important prism through which to examine this aspect of Judaism and psychiatry. An ultra orthodox Jew, who won the Nobel Prize for literature, his work is resplendent with references to insanity and psychiatry and his psychological insights bring us full cycle back to the influence of the Old Testament and its rich psychological descriptions.
2.1.2
THE BIBLE
References to psychiatric conditions appear throughout the Bible and Prophets. Deuteronomy 28:28, 34 views madness as punishment for disobeying the commandments: ‘The LORD will afflict you with madness, blindness and confusion of mind.’ Several verses later, the curses continue in Deuteronomy 28:34 ‘The sights you see will drive you mad.’ It is also clear that the concept of a mentally incompetent patient was already established in the Bible. In First Samuel 21:14 Achish said to his servants, ‘Lo, ye see the man is mad:
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wherefore then have ye brought him to me?’. First Samuel 21:15 says: ‘Have I need of mad men, that ye have brought this fellow to play the mad man in my presence? Shall this fellow come into my house?’. Kings 2 9:11 describes the following: When Jehu went out to his fellow officers, one of them asked him, ‘Is all well? wherefore came this mad fellow to thee?’, ‘Ye know the man, and his communication’ Jehu replied. In Prophets, references to psychiatric symptoms are regarded as a type of supernatural punishment: (Zechariah 12:4) ‘In that day, saith the LORD, I will smite every horse with astonishment, and his rider with madness’. Also, in Hosea 9:7 ‘The days of visitation are come, the days of recompense are come; Israel shall know it: the prophet is a fool, the spiritual man is mad, for the multitude of thine iniquity, and the great hatred’. The tragedy of Saul’s (see below) last years is ascribed to an evil spirit that troubled Saul when the Lord departed from him. Saul’s paranoid fears and jealousy of David could not be assuaged by David’s attempts to help and reassure him by playing the harp (First Samuel. 16:14–23; 18:10ff. 19:9–10). Later, David himself, in order to escape from Achish, simulated insanity: ‘And he changed his behavior before them, and feigned himself mad in their hands, and scrabbled on the doors of the gate, and let his spittle fall down upon his beard.’ (21:11–16). The Bible does not speak of treatment of mental illness or recognize insanity as illness. On the contrary, it was enjoined that the person who was seen to be possessed by spirits should be stoned to death (Lev. 20:27); yet the Bible abounds in counsel for mental health, usually with an ethical intention. In Proverbs it is held that understanding is ‘a wellspring of life’ (16:22) and that ‘a merry heart doeth good like medicine’ (17:22).
2.1.2.1
Saul the son of Kisch
Saul was the first king of Israel. The story of Saul has an especial appeal for the psychiatric reader who is not particularly religious. The underlying motives and emotions that drive this tragic figure are complex and deeply interesting for psychiatry. Saul is also a central and unique figure in Judaic culture and thus his story has a definite place in a chapter of psychiatry and Judaism. Saul was a charismatic and dominant leader of the Jews who was active around 1025 to 1004 BC, a crucial period in the history of the Jews. Haim Nachman Bialik, the national poet of modern Israel described the situation in a speech given on the occasion of the opening of the Hebrew University in Jerusalem, summarizing 4000 years of Jewish history and capturing the spirit of Judaism: ‘Four thousand years ago the country was infested by gangs from Ur Casdim, from Aram, from Egypt and from the Arabian Desert. These peoples were divided by tribal loyalties and completely disunited. From these inauspicious beginnings, after seemingly insignificant and disparate events the small and poor nation of Israel was born. From this ragtag rabble mostly shepherds and cowboys, farmers and wood cutters a core of inspired visionaries arose who carried the spirit of GOD within them and spoke with thunder and lightning. These people rose above the petty needs of the day and dared to look at eternity, to the sky and to the earth. It was they who laid the cornerstone for universal culture and religion. Their voices still speak to us across the centuries after the rise and fall of many a great nation carried away by the tides of history’.
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In a period of spiritual and political crisis the nation asks the prophet Samuel to find them a king. (First Samuel 9:16) ‘To morrow about this time I will send thee a man out of the land of Benjamin, and thou shalt anoint him to be captain over my people Israel, that he may save my people out of the hand of the Philistines: for I have looked upon my people, because their cry is come unto me.’ Samuel refuses at first, however, after receiving orders from God he crowns Saul as king. The first description of Saul is as follows (First Samuel 9:1–2) ‘Now there was a man of Benjamin, whose name was Kish, the son of Abiel, the son of Zeror, the son of Bechorath, the son of Aphiah, a Benjamite, a mighty man of power. And he had a son, whose name was Saul, a choice young man, and a goodly: and there was not among the children of Israel a goodlier person than he: from his shoulders and upward he was higher than any of the people.’ There is no one better than he! Yet more of Saul’s character can be seen from the story of his father’s mules that went astray which were sought by Saul and his servant boy. This story shows up Saul’s modesty as a central feature of his character (First Samuel 9:5) ‘And when they were come to the land of Zuph, Saul said to his servant that was with him, Come, and let us return; lest my father leave caring for the asses, and take thought for us’. By placing himself at the same level as his servant Saul shows his lack of arrogance and his sense of equality. Saul says to Samuel (First Samuel 9:21) ‘And Saul answered and said, Am not I a Benjamite, of the smallest of the tribes of Israel? and my family the least of all the families of the tribe of Benjamin? wherefore then speakest thou so to me?’. Thus for Saul the charismatic but humble leader, now crowned as King of Israel, lay many awesome challenges. In the realm of affairs of state and politics he manages to unify the people, establish a stable and efficient army, and expand the borders of the Kingdom of Israel. All this in a time when (First Samuel 13:19) ‘Now there was no smith found throughout all the land of Israel’. Moreover, Saul also achieves major progress in spiritual and religious matters and purifies the land from sorcerers and idol worshippers. Until this point we have known Saul as a major statesman and leader, with a fine character, modest and merciful who has led the people to stunning victories and has unified the people into stable nationhood. From here, however, the story takes a dramatic turn. The idyllic story cracks and the inexorable tragedy entails. We shall try to follow the unfolding of events and the psychological processes that envelop Saul. The turn in the story begins with the tale of Agag the Malachite. God commands Saul to annihilate the Malachite nation including their king, their cattle and their sheep. Saul, however, spares Agag and even gives in to the supplications of the people and spares the livestock. Saul makes a tragic mistake which eventually leads to the loss of his kingdom and to his gradual ruin. What brought about this fatal error of judgment? By sparing Agag he shows his modest and sympathetic character but at the expense of showing weakness by giving in to the people and sparing the cattle (First Samuel 15:24) ‘And Saul said unto Samuel, I have sinned: for I have transgressed the commandment of the LORD, and thy words: because I feared the people, and obeyed their voice.’ How can we explain the grave consequences of a seemingly minor mistake? Perhaps this was not such a minor infraction but a misjudgment in understanding the task that he had been given as King of Israel. In the language of the Bible he had rebelled against the Word of the Lord, and from another point of view he failed to grasp the enormity of his duty and failed to grow into the required capabilities. Samuel
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says to Saul (First Samuel 15:17) ‘When thou waste little in thine own sight, wast thou not made the head of the tribes of Israel, and the LORD anointed thee king over Israel?’ In the words of Samuel he is not fit for the enormity and importance of his role because of his lack of self esteem. There is a major gap between Saul’s character with its modesty and benevolence and the majestic task which he has undertaken. Thus this seemingly minor error brings about a major turn of events in the story. The drama assumes the proportions of an Aristotelians tragedy [1], starting with the ‘fatal mistake’ or ‘missing the point’. Here we turn to the relationship between Saul and David. Their first meeting occurs when Saul is in crisis. He has been forsaken by Samuel and by God (the two father figures in the story), his kingdom has been taken from him and will eventually be given to someone better than he, and now his soul is tormented (First Samuel 16:14) ‘But the Spirit of the LORD departed from Saul, and an evil spirit from the LORD troubled him.’ In this state he meets David who plays the violin with extreme beauty in the hope of curing the king from his melancholy (First Samuel 16:16) ‘Let our lord now command thy servants, which are before thee, to seek out a man, who is a cunning player on the violin: and it shall come to pass, when the evil spirit from God is upon thee, that he shall play with his hand, and thou shalt be well.’ The treatment is successful, the music soothes Saul and he recovers. Moreover now he has come to love David (First Samuel 16:21) ‘And David came to Saul, and stood before him: and he loved him greatly; and he became his armor bearer.’ At this point Saul does not realize that David is destined to be the more ‘suitable’ person who will take the kingdom from him. Jonathan, Saul’s son also loves David (First Samuel 18:1) ‘. . . the soul of Jonathan was knit with the soul of David, and Jonathan loved him as his own soul.’ While Michal, Saul’s daughter, marries David. Subsequently, in the episode with Goliath, David surpasses Saul and achieves a great victory where Saul fails and was completely helpless. On David’s victorious return from yet another successful encounter with the Philistines we begin to see the jealousy growing in the heart of Saul (First Samuel 18:8) ‘And Saul was very wroth, and the saying displeased him; and he said, They have ascribed unto David ten thousands, and to me they have ascribed but thousands: and what can he have more but the kingdom?’. Saul’s initial love for David sours and his jealousy threatens to drive him insane. He becomes paranoid and is full of conspiratorial fears. He wishes to murder David and pursues him obsessively. Envy becomes the driving motif in the relation between the two protagonists of the tale. Saul loses everything, David wins everything. Saul loses his kingdom, the love of his children, victory and glory and most importantly the love of Samuel and God, his two father figures. All these now pass to David. Saul’s murderous feelings intensify, he pursues David, and in a dramatic encounter David refuses to kill Saul and finds himself at Saul’s mercy. Suddenly Saul reverts to his old nature. Generous and benevolent he spares David (First Samuel 24:16) ‘And it came to pass, when David had made an end of speaking these words unto Saul, that Saul said, Is this thy voice, my son David? And Saul lifted up his voice, and wept.’ The conflict between Saul’s love and jealous hatred of David arises once again. In the words of the Song of Songs (Song of Solomon 8:6) ‘for love is strong as death; jealousy is cruel as the grave’. Jealousy and envy are common in Jewish sources such as the story of Cain and Able, and the Old Testament realizes the centrality of these forces in human nature and their connection with mental anguish.
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The story of the sorceress is yet another step in the inexorable downfall of Saul. After purifying the land of sorcery, Saul abandoned by God turns to the very characters who he once abhorred. Tormented by despair he reclaims Samuel from the dead in order to ask him for help (First Samuel 28:15) ‘And Samuel said to Saul, Why hast thou disquieted me, to bring me up? And Saul answered, I am sore distressed; for the Philistines make war against me, and God is departed from me, and answereth me no more, neither by prophets, nor by dreams: therefore I have called thee, that thou mayest make known unto me what I shall do.’ Samuel foresees Saul’s defeat at the hand of the Philistines and Saul falls prostrate on the ground (First Samuel 28:20) ‘Then Saul fell straightway all along on the earth, and was sore afraid, because of the words of Samuel: and there was no strength in him’. He is completely distraught and broken (perhaps analogous to the stage of pathos in Greek tragedy). In the ensuing battle with the Philistines, Saul’s three sons are slain, he asks his armor bearer to kill him and when his request is refused he falls on his own sword. Thus suicide is the ultimate conclusion to this sorry tale. Following Saul’s death, David gives him his final rites in the words of his famous lament (Second Samuel 1:23–25) ‘Saul and Jonathan were lovely and pleasant in their lives, and in their death they were not divided: they were swifter than eagles, they were stronger than lions. Ye daughters of Israel, weep over Saul, who clothed you in scarlet, with other delights, who put on ornaments of gold upon your apparel. How are the mighty fallen in the midst of the battle!’ Thus the story of Saul, as told in the Bible from a Theo-centric point of view, but from which we can learn much about the psychology of man in an anthropocentric way. Seemingly a simple story it contains much of the complexity of human emotions: great loves, great hatreds, tremendous jealousies, father/son conflicts and encounters with fateful events. Saul, who at first is an admirable character, full of goodwill and charity, becomes a tragic hero when he breaks down; burdened by the challenges he is given by life and God. Abandoned by his father figures God and Samuel and then broken by his envy of David who took his father’s love he becomes tormented and deranged. Unlike his Homerian counterpart, Odysseus, he is not a man of ‘many devices’. On the contrary he is without fault. Perhaps his very lack of deviances brings about his downfall. Thus the Jewish Sages comment: The fall of Saul’s Kingdom was brought about by his faultless character. Thus these rich psychological descriptions make the Jewish traditions of the Old Testament, together with epics of Homerian literature, a model on which modern psychiatry can base its psychological analyses and understandings of the complexities of human behavior. For an excellent example of such an analysis dealing directly with Saul see Van Praag [2].
2.1.3 2.1.3.1
TRADITIONAL JUDAISM The Talmud [3]
Following the fall of the second temple the rabbis compiled the oral tradition of the Jewish law which was meant to serve the Jewish people who did not now have a physical temple. This oral tradition is called the Talmud. Talmudic references to the psychiatric patient largely dealt with his competence to perform commandments and responsibilities within the community. The first source is tractate Trumot ‘The deaf, the mad, and the child cannot bring tithes because a tithe requires competence and they are incompetent.’ Thus in the Talmud, mention
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of mental illness is generally of a legal nature. The episodic nature of mental illness is taken into account on several occasions and there are references to periods when the person is of lucid or of unsound mind. There are also suggestions of a possible classification of mental illness such as a mental defect, confusion, acute and cyclical psychoses, and those which result from physical illness. The Talmud recognizes mental illness and is chary of accepting popular definitions such as: ‘he who goes out alone at night, who sleeps in the cemetery and tears his clothes’ (Tosef., Ter. 1:3, and cf. Hag 3b). The word shoteh which contains the idea of walking to and fro without purpose is used to describe the mentally ill. The legal and social implications of insanity are frequently referred to in the Talmud. The mentally ill are not responsible for the damage they cause and those who injure them must bear the responsibility; the insane are not responsible for the shame they cause. They may not marry but, contrary to Greek concepts, in periods of lucidity the individual is considered healthy and capable from every other point of view. The Talmud sets very little store by magical medicines and cures for mental illness which were then current among the nations and were frequently found among Jews in the Middle Ages. It prefers to admit frankly the lack of effective treatment. We see that the Torah gives importance to the prevention of mental illness so that a person does not come to the point where he cannot withstand stress and succumbs to mental illness. King Solomon wrote in Proverbs 18:8 ‘The soul of man will sustain his illnesses.’ In many legal domains the importance of tending to one’s mental well-being is given highest priority. For example, a woman before giving birth is allowed to desecrate the Sabbath in order to ensure her emotional comfort, because mental stress is seen as dangerous to her and her baby’s well being. Another example is a terminally ill patient where there are many laws regarding how to communicate with him, and the need to fulfill his wishes and the reason is to insure that his emotional well-being is not damaged which would endanger his physical condition. In this respect the Jewish Law gives prominence to the mental aspects [4].
2.1.3.2
The medieval period [4]
In the twelfth century, the famous physician Maimonides took this dispute up in Hilchot Aydut 9:9, 10. There he writes: Shoteh is disqualified for giving testimony. . . and we are not referring to the shoteh who walks around naked, and breaks utensils, and throws stones exclusively [for he is a complete shoteh] rather anyone whose mind is deranged, and whose mind is disturbed constantly in any aspect, even though he speaks and questions appropriately in other areas, behold he is disqualified, and he is still considered a shoteh.
He further writes that the investigation of incompetence is dependent on a mental examination by experts in the mental sphere: ‘The inordinately foolish who are unable to discriminate between contradictory matters and who do not comprehend matters as other people do and similarly those who are mentally disoriented and impulsive and those who are excessively deranged [in conduct] are included in the category of shotim. This matter [is to be determined] in accordance with the perception of the judge for it is impossible to be precise in writing’.
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Due to the above source it is upon the ‘judges’ to determine in every area of Jewish Law whether one is sufficiently competent in order to perform acts according to the law, such as marital transactions, material possessions, damages, and oath taking. Maimonides was also an accomplished physician. His work Pirkei Moshe (‘The Aphorisms of Moses’) distinguishes clearly between motor and sensory nerves and voluntary and automatic activity. This book also deals with the anatomy of the brain and organic conditions such as epilepsy, weakness, contractions and tremor. Maimonides’ view of the influence of emotion on bodily function, in producing illness and retarding cure, was unique in his time. He was thus the father of psychosomatic medicine. In Hanhagat ha-Beri’ut (‘The Regimen of Health’) he sets out these views and instructions for attention to and the mitigation of the emotional state of the patient. He does, however, recognize the limitations of psychiatric care. The ‘Sefer Madda’ in Maimonides’ Code sets out clearly his views on the promotion of individual mental health. His orientation to it is, of course, profoundly ethical, yet he relates mental health no less to the pragmatic functioning of the body and its appetites and effects. In essence this view recommends the middle road between indulgence and asceticism. He abjures all magical procedures. The medieval flowering of Jewish medicine was followed by a prolonged period of folk medicine practiced by peripatetic healers. They acquired a reputation for healing as wonderworkers through incantations, amulets, etc. They treated mental patients as if they were afflicted by spirits, devils and impure influences. The founder of the Hasidic movement, Israel Ben Eliezer, in the eighteenth century, acquired his medical reputation by way of a rapid cure of a mental case. In the Middle Ages Jewish physicians, no less than others, were dependent on the humeral theories of Greek and Roman medicine (Hippocrates and Galen). Some Jewish physicians made original discoveries and contributions. Asaph, the earliest Jewish physician known by name who lived apparently in the sixth or seventh century, felt that the heart is the seat of the soul and vital spirit. In his work, The Book of Medicines, he refers to the disturbed behavior of epileptics and to psychosis–phreneticus. Shabbetai Donnolo, who lived in the tenth century, wrote in one of his medical books an analysis of the psychiatric conditions of melancholia and of nightmare. His description of mania contains a complex of conditions and undoubtedly included schizophrenia. Donnolo’s psychiatric views, while avoiding the magical element, are derivative from the humoral theory of the Greeks. Nevertheless, though some of his explanations could be termed psychological his treatment was almost purely medicinal [4]. Although traditional Talmudic writings have much relevance to the understanding of human nature and psychology, and Rabbinical authorities such as Maimonides, have written about mental illness, modern orthodoxy has based much of its attitudes to psychiatry on the tradition of the Mussar [5]. The modern translation of this tradition into popular use has been best articulated by Rabbi Dr. Abraham Twersky.
2.1.3.3
Mussar [5]
Much of the Rabbinic literature relevant to psychiatry is based on ideas developed in the Mussar. Mussar is a path of contemplative practices and exercises that have evolved over the past thousand years to help an individual soul to pinpoint and then to break through the barriers that surround and obstruct the flow of inner light in our lives. Mussar is a treasury of
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techniques and understandings that offers immensely valuable guidance for the journey of our lives. The goal of Mussar practice is to release the light of holiness that lives within the soul. From its origins in the tenth century, Mussar was a practice of the solitary seeker, until in the nineteenth century it became the basis for a popular social/spiritual movement. The Mussar movement arose among the non-Hasidic Orthodox Lithuanian Jews, and became a trend in their yeshivas (‘Talmudic schools’). Its founding is attributed to Rabbi Yisrael Lipkin Salanter (1810–1883), who was inspired greatly by the teachings of Reb Zundel Salant. Mussar, which embraces psychology and ethics, starts with the premise that ‘human beings are created with a yetzer tov (good inclination) and a yetzer hara (evil inclination)’, and these are constantly at odds locked in an ongoing struggle throughout a person’s lifetime. Luzzatto dramatically personifies the yetzer hara as a warrior dedicated to deluding and misleading the human mind (ish milchamah hu u-milumad b’armemiut), causing it to mix up moral categories and to resist change and growth. He likens human confusion to a labyrinthine garden (Ha l’mah zeh domeh? l’gan hamivuchah); the only way the bewildered soul can find his way out is by listening to one who occupies a position of discernment and who warns, ‘This is the path, take it!’ The great human vulnerability to the temptations of the yetzer hara can be combated by following the mitzvot (commandments) which are designed to keep the minds of men and women focused on the spiritual high ground, on their divinely inspired possibilities rather than the base dictates of the senses. In its development as a distinct genre of Jewish writing and thought, mussar tended toward a dim view of human nature, emphasizing the potency of the yetzer hara, the mighty efforts required to defeat it, and, in some of the darker works, the hellish punishments that would meet the morally lazy soul. ‘Jewish psychology rests upon the axiom that basically man has free choice in the realm of good and evil; that his behavior is not predetermined; that there is nothing from within or without forcing him to adopt a given behavior’ [6]. Man is responsible for his behavior. This is in complete contradistinction to both the principles of psychoanalysis and of therapies based on learning theory [6]. Perhaps the most prominent adapter of the principles of Mussar to modern psychiatry is Rabbi Dr. Abraham J. Twerski who is a well known Hasidic Rabbi and a psychiatrist. His professional specialty is in Substance Abuse, and he founded the Gateway Rehabilitation Center, Pittsburg. Twerski grew up with this idea of the yetzer hara as Satan, the Tempter, and ‘an angel created by God with a mission’. He shows special concern for the ways in which the yetzer hara confuses the mind, transforming it into a moral nemesis: ‘If you cannot resist temptation, that may be bad enough, but at least you may feel the pangs of your conscience and decide that doing something wrong is just not worth it. But if you deceive yourself that what you are doing is really fight, then you may never have a chance to correct your behavior. If you have some desires that would result in your doing wrong, don’t delude yourself that wrong is right.’ Twerski made an effort to combine Mussar with the 12 steps approach of alcoholics’ anonymous. The resemblance Twerski perceives between Mussar and 12 steps is a dominant theme in his writings. He depends fundamentally on psychological categories in spite of his rejection of psychoanalysis as a therapeutic tool. He does accept modern psychiatric practice stating for example that ‘Modern medical science now knows that depression and many related emotional conditions are not bad words at all’. Many such moods are physical problems that can be remedied with the proper understanding and treatment.’
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Although he would be the first to admit that Torah contains all the wisdom people need if only they knew how to look for it, he also states that: ‘When a person consults a psychiatrist or psychologist about a problem, he has already taken a major step toward its solution: he has recognized that there is a problem and has admitted that he needs help.’ If a person seems incapacitated by depression, Twerski must investigate the possibility of a biochemical problem before resorting to the conventional prescription of Mussar – the performance of mitzvot. The old Mussar formula of complete free will though not completely outmoded by modem psychology cannot stand uncontested and unamended in the Jewish world as it once did. His enthusiasm for the methodology of AA led inexorably to this realization, for the organization’s operating principle was to replace the old and largely inefficient moralistic approach to drinking with a more nuanced and empathic concept of addictive behavior. Recognizing the inherent limitations of moral exhortation and admonition in dealing with addicts, Twerski preached to his fellow therapists: you cannot rely on the assumption that people are necessarily in control of themselves.’ [7]. The idea that habitual conduct may overwhelm the mind – not simply challenge but overwhelm it – is something alien to classic Mussar, even though this literature often betrayed a pessimistic sense of the intractability of habit. Mussar’s major premise was, and had to be, that the rational mind is God’s gift enabling men and women to discern and defeat the evil urge. The twentieth-century understanding of the limits of rationality, purveyed in Twerski’s case through the field of mental physiology, undermined at least this one of Mussar’s cornerstones. [7] An accessible and interesting example of Twerski’s writings for those interested in knowing more is ‘The Zeide Reb Motele’ [8].
2.1.4
FREUD
A controversial few could argue the huge influence psychoanalysis has had on psychiatry. Also controversial in the extreme has been the debate as to whether psychoanalysis has Jewish roots and to what extent Freud’s Judaism influenced his thinking. Perhaps the most influential discussion of this issue is the book Freud’s Moses-Judaism Terminable and Interminable by Yerushalmi [9]. Yet another major resource is David Meghnagi’s volume Freud and Judaism [10]. Yerushalmi’s analysis takes its origin from Moses and Monotheism [11], Sigmund Freud’s last and most controversial book published in 1939. The book argued, in brief, that monotheism was an Egyptian – not a Jewish – discovery, originating when the Pharaoh Ikhnaton called for the worship of one god, the sun god, Aton. According to Freud, Moses was an Egyptian priest or aristocrat who fervently believed in this form of monotheism. When Ikhnaton died and Egyptians re-embraced their earlier gods, Moses decided to save the Aton religion from extinction by making himself head of an oppressed Semitic tribe then living in Egypt. He gave these former slaves a spiritualized, imageless form of monotheism, but they were unable to uphold the strict demands of this new faith. They ended up killing Moses, and later repressed the memory of that murder. Over a period of centuries, the submerged tradition of this true faith reasserted itself and emerged victorious, though the memory of Moses’s murder continued to be repressed. Yerushalmi attempts to situate the book within the larger context of Freud’s attitudes toward religion, Judaism and anti-Semitism. The immediate impulse for writing Moses and
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Monotheism seems to have been the advent of Hitler and the Nazis, a development that heightened Freud’s need to grapple with what he called the question of ‘how the Jews have come to be what they are and why they have attracted this undying hatred.’ Yerushalmi, however, notes that the finished book has been almost routinely regarded by scholars as a manifestation of ‘Freud’s deep “ambivalence” about his own Jewishness.’ Freud distanced himself, in public, from his Jewish upbringing in order that psychoanalysis might be regarded as a universal science, not a ‘Jewish national affair’, while privately feeling a deep sense of solidarity with other Jews, and a suspicion of others, as he wrote one Jewish disciple, who ‘will only exploit us and will never understand and appreciate us’. These perceptions were heightened by Freud’s break with Carl Jung; a disciple who it had initially seemed would help spread the doctrine of psychoanalysis to the gentile world but who ended up flirting with the Nazi regime. In writing Moses and Monotheism, Freud was not only attempting to come to terms with the persecution Jews were facing throughout Europe in the 1930s, but he was also fulfilling his own father’s wish that he return to a study of the Bible. One of the central arguments of Moses and Monotheism is that there is a hypothetical genetic transmission of unconscious memories. This theory served as a kind of explanation of ‘the powerful feeling that, for better or worse, one cannot really cease being Jewish’, the sense that despite his repudiation of the religious aspects of Judaism, ‘he was still so Jewish’. In the last chapter of his study, Yerushalmi goes even further. Addressing Freud directly, he writes: ‘I think that in your innermost heart you believed that psychoanalysis is itself a further, if not final, metamorphosed extension of Judaism, divested of its illusory religious forms but retaining its essential monotheistic characteristics, at least as you understood and described them. In short, I think you believed that just as you are a godless Jew, psychoanalysis is a godless Judaism’.
2.1.5
AGNON, JUDAISM AND INSANITY
S. Y. Agnon was born in 1987, in Buczacz, a small town in Galicia, on the threshold of a new century. The changes occurring in the traditional Jewish way of life towards the end of the nineteenth century trickled into the literature of the period and soon became its main theme. At the beginning of the twentieth century the focus of interest gradually shifted from vacillation between new and old towards a more cautious appraisal of Jewish reality in an attempt to acquire a more objective and mature perspective. Agnon played a major role in this process. One cannot deal with the concept of Judaism and Jewish tradition, including all the aspects and complexities appearing in Agnon’s works, but, as Baruch Kurzweil so aptly stated, ‘Agnon was the first to broach his subject, Jewish existence, as a true epic writer, without didactic intentions, war cries, or anti-religious sentiments and without the pathos of the religious fanatic’. [12]. In his stories Agnon recreates the world of the past, that of Jewish Orthodoxy. He describes this world with great love and admiration, taking leave of it as it declines and fades away. We shall refer to three stories in which mental illness plays a major role. The stories appear in the book At the Handles of the Lock, a collection of love stories, or, to be more exact, stories of love unfulfilled. We shall examine how Agnon’s ambivalent attitude concerning the Jewish world in the Diaspora, mental illness and relationships between
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men and women, are all linked together. We shall try to see how Agnon, by elaborating on these themes, drives his point home, and how by developing one aspect he enhances the significance of the other. A Simple Story [13] (Agnon 1961), which all commentators agree is not at all simple, is defined by some as the first realistic Hebrew novel, and by others as a novella describing Jewish society in the Diaspora combined with psychological analysis of the human mind which loves to distraction. The main issue is the overt and covert changes in a society which is frozen in time, pretending that nothing has changed. The story reveals the reactionary atmosphere based on the beliefs of the ancestors prevailing in Jewish society in the Diaspora. The descriptions of life in the small town, the distortions of the first breaths of the twentieth century, (the name of the town in the story Szybusz, is a distortion, Shibush in Hebrew, of the name of Agnon’s hometown, Buczacz) all go beyond the boundaries of the town and become an epos to the Jewish community in the Diaspora during its transition from the secure past, towards an obscure future. The plot revolves round the youth Hirshl who, since the age of sixteen, is involved in many conflicts concerning his relationships with women, which gradually drive him to insanity. The story describes the process of loss of sanity, hospitalization, treatment and recovery. If one adopts a ‘DSM view’ of what is happening to Hirshl, one can discern that Agnon provides a most accurate description of the gradual development of a psychotic state. First, Hirshl has a pronounced hereditary predisposition for psychiatric illness. His uncle was insane and perhaps his grandfather also suffered from mental illness. In addition, he is at the suitable age for the first manifestation of a psychotic crisis and he is in a constant state of increasing stress about his impending marriage to a woman he doesn’t love. Hirshl becomes more and more agitated, his insomnia is getting worse and his general functioning is deteriorating. His appetite is poor and he is losing weight. Sleeping pills do not have the desired effect. The peak of the crisis is reached when severe disorders in perception occur: Hirshl goes to the Beit Hamidrash (House of Learning) but cannot say his prayers as he feels his head is banging against the wall. He then runs into the woods where he imagines the trees are important dignitaries and he doffs his cap to them. His behavior becomes more and more disorientated. He falls to the ground, quacks like a duck, spits on himself, places his shoe on his head, and in the end, is totally incapable of returning home. When he is finally found in the evening, he is asked a few questions and one can gather from his confused answers that he is not aware of himself or of the time.When his family realizes the seriousness of his condition, they immediately hospitalize him in a psychiatric facility in the city nearby. Here too the description is very realistic. As no anti-psychotic drugs were available at the time, a treatment regime consisting mainly of rest is begun. Opiates are administered, gradually reducing the dosage. When the patient becomes more composed, Dr. Langsam, whose name indicates the tempo and nature of his treatment methods, starts Hirshl on supportive psychotherapeutic treatment, and, as a result, his condition gradually stabilizes. When discharged, Hirshl is in complete remission: He no longer suffers from delusions, has no disturbances of perception, his behavior is well organized. His appetite has improved, he is gaining weight and he no longer suffers from insomnia. If the DSM description is ignored for a moment, we can see that there are several other reasons for Hirshl’s madness, perhaps even too many [14]. Some point to at least four different arguments which might serve as explanations why this young man lost his sanity [15]. From a psychological viewpoint, his erotic frustration and his efforts to escape his mother’s despotism bring about his breakdown. From a social point of view Hirshl’s
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crisis could have been the result of his rebellion against the Jewish world he lives in and its castrating conventions. It is not by chance that at the peak of the crisis Hirshl runs off from ‘Bet Hamidrash’ into the woods. One can explain his madness as the realization of an ancient curse cast on the family because one of his ancestors offended the local rabbi. His madness also has its secondary gain: it enables Hirshl to evade the recruiting commission threatening to arrive in town. In this story, the transition from sanity to madness signifies the withdrawal from a conventional life style and moving towards something different. This is caused by a clash of two conflicting concepts, the religious way of life based on the prerogative of collective experience, and the modern way of life, based on personal experience and free choice. In the former, the religious values and precepts concerning issues between man and his Maker and the cycle of the Jewish festivals, impart a certain pace and dimension to family and community life; (even though this life style also has its spiritually immoral aspect as portrayed by the behavior of the characters in the story). The other life style wishes to create a new society and way of life which is primarily concerned with individual identity and personal freedom. As in the previous story, In the Prime of her Life [16] (Agnon 1961), also deals with the painful results of unfulfilled love. In this novella it is the women who suffer emotional torment. Tirza’s mother, Leah, who, like Hirshl, was forced to marry a man she didn’t love, suffers from symptoms of depression with a pronounced somatic overlay and spends most of her days in bed not functioning at all, until her dying day. Her daughter, Tirza, who endeavors to recreate her mother’s love, develops similar symptoms when distressed. She meets Mazal, the man her mother loved in her youth, falls in love with him and opens her heart to him. Like Hirshl, she leaves the village and escapes into the woods before the peak of the crisis is reached. At this stage, Tirza’s illness is a replica of her mother’s experience but also serves as a postponing and paralyzing factor before taking the dangerous and erroneous step of embarking on a relationship with Mazal. The common disease of mother and daughter, with its chronic manifestation in the mother and its acute form in the daughter, serves as a means of imparting the main message of the story: that everyone has their own destiny and that what is distorted cannot be set right. Various Jewish and biblical elements help to bring the message across, and lend the story its unique style and atmosphere. For example, the Mizrach1 on the wall and the prayer embroidered on it signifies the covenant between God and the people of Israel, lending a sense of sanctity to the bond between Leah and Mazal and to their pure love. Mazal reads the prayer out loud: ‘Blessed is he who will not forget you, and man will forever strive towards you’. With this scene in the background, the parallel situation in which Tirza tries to repeat the scenario but Mazal refuses to co-operate and remains silent, seems artificial and one-sided. The biblical names and language express all that is desirable and exalted. The excerpts from the Bible highlight the difference between the main characters of the story and those of the Bible, the difference between that which is desired and that which has been missed, the pity of it all, the fact that their love was never to be consummated and that both marriages, that of Leah and Mintz and that of Mazal and Tirzah, are so disappointing. On a broader plane, this novella also deals with the struggle between generations over a new, more personal concept of life, causing the disintegration of
Mizrach ¼ East. An embroidered or painted decoration hung on the wall to indicate the direction of Jerusalem, towards east, the direction religious Jews face whilst saying their prayers.
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the spiritual and social structure of the traditional community. Again, the illness is the mental reaction to the violation of Jewish society. In the short story ‘The Doctor and his Divorcee’ [17] Agnon again inter-twines the mental state of his main characters with biblical elements in order to emphasize the topics he finds most intriguing: unrequited love, the distortions of the past which cannot be corrected, and the criticism of society. The main character, a physician, suffers from an obsessive disorder which serves as a means of moving the plot along, in the concrete sense. His beloved confesses to having had a previous relationship, information which serves as a trigger for the exacerbation of his obsessive fancies. These are described as ego-dystonic, and despite all his efforts, the doctor cannot restrain himself. As is usually the case in obsessive disturbances, when he manages to distract himself for a short while, the obsessive thoughts recur with greater intensity. The biblical aspect of the story is obvious from the moment the principal female character is named Dinah, here again the message is that what is distorted cannot be repaired. In Agnon’s story just as in the Bible, the main character, Dinah, is described as flawed, that her purity has been sullied before her marriage. An effort to remedy the situation appears in both stories, in the Bible there is the proposal of marriage and in our story there is Dinah’s devotion and love for the doctor. Both stories relate the terrible outcome of jealousy: in the biblical story the men of Nablus are all murdered and in our story Dinah is subjected to severe mental abuse, which is comparable to murder. This story does not occur in Poland at the beginning of the twentieth century but in Vienna between the two World Wars. Agnon describes a world which lacks all moral standards and is steeped in feelings of jealousy, a world in which the individual and his personal suffering are ignored. We are introduced to this world through the main characters of the story, especially through the role of the doctor. The mental illness is the means of creating him as a tragic figure, because he is aware of the pain and suffering he is causing Dinah, but he cannot help himself. He tries to grapple with his destiny but is unsuccessful. He fails because in reality he is a fraud: he pretends to be a successful scientist but in reality he is driven by his urges, imprisoned by the conventions of the old world, by his obsession with issues of social class, birth and wealth. The principal characters in all three stories suffer from mental illness. The description of the illness serves Agnon as a powerful vehicle in describing the uncontrolled motion of his characters in a confusing reality which is constantly changing, within a Jewish world in the process of transformation on the one hand and constricted by its old conventions on the other; a world where cruelty and compassion, sanity and madness are all blended together. His stories also show how biblical descriptions entwined with Jewish tradition can enrich our understanding of psychological suffering. For an English translation of the stories cited here see Yudkin 1988 [18].
2.1.6
CONCLUSIONS
Writing a chapter on psychiatry and Judaism is a very complex task. During the work on this chapter we realized more and more the enormity and complexity of this issue, and the responsibility we took upon ourselves in attempting to describe the relation between the two. In order to understand the connection between psychiatry and Judaism one must first
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define the two, and then find those areas in which they connect and influence one another, and we felt a little pretentious. Therefore, in this chapter, we did not aspire to define the relation between Judaism and psychiatry but to enlighten a few perspectives, guided by our own views and personal choices. We told the story of Saul Ben Kisch, the first King of Israel, written in the book of all books, the Bible, from which we feel one can learn a lot about human psychology. That story was written in a theo-centric approach, and yet we read it from a modern psychiatric point of view in which the individual is the center of attention. Thereafter we addressed the Mussar, a certain Jewish approach which gives its own view on the human soul and which the Jewish rabbi and psychiatrist Dr. Abraham J. Twerski adopted and adapted by his own comprehension and utilized it to treat patients of substance abuse. Agnon, the renowned Jewish writer, winner of the Nobel Prize for literature, was also addressed in this chapter. We attempted to learn from his stories about the connection between Judaism, mental health and mental illness. Also mentioned, naturally, is Freud, a Jewish neurologist and psychiatrist, founder of the psychoanalytic school of psychiatry, who himself addressed the question of the relation between Judaism and psychiatry, even if by trying to separate between the two (which in itself shows there is a strong relation, otherwise why try to detach them?). In the modern world we live in, as secular Jewish psychiatrists living in Israel, we revere the individual. We live and work in an online world, a global village, exchanging ideas, reading and writing articles written by different people from different cultures and religions, relating to the DSM and talking about descriptive diagnoses, and most of the time we feel that we are very similar to our colleagues from all over the world. And yet we feel that perhaps there is truth in the theory about a hypothetical ‘genetic’ transmission of unconscious memories which ties Jews together with memories of 4000 years of Jewish existence. Each one of us chose to write about a different part of Jewish heritage, each one grasps his ‘Jewishness’ in a different way, and still there is a connection. It is probably not possible for us as psychiatrists, as we are treating patients, to completely detach ourselves from our background, and in this way we probably do to some extent practice a Jewish form of psychiatry – just how far this is from the practice of psychiatry by non-Jews must remain a moot question. It is up to the readers of this chapter to come to their own conclusions, after reading our thoughts on the matter, as to whether there is such a thing as Judaism and psychiatry. This is a profound question which must await an answer from keener minds than our own.
REFERENCES 1. Shemesh D (1986) Studies of the Book of Samuel. Kiryat Sefer Edition, Jerusalem (in Hebrew). 2. Van Praag Herman M (1986) The Downfall of King Saul: The Neurobiological Consequences of Losing Hope. Judaism 35, 421. 3. Rodkinson M The Babylonian Talmud (1918) www.sacred-texts.com/jud/talmud 4. Berenbaum M & Skolnik F (2007) Encyclopedia Judaica Vol. 16, 2nd edn. Macmillan Reference USA, Detroit, pp. 684–687. 5. Werblowsky RJZ (1964) Faith hope and trust: a study in the concept of bittahon. Annual of Jewish Studies 1, 95–139. 6. Amsel N (1994) The Jewish Encyclopedia of Moral and Ethical Issues. Rowman & Littlefield Publishers, Inc., USA, Lanham, MD, p. 145.
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7. Heinze AR (1999) The Americanization of Mussar: Abraham Twerski’s Twelve Steps, Judaism 48, 450–469. 8. Twerski A The Zeide Reb Motele (2002) Artscroll/Mesorah Publications, Brooklyn, New York. 9. Yerushalmi YH (1992) Freud’s Moses: Judaism Terminable and Interminable. Yale University Press, New Haven. 10. Meghnagi D (1993) Freud and Judaism. Karnac Books, London. 11. Freud S (1939) Moses and Monotheism. Hogarth Press and Institute of Psycho-Analysis, London. 12. Kurzweil B (1962) Essays on the Stories of S.Y. Agnon Shoken Edition, Jerusalem and Tel-Aviv (in Hebrew). 13. Agnon SY (1961) A Simple Story in ‘At the Handles of the Lock’. Shoken Edition, Jerusalem and Tel-Aviv (in Hebrew). 14. Oz A (1993) Stolen Water and Bread Eaten in Secret in ‘The Silence of Heaven’. Keter Edition, Jerusalem (in Hebrew). 15. Shaked M (1982) Was Hirshl Crazy? Hasafrut 32, pp. 132–147 (in Hebrew). 16. Agnon SY (1961) In the Prime of her Life in ‘At the Handles of the Lock’. Shoken Edition. Jerusalem and Tel-Aviv (in Hebrew). 17. Agnon SY (1961) The Doctor and his Divorcee in ‘At the Handles of the Lock’. Shoken Edition, Jerusalem and Tel-Aviv (in Hebrew). 18. Yudkin LI (1988) Agnon: Texts and Contexts in English Translation. M. Wiener Pub, New York.
For further reading Berenbaum M & Skolnik F (2007) Encyclopedia Judaica Vol. 16, 2nd edn. Macmillan Reference USA, Detroit, pp. 684–687.
CHAPTER 2.2
Christianity and Psychiatry John R. Peteet Associate Professor of Psychiatry, United States of America
Approximately 2.2 billion people, or about a third of the world’s population, call themselves Christians. Christianity and psychiatry share a rich history, which continues to evolve. This history has been shaped by both culture and the diversity of Christian traditions [1, 2], which comprises, in addition to the major Protestant, Catholic and Orthodox traditions, thousands of smaller denominations. Here we will consider what most would agree is central to the Christian worldview; what this world view implies about mental health, mental illness and its treatment; sources of tension at the interface between psychiatry and Christian faith; and opportunities for constructive engagement.
2.2.1
THE CHRISTIAN WORLDVIEW
Christians believe that an intelligence beyond the universe created it. Human beings, formed in God’s image, were originally in intimate communication with their Creator. However, their rebellion led to estrangement, and the presence of illness in the world. God used the lives of prophets and others to call people back into relationship with him, and ultimately revealed himself in the life, death and resurrection of his son Jesus. Knowing and following Jesus is transforming of a person’s attitudes, experiences and way of life in the direction of becoming more generous, compassionate, and forgiving. Like Jews and Muslims, Christians believe that God’s Word is found in an authoritative book (the Bible). They also believe in a God who speaks (though they may differ in how), and listens to prayer. Unlike Eastern religions, they believe that history is linear, rather than circular. Worldwide, diversity within Christianity reflects differences along at least four axes: (1) Understandings of how to interpret the Bible – from fundamentalists who believe in a six day creation to liberal, or ‘mainline’ Christians who focus more on social and ethical imperatives to be drawn from its teachings; (2) Expectations of engagement in supernatural activity of God, from those who believe in praying for miracles to those who believe that, if they occurred, these were limited to biblical times; (3) Styles of worship, ranging from highly structured, formal liturgies (e.g. Catholic, Orthodox) to spontaneously expressive
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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forms (e.g. Pentecostal); (4) Predominance of emphasis on correct belief (many evangelicals), vs. spiritual experience (charismatics), vs. social action (liberal Protestants, Catholics), vs. spiritual practices (liturgical traditions).
2.2.2
MENTAL HEALTH
Unlike dualists and Eastern mystics, Christians regard the body and the mind as distinct but inseparable. As a result, they are generally comfortable with contemporary psychiatry’s biopsychosocial approach to human problems. They also acknowledge that optimal human functioning includes adaptive capacities of the individual to reflect, and regulate emotion. However, Christians believe that human flourishing depends on more than optimally functioning biological or psychological processes, and is not achievable in a state of detachment. Rather, optimal adaptation is relational, and directed toward what is most important in life. It entails having a solid identity, realistic hope, meaningful activity, authentic relationships, a mature moral life, and a balance between autonomy and respect for authority. These emergent elements of a fully effective life are only intelligible against a ‘horizon of significance’ [3], which for a Christian is his relationship to God. Christians believe that it is best for human beings to live as they were created, rather than as they might independently choose, and that this has behavioral implications – for example, Christians see a link between sexual intimacy and commitment. Conservative and liberal Christians may interpret differently whether some biblical teachings (such as those regarding homosexuality) are culturally bound, and hence less binding than those teaching ethical principles such as social justice.
2.2.3
MENTAL ILLNESS
Hebrew and Christian texts describe several forms of major mental illness, including King Saul’s mood swings, Nebuchadnezzar’s psychosis during which he ate grass, and the harm self-inflicted by the deranged man whom Jesus healed. Biblical authors typically regard these as out of the individual’s control, and a cause of suffering. Consistent with medical knowledge of the time, some individuals who would now be identified as mentally ill were regarded in biblical times as demonically possessed. Contemporary Christians generally accept standard definitions of mental disorders. However, more conservative believers may question their application, based on their particular readings of scripture. For example, they may wonder whether the category of possession has been adequately considered in a patient with dissociative symptoms (Roman Catholics have established a procedure for systematically evaluating medical and other evidence before referring the case to an ordained exorcist). Depression, anxiety and compulsive religious practices can also sometimes be difficult for Christians to distinguish from spiritual failure, since their faith promises joy, peace and freedom. Christians share with positive psychology a greater emphasis on what enhances human flourishing than on psychopathology. For example, they recognize the importance of successfully accomplishing the universal moral tasks of developing moral commitments, making moral decisions, implementing these decisions, assessing the correspondence between their ideals and behavior, dealing effectively with moral failure, and developing
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morally admirable character traits, or virtues [4]. As corollaries of this, they may see moral distress as worthy of clinical attention, and personality disorders as deficits in morally admired character traits, or virtues [5], and therefore eligible for spiritual intervention. Similarly, they regard existential concerns surrounding identity, hope, meaning/purpose, morality and autonomy in relationship to authority as reflecting human needs for spiritual answers. The emphasis of Christians on a larger context also casts a different light on distress as a defining criterion of psychopathology. For example, they see painful conditions such as the ‘Dark Night of the Soul’ as potentially conducive to spiritual growth. The sixteenth century Spanish mystic St. John of the Cross described the dark night of the soul as an experience of disenchantment with a person’s usual spirituality in which God may seem distant, meditation forced and prayer empty. The individual may struggle to find gratification elsewhere, question God, or become confused by his attempts to understand. However, if this dark (in the sense of obscure) process is marked by a desire to love God, it can represent growth taking place in that relationship in two phases, at an unconscious level. In the first phase, which St. John termed the ‘dark night of the senses’, the individual becomes disenchanted with its usual activities – as a log is blackened by a fire. Emmer [6] (2004) summarizes the three indicators of this phase as follows: 1. The soul finds no satisfaction in either the things of God or in other creatures. 2. The soul is troubled by the impression that it has turned away from God; it interprets its distaste for the things of God as a falling away from Him. 3. The soul finds itself no longer capable of meditating and using the imagination in its prayer, despite fervent attempts to do so. During the second, ‘dark night of the spirit’, the soul is challenged to let go of core, self-centered assumptions and commitments that prevent union with God. In St. John’s imagery, the log is not only blackened, but consumed. Eventually, the suffering caused by raw sensitivity to the world leads to the awareness of a path. In St. John’s words, ‘Undetected I slip away – my house, at last, grown still.’ While in the dark night of the soul an individual loses the ability to enjoy God and life, but unlike in classical depression, he still feels a strong desire to know and to please Him. Gerald May also notes that while the dark night of the soul may be complicated by depression, it is typically not accompanied by a loss of effectiveness, a sense of humor or compassion for others [7, pp. 84–92]. Christians also see the sacrifice of one’s own comfort or self-interest as essential to Christian discipleship in an unjust world. In Jesus’ words, a person must lose his life to save it. This challenge is sometimes understood by non-believers as masochism, and distorted by believers to mean a denial of healthy self interest for the sake of suffering itself. Clinicians unfamiliar with Christian practices such as speaking in tongues (particularly common in the developing world), or hearing from God may confuse these with psychopathology. It can help for them to confer with more experienced colleagues, or with members of a patient’s faith community in order (for example) to distinguish depression from the disillusionment with God, ritualized religious observances of scrupulosity from OCD, or psychosis from the normative experience of hearing God’s ‘voice’. A clinician who is familiar with the Dark Night of the Soul would include this in his differential diagnosis of depression in a Christian patient. One who is familiar with the ritualistic nature of some spiritual practices (such as chanting, or saying the rosary) will include these in the
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differential diagnosis of OCD in a scrupulous patient within a liturgical and/or monastic tradition, and be wise to ask members of the patient’s religious community if the behavior seems excessive to them. And a clinician who is familiar with the way that many Evangelical and charismatic Christians talk of hearing from God as an everyday (not usually audible) experience will ask whether this is what is meant when a patient says that God told him to move in a certain direction.
2.2.4
TREATMENT
Jesus healed the sick, including the deranged, and cared for the disadvantaged. Some Christians have since mistreated individuals whom they regarded as possessed, but beginning in medieval times, religious institutions such as monasteries have provided the mentally ill with humane care. Benjamin Rush, the founder of the American Psychiatric Association, worked during the Moral Treatment period to provide humane care for the mentally ill, accessible to the poor, under the motto ‘Take care of them and I will repay thee’ [8]. Within the last century, institutions such as Pine Rest Christian Hospital in Michigan and numerous clinics have emerged to provide psychiatric care within a Christian context [9]. Faith can play an important role in the treatment of Christian patients in several arenas, both as a source of distress and as a resource. One arena is patients’ disappointment with themselves. They may experience guilt for failures ‘in thought, word and deed’ but find themselves unable to accept the forgiveness that their faith offers. Clinicians can help them to understand whether they need to address problematic repetitive behavior, or a sense of unworthiness rooted in their emotional past; reassess their understanding of their faith; or find a better way to practice it. Clinicians can also help them understand the issues evoked for them by judgment coming from church authorities over abortion, divorce, or other proscribed behavior. A related arena is patients’ disappointments with others, which can give rise to anger, difficulty forgiving, and guilt over these emotions as un-Christian. Jesus’ statements about the importance of inner attitudes (lust as the same as adultery, and hatred as murder) can lead some Christians to feel too ashamed of these feelings to acknowledge, express and explore them in therapy. Therapists may need to help them recall other scriptures that emphasize the importance of controlling the expression of desire, and of openly examining all of the contents of one’s heart. At the same time, therapists of Christian patients need to use caution in encouraging anger, since these patients may hear this as conflicting with Jesus’ commands to forgive, and to love their enemies. A third arena is disappointment with God. Believers who expect God to act in their everyday lives are particularly vulnerable to becoming disillusioned when their prayers for healing, guidance or protection seem to go unanswered. A history of trauma or neglect by authorities who should have protected them earlier in life may lead them to experience God in the same way. Clinicians can help them see such connections, remind them that many biblical persons of faith strongly questioned God, and acknowledge that feeling unable to trust God can be for them a significant loss. A fourth arena is moral decision-making. For many serious Christians, the prime criterion in determining the choice of a career, or deciding a marriage partner, is whether it is God’s will. They may struggle in treatment to weigh their desires for personal gratification, their
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family and other obligations, and their understanding of what it means to follow Jesus. Therapists can sometimes help them think through these issues more dispassionately than other figures in their lives, with a view to how their emotional vulnerabilities figure in their choices. Yet another arena is the frank distortion of faith by emotion. Depressed individuals who experience guilt in religious terms may feel that only judgmental scriptures and teachings apply to them. Anxious patients may worry, despite what their pastors tell them, that they have committed the unpardonable sin. Psychotic and other patients may believe that God is directing them to do, or to avoid doing what they seem disinclined for other reasons to do, or avoid. Therapists need to respect the importance of faith to such patients, and while eschewing the role of religious authorities, look for ways to help them examine the influence of their emotions on their understanding of their faith. They may also need to help them find resources that can help them approach these distortions from within a religious context. Finally, distorted theology can reinforce psychopathology in some individuals. Branches of Christianity that advocate an abstinent life style, teach the complete unworthiness of human beings, or emphasize that women should be subservient to men may contribute to the difficulty that their members may have in finding appropriate expressions of desire, accepting themselves as having worth in the eyes of God, or accepting the teaching that in Christ there is ‘neither male nor female’. Therapists can help such patients to examine for themselves whether the teachings they have received are a reasoned interpretation of the scriptures, and whether there might be alternative points of view worth considering. Generally speaking, the worldview of Christian patients shapes therapeutic work with them in at least three ways. First, as suggested above, Christians regard personal improvement, whether through psychotherapy or psychopharmacology, as only a relative good. Psychological insight and the support of a therapist are not enough to make one fully happy. Rather, to have a sense of their worth, humans need to love, and be loved by others, and are helped to do so by experiencing God’s love. Furthermore, to deal with their failures and those of others, they need to forgive and experience forgiveness, made more possible by experiencing God’s forgiveness. What implications does this have for treating a depressed Christian patient, for example? A therapist would want to explore whether there was a spiritual component to his depression (e.g., guilt or feelings of worthlessness expressed in the terms of his faith). If so, he would want to know whether his faith was a source of comfort or distress, and how he could bring its resources (e.g., related to feeling loved, or forgiven) to bear on the patient’s struggles. Second, as noted above, Christians recognize a call to self-sacrifice – to emptying themselves of their own selfish wills by ‘bearing the cross’, the instrument of their own execution – in order to give themselves fully to God and the service of others. Models for this include Jesus, the martyrs of history, and Martin Luther King, Jr. in our own time. Depressed and anxious individuals, particularly those who have been forced to submit to an abuser, can experience this as a heavy obligation, and as a threat to attempts to rebuild a damaged sense of self. How can a therapist help such a patient who is struggling, for example, with whether they have a Christian duty to accommodate a demanding spouse? One way is to help them remember that while the Christian scriptures emphasize that suffering for a good cause can result in personal growth, they do not endorse it for its own sake, and in fact call for joyful living. Another way is to help them understand that Jesus’ command to love others as oneself implies that one ought to love oneself. This provides a basis for exploring together whether
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the patient’s sacrifice would be helpful to its object and to themselves, and chosen freely, rather than out of habit or a distorted sense of self. Third, Christians’ disappointed expectations for healing, or for a better life can become significant issues in their treatment. A bereaved individual, a depressed patient, or survivor of clergy sexual abuse may feel guilty for losing his faith, angry with God for allowing his pain, or in despair at losing a formerly valued relationship with God. The therapist of such patients faces the challenge of validating and exploring their negative thoughts and feelings, while keeping open the possibility that they will be able to find in their faith a positive resource. As noted above, patients who are asking for help in their struggles with God may find it helpful to consider examples in the scriptures of disappointed believers who voiced similar feelings to God. While Christians recognize the importance of including the spiritual dimension of life within any therapist’s frame, they resist the instrumental application of spiritual practices such as prayer or meditation to promote health apart from the tradition out of which they grew, since this can easily distort their meaning within that tradition [10]. Health may be a benefit of faith and even the occasion for it, as for many individuals healed by Jesus. Yet more is at stake in pursuing faith than its therapeutic benefits. The fact that marriage is associated with better health outcomes is not reason enough to recommend that patients marry. Both spiritually oriented therapists, and ‘health and wealth’ preachers can forget that central to following Jesus is losing life in order to find it. Therapists who encourage spiritual practices for Christian patients also need to recognize the dangers of becoming spiritual authorities for their patients. These dangers include losing focus on the psychological aims of their work, distorting the therapeutic frame so that for example transference-based interpretation is not feasible, offering direction in areas where the therapist may not be expert or competent, and failing to help patients work through their difficulty engaging with more appropriate sources of spiritual support. How then can therapists help Christian patients make best use of the guidance and resources of their faith in dealing with issues that arise in treatment? One way is to examine with them exactly how they are deciding on a direction, whether from relying on the scriptures, on an inner sense of God’s direction or on the teaching of the church. A believer with same sex attraction may believe from reading scripture that it is wrong for him to act on these feelings. An abuse survivor may feel a duty to forgive the perpetrator. Partners in a difficult marriage may believe God wants them to do everything they can to work out their differences. Believers can find these senses of direction helpful, but they may also find them unreasonable, and a source of distress. Therapists can help them distinguish clearly what they believe their faith teaches, what they themselves feel is right, and how they can resolve discrepancies – for example, by learning more about differing Christian approaches to homosexuality. Throckmorton and Yarhouse [11] describe such a process in their sexual identity therapy, a practice framework for managing sexual identity conflicts. Their recommendations provide conceptual and empirical support for clinical interventions leading to sexual identity outcomes that respect the personal values, religious beliefs and sexual attractions of affected individuals. Christians may also find resources in their faith for helping them to live in accordance with what they have come to believe is best. Prayer, worship, service and participation in other ‘spiritual disciplines’ can offer what human relationships cannot: ultimate purpose, forgiveness, acceptance, and connection with their Creator [12]. While these can be difficult to apprehend scientifically, and attempts to study effects of intercessory prayer on healing
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have drawn criticism [13–15], a growing body of research correlates religious activity [16], hope and purpose [17] with measures of well-being. An important focus of the treatment of an individual who has experienced these benefits may therefore be to address obstacles to accessing these. These may include disappointment with a pastor; anger at God; a rigid, judgmental childhood church experience; or barriers presented by depression, anxiety, and problematic personality traits.
2.2.5
SOURCES OF TENSION
Tensions continue to exist on several levels between Christianity and psychiatry. These tensions have their roots in (a) gaps in knowledge, (b) historical developments within psychiatry, and (c) ongoing biases and misunderstandings, and (d) differences in emphasis or approach. Some secularists, notably the evolutionary biologist Stephen J. Gould, have contended that religion and science are so different in their purview as to be ‘nonoverlapping magisteria’ [18]. It is true that Christianity and psychiatry emphasize different ways of knowing: Christians use scripture, and their experience of God, while psychiatrists emphasize scientific observation and clinical judgment. It is also true that tension sometimes arises because both psychiatry and Christian faith suggest competing answers to many of the same questions, such as what is best for individuals and societies, how to deal with failures to live up to ideals, and the relationships between human beings and larger realities. Yet it is important to remember that full answers to many human concerns are beyond the reach of either science or faith. How exactly did human beings come to be as they are? What accounts for evil? What purpose can be found in adversity? Interdisciplinary research that takes both kinds of knowledge into account is growing. One example is forgiveness [19], which in addition to being a quintessentially Christian ideal has become the subject of investigation into its essential elements, measurement, antecedents, interpersonal and psychological effects, and usefulness in therapy. Four stages of forgiveness are: (1) acknowledging deep and unfair hurt; (2) wishing that one’s ‘enemy’ suffer; (3) beginning to see the ‘enemy’ in a new light (for a Christian, as another child of God), and (4) reconciling, which depends on both parties. Questions now being asked concerning the relationship of forgiveness to psychological and theological theory, as well as to its potential benefits and drawbacks in practice. Another is the virtues [20], which have come to be studied not only from theological and philosophical perspectives, but also from the perspective of positive psychology for their origins and functions as ingredients of human flourishing. A third example is love [21], which is being studied in similar ways. Yet to date, such collaborative scholarship is the exception. More often, investigators choose one or another paradigm with which to fill in gaps in their understanding. The hostility between science and religion that developed during the Enlightenment found expression in Freud’s attacks on Christianity as an immature form of wish-fulfillment. Subsequent analysts such as William Meissner and Ana-Maria Rizutto have since modified Freud’s teaching about how faith develops, but many Christians came to regard psychoanalysis as anti-religious. For years, academic psychiatry either neglected spirituality, or tended to present it in a negative light [22]. On the other hand, Freud’s longest correspondence was with a Swiss pastor and psychoanalyst. Their dialogue continues to be recognized by the annual Oskar Pfister Award, conjointly sponsored by the American Psychiatric
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Association and the Association of Professional Chaplains and given to an individual who has made outstanding contributions at the interface between psychiatry and religion. Pastoral counselors and chaplains have long since embraced psychoanalytic insights, incorporating many of them into Clinical Pastoral Education (CPE). Christians have often felt less directly threatened by the growth of descriptive and biological psychiatry, rarely taking on its proponents directly over such questions as whether depression is an illness, a problem in living or a lack of faith [23]. Several recent developments have led to a greater appreciation of spirituality within medicine and psychiatry. Twelve Step programs such as Alcoholics Anonymous (AA), with Christian and Jungian origins, are standard interventions in treating addictive disorders. Participants in AA, which describes itself as a spiritual approach, acknowledge that they are powerless over their addiction, turn themselves over to a Higher Power, take a ‘fearless moral inventory’, confess to another person, make amends, and take steps to be of service to others. Palliative care now includes spiritual assessment and care among its goals of treatment at the end of life [24]. The growth of integrative medicine has led to the use of spiritually oriented approaches such as mindfulness and meditation, including evidencebased psychiatric treatments such as dialectical behavior therapy (DBT). Spiritually oriented interventions, some of them explicitly Christian, have gained in acceptance [25]. These include spiritual direction, mindfulness, spiritually oriented cognitive behavior therapy (CBT), meaning centered and forgiveness promoting psychotherapy. Scholarly efforts to integrate Christianity and psychology have grown during the past 50 years. Currently, seven doctoral programs in clinical psychology in the U.S. at Christian institutions of higher learning accredited by the American Psychological Association encourage students to explore connections between the insights of psychology and the wisdom of their faith. They attempt, at a scholarly and practical level, to integrate Christian truth with psychology in courses such as ‘Social, Cultural and Spiritual Foundations of Mental Health’ and Theological Anthropology’. Similar programs now exist around the world. For example, the Moscow Christian School of Psychology offers a three-year curriculum focused on the treatment of children, adolescents and families. Two professional organizations, the Christian Association of Psychological Studies (CAPS), which hosts international conferences, and the almost 50,000 member American Association of Christian Counselors (AACC), and two journals, The Journal of Psychology and Theology and the Journal of Psychology and Christianity concern themselves with these issues. The Psychiatry Section of the Christian Medical and Dental Association, with a membership of approximately 200 psychiatrists, meets every year at the Annual Meeting of the American Psychiatric Association to consider ways of relating and integrating faith and psychiatric practice. Some biases that psychiatry and Christianity have toward each other persist, with attendant mistrust. Many conservative Christians (and adherents of other faiths), aware that psychiatrists are on average less religious than the general public, fear that a secular therapist will either undermine their value concerns (for example, regarding divorce, homosexuality or abortion), or fail to help them incorporate these into their treatment. Many Christians also struggle with whether it is right to take an antidepressant, rather than to pray for more faith. A few contend that biblical counseling is a preferred alternative to treatment by a mental health professional [26]. Christians may ask clinicians what their experience or attitude is toward their faith, and psychiatrists need to develop honest, therapeutic responses to such questions. This is more difficult when psychiatrists who see troubled Christians, particularly those who have been unable to find what they need in their
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religious communities, have developed impressions of Christianity as judgmental, masochistic, misogynistic, homophobic and monolithic. If they are unfamiliar with the wide range of belief and practice among Christians, they may be tempted to try to rescue these individuals from a dysfunctional set of beliefs, rather than to look for ways that their faith and its mature representatives could be resources for their growth and healing.
2.2.6
OPPORTUNITIES FOR CONSTRUCTIVE ENGAGEMENT
Distinguishing the roles of therapist and pastor is perhaps the first step toward constructive engagement. Though broad in its purview, psychiatry is a specialty of medicine, and a psychotherapist serves a different social role from that of a pastor. The psychiatrist’s duty to treat mental disorders, as defined by a consensus of secular professionals, mandates that he not substitute his own religious or spiritual ‘commitments or religious/spiritual ritual for professionally accepted diagnostic methods or therapeutic practice’ [27]. In many communities Christian pastors provide considerable help for individuals with such disorders [28]. However, their aim is to enlist God’s help for individuals struggling to become more whole, on behalf of a caring community. Both a spiritual director such as a pastor and a psychotherapist may explore limiting conflicts and potential solutions, but the primary aim of the spiritual director is to foster growth in the individual’s relationship to God rather than to relieve symptoms, improve functioning or even change character [29]. Viewed from the mental health side of the natural boundaries between them, Christian faith can offer important resources for patients dealing with existential concerns in areas such as identity, hope, meaning/purpose, morality and autonomy in relation to ultimate authority [30]. Viewed from a Christian perspective, mental health treatment offers relief of suffering, and psychological help for individuals in addressing obstacles to spiritual progress – for example, an inability to forgive, accept grace or trust related to unresolved trauma. Consider briefly the implications of engaging both faith-based and psychiatric perspectives in diagnosis, treatment and delivery of care.
2.2.7
DIAGNOSIS
Christians can provide psychiatrists with contextual information about religious beliefs and cultural practices that can help them understand whether an individual who claims to hear God’s voice is psychotic, or whether his sense of guilt is a symptom of depression. Similarly, psychiatrists can provide expertise on the nature of psychosis or depression that can help Christians understand whether patients who express their symptoms in religious terms need somatic treatment as well as spiritual support. Christian categories may provide a better way of conceptualizing certain phenomena than psychiatric categories of disorder. This may be true for sub-syndromal or sub-threshold forms of anxiety or depression that are related to existential or spiritual concerns [31]. It may also be true in the case of personality disorders. Cloninger [5] proposes that patients with personality disorders can be most clearly understood as having deficits in the coherence of their fundamental assumptions and schemas about life – i.e. deficits that can be considered spiritual. This proposed change is based on both the history of well-intentioned but unsatisfactory attempts to classify personality disorders without reference to virtues and
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vices, and on modern needs for improved treatment planning. A patient’s religious or spiritual outlook also shapes, and is shaped by, post-trauma symptoms in a number of ways. These include the influence of religion and spirituality on worldview; religious or spiritual coping strategies; an individual’s perception of the moral meaning of the traumatic event; and social forces that contextualize the traumatic event.
2.2.8
TREATMENT APPROACHES
Psychodynamic principles, some of which can be found in the Psalms and the writings of Paul, have long informed much Christian pastoral counseling and psychotherapy. More recently Christians who practice, study and teach psychotherapy have more formally incorporated familiar spiritual interventions (e.g. regarding ‘knowing the truth’, and having one’s ‘mind transformed’) into cognitive behavioral (CBT), forgiveness promoting, and the integrative therapies described by Richards and Bergin [32], and Pargament [33]. They share with humanistic and existentially oriented clinicians an emphasis on meaning and the intrinsic value of the individual. Secular clinicians are now more aware of the importance of helping patients make use of spiritual resources [21] and of effectively addressing spiritual problems in psychotherapy, including through referral [31]. The potential for collaboration is particularly evident in efforts to help patients by combining spiritual direction and traditional psychotherapy [29].
2.2.9
DELIVERY OF CARE
Where misunderstandings and bias have lessened, clinicians and Christians have developed several models of delivering integrated mental health and spiritual care: through a single individual; through a religious individual working in a secular institution; and through a mental health clinician working in a faith-based organization. An individual therapist can incorporate many of the spiritual treatment approaches referenced above into his work with a believing patient, so long as he is aware of potential tensions inherent in the dual role of priest and healer, and of the importance of a community in healing fully. He is most likely to be effective if both trusted by local Christians and respected by the wider medical and mental health communities. Arguably, most spiritual care for hospitalized patients is provided by religious representatives (chaplains and clergy) working in secular institutions. In the U.S.A., the Joint Commission for Accreditation of Health Care Organizations (JCAHO) sets standards for such care. Typically, hospital-based chaplains are ecumenical, able to serve both Christians and non-Christians, although some conservative Christians prefer to use their own pastors. In addition to explicitly spiritual care, most provide considerable emotional support, and attention to patients’ existential needs. Finally, faith-based organizations such as churches, missions and clinics increasingly provide access to mental healthcare through the activities of the clergy [28], pastoral counseling staff, and mental health clinicians who may or may not work on site. Koenig [9] has described several levels of this integration: local religious congregations, networking and advocacy organizations, mission-driven faith-based services, and faith-integrated counseling services. Larger faith-based network and advocacy groups also provide social
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services [9, pp. 161–172]. African-American churches in particular have become a venue for educating congregants about psychiatric conditions and reducing the stigma that continues to surround them in some religious circles. However, with the exception of a few programs such as Living Waters [35], faith based organizations offer co-ordinated rather than integrated care, directed more often at coping and recovery from symptoms than at synergizing deeper spiritual and emotional transformation.
2.2.10
FUTURE DIRECTIONS
As psychiatrists recognize the contributions to the mental health of their patients made by positive psychology, spiritual approaches such as AA, and integrative medicine, they are likely to become more open to consider the benefits of faith. As Christians in turn become less fearful of psychiatry, they are more likely to turn to secular mental health clinicians for help before they have become desperate, and disillusioned by their traditional spiritual sources of support. Such openness to positive experience between Christians and mental health professionals will be critical to realizing the opportunities suggested above for collaboration, and for consolidating them through teaching and research. Scholarship that takes place both outside the walls of Christian institutions will be increasingly important in drawing the attention of both secular psychiatrists and of Christians used to living within those walls. In summary, while psychiatry and Christianity share insights, values and concerns about the human condition, they differ in ways of knowing, emphasis, approach and role. Confusion about these differences has historically made clinicians vulnerable to psychologizing spiritual experience, believers vulnerable to spiritualizing mental illness, and both vulnerable to mistrusting and misunderstanding where each other stands. Clarifying the natural boundaries between psychiatry and the Christian faith has made it increasingly possible for professionals and patients to move between them with integrity, respect and appreciation. Recently, it has also become more possible for them to collaborate at points in diagnosis, treatment and delivery of care where the contributions of both are vitally needed.
REFERENCES 1. Servis ME (2004) Protestant Christians. In: Josephson AJ and Peteet JR (eds.) Handbook of Spirituality and World View in Clinical Practice. American Psychiatric Publishing, Inc, Washington, D.C., pp. 63–76. 2. Hughes JM (2004) Catholic Christians. In: Josephson AJ and Peteet JR (eds.) Handbook of Spirituality and World View in Clinical Practice. American Psychiatric Publishing, Inc, Washington, D.C., pp. 77–90. 3. Taylor C (1991) The Ethics of Authenticity. Harvard University Press, Cambridge, Mass., pp. 31–41. 4. Peteet JR (2004) Doing the Right Thing: An Approach to Moral Issues in Mental Health Treatment. American Psychiatric Association Press, Inc., Washington, D.C. 5. Cloninger CR Religious and spiritual issues in personality disorders: background for the development of DSM-V. In: Peteet JR, Narrow W & Lu F (eds.) Religious and Spiritual Considerations in Psychiatric Diagnosis. American Psychiatric Publishing, Inc., Washington, D.C., in press.
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6. Emmer C Discernment of the dark night of the senses. The Weight of Glory, March 24, 2004. http://www.doxaweb.com/blog/2004/03/discernment-of-night-of-senses.htm. Accessed September 15, 2009. 7. May GG (1982) Care of Mind, Care of Spirit: Psychiatric Dimensions of Spiritual Direction. Harper & Row, San Francisco. 8. Braceland FJ (1976) A Bicentennial address: Benjamin Rush and those who came after him. American Journal of Psychiatry 133, 1251–1258. 9. Koenig HG (2005) Faith and Mental Health: Religious Resources for Healing, Templeton Foundation Press, West Conshohocken, PA. 10. Shuman JJ, Meador KG (2003) Heal Thyself: Spirituality, Medicine, and the Distortion of Christianity. Oxford University Press, New York. 11. Throckmorton W, Yarhouse MA (2006) http://wthrockmorton.com/wp-content/uploads/2007/ 04/sexualidentitytherapyframeworkfinal.pdf, Accessed 2/14/09 12. Willard D (1998) The Spirit of the Disciplines: Understanding How God Changes Lives. Harper Collins, New York. 13. Sloan RP, Ramakrishnan R (2006). Science, medicine, and intercessory prayer. Perspectives in Biology and Medicine 49, 504–514. 14. Turner DD (2006) Just another drug? A philosophical assessment of randomised controlled studies on intercessory prayer. Journal of Medical Ethics 32, 487–490. 15. Roberts L, Ahmed I, Hall S (2007) Intercessory prayer for the alleviation of ill health. Cochrane Database of Systematic Reviews, Issue 1. Art.No.: CD000368. DOI: 10.1002/14651858. CD000368.pub2. 16. Koenig HG (ed.) (1998) Handbook of Religion and Mental Health. Academic Press, San Diego, CA. 17. Seligman M (2002) Authentic Happiness. Basic Books, New York. 18. Gould SJ (1997) ‘Nonoverlapping magisteria.’ Natural History 106, 16–22. 19. McCullough ME, Pargament KI et al. (2000) Forgiveness: Theory, Research, and Practice. Guilford Press, New York. 20. Carr A (2004) Positive Psychology: the Science of Happiness and Human Strengths. BrunnerRoutledge, New York. 21. The Institute for Research on Unlimited Love, http://www.unlimitedloveinstitute.org/, Accessed 10/19/07 22. Larson DB, Pattison EM, Blazer DG et al. (1986) Systematic analysis of research on religious variables in four major psychiatric journals, 1978–1982. American Journal of Psychiatry 143, 329–334. 23. Blazer DG (1998) Freud vs. God: How Psychiatry Lost its Soul and Christianity Lost its Mind. InterVarsity Press, Downers Grove, IL. 24. Sulmasy DP (2006) Spiritual issues in the care of dying patients: ‘. . . it’s okay between me and god’. Journal of the American Medical Association 296, 1385–1392. 25. Sperry L, Shafranske EP (2005) Spiritually Oriented Psychotherapy. American Psychological Association, Washington, DC. 26. Adams JE (1972) Competent to Counsel. Baker Book House, Grand Rapids, MI. 27. American Psychiatric Association (2006) Religious/Spiritual Commitments and Psychiatric Practice: Resource Document. Retrieved 10/19/07, from http://www.psych.org/edu/other_res/ lib_archives/archives/200604.pdf. 28. Young JL, Griffith EE, Williams DR et al. (2003) The integral role of pastoral counseling by African-American clergy in community mental health. Psychiatric Services 54, 688–692. 29. Benner DG (2005) Intensive soul care: integrating psychotherapy and spiritual direction. In: Sperry L & Shafranske EP (eds.) Spiritually Oriented Psychotherapy, American Psychological Association, Washington, D.C., pp. 287–306. 30. Peteet JR (2004) Therapeutic Implications of World View. In: Josephson AJ and Peteet JR (eds.) Handbook of Spirituality and World View in Clinical Practice. American Psychiatric Publishing, Inc, Washington, D.C, pp. 47–62.
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31. Peteet JR, Narrow W, & Lu F (eds.) Religious and Spiritual Considerations in Psychiatric Diagnosis. American Psychiatric Publishing, Inc., Washington, D.C., in press. 32. Richards PS, Bergin AE (2005) A Spiritual Strategy for Counseling and Psychotherapy, American Psychological Association, Washington, D.C. 33. Pargament KI (2007) Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred. Guilford Press, New York. 34. Peteet JR (1994) Approaching spiritual issues in psychotherapy: a conceptual framework. Journal of Psychotherapy Practice and Research 3, 237–245. 35. Living Waters, http://www.desertstream.org/programslivingwaters1.htm. Accessed 10/27/07.
CHAPTER 2.3
Religion and Mental Health in Islam Ahmed Okasha Professor and Director of WHO Collabarating Center for Research and Training in Mental Health, Egypt
2.3.1
INTRODUCTION
Psychiatry and religion both draw upon rich traditions of human thought and practice. In fact, psychiatry is the branch of medicine that most prominently incorporates the humanities and social sciences in its scientific base and in its treatment of illness. In parallel fashion, all religions offer some type of explanation of how the universe was created, how life is maintained, and what happens when life ceases to exist. All religions attempt to give their followers explanations for life’s meaning, including rationales for the reality of human suffering. Religious symbols, beliefs, myths, and rites enable individuals and groups to deal with the ultimate conditions of existence that are experienced by members of every society [1]. For much of history, a single individual, in most world cultures, performed the separate functions of religious practice and healing. Only with the explosive growth of scientific knowledge in the twentieth century have the roles of religious and medical healers become separate. Mental health providers in developed countries are increasingly treating patients whose backgrounds are very different from their own, so it is important for them to understand cultural belief systems including religious thought and practice that relate to mental health and illness. An increased awareness of religion in contemporary societies has both positive and negative aspects. From a positive point of view, religious belief systems may provide understandable explanations for traumatic life events or provide meaning for the individual or groups. From a negative point of view, any religious fundamentalism, regardless of a belief system, can be damaging not only to individual mental health and social adjustment but also to peaceful coexistence among cultures. Unfortunately, one can look across the globe from Northern Ireland, Balkans, Africa to the Middle East and beyond for some prominent examples of how the politicization of religious beliefs can destroy lives and cultures. In fact, in the future, psychiatrists will increasingly be required to confront numerous ethical and social policy issues with religious components, in addition to meeting patient Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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demands for more comprehensive psychiatric approaches that incorporate spiritual perspectives. Lu [2, 3] explored the rationale and purpose of recent mandates for the inclusion of spiritual and religious course content in psychiatric training programs. Larson and colleagues [4] assessed the presentation and interpretation of religion in the area of psychiatric nosology. These authors systematically reviewed the DSM-III-R [5] for evidence of bias against religion and, in particular, for insensitive representations of religion. Of the 45 case examples used in the glossary to illustrate technical terms, 10 (22.2%) had religious content. Larson et al. [6] concluded that religion was over represented in case examples of psychopathology. This problem has been largely dealt with in DSM-IV [7] which includes a V code for ‘religious or spiritual problems’, indicating greater sensitivity to religious concerns. Psychiatrists will need to seek special knowledge about religious traditions that are unfamiliar to them, particularly Fundamentalist Christianity, New Age spirituality, Buddhism, Hinduism, and Islam, as well as seek information about the larger religious cults. We also found that psychiatry rarely has used state-of-the-art, multidimensional assessments of religion, including measures of religious beliefs, attitudes, and practices because religion has remained on the periphery of professional interest, and psychiatrists have been unaware of the generally beneficial association religion has with mental health status. In a 12-year review of all articles appearing in the American Journal of Psychiatry and the Archives of General Psychiatry, 72% of the religious commitment variables were beneficial to mental health: participation in religious, social support, prayers and a relationship with God were beneficial in 92% of citations. There were similar findings in a review of the Journal of Family Practice. In a British epidemiological study, church-going and a vital religion was found to be a protective factor from vulnerability to depression [8]. Only 3% of a qualitative review of the total output of four major psychiatric journals between 1978–82 contained a qualified religious variable, and only three out of 3777 articles scanned were centrally and qualitatively concerned with traditional religious phenomena. This deficiency has attracted protest [8]. Neelman and King conducted a study on psychiatrists’ religious attitudes in their clinical practice. Although only 27% reported a religious affiliation and 23% a belief in God, 92% felt that psychiatrists should concern themselves with the religious leanings of their patients [9].
2.3.2
ANCIENT EGYPT
Like most lads among my boyhood associates, I learned the Ten Commandments. I was taught to reverence them because I was assured that they came down from the skies into the hands of Moses, and that obedience to them was, therefore, secretly incumbent upon me. I remember that whenever I fibbed, I found consolation in the fact that there was no commandment, ‘Thou shalt not lie,’ and that the Decalogue forbade lying only as a ‘false witness’ giving testimony before the courts where it might damage one’s neighbor. In later years, when I was much older, I began to be troubled by the fact that a code of morals which did not forbid lying seemed imperfect; but it was a long time before I raised the interesting question: How has my own realization of this imperfection arisen? Where did I myself get the moral yardstick by which I discovered this shortcoming in the Decalogue? When that experience began, it was a dark day for my inherited respect for the theological dogma
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of ‘revelation.’ I had more disquieting experiences before me when, as a young orientalist, I found that the Egyptians had possessed a standard of morals far superior to that of the Decalogue over a thousand years before the Decalogue was written [10]. James Breasted in his book The Dawn of Consciousness stated that the Egyptians gave birth to the consciousnesses believing in one God and the afterworld without a prophet [10].
2.3.2.1
Egyptian beliefs and health
Man’s beliefs have always molded his magical practices and his medical theories. The principles underlying Egyptian magical practices may be summarized as follows: 1. Belief in the existence of an immaterial and impersonal force permeating the universe, a force that the magician could seize and mold to his own ends. 2. The law of mystical participation. This asserts that mysterious ties in the universe hold all things together, and that any change in one part evokes responses in the whole. 3. A system of logic based on analogy and similarity, that deduces identity and solidarity between two things from a resemblance of form or name, e.g. the name given at birth influences destiny, the resemblance of a plant to an organ by its shape or name grants it power to heal that organ. 4. The law of solidarity which holds that a body remains forever linked to any fragment detached from it, hence it is possible to act on beings through nail clippings, used clothing, etc. 5. The primitive conception, still held by tribesmen today, that looks upon death as a protracted sleep during which the deceased pursue their normal lives, accomplish their usual activities or even their conjugal duties, like Osiris who after death fathered a child from Isis. The dead could also visit the living in the form of dreams by night and as ghosts by day. In ancient Egypt, the philosophy of life and death centered upon the idea that these were part of a continuous cycle, hence the belief in life after death demanded elaborate funeral ceremonies and complex rituals in preparation for it. This belief emphasized the psychology of the dead and the personality of the hereafter. Death, as opposed to life, did not exist in the Egyptian mind. His language had no sign to express it. To him, death was nothing but a further step in life during which his soul or Ba could return from yonder to reinvest his body and resume with it his interrupted life. The primary duty of preserving the shape of the deceased was to allow the Ba to recognize it before reanimating it. One of the worst outrages that could be inflicted on a dead man was to let his body decay, to erase his name, or to disfigure his body beyond recognition. The custom of embalming continued until the first centuries of the Christian era. At first it was limited to Pharaohs, notables and priests, but it slowly spread among the people [11].
2.3.2.2
The heart
There is no known physician’s title in pharaonic times to suggest specialization in mental diseases, although psychic and mental symptoms are mentioned in many clinical
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observations, mainly in the Book of the Heart [12]. In Ebbell’s translation of the Ebers papyrus, the words ‘heart’ and ‘mind’ occur in 14 prescriptions, so it seems that the heart and the mind meant the same thing in Ancient Egypt. Indeed, personality types were attributed according to the color and shape of the heart, e.g. long-, short-, white-, and black-hearted. It seems that the lay assumption of white-hearted individuals originated from ancient Egyptian beliefs. The heart was believed to be the center of physical and emotional life, of the will and of the intellect [13]. All the feelings, conditions of the soul, traits of character and temperament were expressed by various idioms referring to the heart. For example, being happy was described as ‘long of heart’ and depressed as ‘short of heart’. A confident person was called ‘he who fills the heart’. ‘To drown the heart’ meant to hide one’s thoughts, and ‘to wash the heart’ was to satisfy one’s desire. ‘Dryness of the heart’ referred to forgetfulness which was said to be the result of thrombosis [11].
2.3.2.3
Suicide
Here we are confronted with the very essence of Egyptian ethics. The Egyptians felt that not only the Ba (soul), but also the whole body and its organs, heart, liver, kidneys, etc., came under the responsibility of the gods and were the dwelling places of the divine powers. The question whether suicide is sinful and thus subject to eternal reprobation becomes irrelevant, if preserving the corpse by embalming it and supplying it with offerings suffices to keep the soul alive. It apparently does not matter much if man reaches death by committing suicide or by awaiting it deliberately, as long as the corpse itself is not extinguished by fire or drowning. Apart from Cleopatra’s suicide, this problem was not an issue in Ancient Egyptian literature [11].
2.3.2.4
Psychological aspects of treatment
Sigerist wrote that: ‘Suggestion played an important part in all forms of treatment, even those that seem most rational to us. Religious people always felt that the daily bread they ate which sustained life and re-created it constantly was a great mystery. And how much more mysterious were drugs’ [14]. Greek and Roman visitors were particularly impressed by the Egyptian cults and eagerly adopted them, the more so as the less clearly they understood them. But one thing they did understand was that all these cults promised healing of mind and body. Magico-religious therapy was primarily aetiological, its aim being to remove the cause of the disease by driving out a demon or the ghost of a dead person, or by reconciling the patient with the transcendental world. Empirical-rational therapy, on the other hand, was for the most part symptomatic. The symptoms were considered to be the disease, and drugs were given or an incision was performed to relieve the sick person of a symptom or a group of symptoms. We also find aetiological treatments, however, and sometimes the cause was considered as the disease. One of the psycho-therapeutic methods used in Ancient Egypt was the ‘incubation’ or the ‘temple sleep’. This was associated with Imhotep, the earliest known physician in history. I.em.ho.tep., ‘He who comes in peace’ was the physician vizier of the Pharaoh Zoser who
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built the Saqqara pyramid, 2980–2900 BC. He was worshipped at Memphis and a temple was constructed in his honor on the island of Philae. The temple was a busy center for sleep treatment. The course of treatment depended greatly on the manifestations and contents of dreams which were, of course, highly affected by the psycho-religious climate of the temple, or the confidence in the supernatural powers of the deity and on the suggestive procedures carried out by the divine healers [15]. There are important lessons to be learnt from the examination of beliefs and practices relating to mental disorders that exist in various cultures throughout the world. In many nonWestern cultures, native practitioners, to whom modern psychiatry is unknown, treat emotionally disturbed persons. The examination of the emotional attitude and interpersonal elements in these various forms of psychological treatments offers the psychiatrist a broad perspective from which to understand the basic components of our own present day systems of psychiatry and psychotherapy.
2.3.3
MENTAL HEALTH IN ISLAM
The Moslems need to understand from where Western culture generates its strength instead of just mimicking the West by using its products, they should think about applying a different kind of Western value, which leads to economical and social development, namely values that grant dignity for all citizens. So far, they find all kinds of social and religious excuses when they are confronted with those values; equality, human rights, dignity and justice for all. Translated and digested, improved and developed, the knowledge of preceding cultures thus contributes their product to the current culture. For Moslems, this would mean a reorientation towards itself, consisting in reviving thinkers, such as Abul Ala’ al–Maarri, Ibn Sina, Ibn Khaldun, Ibn Rushd, Ibn Tufail and many others who have largely contributed to humanity. Moslems need to be makers of culture again. The only way to achieve this goal is to establish internal order: i.e. to cultivate things in common, to be aware of their unity. Beginning with childhood, the sense of belonging to the Islamic Culture needs to be re-installed in an atmosphere of freedom of thought and tolerance. To really be able to contribute to the world’s culture again, the mental attitude towards creativity, work and productivity in the Moslem world must become more serious. People need to be encouraged in their creativity in searching for dimensions and horizons to find solutions to the problems they have. These might be solutions that nobody ever thought of before and that might go against tradition, but the struggle between advocates of the cultural heritage and supporters of the new will bring about stimulating discussions and encourage finding realistic answers. We believe the dialogue between all political views can be successful if freedom of thought is guaranteed. Looking back, we may say that Islamic medicine and science reflected ‘The light of the Hellenic sun, when its day had fled, and that they shone like a moon, illuminating the darkest night of the European Middle Ages’ [16]. Medicine languished for many centuries after the death of the Greek physicians Hippocrates and Galen, medicine’s founding fathers. The bubonic plague, which started around 500 AD, was partly to blame. It took its toll over the next 200 years and signaled the beginning of Europe’s Dark Ages. War, disease, superstition and religious zealotry were rife. Physicians practiced in isolation, and monks were the principal guardians of both the spiritual and physical health of the population. Around the seventh century, however, a newly inspired and emboldened sect – Islam – spread its
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influence over much of the Middle East and Europe. Islam resuscitated the dying culture of Greek medicine and richly fortified it with astute observations and scholarship. Islam began in Mecca with Mohamed (570–632), to whom was revealed the spiritual teachings of the Qur’an (Koran). After an assassination attempt in 622, Mohamed and his followers fled Mecca for Medina and this became the first year of Islam, referred to as Hegira. Adherents of Islam are known as Muslims, and by the time of Mohamed’s death, Islam had won over all of Arabia. Within the next 100 years, the Arabic Caliphs (Mohamed’s successors) established the Saracen Empire by extending the Muslim conquest to half of Byzantine Asia, Persia, Egypt, North Africa and Spain. The first Caliph was Abu Bakar, who immediately invaded the East Roman Empire and Persia. Successive Caliphs preserved Islam’s hold for several more centuries but it eventually lost its influence, depleted by defect of acculturation. The Muslims were the cultural, literary and scientific leaders of their time. They introduced not only their religion and culture, but also the windmill, fireworks (also claimed by the Chinese), windowpanes, street lights and fruit cultivation. Islamic scholars were prodigious in philosophy, chemistry, astronomy, mathematics and medicine. The Arabic Language gave us words like algebra, zero, syrup, algorithm and alcohol, and they bequeathed the Arabic numeral system, the alphabet of mathematics [17]. Islamic tradition includes the Noble Qur’an (which is the Holy book for Muslims), Sunnah or the practical traditions of the Prophet Mohamed, Hadith or the oral sayings attributed to the Prophet, fiqh (Jurisprudence or schools of law) and the shariah (code of law) which regulated the diverse aspects of Muslim life [18]. The approach of Islam to mental illness can be traced to the following: The Holy Text (the Koran): The most common word used to refer to the mad person, i.e. insane or psychotic in the Koran is ‘majnoon’. This is mentioned five times to ascribe how prophets were perceived. The same word is used by the masses to describe the perceived eccentricity of all prophets when they attempt to guide their people to enlightenment. It is sometimes coupled with being a magician or a teacher. In a sense, there seems to be a positive connotation to madness that would flatter the antipsychiatry concept of madness, that flourished in the mid-1960s. The word ‘majnoon’ is originally derived from the word ‘jinn’ (the word ‘jinn’ in Arabic has a common origin with overlapping words with different connotations and can be traced to refer to a shelter, screen, shield, paradise, embryo and madness). The current belief that the Islamic concept of the insane is that he is possessed by a ‘jinn’ should not be confused with the concept of the Middle Ages. In Islam, the ‘jinn’ is not necessarily a demon, i.e. an evil spirit. It is a supernatural spirit, lower than the angles, and has the power of assuming human and animal forms that can be either good or bad. Some jinn are believers, listen to Koran and help human fairness. Moreover, Islam is not devoted to human beings but also to the spiritual world at large. In the Koran, almost always, the jinn and the human being are mentioned together. This has altered the concept and the management of the insane, although they may be perceived as being possessed because the possession may be by a good or a bad spirit. Consequently there is no place to generalize punishment or give to condemnation unconditionally. Apart from the concept of the insane as being possessed, we have another positive concept where the insane is taken as the one who dares to be innovative, original, creative or attempts to find alternatives to a static and stagnant mode of living. It is also to be found in various attitudes towards certain mystics such as Sufism, where the expansion of self and consciousness has been taken as a rationale to label some of the Sufis as psychotic.
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The autobiographies of some Sufis reveal the occurrence of psychotic symptoms and many mental sufferings in their paths to self-salvation. The last concept of mental illness is the consequence of the disharmony or constriction of consciousness, which non-believers are susceptible to. It is related to the denaturing of our basic structure (Al Fitrah) and disruption of our harmonious existence by egoism, detachment or alienation, partly presented by the loss of integrative insight. The prevailing concept of mental illness at a particular stage in the Islamic world depends on the dominance of development or deterioration of genuine Islamic issues. For instance, during deterioration, the negative concepts of the insane as being possessed by evil spirits dominates, whereas during periods of enlightenment and creative epochs, the disharmony concept dominates and so forth. Islam also identified the unity of body and psyche. The psyche (Elnafs) was mentioned 185 times in the Koran as a broad reference to human existence, meaning at different times, body, behavior, affect, and/or conduct i.e. a total psychosomatic unity [19].
2.3.4 2.3.4.1
SOME ISLAMIC SCHOLARS AND MENTAL HEALTH El Rhazes
El Rhazes was born in Al-Razy, a city only a few miles south of Tehran, Persia (now Iran). Little is known of his childhood except that he loved music, and that he was an accomplished flute player. At an early age, he developed an interest in philosophy, chemistry and medicine, and later trained in Baghdad. Rhazes was renowned for his clinical acumen, and many patients came from far to seek his expertise. He was a fastidious worker and took great pains to elicit a detailed medical history. He put his observations in writing and paid special attention to the social, family and psychological history. He was a revered teacher and was insistent on using the differential diagnosis approach, a methodology that continues to underpin modern day clinical medicine. He was one of the first to appreciate the influence of the psyche on the physical condition, and he used the salutary role of music to promote healing. As a teacher, he urged his students ‘to behave in manner and virtues, stressing the holiness of the medical profession, opposing all kinds of jugglery, caring much for healing the poor free of charge and even giving them money’. It should come as no surprise that Rhazes, the careful clinician, was also a prolific author. His best known work was the encyclopaedic 22-volume ‘Continens’ ‘Al-Hawi’ which was completed only after his death by his disciples. Continens was translated and reprinted several times, and became the reference textbook of medicine in Europe well into the mid-sixteenth century. This encyclopaedia was not a mere translated version of Galenic thoughts. It contained all recorded teachings in Greece, Persia, India and Syria, as well as Rhazes’ personal observations and experiences regarding physiology, diagnosis and treatment. Unfortunately, only ten of the 22 volumes have survived to the present day. Rhazes was known for another important book, one describing smallpox and measles. He had many other books to his name: books on philosophy, nutrition, drugs, chemistry and spiritual medicine. In total, Rhazes wrote some 224 books, including a treatise entitled: ‘Reasons for catching cold in Spring after smelling roses’ Through sheer force of logic and careful observation, he had stumbled upon the condition of pollen allergy. Like his brilliant hypothesis on the relationship between putrefaction and air purity, the
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genius of Rhazes was on full display – ‘a moon illuminating the darkest night of the European Middle Ages [20].’ The teaching of the great clinician Rhazes had a profound influence on Arab as well as European medicine. The two most important books of Rhazes are ‘El Mansuri’ and ‘Al-Hawi’. The first consisting of ten chapters, includes the definition and nature of temperaments, the dominant, numerous and comprehensive guides to physiognomy. ‘Al-Hawi’ is the greatest medical encyclopedia produced by a Moslem physician. It was translated into Latin in 1279 and published in 1486. It is the first clinical book presenting the complaints, signs, differential diagnosis and the effective treatment of illness.
2.3.4.2
Avicenna
One hundred years later. ‘El-Canoon’ the law of medicine by Avicenna was a monumental, educational, and scientific book with better classification. Even as monks, quacks, barbers, and blood letters littered the medical landscape of Europe’s Dark Ages, Islam strove to restore the intellect of the past and inject fresh inspiration. Avicenna’s legacy was the ‘Canoon of Medicine’, a book destined to influence medicine for the next 600 years [20]. An unlikely tale concerning the cure of a psychiatric patient is often attributed to Avicenna. A man who believed himself to be a cow asked to be sacrificed. Approaching the patient, Avicenna exclaimed that he should indeed be sent to the slaughter house. When the happy patient mooed loudly in agreement, Avicenna quickly proclaimed that the cow was too thin and had to be fattened before slaughter. His aides fed the patient, and as the man regained his health, he soon fell out of his melancholia and was cured of his delusion. Avicenna claimed Islam’s highest medical honour for his encyclopedic work, the ‘Canoon of Medicine’, a one-million word summation of Graeco-Arabian medicine that incorporated his own clinical observations together with all the medical teachings of Hippocrates and Galen. This undisputed piece de resistance offered up by the Arabic world to Western medicine was of unsurpassed scholarship and dogma. Avicenna systematically and laboriously catalogued all that was known about the mysteries of the healing art. The Canoon is divided into five books, and these are, in turn, subdivided. A typical medical school curriculum covered all five books that were taught in the order written. Medical therapeutics was featured prominently in these books, the Arabs being the first to establish privatelyowned pharmacies in the eighth century. Some 760 drugs were codified in the Canoon [20].
2.3.4.3
El Ghazali
The twelfth century philosopher and Sufi, El Ghazali quotes in his Book of Knowledge this line from El-Mutanabbi: ‘To the sick man. sweet water tastes bitter in the mouth’. Ghazali’s work not only predates Pavlov, but also exceeds, contemporary knowledge of conditioning. At the time of writing, informed opinion is split between whether indoctrination, whether overt of covert is desirable or otherwise, whether too, it is inescapable or not. His books were burnt by Mediterranean bigots from Spain to Syria. Nowadays they are not put into the flames, but their effect, except among Sufis, is perhaps less and they are not read very much. Ghazali’s scientific, psychological discoveries, though widely appreciated by academics of all kinds, have not been given the attention they deserve because he specifically disclaims
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the knowledge or logical method as their origin. He arrived at his knowledge through his upbringing in Sufism, among Sufis and through a form of direct perception of the truth which has nothing to do with mechanical intellect. This, of course, at once puts him outside the pale of scientists. What is rather curious, however, is that his discoveries are so astonishing that one would have thought that investigators would have liked to find out how he made them. The influence of Ghazali on Western thought is admitted to be enormous but this influence itself shows the working of conditioning: the philosophers of medieval Christendom, who adopted many of his ideas, did so selectively completely ignoring the parts which were embarrassing to their own indoctrination activities. To quote him: ‘Parable of the People with a Higher Aim: Imam El- Ghazali relates to tradition from the life of Isa, ibn Maryam: (Jesus. Son of Mary) Isa one day saw some people sitting miserably on a wall by the roadside, he asked: ‘What is your affliction ?’ They said: ‘We have become like this through our fear of Hell’. He went on his way, and saw a number of people grouped disconsolately in various postures by the wayside. He said: ‘What is your affliction.’ They said: ‘Desire for Paradise has made us like this’. He went on his way, until he came to a third group of people. They looked like people who had endured much but their faces shone with joy. Isa asked them: ‘What has made you like this?’ and they answered: ‘The Spirit of Truth. We have seen reality and this has made us oblivious of lesser goals’. Isa said: ‘These are the people who attain. On the Day of Accounting, these are they who will be in the Presence of God.”
Man was made for learning: A camel is stronger than a man; an elephant is larger; a lion has greater valor; cattle can eat more than man; birds are more virile. Man was made for the purpose of learning. Possessions: You possess only whatever will not be lost in a shipwreck. Gain and Loss: I should like to know what a man who has no knowledge has really gained, and what a man of knowledge has not gained.
2.3.4.4
Ibn Rushd
Ibn Rushd, Spanish Muslim Philosopher, made remarkable contributions in philosophy, logic, medicine, music and jurisprudence. In medicine, his well-known book ‘Kitab al-Kulyat fi al-Tib’ ‘Book of Medicine Totality’ was written before 1162 A.D.
2.3.4.5
Ibn Khaldoun
Ibn Khaldoun was the first author to give a clear description of the relationship between mental health and culture. He described the effect of urbanization on Islamic tribal warriors when they moved from nomadic life to live in towns. The movement was associated with an increase in the prevalence of psychological ailments namely jealousy, suspiciousness, self-indulgence and fear of others. He viewed this behavior as a reaction to the change of social structure, after the tribal system failed to adjust to the process of urbanization. Such failure was, in Ibn Khaldoun’s view, the origin of the Islamic civilization world’s decline [21].
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Survival
Fulfilling Nafs
Trust in God
Fulfilled Nafs
Patience Poverty
Secure Nafs
Renunciation
Inspired Nafs Accusing Nafs
Abstinence
SUPER EGO Genital Stage
Annihilation
7 Stages of the Sufi Path (Magamat)
Complete Nafs
Human Nafs Repentance
EGO
Animal Nafs
ID
Vegetative Nafs SUFISM
Nafs = Psyche
Phallic Stage
Maturity Adulthood Early adulthood Adolescence Puberty Latency Locomotorphallic
Anal Stage
Muscular Anal
Oral Stage
Oral Sensory
FREUD
ERIKSON
(Psychosexual)
(Social model)
Figure 2.3.1 Comparison of stages of human development in Islamic SUFI PATH versus Freud and Erikson [48].
The above table is self-explanatory. It compares the Islamic view of personality development with the theories of Freud and Erikson.
2.3.5
THE CAIRO DECLARATION ON HUMAN RIGHTS IN ISLAM
The Cairo Declaration on Human Rights in Islam was adopted and issued at the 19th Islamic Conference of Foreign Ministers in Cairo on 5th August 1990. The declaration reaffirms the civilizing and historical role of the Islamic Ummah (Nation) which God made the best nation that has given mankind a universal and wellbalanced civilization in which harmony is established between this life and the hereafter, and knowledge is combined with faith. There is a role that this Ummah should play to guide a humanity confused by competing trends and ideologies and to provide solutions to the chronic problems of this materialistic civilization. The wish is to contribute to the efforts of mankind to assert human rights, to protect man from exploitation and persecution, and to affirm his freedom and right to a dignified life in accordance with the Islamic Shariah. Convinced that mankind which has reached an advanced stage in materialistic science is still, and shall remain, in dire need of faith to support its civilization and of a self-motivating force to guard its rights. Believing that fundamental rights and universal freedoms in Islam are an integral part of the Islamic religion and that no one, as a matter of principle, has the right to suspend them in whole or in part or violate or ignore them in as much as they are binding, divine commandments, which are contained in the Revealed Books of God and were sent through the last of His Prophets to complete the preceding divine messages thereby making their observance an act of worship and
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their neglect or violation an abominable sin, and accordingly every person is individually responsible—and the Ummah collectively responsible—for their safeguard. Proceeding from the above-mentioned principles, 25 articles were ratified, salient points will be alluded to in the next text. Article 1 (a) All human beings form one family whose members are united by submission to God and descent from Adam. All men are equal in terms of basic human dignity and basic obligations and responsibilities, without any discrimination on the grounds of race, color, language, sex, religious belief, political affiliation, social status or other considerations. True faith is the guarantee for enhancing such dignity along the path to human perfection. Article 2 (a) Life is a God-given gift and the right to life is guaranteed to every human being. It is the duty of individuals, societies and states to protect this right from any violation, and it is prohibited to take away life except for a Shari’ah-prescribed reason. (b) It is forbidden to resort to such means as may result in the genocidal annihilation of mankind. (c) The preservation of human life throughout the term of time willed by God is a duty prescribed by Shari’ah. (d) Safety from bodily harm is a guaranteed right. It is the duty of the state to safeguard it, and it is prohibited to breach it without a Shari’ah-prescribed reason. Article 3 (a) In the event of the use of force and in case of armed conflict, it is not permissible to kill non-belligerents such as old men, women and children. The wounded and the sick shall have the right to medical treatment; and prisoners of war shall have the right to be fed, sheltered and clothed. It is prohibited to mutilate dead bodies. It is a duty to exchange prisoners of war and to arrange visits or reunions of the families separated by the circumstances of war. (b) It is prohibited to fell trees, to damage crops or livestock, and to destroy the enemy’s civilian buildings and installations by shelling, blasting or any other means. Article 4 Woman is equal to man in human dignity, and has rights to enjoy as well as duties to perform; she has her own civil entity and financial independence, and the right to retain her name and lineage. Article 5 Islam is the religion of unspoiled nature. It is prohibited to exercise any form of compulsion on man or to exploit his poverty or ignorance in order to convert him to another religion or to atheism. Article 6 (a) Human beings are born free, and no one has the right to enslave, humiliate, oppress or exploit them, and there can be no subjugation but to God the Most High.
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(b) Colonialism of all types, being one of the most evil forms of enslavement, is totally prohibited. Peoples suffering from colonialism have the full right to freedom and selfdetermination. It is the duty of all States and peoples to support the struggle of colonized peoples for the liquidation of all forms of colonialism and occupation, and all States and peoples have the right to preserve their independent identity and exercise control over their wealth and natural resources. Article 7 (a) Everyone shall have the right to live in security for himself, his religion, his dependents, his honour and his property [18].
2.3.6 RIGHTS OF WOMEN: QUR’ANIC IDEALS VERSUS MUSLIM PRACTICE Certainly, if by ‘Islam’ is meant ‘Qur’anic Islam’, the rights that it has given to women are, indeed, very impressive. Not only do women partake of all ‘General Rights’ for any individual, they are also the subject of much particular concern in the Qur’an. Underlying much of the Qur’an’s legislation on women-related issues is the recognition that women have been disadvantaged persons in history to whom justice needs to be done by Muslim ‘Ummah’. However, in practice, very little of these Qur’anic ideals were practiced down the ages due to the patriarchal, male-biased nature of Muslim countries and cultures. To list the peculiar rights of women in Islam, one could only summarize as follows. In a truly Islamic society, a woman will have: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12)
Right and duty to obtain education. Right to have their own independent property. Right to work to earn money, if she wishes it. Equality of reward for equal deeds. Right to express her opinion and be heard. Right to provisions from the husband for all her needs. Right to negotiate marriage terms of her choice. Right to obtain divorce from her husband, even on the grounds that she simply cannot tolerate him. Right to keep all her money (she is not responsible to maintain any relation). Right to get sexual satisfaction from her husband. Right to have custody of young children after divorce. Right to refuse any marriage that does not please her.
All these rights are added to other general rights that a woman shares with a man in the eyes of Islam [18].
2.3.7
RELIGION AND POVERTY
Is religion the opium of the poor, oppressed people? Is poverty a determined destiny in religion?
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Revolt against consumer materialism in religion is manifested in some examples: * *
*
*
In Hinduism: ‘When you have the golden gift of contentment, you have everything.’ In Islam: ‘It is difficult for a man laden with riches to climb the steep path that leads to bliss’, ‘Riches are not from an abundance of worldly goods, but from a contented mind.’ In Taoism: ‘He who knows he has enough is rich’. ‘To take all one wants is never as good as to stop when one should.’ In Christianity: ‘Beware! Be on your guard all kinds of greed: a man’s life does not consist in the abundance of his possessions [19].’
Sims rejected the idea of the psychiatrist as being totally reflexive, and considered it ill conceived and outdated. He believes that there is no such thing as ‘valueless’ psychiatry. All of us, as we practice, carry our values, standards, aims and goals from the rest of life into our psychiatry, and the same applies to our patients [22]. Some surveys have shown that mental health professionals, especially psychologists, are less involved in traditional religious practices than those they serve [23, 24]. However, more recent surveys suggest that the ‘religiosity gap’ between therapist and client may be narrowing [25, 26]. Speck argued that we need to distinguish between spirituality and religiosity. The former refers to an experience of contact with a higher power, whereas the latter also includes the outward framework for religious experience [27]. Sims mentioned five aspects of spirituality to be considered by the psychiatrist. They included looking for Meaning in Life, Human Solidarity, Wholeness of the Person: being body, mind and spirit, Moral Aspects: what is seen as good, as opposed to what is seen as bad, and Awareness of God: the connection between God and man. Religion can be a major source of ego support. Life is difficult and the world presents an unpredictable and risky environment. The complexities of modern life make such a statement even more obvious. Religion, usually including a community of shared beliefs, offers support and structure for coping with such stressful, inevitable events. It may also enhance positive experiences, such as hope and optimism [22].
2.3.8
ISLAMIC CULTURE AND MENTAL HEALTH
The following table expresses the influence of religion and conformity to the Islamic culture in interpersonal relationship, the perception of disease and the attribution of all events to God’s will between Islamic and Western societies [28]. Table 2.3.1 Societies
The Influence of Religion and Cultural Conformity within Islamic and Western
Islamic Society
Western Society
family and group oriented extended family (not so geographical as before, but conceptual) status determined by age and position in the family, care of elderly relationship between kin obligatory arranged marriages with an element of choice dependent on interfamilial relationship
individual oriented nuclear family status achieved by own efforts determined by individual choice choice of marital partner, determined by interpersonal relationship
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extensive knowledge for distant relatives decision making dependent on the family locus of control external respect and holiness of the decision of the physician rarely malpractice suing deference is God’s will doctor patient relationship is still healthy individual can be replaced. The family should continue and the pride is in the family tie pride in family care for the mental patient dependence on God in health and disease, attribution of illness and recovery to God’s will
2.3.9
restricted only close relatives autonomy of individual locus of control internal doubt in doctor patient relationship common self determined mistrust irreplaceable, self pride community self determined
RELIGION, SPIRITUALITY AND MENTAL HEALTH
Religion can provide a source of explanation and understanding of questions such as the meaning of life and death. Many authors, including Frankl [29, 30] have emphasized the importance of searching for life’s meaning. Frankl commented on the despair of those living in an ‘existential vacuum’. He believed that frantic efforts to combat boredom and a sense of emptiness through sexual encounters and other means are futile. Religion has an important role in social integration and control. Religion is part of the culture or way of life of a society, and it helps to maintain cultural traditions. Society can only survive if people share some common beliefs about right and wrong behavior. Durkheim saw religion as a kind of social glue, binding society together and integrating individuals into it by encouraging them to accept basic social values. So, it is mainly through religion that an individual is socialized into the values of society. This set of moral beliefs and values may have been so deeply ingrained through socialization that it may have an effect on the everyday behavior of believers and non-believers alike. If some rule is broken, most individuals will experience a guilty conscience about doing something ‘wrong’, and this is a powerful socializing and controlling influence over the individual. Another important sociological function of religion is social support. Religious doctrines encourage positive social attitudes and self-sacrifice. Studies have shown that religiosity is strongly related to almost every dimension of social support. In the United States of America, one study confirmed that support for the elderly from church members exceeds that from all other sources combined. Social support in turn is related to lower rates of depression, anxiety, loneliness, and other mental health problems. Indeed, emotional support from others is a major therapeutic tool used in all forms of counseling and psychotherapy [31]. During the past half-century, especially the last 20 years, a number of well-designed studies have examined the relationship between mental health and religious belief, commitment or practice. The following is a review of the relationship between the use of religion as a coping behavior and depression in a sample of almost 1000 hospitalized medically ill men. People who used religion as a coping behavior were compared with those who said they coped in other ways (staying busy, visiting friends or family, and so forth). Patients who depended heavily on their religious faith to cope were significantly less depressed than those who did
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not. Two hundred and two patients were then followed up for an average of six months after they were discharged from hospital. The objective was to determine what characteristics of patients in the study would predict who later became depressed. The only characteristic that predicted lower rates of depression was not the level of support from family or friends, not physical health status, and not even income or education level but rather the extent to which patients relied on their religious faith to cope. This was the only factor that predicted significantly better mental health six months later. Although health professionals seem to be less interested in positive states of mind than in mental disorders, several studies reported positive association between religious commitment and well-being among persons of all ages [32–36]. Other investigators have also found a positive association between religion and happiness [37–39]. Satisfaction with life is thought to be a cognitive aspect of happiness. Examining a national sample of black Americans, Jeffrey Levin and colleagues [40] found that persons who were more religiously involved experienced significantly greater life satisfaction, even after taking into account the effects of physical health status and other conventional predictors of well-being. In a large study examining the relationship between anxiety and religious activity in a sample of almost 3000 persons, it was found that people with religious commitment experienced significantly lower rates of anxiety disorder compared to the non-religious group [41]. Other investigators have reported similar results (lower levels of anxiety among the more religious) in samples of both healthy and medically ill subjects [42–44]. In 1980, Koenig and his colleagues conducted a study on 4000 persons in central North Carolina to determine whether those who were more religiously active would be more or less depressed than those who were not religious. Persons who were more involved in religious activities were only about one-half as likely to be depressed as those who were less religious. The finding was true regardless of age, sex, race, level of social support, and the degree of physical illness or functional disability. This study was presented at the American Association for the Advancement of Science annual meeting [45]. Similarly beliefs about mental illnesses and their treatment are closely tied to beliefs about sins and sufferings in many societies and views that mental illnesses may result from some kind of separation from the divine, or even possession by evil still prevails in many cultures. If we look at the interaction of psychiatry and religion, a number of factors appear to be playing an important role. Beliefs of the patient, beliefs of the mental health professionals, cultural influences and attitudes and beliefs about treatment of the mental illnesses, all have variable influences in this regard. Unfortunately, many misconceptions about Islam and Muslims are prevalent in the Western world and are creating more conflicts and difficulties in understanding the view points of Muslims [46]. Islam, in its true sense, is not simply a religion but is also a way of life and gives a number of directions about leading life and sorting out the day-to-day problems. There are five pillars of Islam i.e., faith in oneness of Allah and prophet Muhammed being the last prophet, prayers five times a day, fasting in the month of Ramadam, Zakat (Alms) and Pilgrimage to Mecca at least once in a life time if one can afford it. These are the basic pillars and every Muslim has to believe and practice on these principles. In addition to the pillars of Islam, the Code of Conduct to lead day-to-day life has been explained in the religion with some approvals and disapprovals. Mental illnesses are also recognized as disease entities and emphasis has been made about the care and the rights of the mentally ill. Islamic doctoring has dealt with a number of psychosocial issues including marital relationships, child rearing, family care, adoption,
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orphanages, women’s rights, love, mercy, dutifulness, justice, modesty, as well as topics that include well defined guiding principles for normal and civic duties. In terms of religious practices, clergy or priests have no mediation function between man and God. Their only function is to guide the people to the code of conduct in terms of day-to-day living, quoting of right (halal) and wrong (haram) forms the basis of principles of daily life. If we look from a psychological point of view, the concept of ego and super ego along with consciousness and sub-consciousness are imbedded in such coding of life. The development of ego or self is governed by the pillars of Islam and the super ego is strengthened by the acceptance of behavior by the social norms of the society. Similarly internalization of socially shared religious criteria forms the basis of group ego and this is how the integration of self and society is determined in terms of healthy functioning [47]. The role of Islamic in coping behavior can be expressed by what happened in Tsunami in Indonesia. Hundreds of children lost their parents in Achte in Indonesia and the WHO sent experts to deal with Post Traumatic Stress Disorder (PTSD). However, because of their resilience and their coping behavior following their fundamentalist Islamic upbringing that everything was attributed to God’s will, there was no PTSD. Some experts stated that PTSD is a Western diagnosis as in some Islamic culture it is rather infrequent [49].
2.3.10
THE CONCEPT OF MENTAL ILLNESS IN ISLAMIC SOCIETIES
Moslems attribute all events in life to God’s will and it can be understood that the concept of mental illness can be influenced by cultural and religious aspects. For example, negative symptoms can be attributed, in some sectors of Moslem societies, to deeper contemplation about God i.e. virtuous and pious, to the extent that avolition, anhedonia, indifference and blunting of the effect of secondary psychiatric disorders, can be considered desirable social traits in certain religious cults, and so these conditions can be missed. Again positive symptoms can be attributed as gifted from God by extraordinary perception i.e. a special person. There may be religious interpretations to personality disorders e.g. schizotypal can be explained as being close to God, schizoid as a kind person, paranoid as careful, avoidant as religious and anankastic as meticulous in following religious rituals.
2.3.10.1
Obsessive compulsive disorder and Islam
The role of religious upbringing has been evident in the phenomenology of Obsessive Compulsive Disorder (OCD) among Moslems. The psychosociocultural factors are so varied that they can affect the onset, phenomenology and outcome of OCD. They can even affect response to treatment. The emphasis on religious rituals and the warding off of blasphemous thoughts through repeated religious phrases could explain the high prevalence of religious obsessions and repeating compulsions among our Egyptian sample. This is true even if the participants in the study were not practicing their religious duties. To elaborate further, Moslems, who constitute almost 90% of the Egyptian population, are required to pray five times a day. Each prayer is preceded with a ritualistic cleansing process (Wudu or ablution), which involves washing several parts of the body in a specific order, each three times. This ablution is invalidated by any form of excretion or ejaculation and, for some
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radical Moslems, by any contact with the opposite sex. Women are not allowed to pray or touch the Koran during their menstruation, after which they should clean their bodies through a ritualistic bath. The prayers themselves vary in length and consist of certain phrases and suras from the Holy Koran that have to be read in a certain sequence [48]. The emphasis on cleanliness or ritual purity is the cornerstone of most of the compulsive rituals. The number of prayers and their verbal content can be the subject of scrupulousness, checking and repetition. The ritualistic cleansing procedures can also be a source of obsessions and compulsions about religious purity. Other evidence of the religious connotation inherent in OCD in Moslem culture lies in the word weswas in Arabic. This term is used in reference to the devil and, at the same time is used as a name for obsessions. Blasphemous thoughts are common and if the patient goes to the religious people, it is usually attributed to the weswas which here means the devil and not obsession which aggravates the agony of the patient who considers himself sinful. It is also characteristic of a conservative society like Egypt to expect sexual obsessions to be among the most frequent in female patients. Although it is accepted socially (but prohibited religiously) for Egyptian males to have a wide range of sexual freedom in all stages of their lives, sexual matters remain an issue of prohibition, sin, impurity and shame for Egyptian women. The female gender is surrounded by so many religious and sexual taboos that the issue becomes a rich pool for worries, ruminations and cleansing compulsions in women susceptible to developing OCD. Christians represent approximately 10% of the population in Egypt, which was equivalent to the percentage in our study sample population. The presenting symptoms for these patients were almost similar in terms of obsessions, where religious and sexual thoughts were predominant. However, there was a marked difference in rituals, which were more frequent in Moslems. This emphasizes the role of ritualistic Islamic upbringing, as compared with a Christian upbringing, in our community. A comparison was also drawn between the most prevalent symptoms in our sample and those of other studies performed in India, England and Jerusalem. Contamination obsessions were the most frequent in all studies. However, the similarities of the contents of obsessions between Moslems and Jews, as compared with Hindus and Christians, signify the role played by cultural and religious factors in the presentation of OCD. The obsessional contents of the samples from Egypt and Jerusalem were similar, dealing mainly with matters of religion, cleanliness and dirt. Common themes between the Indian and British samples, on the other hand, were mostly related to orderliness and aggressive issues [48, 50–53].
2.3.10.2
Hysteria and possession
The perception of hysteria as a primitive mechanism of defense against frustration was previously mentioned by Tewfik and Okasha [54], who reported hysterical spells to be related to sexual rivalry, jealousy, and domestic quarrels in the setting of closed, fervently religious communities where a belief in possession by external agencies exists, or where people are easily excitable and emotional and have a high level of acceptance for each other’s outbursts. Hysterical disorders also affect a large proportion of the patients who attend traditional healers in our region. In a study conducted by Okasha in 1966 [55] around El Zar cult in Egypt (a musical, semi religious dance in a group setting for exorcising evil spirits) it was found that 52% of Zar adherents had a hysterical personality and 40% of them
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had, at the time of their attendance, a diagnosis of ‘hysteria’ with one or more of its presentations. The therapeutic effect of El Zar was most beneficial in this disorder compared with other disorders. With the increasing complexity of our society and the intrusion of values that accompany the industrialized Western example, competition and rivalry are gradually becoming hallmarks of everyday behavior, with an increasing stress on individuality and single personal achievements especially in the work sphere. People shut out of this sphere for one reason or another, or those who fail to cope with this new alien pattern, frequently resort to mental symptoms for defense. The decline in the prevalence of hysteria indicates that this primitive mental mechanism no longer suffices, with people tending more to other behaviors that can be termed under parasuicide [56]. Another category which used to be diagnosed as hysteria in our context is a condition presenting with bizarre behavior, pseudohallucinations that have a wish-fulfilling character, and a culturally bound delusional system characterized by a belief that one is possessed and controlled by paranatural forces (jinnes, devils, etc.). This possession can sometimes lead the individual to live a double life: one that is his and the other that belongs to the possessing agent. Although this picture greatly overlaps with the definition of multiple personality given by Ellen Berger [57], this category is more likely to be included under brief reactive psychosis, schizophreniform disorder, or atypical psychosis. These categories comprised another 6.7% of our sample. The prevalence of these disorders has been reported by several other investigators. Wessels [58] reported hysterical dissociative states in an African context characterized by hearing voices, thought inferences, and feeling harmed. Okasha [59] referred to the prevalence of this condition, termed in the ICD-10 ‘acute polymorphic psychotic disorder’, which encompasses a wide variety of reactions, with multiple symptomatologies which begin in response to stress and usually show a good recovery. The psychopathology of all those conversion and dissociative states are ushered and maintained by the religious upbringing [54].
2.3.10.3
Perception of suicide in Islam
Islam advocates preservation of life. Suicide or harming oneself is prohibited. There have been a number of reports that confirm that suicidal acts are less common in severely depressed Muslim patients. They may be having the suicidal thoughts equal to non-Muslim patients, but, when it comes to ending life, the frequency of suicidal acts or rituals decreases significantly. The religion thus provides a shield and this is an important aspect of Islamic religion that can be used successfully in dealing with the suicidal problems and complications. *
*
Suicide in Islam is ‘Haram’ which means prohibited by religion because it manipulates something that is meant to be only God’s concern i.e. life and it indicates lack of trust in God. Making things better, however, haram also means unjust to self, unjust to others and, as mentioned in the holy Quran, ‘Take not life which Allah has made sacred, except by way of justice and law, thus does he command you, that you may learn wisdom’ (Surat Al Anam 151) ‘Nor take life which Allah has made sacred except for just cause. And if anyone is slain wrongfully, we have given his authority to demand (Qisas) or to forgive, but let him not exceed bounds in the matter of taking life, for he is helped (by law)’. (Suraat Al Israa (33)
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Suicide as a Leading Cause of Death comes seventh in Europe, eighth Western Pacific, 16th South East Asia, number 25 in East Mediterranean region (all Moslems) so it is not an urgent health problem [47]. In Israel, suicide rates are 3 fold higher for Jews than for Arabs (9.8 vs. 2.9), higher for men than women, the same for UEC (undermined external causes) 7.2 vs. 3.7. In Egypt, Okasha (1979) reported suicide in a selective catchment area as 3.5/100.000. lower than reported suicide in different parts of the world [60]. Some Islamic scholars denounce the belief that suicide bombers are martyrs, as they had predetermined suicidal intention which nullifies martyrdom. Killing civilians and the innocent is not Islamic. Feelings of hopelessness and the intention to kill oneself are not common among Muslims, for whom losing hope in relief by God and self-inflicted death are blasphemous and punishable in the afterlife. Suicidal behavior drops markedly in frequency during the Holy month of fasting in Ramadan, however, rates of suicide attempts (parasuicide), which are more likely to be intended to elicit care, have no significant associations with religiousness among Moslems. There is extreme under-reporting in Arab countries, as it is a stigma to the family especially in the case of female suicides usually taken to indicate breaking of moral codes and fear of police investigations. Suicide has a very high rate in areas of conflict questioning the notion that national conflict decreases rates of depression and suicide. Reasons for committing suicide in some Arab societies, as in Bahrain, include problems with parents, school or work, social isolation and problems with a partner; in Saudi Arabia: health and family-related stressors; in Jordan: males: being single, unemployed; females: marriage, sociocultural problems, in Kuwait: family discord. Personal and family problems constitute the main trigger for suicide and attempted suicide in traditional societies. In industrial societies, work related problems are more prevalent among suicide attempters.
2.3.10.4
Drug abuse and intoxication in Islam
The five imperatives of Islam are the preservation of religion, mind, body, wealth and honour. A Muslim is enjoined by texts in the Quran and in the Sunna to avoid anything that may cause his own death or bring about his own destruction, as God says: ‘And cast not yourselves to ruin with your own, hands’, (Bakara Soura: 195). ‘And kill not yourselves’ (All Nesaa Soura: 129). A Muslim is responsible to God for his wealth and body, as the saying of the Prophet declares; ‘No slave of God shall move on the Day of Judgment until he is asked about his life and how he spent it, his knowledge and what he did with it, his wealth and whence he obtained it and how he spent it, and his body and how he used it’ (reported by Al-Tirmithi). Smoking and illicit drugs constitute an excess and an act of squandering which is banned by the words of God: ‘squander not in the manner of a spendthrift’; and it constitutes a hardship for those who can hardly afford it as it deprives them of some essential requirements of life. It has become clear that smoking and illicit drugs, in no matter which form or by which means, causes people a great deal of damage sooner or later, both to health and to wealth, as well as a variety of diseases. Consequently, and by virtue of these texts, the use of narcotics is forbidden. No Muslim is allowed to use psychoactive substance of any kind or in any form. This is essential for the preservation of life and wealth, to avoid the harm that
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medicine has proved and to maintain the well-being of families and society. A believer who is in a healthy condition is better and dearer to God than a believer in a weak condition. It is for a definite reason that Islam resorted to a gradual approach in prohibiting intoxicants. Islam did not speak out against intoxicating drinks until the fifth year of the Prophet’s settling in Medina. In other words, its gradual prohibition started 18 years after the beginning of Islamic revelations. The reason for this is found in the nature of such addictioncausing substances. They require a gentle, gradual approach. The starting point in forbidding wines and intoxicants was that Muslims were not allowed to offer their prayers when they were under the influence of drink. This meant that a Muslim who offered his five daily prayers must stay sober throughout the day until well after nightfall. In the second stage, Islam acknowledged that there were some benefits in wine and drinks, but it stated clearly that its evil was greater than its benefit. At this point, those endowed with a measure of wisdom realized that it was disapproved of and Islam would never approve of something which produced more harm than good. Therefore some people abstained from drinking at that stage, but the majority continued to drink. Then the final stage; arrived when Muslims had shown their true metal and that they were resolved to uphold Islamic teachings at all costs. Hence, the final stage included a complete and full prohibition: ‘Believers, intoxicants and gambling, (dedication of) stones and divination by arrows, are all an abomination of Satan’s work. Refrain from such abomination so that you may prosper.’ At the time the divine Message of Islam was revealed, and for many generations to follow, neither Arabs nor any other Muslims had any contact with tobacco. It was only towards the end of the tenth or early in the eleventh century after hijra (late sixteenth and early seventeenth century), that they had their first encounter with smoking. This fact explains why no conclusive ruling on smoking was made at the time and no direct divine ruling on smoking was ever revealed. Those experts of fiqh (Islamic jurisprudence) who were contemporaries of the smoking phenomenon tried their best to derive from religious provisions some kind of ruling on smoking, but their task was not easy. In the absence of direct and clear-cut religious provisions classifying smoking under one of the five verdicts of Islamic law (inevitability, impermissibility, abominability, recommendability, and permissibility), it is quite understandable that the jurists were of diverse opinion with regard to smoking. Some of them ruled that smoking was haram, others were of the opinion that it was abominable, a third group judged it to be permissible, a fourth group did not wish to give a ruling one way or the other on account of the fact that physical and financial hazards and effects of smoking differ from one person to another. God tells us that the Prophet allows them (His followers) as lawful what is good and pure and prohibits them from what is bad and impure. Undoubtedly, smoking is impure. God enjoins people not to kill themselves and not to make their hands contribute to their own destruction smoking is a means of self-destruction. A saying of the Prophet enjoins: ‘Cause harm neither to yourself nor to others’. Since smoking is at the root of much harm, it is haram [47].
2.3.10.5
Other psychological aspects
Stress, another common presentation in mental health, can also be managed in terms of Islamic perspectives. Stress is considered as a test of endurance and patience. It is accepted
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as God’s will, calling for patience and then appealing to God to relieve stress. This is a very interesting concept as here there is no hopelessness, but, there is a hope and one approaches God to get guidance and help to overcome the stress. Looking from the religious perspectives, stress also elicits the support of others, limits personal responsibility towards events and is based on forgiveness and generosity. Guilt, an important psychopathology, is also explained in a more favorable prognostic way in the Islamic religion. The concept is that no one is expected to do more than what could be done by any individual and one is not responsible for the sufferings or the wrongs of others. Attributing all wrongs beyond one’s own control and asking for forgiveness by God’s mercy helps to alleviate the guilt through the religious concepts. Regarding anxiety and anger management, teachings of Islam assure that you are going to control yourself at the times of anger and irritability by thinking of God and you are exposing yourself to feared situations with a strong intent to surmount. Islam has very clearly stressed the importance of conflict resolution in all fields of life and it has been mentioned in the Koran in different verses that Islam promotes and supports inter-personal conflict resolution. This is again an important approach while dealing with the day-to-day difficulties and conflicts [46]. Another psychological aspect of understanding and following Islamic religion is based on role modeling. Islam supports modeling and the prophet Muhammed has been considered as the best model amongst the people. He was considered the most honest, reliable and trustworthy even before Islam and used to be called ‘Muhammed the Honest’. Through the role modeling, it is reinforced that Muslims must follow their religious head and obtain guidance from his life. In terms of interpersonal approaches, Islam supports the development of mature interpersonal roles and the formation of mature group relations in society. This helps members of society to relate to others and co-operate with fostering care for each other [46]. In a substantial number of studies, across diverse groups and dealing with diverse problems, religious coping emerges as an important predictor of adjustment. Religion serves an important preventive role. Serious problems such as alcohol and drug abuse, parasuicide, AIDS, child abuse, sexual deviations and high-risk behaviors are prevented from developing in the first place.
2.3.10.6
Mental hospitals
The first Islamic mental hospital appears to have been established by the early eighth century (705 A.D.) in Baghdad in Iraq and to have been modeled on the East Christian institutions, which would seem to have been mainly monastic infirmaries. Among the hospitals that appeared throughout the Islamic world, perhaps the most famous one was that created in Cairo by the Egyptian, Sultan al-Mansour Kalaoon in 683/1284 A.D. [19]. The fourteenth century Kalaoon Hospital in Cairo had sections for surgery, ophthalmology, medical and mental illnesses. Contributions by the wealthy of Cairo allowed a high standard of medical care and provided for patients during convalescence until they were gainfully occupied. Two features were striking: the care of mental patients in a general hospital, and the involvement of the community in the welfare of the patient, which foreshadowed modern trends by six centuries [19]. Baghdad hospital was followed by Cairo (800 A.D.) Damascus and Allepo (1270 A.D.)
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It was through the Arab culture in Spain that Mental Hospitals were first built there e.g. Valencia, Seville, etc and from there spread to Europe.
2.3.11
CONCLUSION
In conclusion, religion clearly deserves greater recognition and attention from all mental health professionals. It represents resources that can help people cope better with emotional distress. Cox recommended that a ‘religious history’ – with any linked spiritual meaning – should be a routine component of the psychiatric assessment, and of preparing a culturally sensitive ‘Care Plan’. He also urged that a religious counselor should be included as a member of the multidisciplinary team [61]. Indeed, several spiritual strategies for counseling and psychotherapy have already been proposed [62]. This fascinating area of rapidly growing research should invite mental health professionals to seriously consider adopting the more comprehensive holistic ‘bio-psycho-socio-spiritual’ model when dealing with mental health problems.
REFERENCES 1. Boehnlein K James (2000). Introduction in Psychiatry and Religion. The Convergence of Mind and Spirit. Ed. James Boehnlein. American Psychiatric Press. Inc. Washington. 2. Lu FG, Lim RF, Mezzich JE (1995) Issues in the assessment and diagnosis of culturally diverse individual. In: Oldham J & Riba M (eds.) American Psychiatric Press Annual Review of Psychiatry 14. American Psychiatric Press, Washington, DC, pp. 477–510. 3. Lu FG, Bowman E, Juthani N (1995) Psychiatric Training about Religion and Spirituality: Toward a Model Curriculum. Workshop presented at the Mid-Winter Meeting, American Association of Directors of Psychiatric Residency Training, Tucson, AZ, January 14. 4. Larson DB, Thielman SB, Greenworld MA, et al. (1993) Religious content in the DSM-III-R glossary of technical terms. American Journal of Psychiatry 150, 1884–1885, 1993. 5. American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised, Glossary of Technical Terms (Appendix C). American Psychiatric Association, Washington, DC. 6. Larson DB, Thielman SB, Greenworld MA, et al. (1993) Religious content in the DSM-III-R glossary of technical terms. American Journal of Psychiatry 150, 1884–1885. 7. American Psychiatric Association (1994) American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. American Psychiatric Association, Washington, DC. 8. Brown GW & Prudo R (1981) Psychiatric disorder in a rural and an urban population. I: Etiology of depression. Psychological Medicine 11, 581–599. 9. Neelman J & King M (1993) Psychiatrists’ religious attitudes in relation to their clinical practice: a survey of 231 psychiatrists. Acta Psychiatrica Scandinavica 88, 420–424. 10. Breasted JH (1934) The Dawn of Consciousness. Charles Scriber’s Sons. New York – London. 11. Okasha A & Okasha T (2000) Notes on mental disorders in Pharaonic Egypt. History of Psychiatry xi, 413–424. 12. Ebbell B (1937) The Papyrus Ebers. Levin and Munksgaard, Copenhagen. 13. Posener G (1936) La premiere domination perse en Egypte, Bibliotheque d’etudes Vol. 11 Le Caire, Cairo.
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14. Sigerist HE (1951) A History of Medicine: Volume1: Primitive and Archaic Medicine. Oxford University Press, New York. 15. Baasher T (1975) The Arabic Countries. In: Howells TG (ed.) World History of Psychiatry. Churchill Livingstone, New York/London, pp. 211–223. 16. Zahoor A (1997) Muslim History. In: Arnold ThW and Guillaume A (eds.) Legacy of Islam. Oxford University Press, London. 17. Tan SY (2002) Medicine in Stamps: Rhazes (835–925 A.D.) Medical Scholar of Islam. Singapore Medical Journal 43, 331–332. 18. The Islamic Conference number 19 for Ministers of Foreign Affairs of Islamic States issued in August 1990, in Cairo: the Cairo Declaration of Human Rights in Islam. www.religlaw.org/ interdocs/docs/cairohrislam1990.htm. 19. Okasha A (2005) History of Psychiatry in Egypt from Pharonic to the Islamic Eras Read at XIII World Congress of Psychiatry – Cairo – September 2005. 20. Tan SY (2002) Medicine in Stamps: Avicenna (980 – 1037): Prince of Physicians. Singapore Medical Journal 43, 445–446. 21. Ibn Khaldoun AM (2006) Ibn Khaldoun Introduction (1390) Revised by Wafi, A. Nahdet Misr Publishing House, Cairo. 22. Sims ACP (1994) Psyche-Spirit as well as mind. British Journal of Psychiatry 165, 441–446. 23. Ragan C, Malony HN, Beit-Hallahmi B (1980) Psychologists and religion: professional factors associated with personal belief. Review of Religious Research, 21, 208–217. 24. Shafranske EP, Gorsuch RL (1984) Factors associated with perceptions of spirituality in psychotherapy. Journal of Transpersonal Psychology 16, 231–241. 25. Bergin AE, Jensen JP (1990) Religiosity of psychotherapists: A national survey. Psychotherapy 27, 3–7. 26. Shafranske EP, Malony HN (1990) Clinical psychologists’ religious and spiritual orientations and their practice of psychotherapy. Psychotherapy 27, 72–78. 27. Speck PW (1997) Being There: Pastoral Care in Time of Illness. SPCK, London. 28. Okasha A (2000) The Impact of Arab Culture on Psychiatric Ethics. In: Okasha A, ArboledaFlorez J & Sartorius N (eds.) Ethics Culture and Psychiatry. American Psychiatric Press, Washington, DC, pp. 15–23. 29. Frankl V (1965) The Doctor and the Soul: from Psychotherapy to Logotherapy. Knopf, New York. 30. Peck DL (1988) Religious conviction, coping, and hope. Case Analyses 2, 201–219. 31. Browne K (1998) The Role of Religion in Society. An introduction to sociology, 2nd edn. Polity Press, Cambridge, pp. 346–349. 32. Koenig HG (1988) Religious behaviours and death anxiety in later life. Hospice Journal 4, 3–24. 33. Levin JS, Markides KS (1988) Religious attendance and psychological well-being in middleaged and older Mexican Americans. Sociological Analysis 49, 66–72. 34. Koenig HG, Futterman A (1995) Religion and health outcomes. A paper presented at Conference on Methodological Approaches to the Study of Religion, National Institute on Aging. 35. Ellison CG, Glass TA, et al. (1989) Does religious commitment contribute to individual life satisfaction? Social Forces, 68, 100–123. 36. Ellison CG (1991) Religious involvement and subjective well-being. Journal of Health and Social Behaviour 32, 80–99. 37. Poloma MM, Pendleton BF (1990) Religious domains and general wellbeing. Social Indicators Research 22, 255–276. 38. Robbins M, Francis LJ (1996) Are religious people happier? Research in Religious Education. Smyth & Helwys, Georgia. 39. Lewis CA, Joseph S (1995) Convergent validity of the Depression-Happiness Scale with measures of happiness and satisfaction with life. Psychological Reports 76, 876–878. 40. Levin JS, Chatters LM, Taylor RJ (1994) Religious effects on health status and life satisfaction among Black Americans. Journal of Gerontology 50B, S154–S163.
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41. Koenig HG, Ford, SM, et al. (1993) Religion and anxiety disorder. Journal of Anxiety Disorder 7, 321–342. 42. Thorson JA, Powell FC (1990) Meanings of death and intrinsic religiosity. Journal of Clinical Psychology 46, 379–391. 43. Morris PA (1982) The effect of pilgrimage on anxiety, depression and religious attitudes. Psychological Medicine 12, 291–294. 44. Kaczorowski JM. Spiritual well-being and anxiety in adults diagnosed with cancer. The Hospice Journal 5, 105–116. 45. Koenig HG (1996) Report on Depressive disorder in hospitalised medically ill elders. Funded by National Institutes of Mental Health, New York. 46. Javed A (2006) World Congress of Psychosocial Rehabilitation WAPR Regional meeting, Hungary 2006. Personal communication. 47. WHO (2000) Regional Office for Eastern Mediterranean – EMRO, WHO publications, Alexandria, Egypt. 48. Okasha A (2004) OCD in Egyptian Adolescents: The effect of culture and religion. Psychiatric Times, April 2004 Special Edition. 49. Okasha A (2005) The WPA Tsunami Programme. World Psychiatry 4, 65. 50. Akhtar S, Wig NN, Varma VK et al. (1975) A phenomenological analysis of symptoms in obsessive compulsive neurosis. British Journal of Psychiatry 127, 342–348. 51. Greenberg D (1984) Are religious compulsions religious or compulsive? A phenomenological study. American Journal of Psychotherapy 38, 524–532. 52. Khanna S, Channabasavanna SM (1988) Phenomenology of obsessions in obsessive compulsive neurosis. Psychopathology 21, 12–18. 53. Pollitt J (1957) Natural history of obsessional states. British Medical Journal 1 (no. 5012) pp. 194–198. 54. Tewfik GI, Okasha A (1965) Psychosis and immigration. Postgraduate Medical Journal 41, 603–607. 55. Okasha A (1966) A cultural psychiatric study of El Zar cult in U.A.R. British Journal of Psychiatry 112, 1217–1221. 56. Okasha A, et al. (1993) Presentation of hysteria in a sample of Egyptian patients – an Update. Neurology, Psychiatry and Brain Research 1, 155–159. 57. Ellenberger H. (1970) The Discovery of the Unconscious. Basic Books, New York. 58. Wessels WH (1984) Transcultural aspects of psychiatry. In: Shapiro HA (ed.) Medicine and Health in Developing South Africa. College of Medicine of South Africa, Johannesburg. 59. Okasha A (1993) Presentation of acute psychosis in an Egyptian sample (transcultural comparison). Comprehensive Psychiatry 34, pp. 4–9. 60. Okasha A and Lotaif F (1979) Attempted Suicide: An Egyptian Investigation. Acta Psychiatrica Scandinavica 60, 69–75. 61. Cox JL (1996) Psychiatry and religion: a general psychiatrist’s perspective. In: Bhugra D (ed.) Psychiatry and Religion. Context, Consensus and Controversies. Routledge, London. 62. Richards PS, Bergin AE (1997) A Spiritual Strategy for Counseling and Psychotherapy. American Psychological Association, Washington, DC.
CHAPTER 2.4
Psychiatry and African Religion Frank G. Njenga and Anna Nguithi Consultant Psychiatrist, Kenya
Sam G. Gatere Psychiatrist, Kenya
2.4.1
INTRODUCTION
There are three identifiable phases in the description of psychiatry and religion in Africa. These are the pre-colonial, colonial and post-colonial phases. For a massive continent with great diversity in geography, culture and history, any attempt to bring the pertinent issues together in a single chapter is likely to create controversy because of over, and in some cases, under emphasis of some aspects seen as critical by the different critics. This chapter will therefore not attempt to cover the entire periods, regions or even religions, but will rather paint a picture that will help the reader obtain a fair picture of the state of religion and psychiatry in the different times, and regions. The authors’ experiences in the field will be evident throughout the chapter.
2.4.2
PRE-COLONIAL ERA – PRE 1850
The Sub-Saharan part of the continent was inhabited by diverse groups of people, including the Bantu, Hamitic and Nilo-Hamitic among others. Each of these groups had varied systems of religion and ancestor worship as well as sacrificial practices that characterized and identified the regional and tribal groupings. Each region to the east, north and west of Africa was dominated by a particular group, though the boundaries were not clear. The east and southern African parts were dominated by the Bantu, while Hamitic and Nilo-Hamitic occupied the northern and western parts of the continent. To this day, these broad regions remain unchanged in principle, although the groups have moved in all directions and many have intermarried. The Gikuyu people of East Africa are a typical example of the Bantu. They maintained a close and vital relationship with spiritual beings and entities. Their daily lives both as
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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individuals and groups were influenced by their belief in the supernatural. They had clearly defined systems of worship that ensured continuous contact with their God, ancestors, and the unborn. They were at all times careful not to upset the balance [1]. The Yoruba believed that the God of divination – ‘Ifa’ is the one through who man can detect the cause of mental illness. These beliefs have, over the years, affected not just the Africans’ perception of mental health and disease but also the responses of the people to such diseases [2]. Schizophrenia, epilepsy and other psychoses have been seen as being the result of the work of these malevolent spirits that must be appeased in one way or another to achieve harmony and health. Among the Shona of Zimbabwe, most illness is regarded as ‘normal’, such as the common cold and flu. However, persistent and debilitating illness often resulted from angry spirits, most commonly ‘vadzimu’, the ngozi and the mashawe. The latter were alien spirits, the first ancestor spirits, while the second were spirits of those who died naturally. The people had to know which spirit was which to be able to appease them! Supernatural forces were used as explanations for all aspects of their lives including health, good and bad luck, rain, drought and all other phenomenon around them [2]. In particular, bad health was seen as a result of displeasure by the gods. The Shona and Gikuyu shared these belief systems possibly because of their Bantu origins. In West Africa, the Yoruba conceive of the supernatural powers as being of two types – malevolent and benevolent. The former are regarded as belligerent enemies of man causing disease, while the latter are responsible for good health and well-being. Mental illness in particular is the result of effects of the malevolent spirits. ‘Were’ is a disease of mind that acts through the spirits and in the same way affects the soul. The distinction in the African between the spirit and the soul and mind is often unclear. The Swahili word for spirit is pepo. The same word means devil, but also means paradise. The soul, (roho) is, like the spirit, unseen and responsible for the life of the person. The Shona further held beliefs with regard to the environmental causes of disease. For example evil power not related to the creator was the environmental cause of bad or negative physical or earthly factors leading to bad health. Such evil spirits could lead to mental illness and religious intercession could cause corresponding reversal of the harm. Another potential area of confusion is the belief of the link between the dead and the living. Many Africans still believe that they have regular visits from the spirits of dead relatives. They hold these beliefs firmly and sometimes act out instructions from the dead. On occasion, the psychiatrist will be asked to treat ‘such delusions’. For the African, visits from the dead can be good or evil in their intentions. Sometimes, they remind the person visited of the debt owed to in-laws on account of goats not paid for in a previous generation. A psychiatrist who ignores these Africans does so at their own clinical peril and is advised to make themselves familiar with these belief systems. CASE NO. 1 M.K. is a 26 year old man who was admitted with a first time episode of psychosis. He was obviously manic. Aweek later, he was much better though still quite restless and accelerated. The relatives requested the psychiatrist not to discharge but to be allowed to take him home for three days. They explained
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that there was an important ceremony that the patient had to attend. They promised to supervise his medication when he was away. They later explained that they had realized that the ‘cause’ of the young man’s illness was the fact that his mother’s dowry had not been fully paid. The maternal grandfather had been unhappy about this and had since died. The ceremony was to pay dowry to their mother’s family and thus appease the spirit of the dead. All were now at peace and had faith that his recovery would be complete! This type of communication would come via a visit from the dead or through divinely inspired dream.
In all these traditional societies therefore, religion, spirituality and mental health and disease of the African were intimately interrelated. As though to complicate the life of the African, external forces began to bear on the continent as early as the fifteenth century, many believe earlier. The spread of Islam from the north east was rapid. It changed the ways of life and thinking of ancient civilizations including the legendary Kingdoms of Mali. Timbuktu is the best known example of one such kingdom whose Kings travelled to Mecca with tons of gold for the statutory Hajj pilgrimage. The recent discovery of written ancient scripts in the desert has confirmed that the African could and did write long before the influence of the West. Beneath the sands of Mali and as the secrets of the ancient Kingdoms make themselves known we are likely to know more of the ancient practices of the African. Some may have relevance to the understanding of religious and spiritual practices of the early African. For now, the myth that African history was exclusively oral in origin has been broken. The melting point of modern Islam and traditional African religions in the continent is best exemplified by the impact on the politics of some of the regions. Sudan with its predominantly Muslim North must find a way of co-existing with the south that is predominantly Christian and animist. The roots of these conflicts go back centuries, to the spread of Islam. Apart from following its own calendar, Ethiopia is set aside from the rest of Africa in having a well established orthodox church with centuries-old history and tradition as well as its special and historic relationship with the Queen of Sheba and the Jews. Some Ethiopian people have closer spiritual and religious links to the Jews than they have to the typical African. These examples go to illustrate the diversity of the continent with regard to religion and by extension their views on psychiatry and mental health in general.
2.4.3
THE COLONIAL ERA – 1850–1960
As the West ‘discovered’ Africa, European influence moved rapidly in all directions, with the imperial powers colonizing and declaring protectorates across the continent. The Dutch, French, English, German, Portuguese and Belgians scrambled for the continent, dividing it among themselves along lines that did not take account of the tribes or traditions of the people of Africa. Lines drawn in East Africa, for example, put some Masai people in Tanganyika (a German Protectorate) while the other half remained in Kenya. Half the Somali (mostly Islamic faithfuls) were to live in the northern part of Kenya while the other half went to Somalia (an Italian territory). To the west, the Pokot were to be divided between Kenya and Uganda (the latter a kingdom, and Kenya which was to become a British colony!). To this day, ethnic, religious and land wars erupt from time to time in these and other regions of Africa as the different tribes compete for resources. Religious, spiritual and ethnic tensions with serious mental health consequences remain. (See below).
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One of the longest and bloodiest wars in Africa is the Sudan civil war in which the Muslim north rule the whole country which includes a large group of Christians and animists living in the south, more allied in language and custom to northern Uganda. Though not the sole reason for the war, part of it is the perceived oppression of Christians by the Muslims from the north. The mental health consequence of this partly religious war is enormous and continuing. The other important influence of the entry of the European into Africa was the alienation of the educated African from his tribe and culture. The ‘properly’ educated African was expected to assimilate the habits and culture of the ‘white man’ in total abandonment of the culture of his people. Okot P’Bitek [3] is one of the most prolific poets of East Africa – He writes, ‘Black People are primitive, and their ways are utterly harmful, their dances are mortal sins they are ignorant, poor and diseased!’
There was also a clear conflict of culture and religion. This is how P’Bitek [3] describes the Christians feast’ of Holy Communion: ‘And he (the Priest) was calling people to eat human flesh! He put little bits in their hands and they ate it up!’ Then he took a cup, he said there was human blood in the cup and gave it to the people to drink!
Though presented as mainly a political and economic problem, the civil war in the Sudan is equally religious and spiritual as each of the groups perform their perceived duty of maintaining their identity and seeking to influence the other. As the war raged, Muslim, Christian and traditional African religious practices and systems of spiritual belief interfaced and as a result of the wars caused some of the highest casualties of any African civil war, as well as a high prevalence of mental disorders, including Post Traumatic Stress Disorder (PTSD) [4]. The situation to the north was no different as the people of Algeria were to find out. Franz Fanon [5] in his book The Wretched of the Earth states, ‘The nature of North Africa whose superior and cortical activities are only slightly developed is a primitive creature whose life is essentially vegetative and instinctive, is above all regulated by his diencephalon.’ [5, p. 243]. Writing about the same Africans, Professor Porot states [5, p 243] ‘Primitivism is not lack of maturity . . . . . . . It is a social condition which has reached the limit of its evolution. It is logically and spiritually adopted to a life different from ours’. These views from leading European academics were to shape colonial history in Africa. In this regard, religion, politics of the day, culture and mental health find a common melting pot and add much confusion to already disparate groups. In his other book Black Skin, White Masks, Fanon describes the desperate efforts of the black man to become white to escape the wrath of his colonizers, often with disastrous consequences. Fanon [6, p. 63] states, ‘out of the blackest part of my soul, across the Zebra stripping of my mind, surges this desire to be suddenly white’: ‘I wish to be acknowledged not as black but as white’ ‘By loving me, she proves that I am worthy of white love. I am loved like a white man’. The wars in the minds of the African were emotional, spiritual, psychological and vicious.
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In the early 1950s, Kenya found herself in the middle of one of the bloodiest wars of liberation to have hit Africa. What started off as a crisis of land distribution between the natives and colonialists soon transformed itself into a class war, before mutating into a religious war between the ‘athomi’ and the ‘washeji’. The former were educated and Christians and the latter poor, uneducated followers of traditional religions. In pursuit of their respective spiritual and land agendas, acts of gross violation of human rights were committed, in the name of their respective Gods, causing much unhappiness, mental and physical harm as well as displacement of hundreds of thousands of people with dire mental health consequences. In a recent study of the survivors of that war, Njau [7] found 70% of the veterans still show signs of PTSD, 50 years after the war. Many children brought up in central Kenya in this period witnessed acts of violence, were brought up as orphans and were pulled apart by the two groups of Christians and African Church Movements. Apartheid in South Africa included the need to protect Christian values against the negative and damaging influence of traditional African religions. Colonial African history is full of examples of the influence of colonialism, religion, traditional beliefs and practices in mental health and well-being. The long term consequences of life in the colonial era remain unclear but it is possible and desirable for the African academic to remain conscious of this period of African history in his attempts to understand some of the challenges in mental health that persist to date. A number of Africans from this era, for example, married across racial boundaries to achieve true whiteness and civilization and have as a consequence two sets of adult offspring from the two eras of African history (colonial, post colonial). Experienced clinicians describe patients who present with issues of racial, spiritual and other identity crisis that come to the attention of the expert disguised as alcohol and substance abuse or as depressive states. Some understanding of these deeper issues that go back a generation or two may be helpful. Another important contemporary challenge to the clinician is the cross generational guilt experienced by those who remained loyal to Christianity and the white man verses those who remained faithful to their traditional customs and gods. Some families have in some parts of Africa been ostracized for their historical roles that the current generations may be unaware of. There are names of chiefs who in the wars of liberation were associated with traitors which still causes eyebrows to be raised when mentioned because of the stigma of those names. Clinicians need to be aware of the history of the communities within which they work, as some communities, marginalized for historical reasons, might have higher than expected rates of emotional disorders.
2.4.4
POST COLONIAL ERA
As African states emerged from colonial rule in the 1960s, political liberation came close on the heels and needs for theological liberation. This period has seen the emergence of many religious groups across the continent, many preaching the need to liberate the people from their current problems of poverty and disease, rather than embrace the philosophy of the Christian and Muslim that promises an eternal life of happiness. For this and other reasons, numerous splinter groups have emerged from the main Christian groups and the Pentecostal movement has spread rapidly across the continent. The promise of earthly, physical,
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spiritual and economic healing and prosperity have acted in concert to shape the direction of the belief systems of the modern African and have alienated him in many ways from the belief systems of his parents and grandparents. This nomadic spiritual existence has existed in parallel with rapid urbanization, breakdown of traditional system of social control and cohesion often blamed by some experts on the deterioration of morality, the spread of AIDS and the rapid increase in drug and substance abuse. These theories create fertile grounds for research by African academics.
2.4.5
COMMON THEMES
Against the background of a turbulent past, mosaic character of the continents’ spiritual landscape, coupled by the challenge of an uncertain future, common themes seem to emerge that characterize the African and his spiritual/religious life. These themes include but are not limited to the following: (i) High numbers of Africans believing in the existences of a supernatural being. (ii) The powers of the spirits to influence and in some cases interfere with their lives, positively or negatively. (iii) The need and importance of rituals to please the spirits and maintain a link with them and the ancestors. (iv) The link between the past, present and future generations in a common bond and in harmony with nature. (v) The existence of malevolent and benevolent spirits. (vi) The link between spirits and mental health and the need to appease the spirits for the achievement of good health. Some of these common themes are distinct in their expression in some religions and cultures while in some others the distinction is less clear. Their definition and character also changes with time and also from culture to culture and is also influenced by the educational level of the believer. For this reason, the permutations are complex, numerous and at best confusing and any attempt to explain them all in simple terms is bound to fail. For example, a Kenyan Mkamba from Kitui could (if from a poor rural non Christian background) accept in full the power of the spirits as the cause of his son’s illness and proceed to seek divination of his cure while his brother, who is well educated, urban and Christian, would have a son with the same symptoms and understand it as being caused by ‘chemical imbalances in his brain’. In practice, these brothers from the same village live in different worlds and have different experiences of the spiritual world. The clinician found by the two brothers would need to understand the language of each and respond to them with compassion and understanding. The young, well educated, enthusiastic mental health expert from Europe could see it as his duty to ‘liberate’ his rural patient from ignorant bliss. In the process, experience shows he would most likely lose the patient to a traditional healer who understands much better the ways of the gods and spirits. Experienced clinicians in Africa have developed styles and metaphors that enable them to make the best use of their knowledge and experience from both worlds. It is the height of clinical ignorance for the mental health worker to fail or refuse to take account of the belief system of his patient. A surgeon, baffled by the extreme behavior of his son who had classical features of (Attention Deficit Hyperactivity Disorder) ADHD, sought divine intervention from a
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traditional healer because he could not understand the ‘spirits’ that seemed to consume his son, sending him from the extremes of ‘good’ behavior at one moment, to the behavior of one possessed by the devil, including stealing money to go drinking and smoking cannabis! The contradiction in this belief system is common and confusing to younger psychiatrists and theologians who feel unprepared to deal with this type of dichotomy in their colleagues. Medical colleagues are not immune to this type of dilemma as they oscillate between tradition and modernity. In Europe, many churches are closing down as more and more Europeans abandon traditional Christian religious practices. The opposite is true in Africa, where ever growing numbers turn to the church as a source of hope for today and the future. The emergent (mainly Pentecostal churches) preach the gospel of the here and now, many addressing social, economic and health needs of their faithfuls in parallel with their spiritual needs. This approach has seen the rapid growth of these churches as the Africans abandon the ‘promises of the kingdom of heaven’ as preached by the more established traditional Christian churches. In these more ‘modern’ churches, established methods of dealing with problems and disputes ‘by prayer alone’ have been abandoned, with the African churches largely adopting pragmatic and contemporary methods of counselling for those in need of counselling for both spiritual and secular needs. The approach to health and disease by the modern African is changing rapidly, often beyond recognition as traditionally African as they embrace modernity. Across the continent, many Christian movements are attracting young people to their fold by preaching and practicing ‘bread and butter theology’ of the here and now, approaching the spiritual matters in a practical and pragmatic way. In this way, the churches are becoming significant players in the mental health field as they provide real alternative sources of what would ordinarily be seen as ‘clinical services’. The modern day mental health worker must find novel and practical ways of remaining faithful to his profession while at the same time remaining relevant in their rapidly changing ‘market place’ in Africa. Working with faith based organizations can be very rewarding to the mental health worker. In traditional religious practices in Africa, rituals and symbols took centre stage in the expression of spiritualism. Places of worship were clearly defined by the elders, with different tribes relating to different trees, herbs, animals, rocks and other places of worship. Shrines were treated with the greatest respect, and in some instances, such as the Kenyan forests of the people of the coast (Kaya), have served the important function of environmental preservation. The mugumo tree is sacred to the Agikuyu people as are other indigenous trees. It is not to be cut down! The link between religious practices and the environment is thus illustrated. It is from the same forests that medicines for various ailments are to be found. These are the places of prayer and worship for the removal from individuals and society of the evil spirits that could cause mental illness. This complex interrelationship between culture, religion and environment is to be found in many parts of Africa. To the uninitiated mental health worker in Africa, respect for trees, herbs, rocks and other places of worship could be seen as a ‘delusion’. In his book Facing Mt. Kenya Kenyatta [1] describes the concept of a deity. ‘Ngai the creator and giver of all things has no father, mother, or companion of any kind’. This is ‘clearly’ in marked contrast to the Christian doctrine where we know that the Lord Jesus Christ had a mother (Mary), Father in heaven and brothers. To the traditional African, these concepts are most confusing. How could God have a mother and father!
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According to the Gikuyu, Ngai, lives in the sky, but has temporally homes on earth. He carries out general inspections of his people from time to time and would largely prefer to be left alone, unless the people have a special or urgent need such as illness or drought! Unlike the Christian God, he does not demand regular worship! When on earth, he spends most of his time on top of Mount Kenya – Kere Nyaga. The different characteristics of the gods are a source of some conflict in the minds of some Africans. To this day, many Africans believe in simultaneous existence of the two gods. They would therefore go to a Christian service on Sunday morning and go via the ‘office’ of the traditional diviner for an opinion on who would win a football match or political contest in the afternoon. The same person would call a priest to pray for his depressed wife on the Monday, and on the Tuesday, slaughter a lamb of ‘one skin’ as a sacrifice to his tribal god to help heal the wife from the troubles of her spirit. The psychiatrist practicing in Africa today must live in harmony with these apparent contradictions. The distinction between culture and religion is in many cases difficult to make as one merges with the other imperceptibly. The African is in this respect similar in his customs and beliefs to the rest of the world. The following examples illustrate this subject well.
2.4.5.1
Marriage
The Christian doctrine is clear on the instruction to its faithful to marry one wife and to live with her ‘till death do you part’. African religious practices on the other hand permit and in the view of some, encourage the man to marry several wives. Temporary sexual unions are permitted for men as they travel to far away lands but only with wives of their age mates who are people who were circumcised at the same time or season. The symbolism of pouring blood in circumcision on the same day binds the tribesmen from Masailand in a way that goes beyond a brotherhood. Members of the same age group will die for each other and will share the most intimate belongings including wives. A man who finds a spear planted at the entrance of his wife’s hut will know that a person of his age has been welcomed to his home and will go and sleep elsewhere! The crisis brought by these fundamental differences in belief systems have caused much distress to the Christian church faithful of modern Africa, as they try to embrace both Christianity and their traditional African persuasions. This problem remains largely unresolved for these Africans who, after marrying several wives, later ‘see the light’ and decide to seek salvation through Christ. The dilemma then is what to do with their new found faith and their many wives. Deep spiritual matters such as receiving holy sacrament while one remains polygamous continue to be at the centre of heated debates. Some are persuaded to ‘bless’ all the unions with their existing wives and take no others in future, while others discard all others leaving one! The mental anguish visiting the man, wives and the many offspring could and often does lead to mental disorders. The system of polygamy is intended to ensure that early in their lives (before the age of 20) all women ‘belong to a man’ to avoid them becoming loose or prostitutes. (The Gikuyu people have no word for prostitute!) Polygamy in a sense therefore is intended to retain a measure of morality and cohesion. The request for the man to take a second or further wives comes from the first wife herself, who would see it as a blessing from God, that she is now for example a new mother, unable to attend to the needs of her husband, both physical, like cooking for him, as well as sexual, and she would encourage him to take ‘the daughter of so and so’ whom she had identified as a hard working diligent person to become
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her co-wife. In this respect, Gikuyu custom and practices of Islam have commonality in that it is only with the consent and at times request of the wife that a man takes on further marital responsibility. Though this is the traditional practice, many men in Africa take advantage of the system to marry additional wives without the consent of the first. Many Muslim and Christian women in Africa come to the attention of the psychiatrist because of depressive states resulting from these practices. The clinician must be aware of both customs and sanctions which may be used as excuses to escape responsibility. Bigamy is expressly forbidden although in some tribes a barren woman can ‘marry’ another woman who would bear children with a man or men chosen by her. The children would ‘belong’ to the barren woman as though she was the father. In other tribes, such as the Luo of Kenya, a woman becomes available for inheritance by a close relative of her dead husband in accordance with custom. Some young women find the custom repugnant and fall foul of the tribe in the process. This practice of wife inheritance has found criticism in medical and religious circles as it promotes the spread of HIV. Of similar if not greater controversy, is the process that leads to the actual act of marriage, as it sees a major clash between tradition and modern Christian practices. In this regard, the ceremony of ‘ngurario’ and ‘ruracio’ among the Gikuyu have attracted much attention. In the former ceremony, blood from the ceremonial sheep is sprinkled on the ground and on the animals brought by the boy’s family. This is to signify the union between the two clans, and the acceptance of the animals as being given in good faith and to keep away bad and evil spirits. A ceremony that involves the mention of any blood, other than that of Jesus Christ raises many protests among the Christian faithful. To them the blood of Jesus was sufficient to wash away all sins! Many otherwise happy families are torn apart by the conflict between these two cultures and the doctor could be called upon to offer an expert’s opinion. As this debate rages, new frontiers of disagreement arise. African tradition demands the payment of a dowry before a boy can take a girl to be his wife. The ceremony leading to the agreement on how many animals are to be ‘paid’ has been the subject of much controversy as many Westerners and other observers have seen it as the ‘sale’ of the girl to the man. No such intention existed in African tradition or practice of religion. The sole purpose of this transaction is to cement the relationship between the clans that are to become in-laws and the whole rather lengthy process was intended to bring a better and deeper understanding between the clans. It was indeed the first exercise in conflict resolution between the in-laws to be. In practical terms, African marriages were unions between clans first, and then between individuals.
2.4.5.2
Sexual practices
Education on acceptable sexual practices in Africa was conducted formally with tribal structures and organization. Among the things taught were rules and regulations governing sexual contact between a man and woman. In this regard, any act of a sexual nature between same sexed individuals was beyond the comprehension of the African and clearly an act deriving from the evil one himself. Unnatural acts with animals were similarly viewed and frowned upon. To this day, the single most likely cause of the split in the Anglican Church is the abhorrence of the African faithful to the thought that the church might have ‘given in’ to ‘the acts of the devil that permit homosexuality’. The African, with few exceptions is united in this view. No amount of education seems sufficient to ‘cure’ the majority of Sub-Sahara
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Africans of this homophobia. No rational explanation seems to have come forward and experts have generally accepted this as part of the culture of the African. Homosexuality is sinful and homosexuals must suffer punishment from God. The African Christian movement seems unable to see this matter in any other light. This has led to much suffering of gay and lesbian people in Africa with serious mental health consequences. To safeguard the young from ‘nervous and psychic maladjustment’ some African tribes developed well controlled systems of sexual contact that did not permit penetration. One such system of platonic love and necking was known as ombani na ngweko, which is the equivalent of kissing and fondling as seen among teenagers from the West. Whereas the African has problems with people ‘exchanging saliva and seeming to choke each other’, the traditional African Christian church had problems permitting teenagers ‘sleeping together before marriage’ as envisaged in the African tradition of ngweko. The African was also clear on the ‘proper’ sexual practices, limited to the ‘natural form’ between men and women, acting in a normal way i.e. the regular one of the face to face contact. Any other position was taboo. Sexual intercourse during the day or while food was cooking would bring a bad omen to the clan. These and other customs were taught by the tribal leaders separately to boys and girls leading to good and healthy attitudes to sexuality. The link between some of these African practices and mental health is indirect, and is sometimes seen in clinical practice. On the one hand, the clinician is at times expected to offer an opinion when he sees a wife in a polygamous union who is depressed. In some cases, the man uses his newly found religious persuasion to try and escape his responsibilities to his second or third wife. Women on the other hand pose challenging clinical situations when they ‘convert’ and deny their husbands conjugal rights on the basis of their newly found faith which requires that a man have only one wife. Often, these conflicts are but the presenting face of deeper marital problems. The clinician must be aware of the many different issues that lead to marital conflict. African religions and cultural practices permitted couples to engage in sexual relations with people other than their spouses in certain circumstances. (See above). Men on long journeys could sleep with the wives of age mates, while apparently barren women could sleep with men other than their husbands as an experiment to see if they could get pregnant. Impotent men were similarly encouraged to experiment with other women to see if this would cure them. The purpose of marriage in many African traditions was for procreation and hence perpetuation of the tribe and any ‘weakness’ in procreation was taken very seriously and as a curse. Some of the traditional practices still bring couples to mental health experts for resolution in the event of emotional, spiritual or psychological conflicts. When husbands insist on ‘sleeping out’ to see if their seed can bring forth children, the stage is set for conflict in Christian marriages.
2.4.5.3
Grief
The African God, by and large has the power to give and take away, as all things belong to him. In the event of a major calamity, such as the death of a wife, child or brother, the African accepts this with resignation and describes it as the will of God whose duty and mandate is to give and take away without question. In Kiswahili, the term ‘shauri ya mungu’ has this meaning and connotation. He who gives must be permitted to take away. Increasingly, conflicts have entered the realm of mental health as some experts try to ‘treat’ Africans who
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seem immune to the loss of their loved ones! Different African tribes have traditional and modern mourning practices that differ widely and which cause much confusion in the West and in the minds of inexperienced African psychiatrists and other mental health workers. The Luo people of western Kenya for example express grief following death loudly, dramatically and in public. The initial act of mourning is followed by a very elaborate series of events preceding, during and after the burial that involves eating, song, dance and expression of grief and gratitude to God for the life of the departed. To some other tribes, this outward show of emotion is alien as they prefer to mourn in silence. The magnitude and duration of the funeral ceremony among the Luo is commensurate with the importance and stature of the dead. A great man (or woman) would be buried after several weeks of preparation for a big and dignified burial that would do justice to his departed soul and memory. The Yoruba of Nigeria have similar ways of dealing with death that gives the family and clan the chance to let go of their loved ones. Some Bantu tribes of East Africa on the other hand seem to treat their dead with apparent contempt! In their tradition, the dead are left for the hyenas to feast on! Indeed, in some customs, in the event of what seemed like terminal illness, the critically ill would be left outside overnight. If eaten by hyenas at night, this would be evidence that death had indeed taken place, if not then clearly the person was no fit meal for the hyenas and would be brought back to the homestead. Death, mourning and the aftermath has great spiritual and mental health dimensions and the extent to which the individual deals with death has significance for mental health and spiritual relationships. In clinical practice in Africa, many people come to the attention of mental health workers following unresolved grief, which has failed to find resolution in either modern practices or tradition. The challenge to the clinician is to have a deep understanding of mental health, spiritual beliefs and cultural practices of the people he seeks to help! Sadly, few medical schools teach this aspect of health and well-being. The mental health worker is encouraged to mix and mingle with elders, spiritual and cultural leaders of the community in which he works as part of his legitimate continuing medical and professional education.
CASE NO. 2 A 30 year old woman was brought to the emergency room on a Sunday, impeccably dressed, a rosary in her hands and speaking in an English dialect that the attending team could not comprehend. Some thought this was typical schizophrenia neologisms while others said she was speaking in tongues as some Christians in the area often do. The hospital Chaplain was called in and settled the debate. This was not the language of spiritual tongues, and must be mental illness. Help for the clinician can come from many sources. In Africa, friends, relatives, priests and grandparents can be very helpful.
2.4.5.4
Suicide
In most cases, suicide is the result of a depressive illness, often in Africa, an unrecognized illness. Depression in turn is usually viewed as evidence of the displeasure of God. The
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depressed person has in the view of many only himself to blame for displeasing God to the extent of punishing him in this way. Those in many African societies who contemplate or commit suicide are therefore sinners who bring shame and scandal to the clan and family. Many African Christian churches will simply not participate in funeral ceremonies for suicide victims as they represent the ultimate in cowardice and betrayal to God who is the sole true owner of one’s life. The families of those who die from suicide in Africa therefore suffer the double tragedy of the loss of their loved ones as well as the loss of face in the community. Many recent efforts by psychiatrists to teach modern Christian churches that depression and suicide are other than sins have in many instances been met with skepticism. Suicide is one of the most difficult subjects between mental health workers and the church. The church in Africa is of the firm view that ‘thou shall not kill’ (even thyself) while mental health workers believe many people kill or attempt to kill themselves as the result of depression which is a treatable medical condition. In this crisis, lies the opportunity for the two to work together. African psychiatrist and spiritual leaders need to engage for the benefit of their mutual clients. Efforts in many parts of Africa to engage the church as well as traditional healers are ongoing and the mental health worker is encouraged to participate in the debates and exchanges of views, which take place in both formal and informal settings.
CASE NO. 3 A 25 year old university student was referred by the Chaplaincy Services for evaluation. She held the delusion that she was Lucifer (the devil) who had entered her body replacing her original self. Although she spoke like a woman, it was in fact the voice of the devil himself. Following treatment, she regained insight and took her normal identity going back to complete her university studies. This case illustrates the common finding of religious delusions being the primary presentation of schizophrenia and other psychosis. Many such cases first land in the hands of priests who must be educated on how to work with the psychiatrist.
2.4.6 CONTEMPORARY AFRICAN POLITICS, RELIGION AND CULTURE The wars for African liberation have at times been as bloody as they have been prolonged. As far back as 1911, a leader of the Akamba people of East Kenya suffered the wrath of the colonial powers after he had received a ‘vision from God’ that Europeans would leave the land of the Akambas. This message from the Akamba God brought many people to listen to him but he was soon to be removed from their midst by the Government for showing ‘religious mania’ (not foresight). Such African prophets were described in colonial literature as showing delusions of persecution about (land taken away by Europeans), obsessive religiosity (constant prayer) as well as religious mania for praying loudly! In 1945, prophet Elijah Masinde from West Kenya was sent to the Mathare Mental Hospital and admitted under the diagnosis of a religious manic. His particular type of mania that called for the return of the people’s land and dignity was seen as being particularly dangerous to the welfare and
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stability of the community as a whole. In this state of mania, he advocated for the removal from his home of all Europeans! Psychiatry, politics and metal asylum made for strange bedfellows! Demands for political rights were given psychiatric labels and beds [8].
CASE NO.4 M.W. is a 60 year old man with a history of recurrent Psychosis for many years. He was a polygamist with many children. He was a leader of a Christian sect in western Kenya and was said to be a charismatic and eloquent preacher. During the onset of his manic episodes, he would castigate and ‘discipline’ his followers for their sins by physical beatings. They would accept this ‘correction’ and only brought him to hospital when he became completely unmanageable. During his hospitalization, his many followers would visit him and once he was well, he would be restored back as their spiritual leader. There is no evidence that Elijah Masinde suffered from mental illness of this type.
The eminent psychiatrist of the day who examined Masinde (Carothers) stated confidently that he would retain these persecutory attitude and peculiar religious ideas unto death. On the basis of this learned medical opinion, social, political and religious interpretations led to the incarceration of an African prophet. In being persecuted in his country, he joins many others before him, including the Lord Jesus Christ in being persecuted and betrayed for speaking for the wretched of the earth. In the case example below, a psychiatric patient finds peace in being a prophet chosen by God.
CASE NO.5 T. N. is a 55 year old male, a married successful business man. He has suffered from Epilepsy and Bipolar Disorder for the last 10 years. When well, T. N. is a deeply religious man who is very active in his church. He believes that a true God cannot “allow” a true believer to suffer from a mental disorder. He therefore never takes his medication for more than a few weeks as this implies a lack faith. As a consequence of the poor compliance with treatment and follow-up, he has experienced frequent relapses. During the most recent relapse, he had become deluded that he was a prophet with a special message for a friend. He visited the friend at night, talked to him until 2.30 a.m. and it was only when he had a generalized fit that the friend realized all was not well. After all these misfortunes, the prophet has concluded that God has placed him in the place of other prophets like Daniel who suffered in the den of Lions. The persecution from his wife, bankers and others, is the evidence that he is the one chosen by God! He is at peace with himself and the world.
Fanon [5], in graphic detail, describes the interface between African liberation and European religious and cultural beliefs. The ‘fact’ that he, the (Algerian) was ‘a born
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criminal liar, slacker, robber and in need of feeling warm blood to bathe his hands in as he killed the French’, was taught and preached as gospel truth. By extension, this process of reasoning made the Algerian a product of the work and life of the devil to be crushed by all followers of Christ. This abuse of human rights, though on the face of it, cultural, also bore religious and spiritual implications since murderers could not enjoy eternal life by any stretch of the imagination. In a similar vein, and in expression of ‘scientific knowledge’, Carothers [9] opined that ‘the normal African is like a lobotomised European’. The significance of this opinion in relation to capacity to lead a meaningful spiritual life is clear. A lobotomized man simply has no capacity. The African of the day was thus saved modern diseases such as depression, the capacity for guilt as well as a capacity to enjoy a spiritual life. Fanon [6] in his book ‘Black Skins, White Masks’ [6, p. 95] writes, ‘If Negroes are impervious to the teaching of Christ, this is not because they are incapable of assimilating them . . . . . . . . . It is utopian to expect the Negro to abstract values into his outlook on the world when he has barely enough food to keep alive’.
2.4.7
SELF ESTEEM
Since many African students were, in the 1940s and 1950s taught by Europeans, seeds of self doubt and low self esteem were planted and were to achieve full expression as some Africans at the time of independence attempted to become more European than their teachers! For many, this lead to disasters at the family level as many had to part ways with their wives and children as the wives could not keep up with ‘European ways’. The practicing psychiatrist in Africa still sees remnants of the destruction visited on some families by these practices of abandonment of pre-independence families. Consecutive generations of the African have continued their search for happiness through material goods, in many instances lacking attachment to traditional religious beliefs and without links to any spiritual positions. In their hour of need, these Africans find themselves floating in search of help or support. The link between urban violence and the absence of social support systems is a matter of discussion among African academics. It is postulated here, that part of the violence seen in African cities represents the absence of ‘external sanctions’ as one would expect in a traditional society where the common community good was at a premium. In the city slums, where anonymity is the order of the day, acts of violence are not met with any form of social sanction and are hence perpetrated. In a study of the experience of violence in Nairobi in 1998, Njenga [10] found that 98% of the random sample had experienced at least one in a list of violent acts that include robbery, carjacking, harassment by the police etc. Children studied by Seedat [11] and her colleagues in Nairobi and Cape Town showed very high levels of PTSD. It may be possible that these transitional peri-urban dwellers of Africa are neither rural nor urban and in this way lack both spiritual and cultural bonds of both settings. Such people would be expected to have many risk factors for mental disorders, in particular depression. Crime, HIV/AIDS, drug and substance abuse as well as extreme poverty are common in these marginalized areas. There is a corresponding mushrooming of small churches in these communities as the people look up to God for salvation and removal from this sadness. Many poor people in Africa are exploited by ‘men and women of God’ who extort large amounts of money from slum dwellers as they lead lives of opulent decadence in the wealthy parts of the city and abroad. Theologians and mental health workers have the challenge of working together to understand this rapidly ‘spiritual industry’ that exploits the poorest of the poor.
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Though indirect, it is possible that linkages in society with a religious or spiritual being might be promotive of societal cohesion. This is precisely what seems to be lacking in periurban communities. The people in these areas seem to lack an anchor. In a study of reported violence in Nairobi in 2005, Njenga [12] found daily newspaper reports of killings, rape, indecent assault of minors, among other acts of domestic violence. A similar study by FIDA [13] among women visiting a shelter for women established that alcohol abuse, low self esteem and poverty played a key role in the violence. The women remained in their marriages because of fear, threats, and suspicion that no one would believe them. As a result, they suffered sexually transmitted diseases, miscarriages, hospitalizations and in some cases deaths were reported.
REFERENCES 1. Kenyatta J (1995) Facing Mount Kenya: The Traditional Life of the Gikuyu. Kenway Publications, Kenya. 2. Njenga F, Acuda W, Patel V, Maj M (2005) Essentials of Clinical Psychiatry for sub-Saharan Africa. Masson, Italy. 3. p’Bitek O (2003) Poets of Africa: Song of Lawino and Song of Ocol. East African Educational Publishers, Kenya. 4. Peltzer K (1999) Trauma and mental health problems of Sudanese refugees in Uganda. Central African Journal of Medicine 45, 110–114. 5. Fanon Fr (2001) The Wretched of the Earth (reprint). Penguin Classics, New York. 6. Fanon Fr (1986) Black Skin, White Masks, Pluto Press, London. 7. Njau Joseph WM (2005) Post-Traumatic Stress Disorder Among the Heads of Households of Ethnic Clashes Survivors in the Rift Valley Province, Kenya: A Comparative Study. Medical Psychiatry Thesis University of Nairobi, Kenya. 8. Mahone S (2006) The Psychology of Rebellion: Colonial Medical Responses to Dissent in British East Africa. Journal of African History 47, 241–258. 9. Carothers JC (1951) Frontal Lobe Function and the African. Journal of Mental Science 97, 12–48. 10. Njenga FG, Nyamai C (1999) American Embassy Bombing in Nairobi, August 7, 1998: An Opportunity for the Advancement of Science. Paper presented at the World Psychiatric Association Conference in Hamburg, Germany, August. 11. Seedat S, Nyamai C, Njenga FG, Vythilingum B, Stein DJ (2004) Trauma Exposure and Posttraumatic Stress Symptoms in Adolescents: A Schools’ Survey in Cape Town (South Africa) and Nairobi (Kenya). British Journal of Psychiatry 184, 169–175. 12. Njenga FG (2005) Behind Closed Doors in Africa: The Case of Women and Children. Paper presented at the American Psychiatric Annual Meeting. 13. Njenga FG (2006) Promoting Mental Health Among Vulnerable Women: Mental Health Status of Women attending a Shelter for Battered Women in Kenya. Paper presented at the World Psychiatric Association Regional Meeting in Lima, Peru. December.
CHAPTER 2.5
Hinduism and Mental Health R. Srinivasa Murthy Professor of Psychiatry, India
2.5.1
INTRODUCTION
Hinduism is the oldest religion of mankind. The Hindu religion is an ocean of spiritual teachings about all aspects of life and consciousness. Mental health is an important component of Hinduism. There are five areas in which mental health is reflected in Hinduism. Firstly, spirituality is an essential feature of the practice of Hinduism. Secondly, there is emphasis on unity of the body and mind. Thirdly, yoga and meditation provide a practical way of addressing health in general and mental health in particular. Fourthly, Bhagavadgita, one of the key texts of Hinduism, is an excellent illustration of the application of the psychological interventions to life situations. Fifthly, the concept of ashramas (stages of life) provides a guide to master the changes during the life-course of individuals. Presenting mental health concepts and practices of Hinduism is a challenge. The chapter begins with a description of the history of Hinduism. This is followed by the concept of mind and mental health, causes of mental disorders and treatment as described in the religious texts and the medical texts. The next section summarizes the efforts at relating the concepts of mental disorders with modern psychiatric classification and scientific study of the mental health practices. The next section considers the current practice of mental health interventions in the general community. The last section identifies some of the important contributions of Hinduism and mental health as relevant to Indian mental health programmes and to the larger understanding of mental health in the world. The current chapter is based on the literature from wide variety of sources and authors.
2.5.2
HINDUISM AS A RELIGION
Wig [1] has pointed out the difficulties in any generalization about the Indian mind as being very difficult, and many concepts described as ‘typically’ Indian are soon likely to be contradicted. The chief reason for this is the Indian civilization is one of the oldest continuing civilizations, with thousands of years of history. During its existence it has assimilated many influences, which have shaped modern Indian thought. Unlike many
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright 2010 John Wiley & Sons, Ltd
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others, however, Indian civilization has thoroughly absorbed the previous cultures into the new ones without making a clean break, with the past cultural values. For this reason, in modern Indian religious thought one can easily pick out the strands of old Aryan and Buddhist teachings, along with the influence of latter day Hinduism, medieval Islam and modern European thinking. It is interesting to point out that ‘Hinduism’ is not the original name of Indian religion. Its adherents never gave it any particular name except ‘dharma’, which simply means ‘the eternal law that supports and sustains those who practice it.’ Actually the origin of the words ‘Hindu’ and ‘Hinduism’ is geographical. The land of the river Sindhu (Indus) and the people inhabiting it came to be known as ‘Hindu’ among the ancient Persians, in whose language, the ‘S’ of Sanskrit became ‘H’ and this name has somehow stuck [2]. Hinduism appears to many as a jigsaw puzzle. But if one knows where to put the pieces, not only is the puzzle easily solved, but also gives rise to a beautiful picture. Hinduism is a religion because it accepts the existence of God and posits him as the final goal of our life. It places before us many paths that suit persons of different temperaments, but leading to the same beatific experience of that God. Hinduism gives the moral and ethical disciplines that help a human being to purify himself and become fit for the pursuit of God. It provides enough scope and opportunity for its adherents to get emotional satisfaction through its rituals and festivals. It recognizes the shortcomings of the powers of the human intellect in matters spiritual and experiential, and hence gives due recognition to the revealed word of God, the Vedas. Following the maxim that the same cap cannot fit everybody, it gives different modes and methods of sadhanas or spiritual disciplines to aspirants of different temperaments. Hinduism is a philosophy as it gives, through rational analysis and in a convincing manner, a knowledge about the ultimate truths behind man and the universe, and also the final goal and the path. It has given freedom of thinking and expression to all schools and subschools of thought, though they may not agree among themselves. Differences of opinions are respected whereas the spiritual seekers are given the full liberty to opt for any one of them. Hinduism is a culture, because it encourages all aspects of culture like music, dancing, drawing, sculpturing and other arts, but as reflecting the glory of the divine and also as aids to spiritual evolution, if the right attitude is adopted. Further, Hinduism, is both ancient and modern, ancient in its eternal value-system, but modern in that it is always open to new ideas and ever ready to replenish its treasure-house of knowledge, wisdom and virtues. Hinduism has survived the vicissitudes of history and onslaughts of time, exactly because of the various factors mentioned above. Knipe describes Hinduism as follows: ‘Hinduism is the label applied to the dominant religious tradition of South Asia or the Indian subcontinent (the modern nations of India, SriLanka, Nepal, Sikkim). With the ambiguous exception of China, whose traditions are undergoing current revivals, Hinduism, of all the world’s religions, has far the largest population in a single cohesive region. It is also the oldest continuous religious tradition, with its roots partially in the obscure antiquity of the Indus Valley civilization (c.2300–1700BCE), partially in the Indo-Aryan Vedic civilization (C.1500 BCE following), and partially in the undated and non-literate hunting/collecting, nomadic pastoralist, and agrarian fold traditions of the hundred odd linguistic and sub-cultural regions of India. Although there is no question about the location, size, and antiquity of Hinduism, there is considerable debate concerning its definition. Unlike the religions of western Asia (the biblical traditions, Zoroastrianism, and Islam) there no prerequisite deity, revelation, scripture, ecclesiastical structure, credo, or ritual. Deities, mythologies, sacred texts,
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god-men, religious communities, vows, rituals, and festivals abound, perhaps more energetically in Hinduism than in any faith, but still there is nothing remotely like a prescription whereby we may locate a Hindu. What has emerged in the last two thousand years, however, is a general consensus centering on a worldview that embraces certain respected, if not universally shared, notions of Hindu tradition, belief, society and ritual life. In seeking the fundamentals of Hindu belief we may isolate in particular the recognition of karma (a cosmic, impersonal accounting of individual human ‘action’ by which past and present deeds bear consequences in present and future life conditions) and samsara (rebirth, transmigration). For a Hindu they are virtually undisputed facts of existence, although the scope for interpretation is unlimited. As a response to the doctrines of karma and samsara Hindu belief has produced the key notion of moksa (liberation, release from karma and samsara). While there are numerous designated paths to this transcendent state (devotion to a deity, meritorious behaviour, ascetic technique, soteriological knowledge), there is general consensus that its attainment, even after some remote future existence, is the sine qua non of human life and the solution to the bondage of transmigration’ [3, p. 95–96].
One other view illustrates the complexity of Hindu religion: ‘The Hindu religion is an ocean of spiritual teachings about all aspects of life and consciousness.It is the world’s oldest religion, going back to the very dawn of history. It sees its origin in the cosmic mind itself. Yet Hinduism is perhaps the world’s youngest religion because of it emphasises the authority of living teachers and allows for correction and evolution over time. Hinduism is the most diverse religious tradition in the world. It could be said that there are probably more religions inside of Hinduism than outside of it. It has numerous saints, sages and yogis, both male and female, from ancient to modern times. Hinduism is the world’s largest biblical tradition, with nearly a billion followers worldwide. It could be called the world’s largest non-organised religion as it emphasises individual spiritual experience, the realisation of the higher self over any religious institution, book, dogma or saviour. Hinduism is the world’s largest pluralistic tradition, recognising One truth – an eternal reality of Being – Consciousness Bliss in all beings – but also many paths to realise it. Hinduism has probably the world’s largest literature of spirituality, mysticism, and yoga. It provides complete spiritual culture including art, dance, sculpture, medicine, and science,with all these subjects explained according to a science of consciousness’ [4].
2.5.2.1
How does Hinduism differ from other major religions?
Wig [5] quoting Radhakrishnan and Charles Moore, has addressed this issue of contrasting approaches of Hinduism and other religions as follows: ‘In Indian languages there is no equivalent term to convey the meaning of the word ‘religion’. The nearest term ‘dharma’ is not an equivalent of religion. It is a mixture of cosmic order, sacred law, and religious duty etc. In Jewish-Christian-Islamic tradition there is one God, one book, one final prophet. As a result, religious history and written code of laws play a very important role in the Jewish-Christian-Islamic religions. In India, on the other hand, philosophy and mythology occupy much more prominent position in the religious teachings. Another striking difference between Indian and Western religions is the concept of ‘God’. Or ‘Divine Reality’. In Jewish-Christian-Islamic religions, ‘God’ is the creator of the universe and everything in it. Thus the Creator, in a way is ‘outside’ this world which he has created. In Indian tradition ‘God’ is not ‘out there somewhere’ but is within you and within everything.
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The creation is continuity of the Creator like a spider’s web which is part of the spider. This thought is beautifully expressed in Sanskrit in the opening invocation to the famous Isa Upanisad- ‘that is whole. This is whole. From the whole emerges the whole. The whole is taken from the whole but the whole remains.’ In other words, the Ultimate Reality or brahman, as we say in India, is both transcendent and immanent. The creation of the universe does not in any manner affect the integrity of Brahman’.
Wig [5] has further elaborated the differences between Indian and Western philosophical traditions as follows: (i) the chief mark of Indian philosophy is its concentration upon the spiritual. Both in life and in philosophy the spiritual motive is predominant in India. Neither man nor the universe is looked upon as physical in essence and material welfare is never recognized as the only goal of human life; (ii) In India, philosophy and religion are intimately related. Philosophy is never considered as merely an intellectual exercise. Every Indian system seeks the truth not as ‘academic knowledge for its own sake’ but to learn the truth which shall make the man free; (iii) Indian philosophy is characterized by introspective approach to reality. In pursuit of truth, Indian philosophy has been strongly dominated by concern with inner life and self of man rather than the external worlds of physical nature; (iv) Indian philosophy is essentially idealistic.the tendency of Indian philosophy, especially Hinduism, has been in the direction of monistic idealism. Almost all schools of Indian philosophy believe that reality is ultimately one and spiritual; (v) Indian philosophy make unquestioned and extensive use of reason, but intuition is accepted as the major methods through which the ultimate can be known. Reason and intellectual knowledge are not enough. Reason is not useless or fallacious, but it is insufficient. To know reality one must know the truth in Indian philosophy, one has to realize it and live it; (vi) The Indian philosophy is dominated by synthetic tradition which is essential to the spirit and method of Indian philosophy. According to Indian tradition, true religion comprehends all religions; hence the famous Sanskrit saying’ God is one but men call him by many names.
2.5.3
CONCEPT OF MENTAL HEALTH
A number of Indian psychiatrists and other scholars have studied the development and concepts of mental health in Hinduism through a long history of over 12000 years [6–22]. The following sections draw heavily from these sources and are a synthesis based on the presentations of different authors.
2.5.3.1
Concept of mind in Vedas (10000 to 5000BC) [10]
Vedas is the earliest script of human race. Mind was conceived to be a functional element of atman (soul which is self) in Vedas. In Rig Veda and Yajur Veda, there is mention of prayer through mantras (rhymes) for noble thoughts to come in the mind. There is emphasis on prevention of mental pain (depression). In Rigveda, the speed of mind, curiosity for methods of mental happiness, prayers for mental happiness and methods of increasing medha (intelligence) have been described. The power of mind in healing has also been described in Rigveda. In Yajurveda, the mind has been conceptualized as the inner flame of knowledge. Mind has also been described as the basis of consciousness and instrument of knowledge. In Atharveda, mind has been described as an instrument of hypnotism. There are detailed
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descriptions of preservation of will power, emotions, inspiration and consciousness. The text also describes emotional states like grief, envy, pleasure, hostility, attachment, laziness etc. The description of Unmad (psychosis) is as a deluded state of mind.
2.5.3.2
Era of Upanishads (5000–2500 BC) [10]
The Chandogya Upanishad, Shwetashwaropanishad describe what is mind, and the various states of mind. There are descriptions of theories of perception, thought, chitta and smriti (memory). There is a description of prakriti, which can be equated with personality in modern psychiatry. Upanishad describes the different states of mind: waking state, dreaming state, deep sleep state and Samadhi. The psychopathology of the mind was understood in terms of the trigunas and tridosas.
2.5.3.3
Era of Bhagawad Gita (3500 BC) [10]
Bhagavad Gita is one of the most translated religious classics in the world. The beauty and sublimity of the work, the eternal relevance to the problems of human life and its universal approach that helps to consider the whole creation as one are the special features of this important text. It presents a detailed account of human emotions and cognitive deviations. The human mind and its weaknesses are elaborated. There is an emphasis on how to gain mastery over the vacillating mind. The consequences of failure to attain such mastery are illustrated. Having understood these, there is a method to overcome these cognitive distortions as well as attaining full control over the mind. Essentially, Gita shows a way out of worldly concerns and teaches that a person can be his/her own master.
2.5.3.4
Ayurveda [7, 17–20, 23]
In India and neighboring countries, like Nepal, Bangladesh and Sri Lanka, a highly developed and elaborate system of medicine has flourished for nearly three thousand years. It is generally known by the name of Ayurveda (the science of life). There are many medical texts dating back to the first and second century AD which describe in detail the principles of Ayurveda. The two best known medical works are by the Ayurvedic physicians Caraka and Susruta. These books were originally compiled sometime between the third century BC and the third century AD. The principles of Ayurvedic medicine, like in other Indian philosophical systems, were probably well developed by the third century BC. In Ayurveda the fundamental principle of health is the proper balance between five elements (Bhutas) and three humors (Dosas). The balance occurs at different levels: physical, physiological, psychological and finally spiritual – the state of bliss in which the ultimate goal is tranquility. The human being is considered an integral part of nature and is made up of the same five elements (Bhutas) that constitute the universe, namely, water, air, fire, earth and sky. The three humors or Dosas recognized in Ayurvedic medicine are Kaph (phlegm), pitta (bile) and Vata (wind). People in India describe the states of health and disease still popularly use these terms for the three Dosas. Another concept that is very
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central to Ayurvedic medicine and Indian philosophy is the Tri-guna or the theory of three inherent qualities or modes of nature. These three gunas are: Sattva (variously translated as light, goodness or purity), Rajas (action, energy, passion) and Tamas (darkness, inertia). In the medical and religious texts, the theory of three gunas is used repeatedly to describe different types of personalities, food, action, etc. Weiss et al. [11] have examined the prevalence of the humoral concepts of mental illness in India. Based on interviews with patients at three allopathic psychiatric clinics in Bombay, Bangalore and Varanasi, employing a preliminary version of the Explanatory Model Interview for Classification (EMIC) to elicit indigenous explanations of illness and patterns of prior help seeking, discuss popular humoral theories of mental disorder. Even though most laypersons are unfamiliar with the content of the classical treatises of Ayurveda, the humoral traditions which they represent influence current perceptions. Case vignettes clarify the nature of the relationship between cultural, familial and personal factors that influence the experience of illness. All the major Ayurvedic texts like Carak Samhita and Susruta Samhita have a separate section dealing with insanity (unmada) [19]. In addition, there are chapters on spirit possession (bhutonmada) and epilepsy (apasmara). Different types of convulsions, paralysis, fainting and intoxications are also well described. There is a detailed description of different types of spirit possessions. Twenty-one sub-types based on three groups of sattava, rajas and tamas are described. Though at times the descriptions appear artificial, some of them have clear resemblance to some modern descriptions of personality disorders, psychosis, and mental retardation. The chapters on unmada (insanity) are very well written, both in Caraka Samhita and Susruta Samhita. Six types of mental disorders are well recognized: vatonmad caused by vata dosa; kaphonmad caused by kapha dosa;pittonmad caused by pitta dosa; sampattonmad caused by combined dosas; vishajonmada caused by intoxications and poisons and shokaja unmad caused by excessive grief.
2.5.3.5
Personality in Ayurveda [13]
Basically three personalities are recognized in Ayurveda, namely the pure (satvic), passionate (rajas) and ignorant (tamas). The pure mind is considered to be without any taint as it represents the beneficient aspect of the intelligence; the passionate mind is tainted as it represents the violent aspects; the ignorant mind is also tainted on account of its representing the deluded past. Several variations of personality types are possible due to several combinations of body type. Caraka Samhita (1949) describes 16 personality types. 7 belong to the satvic type, 5 to the rajas type and 4 to the tamas type. The development of the constitution is determined by the time of conception, the diet and drink of the mother during gestation.
Satvic personality types 1. Brahma type: Individual is impartial, pure, devoted to truth, self-controlled, endowed with knowledge, understanding and power of exposition and reply, possessed of good memory, free from greed, conceit, desire, infatuation, and intolerance. Individual is
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capable of scientific, phoilosophical and religious discourses. The name Brahma is derived from the Indian Trinity responsible for creation. Rishi type: Individual is devoted to sacrifice, study, vows, celibacy. Individual is hospitable, devoid of pride and endowed with genius, eloquence, and retentive power. Rishi is one who is devoted to contemplation and is a bachelor. Indra type: Individual is brave, energetic, and authoratative of speech; endowed with splendor, possesses foresight and is given to pursuit of wealth, virtue and sensual pleasures. Individual is blameless in work. Indra was known as the king of gods. Yama type: The conduct of the individual is governed by consideration of property, authority. Individual is free from passions, attachment, is unattainable, is constantly up and about and has a good memory. Yama is the god into whose realm the souls enter after death. Varuna type: Individual is valiant, courageous, intolerant of uncleanliness, devoted to the performance of sacrifices, fond of aquatic sports,and anger and favor are well placed. Varuna is the deity who presides over the cosmic order. Kubera type: Individual commands status, honor, luxuries and attendants. Individual is given to pleasures of recreation and the anger and favor are patent. God Kubera is known for his wealth. Gandharva type: Individual is fond of dancing, song, music and praise and is well versed in history, poetry and stories. Though addicted to pleasures of fragrant unguementa, garlands, women and recreation, individual is free from envy. Gangharva denotes a celestial dancer living among the trees.
Rajas personality types Asura type: Individual is valiant, despotic, possessed of authority, terrifying, pitiless, and fond of self-adulation. Asura is the enemy of God. Rakshasa type: Individual is cruel, gluttonous, intolerant, and full of hate, fond of flesh, foods, somnolent and of indolent disposition. Individual is capable of biding time and striking. Rakshasa is a demon with evil designs. Pisaca type: Individual eats voraciously, is fond of secret company with women, hates cleanliness, and is given to abnormal recreations and of food. Pisacha is a demon who loves luxury and women. Sarpa type: Individual is brave, touchy, of indolent disposition, arouses fear in the beholder, and is addicted to pleasures of food and recreation. Preta type: Individual is fond of food. The character, and conduct are of painful disposition. Individual is envious, covetous, and disinclined to work. Individual lacks the power of discrimination. Pretas haunt the burial ground and live on human corpses. Sakuna type: Individual is constantly devoted to eating and sports. Individual is fickle, intolerant and unacquisitive.
Tamas personality types Pasva type: Individual is mentally deficient, disgusting in behavior and dietetic habits, abandoned to sexual pleasures and given to somnolent habits.
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Matsya type: Individual is too poorly endowed, cowardly, gluttonous, fickle, prone to anger and sensuality. Individual loves water and its itinerant habits. Vanaspatya type: Individual is lazy, and exclusively devoted to the business of eating. Individual is of subnormal intellect. From the above descriptions, it can be seen that Ayurvedic writers conceived personality as comprising multiple dimensions: intellectual, social, emotional, spiritual and moral. Dube et al. [13] has attempted to demonstrate close similarity between Ayurvedan and Lewin’s field (Gestalt) theories. Significance of Tridosh (Vet, Pitta and Kaf), by vitiating the chemical balance, as etiological factors of mental illness are described. Sixteen personality types and their correspondence with 16 types of mental disorders are mentioned.
2.5.3.6
Classification of insanity
Ayurveda describes diseases resulting from the excessive use (atiyoga), deficient use (ayoga), or improper use (mithyayoga) of the mind. These diseases are known to result from the misuse of intelligence. Insanity ‘is the unsettled condition of the mind, understanding, consciousness, perception, memory inclination, character, behaviour and conduct’.
Aetiology of insanity An evil deed, living alone in a deserted house, passing through a crossing of four roads (such places are supposed to be haunted by evil spirits); sexual intercourse at twilight, on new or full moon nights, or with a menstruating woman, improper recitation of scriptures, defective ceremonials, breaking of vows or celibacy in bramhacharya, misbehavior in battlefield, destruction of country, community, or city, non-observance of rituals at the time of solar, lunar eclipse or by a woman during labor, contact with unclean or inauspicious objects, bleeding, purging, vomiting, visit to holy places and temples in an unclean and improper state, remaining unclean after eating meat, honey, til or gur or after passing urine or stool, walking at night through a city or a town, cross roads, gardens, cremation grounds, slaughter houses, or insulting a brahmin, teacher, gods, or ascetics or at the time of doing, any blameworthy act.
Symptoms of insanity Feeling of void in the head, noises in the ears, hurried respiration, anorexia, cardiac spasm, misplaced mental absorption, anxiety, palpitation, intoxicated condition of the mind, frequently dreaming of roving, moving or sitting on the wheel of the oil press, of being churned as it were by whirlwinds, or sinking in whirlpools of tinged waters. The general symptoms are: confusion of intellect, extreme fickleness of mind, agitation of eyes, unsteadiness, incoherence of speech, mental vacuity. Ill person knows no mental ease. Deprived of memory, understanding and wits, keeps the mind wavering restlessly. Further Caraka also describes the etiology and symptomatology of some eight types resulting from ‘possession’. Among the general symptoms of this type are included symptoms of super human strength, energy, capacity to grasp, memory, understanding, speech and knowledge.
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The specific symptoms of some of the types of insanity are: Vata Variety: constant wandering, jerking of eyelids, brows, lips, and other parts of the body, incoherant talk, laughing, dancing, singing, loudly imitating the sounds of the lute, flute, conch, adorning with queer and unornamental objects, hangering after unobtainable . . . viands, emaciation,swelling redness of eyes. Pitta variety: Irritability, anger, excitement in the wrong places, striking oneself, or others with weapons, sticks of fists, nudity, craving for shade, cold water and food, prolonged attacks of anguish, coppery, green, yellow and furious look of the eyes. Kapha variety: rooted to one spot, silence, no inclination for movement, dribbling of saliva, lack of desire for food, love of solitude, constant somnolence, whiteness and fixing of eyes. Stated briefly, vatonmad is schizophrenia, pittonmad is mania and kaphonmad is depression. (Rao 1978).
2.5.4
THERAPY
The symbiotic relationship between ‘psyche’ and ‘soma’ was recognized in Ayurveda, attributing the highest importance to psychic energy as the propulsive power of creation – the original force. The main therapies are: i. suggestion, auto-suggestion, hynotism, assurance, persuasion and ritualistic therapy; ii. transferring of symptoms; iii. confession, penance, and sacrifice; iv. use of natural elements; v. medicine and endocrine therapies; and vi. tantric and yogic practices [13, 14]. Dube et al. [13] describe the selection and training procedures, ethical codes, metaphysical theories and principles of psychiatric treatments as practiced in Ayurveda. Three treatment approaches for psychological disorders are: ministered therapies (psychotherapies), performance therapies (rituals), auto-therapies. Other forms of therapies mentioned are herbal, physical and natural. Treatments were administered with benediction. Man was treated as a whole with a psychosomatic approach. The therapeutic measures for insanities vary from words of sympathy and comfort to terrorizing by means of snakes, from purgation to venesection. The other measures are purification procedures by emetics and diaphoretics. If they were of no avail, ocular and nasal instillations with medicated ghee were recommended. The drugs used included colosynth, pepper, valerian, turmeric, indian sarpasarilla, cardamom, cinnamon, leaf, sandalwood, garlic, pomegranate, jejube, radish, ginger, and asafoetida, goat’s and cow’s urine, and ox and jackal bile were used as vehicles. In some instances of disoriented mind such measures as anointing with mustard oil, exposure to sunlight, branding with hot irons, or scourging with a whip were recommended. Terrorizing by snakes whose fangs have been removed or by trained elephants or lions, or by men dressed as bandits or men with weapons and intimidation with threats of immediate excecution were employed when all other measures failed on the plea that threat of life is more patient than fear of bodily injury. Rowalfia serpentina was a popular drug for insanity in ancient India. Known as Sarpagandha in Sanskrit, it was used in treating a variety of diseases and symptoms ranging from constipation to insanity. The importance of this drug lies in reserpine, the active component, which was discovered to have value in the treatment of hypertension and mental disorders during the twentieth century, while it was in use in Ayurveda for thousands of years for the treatment of mental disorders.
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MAIN ISSUES
Yoga and meditation
Yoga is a discipline, a system that evolved in India several thousand years ago to facilitate the evolution of consciousness. It offers a worldview, a life style and a series of techniques by which changes in human awareness can be brought about. The basic aim of yoga is growth, development and evolution of mind. The yogic techniques when practiced correctly give rise to certain types of reactions within the person, so that there are qualitative and quantitative changes in awareness. There are various systems of yoga. All point towards the same end i.e bringing about altered states of consciousness, which is known as the cosmic consciousness,transcendental illumination or samadhi [24]. Yoga and meditation are probably the most visible aspect of Hinduism in non-Hindu populations and have received wide acceptance all over the world. Patanjali yoga gives a complete, comprehensive overview, integrating and placing the various types of yoga in their place in the development of the human experience. The eight steps of Patanjali Yoga are follows: 1. Yama – universal moral commandments; 2. Niyama – self purification by discipline; 3. Asanas-postures of the body; 4. Pranayam – rhythmic control of breath; 5. Prathyahar – withdrawl and emancipation of the mind from the senses and exterior objects; 6. Dharana – beginning of concentration; 7. dhyana – an uninterrupted flow of concentration; and 8. Samadhi – a state of super consciousness brought by profound meditation and concentration in which the individual becomes one with the object of meditation. Yamas and Niyamas control the passions and emotions and keep a person in harmony with his fellowmen. Asanas keeps the body healthy and strong. Pranayama stills the restless mind. These four constitute the ‘outward practices’ of yoga. Pratyahar, Dharana, Dhyana and Samadhi take the person within himself. They keep in harmony with himself and his maker. These are the ‘inner practices’ of yoga. In recent years, practice of yoga and its benefits has come under scientific scrutiny. Scientific studies have focused on three groups of effects. The first set of studies focus on the changes among the normal healthy volunteers practicing yoga. These studies point to the positive physical and mental health. Second group of studies describe the physiological and biochemical changes after yoga practice. Many studies in this category point to enhanced physical and mental functioning following regular practice of yoga. The third set of studies examine the therapeutic application in a number of clinical conditions, pointing to the positive benefits (considered under the subsequent section).
2.5.4.2
Psychotherapy
For insanity, resulting from exogenous causes, charms and privations, worship, sacrifices, incantations, propitiatory rites and ceremonies and pilgrimages to sacred places are suggested. There are two groups of psychotherapy, namely, the ministered therapies and the performance therapies. Ministered therapies include: sadesh (suggestion), pravartanand ashvasan (persuasion and assurance), samvashikaran (hypnotism), explanation and psychotherapeutic analysis. Performance therapies include, ritualistic seances, bramha kavach (devine armour), utarna (lifting), havana (offering to fire), atma chikitsa (autoi therapies) like sankalp (vow), prayaschitta (atonement for guilt), swekarokti (admittance of bad and immoral acts committed), tapa (penance), tyag (sacrifice-renunciation).
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A very important text relating to psychotherapy in Hinduism is Bhagavad Gita [9, 15, 25, 26]. The methods used by Lord Krishna to help his discipline Arjuna in the war situation is considered by many to contain the best principles of psychotherapy. Because of the central importance of Bhagavad Gita, it is considered in detail. The Bhagavadgita, popularly known as the Gita, is one of the outstanding religious classics of the world. It is also one of the most translated religious classics of the world. Hindus, irrespective of their sects and denominations, cherish great reverence for this book. The book is dated by modern historians and varies from 1424 BC, to 525 BC. The book forms an integral part of a much bigger epic, the Mahabharata. The core of the Gita is a poetical work in the form of a dialogue between Lord Krishna and Arjuna, on the battlefield of Kurukshetra. The setting of the battlefield contributes a dramatic element to the book and relates religion to the realities of life. (2, p. 255, Vol 1). On the battlefield two groups of cousins are at war over the kingdom. Arjuna is torn between his responsibility as a warrior and the emotions of killing his teachers and the cousins. ‘For the mind is restless, turbulent, obstinate and very strong. O Krishna, and to subdue it, I think, is more difficult than controlling the wind.’ [2, p. 225]
Arjuna despairs and refuses to fight. He is paralyzed by fear and guilt. He tells Lord Krishna that he cannot fight. Overwhelmed by his condition, he asks Krishna to help him. In 18 chapters a dialogue ensues between Krishna and Arjuna that leads to the resolution of Arjuna’s crisis and his existential transformation. Arjuna’s position is typical of the human situation, easily liable and upset or confused during periods of crisis. The questions that he raises and the solutions that Lord Krishna offers are relevant to the current situation. Many scholars consider the dialogue an excellent illustration of psychotherapy. [15] The central message of Krishna is: ‘Your entitlement is only to the rite, not ever to its fruits. Be not motivated by the fruits of the acts, but also do not purposely seek to avoid acting. Abandon self-interest, Dhananjaya, and perform the acts while applying single mindedness. Remain equable in success and failure – this equableness is called the application, for the act as such is far inferior to the application of singleness of purpose to it’ [26, Gita Chapter 2, 48–49].
Krishna further states: ‘For him who has conquered the mind, the mind is the best of friends; but for one who has failed to do so, his mind will remain the greatest enemy’ . . .’ For one who has conquered the mind, the Supersoul is already reached, for he has attained tranquillity. To such a man happiness and distress, heat and cold, honmor and dishonour are the same’ [2, p. 204]
Reddy [15] relates Gita with psychoanalysis as follows. In the Gita, Krishna functions as Arjuna’s teacher and psychoanalyst. Krishna’s analytic (therapeutic) function is not interpretative per se but more as an object that facilitates Arjuna’s ego (psychic) development and maturation. Specifically, it is Krishna’s allowing Arjuna to use him as a transformational object . . . from a psychoanalytic viewpoint, the cardinal techniques of abstinence, anonymity, and neutrality are both observed and violated by Krishna. The pivotal and transformative violation of anonymity, by Krishna’s self-disclosure promotes
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the therapeutic regression and psychic reorganization that leads to Arjuna’s existential transformation. Sri Aurobindo [25] summarizes the importance of Gita to mankind as follows: The argument of the Gita resolves itself into three great steps by which action rises out of the human into the divine plane leaving the bondage of the lower for the liberty of a higher law. First, by the renunciation of desire and a perfect equality works have to be done as a sacrifice by man as the doer, a sacrifice to deity who is the supreme and only Self though by him not yet realised in his own being. This is the initial step. Secondly, not only the desire of the fruit, but the claim to be the doer of works has to be renounced in the realisation of the Self as the equal, the inactive, the immutable principle all works as simply the operation of the universal Force, of the Nature-soul, Prakriti, the unequal, active, mutable power. Lastly, the supreme Self has to be seen as the supreme Purusha governing this Prakriti, of whom the soul in Nature is a partial manifestation, by whom all works are directed, in perfect transcendence, through Nature. To him love and adoration and the sacrifice of works have to be offered; the whole being has to be surrendered to Him and the whole consciousness raised up to dwell in this divine consciousness so that the human soul may share in His divine transcendence of Nature and of His works and act in a perfect spiritual liberty [25, p. 37].
2.5.5
SUICIDE
Suicide in the Hindu religion can be conflicting and confusing. There is a strong condemnation of suicides in general, but religious suicides were accepted and tolerated. It is difficult to find a particular term signifying individual suicides in Hinduism, though the most often used nomenclature is ‘atmaghataka’. Suicides were prevalent even during Vedic times. Vedic scholars are divided on the subject of whether Vedic injunctions allowed self destruction, or if it was just a symbolic ritual. The Upanishad categorically condemned suicide. The Isavasya Upanishad states that ‘he who takes his self, reaches, after death, the sunless region covered by impenetrable darkness’. Kautalya in Arthasastra condemns, in very strong language, those men and women, who, under infatuation of love, anger or other sinful passion, commit or cause to commit, suicide by means of rope, arms or poison. According to him, they should be dragged by rope on the public road and funeral rites should not be performed. He had also instituted precedence for determination of death by suicide or homicide. The procedure was called ‘Kantakasodhana’ performed by commissioners, who examined the bodies, ascertained the circumstances, and tried to find the cause of death. From the writings of Dharmashastra (the Hindu book of code, conduct and ethics), it can be understood that suicide, and attempted suicide, were to be condemned as a great sin. However, there is a separate section titled, ‘Allowable suicides’, where suicides were accepted in the following situations: (i) a person was allowed to commit suicide to expiate sins committed by him (like murder of a Brahmin or incest); (ii) by a hermit starting on the Great Journey (mahaparasthana), suffering from incurable diseases and unable to perform the duties of his order; (iii) an old man or one who cannot observe the rules of bodily purifications (e.g. one who cannot control his bodily functions, or who is so ill, so as to be beyond medical skill); (iv) even a householder may resort to suicide, if his life’s work is over, if he has no desire for the pleasures of life, does not desire to live on, and is convinced of the ephemeral nature of life, then he may kill himself by fasting in the Himalayas;
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(v) religious suicides and (vi) sati. Mass suicides and suicide pacts are also common in Hindu mythology. In Ramayana, Rama’s brother Lakshmana drowned in the river Sarayu. Rama, having already lost his wife and mother, also drowns in the river with his other brothers. This prompted the people of Ayodya (his kingdom) to commit mass suicide by drowning. (Vijayakumar 2008, Personal Communication)
2.5.6
DEATH AND END OF LIFE
Firth [14] summarizes the Hindu view of end of life as follows: Hindus have specific beliefs in common that influence their attitudes to death. These beliefs relate not to the end of life period, but to transition to other life, whether by reincarnation, life in heaven with God, or absorption into the Brahman(the ultimate reality). They provide direction through the whole of life by appropriate religious rituals and meritorious acts which relate to the dharma of one’s class, by prayer and meditation. Of particular importance is the notion of good death, which provides a model of how to die; a bad death is greatly feared.
The central belief in Hinduism is that there is a soul in all living beings, which transmigrates from one life to another including animal life. A good death occurs in old age, at the right astrological time, and in the right place. A good death should be prepared for throughout life and entered into consciously and willingly. Bad deaths are violent, premature and uncontrolled deaths in the wrong place and at the wrong time, signified by vomit, faeces, urine, and an unpleasant expression. Hindu ethics on the whole come out strongly against involuntary euthanasia, because it contradicts the principle of autonomy and can lead to abuse.
2.5.7
PREVENTIVE PSYCHIATRY
The man of strong mind, who abstains from flesh and alcohol, observes awholesome diet and is always dutiful and pure, will never fall a victim to insanity, whether exogenous or endogenous. One of important contributions of Hinduism is the concept of four stages of life or four ashramas [23]. These ashramas are: (i) brahmacharya or studentship; (ii) grahast or householder; (iii) vaanaprastha or forest dweller and (iv) sanyas or ascetic. The ethical code of the four ashramaswas was well established a thousand years ago in India and it was seriously pursued as an ideal way of life till recently. The essence of the four stages of life is the regulation of the life of individuals. The four stages of life outlined in Hinduism, provide a systematic and timely guidance for life at the different ages of an individual. Wig [23] argues that this is relevant even in modern life, specifically the vaanaprashtha ashram. He considers this an important concept of the Indian way of life. The basis or central theme of Hinduism is the idea of Tyaga or renunciation. In practical terms, facing old age is to gradually prepare for the changes associated with ageing and to handle it gracefully with peace of mind. In practical terms, ultimate happiness and peace of mind can not come by changing environment only, but by changing oneself. Specifically, facing old age can be successfully approached by (i) voluntarily withdrawing self from routine rush of life and live life close to nature; (ii) deliberately choosing to live a simple life by not increasing resources
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to meet the needs but reducing the needs to meet the resources available; (iii) give back to society through service for the welfare of society; and (iv) pursuit of the spiritual path.
2.5.8
CLASSIFICATION OF MENTAL DISORDERS
Caraka described the following classification of insanity (Unmad): 1. Endogenous group insanity produced by bodily humors – vatomnad, pittonmad, kaphonmad and sannipathonmad; and insanity produced by mental humors – rajasonmad, tamosnamad, insanity produced by a combination of the above two and exogenous group – adhijonmad, vishahjonmad. 2. Many psychiatrists in India have made serious attempts to equate some of the Ayurvedic descriptions to modern psychiatric diagnostic terms. The results are neither uniform nor comparable. In Ayurveda there are no separate chapters on neurosis or stress-related somatic illness. However, in Ayurveda there are numerous references that suggest that the influence of the psychological and environmental factors on health and disease was well recognized. 3. Dube [12] has systematically examined the nosology and therapy of mental illness in Ayurveda by comparing the clinical conditions described in Ayurveda with clinical conditions described in the International Classification of Diseases. The 16 types of personality constitution when broken down into mental diseases are likely to suffer from illnesses which can correspond to 16 different mental disorders. Dube has described correspondence of Ayurvedic diagnostic categories with equivalent ICD diagnosis. For example, devgraheetand kafaj are similar to simple schizophrenia; vataj, gandharvagraheet is similar to mania; pittagraheet, manasdukh is equivalent to depression; pittaj and rakshasgraheet is similar to catatonic schizophrenia; paishachgraheet is similar to hebephrenic schizophrenia; shaponmatt is equivalent to hysteria; daityagraheet is similar to antisocial personality; sarpgraheet is equivalent to organic psychosis; nishd is similar to mental deficiency; vaital, kushmand and vishjonmad are similar to organic psychoses; atatvavibhinesh relates to senile and pre-senile dementia and aukiran is similar to chronic psychoses.
2.5.9
RESEARCH STUDIES OF YOGA
Systematic research into yogic practices and their effect in different mental disorders has been a recent development during the second half of the twentieth century. There is a resurgence of academic interest in the effects of different types of yogic practices and the mental health effects of BhagavadGita. For example, during February 2006, there was a World Conference on ‘expanding paradims: science, consciousness and spirituality’ at the All India Institute of Medical Sciences, New Delhi. In March 2007, a national seminar on ‘yoga therapy for psychiatric and neurological disorders’ was organized at Delhi and Bangalore. In September 2008, a two-day conference examined the mental health aspects of Bhagavad Gita at Bangalore. In January 2009, the Indian Psychiatric Society brought out a volume on ‘Spirituality and Mental Health’ containing over three dozen articles on various
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aspects of spiritualism and mental health. All of this leads one to conclude that there will be greater examination of spirituality in general and the impact of yoga and meditation in particular, in the coming years, using a wide variety of physiological and psychological tools. The following is a brief review of the research efforts. Initial research reports of the use of yoga and meditation were with a wide range of mental disorders [27–29]. In addition the special relationship between the patient and the therapist in the Indian context and its advantages were explored [30]. This was followed by comparison of standard treatment with yoga in psychoneuroses, [31–41]; anxiety [42], drug addiction [39], psychogenic headache [43]. There was also a number of studies on the various aspects of TM and its physiological effects [44–46]. Recently, a series of research studies has examined the usefulness of yoga in psychiatric disorders. Sudarshan Kriya Yoga (SKY) is a procedure that involves essentially rhythmic hyperventilation at different rates of breathing. Janakiramaiah and colleagues [47] treated 48 patients diagnosed as dysthymia with SKY alone. It was an out patient study. A trained SKY teacher taught the procedure in the first two weeks and patients practiced the same at home. At the end of the study (3 months) 37 patients were available. 25/37 (68%) of patients were remitted at the end of one as well as three months after the start of SKY. Seven of these practice SKY irregularly (<3 times a week). None of these seven patients were remitted at the end of the study. That close to 70% responded favorably to the sole treatment with SKY in this open study encouraged the authors to test SKY in randomized controlled studies. The next study compared relative antidepressant efficacy of SKY in melancholia with two of the standard treatments, namely electroconvulsive therapy and antidepressant medication. Forty-five hospitalized patients were randomly assigned to the three groups. Assessments were weekly for four weeks. Remission at the end of the trial period were 93, 73 and 63% in the ECT, antidepressant and SKY groups. Authors conclude that SKY can be a potential alternative to drugs in melancholia as a first line of treatment [48]. The authors also examined to see if the therapeutic potential of SKY is contributed by the hyperventilation component solely. Fifteen each of patients with major depressive disorder were randomly assigned to receive either the partial SKY (procedure sans hyper ventilation part of kriya) or full SKY. Full SKY produced 75% remission whereas the partial SKY produced 45% remission [49]. An open trial examined the normalization of P300 amplitude following treatment in dysthymia in a group of 15 patients who practiced SKY, compared with 15 controls (depressive episode with somatic symptoms) and who received ECT or antidepressants and 15 normals. The P300 amplitude increased with the symptomatic improvement of dysthymic group and normalized at 3 months. There was no significant difference between the three groups or across the occasions [50]. The next study examined whether P300 ERP amplitude predicts antidepressant response to SKY. Fifteen dysthymics and 15 melancholics received SKYas the sole treatment and were assessed at pre-treatment, 1 and 3 months. Twenty-two patients responded favorably to SKY. The pre-treatment P300 amplitude neither distinguished responders and non-responders nor was associated with different rates of response. Researchers concluded that SKY therapy is uniformly effective regardless of the pre-treatment P300 amplitude [51]. In another study the antidepressant effect in alcohol dependent individuals was studied using SKY. Following a week of detoxification, 60 alcohol dependent individuals were randomly assigned to receive SKY, or control group for two weeks. Morning plasma cortosol, ACTH and prolactin were measured before the start of therapy and at the end of two weeks, along with a clinical rating of the depressive symptoms. At the end of the study period, there was a greater degree of
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reduction of the depressive symptoms in the SKY group. In both the groups plasma cortisol as well as ACTH fell after two weeks but to a significantly greater degree than in the SKY group. The authors conclude that the study results support the antidepressant effects of Sky reported in the earlier studies [52]. In the most recent study, efficacy of yoga therapy as an add on treatment to the ongoing antipsychotic treatment was the focus. Sixty-one moderately ill schizophrenic patients were randomly assigned to yoga therapy and physical exercise therapy for four months. Forty-one patients completed the trial. Subjects in the yoga therapy group had significantly less psychopathology than those in the physical exercise therapy group. The yoga group had significantly greater social and occupational functioning and quality of life, leading to the conclusion that both non-pharmacological interventions contribute to reduction in symptoms with yoga therapy having better efficacy [53]. The increased interest in Eastern therapies and the availability of measures to study the effects should result in more sophisticated studies of effectiveness of the different therapies in different mental disorders. There is also reexamination of the ancient Indian wisdom towards modern mental health practice [54–57]. Avery striking aspect of the current application of mental health concepts and practices of Hinduism is the large popular use of the techniques among the general population. These have ranged from books addressing the Eastern approach to understanding mind-body relationships [58, 59]. The new age gurus have been marketing the methods to achieve nirvana specially addressed to the urban stressed populations. Unlike the gurus of the past, the current plethora of gurus are trendy, urbane and presenting the ancient practices in a modern way, sometimes referred to as ‘providing a user friendly designer manual for modern living’ [60–62].
2.5.10
OTHER ASPECTS
The current review would be incomplete without referring to some of the features of Hinduism that are not positive. The society was divided into four varnas: kshatriyas (warrior), Brahmin (one involved in religious rituals), vaishya (businessman) and sudras (lower classes). This division, which could have had value in organizing society at a historical point in time, has persisted in a relatively rigid manner. This division resulted in exclusion of the sections of population into a wide range of social activities like religion.The worst part of this system, seen in the current times as caste, is the discrimination of a large proportion of the population groups. It is only during the last 200 years and, more specifically, since Independence in 1947, that these rigid barriers are gradually being brought down. The other area of concern has been the relative position of women in society.
2.5.11
IMPLICATIONS FOR MENTAL HEALTH
Internationally, there is a growing awareness of the importance of mental health. There is a challenge to make mental health relevant to the general population as well as to deliver the services. One of the major hurdles for advocacy of ‘mental health care’ in developing countries (besides the limited infrastructure for care) is the low value attached to mental health by the general population. We consider this a result of the predominantly ‘deviant’
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model of mental disorders. The general population think of mental disorders as affecting others or only a small proportion of the population and consequently not relevant to them as part of their day-to-day life. There is a need to change the concept of mental disorders from the deviancy to normalcy model, (i.e. mental life as something which is a part of everyone’s life), that will make mental health an agenda of the general population. Dr. Sartorius has referred to this as increasing the position of mental health in the hierarchy of values of people, ‘when mental health has a high position on the scale of values, it can become the driving force for resolute action’ [63]. In this context, practitioners of Hinduism have imbedded in their religion a strong emphasis on mental health. In India, mental health in one way or another is part of Indian knowledge and daily practice. Everyday we witness thousands of people, following one or other component of well-being through methods described as yoga, meditation, art of living, to name a few. There are five aspects of Hinduism that are directly relevant to the practice of mental health in the international arena. The first is the way Hinduism looks at religion as a way of life unlike that of other religions. Spirituality forms the essence of Hinduism. In addition, Hinduism is open to other viewpoints. This is well illustrated by the following quote from Radhakrishnan, who quotes Arnold Toynbee as follows: As I have gone on, Religion has come to take a more and more prominent place, till in the end it is in the centre of the picture... I have come back to a belief that Religion holds the key to the mystery of existence; but I have not come back to the belief that this key is in the hands of my ancestral Religion exclusively . . .. The Indian religions are not exclusive minded. They are ready to allow that there may be alternative approaches to the mystery. I feel sure that in this they are right, and this catholic-minded Indian religious spirit is the way of salvation for all religions in an age in which we have to learn to live as a single family if we are not to destroy ourselves [64, p. 49].
Second is the recognition of the unity of the body-mind relationship. This is in contrast to the view held till recently in Western medicine. It is only in the recent times that the unity of mind-body has come to be accepted in the West. In a way this recognition is a major development. For example, Harrington reports: ‘In March 2007, I conducted an internet search on Amazon.com using several key words. Amazon showed me 2438 books that were about the ‘mind-body connection’ and 1081 books that were about ‘mind-body medicine’. It also showed me 1992 books about psychoneuroimmunology; 1638 books about social support and health; 1717 books about the health effects of meditation; 5913 books about the placebo effect; 11 724 titles concerned with stress and health; and a whopping 14 075 titles concerned with positive thinking. When I searched on the keyword ‘genomics’ 15 138 titles turned up. Genetics is important in our culture, we knew that, but mind-body medicine appears to be holding its own [58, p. 243]. As noted in earlier sections, in Ayurveda the wholistic approach to health and disease is a central part. It can be expected that there will be greater attention to the Hinduism concept of the mind-body relationship in the coming years. The third has to do with the concept of four stages of life (described earlier). The division of the life stages with their associated guidelines to live in harmony with oneself and the community/nature provides a unique model for the world population that is gradually moving into longer life expectancy. The value of the stages is in helping each individual to
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accept the changes that occur as part of ageing as well as changes in social position with grace, dignity and more importantly with a positive attitude. The value and the application of vanaprasthashram in a practical way, enunciated by Wig [23] is a good example. The fourth contribution is the philosophy of Bhagavad Gita [9, 15]. The approach to discharge one’s responsibility without regard to the results, to consider one’s actions as part of a larger cosmic system have relevance in a modern world where the focus is on individual actions and benefits. The National Institute of Mental Health and Neurosciences, Bangalore has one of the slokas of Gita in its emblem, namely, ‘Equanimity is the goal of all existence’. The fifth contribution of Hinduism is the science of yoga and meditation. As reviewed in earlier sections, there is growing recognition of the value of yoga and meditation as a way of life and to address a number of mental conditions. With greater research, there can be more evidence of the value of these practices. What are the challenges in the area of yoga and meditation on measures to promote mental health? [65, 66]. Firstly, the study of mental health and well-being of a subgroup of practitioners of well-being programs in the general population, rather than looking for universal effects (e.g. like the Maharshi Mahesh Yogi claim that if a certain percentage of the population use transcendental meditation, societies will be free of crime). Such studies can identify specificity of the effects in terms of age, sex, social group or persons experiencing specific situations like grief, disaster or conflict situations. The availability of methods to screen for mental disorders using lay interviewers makes this a real possibility. Secondly, the simplification of the actions to be taken by the individuals for mental well-being, along with local adaptations to take into account the cultural norms, social practices etc, of the core activities so that it is possible to make it a part of routine life and easily integrated into the life of all individuals. Too often these programmes are presented as packages (often with a price) that deters their universal use. Thirdly, longitudinal studies of practitioners of yoga and meditation, for the incidence/ prevalence of disorders, resiliency in different life situations like grief, exposure to trauma, disasters and conflict situation to understand the protective/preventive value of the wellbeing activities. In the coming years, as psychiatry moves from mental illness to mental health and the future psychiatrists will be working with mentally ill persons and with all people with a desire to be well and remain free of mental illnesses, there will be a greater need to base our activities in the religious and spiritual values of different religions. I would like to conclude with a quotation from Venkoba Rao [9] which illustrates both the relevance of Hinduism to modern life as well as the need for modern examination of the concepts and practices to meet the modern world. India is an ancient and great cultural, spiritual and an anthropological laboratory. She has been the nursery of saints and sages, scientists and founders of world’s major religions and promulgators of profound philosophy. Nevertheless, to be satisfied with the glory of the past is to turn into a fossil; but to interpret the old from a new point of view is to revitalize the past and bring in a current of fresh air into the monotonous present (p. 1).
This is the challenge and opportunity for the mental health professionals of India and the world.
2.5.12
ACKNOWLEDGMENTS
Preparation of this chapter was possible only with the support and guidance of a number of professional colleagues. I am specially thankful to Prof. N.N.Wig, Emeritus Professor of
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Postgraduate Institute of Medical Education and Research, Chandigarh, for his continuous support during the preparation of this chapter. Dr. Narayana Reddy, Dr. V.K.Varma, Dr. B.N. Gangadhar, Dr. C.Shamsunder, Dr. Sanjay Dube, Dr. Sudhir Khandelwal, Dr. Meena Vythilingam, Dr. Avdesh Sharma, Col. R.Venugopal, generously provided background materials for the chapter. They provided valuable critical comments on earlier drafts and thus enriched the chapter.
REFERENCES 1. Wig NN (1990) Indian concepts of mental health and their impact on care of the mentally ill. International Journal of Mental Health 18, 71–80. 2. Harshananda (2008) A Concise Encyclopedia of Hinduism-Volumes 1–3. Ramakrishna Mission, Bangalore. 3. Knipe DM (1989) Hinduism and the tradition of Ayurveda. In: Sullivan LE (ed.) Healing and Restoring - health and medicine in the world’s religious traditions. Macmillan, London, pp. 89–126. 4. Frawley D (2002) Forward, in The Complete Idiot’s Guide to Hinduism Johnsen L, Alpha, Indianapolis, pp. 16–17. 5. Wig NN (1999) Mental health and spiritual values. A view from the East. International Review of Psychiatry 11, 92–96. 6. Deb Sikdar BM (1961) Glimpses of medico-psychological practices in ancient India. Indian Journal of Psychiatry 11, 250–259. 7. Varma LP (1965) Psychiatry in Ayurveda. Indian Journal of Psychiatry 7, 292–312. 8. Rao AV (1978) Psychiatric thought in ancient India. Indian Journal of Psychiatry 20, 107–119. 9. Rao AV (1997) Culture, philosophy, mental health. Bharatiya Vidya Bhavan, Mumbai. 10. Gautam S (1999) Mental health in ancient India and its relevance to modern psychiatry. Indian Journal of Psychiatry 41, 5–18. 11. Weiss MG, Desai A, Jadhav S, Gupta L, Channabasavanna SM, Doongaji DR, Behere PB (1988) Humoral concepts of mental illness in India. Social Science & Medicine 27, 471–477. 12. Dube KC (1978) Nosology and therapy of mental illness in Ayurveda. Comparative Medicine East West, 6, 209–228. 13. Dube KC, Kumar A, Dube S (1983) Personality types in Ayurveda, American Medicine of Chinese Medicine 11, 25–34. 14. Dube KC, Kumar A, Dube S (1985) Psychiatric training and therapies in Ayurved. American Journal of Chinese Medicine 13, 13–22. 15. Reddy S (2008) Psychoanalytical process in a sacred Hindu text - the Bhagavadgita. In: Akthar S (ed.) Freud Along the Ganges: Psychoanalytical reflections on the people and culture of India. Rave Media, New Delhi, pp. 309–334. 16. Vallabhaneni MR (2008) Advaitha Vedanta, psychoanalysis and the self. In: Akthar S (ed.) Freud Along the Ganges - psychoanalytical reflections on the people and culture of India. Rave Media, New Delhi, pp. 359–396. 17. Narayana Reddy GN, Ramu MG, Venkataram BS (1987) Concept of manas(psyche) in Ayurveda. NIMHANS Journal 5, 125–131. 18. Balodhi JP (1987) Constituting the outlines of a philosophy of Ayurveda - mainly on mental health import. Indian Journal of Psychiatry 29, 127–130. 19. Valiathyan MS (2003) The Legacy of Caraka. Orient Longman, Hyderabad. 20. Jaggi OP (1986) Mental Tension and its Cure. Orient Paperbacks, Delhi. 21. Kapur RL (1994) Yoga and the state of mind. Seminar 415, 30–34. 22. Firth S (2005) End of life: a Hindu view. The Lancet 366, 682–686. 23. Wig NN (2006) The Joy of Mental Health. Servants of the People Society, Chandigarh.
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MAIN ISSUES
24. Nayar P (2008) Yoga. In: Varma VK, Gupta N (eds.) Psychotherapy in a Traditional Society: Context, concept and practice. Jaypee, New Delhi, pp. 165–178. 25. Aurobindo Sri (1922) Essays on Gita. Sri Aurobindo Ashram, Pondicherry. 26. Prabhupada ACB (1984) Bhagavad-gita, as it is. The Bhaktivedanta Book Trust, Los Angeles. 27. Vahia NS, Vinekar SL, Doongaji DR (1966) Some ancient Indian concepts in the treatment of psychiatric disorders, British Journal of Psychiatry 112, 1089–1096. 28. Vahia NS, Doongaji DR, Jeste DV (1975) Value of Patanjali’s concepts in the treatment of psychoneurosis. In: Arieti S, Chrzanowski G (eds.) New Dimensions of Psychiatry: a world view. John Wiley, New York, pp. 293–304. 29. Vahia NS, Doongaji DR, Jeste DV, Kapoor SN, Indubala A, Nath SR (1973) Further experience with therapy based on the concepts of Patanjali in the treatment of psychiatric disorders. Indian Journal of Psychiatry 15, 32–38. 30. Neki JS (1973) Guru-Chela relationship:the possibility of a therapeutic paradigm. American Journal of Orthopsychiatry 3, 755–766. 31. Sethi BB, Trivedi JK, Anand R (1981) A comparative study of the relative effectiveness of biofeedback and shavasana in tension headache. Indian Journal of Psychiatry 24, 230–237. 32. Sethi BB, Trivedi JK, Srivatsava A, Yadav S (1982) Indigenous therapy in the practice of psychotherapy in India. Indian Journal of Psychiatry 25, 230–234. 33. Singh BB (1984) Ventilatory response to CO2: studies in the neurotic psychiatric patients and practitioners of TM. Journal of American Psychosomatic Society 46, 347–363. 34. Singh V, Madhu A (1987) A study of the effect of yogic practices on certain psychological parameters. Indian Journal of Clinical Psychology 14, 80–83. 35. Verma N (1982) Clinical trials of Yoga Nidra and autogenic training. M. Phil. Dissertation. NIMHANS, Bangalore. 36. Grover P, Varma VK, Verma SK, Pershad D (1987) Relationship between the patient’s attitude towards yoga and the treatment outcome. Indian Journal of Psychiatry 29, 253–258. 37. Grover P, Varma VK, Pershad D, Verma SK (1988) Role of yoga in the treatment of psychoneurosis, Bulletin of PGI 22, 68–77. 38. Grover P, Varma VK, Pershad D, Verma SK (1994) Role of yoga in the treatment of neurotic disorders:current status and future directions. Indian Journal of Psychiatry 36, 153–162. 39. Grover P, Varma VK, Verma SK (1990) Drug addiction: can yoga help? Disabilities and Impairments 3, 89–97. 40. Kohli A, Varma VK, Nehra R (2001) Comparison of the efficacy of psychorelaxation and pharmacotherapy in generalised anxiety disorder, Journal of Personality and Clinical Studies 16, 43–48. 41. Varma VK (1995) Psychotherapy,yoga and meditation. In: Koslow SH, Srinivasa Murthy R, Coelho GV (eds.) Decade of the Brain: India/USA Research in Mental Health and Neurosciences. National Institute of Mental Health, Rockville, MD, pp. 213–218. 42. Sahasi G, Mohan D, and Kacker C (1989) Effectiveness of yogic techniques in the management of anxiety. Journal of Personality and Clinical Studies 5, 51–55. 43. Prabhakar S, Grover P, Berma SK, Chopra JS (1991) Role of yoga in the treatment of psychogenic headache. Neurology India 39, 11–18. 44. Khandelwal S, Deb KS (2008) Transcendental meditation: current status, In: Varma VK, Gupta N(eds.) Psychotherapy in a Traditional Society: Context, concept and practice. Jaypee, New Delhi, pp. 190–205. 45. Alexander CN, O’Connell DF (1994) Treating and preventing alcohol,nicotine, and drug abuse through Transcendental Meditation: a review and statistical meta analysis, Alcoholism Treatment Quarterly 11, 13–87. 46. Wallace RK, Dillbeck M, Jacobe E, Harrington B (1982) The effects of the transcendental meditation and TM-Sidhi programme on the ageing process. International Journal of Neuroscience 16, 53–58.
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47. Janakiramaiah N, Gangadhar BN, Murthy PJNV, et al. (1998) Therapeutic efficacy of Sudarshan Kriya Yoga (SKY) in dysthymic disorder. NIMHANS Journal 16, 21–28. 48. Janakiramaiah N, Gangadhar BN, Murthy PJNV, Harish MG, Subbakrishna DK, Vedamurthachar A (2000) Antidepressant efficacy of Sudarshan Kriya Yoga (SKY) in melancholia: a randomised comparison with electroconvulsive therapy and imipramine, Journal of Affective Disorders 57, 255–259. 49. Rohini V, Pandey RS, Janakiraiah N, Gangadhar BN, Vedamurthachar AA (2000) Comparative study of full and partial Sudarshan Kriya Yoga in major depressive disorder. NIMHANS Journal 18, 53–57. 50. Murthy PJNV, Gangadhar BN, Janakiramaiah N, Subbakrishna DK (1997) Normalisation of P300 amplitude following treatment in dysthymia. Biological Psychiatry 42, 740–743. 51. Murthy PJNV, Gangadhar BN, Janakiramaiah N, Subbakrishna DK (1998). P300 amplitude and antidepressant response to Sudarshan Kriya Yoga (SKY). Journal of Affective Disorders 50, 45–48. 52. Vedamurthachar A, Janakiramiah N, Hegde JM, Shetty TK, Subbakrishna DK, Sureshbabu SV, Gangadhar BN (2006) Antidepressant efficacy and hormonal effects of Sudarshana Kriya Yoga (SKY) in alcohol dependent individuals. Journal of Affective Disorders 94, 249–253. 53. Duraiswamy G, Thirthahalli J, Nagendra HR, Gangadhar BN (2007) Yoga therapy as an add on treatment in the management of patients with schizophrenia - a randoimised controlled trial Acta Psychiatrica Scandinavica 116, 226–232. 54. Neki JS (1977) Psychotherapy in India. Indian Journal of Psychiatry 19, 1–10. 55. Varma VK, Gupta N(eds.) (2008) Psychotherapy in a Traditional Society:Context, concept and practice. Jaypee, New Delhi. 56. Shamsunder C (2008) Relevance of ancient Indian wisdom to modern mental health - a few examples. Indian Journal of Psychiatry 50, 138–143. 57. Akthar S (ed.) (2008) Freud along the Ganges: Psychoanalytical reflections on the people and culture of India. Rave Media, New Delhi. 58. Harrington A (2008) The Cure Within: a history of mind-body medicine. Norton, New York. 59. Gautier F (2002) The Guru of Joy. Books Today, New Delhi. 60. Chopra D (1991) Perfect Health: The complete mind/body guide. Harmony Books, New York. 61. Chopra A, Raval S (2003) Guru chic. India Today, July, 2003. 62. Vasudev S (2003) Stress supermarket. India Today, July 23, 2003. 63. Sartorius N (1990) Editor’s introduction: translating mental health concepts into programmes. International Journal of Mental Health 18, 3–4. 64. Radhakrishnan S (1968) Religion and Culture. Orient Paperbacks, Delhi, p. 49. 65. Srinivasa Murthy R, D’Souza R (2006) Mental Wellbeing: Letter to editor. World Psychiatry 5, 188. 66. Sharma A (2009) Spirituality and mental health. Indian Psychiatric Society in association with Rajayoga Education and Research Foundation, Mount Abu, Delhi.
CHAPTER 2.6
Buddhism and Psychotherapy in Japan Naotaka Shinfuku Professor of Psychiatry and Mental Health, Japan
Kenji Kitanishi Professor of Psychiatry, Japan
2.6.1
PREFACE
Asia has much to contribute to the field of psychiatry. Religion, moral codes and health factors in Asia are precious heritages for the sciences of the mind and brain. Religions in Japan are tolerant of other religions and respect other value systems. Many schools of Buddhism, Christianity and Shinto Sect co-exist in Japan, much like a harmonious mosaic. An Asian moral code, such as Confucianism, dates back over 2500 years and sets the social framework of everyday life for the majority of Asian people. Confucianism teaches respect to the ancestry, elderly, seniority, and the importance of the order forming the traditional value systems of communal-oriented Asian societies. Bushido, derived from Asian moral codes, formed the spirit of the Samurai clan in Japan, and places a high value on societal rather than individual values, which requires self sacrifice for the good of the society. In Asian religion, Buddhism, Taoism and Shinto all support tolerance and acceptance of others’ values. Plural numbers of gods are able to co-exist, with 808 gods existing in Shinto, all having different roles. Ayurveda, Zen meditation and Tai Chi are closely related to the practices of various Asian religions. Asian religions, which are psychosomatic, encompass both mind and body in their daily practices. In Zen temples, monks wake up early in the morning and clean gardens and corridors to perfection, which is considered an integral part of Zen practice. Now we witness the revivals of eastern ways in Asia. A holistic approach, quality of life and the body-mind relationship already existed as the essential components of Asian religions. It is clear that Asia has great potential to contribute to the sciences of the mind in the twenty-first century.
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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MAIN ISSUES
BUDDHISM
Among the cultural heritage of Asia, Buddhism has an overwhelming importance. Buddha was born almost 2500 years ago. As the prince of a small kingdom in India, he left his family to search for the meaning of life, as he saw suffering in all aspects of life with birth, ageing, ill-health and death being the inevitable four phases of human life. He tried many ways to cure his sufferings and finally found Satori (Buddhist Enlightenment through meditation). His story depicts the essence of Buddhism as very similar to what modern psychiatry is searching for – ‘peace of mind’. A countless number of philosophers in India, China, Japan and other countries have added their thoughts and interpretations to the original teachings of Buddha. Original Buddhism was tolerant and flexible in accepting new ideas and adopting a few principles, such as the law of interdependency [1] (Nakamura 1970).
2.6.2.1
Buddhism in Japan
Buddhism was introduced to Japan in the sixth century from Korea. At the beginning of the seventh century, the first Japanese Constitution was promulgated by Prince Shotoku (574–622) based on Buddhist teachings. The so-called Seventeen Article Constitution was constructed with a strong influence of Buddhism. Article 1 of the Constitution is ‘Harmony is the most valuable’. The Principle code for officials is that they not quarrel with each other – consensus is the way to ‘abide’. This spirit has become the backbone of Japanese culture. Since then, many temples have been established throughout Japan to honor Buddhism, and have become the center for religion, culture and educational activities. Zen, established by Dharma, was introduced to Japan around the twelfth century from China, by several Japanese Buddhist monks who went to China to study Zen. Zen was preferred by the warrior class Japanese (Samurai), as it showed the way for enlightenment through hard practice and self control. Dogen (1200–1253) established the Eihei Temple and opened the Soutou Sect, an original Zen Sect, which remains popular in modern Japan. Around the same time, Shinran (1173–1262) preached an easy way for common people to enter into the Buddhist paradise (Saiho-jyodo). His schools were called ‘Jyodo-Shinsyu’ or ‘True Pure Land Sect’, which attracted many common people in poverty who were tormented by continuous internal wars. Shinran preached that once a person praises the name of Amida, then Amida would save them. A simple sermon of Nami-amidabutsu (which means Dear Amida I will follow you) is the key to salvation. Shinran also preached that the love of Amida is profusely provided to save all, with special concern for poor and evil people. The sect grew and is the largest Buddhist Sect in Japan today.
2.6.3
SHINTOISM
Shintoism, along with Buddhism, also plays an important role in the minds of the Japanese. Shintoism was the indigenous religion widespread among Japanese people well before the introduction of Buddhism. It sees gods interwoven in nature and pays respect to the wholesomeness of high mountains, deep forests, pure rivers and ancestors who contribute greatly to their clan. Shinto is, in one respect, similar to Animism. One of Shinto’s passions
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is ‘cleanness and purification’, which has contributed to Japan being a very clean country. Shinto continues to remain popular in the everyday life of Japanese people. Celebrations marking the reaching of age three, five and seven are held at Shinto shrines and remain popular among young Japanese parents in modern Japan. The Emperor has been the head of Shinto schools throughout Japanese history. Modern-day Shinto rituals practiced by the royal family pay importance to rituals related to the cultivation of rice. The origin of Shinto may well be dated back to the introduction of rice into Japan. Buddhism and Shinto have learnt to co-exist peacefully throughout their history, though they had some conflict over the leading religious power in Japanese history.
2.6.4
BUDDHISM AND PSYCHIATRY IN ASIA
Buddhism is widely and profoundly immersed in the mental life of Japanese people, with modern trained psychiatrists no exception. Buddhism is a part of the Japanese psyche and the relationship of Buddhism and psychiatry is at times difficult to describe. Western psychiatry has only existed in Japan and other Asian countries for over one hundred years. Buddhism originated in India, flourished in China, and was introduced into Japan from Korea approximately 1400 years ago. Psychiatry, on the other hand, was born in Europe in the eighteenth to nineteenth century and introduced into Japan around 100 years ago from Germany as a discipline of modern medicine. The Japan Society of Psychiatry and Neurology (JSPN) was established in 1902, and convened the 12thWorld Congress of Psychiatry (WPA) in 2002 in Yokohama to commemorate its 100th Anniversary. Since 1902, German psychiatry has strongly influenced Japanese psychiatry. Psychoanalysis, introduced into Japan from Germany by a psychiatrist, faced much criticism and failed to receive academic recognition before World War II (1941–1945). The end of World War II brought about change to the framework of Japanese psychiatry, which today is influenced by American and British psychiatry. Psychiatry in Asia has grown rapidly in the past 30–40 years. Today, Asian psychiatrists are still searching for the identity of Asian psychiatry, and are only now beginning to look back at the history concerning the relationship between psychiatry and religions in Asia. Eastern Buddhism and Western psychiatry have co-existed for about one hundred years in Japan, though at the beginning, co-existence was not fully recognized by each other. Gradually, Japanese psychiatrists developed psychotherapies based on Buddhism and identified a treasure of Buddhist teachings and trainings as a source for current psychotherapeutic approaches. In this chapter, we will describe, among others, two types of psychotherapies developed in Japan, Morita Therapy [2] (Morita 1998) and Naikan Therapy [3] (Yoshimoto 1972). Morita Therapy was born from the spirit of Zen [4] (Kitanishi 2005), while Naikan Therapy was born from the trainings of the Pure Land Sect [5] (Kawahara 2005).
2.6.5
MORITA THERAPY
Morita Psychotherapy is an experience-based treatment for neurotics developed by the Japanese psychiatrist Shoma Morita (1874–1938) in the early part of the twentieth century. Shoma Morita himself suffered from neurotic tendencies during his adult life while studying at medical school. Worrying about his health conditions, insomnia, and his exams,
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and nearing a nervous breakdown before the graduation examination, he contemplated terminating his studies. However, he continued on, and in doing so, tried to forget all his worries and concentrate only on what was required in order to graduate. This personal experience was rooted in his Zen practice, which ignored thought processes and emphasized direct individual experiences and physical activity. One of the authors (Shinfuku) stayed at a Buddhist temple for six months on entering medical school, following the lifestyle of a Buddhist monk. In the morning, he would rise at 3.30 to clean the long corridor of the temple and its sand gardens, paying particular attention to the task at hand. After such daily practices, which were considered important aspects of Zen training, he was allowed to participate in the morning Zen meditation. Currently, there are few students who practice Zen meditation in Japan. Morita Shoma received an unexpected good score for his examination and later became a psychiatrist. He suffered neurosis and treated himself based on the teachings of Zen. His personal experience is considered the basis for the development of Morita Therapy as a unique Japanese psychotherapy [6, 7] (Morita 1922/1974) (Morita 1926/1974). Later Dr. Morita became chairman of the Department of Psychiatry at Jikei University School of Medicine, Tokyo, Japan. There he developed the original treatment method based on his experience, and applied it to a form of anxiety neurosis called Shinkei-shitsu, meaning ‘neurotic personality’. In 1915, Dr. Morita, at 41 years of age and using his psychotherapy, treated a patient with a panic disorder. This is considered the starting point of ‘Outpatient Morita Therapy’. Dr. Morita discovered that many neurotic problems were caused by vicious cycles of wrong perceptions and confused emotions. In 1919, Dr. Morita began accommodating neurotic patients (Shinkei-shitsu patients) and treating patients at home. This home treatment was marked officially as the first year of ‘Inpatient Morita Therapy’. Original Inpatient Morita Therapy is comprised of the following four phases. 1) Absolute bed rest for one week, with the patient requested to remain in bed for the whole day, except for times required for toilet use and meals. 2) Light work for one week. Most patients seek some activities after one week’s bed rest. Patients were then required to do light work, which involved predominately cleaning the house. Leisure activities were prohibited. During this period, the patient was required to record his behavior in a diary, and was discouraged from writing about his symptoms or thoughts. The diary was to reflect only the physical activities performed. 3) Heavy work for one week. During this time the patient was requested to participate in heavy work such as cleaning corridors and attending gardens. At the end of each day the patient was required to submit a diary to Dr. Morita. Patient’s complaints and symptoms recorded in the diary were not taken into consideration, as Morita’s comments were focused on the progress of the work performance of the patient. 4) During the fourth week, as the patient prepares for discharge, he is advised to live with his symptoms while performing daily duties. The patient is instructed to accept anxiety, rather than trying to dispel it, and at the same time, discover a healthy desire to be active. Dr. Morita valued the patient’s ability to perform daily works and duties. In Morita Therapy, verbal dialogue is not essential, however behavior and experience by the patient is valued. Zen Buddhism also shares similar attitudes with Morita Therapy. Satori (Enlightenment) ignores verbal definition and can be achieved only through internal
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experience and sitting Zen meditation. Orthodox Morita Therapy, in the modern era, is difficult to practice as patients are often busy and have time constraints. The outpatient psychotherapy based on the Morita principle has become popular. Some modern-day Japanese psychiatrists tend to advise neurotic patients to ‘concentrate on what they have to do in their daily activities and avoid paying attention to their symptoms’. A Japanese psychiatrist once called this practice ‘Common Sense Psychotherapy’. Some principles of Morita Therapy are deeply rooted in the Japanese mind, allowing this common-sense approach to be more favored by the daily practice of Japanese psychiatrists rather than an analytical approach.
2.6.6
NAIKAN THERAPY
Naikan is a Japanese word meaning ‘review inside of oneself’, with Nai meaning ‘inner’ and Kan meaning ‘review’. It is a structured method of self reflection that helps in understanding ourselves, our relationships and the fundamental nature of human existence. Naikan was developed by Mr. Yoshimoto Ishin, a devout Buddhist monk of the Jodo Shinsyu Sect (True Pure Land Sect founded by Monk Shinran in the thirteenth century) [8] (Kawahara 1998). Naikan was derived from Mishirabe, which was used for training newly admitted monks of the Jyodo Shinsyu Sect over the centuries. Yoshimoto himself experienced Mishirabe and formulated it as Naikan, which is similar to Mishirabe (‘review of one’s self’). In Japanese, Mi means ‘body or self’ and Shirabe means ‘critical review, check or scrutiny’. Mr. Yoshimoto Ishin (1916–88) grew up in a community with a strong influence of Pure Land Buddhism, and consequently wished to become a Buddhist monk. In 1937 he participated in the training of Mishirabe and experienced enlightenment on the fifth day. This experience was similar to what Shinran called ‘Jinen-Hohni’. He was filled with the love of Amida. Mr. Yoshimoto Ishin was convinced that his mission was to spread Mishirabe to the wider community. He succeeded as a businessman and developed the original method of Mishirabe into the present form of Naikan. Gradually, he diluted its original religious content. In 1953 he retired from his business and established the Naikan Center in Nara Prefecture, devoting his life to the teaching of Naikan as widely as possible. In 1954, Mr. Yoshimoto Ishin introduced Naikan to the inmates of Nara Juvenile Correction Center, and later to several correctional educational programs for juvenile delinquents. Naikan was gradually accepted as a psychological therapy among medical professionals. Naikan training carried out at the Naikan Center required the trainee to spend one week in a secluded area. During this time, the trainee was asked to confront his self and was allowed to leave the area only to sleep, wash, bathe and toilet. The Naikan teacher would instruct the trainee to concentrate to recall his past as precisely as possible, especially his behavior towards other key persons. Naikan Therapy usually starts with a review of the relationship with the trainee’s mother, during which time the teacher asks the following three questions of the trainee: 1) What has your mother provided you? 2) What have you given back to your mother? 3) What troubles have you caused your mother?
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The teacher asks the trainee to do Mishirabe in the following format: 1) 2) 3) 4) 5) 6) 7)
Relationship with Relationship with Relationship with Relationship with Relationship with Relationship with Relationship with
mother. father. brothers and sisters. friends. teachers. partner. other key persons.
The teacher collects the answers every two hours and thanks the trainee, before asking the trainee to do Mishirabe in the following chronological order. If the trainee is aged 25 years, he is requested to recall his relationship with his mother at age 24, and then his relationship with his mother at a younger age, gradually progressing from adulthood, back to childhood, and finally to the trainee’s earliest memory. Original Mishirabe was a means by which the trainee could understand how much affection he received from many people since birth, and to become aware of how little he has returned to others. This method was for the trainee of Jyodo Shinsyu Sect to realize the boundless love of Amida. After the confession of Mishirabe, the teacher thanks and bows to the trainee because it was not the trainee doing Mishirabe, but Amida inside the trainee doing Mishirabe. Mr. Yoshimoto Ishin states that the purpose of Naikan Therapy is to reduce the pathological narcissism and to accept, from birth, the love provided from the mother and other key persons.
2.6.7 2.6.7.1
DISCUSSION Morita therapy and psychoanalysis
Dr. Morita Shoma formulated his psychotherapy at a time when psychoanalysis had been introduced into Japan. Psychotherapy and Morita Therapy have opposite approaches. Dr. Morita Shoma was a fierce critic of psychoanalysis, and had heated discussions with Professor Marui Kiyoyasu of Tohoku University, who introduced psychoanalysis into Japan. Dr. Morita Shoma was extremely critical of attempts to control anxiety by examining and recognizing the causes of anxiety. He asserts that repression is a natural phenomenon, and that many people experience psychological trauma, therefore anxiety cannot be the cause of neurosis. Dr. Morita Shoma’s criticisms were also directed at Dubois’s ‘persuasion method’. He criticized Dubois’s argument that neurosis was caused by false cognitive processes, and that it could be cured through rational persuasion and correct educational methods. Dr. Morita Shoma asserts that what matters is experience and not cognitive process.
2.6.7.2
Time and symptoms in Western and Eastern psychotherapies
There are differences and similarities among psychotherapies in the East and West. The first difference is the attitude toward symptoms such as anxiety, with both Morita Therapy and Naikan Therapy trying to find ways to accept symptoms. On the other hand, Western
2.6 Table 2.6.1
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Major components of different psychotherapies
Psychoanalysis Cognitive Therapy Behavior Therapy Naikan Therapy Morita Therapy
Behavior
Emotion
Cognition
Desire
Therapeutic Milieu
~ * *
* * ~ * *
* * * *
* *
* *
* important; ~ moderate; not important; negative, need to control; positive, need to exercise.
psychotherapies, such as psychoanalysis and behavior therapy, aim to control symptoms. This difference can be explained by the different approaches of Western and Eastern culture to nature – control-oriented culture of the West and adjustment-oriented culture of the East. Another difference is the time factor in life. Past experiences are the key factor in the treatments of Naikan Therapy and psychoanalysis. Naikan Therapy could be considered as well-guided psychotherapy to cure egocentrism of the client. Present experiences are keys to both Morita Therapy and Behavior Therapy. Morita Therapy is sometimes interpreted as behavioral therapy and cognitive therapy by Western psychotherapists. The basic theme of both Naikan Therapy and Morita Therapy is to become aware of the limitation of self, which results in the acceptance of symptoms as they are, and helps the client to realize the self as dependent on human networks. In Western psychotherapy, symptoms such as anxiety are viewed as a negative object to be controlled or eliminated by one’s self (Table 2.6.1). Control of anxiety becomes a major focus in Western psychotherapy. In Eastern psychotherapy it is considered important for the client to learn how to live daily life successfully, even with their symptoms [9] (Kitanishi 1999).
2.6.7.3 Behavior, emotion, cognition, desire and therapeutic milieu of psychotherapies We have tried to analyze the major components of psychotherapies, namely behavior, emotion, cognition, desire and therapeutic milieu. Each psychotherapy gives importance to a specific component. The authors have reviewed psychoanalysis, cognitive therapy, behavior therapy, Naikan Therapy and Morita Therapy. In Western psychotherapies, psychoanalysis and behavioral therapy have opposite tendencies, which show these two approaches have the opposite orientation. Psychotherapy aims to control cognition and desire, while behavioral therapy focuses on the control of behavior giving the cognition and desire less importance. One can recognize a few similarities between cognitive therapy, Naikan Therapy and Morita Therapy, all of which value emotion and cognition. In Eastern psychotherapy, therapeutic milieu is considered important. Psychoanalysis and Morita Therapy see clients’ desires as an important component, both as causes of symptoms and opportunities for cure. However, attitude to desire is different. In psychoanalysis, desire is an object of control.
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But desire is defined positively in Morita Therapy. Desire should be cultivated and adjusted through experiences in Morita Therapy. In many aspects, Morita Therapy and psychoanalysis have opposite approaches. Naikan Therapy has a few similarities with psychoanalysis, as both place importance on the client’s personal past relationship. Japanese psychotherapies (Inpatient Morita Therapy and Naikan Therapy) place importance on therapeutic milieu and therapeutic interpersonal relationships. In this sense, Japanese psychotherapies could be called a sort of milieu therapy similar to therapeutic communities. Japanese psychotherapies have many flaws, including not paying sufficient attention to the client–doctor relationship, lacking in standardized intervention guidelines, and standardized training methods which are considered not sufficient to educate young doctors to study Japanese psychotherapies.
2.6.7.4
Ego and no-ego
There exists clear distinction in several aspects of Western and Eastern psychotherapies, with many authors having cited differences. We would like to point out and discuss the following two points. The first one is ‘how to deal with ego’ and the second one is ‘theory versus experience’ (Table 2.6.2). The first one is the different approach concerning ego. Western psychotherapies (psychoanalysis, cognitive therapy and behavioral therapy) all aim to strengthen the ego. On the other hand, Eastern psychotherapies (Morita Therapy and Naikan Therapy) ask clients to break down their small ego and seek no-ego [10] (Kitanishi 2001). Through the process of seeking the no-ego, the client is expected and encouraged to achieve comprehensive self (positive self). In both therapies, the ultimate goal is similar to Satori (Buddhist enlightenment) and Jinen-Honi (filled with the feeling of thanks to Amida). The second difference is the different focus of Western and Eastern psychotherapies. Western psychotherapies are sophisticated in their theoretical framework, although they tend to single out a specific component and be fragmented. They focus on finding out the causes but are not always effective in treatment. Eastern psychotherapies are experiencebased and empirical, although they tend to be weak in theoretical formulation. They are not analytical, and do not seek the causes of symptoms, tending to focus on recovery. There are many other differences and similarities between psychotherapies of the West and East, and it is important for both to study and gain inspiration from other approaches. Table 2.6.2
Major differences in Western and Asian psychotherapies
Psychoanalysis Cognitive Therapy Behavior Therapy Naikan Therapy Morita Therapy
Strength of Ego
No-ego (Acceptance of Self)
Theoretical
Empirical (Recovery)
* * *
* *
* * *
* *
* important; not important. (by.K. Kitanishi)
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MORITA THERAPY AT PRESENT
Morita Therapy was popular among Japanese psychiatrists before World War II. However, very few Japanese psychiatrists were using Morita Therapy in their practices soon after World War II, for which there may be several reasons. Many Japanese psychiatrists considered Morita Therapy to be obsolete given the strong influence of psychoanalysis and other modern psychotherapies originating from the United States of America. Also, the orthodox Inpatient Morita Therapy required a special treatment setting and a commitment of four weeks. In addition, the introduction of the national insurance scheme and payment systems in psychiatry made it difficult to sufficiently reimburse payment for the Morita Therapy. The number of typical Shinkei-shitsu patients described by Dr. Morita Shoma has decreased in Japan since World War II. Morita Therapy was considered as the therapy of the past in Japan until the 1970s. In the 1980s, Morita Therapy experienced a dramatic revival, when Mr. Okamoto, a successful businessman, donated a large amount of funds to establish the Morita Foundation to promote Morita Therapy. Mr. Okamoto, who suffered from severe neurosis due to a stressful life, which almost caused his death, tried various treatments and was finally cured by Morita Therapy. After recovery, he decided to spend his life promoting Morita Therapy, with his efforts reviving interest in Morita Therapy in Japan. Mr. Okamoto visited China many times and Morita Therapy became widely accepted by Chinese psychiatrists who found the philosophy of Lao Zhi in Morita Therapy, in addition to the spirit of Zen Buddhism. Also, an American psychologist studied Morita Therapy at Jikei University which remains a center of Morita Therapy research in Japan, and a few centers on Morita Therapy have been established in United States of America. The treatment strategy and systems of Morita Therapy have been changed to reflect the changing needs of society. Outpatient Morita Therapy has come to be more valued, as it is easily practiced at outpatients’ clinics. Several techniques have been developed to treat the depression, anxiety disorders and psychosomatic disorders. The focus of Morita Therapy has gradually shifted from inpatient treatment to outpatient treatment, with previous patients of Morita Therapy having formed a self-help group to support each other. The Japanese Society of Morita Therapy was established in 1983, and, in 1998, officially commenced the training program to accredit psychiatrists and mental health professionals to become Morita therapists. The society has over 500 members, publishes journals regularly and convenes annual scientific meetings and international symposiums [11] (Kitanishi & Azuma 2006).
2.6.9
NAIKAN THERAPY AT PRESENT
Naikan Therapy was studied by a group of Japanese psychiatrists with several modifications being made to apply the therapy in psychiatric settings. They are attempting to treat patients with addiction disorders and personality disorders using Naikan Therapy. However, the therapy is more commonly used in correctional settings for juvenile delinquents. It was also introduced to the United States of America by an American psychologist and is used more for the development of personality. Some point out the similarity of Naikan Therapy with psychoanalysis. Naikan Therapy can be considered as psychoanalysis with clear goals for social adaptation through the insight and respect to others. The Japanese Society of Naikan
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Therapy was established in 1978 and has over 500 members including psychiatrists, psychologists and professionals working at juvenile courts and other judicial institutions. The society also convenes annual meetings and publishes journals regularly [12] (Kitanishi 2007).
2.6.10
PSYCHIATRIC PRACTICE AND RELIGION
It is very rare for psychiatrists in Japan to ask patients about their religious beliefs, as they are considered a private matter or not so important. It is only during a very special occasion, such as a patient receiving terminal care, that a doctor will ask the religion of the patient. For the Japanese, religion is an integral part of daily practices rather than an ideological belief. Japanese people, who love to visit temples and shrines, take their children to Shinto shrines to thank and pray for healthy development, to get married in a church, and receive the Buddhist funeral ceremony at the end of life. Many houses used to have small shrines for their ancestors and small tables with Amida figures (Kami-dana). It is a part of life to provide water and flowers every morning to the family shrine. Although not believers of a particular religious faith, the Japanese practice spirituality in their everyday lives. When formally asked about their religious beliefs, the majority of Japanese would respond by saying ‘I have no particular religion’. It may depend on how to interpret religion to answer the question whether Japanese are very religious or not religious.
2.6.11
CONCLUSIONS
There are many differences and similarities between psychotherapies in the West and East. It will be important for both to study and gain inspiration from the differing approaches. Psychiatry means an art to care (iatre) of the mind (psycho). Cultural heritages of the East to care for the mind have not been given due attention for many decades after the introduction of psychiatry, though it has potential resources for sciences of the mind in the twenty-first century.
ACKNOWLEDGMENT The authors would like to express many thanks to Professor Glen Edwards for his valuable advice and extensive editorial works.
REFERENCES 1. Nakamura H (1970) Genshi Bukkyo (Original Buddhism). NHK Books, Tokyo (in Japanese). 2. Morita S (1998) Morita Therapy and the True Nature of Anxiety-Based Disorders (Shinkeishitsu). Translated by Akihisa Kondo and edited by Peg Le Vine. State University of New York Press, Albany, NY. 3. Yoshimoto I (1972) Naikan no hoho to jissen (The practice of Naikan). In: Okumura N, Sato K, Yamamoto H (eds.) Naikan Ryouho (Naikan Therapy). Igakushoin, Tokyo (in Japanese). 4. Kitanishi K (2005) The philosophical background of Morita Therapy. In: Tseng WS, Nishizono M, Chang SC (eds.) Asian Culture and Psychotherapy: Implications for East and West. University of Hawaii Press, Hawaii.
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5. Kawahara R (2005) Japanese Buddhist thought and Naikan Therapy. In: Tseng WS, Nishizono M, Chang SC (eds.) Asian Culture and Psychotherapy: Implications for East and West. University of Hawaii Press, Hawaii. 6. Morita S (1922/1974) Seishinryohou Kogi (Psychotherapy lecture). In: Kora T (ed.) Morita Shoma Zenshu dai 1 kan (Shoma Morita’s collection of essays Vol. 1). Hakuyohsa, Japan (in Japanese). 7. Morita S (1926/1974) Shinkeisuijaku oyobi Kyohakukanen no Konchiho (The Treatment of neurasthenia and obsession). In: Kora T (ed.) Morita Shoma Zenshu dai 2 kan (Shoma Morita’s collection of essays Vol. 2). Hakuyohsa, Japan (in Japanese). 8. Kawahara R (1998) Naikanho no tanjo to fukyuhattenn (The creation and development of Naikan Medication). In: Kawahara R (ed.) Naikanryouho no rinsho (Theory and practice of Naikan Psychotherapy). Shinkoigaku-shuppan, Japan (in Japanese). 9. Kitanishi K (1999) Toyotekitetugaku to Morita ryohou & Naikan ryohou (Asian Philosophy and Morita Therapy and Naikan Therapy). Seishin Igakushi Kenkyu 2, 60–65 (in Japanese). 10. Kitanishi K (2001) Gashu no byori (Pathology of Narcissism). Hakuyosha, Japan (in Japanese). 11. Kitanishi K, Azuma N (2005) Morita Therapy in Modern Times: Review from 1995 to 2004. International Journal of Counseling and Psychotherapy 3, 67–85. 12. Kitanishi K (2007) Philosophical, religious background of Japanese Psychotherapies. Paper presented at JSTP þ WPATPS þ WACP þ Joint Meeting in Kamakura April-2007, Shonan Village Center, pp. 27–29.
CHAPTER 2.7
Psychiatry and Theravada Buddhism Pichet Udomratn Professor of Psychiatry, Thailand
Buddha simply means ‘one who is awakened’. Gautam Buddha (Gautama Siddhartha) is the most famous awakened person but that does not mean that he is the only awakened person. There have been many Buddhas before him and there have been many Buddhas after him – and as long as every human being can become a Buddha, new Buddhas will go on springing up in the future. Everyone has the potentiality. . . . . . .it is only a matter of waiting for the right time. – (Quote from ‘Buddha: his life and teachings’ [2])
2.7.1
INTRODUCTION
Buddhism is not only one of the world’s oldest and most widespread religions; it is also one of the most popular ‘new religious movements’ [1]. It has over 400 million adherents and today there are Buddhists in almost every country in the world [2]. Buddhism first evolved in Asia in the plains around the River Ganges then travelled west to Afghanistan, north to Nepal and Tibet, east via the silk route to China, Korea, Taiwan, Vietnam and south to Sri Lanka – across the seas to many countries in Southeast Asia such as Thailand, Myanmar, Cambodia and Laos [3]. For two millennia Buddhism continued to steadily extend its influence. Then in the nineteenth and twentieth countries came mass migrations by sea and air. As Asians moved to the new worlds of opportunity they took with them their religion and Buddhism began to extend so far east that it became Western too, stretching across the Pacific and into the Americas. The fact that Buddhism can be presented as being in harmony with influential contemporary ideologies has undoubtedly aided its spread in the West [4]. Now, there are over a million Buddhists in Europe and approximately three million in the United States [1]. After the Buddha’s death there were numerous Buddhist communities, distinct in varying degrees from one another, dotting the Indian landscape. The Theravada became the dominant form of Buddhism in Sri Lanka, Thailand, Myanmar, Cambodia and Laos, while in the rest of Asia, the Buddha’s teachings developed further and eventually gave birth to two revolutionary developments within Buddhism. Emerging at the beginning of the first Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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millennium the first of these distinctly new directions known as the Mahayana spread to regions in northern India and beyond to Tibet, China, Korea, Japan and Vietnam. The other revolutionary form of Buddhism is know as Vajrayana, ‘the diamond (vajra) vehicle (yana)’, in reference to its claim to be in possession of practices that lead the practitioner to the indestructible (adamantine, or diamond-like) mind of a Buddha. The popularity of the Vajrayana is mainly found in those Tibetan communities that are now largely in exile in India, Europe, and North America where several varieties of Vajrayana have been preserved [5]. The map below depicts the areas in Asia where Theravada, Mahayana and Vajrayana Buddhism are predominant and in Table 2.7.1 comparing three vehicles of Buddhism.
Theravada Buddhism is the most well known form of Buddhism among Europeans, due to Europe’ s long history as a colonizing force in that part of the world. This is in contrast to the Americans who are more familiar with Mahayana than Theravada because of the United States wartime involvements with Japan, Korea and Vietnam [6]. Though the Theravada and Table 2.7.1
The three vehicles of Buddhism Color of the monks’ robes
Predominant in Asian countries areas
Sehools
Literally meaning
Theravada (other name – Hinayana) Mahayana
’teaching of the elders’ orange Cambodia, Laos, Myanmar, (Hinayana means Sri Lanka, Thailand ‘little vehicle’) ’great vehicle’ In Japanese Zen – China, Japan, Korea, tend to be black Vietnam, Tibet (In Tibet, it is often classified as a separate vehicle called Vajrayana) ’diamond vehicle’ In Tibetan Bhutan, Mongolia, parts of Vajrayana – Nepal, Sikkim, Tibet tend to be yellow
Vajrayana
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Table 2.7.2 List of some of the most common Pali terms and their cognate Sanskrit forms PALI
SANSKRIT
dhamma kamma nibbana sutta sunnata
dharma karma nirvana sutra sunyata
Mahayana forms of Buddhism sometimes appear outwardly vastly different, the two schools, however, agree on the main principles and the basics of the Buddha’s teaching are the same [7]. What differences do result are few and minor and easily traceable. In keeping with their traditional canonical and literary languages, Theravada and Mahayana Buddhist technical terms are written in their Pali and Sanskrit forms, respectively. For example, the Pali term nibbana is always used to refer to the Theravada notion of salvation, while the related Sanskrit term, nirvana is always used to refer to ultimate salvation as conceived within Mahayana Buddhism. In Table 2.7.2 above is a short list of some of the most common Pali terms used in this chapter and their cognate Sanskrit forms sometimes used as alternatives.
2.7.2
THE BUDDHA AND HIS TEACHING
The Buddha said, ‘I teach dukkha and the way out of dukhha’. Dukkha is a Pali word with no simple or convenient English equivalent, but it is often translated as ‘suffering’ and covers all the usual physical and mental problems that most people experience from time to time. It is ordinary, everyday suffering and quite easy to recognize [2]. The Buddha taught that birth is dukkha, sickness is dukkha, aging is dukkha, and death is dukkha. All the sorrow, grief and despair that everyone feels at some time is dukkha. The Buddha also taught that always wanting to be healthy brings dukkha, always wanting to be young and energetic brings dukkha and the fear of death brings dukkha. Attachment to the idea of a permanent entity, that is to say the idea of a ‘self’ or ego, brings dukkha. It is true that life contains many things that seems joyous and pleasurable, which contrasts to dukkha, but joyous and beautiful things are impermanent. Even happy experiences must change and eventually cease; leaving in their wake our desire to re-experience the same phenomena, or even to experience something better. Whatever it is that we as individuals find pleasurable or satisfying can really give no lasting satisfaction and will simply increase our craving or desire for more of the same. The Buddha said that he taught dukkha, but he also taught the way of liberation from dukkha, this has become known as ‘The Four Noble Truths’. The Four Noble Truths are: 1. There is dukkha. 2. Dukkha arises because of tanha (tanha means craving, greed, delusion, egoistic desire and attachment). 3. Dukkha ceases through the elimination of tanha. 4. The Noble Eightfold Path leads to the elimination of tanha, and hence to the cessation of dukkha.
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Buddha sometimes compared himself to a physician, and his diagnosis and prescription are set out much in the manner of a clinical assessment. The first Noble Truth examines the condition, the second explores its causes, the third concludes that a cure is possible, and the fourth prescribes the remedy. Unlike many modern doctors, the Buddha wasn’t primarily interested in surface symptoms. For the cure to be effective he believed it must work from the inside out and that the ‘patient’ must get at the underlying causes of their suffering and take responsibility for their recovery by adopting a new regime for daily life, a fundamental change in attitude and lifestyle [1]. ‘The Noble Eightfold Path’ is a set of techniques which can lead us directly to Nibbana or Nirvana. It is an insight, a wisdom into the true nature of all phenomena, of being able to see every thing and every condition as it actually is and, with this perfect understanding, to be able to totally eliminate tanha and hence dukkha. The eight aspects of the Path are: 1. Right Understanding or Right View; meaning acceptance of the Four Noble Truths. Not blind acceptance or a complete understanding, but rather receptiveness to the teachings and a willingness to examine them in the light of our own experience. 2. Right Thought or Right Resolve; meaning to make a serious commitment to develop the qualities of wisdom and compassion, together with a corresponding determination not to be distracted from the path. 3. Right Speech; telling the truth with sensitivity, speaking in a way which doesn’t hurt or divide others and avoiding gossip and idle chatter. 4. Right Action; abstinence from harmful behavior such as killing, stealing or abusing sensual pleasures. 5. Right Livelihood through not engaging in an occupation which causes hurt to others through the use of wrong speech or wrong action. 6. Right Effort by gaining control of one’s thoughts, restraining negative states of mind and replacing them with positive ones. 7. Right Mindfulness means cultivating constant awareness of one’s body, feelings, mental states and thoughts. 8. Right Meditation or Right Concentration while developing deep levels of calm and insight through various techniques which concentrate the mind and integrate the personality. The Three Characteristics of Existence (The Three Universal Characteristics) Anicca – ‘impermanence’. The Buddha taught that everything is subject to the Law of Cause and Effect: everything that comes into existence must eventually cease to exist. Everything is the creation of preceding causes and, in turn, is the cause of later effects. Everything exists only temporarily and there is nothing that has any permanence. Dukkha – ‘suffering’. Since everything is subject to continual change and decay, clinging to impermanent things or states can only give rise to dukkha of one kind or another, and to one degree or another. Anatta – ‘non Self’. The Buddha taught that since all things are impermanent there can be no permanent, unchanging or immortal entity which we can call a ‘self’ or ‘soul’. It is the deluded belief in a permanent self that causes attachment and craving and that it is these that
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lead to dukkha. Buddhism does not reject the ‘Relative Truth’ of the concept of ‘being’ – of course we all exist – but as a statement of ‘Ultimate Truth’ we have no ‘self’ and are merely a number of aggregates and mental formations dependent for their continuity on many other factors. The Four States of Consciousness: There are four qualities or States of Consciousness that the Buddha taught which should be cultivated. These qualities are often used as meditation subjects. In Pali they are metta (loving – kindness, or universal good will), karuna (compassion), mudita (sympathetic joy) and upekkha (equanimity). Metta is not just the development of warmth or love towards those people that we like, or who have what we personally think of as attractive qualities. It is the cultivation of the wish that all living beings should be happy and free of suffering, and that oneself the individual should be free of enmity and hatred. Karuna is the compassionate understanding of the plight and suffering of other living beings. It is not the same as sympathy or grief, but is a positive willingness and genuine desire to help others who may be in distress. Mudita is the genuine and spontaneous joy at others’ success or happiness. The development of mudita overcomes feelings of envy and jealousy. Upekkha is the ability to keep a composed mind in those situations when it is not possible to do or say anything constructive. Upekkha enables one to meet difficult situations without increasing the difficulty through anxiety or useless activity. The development of upekkha through meditation also greatly decreases our senseless worrying about matters over which we have no control. Kamma: The Buddha said: ‘All beings are the owners of their kamma, heirs of the kamma, born of their kamma, related to their kamma, supported by their kamma’. Kamma is intentional action, through body, speech or mind. It is both a natural law and a force. It is not the result of action, but only the action itself. Kamma may be good (wholesome) or bad (unwholesome) to varying degrees, or neutral. The result of the kamma will be good, bad or neutral accordingly. This is the Law of Cause and Effect, of action and reaction. Bodily kamma includes; for example, killing and stealing, or alternatively being helpful in practical ways to other people. Verbal kamma includes lying, gossiping, using abusive speech to others, or telling the truth. Mental kamma (always the forerunner to bodily and verbal kamma) includes trying to improve the mind through studying the Dhamma or practicing meditation, for example, and by not allowing bad or unwholesome thoughts to arise in the mind but instead to cultivate good or wholesome thoughts.
2.7.2.1
The Buddha’s meditation teaching
The Buddha’s main meditation teachings are contained in a discourse called ‘The Maha Satipatthana Sutta’ – ‘The Four Foundations of Mindfulness’.
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The Buddha said of this teaching: ‘This is the only way for the purification of beings, for the overcoming of sorrow and lamentation, for the destruction of suffering and grief, for reaching the right path, for the Realisation of Nibbana’. The discourse is divided into four parts (the Four Foundations): 1. Contemplation of the body: including mindfulness of breathing and bodily postures, paying full attention to physical activities, the internal physical make – up of the body, the material elements of the body, and the impermanence of the body. These should all be observed and known. 2. Contemplation of feelings: all feelings should be observed and known and how they arise and pass away whether they are pleasant, unpleasant or neutral. 3. Contemplation of the mind (or states of consciousness): the states felt by the mind should be observed and known as well as how such states arise and pass away. Lust, hatred, delusion, ignorance, distraction, the undeveloped mind, the concentrated mind etc. are all included here. 4. Contemplation of mental objects: this foundation is concerned with ethical and intellectual subjects, including the hindrances to mental development and spiritual progress, the factors which contribute directly towards Enlightenment, the factors which make up a ‘being, the external and internal sense bases, the Four Noble Truths and the Noble Eightfold Path’. There are two techniques of meditation practiced by Buddhist meditators: Samadhi and Vipassana.
Samadhi Samadhi is Concentration or Calmness or Samatha Meditation. It helps develop onepointedness of mind. The practice of Samadhi can lead to a very intense, trance-like ‘Absorption States’, in which the consciousness gradually transcends everyday reality to other levels or ‘spheres’. In this trance-like state the hindrances and impurities of the mind may seem to disappear, and the meditator may be deluded into sensations of great tranquility and happiness. In fact, the hindrances are merely suppressed, not eradicated, and Samadhi does not lead to the arising of wisdom insight. Except at the very lowest levels, the spheres are said to be difficult to attain. Samatha meditation is practiced only as an aid to Vipassana, and to increase concentration ability.
Vipassana Vipassana or Insight Meditation, uses the concentration built up from Samatha meditation to observe with bare awareness the constantly changing phenomena occurring within the practitioner’s body and mind. In Vipassana, the meditator ‘opens up’ to everything going on in the body and mind without deliberately trying to exclude or suppress any physical sensation, emotion or thought that arises, whether wholesome or unwholesome, pleasant or unpleasant, subtle or
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intense. All are simply observed, recognized and acknowledged as they arise and pass away. The meditator tries not to feel either aversion or attachment for them, but simply watches dispassionately and objectively with bare awareness. Whilst the meditator does not try to suppress the various phenomena, they are not dwelt upon or allowed to lead to discursive or judgmental thinking. Neither the past nor the future has any reality and the mind exists with just bare awareness only in the present moment, the here and now. It merely observes with equanimity.
2.7.3
BUDDHISM AND NEUROSCIENCE
The neuroscientist Francisco Varela, co-founder of the Mind and Life Institute, had a deep conviction that Buddhists, with their 2500-year history of introspective inquiry into the nature of the mind, had much to offer neuroscientists [8]. The two day meeting called ‘Investigating the Mind’ held at the Massachusetts Institute of Technology (MIT) in September 2003 brought both Buddhist monks and Western neuroscientists together to share their experiences of how the mind works and to collaborate on testing their insights gleaned from meditation. The collaboration between Buddhists and neuroscientists has borne the most fruit to date and in particular in the study of emotions. Buddhist meditation fosters ‘virtuous’ mental states that are said to promote well-being, such as compassion, joy and ‘loving kindness’. This is a different approach from Western psychology, which focuses mainly on anger, fear or depression. A growing number of Western researchers are investigating the potential of Buddhist meditation training to shift the brain into positive emotional states. At this MIT meeting, Richard Davidson from the University of Wisconsin reported his study on brain activity associated with positive emotions in Buddhist monks. Davidson and his colleagues found that a high ratio of activity in the left frontal areas when compared to the right marked either a fleeting positive mood or what Davidson called a positive ‘affective style’, which was the quality of mood that persisted over time. Subjects who were gripped in a negative mood or had generally negative affective styles, ranked lower on the left-to-right ratio. When researchers trigger negative emotion by showing subjects disturbing news photos, the negative emotions faded more quickly in subjects with more left frontal brain activity [9]. Before 1990, we could not determine exactly what was happening in the human brain during meditation as it is difficult to bring together individuals who were accomplished in meditation, in a high-tech laboratory equipped with functional MRI, EEG, EMG and PET trained technicians [10]. However, Buddhist meditative practices have recently received considerable attention for their potential phenomenological and epistemological contribution to cognitive science and as a context in which to investigate neural plasticity related to mental practice [11]. Lazar et al. [12] used functional MRI to identify the brain regions that respond and are active during a simple form of meditation and relaxation. Newberg and Iversen [13] have described two types of meditation: ‘The first type is one in which the subjects simply attempt to clear all thought from their sphere of attention and to reach a subjective state, characterized by a sense of no space, time and thought. This state is also fully integrated and unified, such that there is no sense of self and others. The second form of meditation involves focusing attention on a particular object,
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image, word, or phrase, which may lead to a subjective experience of absorption with the object of focus. In eight Tibetan Buddhist monks, voluntary meditation with sustained attention was initially accompanied by activation in bilateral, but right more than left, prefrontal cortex and cingulated gyrus. This was followed by activation of the inhibitory reticular nucleus of the thalamus, which in turn deaffarented the posterior temporo – occipital areas, minimising the cortical sensory input. The perception of one’s bodily self depends on the activation of posterior, superior parietal lobules. The hippocampus acts to modulate cortical arousal and responsiveness via connections with the prefrontal cortex, amygdala, and hypothalamus. These structures are involved in generating attention, emotion, and imagery’. ‘Activation of the right amygdala in stimulation of the hypothalamus, with subsequent stimulation of the parasympathetic system is associated with a sense of relaxation and profound quiescence, reducing both breathing and heart rates, which in turn, reduces activity of the locus ceruleus. Decreased NE from the locus ceruleus would decrease the stimulation of the hypothalamus; thus, decreasing the stress related production of CRH, ACTH, and cortisol. Argenine vasopressin (AVP) is known to be released during meditation and has been shown to contribute to the maintenance of positive affect, to decrease self-perceived fatigue and arousal, and to significantly improve the consolidation of new memories and learning. Activation of the prefrontal cortex increases the level of free glutamate in the brain, which can stimulate the hypothalamus to release beta-endorphins. Beta-endorphins are known to reduce pain and fear, and to produce a sense of joy and euphoria. Moderately increased levels of serotonin, during meditation, also appear to correlate with a positive affect’ [13].
Recently, a report from Pagnoni and Cekic [14] suggested that a long term effect of regular practice of Buddhist meditation may affect the normal age – related decline of cerebral gray matter volume and attentional performance. The effect of meditation on gray matter volume was most prominent in the putamen, a structure strongly implicated in attentional processing and linked to the well known psychiatric disorder, attention deficit hyperactivity disorder (ADHD) [15]. Buddhist meditation (especially Zen meditation) can be viewed as mirroring in reverse the characteristic deficits of ADHD. Therefore, the study of attention processes mobilized by meditation and their long-term effects could prove useful in clinical settings of psychiatry in the future. Although the evidence is quite sparse, and mainly related to Tibetan (Vajrayana) or Zen Buddhism more than Theravada Buddhism, nonetheless the basic principles of Buddha’s teaching are the same and Buddhists are keenly interested in scientific advances that can help explain their beliefs [16].
2.7.4
BUDDHISM AND PSYCHIATRY
The Tripitaka or the Pali Canon, the written scripture of the Buddha’s teaching, is a very rich resource of documentary evidence of how the Buddha viewed life including illness. There are two kinds of illness [17] as follows: 1. Physical Illness: the Buddha stated that all humans and animals are but companions of birth, aging, sickness and death. No one can escape death. 2. Mental/Spiritual Illness: lack of mindfulness, not seeing one’s own thoughts, e.g. engulfed by sorrow can lead to mental disturbances or nervous breakdown.
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There was a tragic story of ‘Patacara’ who lost her whole family within one single day. Her husband was bitten by a cobra, then her infant was snatched by an eagle while another son drowned in a fast flowing river and finally her parents and her brother died in a fire. She became insane and wandered around town naked. One day she found herself in a hall where the Buddha was preaching. When the Buddha greeted her, ‘May mindfulness be with you, sister’, she came back to herself and was quite ashamed of being naked and immediately asked for some clothes to wear [17]. It seemed that at that time mental illness and spiritual illness were lumped together. However, nowadays we know more about the biological and psychological factors of mental illness, that leads some academics such as Professor Dr. Prawase Wasi [18] to differentiate spiritual illness from mental illness. Spiritual illness is referred to as the state of suffering because of tanha (craving, greed, egoistic desire and attachment) which can be cured by Dhamma (the teachings of the Buddha), while mental illness should be treated by psychotropic drugs and psychological treatments [18]. However, the late Venerable Buddhadasa Bhikkhu one of UNESCO’s list of great international personalities [19] considered Dhamma as a medicine for treating all kind of illnesses. He said ‘Actually, Dhamma is a medicine to cure both bodily and mental illness . . . . Almost all kinds of bodily disorder are caused by the lack of Dhamma. Now let us consider the most widespread diseases at present . . . stomach disorders and neurosis . . . result from decreased blood supply to the organ . . . When we are upset, angry or worried the blood supply going to our stomach will be reduced . . . A person of sound mind will naturally have a good digestive system . . . Dhamma can serve as a medicine that both prevents and heals’ [19]. So, Dhamma in Buddhism and psychiatric treatment aims to help people to have better lives. There are many Buddhist principles that could be applied with patients to improve their mental health such as, believing in the law of kamma, the virtue of forgiveness and the essence of life. Psychiatrists who treat Buddhist patients should learn techniques of applying Dhamma to help their patients [20]. However, there is some difference in views relating to the theory and practice between Buddhism and psychiatry. For example, psychiatry guides psychiatrists to identify the defects and deficiencies of their patients while following the Buddha teaching, Buddhists will focus on their own self, not on others [20]. Therefore, Professor Somporn Bussaratid – a senior Thai psychiatrist, recommended that his colleagues and trainees should introspect themselves as well as practice Buddhist meditation so that their minds will attain the peaceful states which are desirable for the psychiatric practice [20]. In this chapter, I will focus on the contribution of Buddhist teaching to clinical psychiatry in three areas i.e. psychotherapy, the Buddhist twelve steps in the group process for treatment of alcohol and drug addiction and finally a Buddhist approach to suicide prevention.
2.7.5
BUDDHISM AND PSYCHOTHERAPY
According to Shigehiro, there is a theoretical problem that is common to both Buddhism and psychotherapy; that of how to understand the nature of the self and of the mind in relation to suffering in Buddhism, and the various clinical pathologies in psychotherapy [21]. Each school has its own distinct theory of human nature and methods of practice. Thus, despite the
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identification of a common base of problems and claims concerning universal theories of truth, the different schools in each field have difficulty agreeing about the specifics of the problems, general theories and methods of liberation or cure. However, Thanaphum and Suvansuthi [22] viewed that psychotherapy conjoined with Buddhist practice is much more useful for the patients in comparison to those receiving only psychotherapy. Psychotherapy is a psychological treatment for correcting abnormal feeling, thought, affect and/or behavior of the patient. Through a close and continuous relationship, the therapist helps the patient to understand his problem. The cause of the problem is in oneself and in the environment. The therapist helps the patient to accept and improve himself, to learn appropriate means in solving life problems and to repeat the practice of what he has gained from therapy. The patient eventually can self help and lead a happy life. The psychotherapy principle is based on psychological theories. Buddhist practice is the practice in which one follows the teaching of Buddha. Buddha’ s teaching consists of the belief in the law of cause and effect, ‘kamma’ and the result of ‘kamma’, good deeds followed by good effect and bad deeds by bad effect. The person leads his life following the principle of Buddha’s teaching. This is done through continuous selfinspecting, not being careless, checking our actions in doing, speaking and thinking, stopping bad deeds and doing only good ones. Conjoined psychotherapy and Buddhist practice in helping psychiatric patients consists of the conduct of contemporary psychotherapeutic intervention and the integration of Buddhist teaching principle into the guidelines and practice in the patient’s problem-solving approach. Both psychotherapy and Buddhist practice are similar since both follow the law of cause and effect. The therapist advises the patient to self-inspect regularly; try not to act, speak and think badly; attempt to perform good deeds and be reasonable. The patient practices meditation in order to keep the mind calm and stable. He/she learns to forgive those to whom he/she relates and this frees him/her from receiving the effects from his/her bad actions. These make the patient have more faith in Buddhism and more belief in ‘kamma’ [22]. To illustrate how to use the Buddhist concept and Buddhist practice in the treatment of patients, let us read the following case vignette which is a summary from a case report of Prof. Chamlong Disayavanish – a well known Thai psychiatrist [23].
CASE VIGNETTE An adult Thai male patient came to the clinic because of a fear of sharp objects, especially knives, and he avoided them feeling that otherwise something bad would happen to him. Treatment by psychotherapy revealed the reason for his fear. His parents died when he was a small child and his aunt took care of him afterwards but treated him unfairly. He had to quit studying at university, as his aunt did not support him. However, with his great capabilities he was able to run a small business which at last earned him a lot of money. During this period, his aunt’s family was facing a serious financial problem and she asked him for help. Although he assisted her as much as he could, his aunt still requested money from him again and again. He was very angry but could not say anything. His destructive feelings and impulses toward her were repressed to the point that he was not aware of them. After Prof. Disayavanish C gave an active interpretation in the early phase of treatment, the patient began to understand that his phobia stemmed from his aggressive feelings toward his aunt. This unconscious aggressive drive also reactivated his childhood conflicts, creating a great deal of
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anxiety, which was then displaced by the object phobia as mentioned. In spite of his insight into the unconscious conflicts, the intensity of the patient’s phobia did not seem to decrease. He admitted that he was unable to give up his anger and resentment towards his aunt. At this point, Prof. Disayavanish C brought the subject of non-attachment and ‘non-Self’ (anatta), especially regarding – forgiveness, to the patient for consideration. He was also recommended to read Buddhist books on this concept. In the next two sessions he was able to master his negative feelings toward his aunt. He also showed the ability to forgive and feel mercy for her. Through his understanding of non-attachment and ‘non-Self’ he was able to erase pain, anger and retaliatory impulses and replace them with attempts to understand, to see events/things/situations in perspective and thus to feel love, kindness and compassion for her. He began to realize that it was a waste of time to ruminate on his unfortunate childhood and bitter past experience, Shortly after, his phobia symptoms disappeared [23].
In Buddhism, there is a word called sunnata (or in Sanskrit, sunyata) which means the total absence of any object. When the mind is not grasping or clinging to anything whatsoever (as ‘I’ or ‘mine’), it is in a state of emptiness. The mind is then an empty or void mind of emptiness, in the sense of being void of content. All objects are there as usual and the taking processes are going on as usual, but they are not going the way of attachment and clinging with the idea of ‘I’ and ‘mine’. The mind is in a state of non-attachment, ‘nonSelf’ and emptiness which Buddhadasa Bhikkhu called in Thai ‘chit wang’ [24]. According to Prof. Disayavanish C, the concept of non-attachment and emptiness or chit wang should be incorporated into the therapeutic process of Western psychotherapy [23]. Recently, Dr. Likitlersuang proposed the name ‘Wisdom Psychotherapy’ or Psychotherapy in Buddha – Dhamma for the psychotherapeutic treatment which incorporates the core teachings of Buddhism [25]. According to him, Wisdom Psychotherapy can be divided into three levels with each level composed of aspects from ‘The Noble Eightfold Path’ (see Table 2.7.3). However, Dr. Likitlersuang has only reported his idea of this technique after reviewing extensively the Buddha – Dhamma but has not yet reported applying this form of therapy in treatment of patients [25]. In recent years therapists from various clinical orientations have been utilizing the teaching of Buddha to help depressed patients challenge their depressive stance. This so called ‘mindfulness based procedures’ is found in the form of mindfulness – based cognitive Table 2.7.3
Three levels of wisdom psychotherapy [25]
Level 1: Psycho-behavior therapy or training of morality which is composed of * Right Speech * Right Action * Right Livelihood Level 2: Mind therapy or training of concentration which is composed of * Right Effort * Right Mindfulness * Right Concentration Level 3: Wisdom therapy or training of wisdom which is composed of * Right View * Right Thought
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therapy [26, 27] and mindfulness based hypnotherapy [28]. Buddha attributed human suffering to the tendency to cling to thoughts, feelings, and ingrained perceptions of reality and habitual ways of acting in the world. When mindful, one’s attention is not entangled in the past or in the future, and one is not judging or rejecting what is occurring at the moment. One becomes the present and this kind of attention can generate energy, clean-headedness and joy [29]. Depressed patients are encouraged to read books about different cultures and to begin to appreciate what they have. Patients are also provided with a culture–neutral explanation highlighting some of the general differences between Western and non-Western societies in terms of culture, beliefs, values and models of mind. It is expected that such understanding will help the patient to re-examine his meaning of life and appreciate that success and failure are culturally determined [30].
2.7.6
THE BUDDHIST TWELVE STEPS
In the 1950s, clinicians at Wilmur State Hospital in Minnesota developed a treatment program for alcoholism built on a synthesis of the medical model and the experiences of individuals recovering from alcohol dependence using the 12 step principles of Alcoholic Anonymous (AA). The 12 steps was so popular and widely adopted by others that when Dr. Saengcharnchai from Thailand went to the U.S. during 2001–2002, he was very impressed with them. After returning to his hospital in Bangkok, he later developed the Buddhist Twelve Steps by retaining the important substances of the original one and adding the Buddhist self-development principles [31]. Details of the Buddhist Twelve Steps are listed in Table 2.7.4. According to Dr. Saengcharnchai, by using the Buddhist Twelve Steps with other components of rehabilitation, the so called ‘bio-psychosocial-spirituality rehabilitation’ Table 2.7.4
The Buddhist twelve steps [31]
1. I admit my addictive craving over alcohol and drugs, and I cannot take care of myself and my family. 2. I trust and believe that wisdom can lead me to sanity. 3. I wish to have, as my supporter, the Nobel Eightfold Path which is the path to wisdom. 4. I try to understand the Noble Eightfold Path consisting of right view, right thought, right speech, right action, right livelihood, right effort, right mindfulness and right concentration. 5. I admit to myself and my beloved ones about my wrong bodily, verbal and mind actions. 6. I am entirely ready to practice the Noble Eightfold Path. 7. I practice the Noble Eightfold Path every day. 8. I make a list of all persons whom I have harmed and who have harmed me. I really mean to ask for and give forgiveness. 9. With the wisdom leading, I ask for and give forgiveness to such people where possible. 10. I continually practice the Noble Eightfold Path and when I act bad bodily, verbally and through mind actions I promptly admit it and amend it. 11. I try to practice right view, right thought, right speech, right action, right livelihood, right effort, right mindfulness and right concentration so as to obtain wisdom. 12. Having gained wisdom, knowledge and understanding and having quit alcohol and drugs, I will share my knowledge, my understanding and the practice principles to other addicts.
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model at the Phramongkutklao (PMK) Army Hospital or in short, the PMK model, the non-relapsing rate of alcohol and drug addicts within six months were 75.3% and within twelve months were 57.1%. However, further study with the control group was recommended [31].
2.7.7
BUDDHIST APPROACH TO SUICIDE PREVENTION
In Buddhism, suicide is a form of suffering, its origin must derive from craving or desire (tanha). Craving is divided into three types, namely: 1) craving for sensual pleasure (kamatanha); 2) craving for existence (bhava-tanha); and 3) craving for non-existence (vibhavatanha) [32]. The third type of craving may be accompanied by the wrong view, which holds that ‘nothing remains after death; there is complete annihilation of life’ [33]. In Sanskrit, the meaning of vibhava-tanha also includes ‘craving for power’ which is the power to control or even to destroy other people and oneself. In other words, some people believe that suicide is the final solution or the end of all suffering. Thus, a suicidal impulse can be considered as a type of craving for non-existence and suicide can be the outcome of any type of craving [34]. Recently, Prof. Disayavanish C and Prof. Disayavanish P [34] have proposed integrating the relevant doctrines of the Buddha in various aspects of suicide prevention measures such as the Buddhist attitude toward suicide, providing monks with knowledge and understanding about suicide, practice of meditation, etc. In terms of meditation, the loving–kindness (metta) meditation, which is a form of concentration meditation is recommended. As suicide patients tend to act out suicidal fantasies because of a loss of love objects or a narcisistic injury, they may experience overwhelming affects like rage and guilt or identify with a suicide victim. Practicing loving–kindness meditation both to themselves and others will counteract the destructive effects of introjected aggressive impulses and will control anger or aggressive defilement (dosa) which is closely associated with suicide. Another form of mediation, insight meditation, will also help to purify the mind of defilements and help to create will power, increase self confidence and self esteem. According to authors, Buddhist meditation not only promotes mental health but it is also an effective means for the primary prevention of suicide [34].
2.7.8
CONCLUSION
About 20 years ago there was a debate between ‘brainless’ psychiatry and ‘mindless’ psychiatry [35]. But the contributions of Buddhism to psychiatry is both ‘brain-ness’ and ‘mind-ness’. As neuroscientists now learn more and more about neural process in the brain of people with extensive training in Buddhist meditation, we anticipate that the advance of science could at last explain why Buddhists believe that meditation literally transforms their mind. Then Buddhist meditation will perhaps be one of the standard complimentary and alternative treatments in the field of psychiatry. Now, at the new millennium, no one doubts that Buddhism in general – including Theravada Buddhism – is growing in the knowledge area of psychiatry. Many mental health workers and psychiatrists have tried to adapt Dhamma into various forms of psychological treatment [36]. The Buddhist styles of meditation, both calmness and concentration
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meditation, are recommended to suitable patients. But the question is: Will Buddhism continue to contribute more and more to psychiatry? As far as individuals are concerned, however, the process can occur within a single lifetime. We can graft onto our day-to-day existence the sweetness of the Dhamma, learn to live with mindfulness and focus in the present. In the words of the Lord Buddha: Do not chase after the past Or pin your hopes on the future What is past has gone behind, And the future has yet to arrive. . .. . .. If you live with your whole heart From morning to night Then you have truly had an auspicious day.
(Quote from ‘Essential Buddhism. A Complete Guide to Beliefs and Practices’ by Maguire J, 2001)
REFERENCES 1. Morris T (2006) What Do Buddhists Believe? Granta Books, London. 2. Osho (2007) Buddha. His Life and Teachings. lvy Press, East Sussex. 3. Udomratn P (2008) Mental health and Buddhism in Southeast Asia with a focus in Thailand. Abstract Book of the 27th Annual meeting of the Japanese Society of Social Psychiatry, held at International Convention Center, Fukuoka, Japan, during 28–29 February 2008. 4. Keown D (2000) Buddhism: A Very Short Introduction. Oxford University Press, Oxford. 5. Wallis G (2007) Basic Teachings of the Buddha. Modern Library, New York. 6. Maguire J (2001) Essential Buddhism. A Complete Guide to Beliefs and Practices. Pocket Books, New York. 7. Pannapadipo PP (2000) One Step at a Time: Buddhist Meditation for Absolute Beginners. Post Books, Bangkok. 8. Barinaga M (2003) Studying the well-trained mind. Science 302, 44–46. 9. Davidson RJ, Scherer KR, Goldsmith HH (2003). Handbook of Affective Sciences. Oxford University Press, Oxford. 10. Deshmukh VD (2006) Neuroscience of meditation. Scientific World Journal 6, 278–289. 11. Lutz A, Greischar LL, Rawlings NB et al. (2004) Long-term meditations self- induce highamplitude gamma synchrony during mental practice. Proceedings of the National Academy of Science of the United States of America 101, 16369–16373. 12. Lazar SW, Bush G, Gollub R et al. (2000) Functional brain mapping of the relaxation response and meditation. NeuroReport 11, 1581–1585. 13. Newberg AB, Iversen J (2003) The neural basis of the complex mental task of meditation: neurotransmitter and neurochemical considerations. Medical Hypotheses 61, 282–291. 14. Pagnoni G, Cekic M (2007) Age effects on gray matter volume and attentional performance in Zen meditation. Neurobiology of Aging 28, 1623–1627. 15. Konrad K, Neufang S, Hanisch C et al. (2006) Dysfunctional attentional networks in children with attention deficit/hyperactivity disorder: evidence from an event – related functional magnetic resonance imaging study. Biological Psychiatry 59, 643–651. 16. Knight J (2004) Religion and science: Buddhism on the brain. Nature 432, 670. 17. Tanphichitr K (2006) Buddhism Answers Life. 4th edn. Kled Thai, Bangkok.
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18. Wasi P (1981) Record of a Thai Medicine. P. Sampanpanich Publishing, Bangkok. 19. Koffman JP, Liamsiriwattana T (2006) Practical Buddhism: The Legacy of Buddhadasa Bhikkhu. Amarin Printing, Bangkok. 20. Bussaratid S (1981) The psychiatrists and Buddhism. Journal of the Psychiatric Association of Thailand 26, 21–26. 21. Shigehiro T (2006) Transcendence and immanence: Buddhism and psychotherapy in Japan. In: Unno M (ed.) Buddhism and Psychotherapy Across Cultures. Wisdom Publication, Boston, pp. 105–118. 22. Thanaphum S, Suvansuthi R (1990) Conjoined psychotherapy and Buddhist practice in treatment of psychiatric patient: a report of two cases. Journal of the Psychiatric Association of Thailand 35, 83–91. 23. Disayavanish C (1979) Contribution of the Buddhist teaching to psychotherapy. Journal of the Psychiatric Association of Thailand 24, 100–106. 24. Jackson PA (2003) Buddhadasa: Theravada Buddhism and Modernist Reform in Thailand. Silkworm Books, Chiang Mai. 25. Likitlersuang P (2005) Wisdom psychotherapy – psychotherapy in Buddha – Dhamma. Journal of the Psychiatric Association of Thailand 50, 127–132. 26. Ma S, Teasdale J (2004) Mindfulness – based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology 72, 31–40. 27. Segal ZV, Williams JMG, Teasdale JD (2002) Mindfulness – Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse. Guilford Press, New York. 28. Lynn SJ, Das LS, Hallquist MN et al. (2006) Mindfulness, acceptance and hypnosis: cognitive and clinical perspectives. International Journal of Clinical and Experimental Hypnosis 54, 143–166. 29. Germer CK (2005) Mindfulnees: What is it? Does it matter? In: Germer CK, Siegal RD & Fulton PR (eds.) Mindfulness and Psychotherapy. Guildford Press, New York, pp. 3–27. 30. Alladin A (2007) Handbook of Cognitive Hypnotherapy for Depression: An Evidence-Based Approach. Lippincott Williams & Wilkins, Philadelphia. 31. Saengcharnchai P (2005) The Buddhist Twelve Steps and Phramongkutklao Model. Journal of the Office of the Narcotics Control Board 21, 37–45. 32. Gunaratana BH (2001) Eight Mindful Steps to Happiness: Walking the Buddha’s Path. Wisdom Publication, Boston. 33. Phradhammapidok (PA Payutto) (1995) Buddha-dhamma, 6th edn. Mahachulalongkornvidhayalai Printing Press, Bangkok. 34. Disayavanish C, Disayavanish P (2007) A Buddhist approach to suicide prevention. Journal of the Medical Association of Thailand 90, 1680–1688. 35. Lipowski ZJ (1989) Psychiatry: mindless or brainless, both or neither? Canadian Journal of Psychiatry 34, 249–254. 36. Udomratn P (2007) Buddhism and psychiatry in Thailand. Journal of the Psychiatric Association of Thailand 52, 335–336.
Part 3 Core Issues: Religion and Psychopathology INTRODUCTION Psychopathology could be called the core business of psychiatry. All psychiatrists would probably agree with such a statement. The challenge of general psychopathology is to describe, define, differentiate, conceptualize and clarify the diverse phenomena of psychiatric disorders. Interestingly, this psychopathology is not something that can be canonized. On the contrary, there is a continual necessity to rethink how we as psychiatrists and scientists accomplish the complex task of general psychopathology. What could probably be the place of religion and spirituality within this realm? ‘Understanding and explanation’ refer to Karl Jaspers’ terms and to the ‘Methodenstreit’ between the human and the natural sciences, so characteristic of the psychiatric enterprise. The dominance of ‘causal explanation’ over ‘meaningful understanding’, of form over content is troublesome. And in clinical practice this leads to an eclecticism, which has detrimental effects. A too narrow conception of psychopathology, only concerned with objective facts, excludes the all too subjective existential layer. Religious and spiritual aspects influence the way symptoms are experienced and expressed. Conceptual elimination of religious and spiritual aspects may ultimately lead psychiatrists to lose their patients, because the patients do not feel understood. Eclecticism inevitably leads to neglect and ignorance of, difficult to understand, nevertheless human phenomena. It is here that we bump against another, a rather practical boundary. All authors in this third part proceed according to a far more fundamental method. That is what we can learn to do as well, learning to use appropriate methods and research instruments. Underneath symptoms there are not only cognitive-behavioral patterns, interpersonal or psychodynamic conflicts. A deeper, ultimate concern is involved. Religious and spiritual issues and their dynamics are interwoven with the process of symptom formation. The last chapter of this Third Part is an important contribution about measurement and assessment of religious and spiritual variables.
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3.1 Religious Experience and Psychopathology Juan J. Lo´pez-Ibor Jr. & Marı´a Ine´s Lo´pez-Ibor Alcocer 3.2 God’s Champions and Adversaries: About the Borders between Normal and Abnormal Religiosity Herman M. van Praag 3.3 Religion and Psychopathology: Psychosis and Depression Andrew C. P. Sims 3.4 Obsessive Compulsive Disorder and Religion: A Reconnaissance Harold J. G. M. van Megen, Dianne A. den Boer-Wolters & Peter J. Verhagen 3.5 Religion and Psychoanalysis: Past and Present Allan M. Josephson, Armand Nicholi Jr. & Allan Tasman 3.6 On the Psychology of Religious Fundamentalism John, Lord Alderdice 3.7 Measurement at the Interface of Psychiatry and Religion: Issues and Existing Measures Peter C. Hill & Carissa Dwiwardani
CHAPTER 3.1
Religious Experience and Psychopathology Juan J. Lo´pez-Ibor Jr. and Marı´a In es Lo´pez-Ibor Alcocer Professors of Psychiatry, Spain
3.1.1
INTRODUCTION
Even though medicine and psychopathology, on the one hand, and theology on the other, deal with fundamental aspects of the human condition, they are separated from each other for methodological and ideological reasons. Very often, from the psychiatric perspective, religious phenomena have been considered in a one-dimensional and too superficial way, often considering them just as symptoms of a major psychiatric disease or traits of an insufficiently developed personality. Therefore it is not surprising how little future physicians are taught to explore the religiosity of their patients. Although the fact is that religiosity can be an important factor in clinical decisions and religious perspectives, for many individuals, it is one of the most relevant aspects of values attached to clinical circumstances.
3.1.2
PHILOSOPHY AND PSYCHIATRY
Psychiatry needs philosophy because mental patients are confronted with philosophical problems: For instance, delusions in patients suffering from schizophrenia are the result of concerns about the sense of life and the raison d’^etre of nature. The Spanish psychiatrist Sarro´ [1] for many years studied the theme of delusions, mainly in patients with paraphrenia, and came to the conclusion that they corresponded with the themes of myths in ancient cultures. He coined the term mythologems to described such themes (initially 12 but the number increased slowly to up almost 100) which were the expression of the answers that we human beings give to the mysteries or enigmas of nature. Examples of mythologems are fantastic genealogies, such as when a patient believes he belongs to a royal family, or like a patient we had, who believed they were the descendant of a long genealogy of stars starting
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright 2010 John Wiley & Sons, Ltd
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with Antares and followed by Anteritis, and so on; the creation and destruction of the world, such as when a patient keeps his fist closed all the time because if he opens it, the world will disappear, a delusion reminiscent of the myth of Atlas holding up the globe of the world; the fight between good and evil, in which the patient may be the protagonist; immortality as in the delire d’immortalite of Cotard; the ourobouros, the androgynus and so on. Other patients also have philosophical concerns: those suffering from depression, with the meaning of loss and death, neurotic personalities with an exaggerated sense of their own existence, psychopaths with social order, and so on. The problem with patients is that they reach solutions that are candid and subjective. In the words of Bilz [2] patients take the pars pro toto (a part for the whole), a phenomenon also analyzed in the stereotyped movements of patients with schizophrenia [3] and by Fuchs [4, 5] in body dysmorphic disordesr, characterized by a disturbance in the relation to others manifested by an inability to take a meta-perspective. As a consequence, the thoughts of the melancholic patients are centered on suicide, of those with schizophrenia on a delusional interpretation of reality, of those who are neurotic on inhibitions and of psychopaths on nothing but their impulses. The philosopher and the sane person, on the contrary, seek the sense of all of that is beyond concrete circumstances. In his Anthropology the philosopher Immanuel Kant [6] devotes several pages to madness (Verr€ ucktheit) and its different forms. The common thread to all of them is ‘the loss of common sense’ (sensus communis), when somebody’s ‘stream of thoughts follows its own rule, which is contrary to that that conforms to the laws of experience’. Similarly he describes someone who is ‘dull’ (Schwach) as lacking intelligence which is the ‘faculty for discovering the universal from the particular’.
3.1.3
DEMONIAC ILLNESSES
The history of medicine is the history of natural explanations to phenomena considered up to the moment as supernatural. About 2000 years ago Hippocrates, father of medicine, defended what we nowadays call epilepsy or still hi€era nosos (Greek), morbus sacer (Latin) or morbus demoniacus (the demonic sickness), was but an illness not more nor less sacred than others. The quote of Hippocrates [7] still merits attention: It is thus with regard to the disease called Sacred: it appears to me to be nowise more divine nor more sacred than other diseases, but has a natural cause from the originates like other affections. Men regard its nature and cause as divine from ignorance and wonder, because it is not at all like to other diseases. And this notion of its divinity is kept up by their inability to comprehend it, and the simplicity of the mode by which it is cured, for men are freed from it by purifications and incantations. But if it is reckoned divine because it is wonderful, instead of one there are many diseases which would be sacred; for, as I will show, there are others no less wonderful and prodigious, which nobody imagines to be sacred. The quotidian, tertian, and quartan fevers, seem to me no less sacred and divine in their origin than this disease, although they are not reckoned so wonderful. (. . .) Such persons, then, using the divinity as a pretext and screen of their own inability to of their own inability to afford any assistance, have given out that the disease is sacred, adding suitable reasons for this opinion, they have instituted a mode of treatment which is safe for themselves, namely, by applying purifications and incantations, and enforcing abstinence from baths and many articles of food which are unwholesome to men in diseases.
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This brings with it the notion that all natural illnesses may also have something supernatural, that is to say, a meaning beyond the merely biological, which is what humanism brings into medicine. In spite of this, for centuries the names given to this illness in medical terminology and in the vernacular throughout the various historical epochs are an indication of the believed relationship between epilepsy and the supernatural: the holy illness, morbus divinus (the divine), morbus deificus (created by God), morbus coelestis (the heavenly illness), morbus astralis (the stars illness) and morbus lunaticus (the moon induced illness). In Germany in the Middle Ages, a large number of colloquial expressions for epilepsy illustrate the influence of supernatural and divine forces and ‘the falling sickness’: Zuchtrute Christi (rod of Christ), Gewalt Gottes (power of God), schedelnde (sch€uttelnde) Gottesstraf (shaking punishment from God). Even the term ‘Gichterle’, used to describe epileptic fits suffered by small children, which is still a very common expression in Southern Germany, refers to the supposed supernatural (albeit demonic rather than divine) cause of the illness: ‘gichtige Krankheit’ (‘Gichterle is a diminutive of this term) means something like ‘illness passed on through witchcraft and magic’. According to popular Christian piety in the Middle Ages, God had both the power to inflict epilepsy on people (as punishment, penitence or test) and to liberate them from it. Thus, relief from this illness was more likely to be obtained from God, rather than from a physician, and from Christian faith, rather than from medicine. In addition to Christ himself, saints were also frequently called upon to assist in combating the ‘falling illness’. In Hagiotherapy (‘treatment with the sacred and with saints’) there were qualified ‘epilepsy specialists’, the most important of whom – in the German-speaking world – was Saint Valentine, who has remained so until today. The Valentine patronage of epilepsy is probably attributable to the name of the saint: ‘Valentine’ has a phonetic similarity (albeit no etymological relationship) with the German word ‘fallen’ (to fall): Valentine ¼ ‘fall-nethin!’ (don’t fall down!), is a popular wish for people prone to fits. The sentence ‘He must be having a Valentine’s day today’ is still used in the vernacular nowadays to refer to a person who has dropped something for the umpteenth time. For the linguistic reasons mentioned, it is understandable that in countries with a Christian tradition, in which German is not spoken by the majority of the population, Saint Valentine scarcely played a role as patron of the falling sickness. In France, for example, Saint John was an important helper in the fight against epilepsy (mal de Saint Jean), and in AngloSaxon countries, especially in Catholic Ireland, it was Saint Paul (Saint Paul’s disease). In India, ill people frequently call upon the powerful god Shiva, who can bring and send away illnesses. In ancient India ‘apasm^ara’ was an evil epilepsy god. In the ancient Indian medical Caraka script (6th century AD), the name of this demon is used synonymously with the illness ‘epilepsy’. Four ‘apasm^ara’ variations’ (four different types of epilepsy) with varying symptoms were described, and the dancing god Shiva can help to relieve all of them. The Aztec goddess Tlazolteotl was also able to bring about epilepsy or to spare people from it. By penetrating human beings, she could send them into convulsions.
3.1.4
WITCHCRAFT AND MENTAL ILLNESS
In the sixteenth century, a time when central Europe reached its peak in burning witches at the stake, Johannes Weyer (or Wier) [8] said that these were but ‘poor melancholic women’.
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I have therefore chosen to present this story in order that they [those who object to my work] and all others may look upon such tricks with a clearer mental vision and not allow themselves so rashly to be deceived by this illusion, this clouding of their eyes. I do so in order that they may not remain like blind moles in the filth thrust upon them by the demon, but that they may rather allow the cloudy spots or the film to be cleared from their pupils by a physician who offers this salve free of charge to all who wish their eyes to be clear and free of the spirit that dims them.
Already before Weyer, the inquisitor Alonso de Frı´as ended the pursuit of witches in Spain during the second process of the Spanish Inquisition, claiming they were just ill people [9]. Stories of slaughtering children and macabre witches’ Sabbath ceremonies began to spread at the beginning of the year 1610. The inquisitor Juan Valle Alvarado in Zugaramurdi (in Navarre, north of Spain) received many charges based on these stories. With the help of Alonso Becerra Holguı´n and Alonso Salazar Frı´as he promulgated a sentence of 53 condemnations, 11 of them to be burnt at the stake. Five of the death penalties were executed. However, Alonso de Salazar y Frı´as, gave a special vote and obtained authorization to review the process. He examined 1384 children and 420 adults, he collected the potions and gave them to animals in order to find out if they were lethal, he planted secretaries of the court in the places where the Sabbaths were celebrated to verify if indeed they met on the dates of their demonic parties, he even ordered that supposedly offended young girls were subjected to medical examination. The results proved the harmlessness of the potions, the solitude of the places and the virginity of the women. Moreover, he concluded that the declarations at the court were the product of suggestion and that therefore they lacked evidence. Salazar de Frı´as prepared a long report that he sent to the Supreme Inquisitorial Council after which, on March 26, 1611, an edict of pardon was announced by Decree. Juan de Mongasto´n gave an extremely detailed report of this court procedure [10].
3.1.5 PSYCHOPATHOLOGY AND SUPERNATURAL PHENOMENA Science in general and psychopathology in particular, have given greater and greater consideration to natural phenomena as the most important part of supernatural subject matters. The end point of this process is the rejection of religiosity, which if it remains, is only as an expression of a human necessity. In the words of Si Dieu n’existait pas, il faudrait l’inventer. Mais toute la nature nous crie qu’il existe (‘If God did not exist, it would be necessary to invent him. But all nature cries aloud that he does exist’) [11] and Freud is believed to have shown how this invention became possible, based on the similarity of religiosity and the scruples of obsessive neurosis. Obsessive neurosis was for Freud a form of individual religiosity and religiosity, a collective obsessive neurosis. In both cases the origins are the scruples, a defensive psychological mechanism that aims to control anxiety, individual in the first case, collective in the other. For Freud and many others, religion is a metaphor of mental illness [12]. However, this approach fails due to its reductionism. Scruples of conscience of obsessive neurotics are the expression of a subjective morality, that gives priority to the cleanliness of a person’s own conscience. This is the antithesis of religious phenomena which always transcend the individual. Again, we have the pars pro toto phenomenon.
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A similar circumstance is the case of those who suffer scruples of cleanliness, who may even not wash themselves fearing to get dirty, ending up suffering from a notorious lack of personal hygiene. In both cases obsessive rituals serve only a limited goal and are the expressions of a behavior pattern more likely of a magic spell than of a real search for perfection. Clinical psychiatry and the rest of medicine are loaded with religious phenomena and experiences. In neurosis there is a lack of sense of one’s own existence. To Jung, neurosis ‘must be understood, ultimately, as the suffering of a soul which has not discovered its meaning’ [13]. Similarly, in depression the problem of death recurs once and again, but schizophrenia is the ‘religious’ illness par excellence. The delusional schizophrenic patient creates fantastic worlds, full of symbols and new meanings which in some cases become striking apocalyptic visions. So much so that frequently it has been considered that shamans and visionaries from other cultures would have been diagnosed with schizophrenia in our culture. For the physician these religious phenomena are nothing but symptoms, that is to say, signals of an underlying pathology whose significance the physician is unable to explain. It has also been stated that people with schizophrenia are but failed genius in a society that does not tolerate their revelations and needs the complicity of psychiatrists to silence them. Last but not least, the physician has to face up constantly to what has been called the scandals of pain and death.
3.1.6
DELUSION AND RELIGIOUS EXPERIENCE
In this context it is clearly shown how coarse it is to compare delusional ideas of patients suffering from schizophrenia, for example, with mystic or religious revelations, however apocalyptic or innovative they may be. Delusional ideas are individual and therefore frustrated truths. They start and end at the delusional person; they are not oriented towards somebody else. Patients with schizophrenia never share their delusions and hardly ever their worries. Their isolation comprises not only the world of the sane but also of their kind. Delusions are the replacement of common sense by a very private sense and a way to fulfil the need to communicate of every human being. Phenomenological and existentialist influenced psychiatry has described how delusional ideas consist of the desire to control one’s own world, idios kosmos, or the common world, koinos kosmos [14]. Each one of us is in two worlds at the same time, the one of common reality and one’s own in which fantasy, dreams or simple longings and hopes reign. The sane person is able to distinguish one from another, and even to pass from one to another even when doubts about that radical ambiguity of our consciousness assault him or her. In delusions everything is different. Not able to live in a koinos kosmos, the patient substitutes and misappropriates the idios kosmos in such a way so as to not be able to distinguish what is what. All this is carried out accompanied by a deep sense of drama hard to perceive during a superficial treat that only states social withdrawal or a state of emotional dullness, but that can be seen in pictorial productions, in some psychological tests or in a deeper relationship. The brilliant, innovative man, creator of new worlds feeds in an idios kosmos, but immediately communicates it, drags others to participate in it and recognize in themselves the creating force. Truth with capital letters, enriching as a contrast to the private truth of the delusional individual that is but the dramatic effort to reach a truth illness denies.
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3.1.7
CORE ISSUES: RELIGION AND PSYCHOPATHOLOGY
THE PROBLEM OF TRUTH IN PSYCHIATRY
Truth and falseness are a core aspect of psychiatry, but psychiatry sometimes forgets the problem of truth [15]. Let’s start with a common example. One of my first patients was a middle aged German psychiatrist who suffered from schizophrenia. His voices were very painful as they ordered him to have intercourse with his father when visiting him at the hospital and acts of a similar nature. As I tried to reassure him saying that the voices were just irritations of his brain cortex due to his illness, he answered: ‘I see that you are still young in the profession, patients with schizophrenia patients say that they hear voices, but mine are true’. ¨ ber die Wahrheit (On the Truth) and made outstanding Heinroth [16] wrote in 1824 U distinctions on the subjective versus the objective truth and on the behavior of human beings towards the truth versus the behavior of the truth towards human beings. Since then very little has been published on the subject, in spite of the fact that delusions are commonly conceived as false beliefs.
3.1.7.1
Conventional definitions of delusions
In DSM-IV [17] a delusion is defined as: ‘A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everybody else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person’s culture or subculture (e.g., it is not an article of religious faith)’. The origins of this definition can be traced to over two hundred years ago: ‘Error in the ability to judge, fantasise without fever or disturbance of the consciousness’ [18], ‘false and pathological ideas’ [19]. During the nineteenth century in France these definitions were elaborated into: ‘A delusion is a false idea, of pathological origin, highly resistant to logical arguments and which alters the judgement of reality’. The outcome of this perspective was interest in the content, in the themes of delusions leading to an endless list of delusions (reference, influence, persecution, control, jealousy, erotic, guilt, ruin, nihilistic, hypochondriac, grandiosity, messianic, induced, etc.). Karl Jaspers [20] investigated these definitions and established three main criteria for a belief to be considered delusional: certainty (held with absolute conviction), incorrigibility (not changeable by compelling counterargument or proof to the contrary) and impossibility or falsity of content (implausible, bizarre or patently untrue). In spite of the fact that all the characteristics mentioned have been criticized, the approach to define delusions just described has survived for centuries and is accepted as standard teaching all over the world. There are two reasons for this. The first one is very pragmatic, and has to do with the value that they have for diagnosis in everyday clinical practice. It follows that they are also useful for ancillary purposes such as management, communication with other physicians and for forensic issues. The second reason is more subtle, psychiatrists are able to recognize in an immediate way delusional phenomena, but they need a structure of thinking, a frame, on which to phrase their clinical intuitions [21]. The role of intuition for the diagnosis of schizophrenia was described several decades ago under the name of ‘Praecoxgef € uhl’ [22], literarily, the feeling of schizophrenia. The fact that a psychiatric diagnosis is not an exclusive rational endeavor was also underlined by the term ‘Gef € uhlsdiagnose’ [23], affective diagnosis, to be carried out at an emotional level.
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This approach allows grasping the expressivity and depth of the person before any analytical desegregation in parts and symptoms. It is a diagnosis not through the feelings but with the feelings. The above mentioned definitions have often been criticized, Schneider being the first one to do so in depth [24]: Falseness is relative and an accessory (individual and cultural aspects); pathological origin is a vicious circle argumentation; absolute evidence and incorrigibility. There are errors more obstinate than delusions [25].
3.1.7.2
The falseness and impossibility of delusions
Delusions do not necessarily have to be false or ‘incorrect inferences about external reality’. Some religious or spiritual beliefs (such as ‘I believe in the existence of God’) by their nature may not be falsifiable, and hence cannot be described as false or incorrect, no matter whether the person holding these beliefs has been diagnosed as delusional or not [26]. In other situations the delusion may turn out to be true belief [27]. For example, delusional jealousy may result in the faithful partner being driven to infidelity by the constant and unreasonable strain put on them by their delusional spouse. In this case the delusion does not cease to be a delusion because the content later turns out to be true. In other cases, the delusion may be assumed to be false by a doctor or psychiatrist assessing the belief, because it seems to be unlikely, bizarre or held with excessive conviction. Psychiatrists rarely have the time or resources to check the validity of a person’s claims, leading to some true beliefs to be erroneously classified as delusional [28]. This is known as the Martha Mitchell effect, after the wife of the attorney general who alleged that illegal activity was taking place in the White House. At the time her claims were thought to be signs of mental illness, and only after the Watergate scandal broke was she proved right (and hence sane). Another difficulty with the diagnosis of delusions is that almost all of these features can be found in ‘normal’ beliefs. Many religious beliefs hold exactly the same features, yet are not universally considered delusional. According to Thomas Kuhn scientists can hold strong beliefs in scientific theories despite considerable apparent discrepancies with experimental evidence [29]. These factors have led people to note that ‘there is no acceptable (rather than accepted) definition of a delusion’ [30].
3.1.7.3
The structure of delusions
According to Gruhle [31] if the content can not help to distinguish delusions from everyday beliefs, the answer is to be found in the structure of thinking while deluding. He came to the conclusion that what characterizes delusions is that an abnormal meaning is given to an up to then normal perception. Although many different sorts of delusions have been described, all are either delusional perceptions or delusional intuitions [22]. Perception is the process that allows people to interpret and to organize sensations in order to generate an experience of the world, where the individual can safely live and survive. This experience is both meaningful and emotionally loaded, because both aspects are an essential component of the world for each of us. Delusions are perceptions without a motive [30], implicating that there is no understandable connection between the perceived reality and the meaning accorded to it. The abnormality in the attribution of meaning was considered as a lack of
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Sinnges€ atzlichkeit (lit., absence of sense of legitimization), what in essence was a form of recognizing Jaspers’ incomprehensibility [32]. In delusional perception he described two arms of perception: 1) The object is perceived and 2) The meaning is attached to the object. In delusions, the meaning, often self referred, is imposed by the object (the meaning is in the object, that’s why it cannot be discussed). Schneiders’ goal in these descriptions was basically diagnostic. For instance he was much against considering first rank symptoms, that is to say, symptoms leading, in the absence of a brain disturbance, to the diagnosis of what I call schizophrenia, as primary symptoms (basic symptoms from which others can emerge). Hillman [33] in a deep analysis of Freud’s Schreber case reaches the conclusion that the process of thought in delusion is not different from the normal process of thinking. The delusional individual builds his world and fills it with meaning the same way as the ordinary person does. The difference is in the individual who is delusional. In the same way Ey [34] commented as a conclusion of his monumental work ‘Les hallucinations’ that the hallucination does not exist, only the person hallucinating.
3.1.7.4
The Many Meanings of Truth
Truth is not a univocal concept. For our purposes let’s take only two of them. For the philosopher Ferrater Mora [35] there are two concepts of truth: 1) truth as opposed to error (2 þ 2 ¼ 5 is not true because it is an error); and 2) truth as opposed to illusory (the moon is populated by selenites is not true because it is unreal). Furthermore, there are important cultural aspects of truth. In the Old Testament and in the Semitic tradition truth is the acquiescance to God’s will, which is typified by the word amen. In Ancient Rome the concept depended on verification, true is what is real, and the word that represents it is veracity. In all these distinctions the attitude toward truth, already considered by Heinroth, is present. The most accepted concept of truth is the one put forward by Aristotle in his Metaphysics. It is so alive that attempts to rethink modern logical questions with Aristotle’s eyes can be accepted as valid [36]. From the Greek philosopher’s perspective, truth is a matter of being isomorphic (concordant) with the external world. The origin of the correspondence theory is that it is a theory on which the truth of an assertion consists in its correspondence to reality. ‘To say of what is that it is not, or of what is not that it is, is false, while to say of what is that it is, and of what is not that it is not, is true’. Aristotle also added that ‘Falsehood and truth are not in objects . . . but in Logos’. Although Logos is often translated by thought or reason, it actually means thought and speech. Intellectus ex sua natura est locuturus (Thought is by its own nature speech) [37]. Therefore, if delusions are thought disorders, they are also disorders of communication and delusions and hallucinations have more in common than usually accepted, as we will see later. For Heidegger [38] there a concept of truth which is older and lies beneath the Aristotelian one. It is truth as aletheia, a term used by pre-Socratic philosophers with the meaning of revelation. Aletheia (alh qeia) means ‘the state of not being hidden; the state of being evident’, in short ‘disclosedness’ from lethe (lh qh) ‘forgetfulness’, ‘concealment’. The fact is that truth is hidden and needs to be manifested as expressed in the aphorism of Heraclitus [39]: ‘Nature likes to hide’ is sometimes translated as ‘Nature hides zealously its secrets’. From then on Heidegger identifies truth with the freedom not to interfere, not to impose, the freedom of letting things (and human beings) be what they are, in a process that occurs in
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an interpersonal relation. That is why thinking and saying go together as in the word logos. Therefore, the falseness of the delusion is at the same time a lack of freedom and a lack of communication. Truth, freedom and love are notions that go together. On this line, Blankenburg [40] has studied the writings of a patient which were very similar to poems of Rilke and raised the question of the difference between them. The conclusion is that the difference is not in the poems themselves but in the attitude of the authors. The patient may abandon, throw away or use the piece of paper to wrap something in, while Rilke collects the poems with others and brings them to his publishers so that others may read them. In clinical settings truth is not a fact but a process which reaches the point where the truth of the patient and the truth of the doctor coincide [41]. Heidegger’s points of view have, although on very different levels, striking similarities with psychoanalysis. The process of reaching truth, of recovering memories, of giving them a meaning, of incorporating them in one’s own biography, as in Freud’s expression was Es war soll Ich werden (the Id should be replaced b y the Ego) [42] is a process of revelation which occurs in the doctor-patient (or analyst-client) relationship. Here the first principle lies in transference-countertransference, the second in not interfering with the patient’s autonomy [43]. The issue of truth in psychoanalysis has been raised by Lorenzer [44], who asks himself if psychoanalysis can discover the truth getting to know concrete persons?, following Feuerbach’s notion: the nature of human being is no abstractum inherent to each individual. In its reality it is the ensemble of social circumstances. For Lorenzer, the question of truth is the key problem of the theories of knowledge and of political theories (is psychoanalysis going to break the traditional stability of society?). There are strong, although unrecognized, Hebraic roots in Heidegger’s propositions [45]. For instance, the poet in the German philosopher’s writings, is the one who discovers and manifests the truth, he is a creator (poet derives from the Ancient Greek poiesis, ‘creation’). This is exactly what the prophet does for the group of faithful, recreating for them truth hidden in the sacred texts. In a similar way Bakan [46] has found non explicit connections between Freud’s writings and the mystic Jewish tradition and Lo´pez Ibor with Gnostic beliefs and perspectives [47]. Popper [48] has identified the three principles for the search of truth: 1) The principle of fallibility (maybe I am wrong and maybe you are right but, of course, we may both be mistaken); 2) The principle of rational dialogue (we want to critically prove our reasons in favor and against our theories. This critical attitude to which we are obliged to adhere, is part of our intellectual responsibility) and 3) The principle of approach to the truth with the help of the debate (we can almost always approach truth with the help of impersonal critical and objective discussions, and like this we can almost always improve our understanding, even in those cases where we do not reach an agreement. We need others to discover and correct our errors and above all, we need people educated with different ideas, in a different cultural background. Like that we achieve tolerance).
3.1.7.5
Recent perspectives on delusions
As we see, falseness is not a valid criterion as a delusion can be true and still be a delusion. In order to avoid this problem DSM-IV-TR introduces a caveat, ‘delusions persist despite the evidence to the contrary and these beliefs are not ordinarily accepted by other members of the person’s culture or subculture’. But delusions are not beliefs [49] and therefore, it is
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necessary to look for definitions based either on the structure of delusions or on the process of becoming deluded and not merely on the content of delusional phenomena. More recently, delusions have been characterized not by the falsity of their contents, nor by their abnormal structure, but by the attitude of the person towards the perceived reality (Hillma, 1987; Stephens and Graham 2004). For Sass and Parnas [50] delusions are characterized by two complementary distortions of the act of awareness: exaggerated self-consciousness in which aspects of oneself are experienced as akin to external objects (hyperreflexivity) and a weakened sense of existing as a vital and self-coinciding source of awareness and action (diminished self-affection or self-presence). These characteristics are present across positive, negative and disorganization symptoms and are the expression of the distortions of consciousness and the sense of self that are present in delusional activity. Let’s suppose the case of a person with a delusion of jealousy: a man thinks without any reason that his wife is being unfaithful to him with another man and as a result of this conviction he starts to keep watch on his spouse and to interrogate her repeatedly and to seek time and time again for proof of her perfidy. Taking into account the classical definition of delusion as a false idea the cure of the delusion would be very simple. In the words of De Clerambault: ‘plu´t au ciel, Monsieur, qu’il suffise d’etre cocu, pour n’^etre point malade!’ (God’s will, Sir, that it would be enough to be a deceived husband, not to be ill) [51]. If not, it would be enough to tell the wife to really deceive her husband and then, since the infidelity now is real, the feelings of jealousness would not be delusional anymore. Leaving aside this grotesque advice, it happens that it does not work. From time to time, a woman who is being extremely harassed by a jealous husband may confess what she has not done only to put an end to her husband’s delusional pestering. When this happens the delusion does not disappear, it becomes even larger and possibilities for treatment decrease. The delusional idea does not have to be false and a normal structure does not guarantee that all our ideas are correct. John Nash, was asked by one of his colleagues how such an intelligent man like him could have been able to think during the moments he had delusions, that the inhabitants of the moon and the communists were all against him. He answered: The ideas I had about supernatural beings came to me the same way that my mathematical ideas did. So I took them seriously [52]. He also analyzed the mathematical thinking of his great colleagues at Princeton and he reached the conclusion that the mathematical ideas and intuitions of his colleagues had, on many occasions, the same structure as his own delusional ideas [53]. The discovery of truth and freedom are linked together and are part of a very religious discourse: I am the truth and the life; when two of you are talking about me I am there in the middle; truth will make you free, are sentences found in the New Testament.
3.1.7.6
Personal concerns of clinicians and researchers
On the other hand, it is clear that every scientist has deep personal concerns over these basic questions to which I am referring, as many of them have recognized when undergoing the discipline of a strict methodology which is, above all, the safeguarding of errors and absolutism. When Kuhn [54] mentions that the problem of truth is of no interest for science but only for distorted propositions, that is to say they can be refuted since they are only provisional, he is describing an attitude from scientists that does imply a search for the truth, in the sense I referred to above and the ascertainment that it is an unlimited process. In this
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sense the personal relationship of the scientist with truth is uneven. Freud was a radical agnostic as can be deduced from his autobiography and from the testimonies his disciples have revealed. Moving away from this perspective it is possible to say that science does not exist in a world of values, it is possible for the psychopathologist to find enriching perspectives in religious texts, which is the contrary to despising them as metaphors of an illness. In my understanding, science is part of a certain sense of transcendence that is sometimes mistaken with an ideal of material well-being and technical progress or, in more pessimistic times like nowadays, of technical resources to solve the problems raised by technique.
3.1.8
PSYCHOPATHOLOGY OF BEAUTY AND GOODNESS
Science in general and pathology in particular have developed eluding, when not denying, basic questions, that is to say what refers to truth, goodness and beauty and their opposites. However, these questions come to the surface time and time again in clinical practice. Here are some examples. The first one is the body dysmorphic disorder where patients seek plastic surgery for the correction of a supposed deformity that has become a stigma whose presence is feared for what it can reveal about them. In a certain way it is more an ethical problem than an aesthetic one, or better said, physiognomic, in the sense of physiognomy, as the revelation of a hidden essence [55]. These patients remind us of the Greek ideal of goodness linked to beauty, both inseparable, of a beauty that is so because it reveals the best of the individual. This disorder is also known as the Thersites complex [56], because this minor character of the Iliad, described as lame and deformed, as well as wicked and evil.
3.1.8.1
The cosmetic of the personality
Cosmetic or palliative pharmacotherapy is to use a psychotropic agent to make a person who is not ill feel better. It usually intends to mitigate unwanted or unaccepted psychological traits in order to attain a higher order of social normality and acceptability. The issue was raised by Kamer [57] who described how fluoxetine used for the treatment of depression and for other psychiatric disorders was able to eradicate some personality traits also present. He looked at traits previously considered as an expression of human miseries or, in some cases, as the consequence of negative childhood experiences. Kamer even questions whether there could be a ‘pandemic’ of cosmetic psychopharmacology which would lead to the disappearance of phenomena, such as anguish, which are essential for personal realization in the arts, religion, and creativity. Cosmetic and plastic surgery is most often than not carried out in people who do not fulfil criteria for any disease. The interventions in this area are not always necessary from the clinical point of view. But in the case of some psychiatric disorders the situation is different. The fact is that people without a recognizable disease can benefit from a psychotropic drug. Fluoxetine can make non depressed people feel more vital, mentally more alert and therefore more popular, leading to an increased feeling of wellness; shyness became a treatable illness when paroxetine was introduced to treat social phobia and atomoxetine can change the life conditions of adults with a history of Attention Deficit Disorder with
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Hyperactivity. Subthreshold depression or personality disorders are not just ‘non disorders’. The first are a consequence of modern diagnostic criteria and, taking into account that they represent a risk of developing ‘clinical depression’, it seems wise to provide these people with antidepressant treatments. The relief of depressed mood makes the person feel better and the reduction of anhedonia makes him or her enjoy life more, even if those symptoms were present in a subthreshold intensity. The case of personality disorders is similar. Those are not just variants of the personality; they are ‘real disorders’ which may benefit from antidepressants or other treatments. All this may lead to a change in diagnostic habits, lowering thresholds or modifying diagnostic criteria. For instance, the DSM criteria of suffering or disablement are value loaded, and new values, such as well-being may be introduced. But in other cases it may be different. Recently, there has been news on ‘doping’ by musicians, actors and politicians who use betablockers to fight stage fear as a substitute for alcohol, following a paper in The Lancet [58]. Doping is banned in sports, but not in performing arts or activities. Although, we are not dealing with recreational uses, as these drugs have no effects on normal psychological conditions, the issue is, if the role of physicians is only to take care of a patient what is wrong with them asking themselves how they could improve things for a patient. The words of Plato in Gorgias [59] are worth remembering: Beneath medicine, therefore, as I’m saying, lies the flattery of cookery; and beneath gymnastic, according to this same manner, lies cosmetic, in that evildoing, deceitful, ignoble, and unfree, deceiving with shapes, colours, smoothness, and garments, so as to make them, as they take upon themselves an alien beauty, neglect their own beauty that comes through gymnastic.
The problem of good and evil does not exist in science, not even in one such as anthropology, since, in a certain way, the less rational aspects of human beings have been recovered through the modern notion of human nature. Freud observed that human beings always knew they had consciousness, but that his own task consisted in demonstrating that there were also basements in the house. The eagerness was to recover them, in accordance with the expression wo es war, soll ich werden (‘where Id was, Ego should to be’) [60]. The goal of psychoanalysis is to convert neurotic symptoms into common human miseries, that is to say, into conscious ones. According to Lillian-Robinson [61] there is an overlapping between the concepts of neurosis and sin, in the same way that there are philosophical concepts like the fall (Verfallenheit in Heidegger) which refer to the risks that assault us; ‘ab inferos’ which individuals and the species strive to overcome time and time again.
3.1.9
THE MEANING OF ILLNESSES
The person who falls ill is normally confronted with two strangers: death and their own body. We experience our body (body experience or corporality) that has up to then been silent or as a mere presence, since we only get to know our body when we demand too much (tiredness) or when during illness its functions fail. Outside this we perceive the world and our activity in it, but not our organs and limbs that perform these activities. Also, patients are
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faced many times with personal truths denied up to then. Each time more and more illnesses are known that develop from damaging behaviors which, however, are most common (overeating and drinking, dependencies, that is to say, slaveries to an endless number of substances or to certain activities, like gambling or even working). Businessmen, slave to the demands of their performance and efficacy, who are admitted to a coronary unit due to an acute heart attack, are faced with a truth up to then denied, ‘arrogantly denied’ and known by everybody, with the threat of needing to undergo a drastic change in their lives, without knowing how. This arrogant denial is the nucleus of the concept of madness in Classical Greece, the one that lead Oedipus to blind himself when he finally recognized himself as the parricide of Laius [62]. It has been said that a mute medicine was born with Hippocrates, a medicine full of facts and data and but not of words. However, since the end of the nineteenth century, especially after the first works of Freud, the word has been recovered for medicine. Ana O. referred to Breuer’s method of treatment as the talking cure [63]. This process is a deeper process than is usually admitted. In this sense, medicine, which I will call anthropological to simplify (the one that incorporates those concepts to which I am referring to), is a link between those sciences whose vision of nature is unilateral, despite their technical efficacy and philosophy and theology. The perspective of sciences is one-dimensional. This is why Marcusse [64] could refer to modern man with that same expression. In my opinion, deep down sciences come from the secularization of the gnostic thought, which is above all dualistic. Cartesian dualism, the differentiation of the res cogitans from the res extensa expresses a way to think of old tradition. From a methodological point of view and also from a technical one dualism is efficient, from there its success and the impressive scientific heritage accumulated by Western culture since the beginning of Modern Age [65]. This perspective is unidimensional and therefore not free from risks, from there comes the crisis of Western thought whose peak occurred after World War II.
3.1.10
DEEP PSYCHOLOGY
Parting from these facts, some psychotherapists have recognized that deep psychology moves in a religious field which is not the same one as religion, or that both of them share the same spirit of surmounting, of coming back to the roots and of seeking for the truth to which I referred before. Fromm refers to a common nucleus in the ideas, norms and teachings of Lao-Tse, Buda, the Prophets of the Old Testament, Socrates, Jesus, Spinoza and the philosophy of the Age of Enlightenment. The religious perspective refers to another world, while psychiatry and medicine in general refer to facts from this world. The promised liberation is therefore more risky for medicine since it has to take place here and now. Disappointment and a negative social attitude emerge easily against this liberation when it does not fulfil the promises or expectations it has created among the population. It is the so called medical nemesis [66]. However this dichotomy is not correct. Christianity is not a religion of two worlds, of a celestial Jerusalem and another earthly one. This is precisely what appears in some schizophrenic delusions to which I referred before, but to a Reign of God which is already in this world. This, of course, is very well known by theologians and mystics and Saint Teresa [67] expressed it precisely: Entended que, si es en la cocina, entre los pucheros anda el Sen˜or (‘please understand that, if in the kitchen, God is among the stew pots’). This explains the great analogies that exist in language between health and
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going to heaven safely and the way in which a physician has a somewhat religious role and the pastoral somewhat healing role. Once medicine has recovered the word, the differences between both of them are even less. Out of the religious and psychopathological phenomena that raise more questions in common, anxiety is to be highlighted, without doubt because it is the basic radical of human existence. Theology, on the one hand, and deep psychology on the other, move around in a common terrain: deep human worries. Nevertheless and in spite of their commonality and of the help they can render one each other for research purposes they should not be confused. Psychopathological phenomena are not religious, nor the religious ones metaphors of mental illness. Religiosity always implies a transcendence of individuality and some forms of truth and freedom that can only be established apart from an interpersonal relationship. Mental disorder, on the contrary, always implies a difficulty in communicating, a predominance of one’s own world at the expense of a personal relationship. From this perspective, pastoral and medical help and even more the help of the psychotherapist have something in common, which is to give sense to the life of an individual, to establish ways of communication and to help the patient recover that relationship. But, insisting that religiosity remains a symptom of mental disorder is an attitude as archaic as the one that tried to explain mental illnesses as punishments of one or another divinity.
3.1.11
RELIGION AND SPECIFIC MENTAL DISORDERS
Sociocultural influences, including religion, have been designed to play a significant role in the aetiopathogenesis, course, treatment and prevention of some mental disorders, but the literature on religion is very scarce. We will follow the relationship between some specific disorders and religious matters.
3.1.11.1
Eating disorders
Examples of self-starvation are present in the Hellenistic era, although religion and eating disorders have been connected, most notably through descriptions of fasting saints, who expressed their spirituality through an extreme control of their bodies, including abstinence from food. ‘Holy anorexics’ [68] abused their bodies, rejected marriage and sought religious asylum where many perished and became saints. This has been described as ‘spiritual starvation’. One of the best examples is the case of the saint known as Wilgefortis, Uncumber (in England), K€ ummernis (Germanic lands), Liberata (in Italy and France) and Librada (in Spain). The cult of this saint became very popular in the fifteenth century, and was based on an old legend dating from the eighth or ninth century. The legend takes place in North Portugal and there are several versions of it. Essentially Librada was a Christian adolescent, one of nine sisters sometimes said to have been born from the same delivery. Her father, a noble Roman had promised her to an Islamic king, something that she refused. Other versions tell about the pagan king’s intentions to rape her. The young girl decided to suppress the feminine forms of her body by fasting, in order not to sexually attract men. She was extremely successful because not only did she lose weight and shape, but hair grew
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all over her body. The name Wilgefortis has been considered a contraction of the Latin virgo fortis [69], the strong virgin, though here the legend merges with another one, the Volto Santo of Lucca figure of Christ on the Cross, represented bearded and dressed in a full-length tunic like a woman, which lead to consider the figure as a representation of a woman. That is why the name Wilgefortis is also considered as deriving from the Old German ‘heilige Vartez’ (‘holy face’), a translation of the Italian ‘Volto Santo’. The name Liberata or Librada, is due to the fact that God was so impressed with her behavior that He decided to liberate her from her last female attribute, her menstrual periods. From then on, she became the patron of suffering spouses who wanted to be liberated (‘disencumbered’) from their abusive husbands. From the twelfth to the seventeenth centuries, the number of female saints increased dramatically. The Catholic Church recognizes 261 holy women as saints, blessed, venerable or servants of God. Many of these women lived extremely ascetic lives. Asceticism was the way for those women to attain perfection spiritually through complete self-discipline, which resulted in independence from physical needs. Renunciation of the body symbolized the life-aim of ascetics in the Church, the Imitatio Christi: suffering like the Christ [70]. One such saint, Catherine of Siena, led a life of extraordinary asceticism. Catherine abused herself from a young age through self-flagellation. However, the most prominent feature of her asceticism was her self-starvation. Catherine took a vow of virginity in her youth, began her fasting at home, and later moved to a monastery where she became a nun. Catherine regarded her inability to eat both as a punishment from God for her sins, and the means for their expiation. Although her body was emaciated, Catherine frequently displayed the hyperactivity that is commonly experienced by anorexics. Clinicians have noticed the ascetic aspects of adolescents since Anna Freud. Selfdiscipline and denial is an important adaptive resource to defend against hedonistic tendencies, but also to establish mastery over life. Then the practice of strict self-denial is considered as a measure of personal and spiritual discipline, but on the contrary, other authors considered that ascetism may be used as a justification for continuing an eating disorder [71]. Ascetism and intellectualization are the two basic defence mechanisms present in anorexia nervosa. Intellectualization leads to a life style contrasting with the traditional role of the Neolithic mother and housewife. The poet Octavio Paz [72] wrote a beautiful biography of Sor Juana Ines de la Cruz, a Spanish poet living in Mexico during the seventeenth century. She described her as a highly gifted adolescent who enjoyed participating in cultural gatherings at the Mexican salons with aristocrats, artists and high rank priests. Her religious clothes protected her from men’s assails and permitted her to be present at such get-together parties. A study which compared 34 anorexics and two control groups of non-organically ill, nonpsychotic female psychiatric patients found that two MMPI items discriminated between the groups [73]. The anorexics responded significantly more frequently in the affirmative to the items ‘I read in the Bible several times each week’, and ‘I pray several times every day’. The authors did not speculate about these interesting findings in their discussion of the results. As there is currently limited information on the prevalence of eating disorders among religious subcultures as well as meanings attributed to anorexia by anorexics, it remains an open area of potentially important research. Other authors have found a positive relationship between eating disorders and religion, with eating disorders being most prevalent among Catholics and Jews [74]. One aspect of
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religion, that has prorogued anxiety in individuals with eating concerns, is religious activities involving food. Some patients had altered religious practices including avoidance of Holy Communion, resulting in patients feeling extremely guilty [75]. A more recent study [76] found that women who are involved in religion for extrinsic reasons (for personal and social gains and acceptance) tend to be more susceptible to bulimia. The fact that the explanatory model of anorexia fails to recognize sufficiently the ‘culturebound’ and moral aspects of the syndrome implies that potentially important patterns have become irrelevant in the diagnosis process and in the management and treatment of the patients. It must be recognized that there are complex interactions among religious faith and the pathogenesis of anorexia nervosa which can be very relevant for the clinical management of patients. In some of the cases, religious beliefs provide a containment of maladaptive behaviors, through prayer and through a sense of belonging to the religious community. In other cases, the relationship is more profound and it may be difficult to separate the concept of a punitive God from the illness process [77]. There has always been a strong association between eating or refraining to do so and moral value.s Mass media, in particular advertisements and the internet, commonly use religious and moralistic themes in connection with eating and in promoting modern-day ‘nutritional’ consumerism and fundamentalism (diet, discipline and discipleship) by using words such as ‘temptation’, ‘decadent’, ‘heaven’ and ‘purity’ [78]. Currently, patients with anorexia nervosa frequently become chronic with multiple relapses and there is as yet no effective treatment. Cultural factors are not yet understood and may play an important role in the ethiopathogenesis of this disorder.
3.1.11.2
Affective disorders
Religion’s relationship to mental health has historically been questioned as though it were either positive or negative [12, 41, 60]. Now it seems clear that the more appropriate question is which aspects of religious functioning have positive or negative relationships with aspects of mental health. Some studies have found that religious people are less likely to divorce, use less alcohol and drugs, have more access to social support, experience less depression and anxiety, and are less likely to commit suicide. If religious beliefs and practices improve coping, reduce stress, prevent or facilitate the resolution of depression, improve social support, promote healthy behaviors, and prevent alcohol and drug abuse, then a plausible mechanism exists by which physical health may be affected [79]. Positive religious coping strategies include searching for spiritual purification, looking for a new religious direction, providing spiritual support for others, whereas negative religious coping strategies include feeling dissatisfied, attributing the stressor to the devil, interpersonal conflicts, religious doubts, or perceived failures of faith, guilt associated with failures of virtue, fears and condemnation [80]. The relationship between spirituality and mental illness has been less consistent, with some studies showing decreased odds of mental illness and depressions [81]. A large sample found that people considering themselves as spiritual were less likely to have attempted suicide, and among the general population religious attendance of at least once per year is associated with decreased suicide attempts, and this relationship persists even after the influence of social support is removed [82].
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Posttraumatic stress disorder
Contemporary approaches to trauma research have further broadened conceptualizations of outcome by identifying perceived benefits such as positive changes in self-perception and relationships with others. The identification of factors that may contribute to resilience or positive functioning should be taken into consideration in trauma research. One area of functioning that has been implicated as both a means of coping and outcome of traumatic events is religious functioning. The September 11, 2001 terrorist attack triggered a widespread increase in attendance in religious services and practices. This disaster reaction has to be considered as a coping behavior different from other clinical responses [83]. A recent study found a positive relationship between religious functioning, posttraumatic growth and PTSD symptoms, and that may be useful for them to consider referrals to pastoral counselling [84].
3.1.11.4
Obsessive-compulsive disorder and scrupulosity
Cultural factors may influence the nature of obsessions and compulsions associated with the obsessive compulsive disorder (OCD). In fact, a variety of symptoms related to religious thoughts are more prevalent in clinical populations from countries in which religion is at the central core of the society, particularly in Muslim and Jewish Middle Eastern cultures, as compared with clinical populations from the West. The current historical record suggests that Bishop John Moore of Norwich in 1691 delivered the first public address on the topic of scrupulosity, which he referred to as ‘religious melancholy.’ He describes the effect of the disorder on the individual: ‘a flatness in their minds . . . which makes them fear, that what they do, is so defective and unfit to be presented unto God, that he will not accept it. . . . They experience naughty, and sometimes Blasphemous Thoughts which start in their Minds, while they are exercised in the Worship of God . . . despite all their endeavours to stifle and suppress them . . .. The more they struggle with them, the more they increase . . . They are mostly good People . . . for bad men . . . rarely know anything of these kinds of Thoughts’ [85]. Scrupulosity has been described as a psychological disorder primarily characterized by pathological guilt or obsession associated with moral or religious issues that is often accompanied by compulsive moral or religious observance and is highly distressing and maladaptive.’. Scrupulosity has been defined as a set of ‘persistent doubts about sin and irresistible urges to perform excessive religious behaviour’ [86]. It has been described that between 10–30% of OCD patients experience religious obsessions [87], and 5% of OCD patients experience religious obsessions as their primary type of obsession [88]. Assuming that just the 5% of OCD patients with primarily religious obsessions represent scrupulosity, the prevalence of scrupulosity could be considerable, including up to approximately 100 000 people in the United States alone. Scrupulosity patients may become so overwhelmed with moral and religious concerns that they are actually incapable of fully processing all of their thoughts, which contributes to poor awareness [89]. Scrupulosity patients may not be aware of the content or underlying causes related to their disorders, leading some authors to consider that it is an anxiety disorder [90].
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Many scrupulosity patients engage in compulsive confession and restitution-seeking, which often arouses attention from religious authorities and subsequent religious counselling or clinical treatment. Compulsive confession to religious leaders is viewed as a mechanism to resolve feelings of guilt and restore one’s relationship with God and is often apparently pathological in terms of frequency and quality. Patients may withdraw from social and religious communities as a result of dissatisfaction and anxiety, which may further aggravate the condition by depriving patients of reality testing and social support. In response to feelings of meaninglessness, some patients seem to construct their entire existence around the meaning of sin and punishment in an unsuccessful attempt to create a driving purpose for existence. Conversely, purposelessness may lead scrupulosity patients to continuously ruminate about the possibility that life has no inherent meaning, which could constitute a causal component of the pathological doubt and questioning that pervades the lives of scrupulosity patients.
3.1.11.5
Substance use and drunkenness
Man may have been producing alcoholic beverages since the Neolithic Revolution, 10 000 BC. Agriculture started with cereal grasses such as emmer wheat, einkorn wheat and barley which are not those plants with larger seeds which would turn out greater caloric foods. Small cereal seeds are suitable for the production of beer. In any case there are records dating back to 6000 BC of beer production which is recorded in Ancient Egypt and Mesopotamia. The inventions of bread and beer have been parallel and are considered to be responsible for the birth of technology and the founding of civilization. Every culture imposes strong pressure against the use of substances leading to intoxication or controls their use in specific places, at specified time periods during religious ceremonies. The Eleusian Mysteries in Ancient Greece are one of the best known examples of this kind. Twice a year people from all over Greece gathered for several days for ceremonies which had the aim ‘to elevate man above the human sphere into the divine and to assure his redemption by making him a god and so conferring immortality upon him.’ [91] The ceremonies centered on the cult of the goddess Demeter, the one who taught the secrets of agriculture to man. Some scholars believe that the power of the Eleusinian Mysteries came from a beverage consumed at certain moments of the rituals called kykeon. Kykeon was made out of barley and a sort of mint, pennyroyal. Barley can be parasitized by ergot, which contains psychomimetic alkaloids. For other scholars, Ancient Greeks knew how to produce other psychoactive substances. Some religions, particularly Islam, prohibits alcohol consumption altogether. Many others permit the consumption of alcohol but condemn intoxication because it is considered to be a constraint to free will or an action of devils, as expressed in the Bible: ‘Ye are the children of light, and the children of the day: we are not of the night, nor of darkness . . . they that be drunken are drunken in the night. But let us, who are of the day, be sober . . . Abstain from all appearance of evil.’ (1 Thessalonians 5:5, 7–8, 22). Drunkenness or inebriation is the consequence of intoxication with alcoholic beverages and, by extension, by other substances, leading to an impairment of mental and physical faculties. The drunken person behavior is noticeable for the slurred speech, ataxia, poor co-ordination, reduced inhibition, by being clingy to others, invading their personal space and interfering with their behavior. The flushed face, the smell of alcohol and the reddened
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eyes distort the appearance of the drunken person. Drunkenness is accompanied by a wide range of emotions such as anger, sadness, euphoria, light heartedness, joviality, and sexual disinhibition. In short drunkenness is a behavior characterized by a loss of normal rational behavior patterns. There are several Bible passages dealing with alcohol and its evil effects in spite of the fact that potent distilled beverages were then unknown. The first and most quoted is the episode of Noah producing wine which he drank and became intoxicated. This causes him to disgrace himself in front of his family and lead to family strife (Genesis 9:20–27). In the Old Testament, drunkenness was considered worthy of death (Deuteronomy 21:20–21). In Christian theology drunkenness has often been considered to be a sin, even a major one. The New Testament says that those who indulge in strong drink will not inherit the Kingdom (Luke 12: 45–46; 1 Corinthians 6: 9–11; Galatians 5: 19, 21), although wine in itself is not considered an evil; it is the drinking of it in excess (1 Peter 4:3) that displeases God. Jesus himself attended a marriage feast in which wine was being served. It was there that he performed his first miracle: that of changing water into wine (John Chapter 2). Even nowadays there are strong cultural and religious differences in the attitudes towards alcohol. Jewish culturally supported beliefs may discourage drinking and drunkenness as ways of socializing and coping with stress. Thus Jewish men under stress may be relatively more likely to become depressed, and less likely to use and abuse alcohol [92]. Compared to Protestants Jews have less favorable beliefs about alcohol and drink less [93]. Students with no religious affiliation report significantly higher levels of drinking frequency and quantity, getting drunk, celebratory reasons for drinking and perceived drinking norms than those of either Catholic or Protestant religious affiliation. Protestants reported significantly higher levels of perceived drinking control than Catholics [94]. A study in the Western Isles of Scotland reported slight differences between Protestants and Catholics in drinking behavior patterns. Protestants were more likely to endorse an abstinent position, while Catholics were more permissive in their attitudes towards drinking [95].
3.1.11.6
Schizophrenia
Data on phenomenology of delusions, hallucinations or Schneider’s first rank symptoms in schizophrenics demonstrate a remarkable influence of culture on the content of psychotic symptoms. In German psychiatry, Zutt [55] established the term pathoplasticity to describe the culture-sensitive aspect of the manifestations of mental disorders. Schizophrenia religious delusions were described in different cultures and in different times. The term religious delusions includes acute and chronic ideas of being damned by God, or being God. Spirituality and religiousness have been shown to be highly prevalent among patients with schizophrenia; however clinicians are rarely aware of the importance of religion for a patient. Spirituality and religiousness should be integrated into the psychosocial dimension of schizophrenia. Religion can help in reducing anxiety, depression and negative symptoms, and can provide guidelines for interpersonal behavior. In almost two thirds of patients (71%) religion was a positive way of coping and in 14% had a negative effect [96]. Nevertheless there does not seem to be any relationship between religious delusions and personal religiosity [97].
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The relationship between spirituality and adherence to treatment has been studied among patients with severe chronic physical disorders, cancer, and terminal diseases. In some studies it has been proved that being religious increases patients’ satisfaction and adherence to treatment. In people with schizophrenia it improves quality of life, better social support, and more positive representations of the illness and may aid recovery by instilling hope, purpose and meaning of life [98]. There are few studies that have examined how religious affiliation affects delusional thinking [99] but the amount of religious activity prior to psychiatric hospitalization was a strong predictor of the severity of religious delusions currently experience independent of religious affiliation [100].
REFERENCES 1. Sarro´ R (1984) El progreso en la comprensio´n ontolo´gica de los delirios endo´genos. Desde el modelo biografico al metafı´sico. Revista de Psiquiatrı´a y Psycologı´a Medica de Europa y America Latina 5, 311–330. 2. Bilz R (1940) Pars pro toto. Ein Beitrag zur Pathologie menschlicher Affekte und Organfunktionen. Leipzig. 3. Beckmann H & Zimmer R (1981) An ethological interpretation of stereotypy induced by environmental stimulus. Archiv f €ur Psychiatrie und Nervenkrankheiten 230, 81–89. 4. Fuchs T The Phenomenology of Shame, Guilt and the Body in Body Dysmorphic Disorder and Depression. e-mail:
[email protected] 5. Fuchs T (1993) A case of ‘delusional growth’. On the origin and nosologic classification of somatic dysmorphic disorder. Nervenarzt 64, 199–203. 6. Kant I (1964) Anthropologie in Pragmatischer Hinsicht, Werke Band 12, Suhrkamp, Frankfurt/ Main. 7. Lonie IM (1981). The Hippocratic Corpus. In: The Hippocratic Treatises. Walter deGruyter, Berlin and New York. 8. Weyer J (1991) De praestigiis daemonum, in: Johann Weyer, Witches, Devils, and Doctors in the Renaissance: introduction and notes by George Mora; translation by John Shea and preface by John Weber. Medieval Renaissance Texts and Studies. Binghamton, New York. 9. Caro Baroja J (1993) Las brujas y su mundo. Alianza, Madrid. 10. Mongasto´n J. (1611) http://www.vallenajerilla.com/berceo/autor.htm 11. Tallentyre SG (1919) Voltaire in His Letters. Letter to Prince Frederick William of Prussia (1770-11-28), 1919. G. P. Putnam’s Sons, New York and London. 12. Freud S (1939) Moses and Monotheism: Three essays. James Stracheyet al. (eds.) The Standard Edition of the Complete Works of Sigmund Freud, volume 23. The Hogart Press and the Institute of Psychoanalysis, London 1964. 13. Jung C (1933) Psychology and Religion: West and East In: Adler G & Hull RFC (trans. & eds.) The Collected Works of C.G. Jung, volume 11, pp. 327–347. Princeton University Press, Princeton NJ. 14. Kuhn R (1963) Daseinsanalyse und Psychiatrie. In: Bally G, Gruhle HW & Jung R (eds.) Psychiatrie der Gegenwart 1/2, Grundlagen und Methoden der Klinischen Psychiatrie, pp. 853–902. Springer, Berlin-G€ottingen-Heidelberg. ¨ ber verstehende Antropologie. Versuch einer antropologischen Grundlegung der 15. Zutt J (1963) U psychiatrischer Erfahrung. In Gruhle HW, Jung R, Mayer Gross W & M€ uller M (eds.) Psychiatrie der Gegenwart, vol. 1/2, Springer, Berlin. ¨ ber die Wahrheit. C.H.F. Hartmann, Leipzig. 16. Heinroth JCA (1824) U 17. American Psychiatric Association (1993) DSM-IV, Diagnostic and statistical manual of mental disorders. Fourth edition. America Psychiatric Association Press, Washington DC.
3.1
RELIGIOUS EXPERIENCE AND PSYCHOPATHOLOGY
231
€berhaupt und insbesondere, nebst einer 18. Chiarugi V (1795) Abhandlung u€ber den Wahnsinn u Centurie von Beobachtungen. Georg David Meyer, Leipzig. (Translated from ‘Della Pazzia in genere e in spezie’, pp. 1793–1794. 19. Esquirol E (1838) Des maladies mentales considerees sous les rapports medical, hygienique et medico-legal. J.-B. Bailliere, Paris. 20. Jaspers K (1946) Allgemeine Psychopathologie, 4th edn. Springer, Berlin. 21. Spitzer M (1990) On defining delusions. Comprehensive Psychiatry 31, 377–397. 22. R€umke HC (1958) Die klinische Differenzierung innerhalb der Gruppe der Schizophrenien. Nervenarzt 29, 49–58. 23. Binswanger L (1957) Schizophrenie. Neske, Pfullingen. 24. Schneider K (1959). Clinical Psychopathology. Grune and Stratton, New York. 25. Regis E (1887) Traite de Psychiatrie. Doin, Paris. 26. Young AW (2000). Wondrous strange: The neuropsychology of abnormal beliefs. In Coltheart M & Davis M (eds.) Pathologies of belief (pp. 47–74). Blackwell, Oxford. 27. Jones E (1999) The phenomenology of abnormal belief. Philosophy, Psychiatry and Psychology 6, 1–16. 28. Maher BA (1988) Anomalous experience and delusional thinking: The logic of explanations. In: Oltmanns T & Maher B (eds.) Delusional Beliefs. Wiley Interscience, New York. 29. Kuhn T (1962) The Structure of Scientific Revolutions. University of Chicago Press, Chicago Il. 30. David AS (1999) On the impossibility of defining delusions. Philosophy, Psychiatry and Psychology 6, 17–20. ¨ ber Wahn. Nervenarzt 22, 125–126. 31. Gruhle HW (1951) U 32. Jaspers K (1946) Allgemeine Psychopathologie, 4th edn. Springer, Berlin. 33. Hillman J (1987): On Paranoia. In: Eranos Yearbook 1985, Vol. 54: pp. 269–324. The Hidden Course of Events. Insel, Frankfurt. 34. Ey H (1973) Traite des hallucinations. Masson, Paris. 35. Ferrater Mora J (1965) Diccionario de Filosofia, 5th edn. Alianza, Madrid. 36. Crivelli P (2004). Aristotle on Truth, Cambridge University Press, Cambridge. 37. Juan de Santo Tomas (1637-67) Cursus Theologicus. 38. Heidegger M (1996) Being and Time. State University of New York Press, Albany. 39. Robinson TM (1987). Heraclitus: Fragments: A Text and Translation with a Commentary. University of Toronto Press, Toronto. 40. Blankenbur, W (1965): Zur Differentialph€anomenologie der Wahnwahrnehmungen. Eine Studie €uber abnormes Bedeutungserleben. Nervenarzt 36, 285–298. 41. Durand Ch Personal communication. 42. Freud S (1923) Das Ich und das Es. James Stracheyet al (eds.) The Standard Edition of the Complete Works of Sigmund Freud, volume 3. The Hogart Press and the Institute of Psychoanalysis, London 1953–74. 43. Szasz T (1965). The Ethics of Psychoanalysis: The Theory and Method of Autonomous Psychotherapy. Syracuse University Press. New York. 44. Lorenzer A (1974). Die Wahrheit der psychoanalytischer Erkenntnis: Ein historischmaterialistischer Entwurf. Suhrkamp, Frankfurt. 45. Zarader M (1990) La dette impensee. Heidegger et l’heritage hebraı¨que. Seuil, Paris. 46. Bakan D (1958) Sigmund Freud and the Jewish Mystical Tradition. D. van Nostrand, New York. 47. Lo´pez Ibor JJ (1975) Freud y sus ocultos dioses. Planeta, Barcelona. 48. Popper KR (1992) El conocimiento de la ignorancia. Principios para una nueva etica profesional. Universidad Complutense, Madrid. 49. Stephens GL & Graham G (2004) Reconceiving delusion. International Review of Psychiatry 16, 236–241. 50. Sass LA & Parnas J (2003) Schizophrenia, consciousness, and the self. Schizophrenia Bulletin 29, 427–444.
232
CORE ISSUES: RELIGION AND PSYCHOPATHOLOGY
51. De Clerambault G (1921) Les delires passionelles. Erotomanie, jalousie. Societe Clinique de Maladies Mentales 1, pp. 61 et seq. (Also in: De Clerambault G. Oeuvres psychiatriques. PUF, Paris1942 and Fenesie, Paris 1987, pp. 337–346.) 52. Nassar S (1998) A Beautiful Mind. Simon & Schuster, New York. 53. Nash J (1999) Rational Thinking. Is it Easy or Hard? In: Lo´pez-Ibor JJ, Lieh Mak F Visotsky HM & Maj M (eds.) One World, One Language – Paving the Way to Better Perspectives for Mental Health. Hogrefe and Huber, 54. Kuhn TS (1962) The Structure of Scientific Revolutions. Chicago University Press, Chicago Il. 55. Zutt J (1963) Auf dem Wege zu einer anthropologischen Psychiatrie. Springer, BerlinG€ottingen-Heidelberg. 56. Stutte H (1974) Neurotic dissociality caused by a Thersites complex. Praxis der Kinderpsychologie und Kinderpsychiatrie 23, 161–166. 57. Kamer PD (1993) Listening to Prozac. Viking, New York. 58. Brantigan TA, Brantigan CO & Joseph NH (1978) Beta-blockade and musical performance. Lancet 2, 8095–8096. 59. Plato. Gorgias, 465. Translated with introduction, notes, and interpretive essay by James H. Nichols Jr. Cornell University Press. Ithaca NY, 1998. 60. Freud S (1923) Das Ich und das Es. James Stracheyet al (eds.) The Standard Edition of the Complete Works of Sigmund Freud, volume 3. The Hogarth Press and the Institute of Psychoanalysis, London 1953–74. 61. Robinson L & Vogel L (1971) Modernism and History. New Literary History 3, 177–199. 62. Lo´pez Ibor JJ & Lo´pez-Ibor Alin˜o JJ (1974) El cuerpo y la corporalidad. Gredos, Madrid. 63. Freud S & Breuer J (1895) Studies on Hysteria. In: James Strachey et al. (eds.) The Standard Edition of the Complete Works of Sigmund Freud, volume 2. The Hogart Press and the Institute of Psychoanalysis, London 1953–74. 64. Marcuse H (1964) One-Dimensional Man. Beacon, Boston. 65. For a more detailed description see the chapter Science and Transcendence in this same book. 66. Illich I (1975) Medical Nemesis: The Expropriation of Health. Calder & Boyars, Ltd., London. 67. Teresa of Avila (1991) The Way of Perfection (Translated and edited by E. Allison Peers), Doubleday, Random House, New York. 68. Bell R (1985). Holy Anorexia. University of Chicago Press, Chicago. 69. Lacey JH (1982) Anorexia nervosa and a bearded female saint. British Medical Journal (Clinical Research Edition) 285 (6357), 1816–1817. 70. Vandereyken W and Van Deth R (1990) From Fasting Saints to Anorexic Girls: the history of self-starvation. New York University Press, New York. 71. Joughin N, Crisp AH, Halek C, Humprey H (1992) Religious belief and anorexia. International Journal of Eating Disorders 12, 397–406. 72. Paz O (1982) Sor Juana Ines de la Cruz, o, las trampas de la fe. Fondo de Cultura Econo´mica, Mexico. 73. Wilbe, C & Colligan R (1981) Psychologic and behavioral correlates of anorexia nervosa. Journal of Developmental & Behavioral Pediatrics 2, 89–92. 74. Sykes, DK Jr, Gross M, Subishin S (1986) Preliminary findings of demographic variables in patients suffering from anorexia and bulimia. International Journal of Psychosomatics 33, 27–30. 75. Graham MA, Spencer W, Andersen AE (1991) Altered religious practices in patients with eating disorders. International Journal of Eating Disorders 10, 239–243. 76. Smith MH, Richards, PS, Maglio CJ (2994) Examining the relationship between religious orientation and eating disturbances. Eating Behaviour 5, 171–180. 77. Morgan JF, Marsden P, Lacey JH (2000) ‘Spiritual starvation?’: a case series concerning christianity and eating disorders. International Journal of Eating Disorders 28, 476–480. 78. Griffin J and Berry EM (2003) A modern day holy anorexia? Religious language in advertising and anorexia nervosa in the West. European Journal of Clinical Nutrition 57, 43–51.
3.1
RELIGIOUS EXPERIENCE AND PSYCHOPATHOLOGY
233
79. Koening HG (2001) Religion and Medicine III: Developing a Theoretical model. International Journal of Psychiatry in Medicine 31, 199–216. 80. Exeline JJ (2002) The picture is getting clearer, but is the scope too limited. The overlooked questions in psychology of religion. Psychological Inquiry 13, 245–247. 81. Mofidi M, Devellis RF, Balzer DG, Devellis BM, Panter AT, Jordan JM (2006) Spirituality and depressive symptoms is a racially diverse US sample of community-dwelling adults. Journal of Nervous and Mental Disease 194, 975–977. 82. Rasic DT, Belic SL, Elias B, Katz LY, Enns M, Sareen J (2008) Spirituality, religion and suicidal behaviour in a nationally representative sample. Journal of Affective Disorders 2008 Sep 15. [Epub ahead of print]. 83. Bell Meisenhelder J (2002) Terrorism, posttraumatic stress, and religious coping. Issues in Mental Health Nursing 23, 771–782. 84. Harris JI, Erbes CR, Engdahl BE, Olson RHA, Winskowski AM, McMahill J (2008) Christian religious functioning and trauma outcomes. Journal of Clinical Psychology 64, 17–28. 85. Mora G (1969) The scrupulosity syndrome. International Journal of Clinical Psychology 5, 163–164. 86. Abramowitz JS, Huppert D, Cohen AB, Tolin DF and Cahill SP (2002) Religious obsessions and compulsions in a non-clinical sample: The Penn Inventory of Scrupulosity (PIOS). Behaviour Research and Therapy 40, 825–838. 87. Eisen JL; Goodman WK, Keller MP, Worshaw NG, de Marcol M, Luxe DD (1999) Remission and relapse in OCD disorder: a 2 year prospective study. Journal of Clinical Psychology 60, 346–335. 88. Tolin DF, Abramowitz JS, Kosok MS, Foa EB (2001). Fixity of belief, perceptual and magical ideation in OCD patients. Journal of Anxiety Disorders 15, 501–510. 89. Rapport JL (1990) The Boy Who Could Not Stop Washing. The experience and treatment of OCD disorder. New American Library, New York. 90. Miller CH, Dawson HW (2008) Scrupulosity disorder an overview and introductory analysis. Journal of Anxiety Disorders 22, 1042–1052. 91. Nilsson MP (1947) Greek Popular Religion ‘The Religion of Eleusis’. Columbia University Press, New York. 92. Loewenthal KM, Lee M, MacLeod AK, Cook S, Goldblatt V (2003) Drowning your sorrows? Attitudes towards alcohol in UK Jews and Protestants: A thematic analysis. International Journal of Social Psychiatry, 49 (3): 204–215. 93. Loewenthal KM, MacLeod AK, Cook S, Lee M, Goldblatt V (2003) Beliefs about alcohol among UK Jews and Protestants: do they fit the alcohol-depression hypothesis?. Social Psychiatry and Psychiatric Epidemiology 38, 122–127. 94. Patock-Peckham JA, Hutchinson GT, Cheong J, Nagoshi CT (1998) Effect of religion and religiosity on alcohol use in a college student sample. Drug and Alcohol Dependence 49, 81–88. 95. Mullen K, Blaxter M, Dyer S (1986) Religion and attitudes towards alcohol use in the Western Isles. Drug and Alcohol Dependence 18, 51–72. 96. Mohr S, Brand PY, Borras L, Gilieron C, Huguelet P (2006) Toward and integration of spirituality and religiousness into psychosocial dimension of schizophrenia. American Journal of Psychiatry 163, 1952–1959. 97. Rudalvevicıˆiene, P, Stompe T, Narvekovas A (2008) Are religious delusions related to religiosity in schizophrenia. Medicina (Kannas), 44 (7), 529–535. 98. Borras L, Mohr S, Brand PY, Gilieron C, Eytan A and Huguelet P (2007) Religious beliefs in schizophrenia: their relevance for adherence to treatment. Schizophrenia Bulletin 33, 1238–1246. 99. Petters E, Day S, McKenna J, Orbach G (1999), Delusional Ideation in religious and psychotic populations. British Journal of Clinical Psychology 38, 83–96. 100. Getz GE, Fleck DE, Strakowsky SM (2001): Frequency and severity of religious delusions in Christian patients with psychosis. Psychiatry Research 103, 87–91.
CHAPTER 3.2
God’s Champions and Adversaries: About the Borders between Normal and Abnormal Religiosity Herman M. van Praag Emeritus Professor of Psychiatry, The Netherlands
3.2.1
INTRODUCTION
The topic of this treatise is religiosity. I will discuss what I consider to be normal, abnormal and pathological manifestations of religiosity. Religion is and always was an emotion-laden theme, secularization of Western societies notwithstanding. Apparently, secularization has not advanced to such a degree that the concept of God and His worship has become irrelevant. Hence I will inevitably tread on toes; at times of those cherishing this concept, then again of those irritated by merely mentioning His name, but unable to effectuate an emotional divorce. To begin with, I will clarify my points of departure. First, my considerations pertain to the two religions that have shaped the cultures of Western society to such a large extent: Judaism and Christianity. Second, having no degrees in theology or psychology of religion, I am, intellectually speaking, a theological amateur. However, since I am religiously receptive I credit myself, experientially, with some degree of expertise. Moreover, I have to deal with the subject professionally. Being a psychiatrist, I simply cannot permit myself to evade an important segment of the spiritual domain within which man operates. I have to decide where I draw the border between normal and abnormal religiosity, and whether religious variables, in a given case, have played a role and if so, an adverse or beneficial one. For many decades religion has been psychiatry’s stepchild, being considered no more then an archaic remnant of an infantile past. In doing so, psychiatry seriously erred and harmed the interests of numerous patients.
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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CORE ISSUES: RELIGION AND PSYCHOPATHOLOGY
DEFINITIONS
Religion and religiosity are focal points in this exposition. Religion I define as the ideology that has developed around the assumed existence of a super-natural authority. An authority not sensorially perceptible, impervious to empirical studies, that yet exercises a fundamental influence on individuals and on the society in which they live. This authority is called God. The God-figure is experienced either anthropomorphically as a person with human features, or rather as an abstraction, as an impersonal, elusive, inconceivable field of force. ‘An uncaused cause’. Out of awe for the Godhead arose a ritualized system of worship. Affinity with the religious root-idea, I entitle as religiosity, or preferably as religious receptivity. I prefer the latter term because it expresses more pointedly that religious belief is not an all-or-nothing quality, but one that occurs in various degrees of intensity. The construct of religious receptivity includes three elements: *
* *
Receptiveness – emotionally and intellectually – for the concept of God and the transcendent reality it represents. Affinity with worship and rituals associated with the concept of God. Acceptance, at least in broad outline, of the concept of man and the worldview the religion in question champions.
3.2.3
STARTING POINTS
The basic assumption of this exposition holds that religious receptivity is a normal component of the human experiential repertoire, emphatically not a neurosis, not an anachronistic remnant of an infantile past. This point of view raises two questions: * *
What justifies this standpoint? What is normal religiosity?
They will be discussed in the next sections.
3.2.3.1
The normality of religious receptivity
Based on the following grounds I qualify religious receptivity as a normal phenomenon. Normal experientially but also normal intellectually, that is as a conceptualization of the need to lift life out of meaninglessness and the purely accidental.
Search for meaning and spirituality In the life of animals three interests hold central position: self-preservation, procreation and satisfaction of physical needs. Man knows more interests. Prominent among these are: the quest for meaningful goals – desiring to live for something; live a life that somehow matters – and for values that supersede satisfaction of physical needs, that is for spiritual values. Those two interests hang together: meaningful goals are usually found on a spiritual level.
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For man with intellect questions such as: what man’s position is in the cosmos; why it is that one is put into this world; what it is one lives for, are not rhetorical, no expressions of ‘a-meaningful thinking’ [1], but key-questions. Satisfaction of material needs is not enough or one gets enough of it. Matter may fill a life, it does not fulfil it. The gap between filling and fulfilment may be closed with a broad range of intangible values such as: care for fellow man, social involvement, creative activity expressed scientifically, artistically or, less lofty but no less noble, in the desire to just do a good job – in one’s family, in the workplace, in club-life – or in the urge to improve oneself intellectually, emotionally, culturally. Preoccupation with values of this kind, can be experienced as immanent, as originating in one’s inner self, or as transcendent, as prompted, inspired, or even dictated by an agency superior to the human species, who eventually determines its weal and woe. In the latter case one ends up at religion, at a postulated supernatural, mythical authority named God. God has expectations, and makes demands. Fulfilling these is for the believer both a commission and a source of satisfaction. God is for him the sublime and ultimate source of meaning. I use the term mythical not meaning to denigrate. On the contrary. The myth I consider as a superior way to express in a narrative, symbolic way experiences that refuse to be worded in a precise manner, are impossible to concretize, but are experienced intensely as full of meaning, and of essential significance. The God-myth is of that nature. It is solidly rooted in human society and its influence there has been profound and permanent.
Dependency need The relationship of a religious person to God is one of dependency. For that reason Freud [2] qualified it as infantile and, thus, because it concerns adults, as regressive. I think wrongly so. Maturity and dependency are no opposites. A fully independent being – if such creatures exist at all – is a lonely being. No human being is fully self-sufficient. For that reason he is in need of interdependent relationships. Relationships that are complementary and reciprocal. The one fills up where the other has needs, feels vulnerable and vice versa. I consider interdependent relationships as manifestations of maturity. Unwillingness or inability to establish such-like alliances, renders a person lonely, unfulfilled. Rapprochement to God may bring relief. The relationally more astute, too, may feel the need, and seek the warmth of a power perceived as omnipotent, omniscient, and benevolent. The relation to God is per definition one of dependency. Is the relationship of man to God one of mutual dependency? It can be conceived as such. For a religious person God is both guide and protector. God represents both the archetypical father figure and the archetypical mother figure. The concept of God on the other hand is carried by humans. After all, he is unknown to other earthly creatures. ‘The human soul is God’s lamp’ states one of the Proverbs (20:27). If it were not for human beings, God would not exist, at least not according to criteria humans dispose of. The religious believer is like a sculptor. The stone out of which the sculptor will create the work of art contains, as it were, the concept of that work of art, but it is still unformed, shapeless. The sculptor cuts the stone out, by which the unformed is formed and the concept becomes visible. In a similar way man becomes aware of, gets in touch with, one might say: creates God. The relationship of man to God is one of reciprocal dependence. Hence I consider this bond to be normal.
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Emotional response need Intense emotions invoke the need of another, someone who cares to respond. If such a sounding-board is wanting or the available other is unable to respond adequately a profound sense of solitude may set in. One tends to seek refuge ‘higher up’, to turn to a metaphysical resource, to God. I mention three examples, a trio that is easily extendable. Sorrow. One loses part of what one considers to be the raison d’etre of one’s existence: partner or child, job, prestige, power, wealth, and feels in need of support, consolation, of someone who can somehow relativize the trauma, without minimalizing it. One does not find a human comforter and seeks rapprochement to a super-human authority. God as consoler. Or an opposite reaction sets in. God becomes a scapegoat. Why did He do this to me? Why did He, ostensibly almighty, not prevent this tragedy. In both cases God draws nearer. Confrontation with death. The unexpected tiding that death is approaching is shattering. Seldom is all hope abandoned. The hope that a medical intervention exists that may turn one’s condition for the better. ‘God grant, that something can be done’. It is a universal supplication. Death is to God a faithful servant. Gladness. Not often, but once in a while; unexpected, or as apotheosis of a long sustained effort and without support or intervention of others, an aspiration – long cherished – materializes. There is no human agency to tender thanks to. One turns to a superhuman one. Bliss may bring someone closer to God.
Amazement This is a powerful inspirer, and one that works permanently, not incidentally. Existential amazement; amazement that ‘existence exists at all and not a void’ [3]. ’Radical amazement . . . amazement not only at one facet of the world but in the startling fact that there are facts at all’ [4]. Amazement that I am aware of myself and of the outer world; that I can communicate with myself and my fellow-man; that I experience myself as an distinct and unitary entity; as a ‘self’; that I have knowledge about my ‘self’; that my ‘self ’-feeling remains relatively constant overtime; that that ‘self’ has a freewill, is capable of controlling my actions. Wolters [5] maintains, that ‘control of behaviour is completely determined by neural processes’. This neural determinism seems to me a product of fact reversal. A functioning brain is a necessary precondition for one’s actions. The brain, however, is not the initiator. To a large extent I, my ‘self’ initiate actions. I agree with Gillihan and Farah [6]: ‘Our vivid awareness of a self, like awareness more generally, may not be explicable in terms of the mechanistic workings of the brain’, and also with Pinker [7]: ‘The I is not a combination of body parts or brain states or bits of information, but a unity of selfness over time, a single locus that is nowhere in particular’. Selfhood is and will remain, I guess, the quintessential mystery of the human existence. Radical amazement, it is the amazement, the newborn probably experiences when beholding the outside world for the first time.
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One may take those basic and mysterious commodities of life for granted. Others experience amazement, kindling in its turn admiration. They contemplate super-natural forces (i.e. forces beyond the reach of the natural sciences) influencing natural processes. Some extrapolate these postulated influences to the figure of God. It is a postulate neither verifiable nor refutable, just like the Messianic hope of the positivists that one day our knowledge will be boundless, that one day we will know and understand it all, that the natural sciences eventually will make themselves superfluous and, like the Messiah is supposed to do, will usher in the end of (scientific) days. This is metaphysics, as is the concept of God.
Secularization with preservation of faith We live in a time, communis opinio holds, of excessive secularization. This seems to be a correct statement in that church and synagogue attendance has dropped to a fraction of what it used to be. Affinity with religious rituals, moreover, has largely evaporated and the prestige of religious authorities faded away. This statement is incorrect as far as faith, belief in God, in a divine power is concerned. I mention a few examples. In a Gallup poll carried out in 2000, 8 out of 10 Americans assented to the statement that ‘the Bible still speaks to us today, and could even solve most or all of life’s problems’ [8]; 71% expressed that they had never doubted the existence of God, while 67% believed in afterlife and in the reality of heaven [9]. The U.K. National Opinion Poll Survey found that 72% of a random sample had maintained belief in God. A recent study carried out in The Netherlands concluded that approximately 50% of a random sample from the population reported that religious belief played an important role in their lives [10]. An American survey, carried out among hard core natural scientists (biologists, physicists, mathematicians) found that 40% expressed belief in a personal God [11]. According to a recent Newsweek poll, 78% of Americans believe that Jesus rose from the dead [12]. Religious paraphernalia lost in significance. Yet many maintained belief in a metaphysical reality. The observations mentioned in this section, taken together, warrant the conclusion, I think, that religious receptivity constitutes a normal component of man’s experiential reach.
3.2.3.2
Normal religiosity
Religious receptivity I consider to be a normal psychological quality; as normal as for instance aesthetic receptivity is, and as individually variable as to intensity. It functions as a most important guiding system in the search for spirituality. This conclusion raises the question of what is normal religiosity. A universally valid answer does not exist. In the domain of the psyche, moreover, the borders between normal and abnormal are fuzzy. Phenomena we know from psychiatric disorders also occur in the normal population [13, 14]. In the given context I restrict myself to two characteristics that for me personally are essential ones. Open mindedness. Belief in God is conceived as a personal conviction (literally: a personal faith), and is not absolutized, not transformed into a system of absoluta, a system of universal validity. One recognizes, tolerates and respects other belief systems, and is prepared to critical interchange thoughts. Faith is not a fenced off system, but an open philosophy of life.
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Incertitude. The believer realizes that faith, by definition, implies uncertainty. Nothing about the existence of God, His will, His policies is definitely established. He represents the ultimate mystery. The believer guesses. He is by definition an (auto-) dialectician, a questioner, a waverer, constantly on the way to fathom something of the inexplicable. Religious fanatism is foreign to him. In this he may refer to the Bible itself. ‘Though all the peoples walk, Each in the names of its Gods, We will walk in the name of the Lord our God’ (Micha, 4:5). In Messianic times, the time in which mankind and the world in which it lives has attained its perfect shape, it is apparently possible that various concepts of God exist alongside and are mutually respected. Undoubtedly the traditionalists will reject this standpoint as apocryphal or even blasphemous. This is most regrettable. The attitude of the truly faithful towards those that have followed other routes than oneself to attain the belief that their life has a modicum of meaning, should be one of understanding and respect. ‘Love your neighbour as yourself . . . the stranger who resides with you shall be to you as one of your citizens’ (Leviticus 19: 18 and 34). This is a text key to both Judaism and Christianity. Dogmatism and intolerance are hard to reconcile with such attitude. Its negation is a disgrace of what the concept of God stands for.
3.2.4
ABNORMAL RELIGIOUS BEHAVIOR
The normal occurrence of a phenomenon implies that it may also occur in abnormal proportions: deformed, under- or over-developed. This holds both for bodily functions and for features of the psyche, including religious receptivity. I emphasize that the term ‘abnormal’ in this context, does not hold any value judgment. It only indicates that that phenomenon deviates from the norm. The norm is that manifestation form that occurs most frequently, and in a particular society, in a particular period is considered to be normal. I distinguish three forms of abnormal behavior: 1. Variants of the norm. Behaviors that fall beyond the norm, but still within the normal variance of that phenomenon. 2. Abnormal, non pathological phenomena. Abnormal means that those phenomena fall outside the normal variance of the phenomenon. They are, however, not pathological, because they do not harm the well-being of the individual in question, nor that of the society in which he lives. 3. Abnormal, pathological phenomena. Those phenomena also fall beyond the normal variance, but they do harm the individual’s well-being or that of the society in which he lives.I apply this division also to abnormal religious manifestations.
3.2.5 3.2.5.1
ABNORMAL RELIGIOUS BEHAVIOR: HYPORELIGIOSITY Variants of the norm: agnosticism
The agnostic does not know religious feelings or experiences or denies them not to be looked upon as a spiritual fossil. Intellectually speaking, he considers it likely that God is but a complex illusion, religious belief a mystification, penetrating but without any rational
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ground, and the numinous a romantic product of our fantasy. He frankly admits, however, that proof of God’s non-existence is as elusive, as proof of God’s existence. The agnostic lives in the here and now, both feet firmly on the ground. His conscious self is self-sufficient and he feels no need for supernatural excursions that are intellectually offlimit. He presumes that, in principle, everything we observe and experience is intellectually explicable by applying appropriate scientific methodology. For the time being, however, he embraces a waiting attitude because he abides to the standpoint: see before you believe. The agnostic, though a-religious, does not proclaim that only unbelievers are in the right. Agnosticism is a variant of religiosity, an atrophic variant. It is a mental condition grafted upon a deficit: underdeveloped religious receptivity. Few will deny that inability to experience aesthetics can be called a deficit; a curtailment of the potentialities to experience the world in which one lives. ‘Music does not appeal to me’, or ‘paintings have little to say to me’, or ‘nature does not touch me, really’, will generally elicit the reaction: ‘what a pity; you are missing out on something’. For religious insensitivity the same holds. It is a loss because one misses out on something irreplaceable.
3.2.5.2
Abnormal, non pathological manifestations: atheism
The atheist shows a reversed sensitivity for religious experiences. He possesses ‘religious receptors’ but stimulating those does not procure spiritual reward but results in negative feelings, predominantly irritation and anger. His position vis a vis religion is not one of skeptical neutrality, like that of the agnostic, but one of animosity. Only the perceptible, material world, he maintains, is real. The world is composed of elements that are or will be scientifically analyzable and measurable. Concepts like spirit and spirituality suggest the existence of an invisible, mysterious world, beyond the reach of our reason, governed by an agency or agencies of cosmic proportions, capable of tendering meaning to one’s life. All this is delusional. The beliefs of the atheist are undoubtedly reasonable, but no more provable than those of the believer. Atheism is a religious belief with a negative sign. Generally the atheist is not only an ultra-materialist, but at the same time a driven positivist. He entertains a deeply rooted belief in the power of the natural sciences and modern technology. They, and they alone provide the tools to garner genuine knowledge about this world and to further progress. To the extent that life makes sense, man is generating that sense himself. Behind the forces of nature stands no almighty prompter. We came into being – like, mirabile dictu, God himself phrased it – out of dust and to that state we will return. God is the ultimate placebo. In some individuals he produces effects, but not through his power, but through their imagination and anticipation. The atheist, of course, does not deny that in nature all kind of processes proceed with great regularity and predictability, but they are steered by forces that are blind, purposeless, not part of a divine, pre-conceived scheme. The atheist tends to emphasize the negative social impact religions have exercised. He will refer to intolerance, narrowness, and oppressing social control that can be the product of religious belief. Positive social influences will be minimalized: religion as an ideological system boosting communal sense; appealing for benevolence and (in the best of cases) reinforcing respect for fellow-man, (I know: sometimes fostering the contrary, but this is to be qualified as a religious anomaly), and offering an altruistic alternative for narrow
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self-centredness, a predominant focus on self-realization (ignoring that predispositions may harbour evil elements) and behaviors expressing others being perceived as a mere sideshow. The atheist will point to negative political influences: religion having encouraged or at least permitted wars; to the aggressive contents of some Biblical texts. Religious institutions and leaders having preached pacification and the (many) scriptural texts with humanitarian tenor are ignored. From a psychological vantage point the atheist looks at religion as an infantilism, a product of retardation in psychological maturation, promoting dependency and thwarting full maturation of one’s faculties. He will wave aside the fact that religiosity may appear in mature form, promoting mental growth by canalizing spiritual needs; fitting them within a concrete and elaborate Weltanschauung, that – no little bonus – is graced with a phenomenal gallery of religiously inspired works of art. Expressions of religiosity will anger atheists. Possibly they recognize the emotional deficit – i.e. religious insensibility –which may ignite aggression towards those who do possess religious ‘sense organs’. This would be a recognizable psychological reaction. The heavy drinker, for instance, tolerates the teetotaller badly; the drug addict tries to persuade companions to join him; the contactually under-privileged may bear a grudge against his socially more gifted fellow-man. Generally speaking, spite is a potent catalyst of hostility.
3.2.5.3
Does neurotheology support the atheist’s point of view?
The atheist’s point of view seems to be supported by data from recent brain research. Imaging techniques brought to light that religious experiences produced by praying are accompanied by increased blood flow and glucose utilization in certain parts of the limbic system [15]. Those are indications that nerve cells in that region have been activated. Comparable changes are induced by mystic experiences. Furthermore, a negative correlation was found between the density of brain serotonin – 1A receptors and ‘spiritual acceptance’, a variable close to what I call religious receptivity [16]. Finally, Kendler et al. [17] demonstrated that ‘personal devotion’ is to a significant degree determined by genetic, that is by biological factors. Intellectual delicacies for atheists so it seems. These findings seem to support the notion that religious experiences are private fantasies, based on nothing more than peculiar and transient activities in certain brain cells. ‘Indeed, it could be argued’, Joseph [15] put it ‘that the essence of God and of the living soul, may be slumbering within the depth of the ancient limbic lobe, which is buried within the belly of our brain’. Not agnosticism and atheism seem to be deviations of the norm but religious receptivity is. Indeed, so it seems. Religious experiences are accompanied by changes in the brain. That, however, is a matter of course. Every experience presupposes a particular functional state of the brain. Without that there would be no experience. The conclusion, however, that, therefore, religiosity is a purely neurobiological determined phenomenon is misleading. Activation of ‘religious circuits’ (circuits that make religious experiences possible) may indeed be predominantly biological in origin. As a consequence of genetic influences, for instance, their excitability may be increased so that weak or even unrecoverable stimuli produce activation. (Or vice versa, their excitability may be decreased, due to which the
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person in question will be resistant to religious experiences.) A second biological possibility is that acquired processes, such as infection, tumor, brain trauma have rendered ‘religious circuits’ over-excitable. Those possibilities, however, are rare. In most cases ‘religious circuits’ will be activated, and the corresponding emotions/experiences generated by psychological processes, not by a primary abnormality in structure or function of the brain. Religious feelings and experiences are usually generated by psychological needs, the character of which I have discussed before. Spiritual needs develop on a psychological level, are a product of someone’s psychological make up and living circumstances. Gratification of spiritual needs is brought about by induction of religious experiences and feelings. Those feelings and experiences, in their turn, are a product of, are contingent on activation of certain brain circuits. Spiritual needs are generated on a psychological level. Gratification of those needs is effectuated on a biological level. The brain is the instrument enabling gratification of religious needs. The brain is, in most cases, not the origin of those needs. Neuro-theology provides no support for the view that theism, religious belief, is an evolutionary atavism, a veritable anomaly (see Chapter 6.2).
3.2.5.4 Abnormal, pathological manifestations: evangelizing atheism The border between the fringe-normal and the abnormal is reached and easily crossed when the atheist gets on fire and comes to propagate his beliefs or, one step further, comes to consider religious belief as a danger, an evil that has to be fought with dedication. In that case unbelief is turned from a viewpoint into a conviction, a true faith, as irrational, as emotion-laden, as rigid as its counterpart, i.e. pathological hyperreligiosity. The sense of relativity of one’s private standpoint is lost. They assume general validity. Others have to be won over and criticism is countered with impatient contempt. If atheism comes to be an integral component of a political system we have arrived in the midst of a danger zone, both physically and psychologically. Intolerance, oppression, persecution are imminent. Religious manifestations will be put under taboo: the preaching of religious ideas, public worship, the schooling of ministers. Clergy may be persecuted, houses of God be closed, seminaries dissolved. Religious beliefs are conceived as heresy. This happened in the Soviet Union. Many suffered, many were killed. In Communist China the atheist inquisition is still active. Adherents of the Falun Gong, for instance, a meditative grouping with idealistic principles are not tolerated and are locked up in psychiatric institutions, a continuation of a well-tried Soviet tradition [18]. Those are without question pathological excesses of religious unbelief.
3.2.6 ABNORMAL RELIGIOUS MANIFESTATIONS: HYPER-RELIGIOSITY 3.2.6.1
Variants of the norm: coagulation of religious beliefs
Religious beliefs may become solidified. The concept of God loses its character of a human interpretation, an image rather, of a construct that in essence is unknowable.
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Religious premises are absolutized. Religious belief, thus, loses its primal mark: uncertainty, leading to a never ending search for something perceived as exceeding the limits of one’s own ego, and providing guidance to one’s life. Doubts melt away, and make way for intellectual inflexibility and spiritual immobility. One fancies knowing for sure what God’s wishes, what His intentions are, what the scriptures communicate. Prayers may stiffen, deflate emotionally. They then are no more than a source of mental relaxation, of release from daily worries, not a quest for what one considers to be the essentials of one’s life, but degenerate to an empty routine. Religious rituals may also lose in significance. The precision with which they are being performed, outward appearance, becomes more important than emotional charge. Their purpose, intensification of spiritual experiences, is lost. They fail to be internalized. Rituals regress into a series of religious manners. Guilt feelings emerge if one’s performance lacks in punctuality and regularity. Anxiety, more than devotion drives the ritual deeds. Faith coagulation may arise from within or without, in the latter case elicited by religious authorities or agencies. In the former case it usually concerns individuals with a strong need to feel secure, the tendency to cling to a set of well-defined rules of life, and who find it hard to decide in matters that appear to them as fundamental. In those cases religion indeed serves as a remedy for neurotic disabilities. Clergy encouraging faith coagulation damage their office and render their flock a disservice. Religion, in its, for me, ideal shape, steers the quest for spirituality in a particular direction. It does not coerce. It provides the spiritual prospector only with broadly outlined charts and with provisions sufficient to meet only basic necessities of life. Much is left to the ingenuity of the voyager. The journey has no end because authentic religious belief does not know absolute certainties. Hence it remains intellectually challenging and emotionally stimulating. Religion shields from non-committal, unstructured, intellectually empty excursions into the clouds [19, 20]. Religion, by the same token, should shield from empty, intellectually uninteresting and emotionally extinguished dogmatics.
3.2.6.2
Pathological outgrowths of faith coagulation
Coagulation I consider as a still normal variant of religious belief. It becomes a different story when coagulated beliefs cease to be viewed as private convictions, and the urge develops to propagate those notions as universally valid and the only ‘true’ belief. If effectuated in an open dialogue this behavior is perfectly acceptable and is to be qualified as abnormal, but non-pathological. If free exchange of ideas is obstructed, if dogmatic religiosity is forced upon others under penalty of rejection than the qualification abnormal and pathological religious behavior is fitting. The risk is real that not only the ‘errant’s’ conviction is rejected but the ‘errant’ as a person as well. In that case he runs the risk of being expelled. That process starts with lack of respect, and may, via expulsion, ultimately result in persecution. With those behaviors we have entered the realm of forensic religious pathology.
3.2.6.3 Abnormal, non pathological manifestations: religious fancy and exaltation The term ‘religious fancy’ I use to indicate a variety of conditions, all characterized by fading of the symbolic character of the God-idea; now and then, or for longer periods at a
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stretch. Contact with God and the divine assumes concrete features. The experience: ‘it was as if I felt God’s nearness’ changes in ‘God was near’ or ‘I, literally, felt his presence’. Ongoing de-symbolization may lead to visual representation of God and/or other heavenly figures such as angels, saints, demons or to acoustic perceptions, for instance hearing the voice of God or that of His antipole, Satan. Such-like experiences qualify as mystical [21, 22]. They cannot be localized in time or place, possess a high reality-grade, and may be accompanied by intense feelings of peacefulness and bliss, being beyond verbal expression. Such conditions are generally experienced as extremely enriching in that they generate a deeper insight in and understanding of the essentials of one’s existence. They qualify as, what Maslow [23] called, peak experiences. In a direct line with religious fancy lies what I call visionary exaltation. The conviction gains ground that God not only came near but that in doing so procured assignments or imparted insights which the person in question should disseminate in his community or communicate to humankind. Generally these states of mind are accompanied by altered, particularly slightly clouded consciousness. They are usually short-lasting and one remains aware that those experiences are sheer personal, that is: not shared by others. It concerns incidents, not an enduring state of mental perturbation. Doubts expressed by outsiders are accepted. The border between ego and spiritual outer world is preserved and so is the ability to retreat from supernatural spheres to engage in the earthly order of the day. After-effects do occur in some cases. One may report, for instance, that usual worries are now viewed in a different way, less disheartening, or that one gathered a more thorough understanding of fellow-man. I consider mental conditions of this kind as just not pathological, even though the excursions in the supernatural may touch at the delusional and the hallucinatory, and the level of consciousness may come close to a state of trance. If one follows present day’s diagnostic rules to the letter they are to be qualified as maladies. I reject that notion. States of mind deviating considerably from the norm, but are apparently enriching, adding qualities to a personality, qualities that under normal conditions are absent or buried under ordinary commonness, should not be considered as sickness. Alternatively, one should acknowledge that (mental) sickness is not necessarily regressive, but may be creative. Creative malady; this is a credible concept that appeals to me [24]. The biblical prophets are perfect examples. According to present day’s diagnostic criteria they are ‘diagnosable’. Their writings, however, represent highlights in world literature, both from a literary and moral point of view. It would be presumptuous to qualify them bluntly as sick people. Their behaviors deviate considerably from the norm; their creativity was far above the norm. They are perfect examples of creative maladies.
3.2.6.4 Abnormal, pathological manifestations: religious psychosis Religious fancy and exaltation may break through the barrier of reality testing. The excursions beyond the horizon are not temporary anymore; they last. The reality one perceives, assumes the character of the reality. Visions are no fancies anymore, no effigies of an inner state but images of a ‘real’ transcendental world one is privileged to behold. The voice being heard does not originate in one’s own mind but is a voice out of that same transcendental reality.
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In that perceived reality one may change from onlooker, to player. One is, for instance Jesus, a particular prophet, a particular saint, a demon. Not short lived, as in a flash, the as-if character being preserved; not like an actor who has identified strongly with the character he impersonates but still being aware that he is an actor, but permanently and as expression of one’s true nature. Critical faculties get lost. Private religious ideas and spiritual experiences are no longer tested for plausibility; not critically compared with former thoughts or experiences nor with those of others. They are transformed into axioms. The individual gets overwhelmed by religious experiences and they begin to rule his life more and more at the expense of mundane routines. Distancing from them, let alone renouncing them becomes impossible. Mood varies individually between bliss about being chosen, serene confidence in one’s vocation and disquietude over the way one is discharging the imposed obligations. Thinking may become incoherent and behavior chaotic. Companions may feel increasingly uncomfortable. In short the religiously-driven has reached the endpoint of a religious odyssey, lost contact with the world around them, and entered a psychotic universe.
3.2.7
PRACTICAL CONSEQUENCES
The standpoint that religious receptivity is a normal component of the human experiential repertoire has practical consequences. First, a psychiatrist cannot ignore with impunity the domain of religion/spirituality. Religious history taking should become a routine in psychiatric diagnosing. What role does religion play in someone’s life? Does it provide support, cause strain, or does it seem irrelevant. Is he longing for spiritual up-lifts, or are his spiritual needs satisfied, dormant or non-existent. Are religious variables of etiological significance or, on the contrary, a support system. In both cases they should be incorporated in a therapeutic program. Being of potential diagnostic and therapeutic significance, this domain should, furthermore, be incorporated in training programs for residents in psychiatry, not as a frill but as one of the essential entries into man’s persona. Several professional organizations have recognized this. I mention the Royal College of Psychiatrists, the American College for Graduate Medical Training, the American Psychological Association, the World Psychiatric Association. What we are waiting for are detailed guidelines, what to teach, how it should be taught and by whom. In the third place, research should be encouraged. First diagnostic studies: broadly speaking studies into the role religious variables may play in the causation and course of psychiatric disorders. Some data are available. Studies by Braam et al. [25] and Koenig [26–28], for instance, demonstrate that in the depressed elderly religiosity may provide a degree of protection against depression and may facilitate remission. Religiosity was measured on two levels. Extrinsically, registering frequency of church visits and regularity of praying, and intrinsically, trying to gauge the genuineness of religious feelings and the import they have in someone’s life, their salience, relative to other concerns. It appeared to be the plenitude of inner religious life rather than the more formal aspects of religiosity that correlated with the risk of depression and its prognosis. The results so far mainly concern depression and seem encouraging, but much work remains to be done: The concept of stress has to be defined in greater detail; those elements of intrinsic
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religiosity with protective potential have to be established; those subtypes of depression particularly easily influenced by religiosity have to be determined, and mental disorders other than depression have to be studied as to responsiveness to religious contemplations. It also seems conceivable that religiosity might influence mental health in the reverse direction: undermining rather than boosting mental stability. Religion may act as a straight jacket, thwarting spiritual growth, inducing fear and emotionally ‘empty’ preoccupation with religious precepts. Instead of lightening and illuminating life, religion then becomes a burden, a source of worry. Religious beliefs may shrink to remorseful waiting until death arrives. The number of studies about religion as a destabilizing force is even smaller than that on the beneficial effects and thus few data are available. Furthermore, treatment studies, are in order, broadly speaking into the question of what role religious variables might play in psychotherapy and who in those matters might be the better practitioner: psychiatrist or (informed) pastor. Answers to these questions are lacking. For the time being, I presume the psychiatrist to be the preferential provider, on the condition that he disposes of sufficient denominational knowledge; feels at least some affinity with the spiritual needs of his patients; appreciates his lack of spiritual authority and hence is willing to consult the pastor if he threatens to be thrown off the scent; and finds himself capable of maintaining neutrality, suppressing the urge to evangelize or to secularize. The domain of religion/spirituality seems not only relevant for psychiatry but for medicine in general [26–28]. Several studies found that religious involvement and activities are associated with beneficial health outcomes, though these conclusions have been questioned [29–31]. Finally, basic studies, should be initiated, broadly speaking into the question of which components of the complex construct religiosity/spirituality are more relevant in inducing or mending mental perturbations, and whether suitable instruments are available to assess and measure those. If those were found to be wanting, new instruments have to be developed. Obviously the field of psychiatry and religion is wide open for discussion and research, promising both intellectual and spiritual rewards for those willing to take on the challenge.
3.2.8
DISCUSSION
1) Starting point of this treatise was tripartite: * Intellectual open-mindedness for religious concepts, and emotional susceptibility for religious experiences are normal ingredients of the human behavioral repertoire. * Existential incertitude is considered to be the essential characteristic of normal, mature religiosity. Incertitude prompts enquiry. Enquiry into the nature of the God-concept; the essence of the religious imperatives and precepts; Gods intentions with humankind, if any; the most plausible interpretations of scriptural texts; the reality or fictionality not of the so-called transcendental; the significance of all this in the life of the enquirer. The faithful is never sure of his ground. He is the ‘auto-dialectician’ per excellence, for whom the internal religious debate will never end. At best he will reach provisional conclusions, still open for debate. Religiosity and certainty are considered to be a contradiction in terms. As soon as certainty sets in, mature religiosity regresses. * Normality of a phenomenon implies that it may also occur in abnormal proportions, i.e. deformed or transformed towards a surplus or deficit. This also holds for religious phenomena.
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2) If religious receptivity is qualified as the norm, insensitivity for religious experiences (agnosticism) and reversed sensitivity (atheism: a condition in which religious expressions and considerations generate a sense of frustration and rancour rather than spiritual gratification) are to be considered as abnormal, though of course as such not pathological. This statement, no doubt, will get the brows of many an intellectual frowning. Yet, being constitutionally cut off from a valuable part of the experiential repertoire, or cutting oneself off from that, through intellectual reasoning, equates to emotional impoverishment. Loss of experiential capabilities can be qualified as impairment. If in the atheist missionary urge is budding, if he begins to view religion as a humanitarian threat danger looms. Religious belief, then, is considered to be an impediment, thwarting development of the mind; the believer is viewed as narrow-minded, and a prototypical non-intellectual. Religion has to be fought for the sake of a better, more mature society. In dictatorial regimes such fights may be fought, literally, with fire and sword. The atheist-crusader has been abundantly bred in communist societies. This character is a prototypical representative of pathological hyporeligiosity. 3) The most prevalent form of hyperreligiosity is what I call faith coagulation. In its milder forms this is a variant of the norm, but once into being, it shows a strong tendency to intensify, and to take on abnormal proportions. Coagulation means that the religious worldview solidifies, that seeking behavior makes way for spiritual immobility, that modesty – frere et companion of uncertainty – turns into arrogance. Basic elements of the belief system are not conceived anymore as preliminary formulations – because they were put through the sieve of human conceptual limitations – but as axiomatic truths. The notion that these elements are multi-interpretable and that those interpretations, as a rule, cannot be validated fades, and is replaced by the idea that the religious right has only one side: the one oneself adheres to. Understanding and respect for other faith-systems melt away, to be replaced by intolerance. Intolerance in its turn, paves the way for pressure on ‘aliens’ to accept the proper faith, spiritual pressure, economic pressure, even physical pressure, up to straight terror. It is clear that in this sequence the borders between variants, abnormal manifestations and pathological expressions of religious behavior are crossed. Further away from religious norm behavior lies religious fancy, an abnormal but not necessarily pathological form of hyperreligiosity. In that case religious symbols are being concretized, and religious experiences lose their as-if character; are transformed into concrete realities. Consciousness may periodically get clouded or restricted whereby the mysterious experiences get a mystic character. The idea may crop up to be commissioned with a divine charge. In those cases one may speak of religious exaltation. One still realizes that these considerations belong to one’s private sector, not being shared by others. They are for the one concerned real, penetrating and full of meaning all the same. Religious fancy and exaltation are not pathological as long as they remain controllable. If not, if the individual gets overpowered by fancy ideas and images, unable to distinguish between public and private views then one may speak of pathological exaltation or a religious psychosis. 4) Like atheism, faith coagulation may assume pathological proportions. Not only discrepant religious viewpoints are rejected, but so is the holder of those notions. Discrimination and rejection are imminent, and have all too often generated violence and persecution. Excesses of this kind have discredited religion and all of its tributaries. It contributed to the wholesale apostasy among the well-minded, i.e. those who diligently try to treat
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their fellow-man with due respect and for whom the concept of decency is not an inconvenient impediment on the way to self-determination. This secularizing effect is further magnified because clergy often failed to qualify such behavior for what it is: barbarian and in glaring contradiction with the very essence of religiosity: ‘Love your fellow as yourself, I am the Lord’ (Lev. 19:18). Intolerance perverts religious belief, corrodes its foundations and leads to faith rot. Once set in, treatment is quite hopeless. One must place one’s hope on prevention. Particular religious tenets and practices should be changed. Training of future ministers has to be brought under the general denominator of reconciliation, rapprochement and understanding, and to be detached from pedantry. Not dogmatics, but religious pliancy, should be taught, that is awareness that life’s essence can be contemplated from various premises. Outcomes differ, but one outcome is not inherently closer to the truth than the other. It is future clergy that will have to counteract and prevent further crumbling of organized religion. In recent years human beings, in many societies, became more emancipated. Emancipated people demand emancipated religion. Organized religions offered, by and large, the contrary. Dogmatics instead of discussion. Spoon-fed certainties instead of queries. Consequently emancipated people turned away, en masse. This is quite tragic, since religiosity persisted, and was left behind homeless. The reply I often hear is: you overestimate the intellectual and emotional sophistication of large segments of the population. They want clarity and certainties. I am not so sure, and my strongest argument is, again, the lack of popularity of dogmatized, ‘coagulated’ religion in large segments of the population. There is evidently a need for something else. Moreover, one should never underestimate one’s audience, approach them at the highest possible level, lest they feel undervalued and drop out. The suggested remedy clashes with some of the very root ideas of institutionalized religions. I know. The resistance against carrying them through will thus be enormous. Yet, it seems to me, that there is little choice. Going for a new departure, or becoming increasingly irrelevant. Emancipated religion, moreover, could have a tremendous positive impact on further emancipation and humanization of societies and the people within. 5) I emphasize once more that the ‘psychic apparatus’ does not know clear borders between the normal, abnormal and pathological. This holds for religious phenomena too. What’s more, phenomena, known to occur in psychiatric disorders, also occur in the normal population. Their distribution is continuous, though skewed. It seems likely that this holds for abnormal religious phenomena as well. 6) Religiosity is considered to be a normal component of the human experiential repertoire. Consequently, it is entitled to a permanent place in the thinking about the origins and treatment of mental aberrations. Religious history taking should become routine. Detailed guidelines should be drafted to introduce this field in training programs for residents in psychiatry. Instruments to measure religious variables should be investigated as to their utility and new ones developed if necessary. Research programs should be instituted into the beneficial or pathogenic ‘valence’ of religious variables and into the question of whether or not religion should play a role in psychotherapy. Religious variables should be taken seriously by psychiatrists, as much as nowadays biological, social and personality-related considerations are. Finally what truly is the key issue? Assuming that religious receptivity is indeed a normal attribute of man’s psychological equipment, it follows that devaluation and
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enfeebling of religious systems as has been happening over the past so many years, from a psychological vantage point, is a negative. By that, religious receptivity loses direction, lacking both a frame of reference and a matrix. This, in its turn, raises the question whether reconstruction of religious systems is conceivable and if so, under what preconditions. These questions remain largely undiscussed here. I have pursued them in a separate study [32].
3.2.9
SUMMARY
The starting point of this chapter is that religious receptivity is a normal component of man’s experiential repertoire, emphatically not a neurotic remainder of an infantile past. The considerations on which this standpoint is based are discussed and the concept of ‘normal religiosity’ is briefly elucidated. Taking for granted the normalcy of religious receptivity, one may expect abnormal expression-forms to occur: deformations, deficits and excesses. Abnormal religious manifestations are being discussed. Finally, some consequences arising from the postulated normalcy of religious receptivity are mentioned.
REFERENCES 1. Koch S (1981) The nature and limits of psychological knowledge. American Psychologist 36, 257–269. 2. Freud S (1927) The future of an illusion. In: Strackey J (ed.) The Standard Edition, Hogarth Press, London. 3. Safranski R (2000) En toch blijven de religieuze krachten behouden. Lecture for the Thomas More Academy and for the Radboud. Trouw, 21 October, pp. 46–47. 4. Heschel AJ (1965) God in Search of Man. The Jewish Publication Society, Philadelphia. 5. Wolters G (2005) Behavioural control: free will or neural processes (Dutch) De Psycholoog 24, 24–28. 6. Gillihan S and Farah MJ (1997) Is self special? A critical review of the evidence from experimental psychology and cognitive neuroscience. Psychological Bulletin 31, 76–97. 7. Pinker S (1997) How the Mind Works. Norton, New York. 8. Podhoretz N (2002) The Prophets. The Free Press, New York. 9. Shermer M (2000) How We Believe. The search for God in an age of science. Freeman, New York. 10. Neeleman J Personal communication. 11. Larson EJ, Witham L (1997) Scientists are still keeping the faith. Nature 386, 436–438. 12. Meacham J (2005) From Jesus to Christ. Newsweek March 28. 13. Peters ER, Koseph SA, Garety PA (1999) Measurement of delusional ideation in the normal population: introducing the PDI (Peters et al. Delusions Inventory). Schizophrenia Bulletin 25, 553–576. 14. Van Os J, Hansen M, Bijl RV, et al. (2001) Prevalence of psychotic disorder and community level of psychotic symptoms: an urban-rural comparison. Archives of General Psychiatry 58, 663–668. 15. Joseph R (1996) The limbic system and the soul. Evolution and the neuroanatomy of religious experience. In: Joseph R, (ed.) Neuropsychiatry, Neuropsychology, and the Clinical Neurosciences. Emotion, evolutions, cognition, language, memory, brain damage, and abnormal behavior. Williams and Wilkins, Baltimore (Maryland).
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16. Borg J, Andree B, Soderstrom H, et al. (2003) The serotonin system and spiritual experiences. American Journal of Psychiatry 160, 1965–1969. 17. Kendler K, Gardner C, Prescott C (1997) Religion, psychopathology, and substance use and abuse: a multimeasure, genetic-epidemiologic study. American Journal of Psychiatry 154, 322–329. 18. Lyons D, O’Malley A (2002) The labelling of dissent-politics and psychiatry behind the Great Wall. Psychiatry Bulletin 26, 443–444. 19. Van Praag HM (2001) Navigeren. Over professionele en spirituele bestemmingen in mijn leven (Dutch). Psyche en geloof. 12, 28–39. 20. Van Praag HM (2001) Psychiatrie en religie. Een persoonlijke ‘belijdenis’ (Dutch). In: Zock TH, Glas J (eds.) Religie in de psychiatrie, KSGV, Tilburg. 21. Stace WT (1960) Mysticism and Philosophy. Lippincott, Philadelphia. 22. Wulff DM (2000) Mystical experience. In: Gardena E, Lynn SJ, Krippner S, (eds.) Varieties of Anomalous Experience: examining the scientific evidence. American Psychological Association, Washington DC. 23. Maslow AH (1964) Religions, Values and Peak Experiences. Ohio State University Press, Columbus. 24. Van Praag HM (2003) De scheppende ziekte. Over (Joods-) religieuze elementen in het gestoorde zielenleven (Dutch). Psyche en geloof 14, 54–65. 25. Braam A, Beekman A, Deeg D, et al. (1997) Religious involvement and depression in older Dutch citizens. Social Psychiatry and Psychiatric Epidemiology 32, 28–291. 26. Koenig HG, George LK, Peterson BL (1998) Religiosity and remission of depression in medically ill older patients. American Journal of Psychiatry 155, 536–542. 27. Koenig HG (1997) Is Religion Good for Your Health? The effects of religion on physical and mental health, Haworth Pastoral Press, Binghamton NY. 28. Koenig HG, Hays JC, George LK, et al. (1997) Modelling the Cross sectional relationships between religion, physical health, social support and depressive symptoms. American Journal of Geriatric Psychiatry 5, 131–144. 29. Sloan RP, Bagiella E (2002) Claims about religious involvement and health outcomes. Annals of Behavioral Medicine 24, 14–21. 30. Ellison CG, Levin JS (2002) The religion-health connection: evidence, theory, and future directions. Health Education and Behavior 25, 700–720. 31. Dein S, Stygall J (1997) Does being religious help or hinder coping with chronic illness? A critical literature review. Palliative Medicine 11, 291–298. 32. Van Praag HM (2008) God en Psyche. De redelijkheid van het geloven. Visies van een Jood (Dutch). Boom, Amsterdam.
CHAPTER 3.3
Religion and Psychopathology: Psychosis and Depression Andrew C.P. Sims Emeritus Professor of Psychiatry, United Kingdom
3.3.1
INTRODUCTION
Psychoses and depressive disorders include three major groups of conditions: schizophrenia and related disorders, bipolar affective disorder and depressive illnesses – mild to severe. These could be referred to as Major psychiatric disorders. Religious psychopathology is concerned with the distinction between unusual religious experiences and manifestations of psychiatric disorder. Ascertaining the difference depends upon the skilled use of descriptive psychopathology. A brief review of the Jewish and Christian scriptures reveals little evidence of diagnosable psychiatric illness. Bizarre speech or behavior with religious coloring may be associated with psychotic illness, unusual religious experience or both. The relationship between religion and bipolar disorder is discussed and in particular how manic illness affects religious practice. When considering depression, religious belief and psychiatric diagnosis, a distinction between guilt and feelings of guilt has to be made. Caseness becomes relevant; at what point does understandable misery become depressive illness? The relationship between psychosis and depression and religious belief is complex and it is appropriate to explore the psychopathology of these phenomena.
3.3.2
MAJOR PSYCHIATRIC DISORDERS
When investigating the interaction between religious belief and practice and descriptive psychopathology, there are two important considerations. These can be simplified into: how people with religious beliefs manifest their psychiatric symptoms when they become mentally ill; and, how people with established psychiatric disorder express their symptoms in religious terms. Clearly, these two overlap to a considerable extent, but it will be a useful distinction to retain whilst considering the implications and the information of this chapter. An obvious corollary is the issue of distinguishing unusual manifestations of religion in a
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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person without mental illness from the symptoms, with religious content, of a major psychiatric disorder. For the purposes of this chapter, major psychiatric disorders are taken to include schizophrenia and related disorders, bipolar affective disorder, and depressive illnesses – mild to severe. The two currently recognized classifications in use in psychiatry are: The ICD-10 Classification of Mental and Behavioural Disorders, and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The ICD-10 Classification of Mental and Behavioural Disorders (ICD 10) designates these conditions: schizophrenia, schizotypal and delusional disorders, F20-29; and, Mood (affective) disorders [1]. Diagnostic and Statistical Manual of Mental Disorders, (DSM IV) gives, as general headings, schizophrenia and other psychotic disorders and mood disorders [2]. So, the two classifications are broadly similar when defining these conditions, and this forms the subject material with which we will be concerned. I would not want for one moment to imply that the rest of psychiatric disorder is ‘minor’. It is not; neither in terms of premature mortality, nor long term disability, nor suffering for the individual and his or her family and community. ‘Major psychiatric disorder’ is simply a convenient umbrella term to include the three distinct categories listed here. Why is it legitimate to discuss psychotic and affective disorders together? For both, organic factors are likely to be significant aetiologically, and physical treatments, mostly pharmacological, are likely to be effective. Both have long-term consequences for the patient, the family and social milieu, and for mental health professionals providing a service in terms of diagnosis and acute treatment, day-to-day care and prolonged surveillance and follow-up in the community. Both groups of conditions affect outcome: for life and survival, for functioning at work and in the home and a persisting need for care and management. Both types of mental illness affect all aspects of the person: cognition, affect, volition, feelings about self, body image and somatic symptoms. Affective symptoms had occurred in 17% of patients with schizophrenia at five-year follow-up [3]; thus the two conditions may concur with more than random likelihood. Some symptoms are shared, or may appear to be shared, by these different psychiatric illnesses, for example, delusions and disturbance of the thinking process. Finally, some have advocated a continuity theory of aetiology and clinical presentation for affective and schizophrenic disorders; this is not now in line with current understanding. David has written: ‘A tendency to reduce all psychotic disorders to ‘serious mental illness’ is unfortunate. It encourages a sloppy approach to history taking and the mental state examination, and a loose attitude to making a diagnosis and, if pursued, would prevent the discovery of specific treatments [4].’ For this chapter, because of the overlapping of features, but also the important differences between them, the three diagnostic entities will be considered both separately and together. It is rational to look at them in the same chapter, but it would be unacceptable to treat them as one entity. Schizophrenia has had a long and confusing conceptual history over the last two centuries; earlier it was mostly incorporated within the notion of dementia praecox, whilst Bleuler introduced the term schizophrenia in 1908 [5]. This is a long lasting, extremely disabling mental illness that causes suffering to the individual and other people. Onset is generally between the age of 15 and 45; males tend to develop the condition five years younger than females. The life-time risk for developing schizophrenia is about 0.8%, and the point prevalence 2.5 to 5.3 persons per 1000 of the general population. Higher rates have been found in certain parts of the world, for example, northern Sweden, Slovenia, western
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Ireland, Catholics in Canada and Tamils in South India; there have been lower rates found to occur in other places, for example, the Hutterite and Anabaptist communities of U.S.A. The overall incidence may be decreasing in industrialized countries at present. It is a serious mental illness, described as showing positive and negative symptoms. Positive symptoms include delusions, hallucinations and thought disorder, and negative symptoms, a chronic syndrome with loss of various mental abilities including affect, volition and socialization. Starting in early adult life, it may last for decades or permanently, and disrupts life patterns in marriage, work and relationships. It is associated with ill health and premature mortality, especially suicide. There is long term suffering, often with persecutory delusions and low mood. Mood disorders magnify human experiences with an exaggeration of all the emotions. Their psychiatric classification is unsatisfactory and it is probably best to consider bipolar affective disorders and depressive disorders separately, although in clinical practice there will often be overlap. These conditions can occur at any age although bipolar disorder tends to develop in younger adult life and recurrent depression typically becomes more persistent at an older age. The cardinal symptoms of depression are: emotional symptoms, psychomotor symptoms and negative beliefs; so, the symptoms of depression include: depressed mood, loss of interest and pleasure, loss of energy, confidence and self-esteem, feelings of self-reproach and inappropriate guilt, recurring thoughts of death and suicide, loss of concentration, agitation or retardation, sleep disorder and disturbed appetite and weight [6]. Depression may be acute, chronic or recurrent; mild, moderate or severe; and, with or without psychotic symptoms. Characteristically, in mania there is extreme elation of mood, gross over-activity and flight of ideas with pressure of talk. However, mixed affective states are not uncommon and a state of manic irritability may occur, which causes distress to the sufferer and those around him. For bipolar affective disorder to be diagnosed, episodes of both mania and depression must have occurred. The pathological mood of depression is frequently associated with excessive and inappropriate anxiety. Before discussing religious aspects of psychopathology, it is important to have described, in brief, the clinical features because that is how religious belief is expressed in the sufferer from mental illness. A recurring theme will be how belief colors the presenting symptoms of mental illness but the symptoms themselves arise from the specific nature of that psychiatric condition.
3.3.2.1
Religious experience or psychiatric symptoms?
So far, three psychiatric syndromes or symptom complexes have been described; a limited and two-dimensional outline conforming with psychiatric orthodoxy but giving little idea of the clinical reality for the individual case. However, such stereotypes are useful because they are formed from the composite of multiple individual variations. In this nosological approach, certain of the subjective experiences of people who, putatively, suffer from these conditions, are described as symptoms, thus implying that disease or disorder is indeed present. But, when we come to the field of religious experience, which of these unusual manifestations will be ascribed to psychiatric disorder, and regarded as evidence of illness? Belief, especially amongst some religious groups, also provokes unusual subjective experience and consequent behavior; sometimes this can be similar to what has been labeled psychiatrically disordered.
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In order to make a valid distinction, we need to go back to the essentials of descriptive psychopathology and the study of individual personal experience, which is fundamental to psychiatry. Descriptive psychopathology is the precise description and categorization of abnormal experiences as recounted by the patient and observed in his behavior [7]. There are two components to this: careful and informed observation of the patient, and phenomenology, which implies, according to Karl Jaspers, the study of subjective experience [8]. The descriptive psychopathologist is trying to hear what the patient is saying without any theoretical, literary or artistic gloss of interpretation, and without the mechanistic explanations of science used in the wrong context. In order to achieve understanding, phenomenology uses empathy as a precise clinical instrument. Jaspers has contrasted, in considerable detail, understanding with explanation. Understanding, in this sense, involves the use of empathy; it is a subjective evaluation of experience by the ‘understander’, using his or her own qualities of observation as a human being: feeling inside. Explanation is the normal work of natural science involving the observation of phenomena from outside, and objective assessment. Both are required of the practicing doctor, but whereas the method of observation in science is carefully and comprehensively taught, teaching the method of empathy to give subjective understanding is frequently neglected [9]. The evaluation of subjective experience is important, and it can be both predictive and quantifiable. When an individual is bereaved by losing a close relative, it can be predicted that he or she will experience misery and loss. It has been possible to quantify depressive symptoms and compare the degree of depression at different times in the same individual, or differences between individuals at the same time. Whereas most science is concerned with objectivity and with trying to eliminate the observer as far as possible from being a variable within the experiment, descriptive phenomenology tries to make evaluation of the subjective both quantifiable and scientific. When I make an assessment that my patient is depressed, I am, at least to some extent, making a subjective judgment based upon the experienced and disciplined use of empathy: ‘If I felt as my patient looks and describes himself to be, then I would feel . . .’ – this is followed by a description, from his account, of the patient’s subjective state, but using my capacity to feel misery. In psychopathology a distinction is made between form and content. This will be significant for our subsequent discussion of religious psychopathology. The patient is only concerned with the content of an experience: ‘God is telling me to throw away my belongings’, whilst the doctor needs to be concerned with both form and content: ‘is my patient’s belief that God is speaking to her factual; a misinterpretation; delusion; hallucination; or some other form?’ Content reflects the predominant concerns of the patient, for example, a person whose life has centered on money, and fears of poverty, may believe that she is being robbed. The form indicates the type of abnormality of mental experience, and this leads to diagnosis. The importance of this distinction between phenomenological form and content will recur for the rest of this chapter and is dealt with in more detail elsewhere [10]. The nature of form is very important in psychopathology, particularly in those conditions which form the subject of this chapter. Take, for example, the disorder of form, which we call delusion. Other types of experience can be mistaken for delusion; these may be unusual but healthy, or pathological. Delusion has certain characteristics of form. A delusion is a false, unshakeable idea or belief, which is out of keeping with the patient’s educational, cultural and social background; it is held with extraordinary conviction and subjective certainty [7].
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Delusion usually indicates the presence of mental illness, and therefore, it does matter whether this belief of the patient is a delusion, or not. Delusion is experienced as an ordinary notion or assumption rather than a belief, for example, ‘I know it was Susie who broke the champagne glass’, not, ‘I believe . . .’ as a credal statement. Delusion is, according to Jaspers, ultimately un-understandable, that is even putting oneself in that person’s position and seeing the world from their point of view, one is still unable to understand how they could hold that belief with delusional intensity [8]. A delusion is held on delusional grounds. A man knew, with absolute certainty, that his wife was being unfaithful to him. She was, but when he was asked how he knew he said that, ‘when he came out of his house and passed the fifth lamp post on the right, it had gone out. Then, I knew, with certainty, that she was unfaithful.’ Thus the belief was not false but the grounds upon which it was held were delusional. Delusions are held without insight: if someone wonders if they are deluded or not, they almost certainly are not. The person who is deluded does not usually hold the possibility of anyone else doubting what he believes. This, of course, is in marked contrast with religious belief, in which doubt is frequent. Concrete thinking occurs in some psychotic illnesses in which there are abnormal processes of thinking resulting in a literalness of expression and understanding. Abstractions and symbols are interpreted superficially, without tact, finesse or any awareness of nuance: the patient is unable to free himself from what the words literally mean, excluding the more abstract ideas that are also conveyed. This abnormality is concrete thinking. I have known of patients who interpreted literally, that is concretely, the scriptural injunction, ‘if your eye . . . your hand . . . offend . . . cut it off.’ Concreteness, as a psychopathological symptom, is useful in making a distinction between the disturbed thinking of the patient with schizophrenia and the description of internal experience of a person with strong religious beliefs [7].
3.3.2.2 Psychosis and depression in the Jewish and Christian scriptures There has been a vogue for claiming that unusual behavior or eccentricity, especially if it is socially unacceptable, must be madness. Apart from being erroneous, such accusations are unjust to the mentally ill, who do not choose to suffer the way they do. These imputations of mental illness would come, diagnostically, within our remit of ‘psychosis and depression’. Some of those hostile to religion, more often literary people rather than psychiatrists, have considered that amongst the rich characters of the Jewish and Christian scriptures, there are many who are ‘mad’. They would particularly cite colorful Old Testament prophets, such as Ezekiel. In fact, when one uses strict, psychiatric, diagnostic criteria with, for example, rigorously holding precisely to the phenomenological notion of ‘delusion’, clear examples of mental illness are rare in the Bible. Jeremiah was thrown into a miry pit, not because he was mad, but because the authorities knew only too clearly the rational message of what he was proclaiming, and they did not like it. The pictures portrayed by Ezekiel were extremely vivid but they do not in any way conform to what a psychiatrist would recognize as visual hallucination, and, phenomenonologically, they would be described, as vivid imagery; they also had significant spiritual and cultural meaning for the people to whom they were first addressed. The visions of Daniel would, similarly, be regarded as vivid imagery, and
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interpreting other people’s dreams, although remarkably unusual, is in no way an indicator of psychosis. Badness, evil and unrighteousness score high for mention in the Bible with a very large number of references. In contrast the Bible says virtually nothing about mental disorder [11]. The words mad, madman and madness are used in the Old Testament on 22 occasions, and in the New Testament 8. Usually these words are synonymous with pretending to be feeble, erring or foolish. Occasionally they are used to describe furious raving madness, ‘want of thought’ – anoia, and ‘wrong mindedness’ – paraphronia. As examples, David ‘feigned insanity’ in the presence of the king of Gath, apparently convincingly at the time [12]. When Jesus said ’I am the good shepherd . . . I lay down my life for the sheep’, many among the Jewish authorities said: ‘He is demon-possessed and raving mad’ [13]. When Paul is on trial before Festus, he is told: ‘Your great learning is driving you insane’, to which he responds ‘I am not insane, most excellent Festus . . . .’ and then he proceeds to argue his case most eloquently and rationally [14]. In the context of biblical reference to mental illness, there are four accounts that merit more detailed consideration: Kings Saul and Nebuchadnezzar in the Old Testament, and the stories of the healing of the epileptic boy and of Legion in the New Testament.
Case 1 What is the evidence that King Saul suffered from mental illness? He reigned from the age of 30 for 42 years; he is mentioned in about 40 chapters in the Old Testament books of 1 & 2 Samuel and 1 Chronicles; and his state of mind, physique and behavior are frequently described. Despite this relative richness of material, a cautious psychiatrist would consider that there is insufficient evidence, and would be reluctant to make a diagnosis; the few hints are far from conclusive. We read that Saul was a young man without equal in Israel, literally head and shoulders above his fellow soldiers. Before his anointing as King, his sensitivity led to him being concerned about not having a gift to bring to the prophet, and to realizing that his father would be anxious about his being away from home for too long. He was aware of his humble origins and he was initially quite shy about his newly exalted station. Several times we read that God changed Saul’s heart and the Spirit of God came upon him in power. As a result of this he joined in uninhibited dancing and in prophesying. When provoked by his enemies, ‘the Spirit of God came upon him in power and he burned with anger’. His anger was followed by effective and, by contemporary standards, appropriate military action. He could be magnanimous towards his detractors, but also he could be very foolish and he made several rash promises. Acquisition of power turned his head, and, not satisfied with the role of absolute monarch, he aspired to the equally powerful position of priest as well. This was utterly forbidden to him in Jewish law. In response to this, Samuel the prophet had to say, ‘You acted foolishly . . . your kingdom will not endure’. From this point onwards, no longer a young man, his life course and demeanor progressively deteriorates, everything goes wrong. He no longer obeys Samuel, he seeks to kill David who has been chosen to be his successor and he rebels against God. Every now and then there are chinks of insight and he admits to his unrighteousness, saying, ‘I have sinned’. His son Jonathan is frequently aware of his father’s foolish, unjust and homicidal behavior.
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Saul also shows extremes of mood. Both elation and despondency are described, at different times, as the Spirit of God coming upon him: ‘The Spirit of God came upon him and he started prophesying’ on at least two occasions. ‘An evil spirit from the Lord came upon Saul and he tried to pin David to the wall with his spear’. With one sort of spirit he was elated and disinhibited; with the other sort, he was miserable, despondent, filled with jealousy and homicidal rage. On one such occasion, he killed Ahimelech and all his family. Earlier on, the episodes of low mood could be relieved by music, especially David playing the harp. His murderous intentions were not just impulsive but also premeditated – he sent men to watch David’s house and kill him the next day. Saul was intensely afraid of David because he knew him to be ‘more righteous than I. You have treated me well but I have treated you badly‘. Saul’s life ends in him killing himself, but it would be described as heroic and altruistic suicide; he falls on his sword when he knows that the battle is lost. Saul may have experienced mental illness but it is difficult to make an unequivocal diagnosis with the given information. Perhaps he suffered from bipolar affective disorder, but this is not certain. There is evidence of mood swings, from ecstatic elation with disinhibited behavior and excited speech to profound depression with feelings of jealousy, envy and rage, and ultimately suicide: all these are potential indicators of this condition, but not pathognomonic. The elation had more of spiritual enlightenment than manic excitement, the despondency was a realistic reaction to his state, and his suicide was by no means typical of pathological dejection. All in all, the evidence is not convincing. We will now consider the other cases in less detail.
Case 2 We know about Nebuchadnezzar from the books of Jeremiah, Ezekiel and Daniel. His ‘madness’ occurred in the latter part of his reign, probably in mid- to old age [15]. His illness lasted for 7 months, during which time ‘he was driven away from people and ate grass like cattle. His body was drenched with the dew of heaven until his hair grew like the feathers of an eagle and his nails like the claws of a bird.’ This undoubted psychotic illness was prophesied a year before by the prophet Daniel, and was sent by God because the king had ascribed the powers of God to himself. Perhaps, these assertions are the beginnings of his mental illness. At the end of his illness, ‘I, Nebuchadnezzar, raised my eyes towards heaven, and my sanity was restored. Then I praised the Most High . . .’ What diagnosis would we now give to this undoubted mental disorder? The illness has sudden onset with no previous episodes, occurs in later life, recovery is also rapid, and, as far as we are told, permanent. I would want to give a differential diagnosis. The most likely would be: bipolar affective disorder, current episode manic with psychotic symptoms. Other less likely diagnoses are: 1) Schizoaffective disorder of the type that used to be described as late paraphrenia – but the onset, course and full recovery make this unlikely, or 2) some sort of organic psychosis, possibly substance induced. However, there is no supporting evidence, and the course is too long for delirium or an acute psychosis, and too short for dementia.
Case 3 In the story of the epileptic boy, recorded in the New Testament, causation is given as possession by an evil spirit [16]. The description of the fit is quite clear: ‘a spirit has robbed
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him of speech. Whenever it seizes him, it throws him to the ground. He foams at the mouth, gnashes his teeth and becomes rigid.’ We read that, ‘when the spirit saw Jesus, it immediately threw the boy into a convulsion . . .’ This case is interesting because there is no difficulty in making a diagnosis: epilepsy, which is regarded as a psychiatric condition in many parts of the world. Aetiology is stated as being possession by an evil spirit, and treatment was the removal of that spirit. The psychiatrist is left to ponder what that meant at the time, and what it means now.
Case 4 Legion, in the account in Luke’s gospel, had acquired his nick-name because ‘many demons had gone into him’ [17]. All the clinical detail we have is that for a long time the man had not worn clothes nor lived in a house, but lived in the tombs. ‘He was chained hand and foot and kept under guard.’ He was prone to violent outbursts and people were frightened of him; he was notorious locally. We are told that Jesus cast out these demons and they then entered into a herd of pigs. We do not know what the diagnosis would have been in this story in the gospels, but there is certainly no convincing evidence for anything like the phenomenology of modern-day schizophrenia. The Bible does not purport to be a textbook of psychiatry and never attempts to present symptoms for ease of psychiatric diagnosis! Looking for the signs of mental illness does little to help us understand, for example, Saul. That is not why we have the biblical account and the Bible does not give us that sort of information.
3.3.3
TRANSCULTURAL PERSPECTIVE
The problem with any writing on ‘Religion and. . .’ is that it immediately begs the questions, ‘which religion?’ and ‘are the conclusions valid for other religions?’ Religion and psychopathology is no exception. I have had the temerity to entitle this chapter, ‘Religion and Psychopathology’ as if I could comment on all religions and, therefore, know about all faiths and philosophies. Of course, this is not the case but there is a real dilemma here; the person who can state, objectively, ‘religion is, or says . . .’ in doing so puts himself outside religion, and all religion, each faith, can only be known about from inside. I hope that the disadvantage in what I have written of not being able to speak for all religions is outweighed by knowing well the subjective experience of one type of believer. There are two-fold, opposite dangers in studying any topic, such as ‘religion and psychopathology’, from a transcultural perspective. First, one may study the phenomena – religious belief – in different cultures so superficially that one concludes that they are similar across societies and can therefore be treated as equivalents. Second, one realizes that what people are describing from different cultures represent subjective experiences which are radically different, and therefore analogies cannot be drawn. Of these the first is more dangerous because it is more seductive. In considering religious psychopathology the topic of spirit or demon possession can be a useful example of transcultural differences; if it occurs in the context of psychiatric illness, the condition is quite likely to be psychotic [10]. Descriptive terms such as witch, demon,
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spirit, devil, jinn (genie in English), possession have different meanings, and convey different impressions, around the world. From my own limited knowledge, a description of communicating with the spirits of ancestors in Zambia is not the same phenomenon as describing belief in the malign influence of jinn in Pakistan, which is different again from demon possession as experienced by members of a Yorkshire Pentecostal church. The spirits dealt with by a jhankri, or spiritual healer, in Hindu Nepal, or a varama, a healer with special powers in Buddhist Sri Lanka, are also different. Around the world people are not describing precisely the same event, process or experience although they all accept the existence of an immaterial realm. Bavington has demonstrated that in many countries mental illness is believed to be directly due to evil spirits or the influence of magic on the victim [18]. Expatriates felt some reluctance to intervene medically. Western-trained doctors found that they could not help patients who were convinced that they were demon possessed, some of whom ‘died of fear’. Bavington has little doubt that many sufferers from readily identifiable and treatable mental illnesses, especially psychotic disorders, did not receive psychiatric treatment because of the shared belief, by patient and doctor, that the symptom was attributable to evil spirits. A marabout, or native healer, in the Gambia, specialized in treating mental disorders with disturbed behavior – often psychoses in our diagnostic systems. He would ask about his patient’s dreams, sometimes these were perceived as devils seeking to kill the patient. To make a diagnosis he looked at the palms of the hands, the life-lines. Treatment consisted of local herbs and roots, saying verses of the Koran to the patient – and then beating him on the head! Advice has been written for medical practitioners who are faced with patients believed to be possessed by jinn (spirits), in a Muslim culture [19]. A 25-year-old woman was considered by her doctors to be depressed and treated, unsuccessfully, with electro-convulsive therapy. Her family believed her to be possessed by jinn and, after recitation of the Koran and prayer with a faith healer, she recovered completely and remained well five years later. On the other hand, another family also considered a woman, aged 35, to be possessed by jinn and she was treated traditionally. She deteriorated physically, was transferred to hospital and treated successfully for cerebral malaria. If the topic of spirit possession is viewed from a world perspective, the subject is complex; any simple answers to questions are almost certainly inadequate. Sensible doctors, with a ‘foot in both camps’, will look at the issue from both a spiritual and medical standpoint, and recommend the patient and family to do likewise. This is recommended by Sheikh, an academic general practitioner advising on doctors dealing with jinn [20]. It is important to listen to what the putatively possessed person and their family says about their experience, in terms of cause, concerns and expectations, and to know about their cultural and religious background. This may make the description by the subject understandable and even reasonable to the outside observer. It is not necessarily either mental illness or spirit possession, but can be both.
3.3.4
PSYCHOSIS AND RELIGION INTERACTING
Religious belief occurs fairly frequently within the general population, and psychotic, most frequently schizophrenic, symptoms and experience are not uncommon. Therefore, for statistical reasons these two modes of expression will sometimes occur together.
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Aetiologically, they are not connected. A person with previous religious beliefs, on becoming psychotic may well have religious content in his delusions. However, schizophrenia has not caused those beliefs to be religious. Neither does religious belief, of itself, cause schizophrenia. The content of delusions follows the predominant cultural and individual preoccupations of that person. The defining characteristic of psychosis is delusion, not auditory hallucination. Delusion, in British law, has been a fundamental feature of insanity since the statement of Lord Erskine defending Hadfield, who, when clearly mentally ill, fired at King George III in 1800 [21]: ‘Delusions therefore, when there is no frenzy or raving madness, is the true character of insanity.’ Schizophrenia is usually considered to reveal a disturbance of brain function. There is a significant genetic factor for most psychoses, aetiologically, and treatment is predominantly physical, usually pharmacological. However, we would not now think of this being a localized condition but much more a disturbance of neuronal networks. This complexity has been described by Liddle: ‘Not only is the information collected by sensory systems evaluated in the light of a vast and idiosyncratic compilation of information derived from previous experiences and a sophisticated estimation of future needs, but the motivation that governs the selection of action often appears to reflect a very abstract representation of the imperatives (self-defence, satisfaction of hunger and thirst, and reproduction) that govern animal behaviour [22].’ The psychiatrist is called upon to see an individual expressing bizarre religious ideas, amongst other psychological phenomena. The psychiatrist will have to determine whether these notions are evidence of psychopathology, or simply unusual individual or cultural beliefs. It is quite possible for a person to suffer from schizophrenia and to hold religious beliefs, and for the two not to be causally connected. As schizophrenia is a severe illness with serious and long-term consequences, it is important to make the distinction between religious belief and psychiatric symptom. Sometimes we are confused by the language the patient uses, for example, ‘the Lord led me to . . .’ This expression could be used by either a religious believer or someone suffering from a psychotic condition. Table 3.3.1 compares the differences. In the course of psychiatric interview, the subject uses the expression: ‘The Lord led me to . . .’ Is this evidence of mental illness, especially schizophrenia? A religious person will use that expression in a spiritual or metaphorical sense. It may only be retrospectively that he or she realizes the Lord was leading; there was no perceptual experience of leading. Behavior subsequently is sustained and directed towards the goal the person believes was indicated; it is meaningful. Even though the person uses expressions like ‘Jesus came into my heart’, the expression does not imply any invasion of ego boundaries. Belief is held alongside the possibility of doubt, or at least that other people could have doubts. Table 3.3.1
‘The Lord led me to . . .’
Religious Metaphorical, spiritual Sustained, meaningful, goal-directed * No loss of boundaries of self * Beliefs alongside possibility of doubts
Schizophrenic Concrete, physical Unreasonable, bizarre, concrete and trivial * Loss of boundaries; delusional evidence * Delusions etc accepted without doubt
*
*
*
*
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Features suggesting psychiatric morbidity
Conforms with known psychiatric symptoms. Symptoms of mental illness in other, non-religious, areas of life. Life style consistent with psychiatric disorder. Concrete ideas acted on literally.
For the person suffering from schizophrenia, the experience of being led is concrete, physical. There may be a percept of hearing a voice or feeling pressure on the body. What the person says they have been led to do may seem, to the observer, unreasonable, bizarre or trivial. It may be concrete, for example, a literal cutting off the hand when it offends. There is loss of the boundaries of self; this can be seen with ideas of passivity, for example, the person believes that God has actually moved their arm to make a protest. Beliefs may be held on delusional evidence. Delusions are held like ordinary assumptions, and without any doubt. There is no understanding that other people may not be able to share their beliefs. In making the distinction between religious belief and psychotic symptoms with religious content, there are various criteria one can use, although it can sometimes be difficult. Psychiatric morbidity would be suggested by the features in Table 3.3.2 [23]. Both the subjective experience and the observed behavior conform with psychiatric symptoms, that is, the self-description of this particular experience is recognizable as being within the symptomatology of a known psychiatric illness, for example, it has the form of delusion. An in-patient believed with absolute certainty that everyone coming in to her ward in the hospital nodded in her direction because they knew that she was ‘a secret emissary of the Holy Spirit’. There are recognizable symptoms of mental illness in areas of life other than religion; delusions, hallucinations, disturbance of mood, thought disorder, and so on. A person with religious delusions also believed that gas was coming through her front door and making her unconscious sporadically. The lifestyle, behavior and direction of personal goals of the individual subsequent to the event or religious experience are consistent with the natural history of mental disorder rather than with a personally enriching life experience. The manner of life is compatible with the conditions in which delusions occur. I once visited a young man living on his own without any occupation in a filthy, chaotic one room flat whose only friends and contacts were in his church. Other aspects of his conversation confirmed the diagnosis of schizophrenia suggested by his life style. Ideas, beliefs, notions are held concretely and acted on literally. The presence of God in the life of the individual may be experienced, for example, as a physical reality that can be located in a specific part of the body. With the indicators in Table 3.3.3, the experience is more likely to be intrinsic to the person’s belief and less likely to denote psychiatric illness. The person shows some degree of reticence to discuss the experience, especially with those he anticipates will be unsympathetic. The believer, describing a religious experience, will choose carefully to whom he or she talks, the situation in which this conversation takes place, for example, perhaps just the two of them, and the words and phrases used in description. It is described unemotionally with matter-of-fact conviction, and appears ‘authentic’. There is often a degree of surprise that they have had such an experience.
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Table 3.3.3
Features suggesting religious experience without mental illness [10]
In keeping with that individual’s cultural and social background. Not necessarily held on demonstrably delusional grounds. * Religious beliefs are spiritual, abstract, and not concrete, physical. * Religious beliefs are held with insight; the believer can understand others not believing, and he or she may have some doubts. * Reticence and sensitivity in describing the experience. * Religious experience described with unemotional conviction; ‘authentic’. * Doubting by others is accepted and understood. * For religious people without mental illness, bizarre thoughts and actions do not occur in other areas of life, not connected with religion. * Experience makes demands for future activity. * Conforms with religious traditions. * *
The person understands, allows for and even sympathizes with the incredulity of others. He may have doubts concerning the meaning of the experience for himself; he certainly understands that others may have doubts. He usually considers that the experience implies some demands upon his own life. It would be normal for an enriching experience to be followed by increased dedication to religious activity that the person believes to be morally right and appropriate. The religious experience conforms with the subject’s recognizable religious traditions and peer group. One can see certain patterns emerging in different religious traditions, for example, ‘speaking in tongues’, ‘slain in the spirit’.
3.3.5
MANIA AND RELIGIOUS EXPRESSION
For bipolar disorder to be diagnosed, the two pathological states of depression of clinical severity and mania, or its lesser form, hypomania, have both to have been present, either in the same episode or in different episodes through life. Depression will be dealt with in the next section; here we are concerned with mania. Hypomania is an unsatisfactory term; it is as if the clinicians are unable to make up their mind: is it illness or is it simply the expression of an exuberant personality? We do not describe a state of hypo-depression when we cannot make up our minds whether depression has reached ‘caseness’, a clinical degree of severity, or not, so why should we do this for mania? This pedantic point becomes important when we are considering religious behavior. For many of the minority Christian groups who have been established in Britain over recent decades, especially among Afro-Caribbean immigrant communities, expression of faith is much more flamboyant than what has been traditional in the host community. It is easy for the inexperienced psychiatrist to interpret such exuberant behavior as hypomania, ‘hedging their bets’ as to whether it is really pathological or not. Obviously, this is potentially harmful for patients. If they are truly manic, they require treatment; if they are not mentally ill at all, they should not have received a psychiatric label. The term ‘religious mania’ is still occasionally used in the present day by non-psychiatric medical people and the media, although it has been unacceptable in psychiatry for a long time. The notion was that too much religion, like genius, was supposed to drive you mad.
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Both these hypotheses are, of course, fallacious. The term was dangerous for the reputation of both the patient and religion itself. As well as being a description of a current disturbed mental state, mania, it also contained a causative explanation – this person is manic because of religion. This confusion of thinking has been recognized for a long time: George Savage, previously of Bethlem Royal Hospital, wrote in 1886: When two people talk of religious mania, they often confound two things; first, the cases in which patients are constantly speaking about religious matters, more especially those who are forever repeating texts, or with hand wringing and melancholy aspect, are complaining that their souls are lost; and next, the cases which appear to have been produced by some religious movement. There is a very great distinction to be made between the many cases which exhibit some religious symptoms and the few which are really caused by religion itself . . . As a rule, however, religious insanity, so called, is the symptom, not the cause of the disorder [24].
In order to resolve this dilemma we require a rigorous application of descriptive psychopathology. It is the phenomenological distinction between form and content that is important here. Form, in this situation, is the class of subjective experience, mania, with its psychopathological features, which may reveal diagnosis, while content is determined by the cultural context, in these cases religion. This makes the expression religious mania more readily understood; the form may well be mania as part of a major, bipolar affective disorder, with pressure of talk, flight of ideas, grandiosity, over-activity and so on, while the content, because of the patient’s predominant interests, is religious. That is, mania (ICD 10, F30.1) [1] with one or more of the usual causes of affective disorder, none of which are religious belief, developing in a person with religious convictions.
Case 5 A bright undergraduate, in his second year studying history, with no background experience of religious practice, either at home or at school, made several friends who were within an active Christian group in the university. During the spring term an evangelistic mission was held, with an eloquent visiting speaker explaining the elements of the Christian faith and how these made demands upon the individual. This student was very moved by these talks, alternating between almost ecstatic excitement and profound gloom and despondency. He could not sleep. He wrote incessantly about his own internal spiritual experiences and wanted to talk all the time about spiritual matters. At times hewas laughing and singing, and at other times crying. He could not concentrate on his work. This state lasted for about six weeks, and during this time he had changed from being a person who had no religious beliefs to one who described himself as a Christian ‘through accepting Christ as my personal Saviour’. When he returned home for the holiday, he told his parents about his experience and they were both extremely worried about him. His father was a urologist, and he wondered, with little knowledge or experience of psychiatry, whether his son was developing schizophrenia. Meanwhile, at home, the young man was avidly reading the Bible, seeking out a like-minded Christian group in his home town and talking to his family and his old friends from home about his newly found faith. His father remained concerned about him and, through medical contacts, arranged for him to be seen by a doctor with an interest in psychiatry in the University Health Service
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on his return to college. By this time, he was sleeping normally and managing to resume his studies, but his faith and his Christian friends were still his major preoccupation. He graduated a year later and moved to a new city to start his employment. He retained his active faith, made new friends and joined a church in his new town. Over many years subsequently he did not show any characteristic signs or symptoms of either mania or depression. In early middle age, however, he did change his employment, and became a clergyman. Fortunately, this case was well handled. If he had been referred to an unwise practitioner at the time of his maximal excitement, he could easily have received an inappropriate psychiatric diagnosis, most likely ‘hypomania’, and this could have blighted the whole of his subsequent career.
Case 6 During Sunday morning service in a suburban church, a man in his thirties got up from his seat, went to the front of the church, grabbed the candlesticks and threw them on the floor, shouting that they were ‘an abomination to the Lord’. The congregation, including old people and children, none of whom had ever seen him before, were very upset. After a few minutes of disruption, the man left the church. Later on that day the man was seen throwing stones at children in a park whilst shouting that they were damned. The police were called and the man was admitted compulsorily to psychiatric hospital. It transpired that he had come that day from another part of the country, where he was well known to mental health services. He had had several episodes of bipolar disorder, mostly manic, and had been admitted to hospital on many occasions, sometimes compulsorily. He had been on maintenance therapy with lithium carbonate for some time but had recently had an altercation with the community psychiatric nurse responsible for his ongoing care. As a result, he had stopped all his medication, packed his few belongings and taken a bus to the city where he caused the disturbances. For a long time he had believed that certain religious groups were trying to take over the country, and these ideas had previously exploded into violence when associated with manic episodes.
3.3.6
DEPRESSION AND RELIGIOUS BELIEF
One of the key symptoms of depressive disorder is feeling guilty; this may be expressed as ideas of guilt and unworthiness. This is elaborated in more detail in DSM IV: ‘feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)’ [2]. It will readily be seen how this symptom in particular can readily be confused with that sort of religious belief, in which there is an emphasis on personal responsibility and sin. Delusion of guilt, occurring in a person with strong religious belief, is well demonstrated by the English poet, William Cowper (1731–1800). He suffered from bipolar disorder throughout his adult life, with many episodes of severe, sometimes psychotic, depression, and a few of mania, which were less severe. He wrote many of the best known hymns in the English language, and also humorous verse, such as the poem: ‘John Gilpin was a citizen of credit and renown . . .’ This was written in a state of elation during a manic episode when he
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was described as being ‘too happy to sleep’. During an episode of psychotic depression in later life he wrote these lines [25]: ‘Hatred and vengeance, - my eternal portion, Scarce can endure delay of execution, Wait with impatient readiness to seize my Soul in a moment’.
Another example of delusions of guilt and unworthiness is the sonorous letter from a. patient, cited by Emil Kraepelin [26]: ‘I wish to inform you that I have received the cake. Many thanks, but I am not worthy. You sent it on the anniversary of my child’s death, for I am not worthy of my birthday; I must weep myself to death; I cannot live and I cannot die, because I have failed so much, I shall bring my husband and children to hell. We are all lost; we won’t see each other any more; I shall go to the convict prison and my two girls as well, if they do not make away with themselves because they were born in my body.’ Of significance for both of these examples is that they are clearly profoundly depressive in mood, psychotic, that is out of touch with reality, in form and permeated by religious ideas of guilt and damnation. In guilt feelings the guilt described tends to be inappropriate, excessive, unreasonable and out of proportion (for example, a patient who felt profoundly guilty for not feeling any affection for her husband). From the practical, psychiatric point of view, such delusional guilt may be dangerous because, rather than present for appropriate treatment for severe depression, the patient may regard the profound feelings of misery as justifiable punishment for past sins, and commit suicide. Fortunately but ironically, it is often only their religious faith that prevents such people from taking their own lives. It is very important for the psychiatrist to make a clear conceptual difference between guilt and guilt feelings. Guilt is a legal and moral concept applied to wrong acts – the person who is legally and morally guilty may or may not have feelings of guilt. Feeling of guilt is a subjective state, a symptom, and may or may not be associated with legal guilt. In the condition of depressive illness, feeling of guilt is not appropriate in nature or severity to the action of the sufferer. There is now considerable evidence in terms of outcome from depressive illness for those with religious belief and practice. This has been summarized from the detailed collection of data published by Koenig et al. [27]; it therefore represents a meta-analysis from different sources. From mostly American research literature, those with Christian belief and practice tend to have a lower risk for developing depressive disorder and depressive symptoms. Those who are involved in religious community activity, and/or those who highly value their religious faith, are at reduced risk for developing depression, and recover more quickly from the established condition. Organizational religious activities appear to result in most benefit, rather than private religious activities. Religious involvement helps people cope with stressful life circumstances, with consequent lower likelihood of depression. Religious or spiritual activities may lead to a reduction in depressive symptoms. Although the research literature is overwhelmingly in favor of a better outcome associated with religious belief, in terms of less likelihood in developing depression, a better response to treatment, shorter course of illness and better outcome there were a few disadvantages of belief. The favorable outcome summarizes many papers; disadvantages have only been described in single papers:
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With unmarried adolescent mothers, one paper reported higher rates of depression in those who were more religiously active [28]; this was not altogether surprising as the study was conducted within a religious establishment. It has been claimed that there are negative effects of religion on mental health when there is emphasis on original sin [29]. However, this is an assertion rather than a research based finding. Although religious belief tended to protect people from some life crises, it was less likely to do so when religious people faced family as opposed to other sorts of problem [30]. Religious leaders have rightly criticized psychiatrists for medicalizing depression and unhappiness [31]. Most psychiatrists have long worked with a concept of ‘understandable misery’, which they would not regard as illness. Recently there was a debate in the British Medical Journal: ‘Is depression overdiagnosed?’ [32] The two Australian psychiatrists involved in the debate took opposite positions: Yes – Gordon Parker, No - Ian Hickie. Of course, both authors were correct. We are medicalizing sadness but also we miss treatable cases of depressive disorder. The religious aspect in this dilemma is that if we, as psychiatrists, were more prepared to co-operate with ministers of religion, we would greatly benefit the total well-being of our patients. From the psychopathological standpoint, if we were more careful to assess the symptoms and only make a diagnosis when diagnostic criteria are fulfilled, again we would be saving our patients from inappropriate treatment for a disease they do not have.
3.3.7
CONCLUSION
Study of the religious psychopathology of psychosis and depression is of considerable, practical significance: especially for victims, who may become patients, but also for religious leaders and mental health professionals, and society in general. Making a wrong diagnosis and coming to a mistaken opinion may have dire consequences. ‘Major psychiatric disorder’ includes schizophrenia and related disorders, bipolar affective disorder and the depressive disorders. Paying attention to the fundamentals of descriptive psychopathology is helpful in making the important distinction between unusual and flamboyant but mentally healthy religious experience and the symptomatology of mental illness.
REFERENCES 1. World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders, World Health Organization, Geneva. 2. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th edn. American Psychiatric Association, Washington DC. 3. World Health Organization (1979) Schizophrenia: An International Follow-up Study, Wiley, Chichester. 4. David AS (2000) Diagnosis, classification, and differential diagnosis of schizophrenia. In: Gelder MG, Lo´pez-Ibor JJ & Andreasen N New Oxford Textbook of Psychiatry, Oxford University Press, Oxford p. 581. 5. Berrios G (2000) Schizophrenia: a conceptual history. In: Gelder MG, Lo´pez-Ibor JJ & Andreasen N (eds) New Oxford Textbook of Psychiatry, Oxford University Press, Oxford, pp. 567–570.
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6. Bech P (2000) Clinical features of mood disorders and mania. In: Gelder MG, Lo´pez-Ibor JJ & Andreasen N (eds.) New Oxford Textbook of Psychiatry, Oxford University Press, Oxford, pp. 682–688. 7. Sims A (2003) Symptoms in the Mind: An Introduction to Descriptive Psychopathology, 3rd edn. Saunders, Edinburgh. 8. Jaspers K (1959) General Psychopathology, 7th edn. (transl. Hoenig J and Hamilton MW, 1963) Manchester University Press, Manchester. 9. Sims ACP (1992) Symptoms and beliefs. Journal of the Royal Society of Health 112, 1, 42–46. 10. Sims A (2009) Is Faith Delusion? Continuum, London. 11. Sims ACP (2006) What is mental disorder? In: Beer MD & Pocock ND Mad, Bad or Sad? Christian Medical Fellowship, London, p. 3. 12. 1 Samuel 21:13 The Holy Bible: New International Version. Hodder & Stoughton, London. 13. John 10:14–20 The Holy Bible: New International Version. Hodder & Stoughton, London. 14. Acts 26: 24, 25 The Holy Bible: New International Version. Hodder & Stoughton, London. 15. Daniel 4: 28–34 The Holy Bible: New International Version. Hodder & Stoughton, London. 16. Mark 9: 14–27 The Holy Bible: New International Version. Hodder & Stoughton, London. 17. Luke 8: 27–33 The Holy Bible: New International Version. Hodder & Stoughton, London. 18. Bavington J (1985) Mental health. In: Browne SG Heralds of Health: The Saga of Christian Medical Initiatives. London: Christian Medical Fellowship, London, p. 199. 19. Khalifa N & Hardie T (2005) Possession and jinn. Journal of the Royal Society of Medicine 98, 351–353. 20. Sheikh A (2005) Jinn and cross-cultural care. Journal of the Royal Society of Medicine 98, 339–340. 21. West DJ & Walk A (1977) Daniel McNaughton: His Trial and the Aftermath. Headley Brothers, Ashford. 22. Liddle PF (2001) Disordered Mind and Brain: The Neural Basis of Mental Symptoms. Gaskell, London, p. 3. 23. Sims ACP (1992) Symptoms and beliefs. Journal of the Royal Society of Health 112, 1, 42–6. 24. Savage GH (1886) Insanity and Allied Neuroses: Practical and Clinical, 2nd edn. Cassell, London. 25. Cowper W (1822) Lines written during a period of insanity. In: Bruce J (ed.) The Poetical Works of William Cowper, Volume III. Bell and Daldy, London, p. 340. 26. Kraepelin E (1905) Lectures on Clinical Psychiatry, 3rd edn. (transl. Johnston T, 1917) W Wood, New York. 27. Koenig HG, McCullough ME & Larson DB (2001) Handbook of Religion and Health. Oxford University Press, Oxford. 28. Sorenson AM, Grindstaff CF & Turner RJ (1995) Religious involvement among unmarried adolescent mothers: a source of emotional support? Sociology of Religion 56, 71–81. 29. Branden N (1994) The Six Pillars of Self-Esteem. Bantam, New York. 30. Strawbridge WJ, Shema SJ, Cohen RD, Roberts RE & Kaplan GA (1998) Religiosity buffers effects of some stressors on depression but exacerbates others. Journal of Gerontology (social sciences) 53, S118–S126. 31. Carey G (1997) Towards wholeness: Transcending the barriers between religion and psychiatry. British Journal of Psychiatry 170, 396–397. 32. Parker G & Hickie I (2007) Is depression overdiagnosed? British Medical Journal 335, 328–329.
CHAPTER 3.4
Obsessive Compulsive Disorder and Religion: A Reconnaissance Harold J.G.M. van Megen Psychiatrist and Director of the Psychiatric Residency Training Program, The Netherlands
Dianne A. den Boer-Wolters Junior Doctor, The Netherlands
Peter J. Verhagen Psychiatrist and Theologian, The Netherlands
3.4.1
INTRODUCTION
From the early descriptions of Obsessive Compulsive Disorder (OCD) on, a relationship between OCD and religion has been proposed. Of the numerous opinions expressed on this matter, Sigmund Freud’s view is probably the most well known. In his Zukunft einer Illusion he considers religion and culture in general as a human attempt to control their instincts. This strategy was necessary to avoid total anarchy. Freud points to the fact that as a consequence of people’s suppression of instincts (sexual and aggressive impulses), they have to give up its independency, in return they receive a quieter and more secure existence. Although necessary to maintain a livable equilibrium, this is filled with ambivalence. Freud is definitely a non-believer, an atheist, who sees no use/benefit/function in religion. On the contrary, he points to the possible danger of a dependant relationship between the believer and his god. Trust in one’s own observations and intellectual functioning would free the person from this possible dependency and give rise to personal growth [1]. The obsessive compulsive neurosis, as OCD is referred to in Freudian vocabulary, is considered likewise. According to Freud, the neurotic patient too is mainly occupied in attempting to suppress forbidden, aggressive and sexual strivings and impulses which torment him. The obsessive compulsive (OC) symptomatology clarified from Freud’s so called structural perspective (Super-ego/ego/id), is therefore a compromise between the firm Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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super-ego demands on the one hand and the claims from the id on the other hand. The occupation with the OC-symptoms serves as a distraction from anxiety provoking, forbidden, libidinous impulses. Obviously, this ‘neurotic’ solution to the conflict is only partly successful, regarding the hours the patient needs to be occupied. To put it more bluntly, because it is unacceptable for religious (read: conscientious, scrupulous) people to act upon their aggressive and/or sexual impulses or even to admit they have such impulses, they are more sensitive to developing compulsions [1, 2]. Freud was not the first to suggest a relation between OCD, morality and religion. The first description goes back to the sixteenth century of the Church Fathers. John Moore [3] stated in 1562: ‘Naughty and sometimes blasphemous thoughts arose in the minds of certain worshippers, despite their attempts to suppress them, and despite their being good moral people’. ‘Bad men’, he commented, ‘rarely know anything of these kinds of thoughts’. Other examples of the possible relationship between OCD and scrupulosity are the personal experiences of two important church leaders in the history of Christianity: Ignatius of Loyola (founder of the Society of Jesus; the Jesuit order) and Martin Luther (church reformer and founder of Protestant Christianity). Ignatius of Loyola struggled with blasphemous obsessions and obsessions about the question of whether he had sinned or not. He described his personal experience in his book Spiritual Exercises [4]. ‘After I have trodden upon a cross formed by two straws, or after I have thought, said or done some other thing, there comes to me from without a thought that I have sinned; I feel some uneasiness on the subject inasmuch as I doubt and do not doubt; this is probably a scruple and temptation suggested by the enemy’. ‘According to Ignatius, the basis of scrupulosity is an inclination in devout people to go too far in the right direction, to be too cautious, too safe, too sure about pleasing God and too anxious to be certain that they have not sinned’ [3]. Another example from a leading figure in the history of Christianity is Martin Luther. He struggled with scruples concerning whether his confessions were detailed and perfect enough to be absolvable. This sometimes resulted in over six hours of confession after he could still go out and think of another detail in his confession he had omitted [3]. This example shows that Luther suffered from a subform of OCD, namely perfectionism. Correctly or mistakenly, for decades people have suggested a relationship between OCD and religion. This putative relationship calls up several questions: *
* * *
What is known about the phenomenology and epidemiology of OCD in relation to religion? Do religious people make use of the same cognitive strategies as OCD patients do? Is it possible to make a distinction between OCD symptoms and religious rituals? What is known about the treatment of religious obsessive compulsivity?
3.4.2 PHENOMENOLOGY AND EPIDEMIOLOGY OF OCD IN RELATION TO RELIGION In order to be able to elaborate in more detail on the relation between OCD and religion, it is of importance to first define OCD as an illness. In accordance with the Diagnostic Systematic Manual of Psychiatric disorders, revised edition IV (DSM-IV TR) people suffer from either obsessions and/or compulsions for at least one hour a day (APA 2005). Obsessions are defined as persistent and recurrent thoughts, impulses or images that are
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experienced at some time during the disturbance as intrusive and inappropriate, and which cause marked anxiety or distress. Thoughts are not simply excessive worries about real-life problems. People attempt to ignore or suppress such thoughts, impulses or images or to neutralize them with some other thought or action. It is important that the person recognizes that the obsessional thoughts stem from their own mind, this as distinct from and contrary to the delusion, by which deviant thoughts are felt as ego-syntone. Compulsions on the other hand are defined as repetitive behaviors (hand washing, ordering, checking) or mental acts (e.g. praying, counting words in silence) that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The behavior or mental acts are aimed at preventing or reducing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. The severity of OCD symptoms is measured with the Yale-Brown Obsessive Compulsive Scale [6]. The scale ranks from 0–40, the higher score implying a more severe form of OCD (for example: a Y-BOCS score of 28 points means that patients suffer approximately 12 hours a day from obsessions and/or compulsions). Apart from the severity, one can measure the different OC-symptoms with the Y-BOCS checklist (Y-BOCS-CL). Back in the early 1950s, OCD was considered a rare disease, with an estimated prevalence of 0.05%. Recent studies imply a much higher prevalence rate. Currently, the life-time prevalence of OCD is estimated between 2–3% [7–9]. The prevalence rates are about the same in different parts of the world, with two exceptions Taiwan and the Netherlands with a prevalence rate of 0.7 and 0.9% respectively [10, 11]. The difference is probably due to methodological differences, e.g. in the Netherlands the CIDI, a layman’s scale, was used in the community survey. These results make OCD, after phobia, drug-addiction and depression, the fourth most common psychiatric disorder. In addition to the WHO, OCD is found to be one of the ten most disabling diseases [12]. Rasmussen investigated the different types of OCD symptoms of the last 15 years in more than 1000 patients [13]. The most common types of obsessions are: contamination obsessions (38–50%), pathologic doubt (42%), aggressive, sexual and blasphemous obsessions (25%), somatic (hypochondriac) obsessions (7–33%) and need for symmetry and precision (10–33%). The most common compulsions are checking (28–61%), washing (27–50%) and counting (2–36%). Several authors from different countries and cultural backgrounds investigated the prevalence of religious obsessions. At this point it is important to mention/observe that the way religious obsessions are defined in the different studies is far from unequivocal. In the strict sense, religious obsessions consist of blasphemous obsessions; however, they may also consist of an excessive execution of normal religious practise such as excessive church attendance and confession, excessive cleansing before prayer, length of prayer, repetitious praying and over meticulously following dietary laws. Data research has revealed large regional differences in the occurrence of religious obsessions or compulsions in OCD patients (see Figure 3.4.1). In England (0–5%) and Singapore (7%), the percentage of religious OC symptoms in OCD is quite low, whereas in traditional Muslim countries and in orthodox Jewish populations OC-symptoms are estimated between 40–60%. Countries like the U.S. (6–27%), Turkey (11–34%), India (11%) and the Netherlands (11%) take a middle position when it comes to the percentage of religious OC symptoms. The fact that the prevalence rate of OCD throughout the world, with a small exception of Taiwan and the Netherlands, is 2–3% and in contrast, that religion is not equally distributed, suggests that
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Author
Sample
Country
% religious OCS symptoms
Denys 2004 [14]
500
Netherlands
11% (plus agression/sexual)
Rasmussen 1992 [8] Holzer 1994 [15] Foa 1995 [16] Mataix-Cols 1999 [17] Downson 1977 [18] Stern 1978 [19]
35 431 354 41 -
USA USA USA USA United Kingdom United Kingdom
10 26 6% 27% 5 0%
Tezcan 1997 [20] Egrilmez 1997 [21] Akthar 1978 [22]
108 54 82
Turkey Turkey India
34 11% 11%
Shooka 1998 [23] Mahgoub 1991 [24] Okasha 1994 [25] Chia 1996 [26]
50 32 90 283
Bahrain Saudi Arabia Egypt Singapore
40% 50% 60% 7%
Greenberg 1994 [27]
34
Israel
40%
Figure 3.4.1
Religious symptoms in OCD patients.
religion in itself does not influence the extent to which OCD occurs. However, it is likely that religion and especially the orthodox forms do influence the kind of OC symptoms. In other words, if one suffers from OCD and in addition is practising a religion (read in an orthodox way), the OC symptoms most likely occur in the religious context. This is in line with Okasha’s study [25]. In this study they compared the most frequently occurring OC-themes in different countries (Egypt, Israel, India and England). Orthodox religious groups, such as the Muslims in Egypt and the Orthodox Jews in Jerusalem, showed mainly religious themes and themes related to cleanliness and dirt. In contrast, the common themes in British and Indian samples were mainly related to orderliness and aggressiveness. From this he concludes that cultural and religious backgrounds do influence the OC phenomenology to a large extent. Karadag et al. [28] too, in comparing two Muslim countries (Egypt and Turkey), found a relation between the degree of orthodoxy (strictness) and occurrence of religious OC symptoms. In line with these findings are the results of Greenberg and Witztum [27] in a Jewish sample. In a group of 34 OCD patients, they compared the symptom profiles of 19 orthodox religious Jews with a group of 15 non-orthodox religious Jews and found a significantly higher degree of religious OC symptoms in the orthodox group (68 versus 0.07%). Several studies investigated the role of religion in OCD. Steketee et al. [29] compared 32 OCD patients with 24 anxiety (non-OCD) patients. There was no difference in the degree of religiosity. They did find a correlation between the degree of religiosity and the OCD severity and the occurrence of religious OC symptomatology. Raphael and co-workers [30] compared three groups of psychiatric patients (49 OCD patients, 48 patients in psychodynamic psychotherapy and a mixed – ‘general’ – psychiatric group of 51 patients) in a retrospective study. OCD patients were found to be more often religious than patients in the general psychiatric group (21.6 versus 8.2%). Although these studies suggest a positive correlation between religion and OCD, others could not confirm these findings. Tek and Ulug [31] conducted a thorough study in 54 OCD patients using both the Y-BOCS
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and Y-BOCS checklist to measure the OC symptoms and the religious practice index to map the religiosity of the group. Forty-two percent of the patients suffered from religious OC symptoms. No relation was found between the degree of religiosity and the OCD severity nor between the degree of religiosity and the expression of religious symptoms. Nevertheless they found a correlation between the severity of OCD symptomatology and religious OC symptoms. In other words, the occurrence of religious obsessions depends on the severity of OCD and has no relation to someone’s religiosity. Similarly, Hermesh et al. [32] compared three groups (22 OCD patients vs 22 panic disorder patients with agoraphobia vs 22 surgical patients) and found no difference in religiosity either. To summarize, no evidence was found supporting the idea that religion is a causal factor promoting OCD; yet it might be a factor promoting the occurrence of religious obsessions. This suggestion, however, is contradicted by Tek’s findings suggesting that the occurrence of religion is just a sign of the OCD severity and has no relation with religion itself [31].
3.4.3 DO RELIGIOUS PEOPLE MAKE USE OF THE SAME COGNITIVE STRATEGIES AS OCD PATIENTS DO? Since the 1970s psychological research on OCD has mainly concentrated around the role of cognitions. Many different cognitive strategies and models have been proposed to shed more light on psychological underpinnings of OCD [33]. Presently, cognitive psychologists have more or less reached a consensus on which phenomena play a role in the occurrence and maintenance of OCD. These are: 1. Intrusions. As stated earlier, these are recurrent and unwanted images, impulses or ideas that intrude into one’s mind. Intrusions are not pathological in themselves. About 90% of the normal population reports intrusions. Intrusions are only then experienced as abnormal (pathological) when they have reached a certain intensity, frequency and duration [34]. Non-OCD patients seem to pay no attention and disregard the majority of their intrusions. Therefore, appraisal of the intrusions seems to play an important role in whether an intrusion becomes (is experienced as) pathological or not. 2. Appraisal. Appraisal is about how an event or thought is being weighed or appreciated. That in turn depends on how the person values the intrusion (the fact that I have this intrusion means a priori that this thought must be important) and how the responsibility is perceived. A third aspect is one’s conceived ‘obligation to act’ (I must pray, otherwise my mother will not return home safely). 3. Assumptions. Assumptions are defined as unrealistic beliefs, e.g. thinking of something bad or morally reprehensible is equal to acting on it. In 1997 an international group of researchers (Obsessive-Compulsive Cognitions Working Group) developed six cognitive domains that appear of central importance in a wrong appraisal of intrusions in OCD [35, 36]: Inflated responsibility: 1. Beliefs about the importance of thoughts and thought action fusion. 2. Beliefs about the importance of controlling one’s thoughts. 3. Overestimation of threat.
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4. Intolerance of uncertainty. 5. Perfectionism. The second cognitive domain, that of thought action fusion (TAF), needs further elaboration since this strategy is most extensively studied in religious people in relation to OCD. TAF is subdivided into two variants, a moral and a probability variant. The moral TAF consists of the belief that having a morally condemnable thought is equivalent to executing this thought or fantasy. For example, imagining child molesting is as bad as actually doing it. The probability TAF is the belief that thinking of a specific situation increases the probability that this situation will actually occur, e.g. thinking of a possible accident increases the chance that the accident will take place. This probability TAF can pertain both to oneself and to others. Surveying the literature on the relation between OCD and TAF, Berle and Starcevic [37] indeed found a consistent relationship between OCD symptoms and moral, probability and the total TAF. One should, however, bear in mind that this does not hold for all OCD subcategories. In addition to the TAF phenomena, suppression of the intrusion (thought suppression) seems another important feature in creating the OC treadmill. This is illustrated by the socalled ‘white bear experiment’ in which someone is asked not to think of white bears for 10 minutes. As a result of this instruction, the opposite takes place in that people cannot stop thinking of white bears anymore [38]. There is some evidence that probability TAF directly influences OCD, while moral TAF seems to stimulate OCD indirectly through thought suppression [39]. A third strategy deserving attention in this chapter on processes that stimulate OCD, is that of thought control strategies. Wells and Davies [40] have identified five different strategies to control intrusions: distraction, social control, worry, punishment and reappraisal. The authors found a relation between both punishment and worry and the occurrence of psychopathology, including OCD. This hypothesis was confirmed by Abramowitz et al. [41]. He compared three groups of panic disorder (PD) patients, nonanxious controls and OCD patients and found that OCD patients use the worry and especially the punishment control strategies more often than the PD and non-anxious control groups. After having depicted the cognitive strategies which are used in OCD patients, it is of interest to find out whether there is a resemblance in the strategies religious OCD-patients employ. If there is indeed a resemblance, this would imply a greater likelihood for religious people to get OCD. Starting from the basic assumption that religious people in general are more scrupulous than non- religious, Nelson et al. [42] investigated to see if there are specific cognitive domains which correlate with scrupulosity in OCD-patients. They found a positive correlation between scrupulosity and both the importance of and need to control intrusive thoughts, and an inflated sense of responsibility and moral TAF. Studies concerning the relation between OC-symptoms and cognitive behavior in normal persons show similar results. Sica et al. [43] investigated whether cognitive strategies are influenced by the degree of religiosity (in this study Catholic). This could be confirmed in that only in the religious group were both the excessive need to control thoughts and the over-importance of thoughts related to OC-symptoms. These results are not very surprising since in Catholic teachings sinful thoughts are considered equivalent to sinful behavior.
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Similar results have been found in a group of Protestant Christian believers. Orthodoxy correlated positively with a higher degree of OCD related cognitions [44]. In Protestant teachings some thoughts are also considered to be sinful. For example, in the Sermon on the mount, Jesus cautions: ‘You have heard that it was said ‘You shall not commit adultery’; but I say to you, that everyone who looks on a women to lust for her has committed adultery with her already in his heart’ (Matthew 5:27-28; New American Standard Version). The teachings that sinful thoughts are as sinful as acts are rather equivalent to TAF, especially to the moral TAF. Although TAF seems to be an important strategy in both Catholic and Protestant faith, Rassin and Koster [45] found some differences too. In a Catholic sample, religiosity correlated moderately with moral TAF and probability TAF (for others). In the Protestant sample, religiosity correlated fairly strongly with moral TAF, but negatively with probability TAF (for self). Lumped together, a correlation between Catholicism and total TAF could be established, in Protestantism it could not. The existence of a relation between these Christian beliefs and TAF does not imply that this relation exists for any religion. Christians score much higher on the moral TAF than e.g. Jews. On the other hand Christians score lower on the probability TAF than all Jewish denominations. There are no significant differences between the Jewish denominations [46]. The fundamental differences in the religious doctrines probably account for the difference in TAF score between Christians and Jews. Christians put great emphasis on thoughts and intensions, while Jews tend to emphasize action and behavioral adherence. In summary, there is some evidence that people of Christian faith (Roman Catholics and Protestants) make use of cognitive strategies underlying the development of OCD. The results, however, are not substantial enough to make any firm conclusion as to whether these religions might have a pathological effect promoting OCD. Less is known about the cognitive strategy of others like the Jewish or Muslim faith. Considering the fundamental differences between these religions, it is likely that these cognitive strategies differ too.
3.4.4
TREATMENT
There are two evidence based strategies for the treatment of OCD. First, there is cognitive behavioral therapy (CBT) and secondly, the pharmacotherapy. The first pharmacological choice in the treatment of OCD is starting a serotonin reuptake inhibitor like a selective serotonin re-uptake inhibitor (SSRI, e.g. citalopram, escitalopram, fluvoxamine, fluoxetine, sertraline, paroxetine) or a non-selective noradrenalin serotonin re-uptake inhibitor (NSSRI) like clomipramine or venlafaxine. Although head-to-head comparison never proved a significant difference between the clomipramine and the SSRIs, pooled data suggest that the tri-cyclic antidepressant clomipramine is more efficacious than treatment with an SSRI. Nevertheless, SSRIs are the first choice due to their milder side-effect profile. Only after two SSRI trials have failed, is it suggested to start with clomipramine. After an adequate pharmacotherapy (in time and dosages), one can expect an approximate 50% symptom reduction in 50% of the patients. If monotherapy fails, several augmentation strategies can be endeavored by addition of one of the newer atypical antipsychotics (risperidone, quetiapine, olanzepine). Psychological treatment of OCD consists of either cognitive therapy and/or exposure and response prevention. In cognitive therapy one tries to alter the deviant appraisals the patient uses in order to interrupt the intrusion/appraisal/
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fear/compulsion sequence. Exposure and response prevention (ERP) aim to effect (to change) the fact that the patient has learned that performing a compulsion is the (reason for)/cause of the ultimate fear reduction/or: performing a compulsion results in the ultimate fear reduction. With ERP the patient is exposed to factors eliciting anxiety (touching something dirty); as a result, the patient is conditioned to start his compulsion (start washing). Different from the patient’s usual action pattern, he is now to refrain from performing his compulsion. This initially provokes more anxiety, followed by a reduction/ diminution. Repetition of the ERP will condition the patient to the fact that not acting on the obsession will reduce the obsession provoked fear as well. According to Stanley’s review [47] of the effects of CBT, 36% of the patients experience a 70% symptom reduction, 27% a 31 to 69% reduction and 7% experience no effect, while 30% refused CBT treatment. An important difference between CBTand pharmacotherapy is the relapse rate which is much better in behavioral therapy. In the context of this chapter, one should ask oneself whether the treatment of a religious OCD patient should differ from the OCD treatment in general. Before answering this question one should first realize that (orthodox) religious patients are less prone to consulting a psychiatrist. These patients prefer to consult their religious mentors. This is especially true in a highly religious society, such as the ultra-Orthodox Jewish community [48]. A common opinion held in European Christian communities is that most psychiatrists have an antireligious attitude and as a consequence they will try to persuade the patient to abandon their faith. Religious people are therefore shy and as a consequence ambivalent about consulting a psychiatrist. Consequently, treatment will be delayed and patients are treated at a later stage of the disease, which worsens their prognosis. It is important to realize at this point that when talking about treatment, a distinction should be made between religious OCD patients and OCD patients with religious and or blasphemous obsessions. There is some evidence that CBT in patients with religious and sexual obsessions is less effective (Roest 2004). However, in a study by Rufer et al. [49] no significant differences were found between the different obsessions. Secondly, religious patients suffering from blasphemous obsessions often refuse ERP, since they experience such instruction as sinful. Data on pharmacotherapy in religious OCD patients are even scarcer. Nevertheless, there is no reason to expect that the effect of pharmacotherapy in religious patients would differ from the effect in non-religious patients. A couple of articles report on the effect of serotonin re-uptake inhibitors on a subset of OC symptoms. Fallon et al. [50] describes the effect of fluoxetine or clomipramine on ten patients with moral or religious obsessions in an eightweek open trial. Seven out of the ten patients completed the full eight weeks. Two of the initial non-responders, responded only after prolonged treatment. These findings suggest that religious symptoms do not respond differently to standard medication trials. The case report by Lacy and Khatain [51], in which an OCD patient with scrupulous and blasphemous obsessions was treated with clomipramine, are in line with these findings. Particularly in the treatment of religious patients, a positive working alliance is of utmost importance to get significant treatment results [52]. Witztum and Buchbinder [53], both psychiatrists practising in Jerusalem, describe a few case reports on their work with ultraOrthodox Jews, emphasizing the importance of the so-called culture sensitive therapy. They sense this as even more important when there are major therapist-patient differences in cultural or religious backgrounds. They suggest the therapist to be well informed about the patient’s cultural background, and that interventions should be congruent with the patient’s
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framework and based upon the cultural symbols, rituals and metaphors of the patient. To emphasize, the authors give the example of a Jewish patient, consulting the psychiatrist for not being able to pray anymore. As a result he gave up attending synagogue. At first examination he did not seem depressed, although some clinically meaningful signs of depression such as loss of appetite and insomnia were present. After several sessions, he had to reconsider his initial conclusion and diagnosed the patient as suffering from a major depressive episode, finding expression almost completely in the religious domain.
3.4.5
DISCUSSIONS AND CONCLUSIONS
The discussion of the putative relation between religion and the obsessive compulsive disorder has a long history. It started off with the description of the moral obsessions (scruples) in the Middle Ages and is currently still not put to an end. In reviewing the literature, so far, no evidence could be found to ensure religion to be a causal factor in promoting OCD. Genetic factors and familiar predisposition and environmental aspects probably contribute much more to the illness. Nevertheless, religion as much as other cultural phenomena probably contributes more to the kind of OC symptomatology than to the occurrence of OCD itself. Concerning the cognitive strategies, there are indications that both Protestants and Roman Catholics use strategies that underlie the development of OCD. One of those strategies is the conviction that having a morally condemnable thought is equivalent to executing this thought or fantasy. In psychological terms this is called moral thought action fushion (TAF). Utilizing this strategy also hampers the use of exposure and response prevention (ERP) in the treatment of religiously related OC symptoms. Religious people are probably more scrupulous than non-religious people and as a result several thoughts and impulses will be viewed as condemnable and should therefore be suppressed. Suppression of thoughts can in turn provoke obsessional thoughts. The need to suppress unwanted thoughts could be a factor contributing to a subset of OC symptoms (religious, aggressive and sexual obsessions). Further research could shed more light onto this possible relation.
3.4.6 SUMMARY For decades a relationship between obsessive compulsive disorder (OCD) and religion has been suggested. The question emerges as to whether this association is adequately founded on empirical evidence. In an attempt to reveal this possible relation we will successively discuss the history of OCD and religion. In addition, epidemical data will be presented, followed by an elaboration on cognitive strategies which are used in both OCD and religious people. Lastly, differential diagnostic issues and treatment of religious OCD will be critically reviewed.
REFERENCES 1. Freud S (1927) The future of an illusion. In: Freud S (eds.) The Standard Edition of the Complete Works of Sigmund Freud, Vol. IX. Hogarth, London, pp. 1–56.
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2. Freud S (1907) Obsessive actions and religious practices. In: Freud S (eds.) The Standard Edition of the Complete Works of Sigmund Freud, Vol. IX. Hogarth, London, pp. 115–127. 3. Greenberg D, Witztum E, Pisante J (1987) Scrupulosity: religious attitudes and clinical presentations. British Journal of Medical Psychology 60, 29–37. 4. Ignatius Saint (1548). Spiritual Exercises of Saint Ignatius of Loyola. Translated by Delmage L. MA: Daughters of Saint Paul, 1978, Boston. 5. American Psychiatric Association (2005). Diagnostic and statistical manual of mental disorders. 4th ed. American Psychiatric Association, Washington DC 6. Goodman WK, Price LH, Rasmussen SA et al. (1989) The Yale-Brown Obsessive Compulsive Scale. I. Development, Use, and Reliability. Arch Gen Psychiatry 46, 1006–1011. 7. Karno M, Golding JM, Sorenson SB, Burnam MA (1988) The epidemiology of obsessivecompulsive disorder in five US communities. Archives of General Psychiatry 45, 1094–1099. 8. Rasmussen SA, Eisen JL (1992) The epidemiology and clinical features of obsessive compulsive disorder. Psychiatric Clinics of North America 15, 743–758. 9. Samuels J, Nestadt G (1997) Epidemiology and genetics of obsessive-compulsive disorder. International Review of Psychiatry 9, 61–72. 10. Lee Ck, Kwak YS, Yamamoto J et al. (1990) Psychiatric epidemiology in Korea: part 1: gender and age differences in Seoul. Journal of Nervous and Mental Disease 178, 242. 11. Bijl RV, Ravelli A, van Zessen G (1998) Prevalence of psychiatric disorder in the general population: results of the Netherlands mental health survey and Incidence study (NEMESIS). Social Psychiatry and Psychiatric Epidemiology 33, 587–595. 12. Koran LM, Thienemann ML, Davenport R (1996) Quality of life for patients with obsessivecompulsive disorder. American Journal of Psychiatry 153, 783–788. 13. Rasmussen SA, Eisen JL (1998) The epidemiology and clinical features of obsessive compulsive disorder. In: Jenike MA, Baer L, Minichiello WE (eds), Obsessive Compulsive Disorder. St. Louis: Mosby. 14. Denys D, De Geus F, Van Megen HJGM, Westenberg HGM (2004) Symptom structures in obsessive compulsive disorder: Factor analysis on a clinician rated scale and a self report measure. Psychopathology 37, 181–189. 15. Holzer JC, Goodman WK, Mc Dougle C et al. (1994). Obsessive compulsive disorder with and without tic disorder. British Journal of Psychiatry 164, 469–473. 16. Foa E, Kozak M, Goodman W et al. (1995) DSM-IV field trial: Obsessive compulsive disorder. American Journal of Psychiatry 152, 90–96. 17. Mataix-Cols D, Rauch S, Manzo P, Jenike M, Bear L (1999) Use of factor analyzed symptom dimensions to predict outcome with serotonin re-uptake inhibitors and placebo in the treatment of obsessive compulsive disorder. American Journal of Psychiatry 156, 1409–1416. 18. Downson J (1977) The phenomenology of severe obsessive compulsive neurosis. British Journal of Psychiatry 131, 75–78 19. Stern R, Cobb J (1978) Phenomenology of Obsessive compulsive neurosis. British Journal of Psychiatry 132, 233–239. 20. Tezcan E, Millet B (1997) Phenomenology of obsessive compulsive disorders. Forms and characteristics of obsessions and compulsions in East turkey. Encephale 23, 342–350. 21. Egrilmez A, Gulseren L, Kultur S (1997) Phenomenology of obsessions in Turkish series of OCD patients. Psychopathology 30, 106–110 22. Akthar S, Wig N, Varma V, Pershad D, Verma S (1975) A phenomenological analysis of symptoms in obsessive compulsive neurosis. British Journal of Psychiatry 127, 342–348. 23. Shooka A, Al-Haddad MK, Raees A (1998) OCD in Bahrain: a phenomenological profile. International Journal of Social Psychiatry 44, 147–154. 24. Mahgoub OM, Abdel-Hafeiz HB (1991) Pattern of obsessive-compulsive disorder in Eastern Saudi Arabia. British Journal of Psychiatry 158, 840–842.
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25. Okasha A, Saad A, Khalil AH, El Dawla AS, Yehia N (1994) Phenomenology of obsessivecompulsive disorder: a transcultural study. Comprehensive Psychiatry 35, 191–197. 26. Chia B (1996) A Singapore study of OCD. Singapore Medical Journal 37, 402–406. 27. Greenberg D, Witztum E (1994) The influence of cultural factors on obsessive compulsive disorder: religious symptoms in a religious society. The Israel Journal of Psychiatry and Related Sciences 31, 211–220. ¨ zdel O, Atesci FC, Amuk T (2006) OCD symptoms in a sample of 28. Karadag F, Oguzhanoglu NK, O Turkish patients: a phenomenological picture. Depression and Anxiety 23, 145–152. 29. Steketee G, Quay S, Kerrin W (1991) Religion and guilt in OCD patients. Journal of Anxiety Disorders 5, 359–367. 30. Raphael FJ, Rani S, Bale R, Drummond LM (1996) Religion, ethnicity and obsessive-compulsive disorder. International Journal of Social Psychiatry 42, 38–44. 31. Tek C, Ulug B (2001) Religiosity and religious obsessions in obsessive-compulsive disorder. Psychiatry Research 104, 99–108. 32. Hermesh H, Masser-Kavitzky R, Gross-Isseroff R (2003) Obsessive-compulsive disorder and Jewish religiosity. Journal of Nervous and Mental Disease 191, 201–203. 33. Steketee GS, Frost R, Rheaume J, Wilhelm S Cognitive theory and treatment of Obsessive compulsive disorder. In Jenike MA, Bear L, Minichiello WE (eds.) Obsessive Compulsive Disorders, practical management 3rd edn. Mosby, St. Louis. pp. 368–400. 34. Rachman S, de Silva P (1978) Abnormal and normal obsessions. Behaviour Research and Therapy 16, 233–248. 35. Obsessive Compulsive Cognitions Working Group (1997) Cognitive assessment of obsessive compulsive disorder. Behaviour Research and Therapy 35, 667–681. 36. Obsessive Compulsive Cognitions Working Group (2001) Development and initial validation of obsessive beliefs questionnaire and interpretations of intrusions inventory. Behaviour Research and Therapy 39, 987–1005. 37. Berle D, Starcevic V (2005) Thought-action fusion: Review of the literature and future directions. Clinical Psychology Review 25, 263–284. 38. Roest K (2004) Ontwikkelingen in de cognitieve gedragstherapie. Implicaties voor de behandeling van religieuze obsessies. Psyche en Geloof 15, 134–143. 39. Rassin E, Muris P, Schmidt H, Merckelbach H (2000) Relationships between thought-action fusion, thought suppression and obsessive-compulsive symptoms: a structural equation modeling approach. Behaviour Research and Therapy 38, 889–897. 40. Wells A, Davies MI (1994) The thought control questionnaire: a measure of individual differences in the control of unwanted thoughts. Behaviour Research and Therapy 32, 871–878. 41. Abramowitz JS, Whiteside S, Kalsy SA, Tolin DF (2003) Thought control strategies in obsessivecompulsive disorder: a replication and extension. Behaviour Research and Therapy 41, 529–540. 42. Nelson A, Abramowitz JS, Whiteside SP, Daecon BJ (2006) Scrupulosity in patients with obsessive-compulsive disorder: Relationship to clinical and cognitive phenomena. Journal of Anxiety Disorders 20, 1071–1086. 43. Sica C, Novara C, Sanavio E (2002) Religiousness and obsessive-compulsive cognitions and symptoms in an Italian population. Behaviour Research and Therapy 40, 813–823. 44. Abramowitz JS, Deacon BJ, Woods CM, Tolin DF (2004) Association between Protestant religiosity and obsessive-compulsive symptoms and cognitions. Depression and Anxiety 20, 70–76. 45. Rassin E, Koster E (2003) The correlation between thought-action fusion and religiosity in a normal sample. Behaviour Research and Therapy 41, 361–368. 46. Siev J, Cohen AB (2007) Is thought-action fusion related to religiosity? Differences between Christians and Jews. Behaviour Research and Therapy 45, 829–837. 47. Stanley MA, Turner SM (1995) Current status of pharmacological and behavioural treatment of obsessive compulsive disorder. Behavior Therapy 26, 163–186.
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48. Greenberg D, Witztum E (1991) Problems in the treatment of religious patients. American Journal of Psychotherapy 4, 554–565. 49. Rufer M, Fricke S, Moritz S, Kloss M, Hand I (2006) Symptom dimensions in obsessivecompulsive disorder: prediction of cognitive-behavior therapy outcome. Acta Psychiatrica Scandinavica 113, 440–446. 50. Fallon BA, Liebowitz MR, Hollander E et al. (1990) The pharmacotherapy of moral or religious scrupulosity. Journal of Clinical Psychiatry 51, 517–521. 51. Lacy T, Khatain K (1993) Obsessive compulsive disorder manifestation as demonic attack (Letter). Journal of Clinical Psychiatry 54, 398. 52. Vogel PA, Hansen B, Stiles TC, G€otestam KG (2006) Treatment motivation, treatment expectancy, and helping alliance as predictors of outcome in cognitive behavioral treatment of OCD. Journal of Behavior Therapy and Experimental Psychiatry 37, 247–255. 53. Witztum E, Buchbinder JT (2001) Strategic culture sensitive therapy with religious Jews. International Review of Psychiatry 13, 117–124.
CHAPTER 3.5
Religion and Psychoanalysis: Past and Present Allan M. Josephson Professor of Child and Adolescent Psychiatry, United States of America
Armand Nicholi Jr. Clinical Professor of Psychiatry, United States of America
Allan Tasman Professor of Psychiatry and Behavioral Sciences, United States of America
3.5.1
INTRODUCTION
Religion can serve as a vehicle of conflict and, alternatively, a resource enabling individual adaptation. Because many patients retain some degree of religious belief and conviction, the contemporary psychoanalyst or psychoanalytic psychotherapist must be attuned to issues of religion and spirituality as they clearly inform individual psychology. What is the contemporary approach to religious issues in psychoanalysis? The past is well known as Freud personally rejected religious faith, powerfully influencing generations of psychoanalysts. Recent modifications in psychoanalysis have included changes in the conceptual approach to religion and spirituality and in the clinical challenges of assessment, case formulation and managing therapeutic process, specifically, transference and counter transference. This chapter will discuss the legacy of Freud’s views; contemporary shifts in the relationship of psychoanalysis to religion; newer psychoanalytic perspectives on religion and several core clinical issues. Through a discussion of theory and practice, this chapter will identify the current status of the relationship between psychoanalysis and religion and frame future challenges in this area.
3.5.2
DEFINITIONS
Religion and spirituality are linked, yet specific definitions remain illusive. Spirituality is concerned with one’s connection to a transcendent context of meaning and religion is the Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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form that spirituality takes within given traditions [1]. Spirituality has to do with that beyond the material and encompasses features that are not perceived by physical senses yet help people understand the material world [2]. Interestingly, there are increasing numbers who consider themselves spiritual yet take offense to being called religious [3]. Spirituality does not attempt, as religion often does, to integrate negative and positive aspects of experience in a unifying life philosophy. A solely spiritual concept of the divine is typically benevolent, leading to the concept engendering less controversy [4]. The term worldview refers to a cognitive response to life’s most basic questions, a response which is important to individuals whether they consider themselves spiritual or religious. All individuals have a worldview that must be taken into account in therapy. Even patients who do not see themselves as religious possess a specific worldview, often associated with a spiritual perspective, which guides their lives. Freud used the term ‘Weltanschauung’ (worldview) as a cognitive construct by which the individual determines what is right and wrong, what is the good life, what is personally important and, simply, how one will live one’s life [5]. In this sense, everyone has a worldview whether consciously articulated or not. This chapter will use religion, spirituality and worldview somewhat interchangeably. In this chapter, all discussions of psychoanalysis refer to the psychological theories developed by Sigmund Freud and those who followed. ‘Psychoanalytically oriented psychotherapy’, also used somewhat interchangeably with psychoanalysis, will be used in clinical discussions and refers to treatments which incorporate aspects of psychoanalysis, but not all of its classic expressions.
3.5.3 THE RELATIONSHIP BETWEEN PSYCHOANALYSIS, RELIGION AND SPIRITUALITY At first glance, the scientific study of human behavior, as exemplified by psychoanalysis and the search for a transcendent reality appear disjointed. While this chapter will delineate obvious differences, the disciplines of psychoanalysis and religion share common interests, such as an interest in the inner life of individuals and their unique motivations. Religions are often concerned with conversion and a change in perspective, while psychoanalysis is focused on ‘the change of heart’, a change with spiritual connotations [6]. Both disciplines are concerned with parent/child relationships and their protective functions in human behavior. Psychoanalysis and religion have restorative functions and are seen as agents of healing [7]. Human anxieties are also a concern of religion and psychoanalysis, although both disciplines offer different etiological formulations. Both emphasize belief systems, most obviously true with religion yet psychoanalysis has clearly had elements of a belief system in its past [8]. Morality and existential meaning are two other areas of overlapping interest. For religion, morality is an intuitive sense of right and wrong with a basis in a cosmic, created order. Psychoanalysis, on the other hand, describes these issues in the language of health. When Menninger wrote Whatever Became of Sin, he was addressing the fact that evil, or sin, had been transformed to the ‘absence of health’ in psychoanalytic thinking [9]. Sin and psychopathology are not two sides of the same coin, yet they define the manner in which religion and psychoanalysis describe human behavior deviating from a generally acceptable norm [10]. With respect to guilt, psychoanalysis deals with ‘neurotic guilt’, seen
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as an irrational affect, while religions describe existential, or ‘real guilt’, seen as a rational response to a moral code contravened. By definition, a religious worldview provides a schema for ultimate purpose and meaning whereas psychoanalysis has little to say about this matter. However, recent research on psychoanalytic practice indicates that some analysts believe therapy is a failure if patients have not given thought to ‘what life is all about’ [11]. Psychoanalysis and religion share an interest in human relationships, specifically attachment. The child develops beliefs about whether a caregiver is trustworthy through his early life experience, with a secure attachment fostering psychological health [12]. Similarly, the religious perspective addresses a putative innate desire to be connected, or ‘attached’, to a transcendent reality. This view of the self in relationship to others is congruent with what theologians have believed for centuries regarding the self in relationship to a divine presence. Whether this religious reality is merely a psychological projection, as Freud believed, remains a matter of faith. Jones comments that theologians have long known that a psychology based on self in relationship to others, if carried to its ultimate end, yields a ‘strikingly religious vision’ [13]. He concludes, ‘There is no escaping dependency on a self object milieu. There is nothing childish about acknowledging connection to a self sustaining universal matrix’ [13] (p. 135). Finally, some clinicians have attempted to conduct psychoanalytically-oriented psychotherapy considering the parallel dimensions of psychology and religion [14]. A comment must be made about the relationship between science and religion. While the exact scientific nature of psychoanalysis has been debated, it remains housed in the edifice of two scientific disciplines, medicine and psychology. As Gilkey has pointed out, science addresses questions of ‘what?’, or how things work, while religion addresses questions of ‘why?’, or the purpose to which things work [15]. Careful consideration of these distinct differences decreases conflict between the two disciplines. Understanding the psychological effects of prayer does not explain why the phenomenon occurs. Explaining what biological mechanisms are present in evolutionary change does not address why life exists. Conflicts occur when religious approaches attempt to dictate science and answer ‘what’ and ‘how’ questions (e.g., creation/science movement). On the other hand, science cannot address ‘why’ questions (e.g. purpose; cosmology). Jones has argued that ‘when the scientist begins to attempt to weave together discreet bits of empirical knowledge into a grand tapestry to explain and understand vast stretches of reality, she or he passes necessarily into domains of human thought that are also religious’ [16].
3.5.4
THE LEGACY OF FREUD’S VIEWS
The impact of Freud must be addressed before any serious review of the current status of psychoanalysis and religion can be undertaken. Freud’s extensive writings on religion and the psychology of religion have been reviewed fully elsewhere and address two broad themes: diagnostic and developmental [8, 17]. Freud compared religion to the paranoid psychoses and an obsessive compulsive neurosis. Second, he believed religion is a neurotic attempt to resolve the Oedipal conflict, merely an infantile dependency and wish fulfillment. He declared ‘the whole thing is so patently infantile, so foreign to reality that to anyone with a friendly attitude to humanity, it is painful to think that the majority of mortals will ever be able to rise above this view of life’ [18]. This remarkable vehemence accompanied another
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striking position: anyone asking the large questions related to life’s meaning was pathological. While the forcefulness of his presentation indicated that Freud was one sided in these matters, there were some more nuanced aspects to his written work. Freud appeared to believe in conscious volition in addition to psychic causality; it was not all determinism. Freud was personally moral and only wanted to suspend moral restraint for analytic purposes, as he saw religion served a role in instinctual renunciation [19]. Yet many scholars now agree that Freud was not objectivewhen it came to religion [20–24]. For Freud, the obsessive compulsive neurotic was the paradigmatic religious personality. He believed the obsessive’s magical thinking and undoing, and need for omnipotent control, were directly related to religious ritual [25]. What he did not recognize is that many rituals are mixed with grace and open celebration (e.g., anniversaries and birthdays). Also, rituals provide structure essential for healthy psychological development, as most child development theories now recognize. In sum, rituals need not be restrictive but can be celebratory and provide a structure for human development. Freud’s lack of objectivity with respect to religion reflected his worldview. He chose atheism over faith, a personal choice that was not part of his science. These views are not merely of historical interest. Recent research suggests the negative attitude toward spiritual matters continues in the discipline of psychoanalysis [11]. In studies of physicians, religious physicians are much less likely to refer mental health problems to psychiatrists because of their perceived antipathy toward religion [26, 27].
3.5.5
IS PSYCHOANALYSIS A TECHNIQUE OR WORLDVIEW?
Wallace has pointed out there are only two answers to this question [8]. If psychoanalysis is one therapeutic or investigative technique, among others, it clearly can be reconciled with a religious worldview. When Freud demonstrated some psychological functions of religion, he simply added a dimension to the study of religion. On the other hand, when psychoanalysis is seen as a worldview with its own philosophical biases (e.g., the transcendental is merely a sublimation of the instinctual), there is no reconciliation. The utilization of psychoanalysis as worldview has been the greatest obstacle to any rapprochement between psychoanalysis and religion. For the analyst holding these views, the impact and role of spirituality in the lives of his patients will be relatively inaccessible to him. The modern, post-Freudian view is that psychoanalysis is method not worldview. In some ways, the idea is not new, as it was the position of the clergyman-analyst Pfister [28], and the Catholic analyst Zilboorg [29]. As Nicholi has described, Freud had a major preoccupation with worldview as evidenced by his collected works containing more than 150 references to God and more than 50 references to Jesus Christ. Nicholi writes, ‘Freud’s attempt to work out his own worldview and establish a philosophy of life caused him to focus his writings on issues that preoccupy the human spirit’. Nicholi believes ‘these themes, even more than his literary style and his scientific contributions, gave Freud’s writings universal appeal and enduring influence’ [30] (p. 10). While Freud’s vehemence confused psychoanalytic technique with worldview, Riccoeur believes psychoanalysis is ‘iconoclastic’ with respect to faith. He writes that ‘this psychoanalysis is open to a double possibility, that of faith and that of non-faith, but the decision about these two possibilities does not rest with psychoanalysis’ [31] (p. 230).
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Meissner further clarifies that ‘the psychoanalytic perspective, on the other hand, has no interest in theological suppositions or implications. It is concerned with the actual conditions and constraints of the exercise of human freedom. Moreover, it makes its business the discovery of the nature of intrinsic impediments to the individual’s realization of a sense of autonomy. In a sense, then, theology takes up where psychoanalysis leaves off’ [32] (p. 240). In theological literature, C.S. Lewis makes the distinction between psychoanalysis dealing with the ‘raw material’ of human psychology, and then leaving religion and spirituality to address moral choices, decisions theologians view as having transcendent implications [33]. Increasing the power or freedom to choose, does not guarantee what man will choose. The two tasks are simply different and distinct. This is clear if psychoanalysis is seen as technique, addressing the former, leaving religious faith to be concerned with the latter. There are limitations of the scientific, psychoanalytic method. Meissner notes that as the unconscious roots of mystical experiences are elucidated by identifying their developmental roots and understanding their psychic function, psychoanalysts have an understanding of the psychological components of mysticism, nothing more [32] (p. 218). Similarly, describing the experience of the numinous or mapping out internalized object relations or God representations, does not deny the possibility of God’s existence. The concept of God can be described with respect to God representations without negating arguments regarding the actual existence of God, matters beyond psychoanalysis [34]. All experiences, numinous included, demand a psychological understanding. Religious individuals often fear such explanation from below (i.e. scientific) removes explanation from above (i.e. spiritual). Yet, there may be religious and spiritual experiences that are not purely a function of psychosocial determinants. Taking up where psychoanalysis leaves off, it is possible that ‘The hypothesis that among man’s motive to religious experience is an irreducible, God-implanted, heritable, ingrained need for meaning and connection with the transcendent realm-an inner drive to religious behavior’ [19]. The work of Meissner has significantly advanced the notion that the task of psychoanalysis is solely a clinical one. ‘The boundaries between psychoanalysis and religion must remain intact if the dialogue is to have meaning without unnecessary confusion or obfuscation’ [35] (p. 66). Problems arise when psychoanalysts and religious individuals fail to keep in mind what belongs to each domain. This was Freud’s original error, unintended as it may have been. Meissner comments further: ‘There is a difference saying God acts on human beings and that this action can have psychological effects, on the one hand, and saying that God’s action is an aspect of psychological processes on the other. The former preserves the integrity of two respective realms of discourse; the latter overrides them to the confusion of both’ [35] (p. 66). While many of these determinations are not black and white, an attempt to clarify boundaries is important. Indeed, Freud left an opening in The Future of An Illusion regarding the importance of boundary between psychoanalytic technique and worldview. ‘Nothing that I have said here against the truth value of religions needed the support of psychoanalysis; it had been said by others long before analysis came into existence. If the application of the psychoanalytic method makes it possible to find a new argument against the truths of religion, tant pis for religion; but defenders of religion will by the same right make use of psychoanalysis in order to give full value to the affective significance of religious doctrines’ [36] (p. 36–37). Freud’s personal opinions led to psychoanalysis being seen as a secular religion. Freud’s views were so dominant, it was hard to separate them from the treatment technique that he
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was developing. Due to his seminal influence, many psychoanalysts identified with his worldview. The contemporary view holds that nothing inherent in psychoanalysis leads to rejection of religion.
3.5.6
SHIFTS IN THE FREUDIAN VIEWPOINT
While there remain vestiges of an antipathy toward religion, the last several decades have seen several significant shifts in the relationship between psychiatry and psychoanalysis and religion. First, psychiatric research has identified that religious variables have been neglected data in psychiatric research. Larson and colleagues pointed out that only 2.5% of the studies they reviewed had religious variables included in statistical analyses [37]. When such variables were included, it was determined that more often than not, religion played a positive, rather than negative, influence [38]. In DSMIII, for example, the only mention of religion was its inclusion as a risk factor for mental disorder [39, 40]. Since these earlier studies, there has been a recent surge in interest in the interaction between religion and mental health [41–45]. Shifts have also been noted in clinical work as psychoanalysts have increasingly dealt empathically with the religious difficulties of their patients. Analysts no longer interpret everything religious in terms of defense [46]. Clinical literature has clarified that religion can be protective in contributing to adaptation rather than solely being a risk factor for mental disorder [47, 48]. In Meissner’s seminal Psychoanalysis and Religious Experience, he declares that there is a new dialogue between religion and psychoanalysis, with psychoanalysis moving from an authoritarian study of religion to interdisciplinary collaboration and study. In this work, Meissner notes several tensions and polarities in the interaction between psychoanalytic and religious thinking, yet also identifies where a softening of positions has occurred. Meissner categorizes the areas of interface as follows [32] (pp. 205–218): (1) ‘Psychoanalysis now embraces intentionality as a defining characteristic of psychic life, with both conscious and unconscious determinants. Religious orientations have come to accept unconscious life and psychoanalysis has accepted a meaningful account of conscious behavior, as inherently intelligible and relatively autonomous’ (p. 217). (2) The issue of freedom versus determinism seems less adversarial. Psychoanalysis explains a diminution of human freedom by way of psychodynamics. Psychopathology impairs a sense of mastery while treatment removes some of the impediments to an individual feeling more in control and more confident. While we now more clearly understand the causal factors (including the biological) involved in psychic determinism, free will is ‘an executive function of the ego honestly directing the course of action into one meaningful channel, rather than another’ (p. 237). It is now generally recognized that determinism in psychoanalysis only exists retrospectively. In developing a case formulation, psychoanalysts can make any behavioral constellation appear inevitably determined. (3) Analysis emphasizes purposive action, not mere discharge of instinctual energy. Psychoanalysis is now seen as a science that deals with the total complexity of the human organism, including a psychic life that is permeated with meaning and purpose. (4) Reductive explanations of unconscious, or historical, antecedents have given way to a more nuanced understanding of development. For example, verbal conflicts reflective
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of current, troubled relationships in the patient’s life may be involved in a case of sexual unresponsiveness as much as unconscious sexual conflicts. (5) Common ground is more difficult to find on issues of morality and the supernatural. The business of psychoanalysis remains amoral, not immoral, in addressing natural, biopsychosocial processes. In the same token, religion concerns itself with moral and supernatural, or transcendent, processes. Regarding issues of morality, there remains an area of reciprocal influence. Moral choice can be influenced by psychopathology and, as such, the nidus of psychopathology and conflict must be treated before moral choice can be ‘free.’ (6) The independence from drive forces and the relative autonomy of the ego [49] minimizes the tension between religion and psychoanalysis.Shifts in the field of psychoanalysis have mirrored changes in psychiatry and psychology. Positivism argues that reality is granted only to constructs that could be measured empirically, essentially banishing religion from the academic marketplace. This inflexible position has given way to humanistic voices which have emphasized the enhancing and protective functions of religion. Psychotherapy is no longer seen as value neutral [16, 50] and there have been dramatic changes in thinking about disclosure between patient and therapist, with therapist disclosures taking a more pragmatic focus [51, 52]. Two recent studies of psychoanalysts’ current beliefs and practices illustrate shifting psychoanalytic perspectives on religion. Bartoli recruited subjects from all psychoanalytic institutes affiliated with the American Psychoanalytic Association and gathered demographic data on 178 subjects, with 124 responding to open ended questions [53]. She then conducted ten in-depth interviews in a group selected for diversity in demographic variables. In this study, a minority maintain a classic psychoanalytic view of religion as deficit, based on irrational belief. However, the main intellectual thrust continues to shift away from a focus on veracity of religious beliefs to an emphasis on how beliefs are, or are not, associated with psychic conflict. Some analysts personally reject religion but most are concerned with the form religion takes, with the majority of these respondents seeing issues of veracity of belief outside of science. From this study it appears Freud’s promulgation of psychoanalysis as worldview has almost entirely receded. Bartoli found that contemporary analysts are more appreciative of patients’ religious involvement when it confers flexibility with respect to specific beliefs and promotes personality maturity. Intensive interviews revealed that most analysts see psychological and spiritual interpretations of religious material in one of two ways. Those who often avoid discussing religious material, or interpret it as a sign of psychopathology, reduce religious experience to its psychological components, especially defensive maneuvers and compensatory structures. On the other hand, a good number of respondents take a supportive position regarding religious material, as exemplified by the analyst who responded to the study interviewer: ‘I wouldn’t interfere with the patient’s religious experience. I would just try to understand it.’ When the interviewer inquired, ‘And by interfere you mean . . .?’, the analyst responded, ‘Interpret it; interpret it as a need in some way, a psychological need that did not have a spiritual basis in his religious belief, whatever it might be’ [53]. The study demographic data were interesting in that 40% of the respondents did not identify with any religion while 41% of the subjects identified as Jewish. Bartoli notes that reported American census data reveal only 17% identify with no religion and 2% are Jewish. These demographics almost certainly have something to do with the topics of
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psychoanalysis and religion, but are not yet well understood. These data are consistent with what is known of psychiatrists who, in general, are more secular than the patients they are treating [26, 27, 54]. In another qualitative interview research study [11], Simmonds interviewed 25 psychoanalysts and psychoanalytic psychotherapists in London, Sydney and Melbourne. This study explored how these clinicians experienced, conceptualized and worked with spiritual issues and also found some residue of Freudian tradition. Describing their own analyses, several analysts learned not to take spiritual matters to therapy, concerned that religious beliefs would be subject to scrutiny and dismissed as pathological. In this study many see religion as ‘the last taboo’ and they vary with respect to how active they are in questioning matters of faith. Some analysts who had never asked spiritually oriented questions are beginning to wonder whether they should do so as part of an assessment. However, most feel it is enough to primarily attend to what patients report. Participants think that spirituality is a ‘blind spot of psychoanalysis’ and that psychoanalysis is now beginning to emerge from this ‘well defended bunker’. Simmonds comments that ‘extending such metaphors, it can be argued that psychoanalysis is becoming more able to recognize that what was repudiated (projectively?) as “the enemy”, in Freud’s significant phrase, may have value, as well as being potentially defensive, and may even be complex and multifaceted.’ A number of subjects believe that patients want spiritual issues addressed respectfully and non-reductively. These clinicians note that, with respect to religious psychopathology, it is ‘clinically possible to tease out what is perverse and what is towards life and creativity’ [11].
3.5.7
NEW THEORETICAL PERSPECTIVES
The hegemony of Freudian doctrine on religion is over, opening up different ways of conceptualizing and working with religious issues in treatment. These views mirror general changes in psychoanalysis and all reflect, in some manner, a relationship perspective. Arguably self psychology and family systems theory are the two most powerful theories of psychological development in the second half of the twentieth century [13]. Both identify that a separate self is formed out of a relationship matrix and the self continues to influence, and be modified by, relationships. As religion is a special type of relationship, these new perspectives are somewhat congruent with religious faith. ‘Psychoanalytic study of religion will investigate the way beliefs, experiences and practices reflect dynamics involved in construing experience and in the deep structure of their internalized relationships’ [13] (p. 63). From this perspective, religious experience is not warding off the return of the repressed or infantile wish fulfillment, but occurs in the broader context of an individual’s self development. A cohesive self consolidates the internalized object relations derived from relationships with others. For the self to thrive in a matrix of relationships, an individual must benefit from a confluence of protective factors (e.g., a sustaining attachment to an available caregiver) and avoid risk factors (e.g., a neglectful, abusive attachment). A core sense of personal identity is formed from the matrix of relationships and this identity, or self, also influences the matrix of relationships. Various terms are now used to describe how life experience becomes part of ‘self-object relations’, ‘internal working models’ and ‘mental representations’ [13]. Development occurs in the context of relationship, as illustrated by Kohut’s view, that a self exists only in a self-object milieu [55] or
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Winnicott’s view that a baby exists only in relationship to its caregiver [56]. These developmental views are correlated with the clinical observation that problems occur in the context of relationships and therapeutic change occurs through relationships. In Jones’ view of transference, a relational psychoanalysis of religion provides a new category to investigate religion and centers on the reenactment of patterns and affects associated with internalized and generalized object relations. Some have argued that the transferential projecting of affect and past relationships also applies to spirituality. The way one views God, or ultimate reality, shapes how he relates to others and the way one experiences relationships with individuals shapes his view of God [4]. Contemporary psychoanalytic thinking identifies that many belief systems, or spiritual longings, are not so much wish fulfillments as basic human needs. Faith is less an instinctual derivative and more a realistically based, extrinsic concern. Religious impulses are not infantile wishes, but reflect the needs of all people [32]. This shift from wish to need represents a drastic departure from the classic psychoanalytic view of religion to a contemporary, post-Freudian view [13]. This departure runs parallel with the modifications in psychoanalysis which emphasize a relationship perspective: ego psychology, object relations theory, and self psychology. Meissner describes the emergence of psychoanalytic ego psychology as a first step in seeing religion as more than an instinctual derivative. The revolutionary concept of the ego’s independence from drive forces, and its determination by them, opened the door for other perspectives on religion [32]. For Rappaport, the ego is not a passive agent driven by outside agents but maintains a relative autonomy [49]. This relative autonomy has implications for an individual’s independent decision making regarding matters such as religion [57, 58]. For the object relations theorists, including Fairbairn [59], Guntrip [60] and others, development is not solely an intrapsychic phenomenon but one facilitated by the external environment. The human personality develops in continuing interactions with the outside world, especially an individual’s mental representation of God. Guntrip does not invoke the mechanism of distorted God representations, but believes that specific distortions in religion result when a child’s need for a relationship to a caring environment is not adequately met. While the first generation object relation theorists were inclined to make sweeping generalizations about religion as a whole, the clinical studies of Rizzuto identify the mechanisms giving rise to an individual’s mental representation of God [34]. According to Rizzuto, all individuals possess a unique mental image of God that is developed from early experience with parents, influenced by religious instruction. This God representation is an individual type of developing object relation and undergoes revision in response to challenges, life crises, and increasing cognitive capacities. Clinical and empirical research supports the idea that mental representations of the divine stem from, and are reasonably accurate views of, experiences children have had in relationship to their caregivers [34]. Rizzuto was influenced by the English psychoanalyst D.W. Winnicott [56, 61, 62] who describes religion in a realm of experience between the individual world of autistic fantasy and the world of objective reality. Whereas Freud had placed religion in the autistic fantasy realm, adherents of various religions place it in objective reality. For Winnicott, it is an intermediate stage in the human construction of reality and he terms this stage ‘illusory’, an illusion which cannot be satisfied apart from involvement in many creative activities, including religious belief. Many have felt this is unfortunate in that the term appears to harken back to the Freudian rejection of the validity of religion. Rizzuto believes that all
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individuals need this ‘illusory space.’ She comments: ‘After the Oedipal resolution, God is a potentially suitable object and if updated in each crisis of development, may remain so through maturity and the rest of life’ [34] (p. 209). A spiritual approach to life is not to be discarded on the way to independence, but to be reshaped through experience. She believes that ‘men cannot be men without illusions. The type of illusion we select: science, religion or something else, reveals our personal history and the transitional space each of us has created between his objects and himself to find “a resting place” to live in’ [34] (p. 209). In religious terminology, the illusory space is roughly equivalent to the transcendence of spirituality. For Kohut, we are born in relationship and live there all of our lives. He simply states, ‘A self can never exist outside a matrix of self objects’ [55] (p. 61). Transference is not the projection of biological impulses which need release but, through the re-creation of relational patterns, is an evidence of the human condition of relatedness and drive for relationship. While Kohut does not use the language of systems theory, his self psychology is consistent with that theory. Individuals cannot exist without relationships and are interconnected with others in the larger social matrix. Kohut describes psychopathology as the result of empathic failures in childhood which block self development [63, 64]. Healing occurs through a type of re-parenting as the new self is nurtured in the treatment process [65]. Debate between self psychology and object relations theory has revolved around two different views of human nature: the eternally autonomous self and the continually interconnected self. This latter relational view of psychoanalysis more easily accommodates a spiritual viewpoint. At the same time, a person’s felt relational bond with the sacred, or spiritual, reflects their inner object world and their inner object world helps determine their view of the sacred. Eric Erikson delineated the eight ages of psychosocial development and, in his later work, reflected frequently on religious themes [66, 67]. Erikson finds religious roots in the earliest stages of development and sees the first stage of infant development similar to religion which universalizes trust in a higher power. At the same time, religion universalizes mistrust through an understanding of evil. Erikson links some of the most profound aspects of human spiritual experience to early development without responding to the reductionism that had plagued Freud’s, and others’, efforts. He writes: ‘but must we call it regression if man thus seeks again the earliest encounters of his trustful past in his efforts to reach a hope for an eternal future... If this is partial regression, it is a regression which in retracing firmly established pathways, returns to the present amplified and clarified’ [66] (p. 264). Contemporary literature has followed Erikson’s lead and begun to utilize developmental schema to understand religious and faith phenomena [68, 69]. Theoretical shifts in the post-Freudian view of religion can be summarized as follows: (1) In ego psychology, religion leads to mastery of the environment and fosters a sense of identity [57, 58]. (2) In object relations theory, God representations are associated with psychic development, mental health, and mental disorder [34]. (3) In self psychology, sustaining available relationships lead to psychic development and religion has much to say about relationships [13, 55]. The remainder of this chapter leaves the conceptual and discusses contemporary clinical issues in addressing religious and spiritual issues in psychoanalytically oriented practice.
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CLINICAL ISSUES: ASSESSMENT
Recent research among psychoanalysts suggests that most clinicians utilize a traditional approach to assessment: listening to spontaneous material. When passive listening does not reveal apparent religious concerns, active questioning may be useful. There are several psychiatric interviewing guides which assist assessment in this area [70, 71]. Koenig and Pritchett have reported the use of a brief screen, summarized by the acronym FICA, to help structure such religiously oriented questions [72]. FICA refers to: Is religious faith important? How much has it influenced the patient’s life? Is the patient part of a spiritual community? Are there spiritual needs the clinician should address? This screen often can identify areas for further elaboration in cases where religious and spiritual material does not present overtly. More in depth exploration of religious life includes an examination of developmental influences community context, view of God, specific beliefs and practices and spiritual experiences [70]. Other important aspects of assessment focus on whether religious individuals evidence extrinsic or intrinsic faith. Extrinsically religious individuals use religion for social reasons, such as status, whereas intrinsically oriented religious individuals internalize beliefs and live them out regardless of personal or external consequences. Religious individuals can also be characterized along a spectrum from liberal to conservative/fundamental view points. This spectrum exists in all faiths and is related to an individual’s flexibility of thought and level of conviction. The distinction is important as, in extreme, it can be associated with clinical states. Fundamental faith can become harsh, rigid, and be associated with depressive conditions. Liberal faith can be so vaguely defined, it leads to a sense of anomie. Draper has reported on the diagnostic value of religious ideation as another aspect which reveals general psychodynamic issues in assessment [73]. An overriding goal of any psychoanalytic assessment is to fully know and understand the patient. Nicholi sets a high standard with respect to a clinical assessment of religion and worldview. ‘No clinician, regardless of clinical skills, can know the patient without exploring that patient’s worldview. The patient’s worldview gives the clinician insight into the patient’s self image, relationships, values and identity, as well as, how he or she confronts illness, suffering and death. A clinician’s understanding of the patient’s worldview, as well as the clinician’s insight into his or her own worldview, provides the key to establishing the most salubrious doctor/patient relationship [30] (p. 11)’.
3.5.9
CLINICAL ISSUES: CASE FORMULATION
After gathering relevant religious and spiritual data, the clinician faces the task of bringing an often overwhelming amount of clinical material into a meaningful clinical narrative. While some psychoanalysts choose to treat psychopathology, and separate religious beliefs from the clinical encounter, a search for a clear boundary is fruitless as religious factors are often inextricably involved with clinical presentations. What religious information is seminal? What information is ancillary? These straightforward questions help shape the ‘biopsychosociospiritual’ formulation [47, 74]. In the language of developmental psychopathology, religion and spirituality can protect from, or become risk factors for, mental disorder [47]. For example, religion can protect by enhancing an individual’s basic trust in others and in human kind generally. Yet, taken to an
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extreme form, a trusting faith can result in an inability to identify evil, leading the na€ıve to be taken advantage of in relationships. Religion provides a flexible structure for human development which encourages disciplined self control and facilitates the safe expression of sexuality and aggression. However, religious experience can become a rigid and rule bound, mitigating the free enjoyment of human activities such as sexuality. Religion can provide an intellectual basis to address the existential questions engendered by doubt, but a distorted theology can provide an inaccurate view of the world. Glenda, a 17 year old Caucasian female, was referred for psychiatric evaluation. She had unexplained abdominal pain which had necessitated multiple medical consultations, including several exploratory surgeries, to determine the source of pain. The abdominal pain, accompanied by headaches, eventually had no medical explanation. She was referred for psychotherapeutic treatment after being treated in a behaviorally oriented pain management program. In the initial interview the patient stated she had gone to a parochial school, but was currently home schooled. When the clinician commented on her education - ‘Was your family a family offaith?’ - she emphatically stated ‘Faith! Faith! That’s my whole problem.’ She then recounted significant anger toward parochial school peers who, she believed, shunned her. Glenda harbored aggressive fantasies toward them for their social ostracism of her. She openly felt guilt for these angry feelings, yet in confession with her priest, she did not experience understanding but condemnation. She heard she should not be angry and anger was ‘not of God.’ The patient elaborated that in the pain treatment program she had learned that ‘keeping anger inside’ was related to her psychosomatic symptoms. Yet, she was conflicted at expressing her anger more directly, an anger which she believed contravened religious precept. Faith and religion, and their relationship to affective expression, became the recurrent theme of subsequent sessions. Religion can provide a sense of community and a caring, supportive environment, but this same community can frustrate self development by limiting individual autonomy. Finally, religion is first encountered in a developmental context and family shapes early religious experience. Family relationships can become internalized and influence God images, either positively or negatively.
3.5.10
CLINICAL ISSUES: TREATMENT
The formulation sets up tentative hypotheses which are explored in treatment. A psychoanalytic treatment process does not privilege religion and everything religious is open to scrutiny. When analysis is successful, it can open up a deeper understanding of religious convictions. Therapy must distinguish between adaptive aspects of religion and those which are destructive. All religious experience, including the numinous, demands a psychological explanation. As the ultimate goal of psychoanalysis is adaptation, the analyst must support the protective functions of religion. However, consistent interpretation of religious phenomena may weaken faith by focusing on dynamics and function. Even though the analyst may not rule on the legitimacy of faith, specific spiritual experiences may wither under analysis. For example, looking at a patient’s prayer life may weaken the experience. However, with an open, unbiased attitude on the part of the psychotherapist, healthy aspects of the patient’s religion can be supported. Once treatment has begun, accepting the patient’s spirituality often solidifies a therapeutic alliance. Many patients describe surprise when the analyst is open to religious issues and inquires about them [11].
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As Glenda proceeded in psychotherapy, it became clear she had two developmentally derived God representations which appeared in direct conflict. The first image was associated with nurturing parents who had taught her that Christians think of others first, placing others’ wellbeing ahead of self interest. The resulting deferential God image was contrasted by God’s earthly representative, the priest who harshly reprimanded her for the negative affect she harbored, an emotion against God’s wishes. Therapy proceeded to disentangle pathological beliefs from the pathological earthly expression of these beliefs. As the patient grappled with the inappropriateness of the priest’s rejection, her faith diminished and distrust of the Catholic Church increased. In therapy, spiritual concerns must not be seen as evidence of psychopathology. For example, there is often anguish before the spiritual experience of repentance and conversion. This distinction requires spiritual sensitivity as well as diagnostic acumen. In exploring moral choices, individuals may choose to do the wrong (a spiritual issue), or hurt others through narcissistic behavior (a psychopatholgy concern). Just as one would not do surgery for hypertension, it is important not to invoke psychoanalytic tools for what may be a spiritual problem. Peteet has suggested a continuum of four distinct approaches to guide the clinician in working with spiritual and religious problems in psychotherapy [75]. First, in the traditional psychoanalytic approach, the clinician acknowledges the importance of the problem but focuses exclusively on its psychological dimensions. Second, the clinician clarifies and suggests resources for addressing religious and spiritual problems elsewhere, including referral to pastor/clergy as part of a therapeutic team. Third, the psychotherapist addresses problems indirectly, using the patient’s spiritual perspective to foster greater integration of his spiritual and emotional life. This involves becoming aware of the patient’s worldview, either through consultation, or by direct explication by the patient. Finally, the psychotherapist addresses spiritual problems directly through the use of a shared religious or spiritual orientation. This last approach may involve a need for supervision and consultation to avoid boundary intrusions [76, 77]. Supervision and consultation are also strongly encouraged for those uncomfortable with spiritual issues. While not directly identifying with Catholicism, the therapist’s background allowed him to understand some of Glenda’s religious material. He recognized that the she was distorting some theology and tried to work with her own belief system, by referring to her religious tradition and healthy anger expression within that tradition. The therapist was aware of his own background of Christian belief and worked to monitor that countertransference, letting the patient struggle through unhealthy aspects of her faith.
3.5.11
TRANSFERENCE AND COUNTERTRANSFERENCE
Successful management of these reactions regarding religious issues is perhaps the most important factor in psychoanalytic treatment success. Psychotherapy is no longer seen as value neutral; the therapist is no longer a blank slate [13, 42, 50]. While neutrality is a component of therapeutic technique, in the face of issues traditionally seen as moral, analyst neutrality is an ethic or value judgment. Emerging literature suggests the patient’s comfort in relating values and discussing spiritual concerns are in direct relation to the therapist’s comfort in discussing the patient’s worldview [11, 53]. Therapist disclosure, while not part of classic psychoanalytic technique,
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is an area deserving increasing discussion. Self disclosure should be kept at a minimum, but there are situations in general psychiatric practice where disclosure is acceptable, if it is clear that it serves the patient and not the therapist [51]. While analysts can be technically neutral during the therapeutic hour, they cannot be neutral regarding life’s great questions in their personal lives [8, 78] and patients know this. Most therapists downplay the role of their own belief system which may be unstated, unacknowledged, or unconscious. Therapists appropriately realize that revealing their worldview is fraught with problems. This is complicated in that therapists in some geographical areas tend to have belief systems that are more secular than those of the patients they are treating [26, 54, 79]. Peteet [75] has offered guidelines in determining an appropriate degree of self disclosure, stating that it involves several considerations: (1) Some disclosure may be needed at the outset of therapy to establish trust. (2) A level of congruence between therapist and patient worldviews allows for some disclosure. (3) There exists a potential for damage to the treatment process caused by transference and countertransference pressures [76, 77]. (4) The expertise of the therapist in the relevant faith area dictates level of disclosure. It is clear therapists cannot be knowledgeable of all faiths. In addition, all clinicians have a worldview which may influence the clinical encounter. Abernethy and Lancia have proposed a concept, ‘religiocultural’ transference [80], which helps address these issues. This was adapted from the concept of ‘ethnocultural’ transference and ‘ethnocultural’ countertransference which refers to how the patient’s cultural background influences his response to the therapist and to how the therapist’s cultural background influences his response to the patient [81]. In like manner, an examination of ‘religiocultural’ transference is a prerequisite for effectively working with religious themes in the psychotherapeutic process. These authors believe that religiocultural transference and countertransference are based on responses to known, assumed or fantasized aspects of religious backgrounds. They describe inter-religious transference emerging when the patient perceives the therapist and patient have different backgrounds, whereas intra religious transference occurs when the patient perceives that the therapist and patient have similar backgrounds. Inter-religious and intra-religious countertransference occur, respectively, when the therapist perceives that the therapist and patient have different religious backgrounds and when the therapist perceives the therapist and patient have similar backgrounds. This categorization is useful in identifying some of the therapeutic issues inherent in the various combinations. Inter-religious transference often means the therapist is a safer, not idealized, object of the patient’s own faith. While the patient can be more objective in freely sharing any aspect of faith, it is possible that the patient feels that he will not be understood because of the uniqueness of his religious background. With respect to intra-religious transference, the patient may experience guilt for not living up to the ideals that he assumes the therapist shares. More positively, the patient may experience an enhanced therapeutic alliance once believes his worldview is understood by a therapist who shares the same faith. Inter-religious countertransference decreases the chances that the therapist’s religious background will negatively influence therapy. On the other hand, the therapist will need to work much more diligently to understand religious beliefs which may be unusual or, in fact,
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repugnant. In intra-areligious countertransference, the therapist may make premature assumptions about a faith’s meaning to a patient and avoid tough topics. The therapist may also have a past history in the faith which may unduly influence therapy. The therapist may need time to understand how a patient, having essentially the same belief system, may experience it differently. More positively, the therapist may be able to explore more deeply the patient’s conflicts and strengths, using readily understood aspects of the shared faith. Griffith [82] has noted that internalized stigma toward religion from the professional traditions and the culture of psychiatry remains an important general aspect of countertransference, which applies to both inter and intra-religious countertransference. Abernethy and Lancia identify that religiocultural transference and countertransference are considerations in psychotherapy not only when therapist and patient are from different religions, but when they share the same religion. In order to work effectively therapists need to consider and monitor their degree of openness to religious content, be attuned to the meaning of their own religious affiliation, and understand the role of consultation in refining therapist’s skills. Armed with this self knowledge, the therapist will feel more comfortable in interpreting religious content.
3.5.12
CHALLENGES FOR THE FUTURE
Once religion and spirituality are seen as reflecting basic human needs and not mere wish fulfillment, new waters are to be charted. Three areas deserve further attention for the future practice of psychoanalysis: the role of belief in psychic life; how the match or mismatch of worldview of patient and analyst affects the clinical encounter and the effect of contemporary culture change, including increasing interaction of diverse worldviews.
3.5.12.1
Beliefs as worldview and believing as a psychical activity
Psychoanalysis now seems ready to consider beliefs independently and study their psychic function, with Rizzuto being a leading exponent of this concept. She writes that ‘believing is an ever present human activity, a process in which we are always and at all times involved, whether consciously or not, which is indispensable for the normal working of the mind and foundational for psychic life. The believing function is essential for the functioning of the human organism in given milieu’ [83] (p. 435–436). All beliefs, and the relationship of a believer to God, are filtered through representational processes. These representational processes are based on the child’s experience with parents and perform a mediating function which makes it possible to relate to a being who is not physically present. Rizzuto describes believing as a ‘psychic activity that cognitively and affectively interprets, at a given moment, the condition of one’s being, intrapsychically and interpersonally’ [83] (p. 444). This activity can be carried out unconsciously, preconsciously or consciously and is directly related to a spiritual search for meaning. She believes ‘Human beings can no more live without belief and meaning for their existence than live without food’ [84] (p. 41). Rizzuto’s views chart a new course for psychoanalysis. Without using the term, she has described an individual’s need for a worldview. Just as all individuals have physical organs
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of liver, kidney and heart, all individuals have a worldview, specific beliefs that sustain their understanding of who they are in the world and guide them in the choices which define their existence. The role of belief, specifically religious belief, in psychoanalytic theory and practice appears a fruitful area for further investigation.
3.5.12.2
The psychoanalyst’s worldview
In classic psychoanalysis, the analyst was a tabula rasa upon which the patients projected thoughts, feelings and attitudes. While neutrality in conducting therapy remains an important therapeutic tool, no psychoanalyst can be neutral about most of life’s experiences. As Nicholi has pointed out, Freud’s materialistic worldview was not primarily derived from clinical observation, but from cultural influences and his developmental experience [30]. There is considerable evidence that his worldview shaped what he observed, and failed to observe, clinically, and that it was formed before he began his scientific work. As all individuals, including psychoanalytic psychotherapists, possess a worldview, or philosophy of life, it is incumbent on the clinician to be aware of their own worldview. This awareness is essential in guarding against biases which could impair clinical effectiveness. Patients have ways of knowing, through analyst verbal and non verbal productions, the analysts’ perspective on their religious life. The need for psychotherapists to monitor their religious/spiritual counter transference is clear. There are suggestions that doctors who experience spirituality as distinct from psychological descriptions of spirituality may be ‘better prepared to engage with the interrelated yet separate discourses of psychoanalysis and spirituality’ [85]. Therapists who are uncomfortable with their own spirituality may be inhibited in exploring spiritual issues with patients [86]. Such personal discomfort may be exacerbated by training deficits. In Bartoli’s recent study, 97% of psychoanalysts surveyed had no formal training in spirituality and only 34% had some informal training in the area [53]. Thus, the psychoanalyst’s comfort and knowledge with their own worldview is even more important, given the relative lack of instruction and supervision in psychoanalytic training programs. In lieu of this, clinicians are urged to seek consultation from both psychoanalytic colleagues and those in religious professions. This interdisciplinary dialogue can go a long way toward mutual understanding for the betterment of patient care.
3.5.12.3 Contemporary cultural factors in religion and psychoanalysis For the nineteenth and much of the twentieth century, modernism dominated Western thinking. This approach encompassed rationalism, technology, knowledge and science, ultimately devaluing supernatural elements. Gradually, ‘post-modernism’ arose in the second half of the twentieth century. As Harvey provocatively wrote, ‘Post modernism signals the death of such ‘meta narratives’ whose secretly terrorist function was to ground and legitimate the illusion of a ‘universal’ human history’ [87] (p. 9). Hyperbole aside, this comment indicates a serious challenge to religious faith as religions are prime progenitors of ‘meta narratives.’ Many individuals are bewildered at this point in history as they exist in a fragmented, pluralistic culture, left alone as it were to develop their own meaning.
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Spiritualities are found in many places, including the integration of spirituality into psychotherapeutic practice. Many believe that the disappearance of the extended family and the disruption of the nuclear family – offering less constant, less nurturing parenting – have challenged organized religious belief with important implications for psychoanalytic practice. The impact of the ‘global village’ is a contemporary cultural issue of growing importance. All cultures are in increasing contact with each other, abetted by the ease of transportation and the increase in technological communications. As a consequence, the psychoanalyst comes into contact with diverse worldviews more than ever before. Some of the worldviews will be foreign to the analyst and it may not always be possible, or clinically safe, to refer a patient to a clergyperson or spiritual advisor of that worldview tradition. This necessitates the psychoanalyst working with the patient’s worldview or religion and, by implication, becoming somewhat conversant with its basic tenets. This may be achieved by consultation with an authority in the faith. It is likely most effective if the patient can articulate aspects of personal belief to the psychoanalyst who can then determine whether such beliefs are risk factors for, or protect against, psychopathology. Arguably, there are three major religious traditions of which psychoanalysts need to be aware. First, the Abramic traditions (Judaism, Christianity and Islam) refer to the history of Abraham and to varying degrees embrace doctrines related to creation, a ‘fall’ of mankind, ways to redemption and ultimate surrender to God. (70) The yogic traditions of Hinduism and Buddhism believe in karma, reincarnation and mindfulness. Perhaps more than other faiths, culture and religious belief are intertwined for the Hindu and the Buddhist. Because proponents emphasize freedom of thought and diversity, fundamentalism is less common in these faiths. (88) Finally, the naturalist position is not typically seen as a religion but it has all the characteristics of a worldview. Patients (atheists, agnostics, materialists) holding to this ‘tradition’ believe that rational, scientific thought is the highest form of human consciousness. In a universe without purpose, only through scientific means can truth be known. (70) Due to space considerations, this chapter could not address how psychoanalysis and psychoanalytic psychotherapy is conducted with patients of specific faith traditions. There are excellent volumes which address this issue (1, 89) and the beliefs of each of the major world religious traditions are covered in this volume.
3.5.13
CONCLUSION
The dramatic increase in interest in spirituality requires the psychoanalyst to consider religious variables in the assessment and treatment of patients. It now seems clear that any psychoanalytically oriented psychotherapeutic process can improve health and adaptation by minimizing religious risks and maximizing religious protective factors. Minimizing risks includes analyzing and interpreting developmental experiences which have led to maladaptive God representations. Maximizing protection means supporting healthy religion when it is identified through empathic understanding of the patient’s relationship with the transcendent. Patients develop problems through relationships and they experience healing through relationships. Working on human relationships is as far as psychoanalysis can go. Understanding the relationship with the transcendent is where religion, theology and spirituality begin.
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REFERENCES 1. Josephson AM, Peteet JR, (eds.) (2004) Handbook of Spirituality and Worldview in Clinical Practice. American Psychiatric Publishing, Inc., Washington, DC. 2. Miller WR, Thoresen CE (2003) Spirituality, religion, and health: An emerging research field. American Psychologist 58, 24–35. 3. Zinnbauer BJ, Pargament K (2005) Religiousness and spirituality. In: Paloutzian RF, Park CL (eds.) Handbook of the Psychology of Religion and Spirituality. The Guildford Press, New York, pp. 21–42. 4. Gurney AG, Rogers SA (2007) Object-relations and spirituality: revisiting a clinical dialogue. Journal of Clinical Psychology 63, 961–977. 5. Freud S (1962) The question of a weltanschauung. (1933) In: Strachey J (ed.) The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 22. Hogarth Press, London, pp. 158–182. 6. Klein M (1935) A contribution to the psychogenesis of manic-depressive states. In: Love, Guilt and Reparation and Other Works 1921–1945. Hogarth Press, London, pp. 262–289. 7. Robinson LH (1986) Psychoanalysis and religion: a comparison. In: Robinson LH (ed.) Psychiatry and Religion: Overlapping Concerns. American Psychiatric Press, Inc., Washington, D.C., pp. 1–20. 8. Wallace ER (1983) Reflection on the relationship between psychoanalysis and Christianity. Pastoral Psychology 31, 215–243. 9. Menninger K (1973) Whatever Became of Sin? Hawthorn, New York. 10. Pattison EM (1984) Psychoanalysis and the concept of evil. In: Nelson MC, Eigen M (eds.) Evil: Self and Culture. Human Sciences Press, New York, pp. 61–85. 11. Simmonds JG (2004) Heart and spirit: research with psychoanalysts and psychoanalytic psychotherapists about spirituality. International Journal of Psychoanalysis 85, 951–971. 12. Bowlby J (1988) A Secure Base. Basic Books, New York. 13. Jones JW (1991) Contemporary Psychoanalysis & Religion: Transference and Transcendence. Yale University Press, New Haven. 14. Spero MH (1990) Parallel dimensions of experience in psychoanalytic psychotherapy of the religious patient. Psychotherapy 27, 53–71. 15. Gilkey L (1993) Nature, Reality and the Sacred. The Nexus of Science and Religion. Augsburg Fortress, Minneapolis. 16. Jones SL (1994) A constructive relationship for religion with the science and profession of psychology: perhaps the boldest model yet. American Psychologist 49, 184–199. 17. Wulff DM (1996) The psychology of religion: an overview. In: Shafranske EP (ed.) Religion and the Clinical Practice of Psychology. American Psychological Association, Washington, DC, pp. 43–70. 18. Freud S (1961) Civilization and its discontents (1930). In: The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 21. Translated and edited by Strachey J. Hogarth, London, pp. 59–145. 19. Wallace ER (1985) Further reflections on the relationship between psychoanalysis and religion. Journal of Religion and Culture 20, 175–194. 20. Wallace ER (1977) The psychodynamic determinants of ‘Moses and Monotheism.’ Psychiatry 40, 79–87. 21. Wallace ER (1978a) Freud’s father conflict: the history of a dynamic. Psychiatry 41, 33–56. 22. Gay P (1987) Freud, Atheism, and the Making of Psychoanalysis. Yale University Press, New Haven. 23. Kung H, Quinn E(translator) (1979) Freud and the Problem of God. Yale University Press, New Haven.
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24. Nicholi AM (2002) The Question of God: C.S. Lewis and Sigmund Freud Debate God, Love, Sex, and the Meaning of Life. The Free Press, New York. 25. Freud S (1959) Obsessive actions and religious practices. (1907) In: The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 9. Translated and edited by Strachey J. Hogarth, London, pp. 115–127. 26. Curlin FA, Lawrence RE, Odell S et al. (2007a) Religion, spirituality, and medicine: psychiatrists’ and other physicians’ offering observations, interpretations, and clinical approaches. American Journal of Psychiatry 164, 1825–1831. 27. Curlin FA, Odell SV, Lawrence RE et al. (2007b) The relationship between psychiatry and religion among U.S. physicians. Psychiatric Services 58, 1193–1198. 28. Pfister O (1928) Die Illusion einer Zukunft (The illusion of the future). Imago 14, 149–184. 29. Zilboorg G (1962) Psychoanalysis and Religion. Farrar, Straus, and Cudahy, New York. 30. Nicholi AM (2004) Introduction: Definition and significance of a worldview. In: Josephson AM, Peteet J,(eds.) Handbook of Spirituality and Worldview in Clinical Practice. American Psychiatric Publishing, Inc., Washington, DC, pp. 3–14. 31. Ricoceur P (1970) Freud and Philosophy: An Essay on Interpretation. Yale University Press, New Haven. 32. Meissner WW (1984) Psychoanalysis and Religious Experience. Yale University Press, New Haven. 33. Lewis, CS (2001) Morality and psychoanalysis (1963) In: Mere Christianity. HarperCollins, San Francisco, p. 88–93. 34. Rizzuto AM (1979) The Birth of the Living God: A Psychoanalytic Study. The University of Chicago Press, Chicago. 35. Meissner WW (2000) Psychoanalysis and religion: current perspectives. In: Boehnlein JK (ed.) Psychiatry and Religion: The Convergence of Mind and Spirit. American Psychiatric Press, Inc., Washington, D.C., pp. 53–70. 36. Freud S (1961) The future of an illusion (1927). In: The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 21. Translated and edited by Strachey J Hogarth, London, pp. 1–56. 37. Larson DB, Pattison EM, Blazer DG, et al. (1986) Systematic analysis of research on religious variables in four major psychiatric journals. American Journal of Psychiatry 149, 329–334. 38. Larson DB, Sherrill KA, Lyons JS, et al. (1992) Associations between dimensions of religious commitment and mental health reported in the American Journal of Psychiatry and Archives of General Psychiatry: 1978–1989. American Journal of Psychiatry 149, 557–559. 39. Larson DB, Thielman SB, Greenwold M, et al. (1993) Religious content in the DSM-III-R glossary of technical terms. American Journal of Psychiatry 150, 1884–1885. 40. Post SG (1990) DSM-III-R and religion. American Journal of Psychiatry 147, 813. 41. Pargament K (2007) Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred. The Guilford Press, New York. 42. Bartoli E (2007) Religious and spiritual issues in psychotherapy practice: Training the trainer. Psychotherapy: Theory, Research, Practice, Training 44, 54–65. 43. Koenig HG (ed.) (1998) Handbook of Religion and Mental Health. Academic Press, San Diego. 44. Shafranske EP (ed.) (1996) Religion and the Clinical Practice of Psychology. American Psychological Association, Washington, D.C. 45. Sperry L, Shafranske EP (eds.) (2005) Spiritually Oriented Psychotherapy. American Psychological Association, Washington, D.C. 46. Coles R (1995) The Mind’s Fate: A Psychiatrist Looks at His Profession. Back Bay Books, U.S.A. 47. Josephson AM, Peteet JR (2004) Worldview in diagnosis and case formulation. In: Josephson AM, Peteet JR,editors. Handbook of Spirituality and Worldview in Clinical Practice. American Psychiatric Publishing, Inc., Washington, DC, pp. 31–46.
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48. Eichelman B (2007) Religion, spirituality, and medicine. American Journal of Psychiatry 164:12, 1774-1775. 49. Rappaport D (1967) The theory of ego autonomy, (1957). In: Gill M,editor. The Collected Papers of David Rappaport. Basic, New York, pp. 722–744. 50. Bergin AE, Payne IR, Richards PS (1996) Values in psychotherapy. In: Shafranske EP, editor. Religion and the Clinical Practice of Psychology. American Psychological Association, Washington, DC, pp. 297–325. 51. Peteet JR (2004) Therapeutic implications of worldview. In: Josephson AM, Peteet J, editors. Handbook of Spirituality and Worldview in Clinical Practice. American Psychiatric Publishing, Inc., Washington, DC, pp. 47–59. 52. Psychopathology Committee of the Group for the Advancement of Psychiatry. (2001) Reexamination of therapist self-disclosure. Psychiatric Services 52, 1489–1493. 53. Bartoli E (2003) Psychoanalytic practice and the religious patient: a current perspective. Bulletin of the Menninger Clinic 67, 347–366. 54. Josephson AM, Larson DB, Juthani, N (2000) What’s happening in psychiatry regarding spirituality? Psychiatric Annals 30, 533–541. 55. Kohut H (1984) How Does Analysis Cure? University of Chicago Press, Chicago. 56. Winnicott DW (1965) The Maturation Process and the Facilitating Environment. International Universities Press, New York. 57. Hartmann H (1958) Ego Psychology and the Problem of Adaptation. Reprint. (1939) International Universities Press, New York. 58. Hartmann H (1960) Psychoanalysis and Moral Values. International Universities Press, New York. 59. Fairbairn WRD (1943) The repression and the return of bad objects. In: An Object Relations Theory of Personality. Basic Books, Norton, 1952. 60. Guntrip H (1956) Mental Pain and the Cure of Souls. Independent Press, London. 61. Winnicott DW (1953) Transitional objects and transitional phenomena. International Journal of Psycho-Analysis 34, 89–97. 62. Winnicott DW (1971) Playing and Reality. Basic Books, New York. 63. Kohut H (1971) The Analysis of the Self. International Universities Press, New York. 64. Kohut H (1977) The Restoration of the Self. International Universities Press, New York. 65. Baker H, Baker M (1987) Heinz Kohut’s self psychology: an overview. American Journal of Psychiatry 144, 1–9. 66. Erikson EH (1962) Young Man Luther: A Study in Psychoanalysis and History (1958). WW Norton, New York. 67. Erikson EH (1969) Gandhi’s Truth: On the Origins of Militant Nonviolence. WW Norton, New York. 68. Josephson AM (1994) A clinical theology of the developmental process: A child psychiatrist’s perspective. Journal of Psychology and Theology 22, 120–129. 69. Fowler JW (1981) Stages of faith. HarperCollins, New York. 70. Josephson AM, Wiesner I (2004) Worldview in psychiatric assessment. In: Josephson AM, Peteet J, editors. Handbook of Spirituality and Worldview in Clinical Practice. American Psychiatric Publishing, Inc., Washington, DC, pp. 15–30. 71. Josephson AM, Peteet JR (2007) Talking with patients about spirituality and worldview: practical interviewing techniques and strategies. Psychiatric Clinics of North America 30, 181–197. 72. Koenig HG, Pritchett J (1998) Religion and psychotherapy. In: Koenig HG, editor. Handbook of Religion and Mental Health. Academic Press, San Diego, pp. 323–336. 73. Draper E, Meyer CG, Parze Z,et al. (1965) On the diagnostic value of religious ideation. Archives of General Psychiatry 13, 202–207. 74. Sperry L (2005) Integrative spiritually oriented psychotherapy. In: Shafranske EP, Sperry L (eds.) Spiritually Oriented Psychotherapy. American Psychological Association, Washington, D.C., pp. 307–329.
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75. Peteet JR (1994) Approaching spiritual problems in psychotherapy: a conceptual framework. The Journal of Psychotherapy Practice and Research 3, 237–245. 76. Gutheil TG, Gabbard GO (1993) The concept of boundaries in clinical practice: theoretical and risk-management dimensions. American Journal of Psychiatry 150, 188–196. 77. Gutheil TG, Gabbard GO (1998) Misuses and misunderstandings of boundary theory in clinical and regulatory settings. American Journal of Psychiatry 155, 409–414. 78. Linn L, Schwartz L (1958) Psychiatry and Religious Experience. Random House, New York, p. 12. 79. Rubinstein G (1994) Political attitudes and religiosity levels of Israeli psychotherapy practitioners and students. American Journal of Psychotherapy 48, 441–454. 80. Abernethy AD, Lancia JJ (1998) Religion and the psychotherapeutic relationship: transferential and countertransferential dimensions. The Journal of Psychotherapy Practice and Research 7, 281–289. 81. Comaz-Diaz L, Jacobsen FM (1991) Ethnocultural transference and countertransference in the therapeutic dyad. American Journal of Orthopsychiatry 61, 392–402. 82. Griffith JL (2006) Managing religious countertransference in clinical settings. Psychiatric Annals 36, 196–204. 83. Rizzuto AM (2002) Believing and personal and religious beliefs: Psychoanalytic considerations. Psychoanalysis and Contemporary Thought, 25, 433–463. 84. Rizzuto AM (2005) Psychoanalytic considerations about spiritually oriented psychotherapy. In: Sperry L & Shafranske P (eds.) Spiritually Oriented Psychotherapy, American Psychological Association, Washington, DC, pp. 31–50. 85. Shafranske EP (2005) A psychoanalytic approach to spiritually oriented psychotherapy. In: Sperry L, Shafranske EP (eds.) Spiritually Oriented Psychotherapy. American Psychological Association, Washington, DC, pp. 105–130. 86. Schultz-Ross RA, Gutheil TG (1997) Difficulties in integrating spirituality into psychotherapy. The Journal of Psychotherapy Practice and Research 6, 130–138. 87. Harvey D (1990) The Condition of Postmodernity. Basil Blackwell, Cambridge. 88. Juthani, N (2004) Hindus and Buddhists. In: Josephson AM, Peteet J, editors. Handbook of Spirituality and Worldview in Clinical Practice. American Psychiatric Publishing, Inc., Washington, DC, pp. 15–30. 89. Scott Richards P., Bergin A. (eds) (2000) Handbook of Psychotherapy and Religious Diversity. American Psychological Association, Washington, DC.
CHAPTER 3.6
On the Psychology of Religious Fundamentalism John, Lord Alderdice House of Lords (London), Psychiatrist, United Kingdom
3.6.1
INTRODUCTION
It is understandable that many current writers begin their published reflections on the phenomenon of religious fundamentalism by acknowledging the significance of September 11, 2001 and the suicide attacks on the United States of America, in particular on symbols of its economic, military and political power. However there are certain problems with this starting point. Firstly, there is an implied conflation of religious fundamentalism with the use of terrorism and politically motivated violence, a connection that merits further exploration, and secondly it disconnects, by setting to the other side of that watershed, the importance of the Protestant fundamentalism which was substantially mobilized in the U.S. Presidential election campaign of George W Bush the previous year. In addition to Islamic and other religious fundamentalist movements, Protestant fundamentalism had been on the rise in various parts of the world for some time. BBC News reported on 13 July 1999, ‘Heresy trials are to be brought back by the Church of England. After a gap of 150 years tribunals are to be reintroduced for clergy accused of not believing in God.’ Since then the matter has continued to rumble slowly through the governing structures of the Church of England at the same time that the worldwide Anglican Communion is near to schism over the question of the Church’s attitude to homosexuality. This demonstrates a profound divergence and antagonism between those who may be described as liberals or modernists on the one hand, and those taking action against them who we might describe as fundamentalists. That the latter group is not merely conservative is shown by their intolerance of the position of the liberal modernists. The Anglican Communion has always prided itself on being a ‘broad church’ of liberals, conservatives and others, and the views being expressed by the modernist tendency are by no means new, so the threats of schism and formal discussions within the courts of the Church about the reappearance of heresy trials seem to represent something significant about the growth and development of fundamentalism.
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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THE HERESY TRIAL OF J. ERNST DAVEY
The last really significant heresy trial in a major British religious denomination took place in the Irish Presbyterian Church in 1927 when Professor J Ernest Davey, was cleared of the charge after an extensive trial during February and March of that year. This was followed by an appeal by his accusers that was then rejected by the General Assembly in June 1927. The action was taken against the young professor by fundamentalists within the Presbyterian Church in Ireland and despite the fact that the trial took place more than 80 years ago it is important in our wider consideration of the psychology of religious fundamentalism for a number of reasons. Professor Davey was one of the brightest theologians of his day. Born in 1890, a son of the Irish Presbyterian manse, he was showered with prizes from his school days on. He entered Kings College, Cambridge in 1909 taking a series of prizes, and First Class Honors, and was awarded a Fellowship in Theology in 1916, the first such Fellowship to have been awarded in 26 years. He proceeded to the University of Edinburgh with more ‘Firsts’ and the Professor of Hebrew and Semitic Studies at Edinburgh described the quality of his papers as ‘rarely seen in my thirty years experience’. He returned to Belfast in 1917 and was elected to the Chair of Church History in the Presbyterian College aged 27 years. In 1923 he published The Changing Vesture of the Faith [1] based on a series of lectures he had delivered to members of the public in Northern Ireland, and this book, along with Our Faith in God which had come out the previous year, were substantial contributors to his being arraigned on charges of heresy. In The Changing Vesture of the Faith he espouses a psychological approach to understanding the changes and developments of Christian beliefs, institutions and observances over the centuries and he writes in very approving terms of the recent developments of psychoanalysis and how they shed light on these subjects. The Rev James Edgar [2] in his later published challenge to Professor Davey’s position singles out his espousal of this psychological approach and his acceptance of evolution as some of the most toxic aspects of his ‘modernism’ calling for ‘a little more repression and a little less expression’. While this challenge, written in the aftermath of the trial, claims a self-sacrificial engagement in the struggle and denies any wish to criticize Davey as a person, it is couched in strident and angry terms and is dismissive and disrespectful of Davey’s intellectual work, especially where it involves higher criticism, liberal social ideas, evolutionary principles and psychology. Even more interestingly he betrays a clear political position by appealing to the Sons of Ulster (a commonly used term in Northern Ireland, meaning Protestant Unionists) and making regular references in deprecating terms to Germany, recently defeated in World War I. As Dr. Austin Fulton (also a later Moderator of the Presbyterian Church in Ireland) pointed out in his biography of Davey [3] there were a number of elements of the context in which the heresy trial arose that may well have contributed to the fundamentalist/modernist dispute reaching such a pass. World War I had a profound impact on the political framework of Europe, bringing some empires to an end, and beginning the unstitching of those that remained, including the British Empire itself, where that ‘unstitching’ had already begun with the partition of Ireland in 1921. While there had been no conscription in Ireland during the War, young men had answered the call to arms by the tens of thousands, going to their deaths in unimaginable numbers at the Battle of the Somme and all along the front line. This legacy of sacrifice still has an effect reflected in the special meeting of Belfast City Council held every 1 July for the sole purpose of remembering those who fought at the Somme, though the last survivor died years ago.
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3.6.3
ON THE PSYCHOLOGY OF RELIGIOUS FUNDAMENTALISM
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PROTESTANTS AND PARTITION POLITICS IN IRELAND
The Great War, as it is still known, was followed by the War of Independence in Ireland in which the Irish Republican Army (IRA) rebels took on the victorious forces of the British Empire and drove them out of most of the island. Only the six Northern counties remained within the United Kingdom after the partition of 1921, while the 26 southern counties went on to form their own independent and almost totally Catholic nationalist state. Northern Protestants in the early 1920s were therefore terrified that either they would be abandoned by Britain and taken over by the south, or that their province would be destabilized by internal elements of the IRA supported by the Roman Catholic Church and people. Into this frightened Protestant population arrived a fiery fundamentalist preacher called Rev W P Nicholson. A native of the North he had trained with the Presbyterian Church in the U.S.A. He returned with the militant certitude and fundamentalist evangelistic techniques being deployed in the fight against modernism in the United States, as exemplified in the 1925 trial of biology teacher John Scopes, accused of breaking the law by teaching evolution to students in Dayton, Tennessee. It is said that after WP Nicholson arrived home he was warned by a representative of the new Government of Northern Ireland not to use his gifts to stir up trouble with the Catholics because of the potential political risks, and he is reported to have reassured his interlocutor that he would ‘lay off the Papishes’ and concentrate his fire on those of whom he disapproved in the Protestant community – in particular the Plymouth Brethren (a small isolated protestant sect) and ‘liberals, modernists, higher critics and Unitarians’. Fulton expresses the view that without this charismatic focus of discontent the plaintiffs in the heresy case might not have been able to get their case off the ground, and while they lost in an overwhelming vote – 707 supporting Davey and only 82 against – their impact was to be long-lasting. Davey went on to become Principal of the Presbyterian Theological College in Belfast and Moderator of the Presbyterian Church in Ireland, but he wrote relatively little after the trial, other than his life’s work on the Gospel of St. John published more than 30 years later in 1958. By that time a new WP Nicholson had arisen in the form of the young Ian Paisley. Northern Ireland seemed more stable, and his fundamentalism was not taken so seriously for a while, but as he gradually became more of a threat, it was noticeable how reticent the mainstream Presbyterian Church was to rebut his stance. It was as though no leading figure wanted to risk becoming the sacrificial lamb in a new heresy trial. The Free Presbyterian Church that Ian Paisley established grew in size and influence and his sermons and writings viciously attacked both modernists and ‘Romanists’ who he put in the same camp. He participated in anti-civil rights demonstrations and actively contributed to the breakdown into street violence with the resultant burning of Catholic houses, and the reappearance of the IRA and their Protestant alter-egos – the Ulster Volunteer Force (UVF), named after those who had fought in World War I, and the vigilantes of the Ulster Defence Association (UDA). Northern Ireland slid rapidly into what became a 30-year nightmare of terrorism and violence, with more than 3000 people killed and tens of thousands injured out of a population of only one and a half million people. In the resultant chronic political uncertainty over the constitutional future of Northern Ireland Ian Paisley’s political party slowly emerged as a significant political force, and eventually after the prolonged Irish Peace Process of the 1990s, (which Paisley opposed and tried to undermine) resulted in the Good Friday Agreement (a name he abhorred because of its clear religious connotations) his party became the largest political party in Northern Ireland, and he finished his career in 2008
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leading the new power-sharing government as the First Minister of Northern Ireland. Interestingly because of the compromise represented by his going into government with Sinn Fein, the political wing of the IRA, he was forced to relinquish the Moderatorship of the fundamentalist Free Presbyterian Church which he had founded and led for 50 years.
3.6.4 FUNDAMENTALIST CERTAINTY AND POLITICAL UNCERTAINTY It is difficult to avoid the conclusion that in the history of Northern Ireland, there is an intimate connection between the strength and aggressivity of fundamentalist religious views and instability and uncertainty about the political and constitutional future of the province. Despite the insistence of fundamentalists that faith is an individual matter and that each person must make a personal commitment based only on their convictions and relationship with God, there is much evidence that this is more generally a group phenomenon related to political anxiety and fear. Indeed many authors have identified the rise of fundamentalism amongst Protestants in the United States of America and amongst Muslims from Indonesia to Morocco to various aspects of social, economic and political instability and change in the world as they experience it, and I have been struck in my own conversations with religious Islamists on how they are keen to emphasize the importance of the political problems rather than religious differences with the West.
3.6.5
PSYCHOANALYSIS, FAITH AND RELIGION
It is worth exploring Davey’s writings in some more detail because he was one of the first eminent theologians to apply the emergent ideas of psychoanalysis to religion, and one could reasonably assume from the extent of their profound reaction against this modest and shy academic, that what he wrote and said must have struck a particularly notable if dissonant chord with his fundamentalist accusers. Davey starts from the observation that at what he calls ‘the higher end of the scale’, Judaism, Christianity and Islam are remarkably alike in the lines and forms of their development, and proposes that this is due to the similarity of human nature the world over. His first thesis is that life, which is invisible, can only be observed as it is expressed in visible forms. While diversities come from the creativity of individuals, they are then adopted by groups and communities, and the resultant forms give to life, what he describes as habit, consistency and coherence, but also limit spontaneity. The treatment of religion then, from the individual and social psychological viewpoint is, he believes, the truest way of understanding what religion means since individual and social psychology is the study of human nature. An important function of religious forms including those of his own Christian faith is the reassurance they give in the presence of fear of death, danger and discomfort. When sincerely engaged upon, he maintains, the serious thinker must reach the conclusion that there can be no complete certainty in life. Those who seek such a thing must depend on short-cuts to reassurance which, in intellectual terms, will often require the vehement defense of every link in their chain of argument for fear the whole edifice collapses. He contends that in religious faith it is the authenticity of experience and the reality of one’s nature that are the truly important matters rather than the details of belief and doctrinal
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systems, but it is the latter that are misleadingly depended upon for reassurance rather than faith. For the average man then, religion is less a matter of faith than an ethical system with authoritative sanctions, and as such it is an essential of a social being. The institutions of the Church are the answers to man’s craving for ethical and spiritual guidance. These change – ‘the changing vesture of the faith’ – and at any time in history they represent to a great degree the culture and temperament of the people concerned. He observes that Northern Europeans lean towards Protestantism with its Calvinistic or Augustinian points of view, while the Catholics of the South lean towards semi-Pelagian or Scotist tendencies. Ironically the more there has been a concentration on the writing of creeds and confessions of faith, the more the central and indeed common themes of faith, love and the value of the human soul have been ignored, even in the wording of the creeds. The common things of faith and human existence are passed by and the creeds and confessions focus instead on the areas of contention and often contemporary error. This masks what is for him the key to faith, that the search for ideals, for self-completion, is the search for God, a hunger that is part of the human condition and which can only be satisfied in the experience of personality. The expression of such experience is the key to the forms of religion, at least at their best and most authentic, and this is not a matter of logic so much as one of proportion, fitness and balance, ‘keep(ing) abstract reason in its place of servant to life’. This leads him to conclude that the forms of the Church in any age (by which he refers to beliefs, institutions and observances) tend to reflect the political forms and interests of the social organism as it exists in that age. He then moves to consider the tendency to regard matter as evil and so to build an edifice of self-denial and self-mortification, but he points out that actually it is usually the desire which is associated with the body, rather than the matter itself which is the problem, and that ‘instinct for sacrifice’ should represent something temporary for the sake of gain, rather than something in itself. This takes him to the universal presence in societies everywhere of taboos and sacrifices in various forms, and proposes that the special contribution of Christianity in its higher forms is to emphasize consecration rather than renunciation as redemptive. In the early 1920s when Davey’s lectures were given to a mixed lay and clerical audience there was a good deal of discussion about the application of psychoanalysis to society. Social Aspects of Psychoanalysis, for example was published by Ernest Jones in 1923 [4], containing a series of lectures given by senior psychoanalytic figures to the Sociological Society in London. It is not difficult to see how Davey’s observations as a very intelligent and educated young man, soaking up the new findings of psychoanalysis and evolutionary biology before, during and after World War I, when there was the most profound turmoil of thought, society and world order, should lead to such insights into the normal form and function of religion. As psychiatrists, we know that in the study of disturbances of personality and mental life in the psychiatric patient, where the phenomena are easily seen because they are exaggerated and inappropriate, we learn not only about mental pathology, but also about normal mental evolution and function. So it is that in the extremes of social upheaval we may hope to appreciate more of the how and why of large group life. At such a time of frightening uncertainty however it is also easy to see why his message was not a reassuring one and was responded to with attacks and denigration. While his intention was to adumbrate the best of the higher forms of faith, he inevitably, if gently, pointed up the rigidities and pathology of what he referred to as ‘the lower end’ of religion, and in doing so from within the theological faculty of the church rather than from a more remote academic perch, he opened himself
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up for vitriolic abuse from those who by this time were part of a fairly coherent network of religious fundamentalism.
3.6.6
FUNDAMENTALISM AND HOLY SCRIPTURE
The term ‘Fundamentalism’ is generally regarded as having come from a series of 12 essays by two American brothers Lyman and Milton Stewart entitled The Fundamentals: A Testimony to the Truth, published between 1910 and 1915 and promoted by conservative elements in the United States. These views made their way to Britain through various evangelists including those involved in the Keswick movement. Not all those who held to such views wished to be identified as fundamentalists, but they did all share a commitment to defend a supernatural as distinct from a scientific approach to faith. In their very useful survey of The Psychology of Religious Fundamentalism [5], Hood, Hill and Williamson recognize the work of Carpenter, Marsden and others in the Fundamentalism Project which identifies militant opposition to modernity as the key to understanding Protestant fundamentalism and also see this as applicable more generically to describe the religious and cultural phenomena of religious fundamentalism worldwide including within Judaism, Islam, Hinduism and other religions. While applauding much of its work, Hood et al. are concerned that the approach of the ‘Fundamentalist Project’ may be too broad and ‘obscures more than it illuminates’ and they have developed a model which they believe accommodates both an appreciation of the commonality of fundamentalisms as well as a respect for the specifics of each fundamentalist faith. They rightly point out that all attempts to identify a particular personality type as identifying fundamentalist believers has proved nugatory, and maintain that the historical and socio-cultural context is vital in appreciating it as a meaning system. They focus on the importance of a sacred text within fundamentalism as providing the center-piece for understanding it and propose a cognitive model of what they call ‘intra-textuality’. This principle focuses on the absolute pre-requisite of reading a sacred text as the text itself prescribes, accepting as absolute the ‘Truths’ which the text itself prescribes as such. The Divine has spoken and the recorded text is treated as being the only legitimate version of absolute truth, not to be measured by any external measures, but providing meaning to the believer and guidance for life and for the interpretation of all other knowledge. It is not necessarily the case that all elements of the sacred text be considered to have the same level of significance, but the issue can only be resolved ‘intra-textually’ that is to say, under the instruction of the text itself. The value of this model, as the authors point out, is that it not only allows for the differences between fundamentalists who adhere to different sacred texts, but also, because interpretation of the intra-textual meaning will itself vary from individual to individual and from group to group, it allows for the considerable variations between different fundamentalist groupings who hold to the same sacred text, for example within Protestantism. It is certainly the case that they demonstrate the way in which an intra-textual reading provides a coherent, meaningful, unifying philosophy of life, and they identify five key features amongst Protestant fundamentalists – belief in the inerrancy of scripture, a literalist interpretation of the text, the importance of evangelism, separatist behavior and commonly (but not essentially) the doctrine of pre-millenialism. They are also right to urge caution in assuming too close a connection between fundamentalism and violence. The overwhelming
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majority of people who hold to fundamentalist views do not support overt violence in the form of terrorism, however, that is not to say that there is not a degree of militancy in their attitude. There is a different emotional tone in fundamentalism than in conservatism. Fundamentalists press their case in a more vigorous and less tolerant manner. One is unsurprised when fundamentalists grasp the opportunity of a heresy trial, for example. While conservative minded people and so-called evangelicals within Protestantism hold to many of the same doctrinal positions as fundamentalists, they tend to be more prepared to accept that other people have a different perspective, of which they may at times despair, but which they generally accept as part of society and even of church society. I am not entirely convinced by the inclusion of the Amish as fundamentalists by Hood et al. It seems to me that they are instead a rather particular, small conservative group. The intra-textual model also tells us very little about why fundamentalism appears at particular points in history. The intra-textual approach appears meticulously respectful to fundamentalists by dealing with it entirely within the encapsulated bubble of the interpretation of the sacred text, however as far as the fundamentalist is concerned this isolates his convictions from the wider world from which he both wishes to separate himself, but with which he is also inevitably, though conflictually engaged. Protestant fundamentalists may relate their strivings to changes that have taken place in the intellectual and religious order of things, and are then reflected in political and other unwelcome changes that have taken place. The question for observers is whether the ‘truth’ is the reverse – that is that the intellectual and political changes have created an unwelcome uncertainty and instability to which their religious fundamentalism is a response of some kind. The Hood et al. approach is certainly more thoughtful and respectful than the simple contention that fundamentalists are misled by wrong teaching, or worse, however, to separate it off and deal with it as a phenomenon of intra-textuality to avoid disputes about causes and motivations, also strips it of the key to understanding it, both from within and without the religious perspective.
3.6.7
FUNDAMENTALISM AND GROUP PSYCHOLOGY
Vamik Volkan tries a different route of exploration. The FBI were confronted in the United States of America by a number of crises with fundamentalist groups, notably in 1993 when the FBI attacked and burned the Waco cult compound in Texas. Volkan was invited to chair an advisory committee to the agency’s Critical Incident Response Group and he became interested in what he has described as ‘encapsulated’ fundamentalist organizations, not only David Koresh’s Davidians in Waco, but Jim Jones in Jonestown, Shoko Asahara’s Japanese Aum Shinrikyo, Joseph’s DiMambro’s Order of the Solar Temple and others. These are movements that remain isolated within the larger society and tend to induce negative feelings, including fear, in those outside the encapsulated group. From these groups Volkan identified ten common characteristics – a divine text; an absolute leader who is the interpreter of the divine text; a demand for total loyalty to the group and the yielding up of all aspects of life and choice to the group and its leader; tangible benefits for members; feelings of being both omnipotent and yet victimized; extreme sadistic and/or masochistic acts; alteration of the shared ‘morality’; creation of borders (psychological and sometimes physical) between the group and the rest of society; changing of family, gender and sexual norms within the borders; and negative feelings and fear amongst outsiders. These ten observations from socalled ‘encapsulated’ fundamentalists are clearly not entirely separable items. The setting
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down of a border for the group and the creation of different ways of thinking and behaving based on the divine text as (idiosyncratically) interpreted by the single inspired leader will not surprisingly contribute to the sense of omnipotence, the negative attitudes of outsiders, and the resultant and ambivalently unwelcome sense of victimization. Volkan further postulates that when for some reason a significant number of outsiders begin to become sympathetic rather than have negative feelings about the group, perhaps because the wider society has undergone a massive trauma that has resulted in feelings of humiliation and helplessness, the idea of a ‘saviour’ becomes attractive. He refers to the remarkable growth and power of the Taliban in post-Soviet Afghanistan and describes as especially powerful the symbolic link established with Mohammed through the leader, Mulla Omer, publicly putting his arms into the sleeves of a cloak believed to have belonged originally to the prophet Mohammed – this symbolic link collapsing the passage of time and the separateness of the two individuals concerned. While Professor Khurshid Ahmad has disputed the authenticity of reports of this particular event, Volkan has demonstrated a similar mechanism in a number of other case studies in the Balkans, Baltic States, Cyprus and elsewhere. Volkan, who is senior Erik Erikson scholar at Austen Riggs Hospital, sees the phenomenon of fundamentalism as representing a regression in the functioning of a group in the face of a threat or threats to the identity of the large-group, an idea that he has developed out of a revision of Erik Erikson’s description of individual identity [6,7]. Large-group identity – whether it refers to religion, nationality, ethnicity, or shared ideology – he defines as the subjective experience of thousands or millions of people who are linked by a persistent sense of sameness while also sharing some characteristics with ‘others’ who belong to foreign groups. He describes this identity as being part of the psychic development of the large group which emerges out of its, often mythologized, history, and describes how, in a fashion analogous to that of the individual under threat, it is possible for the large group to regress to points in its earlier development where chosen glories and traumas (analogous to fixation points) become infused with emotion and significance and lead to a series of defenses. An example would be the appearance in a people of ‘entitlement ideologies’ such as irredentism where the nation’s difficulty in mourning the loss of people, land or prestige, in, for example, the loss of empire, leads to attempts to deny the losses and seek to recover them either in fact or in symbolic form, sometimes at great cost, and with a continuing significance that is not much diluted by time, and can be re-ignited after years or even centuries. Another example are the ‘purification’ practices where words are purged from a language, symbols removed from view, or worst of all, ethnic cleansing is embarked upon, to repair the damaged sense of identity, in a defense analogous to externalization/projection in the individual. The idea that identity might form a useful bridge between the psychology of the individual and the group has been around for some time. The social anthropologist, John Blacking, for example, explored it in South Africa in the 1970s using musical culture because it showed the link between individual and group feelings and action and the power of something which has affective significance, even if transitory in its performance and experience [8]. He also showed how identity has continuity even when its external cultural expressions adapt to take account of changes in the political context and climate, especially where there is stress or conflict – a musical/cultural version of Davey’s ‘changing vesture’ thesis in the religious aspect of large group identity. One of the important things about Volkan’s work is that he not only applies the concept of identity to the large group but he also sites it within an evolutionary or developmental
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process, which can be put into reverse in the context of trauma. This evolution/dissolution model is familiar to psychoanalysts but, as was demonstrated in a life-time of work by Henri Ey, the French psychiatrist, it comes from the pre-psychoanalytic work of Hughlings Jackson in neurology and psychiatry. Ey developed a neo-Jacksonian approach which he called organo-dynamic because it paid due attention to both biological and psychological aspects of psychiatry, and was based on a model that was congruent with both [9].
3.6.8 REGRESSION AND THE LOSS OF TEMPERO-SPATIAL FUNCTIONS The key features of this model are his explication of mental life as being our construction of ‘reality’ and his application of the development/regression model to that experience of reality. Mental illness in his description is not only a shrinking of human existence and a pathology of freedom, but also a disturbance of our capacity of experiencing reality. We have to understand, he says, the limits set to the sick man’s comprehension of the mental disturbance that makes him sick with a ‘disease of reality’. The reality of the disease consists precisely of the unreality, or the ‘imaginary structure’ of the basic experiences, what Ey calls ‘pathologies of the field of consciousness and personality’, though he uses these terms in a particular way. In the regression or dissolution of the experience of reality, whatever the cause, there are negative features coming from the loss of higher functions, as well as positive symptoms coming from the release of the remaining mental functions, but there is also reconstructive or reparative work which follows, given time. The negative effect of the illness involves the loss of tempero-spatial functions – the temporal function being the capacity to distinguish in the experiencing of time between what is past, present and future, and the spatial function being the experience of what is inside me and what is part of someone else. Such regressions may be sudden, temporary mental crises, or may become chronic, in which case there are adaptations or reconstructions of the personality from the remaining and regressed capacities. In applying such a phenomenological model to large-group identity we can note, as Volkan has pointed out, the temporal regression or ‘collapsing of time’ such that events from the distant past may evoke powerful images and emotions, as though they happened only yesterday. The loss of spatial function in the individual is experienced in primary process thinking, both in the normal and regular dream life from which we can voluntarily waken up, and also in the more terrifying loss of ego boundaries, characteristically with the release phenomena of transitivism and appersonation and the appearance of hallucinations, where the patient’s thoughts or memories are felt to be outside of themselves and directed at them, rather than internal and proceeding from them. Sometimes the dissolution of the self is actually experienced directly in psychosis or in the pre-psychotic period. Various attempts are made by the remaining mental function to make sense of the experience, or repair the ‘reality’ for example through delusion formation. If one applies this to the large group, whatever the cause or trauma, regression would involve a loss of the higher functions which enable history to be experienced as past (temporal function), and for differentiation between individuals within the group as well as between the group and other groups (spatial function). The loss of these functions leads to the collapse of time so that the past invades the present, and the loss of differentiation
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between individual people and between the large group and other large groups leads to what Girard calls a ‘mimetic crisis’ with the attendant danger of violence.
3.6.9
‘VIOLENCE AND THE SACRED’
The importance of the differentiation between individuals and groups in controlling violence is identified in great detail by the French Canadian, Rene Girard in a series of books, but for the purpose of this chapter Violence and the Sacred [10] is probably the most relevant. In human beings, he says, there are not only the instinctual appetites for food or water and so on, which we share with the animal kingdom, but also imitative desire – ‘I want that because I observe that you have it.’ This fundamental mechanism of mimesis or nonconscious imitation of desires inevitably leads to rivalry and in Girard’s view the social constructions of law, culture and religion were essentially mechanisms that set down boundaries for rivalry, which, if uncontrolled, would lead by rapid mimesis to a violent rivalrous crisis. The particular device at the center of this boundary setting is the scapegoat mechanism, by which, instead of everyone being set against everyone in violence, all turn against one individual who is demonized, victimized, sacrificed, and then, since his sacrifice brings peace, is ultimately divinized. Girard identifies this mechanism as key to understanding the foundational myths of what he calls archaic religions. In every repetition of the phenomenon the lynch mob feels itself justified in their violence against this individual who is regarded as the embodiment of some sort of evil. The difference between such myths and Judaeo-Christian religion in particular (as exemplified in the crucifixion of Christ and its ritualization in the Eucharist) he says, is the recognition that the identified victim is actually innocent and that he is being sacrificed, not because of his wickedness, but to rid the community of its evil/violence. The problem is that once the myth of the wickedness of the victim is exposed as a lie the power of the mechanism is destroyed for no-one can feel so justified in scape-goating. In a post 9/11 expression of his thinking [11] Girard says that while the realization of the hypocrisy or ‘lie’ behind the scapegoat mechanism has ensured that we have in many ways become less violent through our insistence on the rights of women, racial and religious minorities, the disabled and other victims or potential victims, this demythologizing has also contributed to more violence through the release of the old mimetic violence which the sacrificial violence was instigated to control.
3.6.10 REGRESSION AND RECONSTRUCTION OF LARGE-GROUP IDENTITY As I have outlined elsewhere [12] if one puts these observations together, the rise of religious fundamentalism may be seen as resulting from a societal regression brought about by the fear of the loss, or in some cases the trauma of actual damage or loss, of large group identity resulting from a combination of rapid socio-political changes in the past century. These might be summarized as follows – the advances in evolutionary science which remove the boundaries between humanity and the rest of the animal kingdom and introduce complexities of thinking which a majority of the population may find difficult to construe; the collapse of traditional authoritarian forms of government (monarchies, empires and tribal chieftains) with the advance of participatory democracy; the developments in information and
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communication technologies, greater speed and ease of travel and the borderless capacity for destruction in the nuclear age, all of which both excite interest and threaten large-group identity; the end of the Cold War, the collapse of communism and the widespread espousal of free market economics; in short the forces which we describe as rapid globalization represent the loss of boundaries and our experience of time and space is shaken. Interestingly however fundamentalists do not generally see their movements as merely going back to the past. They certainly feel that they are identifying key strands from the roots of their faith and tradition, which they feel to have been overlooked, lost or denied, however they describe their activities as ‘revival’, and many readily espouse new technology in their own lives. Professor Ahmad starts his chapter on Jama’at-e-Islami [13] in precisely this way, and in conversation I found him very clear that the Islamist approach was about addressing the modern world, not trying to recreate the past. Hamas and Hizballah also say that are not trying to recreate an old way of living, and there is nothing Amish-like in their style of life. They are instead developing new ways of constructing social and economic models for their communities. From a Jacksonian point of view fundamentalism is not merely a form of regression but also includes the release of functions from an earlier time or lower level of structure and complexity, and most importantly also incorporates an attempt at reconstruction from a position of dissolution. Given what Girard describes as the fundamental mechanism of mimesis (or non-conscious imitation) large-group identity regression may result in a reparative attempt to re-erect the boundaries that could obviate mimetic rivalry, but have been removed by the traumatic loss of or damage to large group identity. It is as though the unsaid message from the frightened community is, ‘We do exist; we are different and we may be acting in an aggressive (scapegoat) way, but it is in order to prevent worse (mimetic) violence.’ This is of enormous importance because it makes clear that it is possible to identify within fundamentalism an innate reparative or reconstructive component, something that is often missed or dismissed by observers. It may not be impossible to relate to this component if it is recognized.
3.6.11
FUNDAMENTALISM, RADICALIZATION AND VIOLENCE
Finally, I return to two of the problems identified at the start of the chapter, the relationship between different fundamentalisms, and the relationship between fundamentalism and violence. Girard’s emphasis on mimetic behavior and the infective nature of violence should alert us that different fundamentalisms will imitate each other and create a cycle of regressive thinking and action. Hence the growth of Protestant fundamentalism within the U.S. is not hermetically sealed from the growth of fundamentalism elsewhere, and not only Protestant fundamentalism, but other religious fundamentalisms too. As the boundaries are dissolved, so the possibility of mimesis of thinking increases. Further, as Volkan points out, and Girard helps to further explain why it is, there is an inherent violence, sadistic and/or masochistic, in the scapegoat mechanism, and therefore insofar as fundamentalists are attempting to reinstitute it, with old and new boundaries there will be an aggressive tone to their approach. It may be militant in its evangelism, aggressive in its language and attitude especially to lukewarm co-religionists who are more of a threat than those who are clearly different, and in its treatment of women in particular, and minorities in general, there will often be abuse and sometimes overt violence. The
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overwhelming majority of fundamentalists however do not become involved in, or supportive of terrorism, and indeed many will abhor it. Those who do become genuinely supportive of, or involved in terrorism seem to have undergone a kind of radicalization which they may share with others who are not religious fundamentalists at all. Many of the young people who get involved in suicide attacks and other terrorist activities are radicalized, but not especially religious, though if they survive they may become religious afterwards while in prison or under the influence of radical clerics or other prisoners. This differentiation between fundamentalist religious convictions and radicalized activists is of great importance in managing the deterioration in global security, and we do not yet understand it fully, save to say that one does not necessarily progress to the other, or require the presence of the other, though they can be present and facilitate each other. A further key question is how far the scapegoat mechanism can really be revived. Perhaps Girard is right to say that it can no longer work for long because the ‘cat is out of the bag’ that the mechanism is based on a lie. I am not yet convinced that he is right because as human beings our capacity for denial is significant. There are in any case possible alternatives. The development of the European Union and some of the other peace processes which have been modeled on it show that in certain contexts a process can be created through which it is possible not only to contain the violence but to work through and transform it by the development of relationships in which differences can be sustained and mimesis limited or directed in positive competition rather than dangerous rivalry. On this, however, I must sound a note of warning because these alternative processes are new and as we can see in Europe, are still susceptible to deteriorate into mimesis and rivalry. While the post-war generations in Europe remembered that the purpose of the European Project was to prevent a return to the rivalries of nation states which had resulted in catastrophic wars, all was well. But now that a new generation of leaders is more concerned with economic success and using the EU as a platform for power to rival the U.S., Russia and China, so the dangers reemerge both within the EU, with the appearance of racism and xenophobia, and also in collusion with a new line of international division with scape-goating of the Islamic world in general, and Iran in particular. In summary, religious fundamentalism can perhaps best be understood as a phenomenon of large group psychology which occurs not merely as a direct result of regression in the face of threat or trauma, but showing three related elements – the loss of some more developed social functions, the return to or release of more elementary social characteristics, and the reconstruction of the large group identity from the remaining functions and faculties of the group. Fundamentalism is characterized by the diminution of individual freedom, a concretizing of thinking and restrictions of behavior, but its ‘purpose’ is to repair or reconstruct the group identity as well as to prevent further breakdown and/or violence and this positive component should not be disregarded.
REFERENCES 1. 2. 3. 4. 5.
Davey JE (1923) The Changing Vesture of the Faith. James Clarke & Co Ltd, London. Edgar J (1928) Presbyterianism on its Trial. Privately published, Belfast. Fulton A (1970) J. Ernest Davey. The Presbyterian Church in Ireland, Belfast. Jones E (1924) Social Aspects of Psychoanalysis. Williams and Norgate, London. Hood RW, Hill PC, Williamson WP (2005) The Psychology of Religious Fundamentalism. The Guilford Press, New York.
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6. Volkan V (2009) Religious Fundamentalism and Violence, In: O’Neil MK, Akhtar S (eds.) On Freud’s ‘The Future of an Illusion’. Karnac Books, London. 7. Volkan V (2008) Large Group Identity, International Relations and Psychoanalysis. Presentation at Psychoanalysis and International Relationships, at Gasteig Cultural Center, Munich. 8. Blacking J (1983) The Concept of Identity and Folk Concepts of Self: A Venda Case Study, In: Jacobson-Widding A (ed.) Identity: Personal and Socio-cultural. Humanities Press Inc, New Jersey, USA. 9. Ey H (1962) Hughlings Jackson’s principles and the organo-dynamic concept of psychiatry. American Journal of Psychiatry 118, 673–682. 10. Girard R (1972) Violence and the Sacred, The Johns Hopkins University Press, Baltimore. 11. Girard R (2005) Violence and Religion, In: Peter Walter (ed.) Das Gewaltpotential des Monotheismus und der Dreieine Gott. Verlag Herder, Freibrug, pp. 180–190. 12. Alderdice J (2003) Liberalism and Fundamentalism, Liberal Aerogramme 46, 13–17. 13. Ahmad K (2006) Great Movements of the 20th Century No 2, Jama’at- e-Islami. The Message pp. 1–8 (http://www.insight-info.com/articles/Item.aspx?i¼412)
CHAPTER 3.7
Measurement at the Interface of Psychiatry and Religion: Issues and Existing Measures Peter C. Hill Professor of Psychology, United States of America
Carissa Dwiwardani Doctoral Graduate Student, United States of America
3.7.1 MEASUREMENT AT THE INTERFACE OF PSYCHIATRY AND RELIGION: ISSUES AND EXISTING MEASURES On September 23, 1999, a NASA orbiter, which had been on a long journey toward Mars, was finally ready to be pushed into Mars’ orbit to relay data to earth [1]. The engineers involved in this project were ready to celebrate the orbiter’s entrance. Much to their dismay, the $125 million orbiter disappeared right after its engine was fired to enter the orbit. An immediate investigation found that the spacecraft had come about 100 km closer to Mars than planned, which caused the engine to overheat and shut down. The orbiter was then propelled beyond Mars and disappeared. This substantial loss was rooted in one glitch in the project: the company that had helped NASA build the spacecraft used English units measurement while NASA used the metric system. The navigation information failed to be transferred from one to the other, and had caused the loss of the spacecraft. NASA paid a great price for one error in measurement. Measurement is also very important in scientific research and is a necessary foundation on which any scientific discipline exists. The study of religion and spirituality is no exception and, in fact, about a quarter century ago in an influential American Psychologist article, Richard Gorsuch [2] argued that the then dominant paradigm for the psychology of religion was one of measurement. Arguing that such a paradigm was both a boon and a bane to the psychology of religion, at the very least it could be said that if good measurement is indeed a sign of a field’s health and maturity, then the psychology of religion was trying to assure itself a long and prosperous life. Though clearly there are many problems with the state of measurement in religion and spirituality, some of which will be pointed out in this chapter, it Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright 2010 John Wiley & Sons, Ltd
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can also be said that current psychology of religion has benefited much by an earlier generation’s preoccupation with measurement. In this sense, the measurement paradigm fulfilled its useful purpose to the point that it can now focus on more content related concerns. It is, therefore, safe to say that researchers and applied professionals have a vast array of measurement instruments for many tasks in the psychology of religion. Virtually all of these measures are self-report scales where participants are requested to respond to multiple items designed to assess such religious and spiritual components as beliefs, attitudes, values and behavior. Such measures must meet certain theoretical and psychometric criteria that will be discussed in the next section of this chapter. We will then review specific measures that meet these criteria and will also consider some alternative methodologies to the use of selfreports. We will conclude by providing guidelines in selecting measures for research and other purposes.
3.7.2 3.7.2.1
GENERAL ISSUES TO CONSIDER IN MEASUREMENT Theoretical considerations
Religiousness and spirituality (RS) involve deeply imbedded beliefs usually related to the transcendent. Assessments of RS continually face the tension between RS’s personal and transcendental nature on one side and the scientific pull to be measurable and empirical on the other [3]. The complexity of RS measurement is increased not only by the diversity of religious expression and the different meanings it may hold for each individual person, but also by various religious traditions and cultures which powerfully influence such individually-held expressions and meanings. Suppose, for example, that one wishes to study (and measure) what values religious people of a particular faith tradition try to implement in the world. Good psychological theory is necessary in determining how such values are typically conceptualized and processed. This could require a theoretical grounding in such social and developmental processes as social cognition, attitudinal formation and translation into behavioral action, and subjective normative perceptions of what important others think. However, in addition to predicting how such values are formed and how they relate to each other, it is also imperative to know what one is seeking to assess and this requires a sensitivity to the specific beliefs and/or teachings of the RS culture. Such indigenization in this example will necessitate consideration of the tradition’s views on such issues as social justice, the environment, the relationship of religion and culture (such as level of political involvement), specific public policy issues, what is considered as an appropriate personal response as an expression of the faith tradition, and so forth. Even then, however, one cannot suppose that all people of a particular faith tradition will necessarily have the same understanding of such values. Levin and Chatters [4] highlight the presumptuous interpretations that often occur when observing seemingly straightforward RS behaviors, such as frequency of prayers. The norm for frequency of prayers in different religious traditions varies highly. Praying five times a day is the norm among Muslims, whereas for other religious traditions, such as Christianity, the guidelines are less clear. This lack of clarity may create more variety in its follower’s frequency of prayers. Assessing religiosity simply based on the frequency of religious behavior may disregard the cultural and sub-cultural contexts in which these behaviors are
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exercised. It is, therefore, crucial for researchers and professionals to carefully take into account both the personal and the abstract nature of RS concepts.
Technical considerations In addition to having a solid theoretical framework, an RS measure also needs to be technically sound. More specifically, a measure needs to be both reliable and valid. Reliability refers to the stability of a scale, and is most often measured in multi-item self-report scales that are typically employed in RS research by the consistency of the scale’s items with each other. Such internal reliability is determined statistically by Cronbach’s alpha coefficient – the higher the coefficient, the more consistent the scale. Should a researcher be interested in measuring an RS dispositional characteristic that is not prone to situational factors, then a less frequently used test-retest approach to measuring reliability is recommended. One way to assess a scale’s test-retest reliability is to administer the scale to the same sample at two different times – typically a two-week interval for many RS constructs [5]. The correlation of scores from the two administrations can then be calculated to determine whether or not they are generally stable. A scale may well be consistent, but it may be consistently measuring something different than what the researcher purports the scale to measure; that is, it lacks validity. Face validity is a non-statistical way of measuring a scale’s validity. It is a judgment about the extent to which the scale seems to measure what it is meant to measure. Though face validity is important due to its possible influences on the attitude with which a respondent may approach the measure, it needs to be supplemented with more objective and empirical measures of validity. Objective approaches to assessing validity include criterion validity, convergent validity, discriminant validity and content validity. Criterion validity refers to the correlation between the scale with another standard or measure. For example, can the scale correctly differentiate between religious and non religious people, determined by another criterion? Convergent validity is the extent to which the scale correlates with another scale that is supposed to measure a similar construct. Divergent validity, on the other hand, is the extent to which the scale is not correlated with another measure that is deemed to be measuring a different construct. When one assesses for content validity, one is measuring the degree to which a scale includes all the domains of the construct of interest. At a minimum, a scale under consideration for research or clinical use should have its validity already established by at least one of these four criteria. In considering RS scales, it is important to ensure that the scales’ items are strictly measuring RS constructs, and not related constructs such as physical or mental health outcomes [6]. Items that assess for life satisfaction or perceived well-being may naturally correlate with health outcomes; therefore, the scales would not be very informative in exploring relationships between RS constructs and health outcomes.
Sample representativeness Ideally, the psychometric properties of a scale (i.e., whether it is judged to be satisfactorily reliable and valid) would be established on a sample representative of the target population
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for research. In reality, however, much of the research that has gone into developing RS scales were based on samples consisting of American college students, who are younger and better educated (two characteristics associated with RS) than the population as a whole [5]. Furthermore, many samples in RS research have been dominated by middle-class Caucasian Protestants [7]. Even when care has been taken by a scale’s developer to be as inclusive as possible, the vast majority of RS scales have been aimed at Judeo-Christians, or at least those who are of theistic backgrounds [8]. Conversely, some scales designed to be as broadly based as possible may unintentionally be culturally insensitive or biased by assuming that what is of primary importance in one, or even most traditions, is also of primary importance in other traditions [7, 9]. The researcher must therefore be cautious in using a scale developed on a sample that is considerably different than the population under study and is encouraged to review all subsequent research that has utilized the scale as a potential indicator of the scale’s appropriateness.
3.7.2.2
A case example
To illustrate the problems of religiously biased RS scales, consider the difficulty of applying one of the most widely utilized RS scales, the Religious Orientation Scale [10], outside the Christian tradition – challenges that we have in fact experienced in our own research on religious orientation within an Indonesian Muslim population. First, the scale uses terminology that exclusively refers to the Christian tradition, such as ‘church’ and ‘Bible study.’ After the words are altered to more generic terminology, however, the scale is still not fit to be used with the Muslim population. One extrinsic item says, ‘One reason for being a church [or mosque] member is that such membership helps to establish a person in the community.’ A review of resources on the Islamic religious beliefs and practices [11–13] suggests that the practice of formal membership does not apply to the mosque. In addition, the item, ‘If I were to join a church [mosque] group I would prefer to join a Bible [Koran] study group rather than a social fellowship’ is not as straightforwardly applicable to the Muslims. It does not appear that mosques hold distinctive religious social fellowship groups. Because Islamic practices are still strongly linked to the collectivistic culture in which the tradition was rooted, it seems that social fellowship is assumed to take place largely outside of the mosque rather than inside as is more common in the Christian tradition. Another difficulty arises in the following extrinsic item: ‘The church [or mosque] is most important as a place to formulate good social relationships.’ This item is not likely to be very robust in differentiating between Muslims who have high extrinsic motivation and Muslims who have low extrinsic motivation. A sense of belongingness to the exclusive mosque or Islamic community is less salient in the Islamic community than in the Christian community [11–13]. This is especially true in countries where Islam is the major religion, and indeed, we have found this to be true in our own research with Indonesian Muslims. Altogether, the difficulty of applying these items to Muslims indicates that the extrinsicsocial category, as a measure operationalized in the Allportian tradition, is not as applicable to Muslims as it is to Christians. This is not to suggest, however, that the concept of extrinsic-social is inappropriate in the Muslim context. In fact, careful empirical work [14] has shown that an extrinsic religious orientation, even one that entails a social dimension, is relevant and measurable among
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Muslims. Specifically, these researchers found incremental validity of their new MuslimChristian Religious Orientation Scale (MCROS) beyond the Allport and Ross’s [10] ROS when the extrinsic social dimension was measured in relation to the broader community and culture rather than to the mosque (e.g., ‘I am religious in order not to have a bad reputation among others’; ‘My commitment to religion is based on the belief that religion is necessary if a society is to be moral’). Even then, however, one must still be careful not to imply that an extrinsic religious orientation is necessarily a less mature religious sentiment, as conceptualized by Allport [15]. Cohen and Hill [16] found not only that American Jews are considerably less intrinsic and more extrinsic than American Protestants, but more importantly do not perceive an extrinsic orientation (including extrinsic-social) as less mature, unlike their Protestant counterparts. In fact, for Jews the intrinsic and extrinsic orientations were significantly positively correlated, something rarely found in the literature [17]. American Catholics, the researchers found, generally fall between the Protestants and the Jews on these measures. From this Cohen and Hill [16] concluded that even within the Judeo-Christian tradition ‘different religious motivations are valued in different religious cultures and that this needs to be recognized when conceptualizing and measuring religious motivations’ (p. 738) and furthermore that ‘religious group differences can be conceptualized as cultural differences that shape personal and social aspects of religious and spiritual motivation, moral judgment, and other processes’ (p. 738). This simple illustration points out that RS measurement is faced with the challenge of religious and cultural pluralism. Is it possible to create a measure which would assess the spirituality of people from all religious traditions? One way this could be achieved is by creating a tradition-free scale for spiritual characteristics that uniformly indicate one’s spirituality. However, this approach may overlook cultural and sub-cultural particularities that are central to the spiritual experience itself [5]. Nonetheless, it is possible that spirituality is a latent construct with characteristic components that are not limited by certain traditions. Identifying and measuring such generic indicators of spirituality could then be translated into more tradition-specific indicators. An example of this approach is found in the work on religious coping by Ken Pargament and associates. After initially conducting research on how people within a Judeo-Christian context utilize their faith to help cope with life stressors [18], they identified general characteristics that have now been translated and measured specifically within a Hindu context [19]. Though laborious, this approach would be highly valuable to the RS field, allowing for cross-cultural comparisons while still respecting tradition-specific RS experiences.
3.7.3
REVIEW OF MEASURES
Several RS measures that have been deemed quality measures based on the above criteria (theoretical basis, reliability, validity and sample representativeness) are reviewed here. Only selected measures were included in this review (for a complete review of measures published before 1999, see [20]). The selection of these measures does not indicate the authors’ seal of approval, but is simply a reflection of measures that meet the criteria reviewed above. The levels of criteria used in screening these measures are the same as those used by [5]: 1) a measure must be clearly grounded in a plausible (but not necessarily consensual) theoretical framework; 2) a measure must show at least good reliability (r > .70) across two or more studies and significant correlations across more than one
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sample on at least two types of validity; and (3) a measure must represent more than a narrowly conceived population (e.g., Evangelicals, Mormons). This is not to say that a measure is necessarily bad if it does not meet particularly the third criterion, for some measures are designed for more narrow populations. It simply means that such measures are not of interest here. Tsang and McCullough’s [21] hierarchical approach to RS provides a helpful framework for understanding the relationship between RS constructs. Level I of their hierarchy refers to dispositional RS, which is an indication of ‘how “religious” a person is,’ p. 349). Level II of the hierarchy is the functional level; in other words, how one’s RS specifically operates in one’s life. The functional level includes constructs such as RS motivation, behaviors and coping mechanisms. The distinction between Level I and Level II constructs is important given that what may be viewed as a relationship between, for example, health and a particular RS function (e.g., religious coping style), may reflect only a high trait-like RS level in the first place. It is therefore advisable to include both Level I and Level II measures if at all possible; a measured Level I RS can then be statistically controlled to disentangle a functional variable from a more general trait-like quality. In our review of specific scales, we will consider first those measures of dispositional RS and then those measures of how RS functions in the life of the individual.
Dispositional RS General RS. General RS is a broad concept that refers to a person’s RS disposition, much like a personality trait. Tsang and McCullough [21] made the case for general RS as a personal trait based on three evidences. First, distinct measures of RS – such as church attendance, private RS practices and perceived importance of RS – tend to correlate meaningfully with each other. Second, factors in multiple-item scales tend to inter-correlate with each other, indicating a higher-order factor. Third, there is evidence that RS may be partially heritable. Paloutzian and Ellison’s [22] Spiritual Well-Being Scale (SWBS) is among the most widely used and well-validated RS measures [5]. This 20-item scale consists of two 10-item subscales: an Existential Well-Being (EWB) scale and a Religious Well-Being (RWB) scale. The RWB items all load together, thus suggesting a general RS factor. Though technically a measure of spiritual well-being, it is useful as a general RS measure and has been used as such in many studies. Piedmont’s Spiritual Transcendence Scale [23] is a measure of ’the capacity of individuals to stand outside of their immediate sense of time and place to view life from a larger more objective perspective’ (p. 988). The measure consists of three subscales: universality, prayer fulfillment and connectedness. The measure, including all three subscales, demonstrates good reliability and validity. It should be noted that although originally developed and tested primarily with American Christian samples, the measure was designed to transcend specific religious traditions and, indeed, the Spiritual Transcendence Scale has now been shown to be cross-culturally generalizable to populations in India [24], the Philippines [25] and Malta [26]. RS commitment. Commitment to the sacred is a relevant construct in health research. The more committed one is to the sacred, the more one integrates RS into one’s life – in which one understands and explains one’s world, experiences, and actions in RS terms [7, 27]. The
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implication is that one is more motivated to strive toward health practices, because one’s physical health has repercussions for the sacred. In addition, an increased cogency of one’s world and experience may have a positive implication on one’s well-being (this issue is related to RS coping, and will later be discussed in more detail). The extent to which these implications are indeed accurate have not yet been fully empirically tested and verified. The Religious Commitment Inventory-10 (RCI-10) is a scale measuring religious commitment that is not limited to a religious tradition. Originally tested primarily among Christian students, the measure’s excellent internal reliability, test-retest reliability, as well as construct, criterion-related, concurrent and discriminant validity has also fared well on representative student samples of Muslims, Hindus, and Buddhists. The Santa Clara Strength of Religious Faith Questionnaire (SCSORF) [28] measures an individual’s faith strength that is not limited to a religious tradition. Though the original measure is brief (10 items) and practical (and is therefore potentially useful among patient populations), a shorter five-item form has also been developed [29]. Both forms have good validity and reliability [30], though both may exhibit possible ceiling effects among those religiously committed [31]. Indeed, many scales created for and normed on the general public may not discriminate well among the highly religious. RS developmental maturity. RS should be viewed as a continuum; it is not likely to be a categorical construct in which one is either religious (or spiritual) or nonreligious (or nonspiritual). The relationship between RS and health is influenced by where one falls on the continuum of RS maturity [6]. The conception of religious maturity is most often unique to each tradition; therefore, RS maturity scales would be most beneficial when they are tradition-specific [6, 32]. The Faith Maturity Scale [33] was created to measure the extent to which a person exhibits attributes of a religiously mature person as understood among the mainline Protestant tradition. Leak and Fish’s [34] Religious Maturity Scale was constructed to measure an individual’s religious maturity as conceptualized by Allport [15]. Maturity, according to Allport, is signified by several characteristics including a commitment that becomes a direction in one’s life, a complex understanding of religious issues, tolerance, and one’s ability to doubt. This is a promising scale with excellent reliability, testretest reliability, good convergent, discriminant and predictive validity tested against a large number of different measures. Although the initial development of this scale only included those from the Christian tradition, it appeared that the scale can be used among those from different denominations within Christianity. However, because the scale is based on Allport’s conceptualization, it may not be useful within other major religious traditions (see our earlier discussion). The Faith Development Scale [35] measures one’s maturity by examining an individual’s level of core religious belief regardless of one’s religious background and culture. Foundational to this scale is the assumption that there is a set of core beliefs that transcend religious and cultural differences. The scale’s initial development involved a sample consisting of those from various European nationality groups as well as various religious traditions; however, the scale’s psychometric properties need to be further tested. Considering the scale’s potential to be used across cultures and religions, further exploring the psychometric potential of this scale would be a worthwhile endeavor. Two scales have been constructed to measure reported RS experiences, or experiences which are perceived to be an encounter with the transcendent. The 23-item Spiritual History Scale consists of four dimensions [36] and has been found to be valid and reliable among those from a theistic background. The four dimensions are God-helped (a measure of both
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seeking help from the divine and experiences of being helped by the divine or by religious activities), Family History of Religiousness (a measure of attachment to and legacy of family of origin’s religiosity), Lifetime Religious Social Support (a measure of lifetime religious involvement), and Cost of Religiousness (a measure of presence or absence of physical, emotional, and interpersonal losses associated with past religious life). The scale was developed among samples consisting of the elderly, designed specifically to assess the correlations between its four factors and late-life health. This scale is a unique measure of religiousness that is both reliable and valid and may be particularly useful when testing predictors of health among the elderly. The Daily Spiritual Experience Scale [37] is a scale that appears more generalizable to those outside a theistic population. Underwood and Teresi claimed that spirituality is the inner construct that is more stable and less vulnerable than religiousness to being affected by nuisance variables. The scale was designed to measure the extent to which one experiences the transcendent in one’s daily life, not those experienced in extraordinary ways. Some of the daily spiritual experiences the scale taps into include awe, joy and a sense of inner peace. Many psychologists of religion [e.g., 38–40] have developed a recent interest, based largely on Bowlby’s [41, 42] notion of infant-caregiver attachment, in perceived closeness to God as an attachment figure. Although God attachment is a fast developing research topic, it has yet to receive little attention from outside the Judeo-Christian tradition. The Attachment to God Inventory [43] is a scale that seeks to measure the extent to which one exhibits avoidance of intimacy and anxiety of abandonment in relation to God. Evidence was found in support of this internally reliable scale’s convergent and construct validity. The Spiritual Assessment Inventory [44, 45] measures spiritual maturity within a Christian framework from an object-relations perspective. This inventory measures the extent to which one’s awareness, instability, grandiosity, realistic acceptance and defensiveness in one’s relationship with God. The SAI has been shown to be predictive of religious college students’ relational maturity. Furthermore, the SAI predicted psychological adjustment above and beyond Gorsuch and McPherson’s [46] intrinsic-extrinsic religious motivation scale and Paloutzian and Ellison’s [22, 47] Spiritual Well-Being Scale (SWBS).
Functional RS RS motivation. RS motivation instruments seek to identify different motives or orientations toward RS. Allport’s [15] conceptualization of intrinsic-extrinsic motivation has long been the dominant model for RS motivation. Although subject to both theoretical and methodological criticism, Allport and Ross’s [10] Religious Orientation Scale (ROS) continues to be widely used. Of the several religious orientation scales which attempt to improve the ROS (some are more fully described later in this chapter), Gorsuch and McPherson’s [46] Revised Religious Orientation Scale has emerged as perhaps the most psychometrically sound and viable. Batson and his colleagues [48] challenge the intrinsic-extrinsic dichotomy, and propose that religious quest is a necessary process in achieving religious maturity. In a religious quest, one asks questions that may challenge one’s own faith, and recognizes that the answers are often not clear-cut. Batson and Schoenrade’s [49, 50] Quest Scale measures the extent to which ’an individual’s religion involves an open-ended, responsive dialogue with existential questions raised by the contradictions and tragedies of life’ (p. 169) [48].
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The Muslim-Christian Religious Orientation Scale [14] was constructed to revise the original ROS scale by more precisely defining religious motivation. In addition to changing the Christian terminology to Muslim terminology in a Persian translation of the scale, the scale distinguishes between extrinsic motivations that are focused on the present world, and those that are focused on life after death. The scale appears to have good reliability, but evidence for its validity has not been consistently found throughout all the subscales. Conceptually, the scale seems to be making progress in capturing the complexity of religious motivations as applicable to both Muslims and Christians. RS participation. The Religious Involvement Inventory [51] is a 14-item inventory that measures a Christian individual’s participation in church beyond Sunday attendance. In addition, the Christian Spiritual Participation Profile [52] is a measure of how much a person is involved in one of the four spiritual development modes (consisting of both corporate and private spiritual disciplines). Both scales were, however, developed only with a Christian population and neither scale has yet to be tested with other religious traditions. Scales such as these are critical when considering the compelling findings that religious participation is linked to a reduced risk of dying, even after controlling for the effects of social support and health practices [53]. Private RS practices. RS private practices include prayer, meditation, reading sacred materials, and other personal activities related to the sacred. Often, items that assess private RS practices converge into a subscale that is part of a larger multidimensional RS scale. Some examples of such subscales are the religious practice dimension, a subscale in DeJong, Faulkner and Warland’s [54] measure of religiosity, and the Jewish Religious Observance subscale in Student Religiosity Questionnaire [55]. The Religious Background and Behavior Scale [56] is a full-scale measure of RS private practices that is reliable and valid. It is one of the few scales that is not limited to Christian private practices, and was constructed for a clinical population. RS support. RS support scales measure the perceived support an individual receives that come from God, one’s religious congregation, or one’s religious leaders. The worldview a religious community shares often serves as a bond among people that allows individuals to experience life together, much like the concept of a support convoy put forth by Kahn and Antonucci [57]. More often than not, kindness, love and respect of humans are highly emphasized among religious communities; therefore, religious communities are often a haven where one can receive support, comfort and assistance in times of need. The Religious Support Scale [58], designed for Christians, was constructed to measure perceived support of a religious nature. The scale’s three subscales – God support, congregational support, and church leader support – were found to be related to lower levels of depression and higher levels of life satisfaction. The scale showed excellent reliability and reasonably adequate validity. Further research using scales such as this one is critical to testing incremental validity of religious support apart from general social support. RS coping. RS coping is a way individuals handle adversity utilizing RS means or beliefs. This type of coping is especially useful when one is faced with uncontrollable stressors. RS coping holds a distinctive nature when compared with other types of coping, as elucidated by Pargament and Park [59]: Spiritual support is available when other forms of social support are lacking; religious explanations become more plausible when other explanations seem unconvincing; ultimate control is still possible through the sacred when life seems to be out of control; and religion
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helps in the search for new objects of significance when old ones are lost or are no longer viable . . . . Perhaps that is why the sacred becomes most compelling for many people when human powers are put to their greatest test. (p. 52)
The Measure of Religious Coping [18] is a valid scale that is potentially applicable among both the general population and the patient population. The reliability of the subscales falls within the moderate to high range. The RCOPE is currently the most frequently used and best RS coping measure. A Hindu version of the RCOPE has been developed and validated among Asian Indians in the US [19] and a parallel scale, though with limited reliability and validity, has been created with Pakistani Muslims [60]. Wong-McDonald and Gorsuch [61] proposed a surrender coping style in addition to Pargament’s coping styles. The Surrender Scale is reliable and exhibited incremental validity in addition to the RCOPE.
Quality of life Quality of life (QOL) is often understood as a construct which captures one’s physical, emotional and social well-being as well as one’s level of functioning [62]. Although there are many QOL assessments, not many include the measurement of spirituality as part of QOL [63, 64]. The Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale [65] is meant to be an inclusive (i.e., across religious traditions) measure of spirituality to be used among the chronically ill. The development of the FACIT-Sp was part of the development of the Functional Assessment of Cancer Therapy-General [66], which is a measure of the quality of life (QOL) of cancer patients. The items in FACT-G, however, do not tap into spirituality; therefore, the FACIT-Sp was developed to measure the spirituality dimension in QOL and to be added to the FACT-G when needed [62]. Peterman et al. [65] rightfully point out that few measures have been validated specifically with people who suffer from chronic illness. Though initially tested with two samples of cancer patients, the FACIT-Sp has now been used with a wide range of chronic illness. It consists of two psychometrically sound subscales: Faith and Meaning/Peace. Initial results suggest that the Faith subscale overlaps considerably with religiousness but the Meaning/Peace subscale appears independent of specific religious belief. Given that there is considerable commonality, but also distinctiveness, between religiousness and spirituality [67], this measure may be useful to assess a spirituality that is both associated with religion and one that is independent of specific religious belief. Fisch et al. [62] found that among cancer patients, the FACIT-Sp is strongly correlated with FACT-G, signifying the importance of spiritual well-being as part of one’s assessment of QOL. The Japanese version of the FACIT-Sp [68] was tested on 306 Japanese cancer patients and was found to have good reliability and validity. This study provides support for the cross-cultural applicability of the FACIT-Sp. QOL is not only an important construct among the chronically ill, it is also important to assess among the aging population. Kane et al. [69] developed the QOL measure specifically for residents of nursing homes. This scale was tested on 1988 nursing home residents from five different states in the U.S. The resulting 10 factors consist of comfort, security, meaningful activity, relationships, functional competence, enjoyment, privacy, dignity, autonomy and spiritual well-being. Emotional well-being, health and functional level were excluded from the measurement because they were deemed to be beyond the scope of the scale. The scale’s 10 domains were found to be correlated with the participants’ emotional
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well-being, as measured by an adaptation of the Dementia Quality of Life Instrument [70, as cited in 69] and global satisfactions with their nursing facility, which provides some support for the validity of the QOL measure. However, the alpha coefficient of these domains only ranged from 0.53 to 0.77, and the spiritual well-being scale only had an alpha of 0.64. Although this scale is one of the few QOL measures which explicitly measure spiritual well-being [63, 64], more studies need to be conducted to further test the reliability of this scale. The World Health Organization Quality of Life assessment [71] consists of 24 facets which are grouped into four general domains: physical, psychological, social relationships and environment. The spirituality/religion/personal beliefs facet consists of four items and is part of the psychological domain. The WHOQOL-100 was tested on 15 different WHO centers worldwide with a total of 4800 participants, consisting of those who use healthcare services and those who are healthy. This scale found good support for its reliability and validity. More importantly, the study provided support for the universality of the construct of QOL and its assessment. A brief version of this scale, called the WHOQOL-BREF [72] has also been shown to have good reliability and validity as well as to correlate highly with WHOQOL-100. The usefulness of the brief scale found support among liver transplant patients [73]. However, it needs to be noted that the brief version only included one item out of each facet; therefore, the spiritual facet is a one-item measurement, which raises concerns of reliability. Those seeking to focus on spirituality in measuring QOL are advised to use the WHOQOL-100 instead of the brief version. The McGill QOL Questionnaire [74] was initially tested among 40 cancer patients, some completed the English version and some completed the French version. Four factors emerged from this study: physical symptoms, psychological symptoms, outlook on life and meaningful existence. This study found support for its construct validity. It must be noted, however, that the items in the meaningful existence domain do not only tap into meaning drawn from one’s spirituality or religious beliefs. This domain also measures meaning drawn from one’s achievement of life goals. However, the meaningful existence domain is an important one, as it was the only domain which correlated with a one-item overall rating of one’s QOL. In subsequent studies, the outlook on life subscale was combined with the meaningful existence subscale to form the existential well-being scale [75]. Although the physical well-being subscale appeared to be problematic, support was found for the convergent validity of the psychological symptoms domain, the meaningful existence domain and the support domain. The QOL as conceptualized in this measure appears to be cross-culturally relevant. This measure was adapted and translated into Chinese and was administrated to 462 palliative care patients in Hong Kong [76]. The same four domains mentioned above also emerged in this study, and this version of the scale was found to be psychometrically sound.
Multidimensional measures When seeking a multidimensional measure that includes both religiosity and spirituality, the multidimensional RS measure by the Fetzer Institute/National Institute of Aging Working Group [77, 78] is one worth considering. In fact, the various RS dimensions used here as different domains of measurement are based on the subscales in this measure. The measure was contained in the 1998 General Social Survey (GSS) and demonstrated both adequate
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internal consistency (reliability) and validity on this nationally representative sample (N ¼ 1445) of Americans. The 33-item measure is also relatively brief, given that it covers 10 different domains. The brevity of the measure (only a few items per domain) may make specific subscales less stable and more prone to measurement error. The scale is useful for both the more traditionally religious and non institutionally spiritual. However, it has not been tested beyond the confines of the United States and its largely Christian population. Nevertheless, there is no single multidimensional scale that matches this scale in terms of its theoretical and technical sophistication and the breadth of RS domains covered. It alone receives our recommendation for researchers seeking a broad multidimensional scale of reasonable length.
Indigenous measures Earlier we discussed some measurement challenges due to religious pluralism. We pointed out that the majority of scales have been developed for research within the Judeo-Christian tradition and that this will often create significant problems for research outside that tradition. Of course, one alternative is to create measures from within other religious cultures. This is no easy task given the complexity of creating reliable, valid, and generalizable measures, even within a religious tradition, that requires both a technical expertise as well as an in-depth working knowledge of the religious culture – a combination often not found within some religious traditions. For example, one measure [14] developed within an Islamic worldview by capable researchers, reflects strictly a Shiite perspective and may not generalize to other Muslims [79]. Recognizing such limitations and their implications for research requires a more sophisticated understanding of Islam than what is found among most non Islamic researchers. Our hope is that as the scientific study of religion continues to expand toward other religious cultures, an increasing number of psychometrically validated measures specific to those traditions may be developed. There are signs that we are now reaching that critical measurement juncture, particularly with regard to the study of Islam, the second largest religion in the world. The recently established Journal of Muslim Mental Health has devoted two special issues in 2007 and 2008 to the topic of measurement and mental health within Islamic religiosity. A number of scales have been developed both within predominantly Islamic countries and within Islamic subcultures in Western countries, particularly the United States. Virtually all of these scales have just recently been developed and not yet tested across multiple samples and studies. Among these promising scales are the Religiosity of Islam Scale [79], developed among a snowball sample of Muslims mostly in the United States with the purpose of being useful universally with both Shiite and Sunni Muslims. The scale contains two subscales: Islamic Beliefs and Islamic Behavioral Practices. The initial version of the scale suffers from a small unrepresentative sample (N ¼ 71; 85% Sunni) and low reliability for the Beliefs subscale; nevertheless, it is an important first step in developing a broad based scale for Muslims. The Psychological Measure of Islamic Religiousness [80] yielded seven distinct and reliable factors: Islamic Beliefs; Islamic Ethical Principles and Universality; Islamic Religious Struggle; Islamic Religious Duty, Obligation, and Exclusivism; Islamic Positive Religious Coping and Identification; Punishing Allah Reappraisal; and Islamic Religious Conversion. This multidimensional measure of Islam is perhaps the most useful scale to date, particularly if applied to mental health research.
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Dover, Miner and Dowson [81] developed the multidimensional Islamic Reflection Scale (IRS) among 123 Australian Muslims and 74 Malaysian Muslims to explore levels of Islamic openness and questing. The scale was shown to be internally consistent and valid and contains a multidimensional factor called Muslim Religious Reflection (MRR) that ’is not simply an Islamic version of questing, but represents a distinct construct that relates in explicable (although, perhaps, not expected) ways to Christian religious reflection and nonreflection’. The Assessment of Muslim Marital Satisfaction [82], developed among Muslims in the United States, will require further psychometric research, but nevertheless shows promise as a research tool for measuring marital satisfaction among Muslims. Other Islamic scales include the Knowledge-Practice Measure of Islamic Religiosity [83] developed Muslim high school students in the United States, the Sahin Index of Islamic Moral Values [84] and the Sahin-Francis Scale of Attitude toward Islam [84]. The latter two scales were tested in a sample of almost 1200 students in Kuwait and both were found to be reliable and valid. Taken together, the recent development of these scales, shows that psychologists of religion are indeed serious about expanding their measurement infrastructure to other religious traditions. Though the vast majority of such efforts have been restricted primarily to the study of Islamic religiosity (and even there, many of the scales involve only pilot studies), we are optimistic that the repertoire of measures will continue to expand to other religious traditions as well, including those outside Abrahamic and other monotheistic roots.
3.7.4
SPIRITUAL ASSESSMENT AND SCREENING
Our discussion to this point has focused primarily on measures that have been developed and used in research. Of course, some of these measures may be used for purposes other than research, particularly by health professionals who provide patient care. A number of resources [e.g., 85–87] are now available that provide health professionals with guidance as to when and how spiritual issues should be addressed. Virtually all recommend that a spiritual history be included somewhere in the assessment package, especially for preoperative patients or patients facing major illnesses and/or terminal diseases. Questions commonly recommended include those about religious denomination, level of activity in a faith community, the degree to which RS beliefs provide comfort, and how RS beliefs might influence medical decisions. However, for those who desire a more structured and thorough instrument, the following measures are recommended. The four dimensional Spiritual History Scale (SHS) [36] has already been reviewed in this chapter. It is a 23-item scale that has been developed and further tested on the elderly. Maugans’ [88] SPIRITual History Scale is a 22-item scale that uses the mnemonic SPIRIT to capture the recommended six dimensions of a spiritual history: spiritual belief system (two items), personal spirituality (five items), integration with a spiritual community (five items), ritualized practices and restrictions (four items), implications for medical care (four items), and terminal events planning (two items). Though we find no psychometric assessment of the Maugans’ scale, the domains and the items tapping those domains maintain strong face validity and will likely provide useful guidance in patient care.
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For those health professionals desiring to assess spiritual needs of patients, Fitchett’s [85] 7X7 Model is recommended, not so much as a specific quantitative measure but more as a set of guidelines for conducting an assessment. The spiritual dimension is but one of seven broad dimensions in Fitchett’s model (the other dimensions being medical, psychological, psychosocial, family systems, ethnic and cultural, and societal issues) and it too consists of seven dimensions (beliefs and meaning, vocation and consequences, experience and emotion, courage and growth, ritual and practice, community, and authority and guidance). Fitchett discusses each of the spiritual dimensions in a qualitative manner through case studies.
3.7.5
OTHER MODALITIES BESIDE SELF-REPORT
Virtually the entire content of this chapter has focused on the use of self-reports to measure RS, understandable in that this form of measurement is common to most social science research and given that most psychology of religion has been conducted within a Western Protestant context that stresses religious beliefs as personal and subjective [16]. Exclusive reliance on self-report measures, however, makes the study of RS vulnerable to bias in the form of demand characteristics and impression management [48], especially when conducted in a context where people are expected to profess certain beliefs and practices [89]. Implicit measures. As a result, RS researchers have begun to test adaptations of indirect measurement techniques from cognitive and social psychology. Some of these measures are referred to as ‘implicit’ measures in that they are, ostensibly, not open to consciousness and therefore not as vulnerable to presentation bias. Typically, such techniques involve participants’ accuracy or speed in performing tasks as an indicator of underlying cognitive structures and processes. One such technique drawing strong interest is judgment speed. Social cognition researchers [e.g., 90] have argued that attitude accessibility, as measured by judgment speed of an object as good or bad, is an indicator of attitude strength. Hill’s [91] proposal that such a measure of attitude accessibility be applied to the psychology of religion was tested in a series of several experiments by Gibson [92]. Results indicated that timing measures are sensitive to the accessibility of people’s God schemas. Similarly, Cohen, Shariff and Hill [93] found that moderately religious people (as indicated by self-report) showed greater response latency when classifying religious stimuli as real or imaginary than did those who self-identified as more strongly religious or as non-religious. The researchers interpreted these results to suggest that those with stronger opinions (either pro or con about religion) had more accessible attitudes. The Implicit Association Test [94], used to measure such social attitudes as racial prejudice, is yet another cognitive timing measure that is perhaps promising but has yet to be applied to the study of RS experience. Yet another alternative strategy to self -report involves memory recall. Research [95] has shown that people recall more adjectives that describe a target person if that person is intimate. Hence, adjectives used to describe mother, an intimate but still familiar target, were recalled more frequently than words rated for familiar but non-intimate targets, such as a well-known public figure. Gibson [92] found, as predicted, that evangelicals, whose God-reference is more intimate but not necessarily more familiar than the God-reference for non-evangelicals and atheists, recalled God adjectives at the same rate as their self-reference
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(familiar and intimate) recall. In contrast, non-evangelicals and atheists remembered more adjectives associated with the self than with God. Alternative methodologies to assess RS experience have appreciable upside potential but are still in their infancy and their continued development warrants careful scrutiny. There is still considerable debate about what such indirect measures, in general, are assessing [see, e.g., 96] and there are few studies that have applied such measures to the RS variable. Therefore, it is premature to recommend their use at this point in time. Other alternative measures. Though not well-developed or frequently used in RS research, other approaches can also be considered. Qualitative research (e.g., interviews, discussions with focus groups) is underutilized as a complement to quantitative research. Qualitative research may help unpack the richness of the RS experience that closed-ended self-report measures frequently miss. Employing others’ (e.g., friends, family members, professional staff) reports on both RS practices and health, an approach especially useful for clinical populations is rarely used. Utilizing nonverbal measures such as picture drawing of RS objects or concepts, a technique frequently used in research with children, has been used only sparingly in RS research. The use of physiological indicators (e.g., immunological functioning, fMRI) of RS experiences has similarly been under utilized. We can expect that as the study of RS experience continues to grow, such alternative measures will be more frequently and effectively employed.
3.7.6
GUIDANCE FOR CHOOSING A MEASURE
Choosing an RS measure calls for several considerations [32]. First, it is imperative that one clearly defines the purposes for which the measure will be used. One who seeks to use a measure for research purposes must consider whether this research is meant to advance understanding in the RS field (often referred to as ‘basic’ research), or whether this research is meant to answer specific empirical questions (applied research). When conducting basic research, the research questions and hypotheses must have a solid foundation in a broad theoretical framework. On the other hand, applied research is often guided by a specific research question (e.g. whether utilizing religious coping contributes to the ego-resiliency of victims of natural disasters), so having a broad theoretical framework in this case is less critical. When seeking to use a measure for non-research purposes, theory is useful to decide whether the measure is appropriate for one’s purposes. Second, clarity on what specific construct in the RS experience one is seeking to measure is imperative for both researchers and clinicians. It is possible to think that one is measuring a broad RS construct, when in reality one is simply studying a specific dimension of RS (e.g. measuring religiosity using questionnaires on religious attendance only). While studying specific dimensions of RS is highly beneficial to the field, especially when related to health constructs, one must be cautious not to generalize the findings to other RS variables. Third, the measures considered need to be reliable and valid. As discussed earlier, a measure that only appears to measure what it is supposed to measure may actually be measuring something different. Therefore, face validity by itself is not sufficient. In most cases it is crucial that a selected measure has gone through rigorous psychometric testing to assess its reliability and validity. Fourth, consider the population among whom the scale will be used. For the researcher, it is imperative that their sample represents the population of interest well. The applied professional must also ensure that the measure is appropriate for the population of interest.
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For example, using a measure that was developed for a specific religious tradition should not be used among a broader more pluralistic population without pilot testing. Fifth, given the complexity of RS variables, one who seeks to measure RS constructs must approach the endeavor with a degree of flexibility and creativity. One may be discouraged when looking for measures for a specific RS construct applied among a specific population (e.g. a measure of RS for people with mental disabilities, a measure of religious beliefs among children of parents with different religious beliefs, etc.). However, one may be surprised at how much one can gain by looking into conceptually-related measures, though some may require modifications to serve one’s specific purposes (e.g. using non verbal measures such as picture drawing for specific mentally disabled populations, using a well-established measure that can be adapted for certain populations, etc.). Utilizing existing measures not only can reduce the amount of effort that goes into the creation of a new, psychometrically sound measure, but it also can better advance the RS field. Use of the same measure (even if slightly modified) allows for better cross study comparisons [5].
3.7.7
CONCLUSION
There is a strong measurement literature, drawn mostly from the psychology of religion, that has resulted in a vast array of measures useful for the interface of religion, spirituality, and psychiatry – an interface that researchers and applied professionals has identified as important to overall well-being. This review is by no means exhaustive, but it does provide the interested researcher with a number of RS instruments to further explore and advance our understanding of this interface.
3.7.8
ABSTRACT
This chapter focuses on measurement and assessment of religiousness and spirituality with both the researcher and applied professional in mind. Specific measures across a variety of religious and spiritual domains are briefly reviewed and, based on theoretic and psychometric criteria of merit, are recommended for consideration. Unique challenges of measuring religiosity and spirituality are examined and possible solutions offered. Other possible modalities besides self report are considered and recent developments in the field discussed. Finally, given the complex nature of these constructs, several considerations are recommended in choosing religious and spiritual measures.
REFERENCES 1. Lloyd R (1999, September 30). Metric mishap caused loss of NASA orbiter. CNN.com. Retrieved November 22, 2007, from http://www.cnn.com/TECH/space/9909/30/mars.metric.02/ 2. Gorsuch RL (1984) Measurement: The boon and bane of investigating religion. American Psychologist 39, 228–236. 3. Sherman AC & Simonton S (2001) Assessment of religiousness and spirituality in health research. In: Plante TG & Sherman AC (eds.) Faith and Health: Psychological Perspectives. Guilford, New York, pp. 139–163.
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4. Levin JS, & Chatters LM. (1998) Research on religion and mental health: An overview of empirical findings and theoretical issues. In: Koenig HG (ed.) Handbook of Religion and Mental Health. Academic Press, San Diego, CA, pp. 33–50. 5. Hill PC (2005) Measurement assessment and issues in the psychology of religion and spirituality. In: Paloutzian RF & and Park CL (eds.) Handbook of thePsychology of Religion and Spirituality. Guilford Press, New York, pp. 43–61. 6. Koenig HG, McCullough ME, & Larson DB (2001) Handbook of Religion and Health. Oxford University Press, New York. 7. Hill PC & Pargament KI (2003) Advances in the conceptualization and measurement of religion and spirituality. American Psychologist 58, 64–76. 8. Gorsuch RL (1988) Psychology of religion. Annual Review of Psychology 39, 201–221. 9. Heelas P (1985) Social anthropology and the psychology of religion. In: Brown LB (ed.) Advances in the Psychology of Religion. Pergamon Press, Oxford, pp. 34–51. 10. Allport GW & Ross JM (1967) Personal religious orientation and prejudice. Journal of Personality and Social Psychology 5, 432–443. 11. Muhammad ‘Ali, M (1990) The religion of Islam. Ahmadiyya Anjuman Isha’at Islam, Columbus, OH. 12. Nigosian SA (2004) Islam: Its History, Teaching, and Practices. Indiana University Press, Bloomington, IN. 13. Rippin A (2005) Muslims: Their Religious Beliefs and Practices 3rd edn Routledge, New York. 14. Ghorbani N, Watson PJ, Ghramaleki AF, et al. (2002) Muslim-Christian Religious Orientation Scales: Distinctions, correlations, and cross-cultural analysis in Iran and the United States. The International Journal for the Psychology of Religion 12, 69–91. 15. Allport GW (1950) The Individual and His Religion. Macmillan, New York. 16. Cohen AB, & Hill PC (2007) Religion as culture: Religious individualism and collectivism among American Catholics, Jews, and Protestants. Journal of Personality 75, 709–742. 17. Donahue MJ (1985) Intrinsic and extrinsic religiousness: Review and meta-analysis. Journal of Personality and Social Psychology 48, 400–419. 18. Pargament KI, Koenig HG & Perez LM (2000) The many methods of religious coping: Development and initial validation of the RCOPE. Journal of Clinical Psychology 56, 519–543. 19. Tarakeshwar N, Pargament KI & Mahoney A (2003) Initial development of a measure of religious coping among Hindus. Journal of Community Psychology 31, 607–628. 20. Hill PC, & Hood RW, Jr. (1999) Measures of Religiosity. Religious Education Press, Birmingham, AL. 21. Tsang J & McCullough ME (2003) Measuring religious constructs: A hierarchical approach to construct organization and scale selection. In: Lopez SJ & Snyder CR (eds.) Positive Psychological Assessment: A Handbook of Models and Measures. American Psychological Association, Washington, DC, pp. 345–360. 22. Paloutzian RF & Ellison CW (1982) Loneliness, spiritual well-being, and quality of life. In: Peplau LA, & Perlman D (eds.) Loneliness: A Sourcebook of Current Theory, Research and Therapy. Wiley Interscience, New York. 23. Piedmont RL (1999) Does spirituality represent the sixth factor of personality? Spiritual transcendence and the Five-Factor Model. Journal of Personality 67, 985–1013. 24. Piedmont RL & Leach MM (2002) Cross-cultural generalizability of the Spiritual Transcendence Scale in India: Spirituality as a universal aspect of human experience. American Behavioral Scientist 45, 1888–1901. 25. Piedmont RL (2007) Cross-cultural generalizability of the Spiritual Transcendence Scale to the Philippines: Spirituality as a human universal. Mental Health, Religion & Culture 10, 89–107. 26. Galea M, Ciarrocchi JW & Piedmont RL (2007) Child abuse, personality, and spirituality as predictors of happiness in Maltese college students. Research in the Social Scientific Study of Religion 18, 141–154.
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27. Worthington EL, Jr., Wade NG, Hight TL, et al. (2003) The Religious Commitment Inventory-10: Development, refinement, and validation of a brief for research and counseling. Journal of Counseling Psychology 50, 84–96. 28. Plante TG & Boccaccini BF (1997) The Santa Clara Strength of Religious Faith Questionnaire. Pastoral Psychology 45, 375–387. 29. Plante TG, Vallaeys CL, Sherman AC, et al. (2002) The development of a brief version of the Santa Clara Strength of Religious Faith Questionnaire. Pastoral Psychology 48, 11–21. 30. Storch EA, Roberti JW, Bagner DM, et al. (2004) Further psychometric properties of the Santa Clara Strength of Religious Faith Questionnaire – Short-Form. Journal of Psychology & Christianity 23, 51–53. 31. Plante TG, & Sherman AC (eds.). (2001). Faith and health: Psychological perspectives. Guilford: New York. 32. Hill PC, Kopp KJ & Bollinger RA (2007) A few good measures: Assessing religion and spirituality in relation to health. In: Plante TG & Thoresen CE (eds.) Spirit, Science, and Health: How the spiritual mind fuels physical wellness. Praeger Publishers/Greenwood Publishing Group, Westport, CT, pp. 25–38. 33. Benson PL, Donahue MJ, & Erickson JA (1993). The Faith Maturity Scale: Conceptualization, measurement, and empirical validation. In Lynn ML & Moberg DL (eds.), Research in the Social Scientific Study of Religion 5, JAI Press, Greenwich, CT. pp. 1–26. 34. Leak GK, & Fish SB (1999) Development and initial validation of a measure of religious maturity. International Journal for the Psychology of Religion 9, 83–103. 35. Maiello C (2005) Degrees of Belief in God: A measure of belief for use in cross culture. Mental Health, Religion & Culture 8, 87–95. 36. Hays JC, Meador KG, Branch PS, et al. (2001) The Spiritual History Scale in four dimensions (SHS-4): Validity and reliability. The Gerontologist 41, 239–249. 37. Underwood LG & Teresi JA (2002) The Daily Spiritual Experience Scale: Development, theoretical description, reliability, exploratory factor analysis, and preliminary construct validity using health-related data. Annals of Behavioral Medicine 24, 22–33. 38. Granqvist P (2002) Attachment and religiosity in adolescence: Cross-sectional and longitudinal evaluations. Personality & Social Psychology Bulletin 28, 260–270. 39. Kirkpatrick LA (1992) An attachment-theory approach to the psychology of religion. The International Journal for the Psychology of Religion 2, 3–28. 40. Kirkpatrick LA (1997) A longitudinal study of changes in religious belief and behavior as a function of individual differences in adult attachment style. Journal for the Scientific Study of Religion 36, 207–217. 41. Bowlby J (1969) Attachment, Vol. 1 of Attachment and loss. London: Hogarth Press. New York: Basic Books. 42. Bowlby J (1973). Separation, Vol. 2 of Attachment and loss. London: Hogarth Press. New York: Basic Books. 43. Beck R & McDonald A (2004) Attachment to God: The Attachment to God Inventory, tests of working model correspondence, and an exploration of faith group differences. Journal of Psychology & Theology 32, 92–103. 44. Hall TW & Edwards KJ (1996) The initial development and factor analysis of the Spiritual Assessment Inventory. Journal of Psychology and Theology 24, 233–246. 45. Hall TW & Edwards KJ (2002) The Spiritual Assessment Inventory: A theistic model and measure for assessing spiritual development. Journal for the Scientific Study of Religion 41, 341–357. 46. Gorsuch RL & McPherson SE (1989) Intrinsic/Extrinsic measurement: I/E-Revised and singleitem scales. Journal for the Scientific Study of Religion 28, 348–354. 47. Ellison CG (1983) Spiritual well-being: Conceptualization and measurement. Journal of Psychology and Theology 11, 330–340.
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48. Batson CD, Schoenrade PA & Ventis WL (1993) Religion and the individual: A socialpsychological perspective. Oxford University Press, New York. 49. Batson CD & Schoenrade PA (1991a) Measuring religion as quest: I. Validity concerns. Journal for the Scientific Study of Religion 30, 416–429. 50. Batson CD & Schoenrade PA (1991b) Measuring religion as quest: II. Reliability concerns. Journal for the Scientific Study of Religion 30, 430–447. 51. Hilty DM & Morgan RL (1985) Construct validation for the Religious Involvement Inventory: Replication. Journal for the Scientific Study of Religion 24, 75–86. 52. Thayer OJ (2004) Constructing a spirituality measure based on learning theory: The Christian Spiritual Participation Profile. Journal of Psychology and Christianity 23, 195–207. 53. Weaver AJ & Koenig HG (2006) Religion, spirituality, and their relevance to medicine: An update. American Family Physician 73, 1336–1337. 54. DeJong GF, Faulkner JE & Warland RH (1976) Dimensions of religiosity reconsidered: Evidence from a cross-cultural study. Social Forces 54, 866–889. 55. Katz YJ (1988) A validation of the Social-Religious-Political Scale. Educational and Psychological Measurement 48, 1025–1028. 56. Connors GJ, Tonigan JS & Miller WR (1996) A measure of religious background and behavior for use in behavior change research. Psychology of Addictive Behaviors 10, 90–96. 57. Kahn RL & Antonucci TC (1980) Convoys over the life course: Attachment, roles, and social support. In: Baltes PB & Brim OG (eds.) Life-span development and behavior. Academic Press, New York, pp. 253–286. 58. Fiala WE, Bjorck JP & Gorsuch R (2002) The Religious Support Scale: Construction, validation and cross-validation. American Journal of Community Psychology 30, 761–786. 59. Pargament KI & Park CL (1997) In times of stress: The religion-coping connection. In: Spilka B & McIntosh DN (eds.) The Psychology of Religion: Theoretical Approaches. Westview Press, Boulder, CO, pp. 43–53. 60. Khan ZH & Watson PJ (2006) Construction of the Pakistani Religious Coping Practices Scale: Correlations with religious coping, religious orientation, and reactions to stress among Muslim university students. The International Journal for the Psychology of Religion 16, 101–112. 61. Wong-McDonald A & Gorsuch RL (2000) Surrender to God: An additional coping style? Journal of Psychology & Theology 28, 149–161. 62. Fisch MJ, Titzer ML, Kristeller JL, et al. (2003) Assessment of quality of life in outpatients with advanced cancer: The accuracy of clinician estimations and the relevance of spiritual wellbeing—A Hoosier Oncology Group Study. Journal of Clinical Oncology 21, 2754–2759. 63. O’Connell KA & Skevington SM (2005) The relevance of spirituality, religion and personal beliefs to health-related quality of life: Themes from focus groups in Britain. Journal of Health Psychology 10, 379–398. 64. O’Connell KA & Skevington SM (2007) To measure or not to measure? Reviewing the assessment of spirituality and religion in health-related quality of life. Chronic Illness 3, 77–87. 65. Peterman AH, Fitchett G, Brady MJ, et al. (2002) Measuring spiritual well-being in people with cancer: The Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp). Annals of Behavioral Medicine 24, 49–58. 66. Cella DF, Tulsky DS, Gray G, et al. (1993) The Functional Assessment of Cancer Therapy Scale: Development and validation of the general measure. Journal of Clinical Oncology 11, 570–579. 67. Hill PC, Pargament KI, Hood RW, Jr., et al. (2000) Conceptualizing religion and spirituality: Points of commonality, points of departure. Journal for the Theory of Social Behaviour 30, 51–77. 68. Noguchi W, Ohno T, Morita S, et al. (2004) Reliability and validity of the Functional Assessment if Chronic Illness of Therapy-Spiritual (FACIT-Sp) for Japanese patients with cancer. Supportive Care in Cancer 12, 240–245. 69. Kane RA, Kling KC, Bershadsky B, et al. (2003) Quality of life measures for nursing home residents. Journals of Gerontology 58A, 240–248.
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70. Brod M, Stewart AL, Sands L, et al. (1999) Conceptualization and measurement of quality of life in dementia: The Dementia Quality of Life Instrument (DQoL). The Gerontologist 39, 25–35. 71. Power M, Bullinger M, Harper A &The World Health Organization Quality of Life Group (1999) The World Health Organization WHOQOL-100: Tests of the Universality of Quality of Life in 15 Different Cultural Groups Worldwide. Health Psychology 18, 495–505. 72. The WHOQOL Group (1998) The World Health Organization WHOQOL-BREF Quality of Life Assessment. Psychological Medicine 28, 551–558. 73. O’Carroll RE, Smith K, Couston M, et al. (2000) A comparison of the WHOQOL-100 and the WHOQOL-BREF in detecting change in quality of life following liver transplantation. Quality of Life Research 9, 121–124. 74. Cohen SR, Mount BM, Strobel MG, et al. (1995) The McGill Quality of Life Questionnaire; A measure of quality of life appropriate for people with advanced disease. A preliminary study of validity and acceptability. Palliative Medicine 9, 207–219. 75. Cohen SR, Mount BM, Bruera E, et al. (1997) Validity of the McGill Quality of Life Questionnaire in the palliative care setting: A multi-centre Canadian study demonstrating the importance of the existential domain. Palliative Medicine 11, 3–20. 76. Lo RSK, Woo J, Zhoc KCH, et al. (2001) Cross-cultural validation of the McGill Quality of Life questionnaire in Hong Kong Chinese. Palliative Medicine 15, 387–397. 77. Fetzer Institute/National Institute of Aging Working Group. (1999). Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research: A Report of the Fetzer Institute/ National Institute on Aging Working Group. John E. Fetzer Institute, Kalamazoo, MI. 78. Idler EL, Musick MA, Ellison CG, et al. (2003) Measuring multiple dimensions of religion and spirituality for health research: Conceptual background and findings from the 1998 General Social Survey. Research on Aging 25, 327–365. 79. Jana-Masri A, Priester PE (2007) The Development and validation of a Qur’an-Based Instrument to Assess Islamic Religiosity: The Religiosity of Islam Scale. Journal of Muslim Mental Health, 2, 177–188. 80. Raiya HA, Pargament KI, Stein C, et al. (2007) Lessons Learned and Challenges Faced in Developing the Psychological Measure of Islamic Religiosity. Journal of Muslim Mental Health 2, 133–154. 81. Dover H, Miner M, Dowson M (2007) The Nature and Structure of Muslim Religious Reflection. Journal of Muslim Mental Health 2, 189–210. 82. Asamaria LA, Solberg KB, Solon PC (2008) The Role of Religiosity in Muslim Spouse Selection and Its Influence on Marital Satisfaction. Journal of Muslim Mental Health 3, 37–52. 83. Alghorani MA (2008) Knowledge-Practice Measure of Islamic Religiosity (KPMIR): A Case of High School Muslim Students in the United States. Journal of Muslim Mental Health 3, 25–36. 84. Francis LJ, Sahin A, Al-Failakawi F (2008) Psychometric Properties of Two Islamic Mmeasures among Young Adults in Kuwait: The Sahin-Francis Scale of Attitude toward Islam and the Sahin Index of Islamic Moral Values. Journal of Muslim Mental Health 3, 9–24. 85. Fitchett G. (2002) Assessing spiritual needs: A guide for caregivers. Academia Renewal Press, Lima, OH. 86. Koenig HG (2007) Spirituality in patient care: Why, how, when, and what, rev. ed. Templeton Foundation Press, West Conshohocken, PA. 87. Taylor EJ (2007) What do I say? Talking with patients about spirituality. Templeton Foundation Press, West Conshohocken, PA. 88. Maugans TA (1996) The SPIRITual history. Archives of Family Medicine 5, 11–16. 89. Burris CT & Navara GS (2002) Morality play – or playing morality: Intrinsic religious orientation and socially desirable responding. Self and Identity 1, 67–76. 90. Fazio RH, Sanbonmatsu DM, Powell MC, et al. (1986) On the automatic activation of attitudes. Journal of Personality and Social Psychology 50, 229–238.
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91. Hill PC (1994) Toward an attitude process model of religious experience. Journal for the Scientific Study of Religion 33, 303–314. 92. Gibson, NJS (2006) The experimental investigation of religious cognition. Unpublished doctoral dissertation [available from http://www.divinity.cam.ac.uk/pcp/personnel/nicholas.html#PhD ], University of Cambridge, England. 93. Cohen AB, Shariff AF, & Hill PC. (2008) The accessibility of religious beliefs. Journal of Research in Personality 42, 1408–1417. 94. Greenwald AG, McGhee DE, & Schwartz JLK (1998) Measuring individual differences in implicit cognition: The Implicit Association Test. Journal of Personality and Social Psychology 74, 1464–1480. 95. Symons CS & Johnson BT (1997) The self-reference effect in memory: A meta-analysis. Psychological Bulletin 121, 371–394. 96. Kinoshita S & Peek-O’Leary M (2005) Does the compatibility effect in race Implicit Association Test reflect familiarity or affect? Psychonomic Bulletin & Review 12, 442–452.
Part 4 Research Issues INTRODUCTION Research is, without doubt, extremely important. We need to keep a few things in mind: 1) Since religiousness and spirituality do not exist in a cultural vacuum they are shaped by all kinds of individual, social and contextual factors. 2) Although religion and spirituality are universal concepts, they vary widely when looked at from a (sub)cultural perspective. It is far too simple to apply or modify Western assumptions and techniques for other religious populations and traditions. It is not selfevident that typical Judeo-Christian religious and spiritual domains are useful in other cultural contexts. Take only the fact that in other than Judeo-Christian spirituality the sacred and the secular are blended wherever you look. Or that in Hinduism prayer is less an expression of religiosity than rituals and celebrations. In Hinduism there is an abundance of ritual activity. Aspects of health-related behavior may be focused on health rituals, as is the case in African religion. 3) Therefore we need a dialogical model in order to (re)discover which (Western) perspectives on religion, spirituality and mental health are useful, need to be adjusted, or need to be rejected. 4) Within such a dialogical model the assumption should not be that any particular religious tradition is superior to, or reducible to another tradition, or reducible to general assumptions about religiousness and spirituality. 5) Within such a dialogical model it would be possible to rediscover the relationality between fields of research, that has been concealed, since we had hidden behind disciplinary boundaries. 6) Psychiatry needs such a dialogical model since attempts to distinguish religious from pathological (psychotic) states are not successful from within. The theoretical (naturalistic, empiristic) commitments of psychiatry, its problematic so-called ‘social dysfunction criterion’, and its ‘hyponarrative’ stance (‘knowing the diagnosis is not the same as knowing the patient’) are in danger of ‘pathologizing’ religious and spiritual, that is to say unusual experiences. 7) Interestingly enough, religious and spiritual experiences are being rehabilitated: from guilty (pathological) until proven innocent (not pathological) to innocent until proven guilty. However, here we again we need a dialogical model: an open communication between methodological naturalism and an epistemology of religion.
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8) Research from various disciplines and different levels of analysis will contribute to our understanding of the interface between psychiatry, religion and spirituality. These levels of analysis are a) the level of everyday experience, as it is communicated, b) the clinical level: diagnosis, decision making and therapy, c) the scientific level: analysis and abstraction of processes, (disordered) functions and relations, d) the meta-theoretical level: description of basic premises and theoretical models. 4.1 Religion and Mental Health: What Do You Mean When You Say ‘Religion’? What Do You Mean When You Say ‘Mental Health’? Charles H. Hackney 4.2 A Moment of Anger, a Lifetime of Favor: Image of God, Personality, and Orthodox Religiosity Elisabeth H.M. Eurelings-Bontekoe & Hanneke Schaap-Jonker 4.3 The Relationship Between an Orthodox Protestant Upbringing and Current Orthodox Protestant Adherence, DSM-IV Axis II B Cluster Personality Disorders and Structural Borderline Personality Organization Elisabeth H.M. Eurelings-Bontekoe & Patrick Luyten 4.4 When Religion Goes Awry: Religious Risk Factors for Poorer Health and WellBeing Hisham Abu Raiya, Kenneth I. Pargament & Gina Magyar-Russell 4.5 Religious Practice and Mental Health: a Moroccan Experience Driss Moussaoui & Nadia Kadri 4.6 Religious and Spiritual Considerations in Psychiatric Diagnosis: Considerations for the DSM-V David Lukoff, C. Robert Cloninger, Marc Galanter, David M. Gellerman, Linda Glickman, Harold G. Koenig, Francis G. Lu, William E. Narrow, John R. Peteet, Samuel B. Thielman & C. Paul Yang
CHAPTER 4.1
Religion and Mental Health: What Do You Mean When You Say ‘Religion’? What Do You Mean When You Say ‘Mental Health’? Charles H. Hackney Professor of Psychology, Canada
4.1.1
INTRODUCTION
Attempts to define and clarify terms play a central role in scholarly activity. ‘What do you mean when you say that?’ is one of the foundational questions of Socratic inquiry [1], and Plato’s Republic represents an extended attempt to define and clarify the meaning of ‘justice.’ Fourth-century Christianity endured decades of controversy, condemnations and excommunications over an issue involving whether the Greek word homoousius or homoiousius should be used in reference to a core theological concept [2]. Debate over bioethical issues such as abortion, euthanasia and the treatment of Alzheimer’s patients require that we grapple with questions about what we mean by ‘person’ [3]. The meanings and boundaries of the term ‘mental disorder’ were pivotal to the decision to remove homosexuality from the third edition of the DSM [4, 5], and the field of psychology recently celebrated one hundred years of debate over what exactly is meant by ‘general intelligence’ [6]. Inquiries into what is meant by ‘religion’ have been no exception to this pattern. Attempts to develop a useful definition of religion have resulted in a multiplicity of contradictory solutions, to such a degree that J. Milton Yinger described it as ‘a truism to say that any definition of religion is likely to be satisfactory only to its author – and often not to him’ [7]. Kant [8] considered true religion to be the end product of rational enquiry into universal principles of practical morality, while Schleiermacher [9] considered doctrines and principles to be the byproduct of the profound emotional experience of encountering the supernatural. Marx believed religion to be entirely the product of economically-based forms
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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of social interaction [10]. Durkheim considered the core of religion to be the formation of a ‘moral community’ centered around a common system of beliefs and practices related to ‘sacred things’ [11]. John Watson considered religion to be a form of exploitive behavior modification, in which those too lazy to work manipulate others into doing their bidding by employing supernatural concepts to instill superstitious fear [12]. Viktor Frankl described religion as a powerful tool for the individual’s search for meaning in the face of suffering and death [13]. Many religious scholars and philosophers focus on religion as a worldview (weltanschauung) in which a set of metatheoretical beliefs about the nature of existence provide a conceptual framework for comprehending and navigating reality [14–16]. Virtue ethicists approach religions as historically-embedded traditions of enquiry into ways and means for the cultivation of an ideal human life [17–19]. Leuba cataloged four dozen scholarly definitions of religion, and declared them all to be unsatisfactory in and of themselves [20]. William James claimed that the wide diversity of available definitions supports the idea that ‘the word “religion” cannot stand for any single principle or essence,’ and that attempts to construct a unidimensional approach to religion is a symptom of ‘all that absolutism and one-sided dogmatism by which both philosophy and religion have been infested’ [21]. Vetter lists 22 possible ‘essentials’ of religion (clergy, afterlife beliefs, sacrifices, etc), and points out that, if the question is ‘do all religions have this?’, the answer to all 22 is ‘no’ [22] Such definitional difficulties led W. S. Cantwell to argue that the notion of ‘religion,’ as a construct which may be considered separable from the rest of life, is a modern fiction, and he goes so far as to recommend that the term be dropped from scholarly discourse [23]. McKinnon counters with a Wittgensteinean approach. He argues that, like Wittgenstein’s famous attempt to define what a ‘game’ is, ‘religion’ has no single essence outside of our discourse about religion, but instead should be thought of as a cluster of phenomena that share ‘family resemblances,’ making the term useful within academic discourse, so long as it is not reified [24].
4.1.2
RELIGION AND MENTAL HEALTH
The relationship between religion and mental health has also been an arena for scholarly disagreement, with some psychiatrists and psychologists claiming religion to be destructive to one’s mental functioning, while others describe it as a possible positive force in people’s lives.
4.1.2.1
Religion as harmful
The name most frequently given as an example of the position that religion is inherently unhealthy is Sigmund Freud. In his Future of an Illusion, Freud provides his famous description of religion as ‘the universal obsessional neurosis of humanity,’ based on the outworkings of the Oedipal complex and attempts by ‘our wretched, ignorant and downtrodden ancestors’ to deal with the terror of the forces of nature by projecting onto them a father-figure who can be appeased [25]. As religion is described as the result of infantile neuroses, Freud believed that psychological growth will be accompanied by a turning-away from religion, both in the life of the individual and in the progress of
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civilization. Freud’s harsh treatment of religion has influenced those who have followed his approach to psychology, resulting in a legacy of mistrust between religionists and psychoanalysts [26, 27]. Post-Freudian psychoanalysts (particularly the ego psychologists and object-relations theorists) have presented a more multifaceted vision of religion, with the result that, though some tension remains, there is less mutual antagonism between religion and psychoanalysis than was once the case [28]. George Vetter also attacked religion as an inherently destructive thing [22]. Drawing largely from behaviorist ideas, Vetter described religion as a set of learned superstitions, not substantively different than B. F. Skinner teaching pigeons to dance through positive reinforcement. Within this approach, patterns of behavior are learned habits, acquired and maintained when emitted behaviors and environmental events co-occur, and Vetter claims this to be the power behind such activities as prayer and worship. Those who pray during times of trouble tend to pray until things go right, and then claim that it was the prayer than led to the positive reversal, and acts such as corporate worship provide a positive emotional experience that allows the practitioner to forget his or her troubles and enjoy an improved mood. The core of Vetter’s argument against religion is that, as a superstition, religious activities are a waste of time, effort and resources that could have been better spent directly dealing with whatever difficulties prompted the religious activities in the first place. Faith therefore leads inevitably to ignorance and suffering, and paralyzes initiative and action. Vetter charges psychologists to strip religion of its pretenses and replace it with a scientific vision of the universe, saying that ‘the way of faith is a sterile, blind, and tragic alley. It is to skepticism and empiricism that man owes everything in which, in light of longer history, he can take pride.’ Albert Ellis is often presented as another psychologist who takes a wholeheartedly negative view of religion [29], and I must confess that I have also been guilty of this oversimplification in the past [30]. However, a look at the progression of Ellis’ writings on religion demonstrates an increase in Ellis’ complexity of thought on the nature of religion, and a gradual softening of his attitude toward the connection between religion and mental health. In an early article on the topic, Ellis maintained that any theistic religion ‘almost by necessity’ will inculcate a sense of sinful worthlessness in the religionist, that ‘the concept of sin is the direct and indirect cause of virtually all neurotic disturbance,’ and that it is the task of psychotherapists to ‘uninvent’ God in their patient’s lives [31]. In later writings [32, 33], Ellis moderated his views somewhat. Religion itself is not the problem, according to Ellis during this stage of his career, only devout religiosity. While he continued to espouse the notion that clients would greatly benefit from jettisoning religious beliefs, and that ‘the less religious they are, the more emotionally healthy they will tend to be,’ if clients refuse to surrender religious beliefs, they can still live comfortably and healthily with a religion of the more liberal, non-absolutist variety. After another interval of two decades, Ellis again revised his position on religion and mental health [34]. Not only is it possible, according to the Albert Ellis of the new millennium, to be a practicing religionist and still be mentally healthy, but even those who practice ‘some forms of absolutist and devout religiosity’ may be highly functioning people. Devout belief in theological concepts such as loving one’s neighbor as oneself, the mercy of God, and the value of self-control are all compatible with rational living (as defined by Ellis’ Rational Emotive Behavior Therapy). Although Ellis never fails to assert the superiority of atheism, and his criteria for religionists’ mental health involve the degree to which their values parallel his, Ellis’ later thought does reflect a willingness to accept the healthiness of at least some kinds of devout religiosity. In addition, several
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religiously-active psychologists have embraced REBT, considering Ellis’ personal antireligious attitudes to be a separate issue from the therapeutic utility of his method [35, 36].
4.1.2.2
Religion as helpful
Other psychologists have been more positive in their assessment of religion. While not discounting the possibility of pathological variants of religiosity, these thinkers consider religion to be a generally positive force in people’s lives, with the corollary that when religion becomes toxic, it is due to the religionist ‘doing it wrong,’ rather than to anything inherently destructive about religion itself. This issue is addressed by Raiya, Pargament and Magyar-Russell in their chapter on religious risk factors in this volume. The authors identify four broad categories of possible ways in which religion can go wrong, resulting in poorer psychological functioning for the believer: problematic religious motivation, problematic attachment to God, problematic religious integration, and problematic ways of religious coping. One of the more prominent advocates of this view, that religion is beneficial when properly practiced, is William James. In his Varieties of Religious Experience, James considers the bigotries and barbarisms perpetrated in the name of religion, and describes them as the result, not of religion, but of the adulteration of religion with the very aggression and self-centeredness that religion is supposed to buffer against: ‘Piety is the mask, the inner force is tribal instinct’ [21]. The religious experience itself, James asserts, fundamentally consists of overcoming the ‘wrongness’ inherent to the human condition through the establishment of a proper connection to spiritual reality, and the result is a ‘new zest which adds itself like a gift to life’ and an ‘assurance of safety and a temper of peace, and, in relation to others, a preponderance of loving affections.’ The ‘healthy-minded’ are able to gratefully enjoy the universe, and the ‘sick souled’ gain the strength to face and (to some extent) conquer the darkness. Harvard psychologist Gordon Allport is known for his numerous contributions to North American psychology, and is considered a foundational figure in the fields of personality and social psychology [37, 38]. In addition to his other wide-ranging specializations, Allport was keenly interested in the role that religion plays in the life of the individual, and approached the topic both as a social scientist [39] and as a believer [40]. In The Individual and His Religion, Allport faces, as did James, the destructive forms of religion, and argues, as did James, that this is not the result of religion per se, but of an insufficiently-developed form of the religious sentiment [41]. Allport makes the distinction between what he calls ‘immature’ and ‘mature’ religiosity, and attempts to answer religion’s critics by claiming that ‘most of the criticism of religion is directed to its immature forms.’ Allport saw psychological development as a movement away from the thorough egocentrism of the infant, and described religious development along the same lines. The religion of immaturity is characterized by simplistic anthropomorphism (e.g., thinking of God as a graybearded king in the sky), magical thinking (e.g., the idea that prayer is about getting everything you ask for), and self-centeredness (e.g., the use of beliefs for self-justification or the pursuit of ‘creature comforts’). It is immature religiosity, Allport argues, that is associated with legalism, prejudice, and fanaticism. Religious maturity is accomplished when the individual moves away from seeing his or her religion in a self-serving light. The mature religionist is reflective and self-critical, developing an understanding of self, others,
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and the universe that is cohesive but well-differentiated, confident but humble, stable but progressing, and productive of a consistent morality. The recognition that one does not know everything about the universe, much less what may lie beyond the universe and beyond the grave, provides tolerance and a willingness to question one’s beliefs. This attitude is extended to one’s group, and the mature religionist is able to attain a certain autonomy from denominational pronouncements, conformity pressures, and in-group biases. Allport’s distinction between immature and mature religiosity was further developed into the concepts of Extrinsic (the one who ‘uses his religion’) and Intrinsic (the one who ‘lives his religion’) religious orientations [39], and subsequent empirical research has supported the psychological preference of Intrinsic over Extrinsic religiosity [42]. This approach has been further refined by C. Daniel Batson’s suggestion to include a Quest orientation, focusing on religion as ‘an endless process of probing and questioning generated by the tensions, contradictions, and tragedies in their own lives and in society’ that Batson claims captures Allport’s emphasis on mature religion’s humble and continuously-developing nature [43]. Dissatisfied with the Freudian emphasis on the ‘will to pleasure’ and the Adlerian ‘will to power,’ Viktor Frankl’s logotherapy, the ‘third Viennese school of psychiatry,’ emphasizes the human ‘will to meaning’ [44]. Placing himself (as did James and Allport) in opposition to the reductionism that continues to this day to permeate much of psychology, Frankl’s approach describes humans as self-transcending creatures. ‘Three factors characterize human existence as such: man’s spirituality, his freedom, his responsibility’ [45], and a psychology that denies these factors denies the humanness of humans. Guided by his clinical practice, his theoretical studies, and his experiences as a prisoner in Nazi concentration camps during World War II, Frankl’s psychology is one in which power and pleasure satisfy human longings only to the degree to which they find their proper place within a life that is given over to ‘a cause to serve or another person to love’ [13]. With the strong emphasis on finding meaning by serving something beyond the self, Frankl’s works are replete with references to religion. For Frankl, religion is one of the possiblevenues for the construction of a meaningful life, possessing enough positivepsychological power to overcome horrors such as those found in the death camps. He does not endorse any specific religion, preferring to craft his theoretical statements around the term ‘spirituality’,1 and strongly urging logotherapists to avoid any conscious attempts to guide their patients toward one belief or another. However, Frankl describes religion and psychotherapy as mutually reinforcing, as both involve coming to grips with issues such as suffering, the finiteness and transitory nature of life, and the search for ultimate meaning: ‘Although religion may not aim at mental health it might result in it. Psychotherapy, in turn, often results in an analogous byproduct; while the doctor is not, and must not be, concerned with helping the patient to regain his belief in God, time and again this is just what occurs, unintended and unexpected as it is’ [45].
4.1.3
DEFINING MENTAL HEALTH
The difficulty of establishing a clear connection between religiosity and mental health is further complicated by the lack of scholarly consensus on how to define mental health. 1
Discussion of the areas of overlap and divergence between the concepts of “religiosity” and “spirituality” is another topic, one that is due full consideration, but is beyond the scope of this chapter. Readers are directed to Hill et al.’s article for one treatment of this issue [46].
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Several different approaches to conceptualizing mental health exist, and disagreements exist within approaches. Influenced by the ‘medical model’ prevalent within psychiatry and clinical psychology, it is common to see mental health defined in terms of a relative absence of pathology [47, 48], an approach which is exemplified by Christopher Boorse’s statement that ‘an organism is healthy at any moment in proportion as it is not diseased’ [49]. However, ongoing difficulties in developing a satisfactory definition of mental illness can make this approach problematic. In the several decades that have passed since Thomas Szasz declared mental illness to be an outmoded ‘myth’ [50] many scholars have attempted to answer his challenge by providing a defensible definition. Gorenstein surveys four major lines of thought within this debate [51]. One possible way of defining mental illness is to describe it in terms of a statistical deviation from the norm. Ausubel’s early attempt to refute Szasz is an example of this line of thought [52]. Ausubel describes mental illness as a ‘gross deviation from a designated range of desirable behavioral variability,’ but this description does not answer Szasz’s charge that what we call an ‘illness’ is actually a violation of social/ethical norms. To begin with, where do we set the cutoff point between a ‘gross’ deviation (requiring clinical intervention) and a ‘sub-gross’ deviation (not requiring clinical intervention)? And by whose standards do we judge the acceptable range of variability, or which behaviors are to be considered relevant to mental health issues? A second possible way of defining mental illness is to embrace the reliance on social standards of acceptable behavior, and define a disorder in terms of social dysfunction. Heilbrun’s argument that pathological behavior and socially-undesirable behavior are ‘almost invariably’ one and the same could be considered an example of this line of thought [53]. While this approach resonates with the idea of humans as inherently social creatures [54–56], making the ability to operate in society an integral component of proper psychological functioning, critics are quick to point out the potential for oppression inherent in this approach, as well as the difficulties posed by historical changes in standards of acceptable behavior. A favorite example given by critics is drapetomania, a diagnosis proposed by nineteenth-century Louisiana physician Samuel Cartwright, in which runaway slaves were described as having an unhealthy desire for freedom [57, 58]. The decision to remove homosexuality from the DSM serves as an example of the effect of historical changes on the field of psychology. As the psychological community’s attitude toward homosexuality changed, did multitudes of homosexual individuals suddenly cease to be mentally ill? And if the psychological community were to reverse that decision, would those individuals (and those born after the original policy change) suddenly become mentally ill? A third possible way of defining mental illness is to develop a theory-driven description of psychopathology. Theoretical statements about desirable and undesirable psychological constructs such as rationality [59], existential despair [60], foolishness [61], and developmental maturity [62] can guide mental health professionals in developing a description of those who are acquiring the undesirable constructs and failing to acquire the desirable constructs. As Gorenstein points out, however, the sheer volume and variety of theoretical possibilities precludes the development of a consensus description of a mentally ill person [51]. A fourth possible way of defining mental illness is to rely upon the subjective discomfort of the individual in question. This approach fits well with the benevolent motivations of most mental health practitioners, who choose this career out of a desire to help those who are suffering, fits well with the ‘medical model’ of clinical psychology, and matches
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commonsense understandings of the difference between a psychological disorder and a mere eccentricity. However, replying upon subjective distress ascribes to the client/patient a degree of perspicaciousness that most psychologists and psychiatrists would reject. For many, a major component of their pathology is itself a lack of understanding of their condition. Those practitioners who work with sexual offenders, for example, may take exception to this approach to understanding mental dysfunction, as such perpetrators often demonstrate a substantive lack of insight into the nature of their actions and the effects of those actions on their victims [63], and a large part of the therapeutic process with this population can involve counteracting perpetrators’ self-justifying cognitive distortions [64]. Widiger and Trull admit that each of the definitional approaches described by Gorenstein is fallible, but claim that his error was in treating each approach in isolation from the others, and that ‘taken together, such indicators such indicators support the validity of the hypothetical construct’ of a mental illness [65]. Similarly, most current attempts to define mental illness are composites of several definitional criteria. Wakefield combines biomedical, social, and moral criteria in his description of a mental disorder as a ‘harmful dysfunction, wherein dysfunction is a scientific and factual term based in evolutionary biology that refers to the failure of an internal mechanism to perform a natural function for which it was designed, and harmful is a value term referring to the consequences that occur to the person because of the dysfunction and are deemed negative by sociocultural standards’ [66]. Wakefield considers this definition of mental illness to be a logical extension of medical concepts of physical disorder to the realm of the mental. Lilienfeld and Marino are among Wakefield’s most strident critics, arguing that his definition of disorder fails on several levels, and proposing that mental illness be thought of as a Roschian ‘fuzzy’ category [67]. Within this approach, multiple definitional criteria (such as those surveyed by Gorenstein) may be employed, with the understanding that these criteria represent prototypical (common, but not critical) characteristics rather than essential features, and that there is no easily-demarcated boundary between disorder and nondisorder.2 Dissatisfied with the medical model, and desiring to widen the scope of the field of mental health, some psychologists have argued that descriptions of mental illness must be augmented by descriptions of mental wellness, and that mental health professionals should expand their practice to include increasing that which is healthy about people, in addition to diminishing that which is unhealthy [68–72]. Prominent advocates of this approach are often found within the ‘positive psychology’ movement [73–76]. Beginning with Martin Seligman’s tenure as president of the American Psychological Association, this movement has been the current focus of efforts to bring the same empirical rigor and institutional support that clinical psychology has enjoyed to bear on issues of positive psychological functioning in individuals [77, 78], groups [79], and societies [80]. Positive psychology, it should be noted, should not be thought of as a monolithic and uniform ‘school’ of psychology, but rather as an ‘umbrella term’ under which may be found a heterogeneous set of researchers giving thought to the psychological aspects of ‘the good life’ [81, 82]. As such (and keeping in mind that not all who examine positive mental health consider themselves members of the positive psychology movement), the reader will find as much debate over the nature of mental health as can be found over the nature of mental illness. 2 For further debate over Wakefield’s approach to the concept of mental disorder, see the Special Section in the August 1999 issue of the Journal of Abnormal Psychology.
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One of the major conceptual divisions that may be found is a distinction between ‘hedonic’ and ‘eudaimonic’ approaches to positive psychological functioning [83]. Within the ‘hedonic’ approach, well-being is defined in terms of the amount of subjective happiness experienced by the person in question. The ongoing work of Ed Diener and colleagues on subjective well-being may be considered one of the more prominent lines of research in this approach to mental health [84–87]. Subjective well-being refers to individuals’ evaluations of their lives, including such areas as work, leisure, love, and relative amounts of positive and negative emotional experiences [88], and at it’s simplest level, is most people’s commonsense understanding of what is meant by the question ‘how are you?’. In addition to its commonsense appeal, this approach to positive well-being is attractive to those who wish to emphasize the variability that exists between individuals and between societies when it comes to questions of what makes a life good, and wish to eschew claims to a universally-applicable definition of mental health. The ‘eudaimonic’ approach downplays the importance of the individual’s subjective evaluation, concurring with Alasdair MacIntyre’s neo-Aristotelian emphasis on ‘a crucial distinction between what any particular individual at any particular time takes to be good for him and what is really good for him as a man’ [89]. Instead, positive psychological functioning is approached in terms of an ideal human life, described in terms of ‘flourishing’ [90], ‘optimal functioning’ [91], ‘fulfillment in living’ [92], and/or the cultivation of the virtues: those excellent character traits found in a highly-functioning person [93–95]. While hedonic enjoyment and eudaimonic flourishing may often co-occur, the stronger emphasis is placed on personal growth and the pursuit of a meaningful life, with subjective happiness findings its place as an outcome of the good life, rather than the good life itself. The recent publication of the APA Dictionary of Psychology will likely be of little help in these discussions [96]. The stated purpose of the dictionary is ‘not to limit the vocabulary, but rather, to delineate the current and evolving understanding of the language used within the field’ of psychology. However, the debate and controversy surrounding the meanings of many terms are not always reflected in this dictionary’s definitions, some of the definitions are simplistic, and some do not accurately reflect common usage of the term within the psychological literature. The definition presented for ‘religiosity,’ for example, is ‘pious, exaggerated religious zeal.’ This definition only seems to fit the use of the term ‘religiosity’ employed by Albert Ellis during the 1980s and early 1990s, and does not reflect how the term is commonly used by psychologists of religion [30, 97–99]. Even definitions in which the APA Dictionary presents an acceptable composite of scholars’ viewpoints (e.g., the definition of ‘mental health’) could be troublesome, as there is a danger of treating this dictionary as authoritative. Rather than delving into the literature covering definitional possibilities, researchers and mental health professionals may be tempted to simply ‘look it up’ and proceed with an oversimplified or unrepresentative definition, a practice that is already too common among researchers and mental health professionals [100].
4.1.4 EMPIRICAL EXAMINATIONS OF RELIGION AND MENTAL HEALTH In empirical studies of this topic, conceptual differences in the meaning of ‘religion’ and of ‘mental health’ cannot help but impact the manner in which researchers carry out their investigations. Specifically, empirical inquiry in this topic most commonly takes the form of
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a correlational study, in which participants’ scores on some indicator of religiosity are compared against their scores on some indicator of mental health, and researchers’ choice of indicator is guided by their (either explicit or implicit) ideas about what religion and mental health are. Researchers studying religion and mental health who are guided by the idea that religion is fundamentally a matter of participation in a social organization are less likely to use established measures of religiosity, preferring to rely on either single items or a small set of items such as frequency of church attendance, observance of rituals, participation in public prayer, or formal affiliation with a religious organization. Examples of this approach include the research of Anson, Antonovsky & Sagy [101], Braam, Beekman, van Tilburg, Deeg & van Tilburg [102], and Williams, Larson, Buckler, Heckmann & Pyle [103]. Within this volume, this conceptualization of religion may be seen in Eurlings-Bontekoe and Luyten’s chapter, in which they examine the relationship between religion and mental health in terms of denominational affiliation. Researchers who are guided by a cognitive view of religion as a set of ideological beliefs or interpretive schemata are more likely to use measures of religiosity such as the Religious World View Scale [104] or the Belief in Divine Intervention Scale [105]. The influence of this understanding of religion may be seen in studies such as those conducted by Blaine & Crocker [106], Dorahy and colleagues [107], and Flannelly, Koenig, Ellison, Galek & Krause [108]. Emphasizing personal devotion, intrinsic orientation, and other emotionally-intensive approaches to religion would lead researchers toward measures of religiosity such as the Christian Religious Internalization Scale [109] or Allport & Ross’ Religious Orientation Scale [39]. Examples of this approach include the work of Bienenfeld, Koenig, Larson & Sherrill [110], Genia & Shaw [111], and Wright, Frost & Wisecarver [112]. Readers are directed to Hill & Hood’s outstanding volume [99] for a much more comprehensive presentation of available measurement options. Researchers studying religion and mental health who emphasize the reduction of pathology in their understanding of mental health are likely to choose a measure of a specific form of psychological disturbance, such as some variant of the Beck Depression Inventory [113] or the General Health Questionnaire [114]. Examples of this pathologycentered approach include the studies conducted by Braam et al. [102], Genia & Shaw [113], and Williams et al. [103]. Those who wish to examine the positive side of psychological functioning, preferring a hedonic definition of positive mental health, would be likely to employ a measure of life satisfaction [115] or subjective well-being [87] as their indicators of choice. Bergan & McConatha [116], Lewis, Lanigan, Joseph & Fockert [117], and Peacock & Poloma [118] serve as examples of this approach. Those who prefer a eudaimonic conceptualization of mental health would choose a measure of flourishing such as self-actualization [119] or existential well-being (e.g., the existential subscale of the Spiritual Well-Being Scale [120]) or a specific virtue or set of character strengths [94]. This approach to mental health can be seen in the work of French & Joseph [121], Rasmussen & Charman [122], and Ryan, Rigby & King [109].
4.1.4.1
Meta-analysis as a disambiguatory tool
Methodological differences such as these may be one of the reasons for the ambiguous nature of the empirical literature on the connection between religiosity and mental health [123]. One possible way of providing some clarity to this field may be to employ
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the tools of meta-analysis. Glass, McGraw & Smith define meta-analysis as ‘the statistical analysis of the summary findings of many empirical studies’ [124]. The quantitative results of numerous studies are converted into a common effect-size metric, and the sample of effect sizes forms a data set, which is then analyzed. This methodological approach allows researchers to quantitatively examine bodies of research, permitting empirically-supportable descriptions of the overall size of an established effect, or of observable patterns between different types of studies.3 Meta-analyses have been used, for example, to examine the effectiveness of therapeutic interventions [126], to compare the merits of different research methods [127], and to advance discussion toward the resolution of contentious social issues [128, 129]. Despite the potential value of this tool, meta-analysis has been under-utilized by psychologists who study religion. Focusing specifically on the connection between religiosity and mental health, a search of the psychological literature4 reveals only three published meta-analytic examinations of this topic. The first of these meta-analyses was conducted by Allen Bergin [97]. Bergin’s analysis of 24 studies published prior to 1980 focused on correlations between religiosity and measures of ‘clinical pathology.’ Of the effect sizes examined, only seven were statistically significant, two of which were negative in nature (higher levels of religiosity associated with poorer mental health) and five were positive (higher levels of religiosity associated with better mental health). On balance, Bergin found only a modest overall relationship between religiousness and better mental health (r ¼ 0.09). That the relationship should consistently be modest across studies is by no means an indictment of the psychological significance of religion, given the substantial number of other variables in a person’s life that can impact their psychological functioning. Bergin draws from the theoretical literature on the multidimensional nature of religion to explain the diversity of findings, suggesting that the various components of religiosity might be organized hierarchically, with a general (‘g’) factor and several specific (‘s’) factors. Witter, Stock, Okun and Haring focused on religiosity and subjective well-being, metaanalyzing the results of 28 studies [130]. Similar to Bergin’s examination, a moderate overall relationship was found (0.16). This meta-analysis did explore the possibility that different approaches to measuring religiousness and subjective well-being may influence the results, differentiating between measures of ‘religious activity’ (e.g., church attendance) and ‘religiosity’ (e.g., self-reported importance of religion), and between five ways of measuring positive psychological functioning (life satisfaction, morale, well-being, quality of life, and happiness). A significant difference was found between measures of religiosity (0.13 for religiosity and 0.18 for religious activity), but not for different approaches to subjective well-being. After an intermission of nearly two decades, Glenn Sanders and I meta-analyzed data from a sample of 35 studies, specifically addressing the topic of definitions of religiosity and mental health [30]. Like the previous two meta-analyses, a moderate positive overall relationship was found (0.10) between religiosity and mental health. Definitions of religiosity were categorized either as institutional (e.g., church attendance), as ideological (e.g., orthodoxy), or in terms of personal devotion (e.g., religious internalization). Definitions of mental health were categorized into indicators of psychological distress (e.g., 3
For a meta-analysis of epic proportions, see Richard, Bond & Stokes-Zoota’s study [125]. Employing the PsycINFO and Academic Search Premiere databases, using the keywords ‘meta-analysis’ and ‘religion,’ ‘religiosity,’ and ‘religiousness.’ 4
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depression), life satisfaction (e.g., subjective well-being), or self-actualization (e.g., a sense of purpose in life). The average affect size was significantly impacted by both the adoption of different definitions of religiosity and the adoption of different definitions of mental health by the researchers. Depending on what combination of definitions were employed, the relationships between religiosity and mental health were either negative (a mean effect size of 0.03 for the relationship between institutional religion and the amelioration of psychological distress), non-significant (ideological religion and psychological distress), or positive (the mean effect size statistic of the strongest positive relationship was 0.32, between religious devotion and self-actualization). These results illustrate the considerable impact of definitional issues on scientific examinations of this subject.
4.1.5
IMPLICATIONS FOR RESEARCH AND PRACTICE
The multidimensional nature of religion and mental health is reflected in studies such as Frazier, Mintz and Mobley’s [131]. In this study, the authors employed a three-dimensional approach to religion (organizational, non organizational, and subjective religiosity) and a six-dimensional approach to mental health (self-acceptance, positive relations with others, autonomy, environmental mastery, purpose in life, and personal growth), allowing the researchers to examine the possibility that certain forms of religion may have stronger or weaker relationships with specific forms of mental health. The World Health Organization’s work on religion and quality of life, using the WHOQOL-SRPB instrument [132] also takes a multidimensional approach, assessing mental health in terms of personal satisfaction (e.g., item F4.1, ‘How much do you enjoy life?’) and distress (e.g., item F8.3, ‘How much do any feelings of sadness or depression interfere with your everyday functioning?’), and religiosity in terms of beliefs (e.g., item F24.2, ‘To what extent do you feel your life to be meaningful?’), spirituality (e.g., item SP1.4, ‘To what extent does any connection to a spiritual being provide you with comfort/reassurance?’), and religious affiliation. While projects such as this are indicators that progress is occurring, the majority of empirical studies continue to make use of oversimplified measures of global religiousness [100]. Future researchers who wish to examine the relationship between religiosity and mental health are encouraged to either employ a multidimensional approach or, if they wish to focus their inquiry on one specific form of religion, avoid generalizing their findings to all forms of religion. Another area of inquiry that reveals only the beginnings of progress is the examination of non-Christian religions. While some scholars have examined the relationship between religion and mental health among faith traditions such as Islam [133, 134],5 Unitarian Universalism [135], and Baha’ı [136], the great majority of studies have focused exclusively on Christian, and to a lesser degree, Jewish, participants. The narrowness of this field of inquiry creates limits on our ability to generalize findings beyond Christianity, prevents researchers from knowing whether or not we have discovered a pattern that is common to most faiths or restricted to Christian adherents, and impairs health professionals’ ability to effectively assist those who belong to non-Christian and/or non-Western traditions [137, 138]. 5
See also the September 2007 and March 2008 issues of the Journal of Muslim Mental Health, which focus specifically on measurement issues.
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Providing mental health services that are sensitive to clients’ religious and spiritual traditions is a recurring theme in the literature on multicultural issues in psychology and psychiatry [139], and religious variables may have an impact on the therapeutic process [140, 141], making it important that mental health professionals develop approaches to training and practice that permit the addressing of religious issues in a manner that is professional and beneficial. Shafranske and Malony encourage psychologists to cultivate an appreciation for religion within their practices, one that is neither simplistically negative nor simplistically positive when it comes to the relationship between religion and mental health [142]. Some forms of religion may be toxic, some helpful, as we see in Rayia, Pargament and Magyar-Russel’s chapter in this volume. Clinicians are encouraged to learn which elements in the client’s spiritual life to employ as therapeutic resources, and which to redirect into healthier forms. Increasing the sophistication with which we approach topics such as religion and mental health can provide benefits beyond the individual therapeutic relationship. As many of the contentious issues that our societies face involve religion, mental health professionals often find themselves in dialogue with clergy and other types of religious professionals. Increasing psychologists’ and psychiatrists’ knowledge of the multidimensional nature of religion could do much to advance this dialogue. And on a more public level, debates on religious issues are often characterized by sadly simplistic conceptions of religion, resulting in immaturity and condemnations on all sides of these arguments. If the fields of psychology and psychiatry exist in a mutually-respectful, constructive, and conceptually-sophisticated dialogue with the world’s religions, and present messages that show a deeper comprehension of these traditions, the effect could be to encourage a more reasonable tone in these discussions. One critical tool in all these processes is to develop a greater awareness and sensitivity to the wide variety of meanings that any given individual may attach to the word ‘religion,’ the multifaceted nature of ‘mental health,’ and the complexity of the relationship between these concepts.
REFERENCES 1. Paul R (1992) Critical Thinking: What Every Person Needs to Survive in a Rapidly Changing World, 2nd edn. Foundation for Critical Thinking, Dillon Beach, CA. 2. Gonzalez JL (1984) The Story of Christianity, Volume 1: The Early Church to the Dawn of the Reformation. HarperCollins, New York. 3. Jones DG (2004) The emergence of persons. In: Jeeves M (ed.) From Cells to Souls—and Beyond: Changing Portraits of Human Nature. William B. Eerdmans Publishing Company, Grand Rapids, MI, pp. 11–33. 4. Stoller RJ, Marmor J, Bieber I, Gold R, Socarides CW, Green R, & Spitzer R. (1973) A symposium: should homosexuality be in the APA nomenclature? American Journal of Psychiatry, 130, 1207–1216. 5. Spitzer RL (1981) The diagnostic status of homosexuality in DSM-III: a reformulation of the issues. American Journal of Psychiatry, 138, 210–215. 6. Lubinski D (2004) Introduction to the special section on cognitive abilities: 100 years after Spearman’s (1904) “General intelligence,’ objectively determined and measured’. Journal of Personality and Social Psychology, 86, 96–111. 7. Yinger JM (1967) Pluralism, religion, and secularism. Journal for the Scientific Study of Religion, 6, 17–28.
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8. Kant I (1960) Religion Within the Limits of Reason Alone, 2nd edn (Greene TM & Hudson HH, trans.). Open Court Publishing, La Salle, IL. (Original work published 1793). 9. Schleiermacher F (1958) On Religion: Speeches to its Cultured Despisers (Oman J, trans.). Harper & Row, New York. (Original work published 1799). 10. Marx K & Engels F (1968) The German Ideology (Ryazanskaya S, trans.). Progress Publishers, Moscow. (Original work published 1888). 11. Durkheim E (1915) The Elementary Forms of the Religious Life (Swain JW, trans.). The Free Press, New York. 12. Watson JB & McDougall W (1928) The Battle of Behaviorism: An Exposition and Exposure. Kegan Paul, Trench, Trubner & Co., Ltd, London. 13. Frankl VE (1984) Man’s Search for Meaning: An Introduction to Logotherapy, 3rd edn. Simon & Schuster, New York. 14. Walsh BJ & Middleton JR (1984) The Transforming Vision: Shaping a Christian World View. InterVarsity Press, Downers Grove, IL. 15. Wolters AM (1985) Creation Regained. William B. Eerdmans Publishing Company, Grand Rapids, MI. 16. Naugle DK (2002) Worldview: The History of a Concept. William B. Eerdmans Publishing Company, Grand Rapids, MI. 17. Murphy N (1997) Using MacIntyre’s method in Christian ethics. In: Murphy N, Kallenberg BJ, & Nation MT (eds.) Virtues and Practices in the Christian Tradition: Christian Ethics After MacIntyre. Trinity Press International, Harrisburg, PA, pp. 30–44. 18. Swearer DK (1998) Buddhist virtue, voluntary poverty, and extensive benevolence. Journal of Religious Ethics, 26, 71–103. 19. Slingerland E (2001) Virtue ethics, the Analects, and the problem of commensurability. Journal of Religious Ethics, 29, 97–125. 20. Leuba JH (1912) A Psychological Study of Religion. Macmillan, New York. 21. James W (1983) The Varieties of Religious Experience: A Study in Human Nature. Penguin Putnam, New York. (Original work published 1902). 22. Vetter GB (1959) Magic and Religion: Their Psychological Nature Origin and Function. Vision Press Limited, London. 23. Cantwell SW (1962) The Meaning and End of Religion: A New Approach to the Religious Traditions of Mankind. The Macmillan Company, New York. 24. McKinnon AM (2002) Sociological definitions, language games, and the ‘essence’ of religion. Method & Theory in the Study of Religion, 14, 61–83. 25. Freud S (1989) The Future of an Illusion (Strachey J, trans.). W. W. Norton & Company, New York. (Original work published 1927). 26. Meissner WW (1984) Psychoanalysis and Religious Experience. Yale University Press, New Haven, CT. 27. Burnham JC (1985) The encounter of Christian theology with deterministic psychology and psychoanalysis. Bulletin of the Menninger Clinic, 49, 321–352. 28. Wallwork E & Wallwork AS (1990) Psychoanalysis and religion: current status of an old antagonism. In: Smith JH & Handelman SA (eds.) Psychoanalysis and Religion. The John Hopkins University Press, Baltimore, MD, pp. 160–173. 29. Bergin AE (1991) Values and religious issues in psychotherapy and mental health. American Psychologist, 46, 394–403. 30. Hackney CH & Sanders GS (2003) Religiosity and mental health: a meta-analysis of recent studies. Journal for the Scientific Study of Religion, 42, 43–55. 31. Ellis A (1960) There is no place for the concept of sin in psychotherapy. Journal of Counseling Psychology, 7, 188–192. 32. Ellis A (1980) Psychotherapy and atheistic values: a reply to A. E. Bergin’s ‘Psychotherapy and religious values.’ Journal of Consulting and Clinical Psychology, 48, 635–639.
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33. Ellis A (1992) Do I really hold that religiousness is irrational and equivalent to emotional disturbance? American Psychologist, 47, 428–429. 34. Ellis A (2000) Can rational emotive behavior therapy (REBT) be effectively used with people who have devout beliefs in God and religion? Professional Psychology: Research and Practice, 31, 29–33. 35. Nielsen SL (1994) Rational-emotive behavior therapy and religion: don’t throw the therapeutic baby out with the holy water! Journal of Psychology and Christianity, 13, 312–322. 36. Johnson WB, Nielsen SL & Ridley CR (2000) Religiously sensitive rational emotive behavior therapy: elegant solutions and ethical risks. Professional Psychology, Research and Practice, 31, 14–20. 37. Pettigrew TF (1969) Gordon William Allport: 1897–1967. Journal of Personality and Social Psychology, 12, 1–5. 38. Nicholson IAM (1998) Gordon Allport, character, and the ‘culture of personality,’ 1897–1937. History of Psychology, 1, 52–68. 39. Allport GW & Ross JM (1967) Personal religious orientation and prejudice. Journal of Personality and Social Psychology, 5, 432–443. 40. Allport GW (1978) Waiting for the Lord: 33 Meditations on God and Man ( Bertocci PA, ed.). Macmillan Publishing Co, New York. 41. Allport GW (1950) The Individual and His Religion: A Psychological Interpretation. Macmillan Publishing Co, New York. 42. Donahue MJ (1985) Intrinsic and extrinsic religiousness: review and meta-analysis. Journal of Personality and Social Psychology, 48, 400–419. 43. Batson CD (1976) Religion as prosocial: agent or double agent? Journal for the Scientific Study of Religion, 15, 29–45. 44. Frankl VE (1969) The Will to Meaning. The New American Library, Inc, New York. 45. Frankl VE (1969) The Doctor and the Soul (Winston R, & Winston C, trans.). Bantam Books, New York. (Original work published 1946). 46. Hill PC, Pargament KI, Hood RW, McCullough ME, Swyers JP, Larson DB, & Zinnbauer BJ (2000) Conceptualizing religion and spirituality: points of commonality, points of departure. Journal for the Theory of Social Behaviour, 30, 51–77. 47. Albee GW (2000) The Boulder model’s fatal flaw. American Psychologist, 55, 247–248. 48. Maddux JE (2005) Stopping the ‘madness’: positive psychology and the deconstruction of the illness ideology and the DSM. In: Snyder CR & Lopez SJ (eds.) Handbook of Positive Psychology. Oxford University Press, New York, pp. 13–25. 49. Boorse C (1976) What a theory of mental health should be. Journal for the Theory of Social Behaviour, 6, 61–84. 50. Szasz TS (1960) The myth of mental illness. American Psychologist, 15, 113–118. 51. Gorenstein EE (1984) Debating mental illness: implications for science, medicine, and social policy. American Psychologist, 39, 50–56. 52. Ausubel DP (1961) Personality disorder is disease. American Psychologist, 16, 69–74. 53. Heilbrun AB (1964) Social-learning theory, social desirability, and the MMPI. Psychological Bulletin, 61, 377–387. 54. MacIntyre A (1999) Dependant Rational Animals: Why Human Beings Need the Virtues. Open Court, Chicago. 55. Foot P (2001) Natural Goodness. Clarendon Press, Oxford. 56. Berscheid E (2002) The human’s greatest strength: other humans. In: Aspinwall LG, & Staudinger UM (eds.) A Psychology of Human Strengths: Fundamental Questions and Future Directions for a Positive Psychology. American Psychological Association, Washington, DC, pp. 37–47. 57. Cartwright SA (1851) Report on the diseases and physical peculiarities of the Negro race. The New Orleans Medical and Surgical Journal, 7, 691–715.
4.1
RELIGION AND MENTAL HEALTH
357
58. Bynum B (2000) Discarded diagnoses. Lancet, 356, 1615. 59. Ellis AE & Harper RA (1961) A Guide to Rational Living. Prentice-Hall, Inc, Englewood Cliffs, NJ. 60. Simon L, Arndt J, Greenberg J, Pyszczynski T & Solomon S (1998) Terror management and meaning: evidence that the opportunity to defend the worldview in response to mortality salience increases the meaningfulness of life in the mildly depressed. Journal of Personality, 66, 359–382. 61. Sternberg RJ (2004) Why smart people can be so foolish. European Psychologist, 9, 145–150. 62. Loevinger J (1966) The meaning and measurement of ego development. American Psychologist, 21, 195–206. 63. Langevin R & Lang RA (1985) Psychological treatment of pedophiles. Behavioral Sciences and the Law, 3, 403–419. 64. Duehn WD (1994) Cognitive-behavioral approaches in the treatment of the child sex offender. In: Granvold DK (ed.), Cognitive and Behavioral Treatment: Methods and Applications. Brooks/Cole Publishing Company, Pacific Grove, CA, pp. 125–134. 65. Widiger TA &Trull TJ (1985) The empty debate over the existence of mental illness: comments on Gorenstein. American Psychologist, 40, 468–470. 66. Wakefield JC (1992) The concept of a mental disorder: on the boundary between biological facts and social values. American Psychologist, 47, 373–388. 67. Lilienfeld SO & Marino L (1995) Mental disorder as a Roschian concept: a critique of Wakefield’s ‘harmful dysfunction’ analysis. Journal of Abnormal Psychology, 104, 411–420. 68. Smith MB (1959) Research strategies toward a conception of positive mental health. American Psychologist, 14, 673–681. 69. Blatt SJ (1964) An attempt to define mental health. Journal of Counseling Psychology, 28, 146–153. 70. Witmer JM & Sweeney TJ (1992) A holistic model for wellness and prevention over the life span. Journal of Counseling and Development, 71, 140–148. 71. Ryff CD & Singer B (1998) The contours of positive human health. Psychological Inquiry, 9, 1–28. 72. Keyes CLM & Lopez SJ (2005) Toward a science of mental health. In: Snyder CR & Lopez SJ (eds.) Handbook of Positive Psychology. Oxford University Press, New York, pp. 45–62. 73. Seligman MEP & Csikszentmihalyi M (2000) Positive psychology: an introduction. American Psychologist, 55, 5–14. 74. Aspinwall LG & Staudinger UM (eds.) (2002) A Psychology of Human Strengths: Fundamental Questions and Future Directions for a Positive Psychology. American Psychological Association, Washington, DC. 75. Linley PA & Joseph S (2004) Positive Psychology in Practice. John Wiley & Sons, Inc, Hoboken, NJ. 76. Snyder CR & Lopez SJ (eds.) (2005) Handbook of Positive Psychology. Oxford University Press, New York. 77. Seligman MEP (2002) Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment. Free Press, New York. 78. Biwas-Diener R & Dean B (2007) Positive Psychology Coaching: Putting the Science of Happiness to Work for Your Clients. John Wiley & Sons, Inc, Hoboken, NJ. 79. Cameron KS, Bright D & Caza A (2004) Exploring the relationships between organizational virtuousness and performance. American Behavioral Scientist, 47, 766–790. 80. Myers DG (2004) Human connections and the good life: balancing individuality and community in public policy. In: Linley PA & Joseph S (eds.), Positive Psychology in Practice. John Wiley & Sons, Inc, Hoboken, NJ, pp. 641–657. 81. Peterson C & Park N (2003) Positive psychology as the evenhanded positive psychologist views it. Psychological Inquiry, 14, 143–147.
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RESEARCH ISSUES
82. Bacon SF (2005) Positive psychology’s two cultures. Review of General Psychology, 9, 181–192. 83. Ryan RM & Deci EL (2001) On happiness and human potentials: a review of research on hedonic and eudaimonic well-being. Annual Review of Psychology, 52, 141–166. 84. Diener E (1984) Subjective well-being. Psychological Bulletin, 95, 542–575. 85. Diener E & Oishi S (2005) The nonobvious social psychology of happiness. Psychological Inquiry, 16, 162–167. 86. Diener E., Sapyta JJ & Suh E (1998) Subjective well-being is essential to well-being. Psychological Inquiry, 9, 33–37. 87. Sandvik E, Diener E & Seidlitz L (1993) Subjective well-being: the convergence and stability of self-report and non-self-report measures. Journal of Personality, 61, 317–342. 88. Diener E (2000) Subjective well-being: the science of happiness and a proposal for a national index. American Psychologist, 55, 34–43. 89. MacIntyre A (1984) After Virtue, 2nd edn. University of Notre Dame Press, Notre Dame, IN. 90. Gable SL & Haidt J (2005) What (and why) is positive psychology? Review of General Psychology, 9, 103–10. 91. King LA, Eells JE & Burton CM (2004) The good life, broadly and narrowly considered. In Linley PA & Joseph S (eds.), Positive Psychology in Practice John Wiley & Sons, Hoboken, NJ, pp. 35–52. 92. Waterman AS (1993) Two conceptions of happiness: contrasts of personal expressiveness (eudaimonia) and hedonic enjoyment. Journal of Personality and Social Psychology, 64, 678–691. 93. Nussbaum MC (2001) The Fragility of Goodness: Luck and Ethics in Greek Tragedy and Philosophy, revised. Cambridge University Press, Cambridge, UK. 94. Peterson C & Seligman MEP (2004) Character Strengths and Virtues: A Handbook and Classification. American Psychological Association, Washington, DC. 95. Fowers B (2005) Virtue and Psychology: Pursuing Excellence in Ordinary Practices. American Psychological Association, Washington, DC. 96. American Psychological Association (2007) APA Dictionary of Psychology. American Psychological Association, Washington, DC. 97. Bergin AE (1983) Religiosity and mental health: a critical reevaluation and meta-analysis. Professional Psychology: Research and Practice, 14, 170–184. 98. Granqvist P, Ivarsson T, Broberg AG & Hagekull B (2007) Examining relations among attachment, religiosity, and new age spirituality using the adult attachment interview. Developmental Psychology, 43, 590–601. 99. Hill PC & Hood RW (eds.) (1999) Measures of Religiosity. Religious Education Press, Birmingham, AL. 100. Hill PC & Pargament KI (2003) Advances in the conceptualization and measurement of religion and spirituality. American Psychologist, 58, 64–74. 101. Anson O, Antonovsky A & Sagy S (1990) Religiosity and well-being among retirees: a question of causality. Behavior, Health, and Aging, 1, 85–97. 102. Braam AW, Beekman ATF, van Tilburg TG, Deeg DJH & van Tilburg W (1997) Religious involvement and depression in older Dutch citizens. Social Psychiatry and Psychiatric Epidemiology, 32, 284–291. 103. Williams DR, Larson DB, Buckler RE, Heckmann RC & Pyle CM (1991) Religion and psychological distress in a community sample. Social Science and Medicine, 32, 1257–1262. 104. Jennings FL (1972) A note on the reliability of several belief scales. Journal for the Scientific Study of Religion, 11, 157–164. 105. Degelman D & Lynn D (1995) The development and preliminary validation of the belief in divine intervention scale. Journal of Psychology and Theology, 23, 37–44. 106. Blaine B & Crocker J (1995) Religiousness, race, and psychological well-being: exploring social psychological mediators. Personality and Social Psychology Bulletin, 21, 1031–1041.
4.1
RELIGION AND MENTAL HEALTH
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107. Dorahy MJ, Lewis CA, Schumacker JF, Akuamoah-Boateng R, Duze & Sibiya TE (1998) A cross-cultural analysis of religion and life satisfaction. Mental Health, Religion & Culture, 1, 37–43. 108. Flannelly KJ, Koenig HG, Ellison CG, Galek K & Krause NK (2006) Belief in life after death and mental health: findings from a national survey. The Journal of Nervous and Mental Disease, 194, 524–529. 109. Ryan RM, Rigby S & King K (1993) Two types of religious internalization and their relations to religious orientations and mental health. Journal of Personality and Social Psychology, 65, 586–596. 110. Bienenfeld D, Koenig HG, Larson F DB & Sherrill KA (1997) Psychosocial predictors of mental health in a population of elderly women. The American Journal of Geriatric Psychiatry, 5, 43–53. 111. Genia V & Shaw DG (1991) Religion, intrinsic-extrinsic orientation, and depression. Review of Religious Research, 32, 274–283. 112. Wright LS, Frost CJ & Wisecarver SJ (1993) Church attendance, meaningfulness of religion, and depressive symptomatology among adolescents. Journal of Youth and Adolescence, 22, 559–568. 113. Stapleton LM, Sander JB & Stark KD (2007) Psychometric properties of the Beck depression inventory for youth in a sample of girls. Psychological Assessment, 19, 230–235. 114. Hardy GE, Shapiro DA, Haynes CE & Rick JE (1999) Validation of the general health questionnaire-12 using a sample of employees from England’s health care services. Psychological Assessment, 11, 159–165. 115. Diener E, Emmons RA, Larsen RJ & Griffin S (1985) The satisfaction with life scale. Journal of Personality Assessment, 49, 71–75. 116. Bergan A & McConatha JT (2000) Religiosity and life satisfaction. Activities, Adaptation, & Aging, 24, 23–34. 117. Lewis CA, Lanigan C, Joseph S & de Fockert J (1997) Religiosity and happiness: no evidence for an association among undergraduates. Personality and Individual Differences, 22, 119–121. 118. Peacock JR & Poloma MM (1999) Religiosity and life satisfaction across the life course. Social Indicators Research, 48, 321–345. 119. Jones A & Crandall R (1986) Validation of a short index of self-actualization. Personality and Social Psychology Bulletin, 12, 63–73. 120. Ellison CW (1983) Spiritual well-being: conceptualization and measurement. Journal of Psychology and Theology, 11, 330–340. 121. French S & Joseph S (1999) Religiosity and its association with happiness, purpose in life, and self-actualisation. Mental Health, Religion & Culture, 2, 117–120. 122. Rasmussen L & Charman T (1995) Personality and religious beliefs: a test of Flugel’s superego projection theory. The International Journal for the Psychology of Religion, 5, 109–117. 123. Gartner J, Larson DB & Allen GD (1991) Religious commitment and mental health: a review of the empirical literature. Journal of Psychology and Theology, 19, 6–25. 124. Glass GV, McGraw B & Smith ML (1981) Meta-analysis in Social Research. SAGE Publications, Newbury Park, CA. 125. Richard FD, Bond Jr. CF & Stokes-Zoota JJ (2003) One hundred years of social psychology quantitatively described. Review of General Psychology, 7, 331–363. 126. Lipsey MW & Wilson DB (1993) The efficacy of psychological, educational, and behavioral treatment: confirmation from meta-analysis. American Psychologist, 48, 1181–1209. 127. Anderson CA, Lindsay JJ & Bushman BJ (1999) Research in the psychological laboratory: truth or triviality? Current Directions in Psychological Science, 8, 3–9. 128. Gershoff ET (2002) Corporal punishment by parents and associated child behaviors and experiences: a meta-analytic and theoretical review. Psychological Bulletin, 128, 539–579.
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129. Baumrind D, Larzelere RE & Cowan PA (2002) Ordinary physical punishment: is it harmful? Comment on Gershoff (2002). Psychological Bulletin, 128, 580–589. 130. Witter RA, Stock WA, Okun MA & Haring MJ (1985) Religion and subjective well-being: a quantitative synthesis. Review of Religious Research, 26, 332–342. 131. Frazier C, Mitz LB & Mobley M (2005) A multidimensional look at religious involvement and psychological well-being among urban elderly African Americans. Journal of Counseling Psychology, 52, 583–590. 132. World Health Organization (2002) WHOQOL Spirituality, Religiousness and Personal Beliefs (SRPB) Field Test Instrument. Retrieved November 5, 2008 from http://www.who.int/ mental_health/media/en/622.pdf. 133. Chaaya M, Sibai AM, Fayad R & El-Roueiheb Z (2007) Religiosity and depression in older people: evidence from underprivileged refugee and non-refugee communities in Lebanon. Aging & Mental Health, 11, 37–44. 134. Hassouneh DM & Kulwicki A (2007) Mental health, discrimination, and trauma in Arab Muslim women living in the US: a pilot study. Mental Health, Religion & Culture, 10, 257–262. 135. Elliott M & Hayward RD (2007) Religion and well-being in a church without a creed. Mental Health, Religion & Culture, 10, 109–126. 136. Maloney M (2006) Polishing the mirror: mental health from a Baha’ı perspective. Journal of Religion and Health, 45, 405–418. 137. Scotton BW (1998) Treating Buddhist patients. In: Koenig HG (ed.) Handbook of Religion and Mental Health. Academic Press, San Diego, CA, pp. 263–270. 138. Somajai A & Chaipoom A (2006) Psychosocial needs of women with cancer of the reproductive system: a comparison between Buddhist and Muslim patients in Thailand. Mental Health, Religion & Culture, 9, 379–388. 139. Sue DW, Bingham RP, Porche-Burke L &Vasquez M (1999) The diversification of psychology: a multicultural revolution. American Psychologist, 54, 1061–1069. 140. Bergin AE, Payne IR & Richards PS (1996) Values in psychotherapy. In: Shafranske EP (ed.) Religion and the Clinical Practice of Psychology. American Psychological Asociation, Washington, DC, pp. 297–325. 141. Worthington Jr. EL, Kurusu TA, McCullough ME & Sandage SJ (1996) Empirical research on religion and psychotherapeutic processes and outcomes: a 10-year review and research prospectus. Psychological Bulletin, 119, 448–487. 142. Shafranske EP & Malony HN (1996) Religion and the clinical practice of psychology: a case for inclusion. In: Shafranske EP (ed.) Religion and the Clinical Practice of Psychology. (pp. 561–586). American Psychological Association, Washington, DC, pp. 561–586.
CHAPTER 4.2
A Moment of Anger, a Lifetime of Favor: Image of God, Personality, and Orthodox Religiosity Elisabeth H.M. Eurelings-Bontekoe Associate Professor of Clinical Psychology, The Netherlands
Hanneke Schaap-Jonker Lecturer in Psychology of Religion, The Netherlands
4.2.1
INTRODUCTION
‘His anger endures but a moment, but his favor is for a lifetime’ sings the psalmist in Psalm 30 about God. In his opinion, God is both the one who can get angry and wrathful when people trespass against his rules, hiding his face from them, and the one who can save them from evil, supporting and helping people as a loving God. Orthodox Protestant people in the Netherlands are used to singing only psalms in their worship services. Recent studies have shown that their faith experience corresponds to the line that is cited in the title of this chapter. Furthermore, empirical research on the relationship between orthodox religiosity and self-control on the one hand and impulsivity on the other suggests that this line can be applied to the personalities of these orthodox-reformed individuals themselves, as orthodox religiosity seems to repress the manifestation and/or acting out of anger. In this chapter, the relationship between orthodox religiosity, personality, and the image of God will be described against the background of mental health and religious denomination. Section one describes studies on the image of God, both in normal and in psychiatric patients. These studies show that there are three distinct determinants of the image of God: personality pathology, psychological distress and religious culture. In addition, this section focuses on the determinants of religious struggle.
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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Section two summarizes the results of a study addressing the differential effects of orthodox religious denomination and orthodox religious upbringing on the manifestation of B cluster personality pathology and structural borderline personality pathology, among a sample that largely consists of orthodox individuals. Results are discussed in the context of what has been described earlier in this chapter about the image of God and religious culture. The study is fully described in another chapter of this book by Eurelings-Bontekoe and Luyten. Prior to a discussion of the studies, it is necessary to describe orthodox Protestant believers. These people belong to Protestant churches in the Calvinistic tradition which emphasize sound doctrine and personal holiness. As a result, they are both theologically and behaviorally conservative and strict. For example, some orthodox churches reject the use of television and the internet. Church involvement and a positive identification with the church and its taught faith are high. In general, orthodox individuals go to church twice on a Sunday, and in some cases they also attend a church service on Wednesdays. Believers regularly pray and read the Bible, which they mainly interpret in a literal way, for example, regarding the existence of hell [1, 2].
4.2.2
THE IMAGE OF GOD
An individual’s God image refers to the personal God who is experienced subjectively, or, in other words, to the meaning that God has to the individual. On the one hand, the God image comprises one’s emotional understanding of God which reflects subjective experiences of God and is developed through a relational, and initially, unconscious process in which parents and significant others play a part [3]. As a result of early interactions between the infant and its parents, the infant develops a characteristic way of relating to others, or a relational structure which is partly unconscious and affects the degree to which the subject is able to establish and maintain open and trustful relationships [4, 5]. This relational structure also has an effect on the God-object relationship. On the other hand, the God image contains one’s cognitive understanding of God, which is based on what a person learns about God in propositional terms, which in turn is related to the doctrines that are taught and found within the family and the [local] religious culture [cf. 6, 7]. The affective and cognitive aspects of the God image are interrelated. Empirical results support this view [8]. The God image is a central element in an individual’s life of faith, because it is intertwined with psychic experience and life history. In this way, it gives insight into the affective quality of the relationship with God and the meaning of religious behavior [9]. The God image can be measured by means of the Questionnaire God Image [8, 10], a measure that taps an individual’s feelings towards God and perceptions of God’s actions. The dimension ‘feelings towards God’, measured by 17 items, consists of three scales, namely Positive Feelings (e.g. security, love), Anxiety, and Anger towards God. The second dimension concerning God’s actions is measured by 16 items which are distributed over three scales, namely Supportive Actions, Ruling and/or Punishing Actions, and Passivity (implying God’s inaction). Examples of items on this second dimension are the statements ‘God guides me,’ and ‘God lets everything take its course’. Answers are scored on a five-point scale, ranging from not at all descriptive [1] to extremely descriptive [5]. The questionnaire has adequate psychometric properties [8] and normative data are available [11].
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The God image: image of self or image of other?
Eurelings-Bontekoe, Hekman-Van Steeg & Verschuur [12] studied the association between attachment styles, among others, and the image of God. They found that not only securely attached individuals experienced positive feelings towards God, but also individuals with a dismissive attachment, which is an insecure attachment style. One possible explanation for the result that both the secure and the insecure, dismissive attachment style relate to positive feelings towards God is that the securely and dismissively attached individuals share a positive image of self, although these individuals differ regarding the model of other (positive in the case of a secure attachment style and negative in the case of a dismissive attachment style) [13]. Individuals with a fearful and preoccupied attachment style experience negative feelings towards God. These individuals differ regarding the model of other (positive in the case of the preoccupied attachment style and negative in the case of the fearful attachment style); however they share a negative model of self. Therefore, the image of God seems to reflect the model of self rather than the model of other. This is concordant with the results of a study among personality disordered patients [14], where the image of God was in line with the self-representation rather than the object-representation. Thus, although among kindergarteners the model of others predicted a loving God concept [15], among adults the God representation seemed especially to be a reflection of self-representation rather than a representation of an ‘external’ object, which may be one of the possible reasons that mental health and well-being are associated with a positive relation to God. Consequently, results of both studies are more confirmative of the so-called correspondence hypothesis of attachment to God, rather than of the compensation hypothesis [16]. The latter hypothesis states that God functions as a compensatory attachment figure for those who, as a child, did not experience a secure attachment relationship with their parents. The first ‘correspondence hypothesis’ states that the internal working model of attachment that one has constitutes the basis for the relationship one has with God. Several other studies [17, 18] have also provided direct support for the correspondence hypothesis.
4.2.2.2 Personality pathology as a determinant of a negative God image Schaap-Jonker, Eurelings-Bontekoe, Verhagen & Zock [14] studied the association between personality pathology according to DSM-IV [19], psychological distress and image of God among a group of 46 psychiatric patients. This study showed that a negative image of God was associated with both personality pathology as well as psychological distress as measured by the Symptom Checklist-90 [20]: the greater the personality pathology and psychological distress present, the more negative was the image of God. Personality pathology of DSM-IV’s cluster A (paranoid, schizoid and schizotypal personality disorders) was related to a passive and detached God image. This finding is not surprising considering that detachment and distrust in interpersonal relations are typical of patients with these disorders. Patients with personality pathology of cluster C, comprising the avoidant, dependent, and obsessive-compulsive personality disorders, were more likely to view God as a judge. Moreover, results revealed that personality pathology mediated the association
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between psychological distress and a negative image of God. The association between a negative image of God and axis I symptomatology, such as depression, disappeared after controlling for personality pathology. Thus, among patients, psychological distress is associated with a negative God image only in the case of personality pathology [14].
4.2.2.3
Psychological distress as a determinant of the God image
In contrast, among non-patients, psychological distress appears to be a more important determinant of negative feelings towards God than personality. However, personality does play a role in the experience of positive feelings towards God and seems to protect the relatively healthy individual from the negative influence a high level of psychological distress can have on the God image. In a study among a non-clinical sample, it was found that psychological distress mediated the effect of personality on negative feelings towards God: a high level of harm avoidance and a low level of self-directedness were only linked to negative feelings towards God if the level of psychological distress was high. The same held for individuals with a preoccupied and fearful attachment style: these individuals reported negative feelings towards God only if there was much psychological distress. In addition, it was found that persons with a healthy balance between self-orientation and orientation towards others, a high self-esteem and a secure attachment, hence persons with a stable personality, maintained positive feelings towards God and/or perceived God’s actions as supportive, irrespective of the level of psychological distress [12]. A study among a non-clinical sample of 201 Dutch adults also showed that affective state and religious culture (see below) were more important predictors of the God image than personality [21]. Anxiety towards God and Anger towards God were best predicted by Negative Affect, as measured by the Positive and Negative Affect Schedule [22, 23]. Neuroticism was the second best predictor. Positive Affect was the most important predictor of Positive Feelings and Supportive Actions.
4.2.2.4 Orthodox religious culture as a determinant of the God image Religious culture appears to be linked to the image of God as well. In a study which was carried out among a non-clinical sample, religious culture (i.e. membership of an orthodox reformed church) also determined the image of God [12]. Orthodox reformed church members tended to experience God as more punitive and more as a judge than Pentecostal church members did. This image of God as a judge was rather independent of personality and attachment variables. This finding was replicated in a study on the relationship between God image, personality, affective state and religious culture, which was conducted among a non-clinical sample of 201 Dutch adults. It was demonstrated that religious culture was an especially significant predictor of aspects of the God image regarding God’s behavior: more orthodox people tended to see God more as a judge and perceive God as more supportive than more liberal persons. Personality factors made only a small contribution to the perceptions of God’s behavior [21]. Another study also found that Orthodox Protestant individuals saw God as a judge more so than Roman Catholics, mainline Calvinists who were members of the Protestant Church of the Netherlands, and Evangelicals or Baptists.
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Remarkably, although in the total group ruling/punishing behavior by God was related to anxiety, in the orthodox Protestant subgroup this association did not exist [8; cf. 24]. The non-threatening nature of the image of God as a judge was confirmed by the study of Braam et al. [25], in which the image of God as a judge was related to positive feelings towards God and positive perceptions of God’s behavior.
4.2.2.5 Personal and normative God image: the experience of religious conflict In a study among 544 Dutch believers that focused on the difference between the personal God image and the God image that people perceived as normative, in other words, the God image they believed they should have according to religious culture, there appeared to be a discrepancy between the personal and the normative God image. In general, people felt that they should experience more positive and less fearful or angry feelings towards God, and that they should perceive God’s behavior as more supportive, as more ruling/punishing and as less passive [26]. However, the degree of discrepancy between the personal and the normative God image was related to mental health and religious denomination. Patients and orthodox believers experienced a more negative God image than they felt they should experience. This difference between personal and normative God image was not necessarily experienced as conflictive. The experience of conflict between people’s own life of faith and the norms of their religious culture was associated with lower religious saliency and higher educational level. The more that religious faith was meaningful to people, the less they experienced conflict. Educational level implied more conflict, with better educated people perhaps thinking and reflecting more critically on their beliefs than less welleducated individuals [22]. Moreover, conflictive feelings were associated with mental health per se and the interaction between mental health and denomination. In general, psychiatric patients experienced more conflict than non-patients. At the same time, the degree to which patients experienced conflict was affected by their religious backgrounds. Orthodox Protestant patients experienced as few conflicts as their normal fellow believers, which suggests that either they are ‘better off’ because they do not experience conflicts to the same extent as patients of other denominations, or they suffer more because their religion does not allow them to experience any conflicts, which in turn might have an additional negative impact on their already frail mental health. It seems that orthodox Protestant religiosity has a suppressive effect on the experience of religious conflict; religious culture not allowing these patients to experience conflict. In connection with the above-mentioned, we would like to make some remarks about ‘religious struggle’. A negative image of God in combination with a more positive normative God image, may give rise to a particular type of religious struggle, namely a struggle with the divine, characterized by doubt about God’s presence and his benevolence [27]. Religious struggle appears to be linked to both positive and negative health outcomes. Regarding the negative outcomes, religious struggles have been associated with several indicators of psychological distress including anxiety, depression and negative mood. Positive outcomes have also been described, such as spiritual growth, openmindedness, self-actualization and lower levels of prejudice [27].
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It may very well be possible that the way an individual handles religious struggle and thus its outcome is, as the image of God itself, related to personality pathology, psychological distress and religious culture. In personality disordered patients, where deep-seated feelings of abandonment by God prevail, this religious struggle may be linked to negative health outcome, whereas in stable individuals the more state-dependent negative image of God may result in a struggle that will eventually be resolved in a positive way. Finally, it may very well be possible that the culturally determined image of God as a ruler/punisher, held by orthodox reformed church members, does not at all imply a religious struggle. Rather, trying to change this image of God among orthodox church members may in fact induce a religious struggle, both an interpersonal and an internal one: it may lead to conflicts with other church members and therefore to a loosening of the tie with the church and the associated social network, which in turn may lead to loss of the social support it provides. Second, it may lead to an internal struggle when the originally internalized image of God is challenged [12].
4.2.3 ORTHODOX RELIGIOSITY AND THE MANIFESTATION OF DESCRIPTIVE AND STRUCTURAL BORDERLINE PERSONALITY PATHOLOGY In all the above-mentioned studies, orthodox Protestant people seem to distinguish themselves from people of other denominations. They see God, in particular, as a judge, and this image of God does not provoke anxiety. They do experience a discrepancy between their actual and their normative image of God, but this discrepancy seems not to be associated with an internal struggle. This is even true among orthodox Protestant patients, whereas patients of other denominations do experience the discrepancy as conflictive. The question arises whether the image of God as a ruler and judge, internalized during early development, has a suppressive effect on feelings and behavior among orthodox Protestants and therefore is associated with a high level of self-control. Many studies have been carried out on the effect of religiosity in general on self-control. For instance, Welch, Tittle and Grasmick [28] studied the relationship between Christian religiosity, self-control and conformity. The study showed that religious people exhibited more self-control than non-religious people but did not support the assumption that the influence of religiosity on obedience to norms was mediated by the capacity for self-control. Self-control and religiosity had independent effects on conformity and misbehavior. Although the relationship with deviance was generally somewhat stronger for self-control than for religiosity, both variables had an inhibiting influence on crime. Besides, they were negatively related to future projections of committing a variety of criminal acts. Results from Cochran, Wood & Arneklev [29] showed that the relationship between religiosity and deviance is spurious: the negative association between the two variables became insignificant after controlling for the level of arousal seeking and social control. Boomsma, De Geus, Van Baal and Koopmans [30] studied the influence of current religiosity and religious upbringing on personality factors (Neuroticism, Extraversion) and several aspects of Sensation Seeking which are associated with impulsivity [31], and on anxiety and depression. Results showed that currently religious subjects and subjects with a religious upbringing scored lower on all scales, except for the Test Attitude (‘Lie’) scale, on which they scored higher. The most consistent effect of religion was on the four scales of the
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Sensation Seeking Questionnaire, especially on the Disinhibition scale. Besides the general diminishing effect of religious upbringing on mean Disinhibition scores, the results provided evidence for a ‘Genotype x Environment’ interaction on Disinhibition scores: the influence of genetic factors on Disinhibition was lower in females who had received a religious upbringing than those who had had a non-religious upbringing; for religious males the heritability for Disinhibition was even zero. Therefore, Boomsma, De Geus, Van Baal and Koopmans [30] conclude that religious upbringing and/or its related aspects tend to reduce the impact of genotype on Disinhibition. Impulsivity is a personality characteristic that is associated with several psychiatric disorders, especially with the B cluster of the DSM-IV axis II [19] personality disorders, comprising the Antisocial Personality Disorder (ASP), the Histrionic Personality Disorder (HPD), the Narcissistic Personality Disorder (NPD) and the Borderline Personality Disorder (BPD). However, descriptive DSM-IV assessment of personality disorders needs to be differentiated from dynamic diagnosis of personality organization [32, 33]. ‘Personality organization’ is a relatively stable structure that consists of various inner representations of early relationships of the self with significant others (in terms of psychodynamic theory: ‘objects’), including the affective quality of these relationships. Kernberg describes three levels of personality organization: the neurotic personality organization (NPO), the borderline personality organization (BPO), and the psychotic personality organization (PPO). The three personality organizations are distinguished on the basis of three dimensions: identity integration (NPO) versus identity diffusion (BPO/PPO), defense mechanisms (predominantly mature/neurotic [NPO] versus predominantly primitive [BPO/PPO]), and reality testing (absent [PPO], frail [BPO] or good [NPO]). Within the BPO diagnosis several types of patients may be distinguished on the basis of their capacity for impulse and behavioral control. The high level borderline organized patients are over-controlled and internalizing, the low level borderline organized patients are characterized by under-control and therefore prone to externalizing, acting out and non-conformity. Eurelings-Bontekoe, Onnink, Williams & Snellen [34] described a new approach to the assessment of personality organization, based on theory-driven profile interpretation of the Dutch Short form of the MMPI [35]. In accordance with Kernberg, they distinguish between high level BPO and low level BPO patients. Eurelings-Bontekoe, Luyten & Snellen [36] found that this method indeed measures structural personality pathology. Low level BPO patients are particularly characterized by low moral standards and the use of primitive defenses [37]. Eurelings-Bontekoe & Luyten [38] carried out a study among 169 religious personality disordered patients. In contrast to most studies, this study investigated both orthodox Protestant upbringing and current orthodox Protestant denomination for one and the same sample, enabling it to address the differential effect of the two religious variables on the manifestation of B cluster personality pathology and structural borderline personality pathology. Results showed that an orthodox upbringing is the most important determinant of the manifestation of antisocial traits and structural low level borderline personality pathology. An orthodox Protestant upbringing, which is associated with an image of God as ruler/ punisher, seems to render people rule-obedient and conforming to social rules. The fact that current orthodox Protestant denomination did not have an independent effect on the
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manifestation of antisocial traits suggests that the low scores on antisocial traits of those who had been raised in an orthodox environment cannot be fully attributed to the phenomenon of ‘social desirability’. The low level of antisocial traits is, however, in line with Rizzuto’s [3] theory on God images, which emphasizes the role of parent-child interactions during the early stages of development, in other words, the upbringing. It may very well be possible that the emphasis orthodox families put on being rule-obedient and being submissive to the father as head of the family1 results firstly in an image of God as a ruler who punishes in the case of transgressions, and subsequently in a high level of self-control and conformity which, in turn, may prevent the development of antisocial traits and behavior. In contrast, current orthodox Protestant denomination appeared to be an independent predictor of less severe borderline symptoms including dissociation, feelings of abandonment, and parasuicide, whereas orthodox Protestant upbringing did not have independent predictive power. This implies that those from a current orthodox denomination report less severe borderline symptoms, independent of whether or not they have been raised in an orthodox environment. A possible explanation could be that a current orthodox environment provides a lot of structure, which may result in less severe borderline symptomatology. Another explanation might be a particular test- taking attitude of orthodox patients. De Lely, Mulder & Birkenh€ager [39] studied the severity of self-reported depression using the Beck Depression Inventory among currently orthodox Protestant patients diagnosed with a clinical depression and found that these patients scored lower on the self-report than nonorthodox depressed patients. De Lely et al. explain this effect by referring to the culture of the orthodox Protestant denomination, where suffering is seen as an essential part of life about which a patient is not allowed to complain. Therefore, the effect of current orthodox Protestant adherence on BPD symptom severity may also be explained by the culturally determined ‘rule’ to deny suffering; a rule that is less important for those not currently belonging to an orthodox Protestant denomination, even if they had been raised in one. Likewise, as described earlier, Schaap-Jonker, Eurelings-Bontekoe, Zock and Jonker [26] found that current orthodox Protestant adherence had a suppressive effect on the experience of religious conflict among patients. It was suggested that an orthodox Protestant culture does not allow patients to experience religious conflict.
4.2.4
DISCUSSION
After years of neglect, the association between religion and mental health has gained considerable interest in psychology and psychiatry since the recognition of ‘Religious and Spiritual Problem’ areas in the DSM-IV [19; 40]. In the field of psychotherapy research many studies have been devoted to the incorporation of religious matters into the psychotherapy of religious clients and to the psychotherapeutic approaches to pastoral care [40]. Although there is a large body of research showing positive associations between religiosity and mental health [41], there is far from consensus amongst researchers regarding which mechanism may account for the observed relationships. Ellison, Boardman, Williams and Jackson [42] studied several factors that are presumed to act as mediators
1
‘Children, obey your parents in the Lord: for this is right’, (Eph. 6: 1; cf. 5: 22–23).
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or moderators between religiosity and mental health, such as the social support provided by the religious community, the avoidance of risk taking behavior by religious people, a higher level of self-esteem and personal mastery of religious people. In addition, they studied the direct effects on health of religious variables such as church attendance and prayer. Finally, they studied whether religiosity might exacerbate the effect of serious life stress, such as marital problems and having deviant children. These life stressors, if attributed to one’s own failure to follow the norms of the religious culture, could induce feelings of failure, shame and guilt, and stigmatization by the religious community. Interestingly, Ellison et al. [42] found that the frequency of church attendance was negatively associated with distress and positively with well-being, and this link was quite direct, not mediated by access to social support and psychological resources. Interesting to note in this respect is that of all denominations orthodox Protestant church members show the highest frequency of church attendance [26]. The direct effect of the frequency of church attendance on mental health might be explained by the stabilizing effect of orthodox religion, providing a relationship with a ‘divine other’, a high level of predictability and meaningfulness related to the belief in eternal life [42]. In addition, church-related social support was unrelated to well-being and, finally, no stress-exacerbating effects of religiosity were found. The studies presented in this chapter may extend the literature in this area by pointing to the role of mental health as a determinant of the God image, by making a distinction between the effects of religiosity among healthy individuals and psychiatric patients, by making a distinction between several denominations, and finally by distinguishing the effects of an orthodox religious upbringing from that of current religious orthodoxy. They also address the important issue of the value of self-report instruments among orthodox Protestant persons. Mental health itself seems to be an important determinant of the God image and thus seems to determine whether religiosity has a positive or negative emotional value to the individual. In the case of severe personality pathology or the presence of pathological personality traits, the image of God is negative and psychological distress also has a negative influence on the God image among these patients. However, in persons with a stable personality, the image of God is positive, and a stable personality seems to protect the individual from the negative influence a high level of psychological distress can have on the God image: stable individuals are able to maintain a positive image of God, irrespective of their level of psychological distress. Therefore, for precisely those who need a supportive image of God the most (those who are personality disordered, depressed, anxious or suffer otherwise from their mental health problems), unfortunately, such an image is not available. Mental health also seems to influence the discrepancy between the personal and the normative God image: in cases of mental health problems this discrepancy is large and is also more usually experienced as an inner conflict. Our results so far also point to the importance of taking denomination, especially of taking the orthodox Protestant denomination, into account in studies on the effect of religion on well-being. In addition it also seems necessary to distinguish between current orthodox denomination and orthodox Protestant upbringing. Orthodox religiosity seems to protect individuals from experiencing inner religious conflicts; orthodox Protestants experience God as a judge, and this image of God is nonthreatening to them, even if they suffer from mental health problems. In contrast, results suggest that the image of God as a judge provides stability, assuring orthodox people that wrong will be punished and good will be rewarded. Orthodox Protestant personality
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disordered patients report to suffer less from borderline pathology, and orthodox Protestant patients with a clinical depression report to experience less severe depression than depressed non-orthodox patients. Moreover, an orthodox Protestant upbringing seems to protect individuals against the development of an antisocial personality. Importantly in this respect, we pointed to a potential effect of orthodox Protestant culture on the way self-reports are being filled in. The orthodox Protestant culture sees suffering as part of life about which one may not complain. Most studies in this field have used selfreports to assess well-being. To the best of our knowledge, no author has ever suggested that the positive effects of religion on health and well-being may be partly linked to this tendency of orthodox religious people to deny suffering. Only Boomsma et al. [26] report a stronger defensive test-taking attitude among orthodox religious persons, but the authors do not further elaborate on this finding. We therefore also strongly recommend the use of indirect methods of assessment of psychopathology, especially projective tests such as the Rorschach [43–46] or the Social Cognition and Object Relation Scale, a well validated system (for a review see 47) to score Thematic Apperception Test narratives [48, 49], in addition to self-reports in studies on the association between religiosity and mental health.
REFERENCES 1. Stoffels H (1995) Als een briesende leeuw: Orthodoxe protestanten in de slag met de tijdgeest. (As a roaring lion. Orthodox protestants fighting a battle against the spirit of the age.) Kok, Kampen. 2. Dekker G, Hart JJM de, Peters JWM (1997) God in Nederland: 1966–1996 (God in the Netherlands: 1996-1996). Anthos, Amsterdam. 3. Rizzuto AM (1979) The Birth of the Living God. University of Chicago Press, Chicago. 4. Schaap-Jonker H (2008) Before the face of God: an interdisciplinary study of the meaning of the sermon and the hearer’s God image, personality and affective state. LIT Verlag, Z€ urich. 5. Shafranske EP (1992). God-Representation as the Transformational Object. In: Finn M & Gartner J (eds.). Object Relations Theory and Religion: Clinical Applications. Praeger, New York, pp. 57–72. 6. Hoffman L (2005) A Developmental Perspective on the God image. In: Cox RH, Ervin-Cox B & Hoffman L (eds.) Spirituality and Psychological Health. Colorado School of Professional Psychology Press, Colorado Springs, pp. 129–147. 7. Meissner WW (1990) The Role of Transitional Conceptualization in Religious Thought. In: Smith, JH & Handelman SH (eds.) Psychoanalysis and Religion. John Hopkins University Press, Baltimore, pp. 95–116. 8. Schaap-Jonker H, Eurelings-Bontekoe EHM, Zock H & Jonker ER (2008) Development and Validation of the Dutch Questionnaire God Image: effects of mental health and religious culture. Mental Health, Religion & Culture 11, 501–515. 9. Tisdale, TC, Key TL, Edwards KJ, Brokaw BF, Kemperman, SR, Cloud H, Townsend J & Okamoto T (1997) Impact of treatment on God image and personal adjustment, and correlations of God image to personal adjustment and object relations development. Journal of Psychology and Theology, 25, 227–239. 10. Murken S (1998) Gottesbeziehung und psychische Gesundheit: Die Entwicklung eines Modells ¨ berpr€ufung. (Relationship with God and Mental Health: The Developund seine empirische U ment of a Model and its Empirical Testing.) Waxmann: M€ unster. 11. Schaap-Jonker H & Eurelings-Bontekoe, EHM (2007) Handleiding Vragenlijst Godsbeeld (Manual Questionnaire God Image). Available from second author. 12. Eurelings-Bontekoe, EHM, Hekman-Van Steeg J & Verschuur MJ (2005) The association between personality, attachment, psychological distress, church denomination and the God concept among a non-clinical sample. Mental Health, Religion & Culture 8, 141–154.
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13. Griffin DW & Bartholomew K (1994) The metaphysics of measurement: the case of adult attachment. Advances in Personal Relationships 5, 17–52. 14. Schaap-Jonker H, Eurelings-Bontekoe E, Verhagen PJ & Zock H (2002) Image of God and personality pathology: an exploratory study among psychiatric patients. Mental Health, Religion & Culture 5, 55–71. 15. Roos SA de, Miedema S & Iedema J (2001) Attachment, working models of self and others, and God concept in Kindergarten. Journal for the Scientific Study of Religion 40, 607–618. 16. Kirkpatrick LA (1995) Attachment theory and religious experience. In: Hood RW Jr (Ed.) Handbook of Religious Experience: Theory and Practice. Religious Education Press, Birmingham, pp 446–475. 17. Kirkpatrick LA (1998) God as a substitute attachment figure: A longitudinal study of adult attachment style and religious change in college students. Personality and Social Psychology Bulletin 24, 961–973. 18. Kirkpatrick LA & Shaver PR (1992) An attachment-theoretical approach to romantic love and religious belief. Personality and Social Psychology Bulletin 18, 266–275. 19. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Washington D.C. 20. Arrindell WA & Ettema JHM (1986) SCL-90. Handleiding bij een multidimensionele psychopathologie indicator. (SCL-90. Manual.) Swets & Zeitlinger, Lisse. 21. Schaap-Jonker H, Eurelings-Bontekoe, EHM, Zock H, Jonker ER & Corveleyn, JMT (2008) Trait or State Dependent? Image of God in relation to Personality Factors, Affectivity, and Religious Denomination. Submitted for publication. 22. Watson D, Clark LA, Tellegen A (1988) Development and validation of brief measures of Positive and Negative Affect: the PANAS Scales. Journal of Personality and Social Psychology 54, 1063–1070. 23. Peeters FPML, Ponds RWHM, Boon-Vermeeren MTG, Hoorweg M, Kraan H & Meertens L (1999) Handleiding bij de Nederlandse vertaling van de Positive and Negative Affect Schedule (PANAS). (Manual of the Dutch translation of the Positive and Negative Affect Schedule (PANAS).) University of Maastricht, Department of Psychiatry and Neuropsychology, Maastricht. 24. Noffke JL & McFadden SH (2001) Denominational and Age Comparisons of God Concepts. Journal for the Scientific Study of Religion 40, 747–756. 25. Braam AW, Schaap-Jonker H, Mooi B, Ritter D de, Beekman ATF & Deeg DJH (2008) God image, religious coping, and mood in old age; results from a community-based pilot study in the Netherlands. Mental Health, Religion & Culture 11, 221–237. 26. Schaap-Jonker H, Eurelings-Bontekoe EHM, Zock H & Jonker ER (2007) The Personal and Normative Image of God: the Role of Religious Culture and Mental Health. Archive for the Psychology of Religion 29, 305–318. 27. Hill PC & Pargament KI (2003) Advances in the conceptualisation and measurement of religion and spirituality. American Psychologist 58, 64–74. 28. Welch MR, Tittle CR & Grasmick HG (2006) Christian religiosity, self-control and social conformity. Social Forces 84, 1605–1623. 29. Cochran JK, Wood PB & Arneklev BJ (1994) Is the religiosity-delinquency relationship spurious? A test of arousal and social control theories. Journal of Research in Crime and Delinquency 31, 92–123. 30. Boomsma DI, Geus EJC de, Baal GCM van & Koopmans JR (1999) A religious upbringing reduces the influence of genetic factors on disinhibition: Evidence for interaction between genotype and environment on personality. Twin Research 2, 115–125. 31. Fossati A, Donate D, Donini M, Novella L, Bagnato M & Maffei C (2001) Temperament, character and attachment patterns in borderline personality disorder. Journal of Personality Disorders 15, 390–402.
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32. Kernberg OF (1984) Severe Personality Disorders. Psychotherapeutic Strategies. Yale University Press, New Haven. 33. Kernberg OF & Caligor E (2005) A psychoanalytic theory of personality disorders. In: Lenzenweger MF & Clarkin JF (eds.), Major theories of personality disorder, 2nd edn. Guilford Press, New York, pp. 114–156. 34. Eurelings-Bontekoe EHM, Onnink A, Williams M & Snellen WM (2008) A new approach to the assessment of structural personality pathology. Theory driven profile interpretation of the Dutch Short Form of the MMPI. New Ideas in Psychology 26, 23–40. 35. Luteijn F & Kok AP (1985) Herziene Handleiding NVM. (Revised Manual DSFM). Harcourt International, Lisse. 36. Eurelings-Bontekoe EHM, Luyten P & Snellen WM (2009) Validation of the theory driven profile interpretation of the Dutch Short form of the MMPI using the TAT Social Cognition and Objectrelations Scale (SCORS). Journal of Personality Assessment, 91, 155–165. 37. Eurelings-Bontekoe EHM, Luyten P, Remijsen M & Koelen JA. Association between personality organization as assessed by theory driven profiles of Dutch Short Form of MMPI and self-reported structural personality pathology. Submitted for publication. 38. Eurelings-Bontekoe, EHM & Luyten P (2010) Influence of a Christian orthodox religious upbringing and present orthodoxy on DSM-IV cluster B personality disorders and structural borderline personality pathology. In: Verhagen PJ, Van Praag HM, Lopez-Ibor JJ, Cox J & Moussaoui D (eds.), Psychiatry and Religion: Beyond Boundaries. Wiley Blackwell, New York, pp. 373–387. 39. Lely AA de, Broek van den WW, Mulder PGH & Birkenhager TKS (2009) Symtpomen bij een depressie; bevindelijk gereformeerden versus niet-kerkelijke patienten (Symptoms of depression in strict calvinistic patients and in patients without religious affiliations: a comparison). Tijdschrift voor Psychiatrie 51, 279–289. 40. Marsh R & Low J (2006) God as other, God as self, God as beyond: a cognitive analytic perspective on the relationship with God. Psychology and Psychotherapy: Theory, Research and Practice 79, 237–255. 41. Culliford L (2002) Spiritual care and psychiatric treatment: an introduction. Advances in psychiatric treatment 8, 249–261. 42. Ellison CG, Boardman JD, Williams DR & Jackson JS (2001) Religious involvement, stress, and mental health: findings from the 1995 Detroit Area Study. Social Forces 80, 215–249. 43. Exner JE (1991) The Rorschach: A Comprehensive System (Vol. 2: Interpretation; 2nd edn). Wiley, New York. 44. Exner JE (1993) The Rorschach: A Comprehensive System (Vol. 1: Basic Foundations; 3rd edn.) Wiley, New York. 45. Exner JE (2000) A primer for Rorschach Interpretation. Rorschach Workshops, Asheville NC. 46. Exner JE (2001) A Rorschach workbook for the Comprehensive System, 5th edn. Rorschach Workshops, Asheville NC. 47. Huprich SK & Greenberg RP (2003) Advances in the assessment of object relations in the 1990s. Clinical Psychology Review 23, 665–698. 48. Westen D (1985) Social Cognition and Object Relations Scale. Original manual to use for training. University of Michigan: Department of Psychology. 49. Westen D, Lohr N, Silk KR, Gold L & Kerber K (1990) Object relations and social cognitions in borderlines, major depressives, and normals: a thematic apperception test analysis. Psychological Assessment 2, 355–364.
CHAPTER 4.3
The Relationship Between an Orthodox Protestant Upbringing and Current Orthodox Protestant Adherence, DSM-IV Axis II B Cluster Personality Disorders and Structural Borderline Personality Organization Elisabeth H.M. Eurelings-Bontekoe Associate Professor of Clinical Psychology, The Netherlands
Patrick Luyten Assistant Professor of Psychology, Belgium
4.3.1
RELIGION AND SELF-CONTROL
There is a wealth of criminological literature on the association between crime and delinquency, yielding inconsistent and inconclusive results [1–3]. Many studies have shown a (low to moderate) inverse relationship between religion and crime [1, 2, 4–6]. However, it has been argued that this relationship might be spurious. For example, Welch, Tittle and Grasmick [7] argue that the relationship between religiosity and deviance might be explained by a third variable, such as self-control. Welch et al. showed that religious people exhibit more self-control than less religious people, but their study did not support the assumption that the influence of religiosity on obedience to norms is mediated by the capacity of self-control: both variables had an independent inhibiting influence on crime. Similarly, Cochran, Wood & Arneklev [3] showed that the relationship between religiosity and criminal behavior might be spurious. In their study of approximately 1600 high school students the negative association between various types of criminal behavior and religiosity Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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was no longer significant after controlling for the level of arousal-seeking and self- and social-control. Boomsma, De Geus, Van Baal and Koopmans [8] studied the influence of current religiosity and religious upbringing on several personality factors. The most consistent finding in their study was that a religious upbringing was associated with lower scores on disinhibition as measured by the sensation seeking questionnaire. Besides the general diminishing effect of religious upbringing on mean disinhibition scores, the results provided evidence for a genotype by environment interaction on disinhibition scores: the influence of genetic factors on disinhibition was lower in women who had had a religious upbringing as compared to women who had had a non-religious upbringing; for religious men there was no evidence for the role of heritability on disinhibition. Therefore, Boomsma et al. [8] conclude that religious upbringing tends to reduce the impact of genotype on disinhibition.
4.3.2
DENOMINATION
Ellison, Boardman, Williams and Jackson [9] have argued that researchers have been reluctant to explore denominational differences in the area of the study of religion and health, to avoid implying that one religion is superior to another. However, the importance of exploring differences in denomination might differ for different societies. Boomsma et al. [8] describe that the degree of denominational segregation is probably much larger in Dutch society than it is in the U.S. or Australia. Boomsma et al. even speak of ‘voluntary apartheid’ in this context which is especially true for people who belong to the orthodox Protestant churches in the Calvinistic tradition, which emphasize sound doctrine and personal holiness. As a result, they are both theologically and behaviorally conservative and strict. For example, some orthodox churches reject the use of television and the internet. Hence church involvement and a positive identification with the church and its teachings are considerable in these societies. In general, orthodox individuals go to church twice on Sundays, and in some cases they also attend a church service on Wednesdays. Believers regularly pray and read the Bible, which they mainly interpret in a literal way, for example regarding the existence of hell [10, 11]. Boomsma et al. [8] reported an effect of denomination on disinhibition, with Roman Catholics scoring higher on this scale than Protestant/Calvinistic respondents. Knopik et al. [12] studied several factors determining the risk of alcohol dependence, including religion, and found that the risk of alcohol dependence was increased in Roman Catholics, but decreased in those reporting an orthodox Protestant religion. Interesting to note in this respect are the results of a study on the image of God among both psychiatric patients and normal controls [13]. These authors found that of all the denominations studied, including Roman Catholics, orthodox Protestant respondents were the most likely to experience God as a ruler and/or punisher. In addition, only among orthodox Protestant respondents was this image of God not associated with anxiety. Therefore, for these people the image of God as a judge is not necessarily threatening. Rather, the religious culture of this denomination, in which God is seen as someone who notices every sin and who will judge every man by his works at the Last Judgment, may account for this image [cf. 14–16]. Hence, taken together, orthodox Protestant people seem to distinguish themselves from people of other religious denominations.
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ORTHODOX PROTESTANTISM, DSM-IV AND STRUCTURAL BPO
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4.3.3 DESCRIPTIVE AND STRUCTURAL DIAGNOSIS OF PERSONALITY PATHOLOGY DSM-IV axis II [17] yields descriptive diagnoses of personality disorders. Of those, the B cluster personality disorders (the Antisocial Personality Disorder [APD], the Histrionic Personality Disorder [HPD], the Narcissistic Personality Disorder [NPD] and the Borderline Personality Disorder [BPD]), are associated with increased levels of externalizing behavior and impulsivity [18]. However, descriptive diagnoses need to be differentiated from the structural diagnosis of personality pathology. As early as 1970, Kernberg proposed a psychoanalytic classification of character pathology and has, since then, extensively described his structural-dynamic vision of personality pathology [19]. The core concept in Kernberg’s structural model is that of ‘personality organization’, a relatively stable structure that consists of various inner representations of early relationships of the self with significant others (in terms of psychodynamic theory: ‘objects’), including the affective quality of these relationships. On the basis of this developmental model, Kernberg describes three levels of personality organization: the neurotic personality organization (NPO), the borderline personality organization (BPO), and the psychotic personality organization (PPO). The three personality organizations are distinguished on the basis of three dimensions: identity integration (NPO) versus identity diffusion (BPO/PPO), defense mechanisms (predominantly mature/neurotic [NPO] versus predominantly primitive [BPO/PPO]), and reality testing (absent [PPO], frail [BPO] or good [NPO]). Approximately 85% of those with a DSM BPD diagnosis function on the borderline level of personality organization, whereas, in contrast, more than 40% of those with a borderline personality organization are not found to suffer from the BPD [20]. Within the BPO, Kernberg [21] makes a distinction between high and low level borderline organized patients, based on the level of self-control. The high level borderline organized patients are over-controlled and internalizing, the low level patients are characterized by under-control and therefore prone to externalizing, acting out and non-conformity. Eurelings-Bontekoe, Onnink, Williams and Snellen [22] described a new approach to the assessment of structural personality pathology, based on the theory-driven profile interpretation of the Dutch Short form of the MMPI (DSFM). In accordance with Kernberg they distinguish between a high level BPO and a low level BPO profile. Eurelings-Bontekoe, Luyten and Snellen [23] found that this method indeed measures structural personality pathology. Patients with low level BPO profiles are particularly characterized by low moral standards and the use of primitive defenses [24].
4.3.4
AIMS OF THE STUDY AND HYPOTHESES
This study aims at extending existing research in two ways. First, this study focuses on the association between externalizing personality pathology and orthodox Protestant religiosity among a sample of personality disordered patients. Second, in contrast to most studies, this study investigates both orthodox Protestant upbringing and current orthodox Protestant denomination in one and the same sample, enabling it to address the question of whether there is an effect by current orthodox Protestant adherence above and beyond the effect of orthodox Protestant upbringing on the manifestation of B cluster personality pathology and structural borderline personality pathology.
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Given the above-mentioned association between Cluster B Personality Disorders (including the BPD) and impulsivity, between religiosity and self-control/conformity/low disinhibition and the finding that a religious upbringing reduces the impact of genotype on the manifestation of impulsivity/disinhibition, we hypothesized that patients with an orthodox Protestant upbringing and current orthodox Protestant adherence would score lower on traits of the cluster B disorders and would have a lower prevalence of the low level impulse ridden BPO profile than patients without an orthodox religious upbringing and without present orthodox adherence. In addition, we hypothesized that current orthodox Protestant adherence and an orthodox Protestant upbringing would inhibit the manifestation of B cluster personality disorder pathology among those with an underlying low level, impulse ridden BPO profile. Finally, in line with results of the study of Boomsma et al. [8], and in line with many studies that point to the importance of early experiences for the development of personality pathology, we expected in all the analyses that orthodox Protestant upbringing would be more strongly (negatively) related to externalizing symptoms than current orthodox Protestant adherence.
4.3.5 4.3.5.1
METHODS Participants
The sample consisted of 169 patients from three Christian mental healthcare centers in the Netherlands, who all sought treatment for personality pathology (105 females (62.1%) and 64 males (37.9%)). Ages ranged from 19 to 73, (M ¼ 38.7, SD ¼ 12.9). Level of education (known for 166 participants) was low (a maximum of 8 years’ education) among 12 respondents (7.2%), medium (a maximum of 14 years’ education) among 144 participants (86.8%) and high (a minimum of 18 years’ education) among 10 (6%) participants. Seventy-one patients (42.5%) were unmarried, 9 were unmarried but living together (5.4%), 23 were widowed (13.8%), 51 were married (30.5%), 13 divorced (7.8%). Marital status was missing for two patients. The majority of patients (N ¼ 115, 81.6%) was raised in an orthodox Protestant denomination. Twenty-six of the patients were raised in a Roman Catholic (N ¼ 17) or non- religious (N ¼ 9) environment (18.4%). Equally, the majority of patients (117; 71.3%) currently belonged to an orthodox Protestant denomination, 12 patients reported to be Roman Catholics (7.3%) and 35 patients reported to be non-religious (21.3%). Of those from a current Protestant orthodox denomination, 94.4% had also been raised in a Protestant orthodox environment, and of those without current orthodox Protestant adherence, 37.5% had been raised in an orthodox Protestant environment. DSM-IV Axis II diagnosis, as assessed by the treating psychiatrist, was known for 124 patients. The majority (69; 55.6%) received the diagnosis ‘Personality Disorder Not Otherwise Specified’. Twenty-one patients (16.9%) were diagnosed with Avoidant PD, 16 patients (12.9%) with Borderline PD, 5 patients (4%) with Obsessive Compulsive PD, 3 patients (2.4%) with Narcissistic PD, and 1 (0.8%) patient with Dependent PD. Diagnosis of personality disorder was postponed in 5 patients (4%), and 4 patients (3.2%) did not receive a personality disorder diagnosis.
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Assessment instruments
Features of Cluster B Personality Disorders according to DSM-IV [17] were assessed using the VKP-IV (Tragenlijst Kenmerken Persoonlijkheid [Questionnaire to Assess Personality Features]; 25, 26). The VKP-IV diagnoses the twelve DSM-IV [17] and the nine ICD-10 personality disorders [27]. The VKP is scored on a three point scale: True (2), Uncertain (1) and False (0). Twelve questions have an additional answer category: NA (Not Applicable). For each personality disorder a dimensional score is calculated by summing the scores on the fully endorsed criteria. Only DSM-IV data will be reported. Type of Borderline Personality Organization was assessed using the theory-driven profile interpretation of the Dutch Short Form of the MMPI (DSFM), as described by Eurelings-Bontekoe, Onnink, Williams & Snellen [22] and Eurelings-Bontekoe, Luyten & Snellen [23]. This questionnaire consists of 83 MMPI items, measuring five personality dimensions: Negativism (22 items), Somatization (20 items), Shyness (15 items), Severe Psychopathology (13 items) and Extraversion (13 items). Items can be answered with ‘right’ (2) or ‘wrong’ (0). Twelve items have reversed scoring. Participants also have the option to respond with a question mark (scored as 1) if they feel uncertain, but are requested to choose as few question marks as possible. Normative data for both normal and psychiatric samples are available [28]. Studies have shown the inventory to be both reliable and valid [28]. Moreover, the temporal stability of the instrument is high [28], rendering it appropriate for structural personality assessment. The profile interpretation implies that the dimensions of the DSFM are not interpreted in isolation, but rather that the scores on the dimensions are combined a priori in a theorydriven way into specific profiles that are subsequently interpreted by using psychodynamic concepts. It is hypothesized that specific profiles of DSFM dimensions refer to underlying structural personality pathology, which cannot be assessed either by studying personality dimensions in isolation, or by merely describing their combinations, but by defining and interpreting several combinations in a theory-driven way. Hypotheses about structural diagnoses are derived from specific combinations of raw scores on the DSFM subscales Negativism (Negative affectivity), Severe Psychopathology (Psychoticism) and Shyness (Constraint). The DSFM Negativism subscale measures the level of negative emotionality (inner tension and subjectively experienced anger). Severe psychopathology is assumed to measure anxiety proneness. High scores on this scale imply an increased proneness to react with anxiety and suspicion under stressful and unstructured circumstances. Therefore, this scale reflects an unstable affect regulation. Shyness is considered to reflect the capacity for inhibition and control, as well as the willingness to adapt to social rules. The higher the score on Shyness, the higher the capacity for control and the higher the social conformity. Five studies have provided evidence for the validity of the DSFM to capture features of structural personality organization [22–24, 29, 30]. In this study we focus on the presence or absence of a low level borderline profile, determined by the combination of below average and lower scores on the subscale Shyness and high to very high scores on the subscale Severe Psychopathology. Scores on Negativism are expected to be generally low, associated with strong externalizing tendencies, but can be high in the case of external stress. Therefore Negativism is not included in this particular structural diagnosis. The low level BPO profile reflects an underlying tendency to low moral
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standards and to impulse ridden, non-conforming and chaotic behavior that will manifest itself particularly under stressful and unstructured conditions [24].
4.3.5.3
Past and present Protestant denomination
Subjects were asked to indicate whether they had been raised in an orthodox Protestant denomination, as a Roman Catholic, or in a non-religious environment. Similarly, subjects were asked to indicate their current religious denomination.
Procedure The study was approved by the Medical Ethical Committee of the Leiden University Hospital. All patients in treatment for personality disorders received a letter with information about the research study. Later they were asked by phone whether they were willing to participate in the study and if so an appointment was made. Usually the participants filled in the questionnaires at the location where they received their treatment.
4.3.5.4
Statistical analyses
Associations between gender, age, level of education and marital status on the one hand and the religious variables/presence of a low level BPO profile on the other were investigated using t-tests for independent samples and chi square analysis. Differences between patients with and without current orthodox Protestant adherence, and between those raised and those not raised in an orthodox Protestant environment regarding traits of the several B cluster personality disorders were studied using MANCOVA. Differences in the prevalence of the low level BPO profile between patients with and without current orthodox Protestant adherence and between patients with and without an orthodox Protestant religious upbringing were studied using chi-square analysis. Several stepwise hierarchical multiple regression analyses (HMRAs) were conducted to investigate the independent power of the two religious variables to predict traits from the cluster B disorders beyond relevant background variables. A logistic hierarchical regression analysis was conducted to investigate the independent power of the two religious variables to predict the presence of the low level BPO profile, beyond relevant biographic data. Finally, the effect of the presence of a low level BPO profile and of the interaction between the presence of this profile and both current orthodox adherence and orthodox Protestant upbringing on traits of the cluster B personality disorders was investigated using two 2-Way MANCOVAs, with presence or absence of the low level BPO profile and current orthodox adherence/orthodox upbringing as the fixed factors, relevant biographic data as the covariates and traits from the B cluster disorders as the dependent variables. Effect sizes were expressed as partial eta squared (h2p ). According to conventional criteria [31] an h2p of 0.01 is small; 0.06 moderate; 0.14 large.
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Results
Influence of background variables on the study variables Patients with current orthodox Protestant adherence were older than those who did not report this adherence (M ¼ 41.03, SD ¼ 12.60 versus M ¼ 33.5, SD ¼ 11.91, t ¼ 3.5, df ¼ 162, p < 0.001) and were more frequently raised in an orthodox Protestant environment (X2 ¼ 52.93, df ¼ 1, p < 0.001). A minority (N ¼ 8; 7%) of those from a current orthodox denomination were unmarried living together or divorced, 107 (93%) were married, widowed or living alone (X2 ¼ 14.82, df ¼ 1, p < 0.001). Likewise, a minority (10; 8.8%) of patients who had been raised in an orthodox Protestant environment reported being divorced or living with a partner outside marriage (X2 ¼ 6.54, df ¼ 1, p < 0.05). Level of education was not associated with current Protestant orthodox adherence (X2 ¼ 11.05, df ¼ 6, ns) or with Protestant orthodox upbringing (X2 ¼ 7.20, df ¼ 6, ns). Men, more frequently than women, reported belonging to a current orthodox denomination (X2 ¼ 4.22, df ¼ 1, p < 0.05). However men had not been raised in a Protestant orthodox environment more frequently than women (X2 ¼ 1.96, df ¼ 1, ns). There were no associations between the presence or absence of a low level BPO profile and age (t ¼ 0.30, df ¼ 160, ns), educational level (X2 ¼ 8.61, df ¼ 6, ns), marital status (X2 ¼ 0.48, df ¼ 1, ns) and gender (X2 ¼ 1.11, df ¼ 1, ns).
4.3.5.6 Current orthodox Protestant adherence/orthodox upbringing and traits of DSM-IV cluster B personality disorders A MANCOVA, with current Protestant orthodox adherence as the independent variable, traits of the DSM-IV B cluster disorders as the dependent variables, and age, marital status (recoded into unmarried living together/divorced and remaining categories) and gender as covariates, showed a significant and almost large main effect for current orthodox Protestant adherence (F(4,160) ¼ 5.55, p < 0.001, h2p ¼ 0:13). There was a significant effect on three of the four B cluster disorders: APD (F(1,160) ¼ 14.45, p < 0.001, h2p ¼ 0:09); BPD (F(1,160) ¼ 15.83, p < 0.001, h2p ¼ 0:09), and HPD (F(1,160) ¼ 7.03, p < 0.01, h2p ¼ 0:04). Orthodox Protestant patients (N ¼ 113) had fewer ASP (M ¼ 2.08, SD ¼ 2.95 versus M ¼ 5.26, SD ¼ 5.11), BPD (M ¼ 6.21, SD ¼ 3.90 versus M ¼ 9.64, SD ¼ 4.82), and HPD (M ¼ 3.34, SD ¼ 2.57 versus M ¼ 4.92, SD ¼ 3.85) features compared to non-orthodox patients (N ¼ 47). A MANCOVA, with being raised in an orthodox Protestant environment as the independent variable, controlling for age and marital status revealed a significant and large main effect for orthodox Protestant upbringing (F(4,138) ¼ 5.88, p < 0.001, h2p ¼ 0:15). The effect for orthodox Protestant upbringing was significant for all four B cluster disorders APD (F(1,138) ¼ 19.81, p < 0.001, h2p ¼ 0:13), BPD (F(1,138) ¼ 5.23, p < 0.05, h2p ¼ 0:04), HPD (F(1,136) ¼ 11.63, p < 0.001; h2p ¼ 0:08) and NPD (F(1,138) ¼ 5.43, p < 0.05, h2p ¼ 0:04). Patients with an orthodox Protestant upbringing (N ¼ 112) reported to be less antisocial (M ¼ 2.05, SD 2.75) than those raised elsewhere (N ¼ 26; M ¼ 6.35, SD 6.14), scored lower on the BPD (M ¼ 6.74, SD 4.11 versus M ¼ 9.65, SD 4.87), reported to be less histrionic (M ¼ 3.36, SD 2.44 versus M ¼ 5.77, SD 4.17), and less narcissistic (M ¼ 2.68, SD 2.82 versus M ¼ 4.39, SD 3.72).
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4.3.5.7 Current orthodox Protestant adherence/orthodox Protestant upbringing and the prevalence of the low level BPO profile Twenty-eight patients (17.3%) had the low level BPO profile, 134 patients (82.7%) had another personality profile. There was no association between current Protestant orthodox adherence and the presence of a low level BPO profile (X2 ¼ 3.45; df ¼ 1; ns). However, there was an association between the presence of this personality profile and orthodox Protestant upbringing (X2 ¼ 9.38; df ¼ 1; p < 0.01). Within the group with an orthodox Protestant upbringing the prevalence of the low level BPO profile was 13.6%, whereas among those raised elsewhere the prevalence was 40%.
4.3.5.8 Relative effects of orthodox Protestant upbringing versus current orthodox adherence on DSM-IV cluster B personality features A series of stepwise HMRAs was carried out, with each of the four cluster B personality features as the dependent variables, to investigate the independent predictive power of the two religious variables. Age, gender and marital status were entered in the first step, orthodox Protestant upbringing in the second step, and current orthodox Protestant adherence in the final step. Dichotomous variables were entered as dummies (male ¼ 1, female ¼ 0; being raised in an orthodox Protestant environment ¼ 1, being raised elsewhere ¼ 0; current orthodox Protestant adherence ¼ 1, current non-orthodox adherence ¼ 0; and unmarried living together or being divorced ¼ 1, other marital status ¼ 0). In the analysis with the APD as the dependent variable, demographic variables accounted for a significant 8% of explained variance in antisocial traits (F(3,136) ¼ 3.81, p < 0.05), with age being a significant negative predictor (b ¼ 0.23, p < 0.01). Orthodox Protestant upbringing accounted for an additional 12% of variance in antisocial traits (F(4,136) ¼ 8.04, p < 0.001, F-change ¼ 19.21, p < 0.001), with orthodox upbringing being negatively related to APD features (b ¼ 0.38, p < 0.001). Entering current Protestant orthodox adherence in the final step did not further improve the model. In this final model orthodox Protestant upbringing was the only significant negative predictor of antisocial traits (b ¼ 0.29, p < 0.01). Results for the BPD showed that the background variables accounted for 9% of explained variance in borderline traits (F(3,136) ¼ 4.26, p < 0.01), females and younger patients scoring higher (b ¼ 0.20, p < 0.05 and b ¼ 0.17, p < 0.05 respectively). Orthodox upbringing accounted for an additional 4% of explained variance in mean borderline scores, beyond the effect of age and gender (F(4,136) ¼ 4.62, p < 0.01, F-change ¼ 5.28, p < 0.05), patients with an orthodox upbringing scoring lower (b ¼ 0.20, p < 0.05). Entering current orthodox adherence explained another 7% of variance in borderline scores (F(5,136) ¼ 6.09, p < 0.001; F-change ¼ 10.64; p < 0.001). In this final model gender and current orthodox adherence were the only significant predictors of borderline traits, with women having higher (b ¼ 0.18, p < 0.05) and patients with current orthodox adherence lower (b ¼ 0.34, p < 0.001) scores on BPD features. Results for the HPD showed that the background variables accounted for a non-significant 5% of explained variance in histrionic traits. Orthodox upbringing accounted for an
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additional 7% of explained variance in mean histrionic scores (F(4,136) ¼ 4.78, p < 0.001, F-change ¼ 11.25, p < 0.001), patients with an orthodox upbringing scoring lower (b ¼ 0.30, p < 0.001). However, in the final model none of the predictors reached significance. In the final HMRA for NPD, none of the predictors reached significance.
4.3.5.9 Independent predictive power of degree of current orthodoxy and orthodox upbringing regarding prevalence of the low level BPO profile A logistic hierarchical regression analysis showed that orthodox Protestant upbringing was the only significant predictor of the presence of a low level BPO profile (Wald ¼ 4.58, df ¼ 1, Exp.B 0.23; 95% CI interval for Exp.B: 0.06–0.88), indicating that people who have been raised in an orthodox Protestant environment are less likely to have this personality organization than those raised elsewhere, independent of present adherence.
4.3.5.10 Do current orthodox adherence and an orthodox Protestant upbringing influence the manifestation of B cluster pathology among those with a low level BPO profile? To answer this question two 2-Way MANCOVAs were carried out with present orthodox adherence or having or not having been raised in an orthodox Protestant denomination and the presence or absence of a low level BPO profile as the fixed factors, and the four DSM-IV Personality Disorder Scales as the dependents. Gender and/or age and civil status were entered as covariates. The first MANCOVA, with current orthodox adherence as one of the fixed factors, showed significant main effects of medium size for both current orthodoxy (F(4,154) ¼ 4.09, p < 0.01, h2p ¼ 0:10) and presence of the low level BPO profile (F(4,154) ¼ 4.36, p < 0.01, h2p ¼ 0:11). Those with current orthodox protestant adherence scored significantly lower on APD (F(1,153) ¼ 12.13, p < 0.001; h2p ¼ 0:08), on BPD (F(1,153) ¼ 10.20, p < 0.01, h2p ¼ 0:07, and on HPD (F(1,153) ¼ 4.99, p < 0.05, h2p ¼ 0:03) features. Those with a low level BPO profile scored significantly higher on three of the four cluster B features: APD (F(1,153) ¼ 13.30, p < 0.001, h2p ¼ 0:08); HPD (F(1,153) ¼ 9.71, p < 0.01, h2p ¼ 0:06); NPD (F(1,153) ¼ 6.06, p < 0.05, h2p ¼ 0:04). The effect of the interaction between the presence or absence of a low level BPO profile and current orthodox protestant adherence was not significant (F(4,153) ¼ 1.21, p ¼ 0.31, h2p ¼ 0:03) indicating that current orthodox Protestant adherence does not influence the manifestation of cluster B traits among those with an underlying impulse ridden personality structure. The second MANCOVA showed significant and large main effects for both orthodox upbringing (F(4,132) ¼ 4.86, p < 0.01, h2p ¼ 0:14,) and presence or absence of a low level BPO profile (F(4,132) ¼ 6.19, p < 0.001, h2p ¼ 0:17). Those with an orthodox upbringing scored significantly lower on the APD (F(1,132) ¼ 18.44, p < 0.001, h2p ¼ 0:13;), on the BPD (F(1, 132) ¼ 4.18, p < 0.05, h2p ¼ 0:03), and on the HPD (F(1,132) ¼ 4.95, p < 0.05, h2p ¼ 0:04). Those with a low level BPO profile scored significantly higher on three of the four cluster B Disorders: APD (F(1,132) ¼ 20.25, p < 0.001, h2p ¼ 0:14); HPD
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(F(1,132) ¼ 8.08, p < 0.01, h2p ¼ 0:06); NPD (F(1,132) ¼ 6.87, p < 0.01, h2p ¼ 0:05). In addition there was a significant and almost large effect of the interaction between orthodox upbringing and the presence or absence of a low level BPO profile (F(4,133) ¼ 4.25, p < 0.01, h2p ¼ 0:12). In general, patients with a low level BPO profile who had been raised in an orthodox Protestant environment scored lower than patients with this profile who had been raised elsewhere. There was a significant univariate interaction effect for the APD (F(1,132) ¼ 15.88, p < 0.001, hp2 ¼ 0.11), implying that patients with a low level BPO profile who had been raised in an orthodox Protestant environment score particularly lower on antisocial traits (M ¼ 2.33, SD ¼ 3.75) than patients with this profile who had been raised elsewhere (M ¼ 9.80, SD ¼ 6.30). In other words, only an orthodox Protestant upbringing, and not present orthodox Protestant adherence, seems to be negatively associated with antisocial traits in persons who, due to their underlying personality organization, are prone to low moral standards, acting out and non-conformity.
4.3.6
DISCUSSION
The results of this study suggest that current orthodox Protestant adherence and orthodox Protestant upbringing relate in different ways to the manifestation of externalizing personality pathology, despite the rather large overlap among the two variables. As expected, an orthodox Protestant upbringing was the only predictor of lower scores on antisocial features in this sample of personality disordered patients. In addition, only an orthodox Protestant upbringing predicted the absence of a low level BPO profile, characterized by low self-control and low moral standards [24]. Finally, only an orthodox Protestant upbringing was associated with fewer features of APD traits among those with an underlying impulse ridden personality structure: patients with a low level BPO profile, who are otherwise typically characterized by antisocial tendencies and low self-control, report much less antisocial tendencies when they have been raised in an orthodox Protestant environment as compared to patients raised in another non-Protestant orthodox parental environment. In other words, patients with low self-control who are structurally at risk for antisocial behavior do not report this behavior in the case of an orthodox Protestant upbringing. Therefore, results suggest, in concordance with the results of Welch et al. [7], that the effect of religiosity on conformity and misbehavior is not mediated by selfcontrol, because low self-control is an inherent feature of all low level BPO patients. However, findings do suggest that the symptomatic manifestation of an underlying impulsive personality structure (i.e. lack of self-control) is moderated by an orthodox upbringing. A very important issue to consider is the following: the present study only used a selfreport questionnaire to assess cluster B personality disorder pathology. Self-reports are vulnerable to the effect of social desirability. So it remains unclear whether patients who have been raised in or who currently belong to an orthodox Protestant denomination are indeed less antisocial or whether they have the tendency, more so than those who have been raised elsewhere or than those without current orthodox adherence, to deny antisocial traits and behavior. However, this self-report explanation does not account for the particularly strong independent effect of orthodox upbringing on the manifestation of antisocial traits. Results suggest that it is not so much current orthodox Protestant adherence that is
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negatively related to antisocial traits and structural low level borderline personality pathology, as whether a patient has been raised in an orthodox Protestant denomination or not. The importance of the early environment in the inhibition of the manifestation of antisocial traits is further underlined by the finding of a significant interaction between the presence of a low level BPO profile and an orthodox Protestant upbringing, especially with regard to antisocial traits. The fact that current orthodox Protestant adherence did not have an independent effect on manifestation of antisocial traits is in line with Rizzuto’s [32] object relational theory on God images, which emphasizes the role of parent-child interactions during early stages of development in the construction of the God image. It is possible that the emphasis orthodox families put on being rule-obedient and being submissive to the father as head of the family may very well have resulted in an image of God as a ruler who punishes in the case of transgressions, as someone who notices every sin and who will judge every man by his works at the Last Judgment [13, 14, 16]. This parental environment may subsequently have resulted in a high level of conformity which, in turn, may prevent the development of antisocial traits and behavior, even among those with an impulse ridden personality structure. In contrast, and against expectations, low scores on the Borderline Disorder were mainly predicted by current orthodox Protestant adherence, whereas orthodox Protestant upbringing did not have independent predictive power. This implies that those with current orthodox adherence report less severe borderline traits, independent of the fact of whether they have been raised in an orthodox environment or not. The social desirability phenomenon may also explain the lower scores on the BPD of both the patients raised in an orthodox environment as well as those with current orthodox adherence, compared with the patients raised elsewhere and without current orthodox adherence respectively. However, this social desirability explanation does not account for the particularly strong effect of current adherence on the manifestation of borderline features. A possible alternative explanation for this finding is therefore that being part of an orthodox Protestant religious culture may provide a lot of external structure which, in turn, may have an inhibitory effect on the manifestation of borderline pathology. Results of De Lely, Mulder & Birkenh€ager [33] may provide a third possible explanation. These authors studied the severity of self-reported depression using the Beck Depression Inventory among currently orthodox Protestant patients diagnosed with a clinical depression and found that these patients scored lower on the self-report than non-orthodox depressed patients. De Lely et al. explain this effect by referring to the culture of the orthodox Protestant denomination, where suffering is seen as an essential part of life, about which a patient is not allowed to complain. Also Boomsma et al. [8] found that religious people scored lower on anxiety and depression. Therefore, the negative association between current orthodox Protestant denomination and self-reported BPD symptom severity may alternatively be explained by the culturally determined ‘rule’ to deny suffering, a rule that is less important to those who at present do not belong to an orthodox Protestant culture, even if they have been raised in an orthodox Protestant denomination. Likewise, Schaap-Jonker, Eurelings-Bontekoe, Zock and Jonker [13] found that belonging to a current orthodox Protestant denomination had a diminishing effect on the experience of religious conflict among patients. It was suggested that an orthodox Protestant culture does not allow patients to experience religious conflict. Interesting to note is that Boomsma et al. [8] also found a more defensive test-taking attitude among religious participants, but these authors did not further discuss this finding.
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To the best of our knowledge, no author has ever suggested that the frequently reported positive effects of religion on health and well-being may be partly linked to this tendency of orthodox religious people to deny suffering on self-reports. As Corveleyn and Luyten [34] describe, most studies in this field have used self-reports to assess well-being. The potential impact of a culturally determined negative attitude concerning complaining may shed a completely different light on the results of studies that, in general, find a positive association between religiosity and well-being [9] in cases where only self-reports have been used to assess well-being. In agreement with Corveleyn and Luyten [34], we would like to make a strong plea for the use of indirect methods of assessment of psychopathology in addition to self-reports in future studies on the association between religiosity and mental health to bypass this potential bias. Many reliable and valid indirect assessment methods are available nowadays that could be used in such studies, such as the Rorschach Comprehensive System [35–38] or the Social Cognition and Object Relation Scale. The latter is a well validated system (for a review see Huprich & Greenberg [39]) that can be scored on Thematic Apperception Test narratives [40–42]. The Rorschach enables the clinician to indirectly assess several indices of depression and coping deficits. Regarding the SCORS, the dimension ‘Affect tone of Relationship Paradigm’ might be of interest, measuring the affective quality of interpersonal relationships and the extent to which the patient expects positive outcomes from social interactions. Finally, results suggest that an orthodox religious upbringing needs to be taken into account as well in studies on the association between crime and religiosity.
4.3.6.1
Limitations of the study
The results of this study need to be viewed in the context of several limitations. First, the study was cross-sectional, implying that results do not allow for causal inferences. Hence results, particularly concerning orthodox upbringing, must be viewed as a ‘context of discovery’ i.e. as a source of hypotheses about the potential effect of the early environment on the manifestation of externalizing personality pathology; hypotheses that need to be tested in longitudinal studies [33]. Participants were recruited from Christian mental healthcare centers, resulting in an overrepresentation of persons with an orthodox religious upbringing and from a current orthodox Protestant denomination. Therefore, the results of this study need to be confirmed using a sample that is less biased towards orthodoxy. In addition, since the sample consisted of personality disordered patients only, it remains unclear whether results may be generalized to normals or non-personality disordered patients.
4.3.6.2
Clinical implications
It seems to be of importance to ask about both orthodox religious upbringing and current orthodox Protestant adherence during the initial assessment of religious patients. If a patient, especially a male patient, reports belonging to a current orthodox Protestant denomination, the severity of borderline symptoms may be under-diagnosed in cases where only self-report questionnaires are being used in the assessment procedure. Therefore, it may also be necessary to apply structured clinical interviews to the assessment of
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DSM–IV Personality Disorders, such as the International Personality Disorder Examination [IPDE; 43], for these patients to prevent under diagnosis of borderline pathology. In addition to the assessment of descriptive (DSM-IV) personality pathology, assessment of structural personality pathology, for instance by using the DSFM profile interpretation, may be useful. Although the prevalence of the low level BPO profile is relatively low among those who have been raised in an orthodox religious environment, if such a profile is present among these patients externalizing tendencies may be missed completely. The behavioral inhibition and social conformity, with which the low level borderline organized patients raised in an orthodox environment may present themselves initially, may suggest that an insight-oriented treatment may be most appropriate. However, since this profile refers to an underlying proneness to impulsivity, non-conformity and acting out under stressful, unstructured conditions, this proneness may become visible later on during treatment, especially in the case of expressive forms of treatment that are aimed at breaking down defense mechanisms, which, among these patients, may have an important function in compensating for their ego-defects.
ACKNOWLEDGMENTS Authors are grateful to Gerdy Rietveld, Corrie van Veenendaal, Astrid van Vuuren, Peter Lanser and Leendert van Rijn for their assistance in collecting the data.
REFERENCES 1. Baier CJ & Wright BRE (2001) ‘If you love me, keep my commandments’: a meta-analysis of the effect of religion on crime. Journal of Research in Crime and Delinquency 38, 3–21. 2. Benda BB (1997) An examination of a reciprocal relationship between religiosity and different forms of delinquency within a theoretical model. Journal of Research in Crime and Delinquency 34, 163–186. 3. Cochran JK, Wood PB & Arneklev BJ (1994) Is the religiosity-delinquency relationship spurious? A test of arousal and social control theories. Journal of Research in Crime and Delinquency 31, 92–123. 4. Chu DC (2007) Religiosity and desistance from drug use. Criminal Justice and Behavior 34, 661–679. 5. Johnson BR, Jang SJ, Larson DB & De Li S (2001) Does adolescent religious commitment matter? A reexamination of the effects of religiosity on delinquency. Journal of Research in Crime and Delinquency 38, 22–44. 6. Johnson BR, De Li S, Larson DB & McCullough M (2000) A systematic review of the religiosity and delinquency literature. Journal of Contemporary Criminal Justice 16, 32–52. 7. Welch MR, Tittle CR & Grasmick HG (2006) Christian religiosity, self-control and social conformity. Social Forces 84, 1605–1623. 8. Boomsma DI, Geus EJC de, Baal GCM van & Koopmans JR (1999) A religious upbringing reduces the influence of genetic factors on disinhibition: Evidence for interaction between genotype and environment on personality. Twin Research 2, 115–125. 9. Ellison CG, Boardman JD, Williams DR & Jackson JS (2001) Religious involvement, stress, and mental health: findings from the 1995 Detroit Area Study. Social Forces 80, 215–249. 10. Stoffels H (1995) Als een briesende leeuw: Orthodoxe-protestanten in de slag met de tijdgeest. (As a roaring lion. Orthodox protestants fighting a battle against the spirit of the age.) Kok, Kampen.
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11. Dekker G, Hart JJM de & Peters JWM (1997) God in Nederland. 1966–1996. (God in the Netherlands. 1966–1996.) Anthos, Amsterdam. 12. Knopik VS, Heath AC, Madden PAF, Bucholz KK, Slutske WS, Nelson EC, Statham D, Whitfield JB & Martin NG (2004) Genetic effects on alcohol dependence risk: re-evaluating the importance of psychiatric and other heritable risk factors. Psychological Medicine 34, 1519–1530. 13. Schaap-Jonker H, Eurelings-Bontekoe EHM, Zock H & Jonker ER (2007) The Personal and Normative Image of God: the Role of Religious Culture and Mental Health. Archive for the Psychology of Religion 29, 305–318. 14. Schaap-Jonker H, Eurelings-Bontekoe E, Verhagen PJ & Zock H (2002) Image of God and personality pathology: an exploratory study among psychiatric patients. Mental Health, Religion & Culture 5, 55–71. 15. Eurelings-Bontekoe EHM, Hekman-Van Steeg J & Verschuur MJ (2005) The association between personality, attachment, psychological distress, church denomination and the God concept among a non-clinical sample. Mental Health, Religion & Culture 8, 141–154. 16. Schaap-Jonker H, Eurelings-Bontekoe EHM, Zock H & Jonker ER (2008) Development and Validation of the Dutch Questionnaire God Image: effects of mental health and religious culture. Mental Health, Religion & Culture 11, 501–515. 17. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Washington D.C. 18. Dowson J, Bazanis E, Rogers R et al. (2004) Impulsivity in patients with Borderline Personality Disorder. Comprehensive Psychiatry 45, 29–36. 19. Kernberg OF & Caligor E (2005) A psychoanalytic theory of personality disorders. In: Lenzenweger MF & Clarkin JF (eds.), Major theories of personality disorder, 2nd edn. Guilford Press, New York, pp. 114–156. 20. Norring C (1993) Borderline Personality Organization and prognosis in eating disorders. Psychoanalytic Psychology 10, 551–572. 21. Kernberg O (1975). Borderline Conditions and Pathological Narcissism. New York: Yason Aronson. 22. Eurelings-Bontekoe EHM, Onnink A, Williams M & Snellen WM (2008) A new approach to the assessment of structural personality pathology. Theory driven profile interpretation of the Dutch Short Form of the MMPI. New Ideas in Psychology 26, 23–40. 23. Eurelings-Bontekoe EHM, Luyten P & Snellen WM (2009) Validation of the theory driven profile interpretation of the Dutch Short form of the MMPI using the TAT Social Cognition and Objectrelations Scale (SCORS). Journal of Personality Assessment 9, 155–165. 24. Eurelings-Bontekoe EHM, Luyten P, Remijsen M & Koelen JA. Association between personality organization as assessed by theory driven profiles of Dutch Short Form of MMPI and self-reported structural personality pathology. Under review. 25. Duijsens IJ, Bruinsma M, Jansen S, Eurelings-Bontekoe EHM & Diekstra RFW (1996) Agreement between self-report and semistructured interviewing in the assessment of personality disorders. Personality and Individual Differences 21, 261–270. 26. Duijsens IJ, Eurelings-Bontekoe EHM & Diekstra RFW (1999) The VKP-IV. DATEC, Leiderdorp. 27. World Health Organization (1993) The ICD-10 Classification of Mental and Behavioral Disorders. Diagnostic Criteria for Research. World Health Organization, Geneva. 28. Luteijn F & Kok AP (1985) Herziene Handleiding NVM. (Revised Manual DSFM). Harcourt International, Lisse. 29. Eurelings-Bontekoe EHM, Dam A van, Luyten P, Verhulst W, Tilburg C van, Heus P de & Koelen JA (2009). Structural diagnosis using Dutch Short Form of MMPI profiles predicts drop out and treatment response in short term cognitive behavioral group therapy for axis I disorders. Journal of Personality Assessment. 91(5) 439–462.
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30. Eurelings-Bontekoe EHM, Luyten P, Ijssenagger M, Koelen JA & Vreeswijk M van. The relationship between Young’s cognitive model of personality disorders and personality organization. Under review. 31. Cohen J (1988) Statistical Power Analysis for the Behavioral Sciences. Erlbaum, Hillsdale, NJ. 32. Rizzuto AM (1979) The Birth of the Living God. University of Chicago Press, Chicago. 33. Lely AA de, Broek van den WW, Mulder PGH & Birkenhager TKS (2009) Symptomen bij een depressie; bevindelijk gereformeerden versus niet-kerkelijke patienten (Symptoms of depression in strict calvinistic patients and in patients without religious affiliations: a comparison). Tijdschrift voor Psychiatrie 51, 279–289. 34. Corveleyn J & Luyten P (2005) Psychodynamic psychologies and religion. Past, present, and future. In: Paloutzian RF & Park CL (eds.) Handbook of the Psychology of Religion and Spirituality. Guilford Press, New York, pp. 80–100. 35. Exner JE (1991) The Rorschach: A Comprehensive System (Vol. 2: Interpretation) 2nd edn. Wiley, New York. 36. Exner JE. (1993) The Rorschach: A Comprehensive System (Vol. 1: Basic Foundations; 3rd edn.) Wiley, New York. 37. Exner JE (2000) A primer for Rorschach Interpretation. Rorschach Workshops, Asheville NC. 38. Exner JE (2001) A Rorschach workbook for the Comprehensive System, 5th edn. Rorschach Workshops, Asheville NC. 39. Huprich SK & Greenberg RP (2003) Advances in the assessment of object relations in the 1990s. Clinical Psychology Review 23, 665–698. 40. Westen D (1985) Social Cognition and Object Relations Scale. Original manual to use for training. University of Michigan: Department of Psychology. 41. Westen D, Lohr N, Silk KR, Gold L & Kerber K (1990) Object relations and social cognitions in borderlines, major depressives, and normals: a thematic apperception test analysis. Psychological Assessment 2, 355–364. 42. Westen D (1991) Clinical Assessment of Object Relations Using the TAT. Journal of Personality Assessment 56, 56–74. 43. Loranger AW, Sartorius N, Andreoli A e.a. (1994) The International Personality Disorder Examination. Archives of Psychiatry 51, 215–224.
CHAPTER 4.4
When Religion Goes Awry: Religious Risk Factors for Poorer Health and Well-Being1 Hisham Abu Raiya Psychology Fellow, United States of America
Kenneth I. Pargament Professor of Psychology, United States of America
Gina Magyar-Russell Psychologist, Instructor of Psychiatry and Behavioral Sciences, United States of America
4.4.1
INTRODUCTION
Religious practices and beliefs are prevalent and important to people in many countries around the world [3]. For example, Gallup polls indicated that 96% of persons living in the United States believe in God, over 90% pray, 69% are church members, and 43% attended church, synagogue, or temple within the past seven days [4]. A Canadian opinion poll in 1993 found that 78% of Canadians affirmed belief in God, with 67% ascribing to the basic tenets of Christianity [5]. Surveys carried out in Israel revealed that between 15–25% of Israeli Jews identify themselves as religious, and 40–50% identify themselves as traditional [6]. In a survey carried out among 1000 Muslim Lebanese, 60% of the respondents considered themselves either religious or very religious, 49% reported praying daily, 53% indicated fasting regularly during the month of Ramadan and 61% reported reading the Holy Qura’n weekly or more [7]. A survey conducted among 181 Hindu individuals living in the United States found that, on average, participants were moderately involved in Hindu religious beliefs and practices [8]. Yet, although religion is a significant human phenomenon, it has received little attention in the mainstream of modern psychological inquiry [9]. Before the 1990s, the relationship 1
Portions of this chapter are drawn from [1] and [2].
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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between religion and health was a neglected area of research; researchers often buried ‘religious’ variables in the methods and results sections of their studies [10]. More recently, the field of psychology has begun to display a growing interest in the influence of religion on people’s psychological well-being [11]. Survey data have revealed clear links between religion and mental and physical health. As a whole, these studies, conducted mostly among Christian samples in the United States, indicate that a greater degree of religious involvement is generally beneficial. Though important, these findings are based on brief, global indices of religion, such as frequency of prayer, self-rated religiousness and frequency of church attendance. Unfortunately, using global indices to assess such a multi-dimensional complex phenomenon can lead to an incomplete and perhaps distorted understanding of religion. Even when significant findings are obtained, we are left with a key question: What is it about religion that can account for these findings? This question cannot be answered unless we get closer to the heart of the religious experience [11]. Stated differently, because religion has been measured in such global ways, these studies provide little information about the ‘specifics’ of religious life. Particularly, this approach to investigation obscures the possibility that certain forms of religiousness have different, even harmful, implications for health and well-being. In this vein, a small but steadily growing body of empirical evidence suggests that some forms of religiousness may be detrimental rather than beneficial. We call these forms of religiousness ‘religious risk factors,’ and they are the focus of this chapter. In what follows, we define religion, suggest criteria for evaluating religion, review theory and empirical evidence relevant to religious risk factors, consider some potential mediators between these risk factors and poorer health and well-being, and point to the clinical implications of this emerging line of study. We conclude by discussing promising directions for future research. We would like to emphasize from the onset that, by drawing exclusive attention to religious risk factors in this chapter, we are not suggesting that religion is generally more destructive than constructive. On the contrary, empirical evidence reveals largely positive associations between religiousness and different indices of health and well-being. Yet, it is important to move from the general to the specific. To achieve a balanced and complete understanding of perhaps the most distinctively human dimension of life, religion, it is crucial for psychologists and mental health professionals to learn about its different manifestations, the harmful as well as the helpful. With these words of caution in mind, we start by defining religion.
4.4.2
DEFINITION OF RELIGION
What is religion? Social scientists and theologians have offered numerous definitions of religion, but have failed to reach a consensus. This state of affairs led sociologist J. Milton Yinger [12] to conclude, ‘. . . any definition of religion is likely to be satisfactory only to its author’ (p. 108). Here we offer a definition of religion that is relevant to the phenomenon of interest – health and well-being. According to Pargament [13], religion is a ‘search for significance in ways related to the sacred’ (p. 32). This perspective is tailored to the psychological venture, and it excludes concerns about the nature of the sacred that have little to do with significant human issues [14].
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This definition includes two important elements: search for significance, and the sacred. The search refers to the process of discovery of the sacred, conservation of the sacred once it has been found, and transformation of the sacred when internal or external pressures require a change [13, 15]. The search can also be understood in terms of the multiple pathways people take to reach their goals and the goals themselves. Religious pathways encompass multiple dimensions, such as ideology, ethical conduct, emotional experience, social intercourse and study. These pathways can lead to diverse goals. They include personal ends, such as meaning in life and self-development, social ends, such as intimacy with others and justice in the world, and spiritual ends, such as closeness to God and living a moral and ethical life [15]. Pargament and Mahoney [15] define the sacred as divine beings, higher powers, or God and other aspects of life that take on divine character by virtue of their association with the divine. What makes religion distinctive is the involvement of the sacred in the pathways and destinations that define the individual’s search for significance. From this perspective, religion is not a fixed set of beliefs and rituals. It is instead a dynamic process in which the sacred becomes a part of the pathways people take in search of whatever they hold significant, including the sacred itself. This process is multifaceted and individualized because people can follow diverse pathways that change over time to achieve significance. They also seek out many different destinations in living. The sacred, the heart of any religious expression, can also take many forms in the search for significance. This conceptual framework offers the foundation for our discussion of religious risk factors.
4.4.3 4.4.3.1
RELIGIOUS RISK FACTORS Overview
Religion is a double-edge sword. On the one hand, it can be a source of growth, strength and social solidarity. On the other hand, it can be a source of personal strain and cruelty toward others, as we see in all-too-common examples of forced conversions, torture and genocide in the name of whatever people hold sacred. There are many kinds of religious problems. But what makes a problem a religious one? What criteria do we use to decide whether religion is a part of the problem, a part of the solution, or simply irrelevant to the problem at hand? These questions are very important, for if we are to fully understand religion, the ways it functions normally and the ways in which it goes awry, we need some guiding criteria.
4.4.3.2
Criteria for evaluating religion
There types of criteria can be used to evaluate the efficacy of religion: truth-based criteria, pragmatic criteria, and process criteria.
Truth-based criteria Do God and the devil exist? Is there heaven? Do bad people go to hell? These are questions about ultimate truths. To the religiously-minded, the value of religious beliefs is intimately
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linked to truth. However, to psychologists, who adhere to the scientific point of view, these are unanswerable questions. Scientists have no way to measure heaven, spiritual presences, or the divine. Neither can science confirm the truth of divine revelation, biblical miracles, predestination, reincarnation, or life after death. Truth-based criteria then are simply an insufficient basis for psychological evaluations of religion.
Pragmatic criteria William James [16] proposed that instead of focusing on the roots of religion, psychologists should consider its fruits. According to James, the right religion, the ‘true’ religion, is the one that works best. James’ approach was utterly pragmatic. Over the past century, following William James, social scientists have focused their attention on the question ‘how well does religion work’ by testing various correlates and consequences of various religious beliefs and practices. This body of research has revealed important links between religion and health and well-being. However, the pragmatic approach to evaluating religion has shortcomings. First, the findings generated based on this approach as a whole have not been particularly helpful to clinicians, perhaps because the research has been too far removed from the clinical context. For instance, a modest correlation between frequency of prayer and life satisfaction in the general population may be statistically significant, but it may not be clinically significant to the psychologist who needs more individualized and contextualized information. Second, applying pragmatic criteria to the evaluation of religion is not always easy. Consider, for example, a clinician seeing a client for psychotherapy. In many instances, the clinician may not know whether a particular type of religiousness is likely to be constructive or destructive to a client. After all, clients come to treatment in the midst of problems; they are in the process of a journey and it can be difficult to predict where their journey may take them. Finally, though the findings of ties between spirituality and measures of health and wellbeing are noteworthy, they may miss the mark for spiritually-minded clinicians and clients who are most interested in the impact of various spiritual beliefs and practices on spiritual criteria of well-being. Hence, pragmatism seems insufficient as a way of evaluating religion. We believe that a fairer evaluation of religion requires attention not only to the outcomes of religion, but also to the process of religion.
Process criteria At its best, spirituality, like a work of art, reflects the harmonious interplay among numerous ingredients. Even though it is difficult to describe this process in words, a few social scientists and theologians have tried. They depict the highest levels of religiousness in terms of equilibrium, vitality, depth, flexibility and interconnectedness. For example, Gordon Allport [17] likened mature religion to ‘a rich pudding, smooth and simple in its blend, but intricate in its ingredients’ (p. 9). Orlo Strunk [18] described mature religion as ‘a dynamic organization of cognitive-affective-conative factors possessing . . . depth and height’ (p. 144). This is definitely not the language of ultimate truths or outcomes; it is the language of process. When the process is the standard for evaluation, the value of religion rests primarily on its quality.
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How do we define an effective religious process? The answer to this important question does not lie within a particular religious tradition, a single belief, practice, or experience or solely within the individual. Religion is a quality of a person in interaction with situations and his/her larger context. We assert that the most effective types of religiousness are those that are well-integrated, those whose pieces work harmoniously together. On the other hand, problems rise when religion is dis-integrated, when the process is discordant and chaotic. Though evaluating religion from the standard of a process is far from simple, we believe that this is the kind of evaluation clinicians typically use in treatment. For example, Butter and Pargament [19] conducted a study that lends support for this assertion. They constructed six vignettes that described individuals engaging in two types of religiousness: wellintegrated and poorly-integrated. Well-integrated vignettes described people whose spiritually was in accord with their social environment, chose religious coping methods that fit the problem at hand, and sought a balanced set of goals. Poorly integrated vignettes depicted people whose spirituality was in discord with their larger social system, used spiritual methods of coping that were ill-suited to the problem at hand, and sought sacred and secular goals that were out of balance. For example, in one well-integrated vignette, a young man faced with a terminal illness decides it is time to discontinue active treatment and surrender ‘everything to God’s will.’ In a comparable poorly-integrated vignette, a young man diagnosed with a treatable illness also decides to discontinue active treatment and surrender control to God. Butter and Pargament asked 83 mental health professionals and 83 clergy to evaluate the level of adjustment of the person in each vignette and to rate the degree to which religion was helpful or harmful in that scenario. It is important to underscore the fact that none of the vignettes presented an outcome. The only difference between the vignettes was in their degree of spiritual integration. The results were unambiguous. Despite the lack of information about outcomes, both mental health professionals and clergy judged religion to be more helpful in the well-integrated than in the poorly-integrated vignettes, and both groups assessed the participants in the wellintegrated scenarios as better adjusted than those in the poorly-integrated vignettes. Furthermore, clergy and mental health professionals did not differ from each other in their ratings. In short, both groups demonstrated sensitivity to the process of spirituality in their evaluations. What do we mean by spiritual integration? A well-integrated spirituality is defined by pathways that are broad and deep, responsive to life’s situations, nurtured by the larger social context, capable of flexibility and continuity, and oriented toward a sacred destination that is large enough to encompass the full range of human potential. A dis-integrated spirituality, on the other hand, is defined by pathways that lack scope and depth, fail to meet the challenges and demands of life events, clash and collide with the surrounding social system, change and shift too easily or not at all, and misdirect the individual in the pursuit of spiritual value. Using these criteria for evaluating religion, we now point to several religious risk factors. Furthermore, we consider some of the theoretical reasons why these forms of religiousness may pose risks to health and well-being, and review empirical studies that indicate that these risk factors are indeed problematic. The religious risk factors are idolatry, extrinsic religiousness and religious introjection, insecure (avoidant and anxious) attachment to God, poor fit between religion and the situation, religious rigidity, lack of religious depth and breadth, religious extremism, appraisals of sacred loss and desecration, and religious
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struggles. These specific risk factors can be grouped under four large categories: problematic religious motivation, problematic attachment to God, problematic religious integration and problematic ways of religious coping.
4.4.3.3
Problematic religious motivation
According to motivational theory, it matters ‘both what you pursue and why you pursue it’ [20]. This notion can be applied to the religious realm too. Initial empirical research suggests that people who devote more of their energy to the pursuit of spiritual ends experience physical and emotional benefits. Emmons, Cheung and Tehrani [21] asked samples of college and community-based adults to generate their personal strivings and found that those who reported a higher proportion of spiritual strivings (e.g., seeking God’s will; seeking to deepen a relationship with God; attempting to live by one’s spiritual beliefs in daily life) manifested greater purpose in life, marital and overall life satisfaction. Furthermore, the correlations between these spiritual strivings and measures of subjective well-being were stronger than the correlations between all other strivings and well-being. Mahoney et al. [22] applied the construct of sanctification to college students’ perceptions of their bodies. Students completed measures of the extent to which they viewed their bodies as being a manifestation of God (e.g., ‘My body is a temple of God’) and as characterized by sacred qualities (e.g., holy, blessed, sacred). Greater levels of both forms of sanctification were related to higher levels of health-protective behaviors, strenuous exercise, satisfaction with one’s body, and disapproval of alcohol consumption as well as to lower levels of illicit drug use, unhealthy eating practices and alcohol consumption. Conversely, people can sanctify destructive spiritual ends. As Parker Palmer [23] wrote, ‘There are real dangers involved when the sacred gets attached to the wrong things’ (p. 25). Palmer was pointing to idolatry. Idolatry is an issue of motivation; it speaks to the ‘what’ part of the motivational theory. Drugs, alcohol, consumerism and self-worship are a few of examples of idolatry, ‘false gods’ in which people attempt to fill a spiritual vacuum in a destructive manner. Consider the example of an individual who confused his thirst for God with his thirst for alcohol: As my alcoholism progressed, my thirst for God increasingly became transmuted into a thirst for the seemingly godlike experiences that alcohol induced. Alcohol gave me a sense of wellbeing and connectedness – and wasn’t that an experience of God? Alcohol released me from the nagging sense that I was never good or competent enough – and wasn’t that God’s grace? [24, p. 31].
Although we are not aware of any empirical studies of idolatry, there are dramatic cases which point to the harmful ramifications of idolatry for health and well-being. Examples include people who dedicate themselves to tyrannical authority figures, and those who make food, drugs and alcohol the center of their lives. Self-worship is another example of idolatry. Commenting on the prevalence of this phenomenon among Nazis in World War II, Carl Jung [25] wrote: ‘God-almightiness’ does not make man divine, it merely fills him with arrogance and arouses everything evil in him. It produces a diabolical caricature of man, and this inhuman mask is so unendurable, such a torture to wear, that he tortures others. He is split in himself, a prey to inexplicable contradictions’ (p. 215).
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Motivational theory also highlights the importance of why people involve themselves in religion. Psychologist Gordon Allport, in a classic work, distinguished between two religious orientations: the extrinsic and intrinsic. According to Allport and Russ [26], the extrinsic orientation is characteristic of those who: are disposed to use religion for their ends. The term is borrowed from axiology, to designate an interest that is held because it serves other, more ultimate interests. Extrinsic values are always instrumental and utilitarian. Persons with this orientation may find religion useful in a variety of ways- to provide security and solace, sociability and distraction, status and self-justification. The embraced creed is lightly held or else selectively shaped to fit more primary goals. In theological terms, the extrinsic type turns to God, but without turning away from self (p. 441).
On the other hand, intrinsically motivated religious individuals approach their religion as an end in itself. A number of studies have linked higher levels of extrinsic religiousness to poorer mental health [27–29]. For example, in a study of religious college students, Bergin, Masters and Richards [28] found a positive correlation between intrinsic religiousness and sociability, sense of well-being, and tolerance, and a negative correlation between extrinsic religiousness and the same criteria. Khan and Watson [29] used measures of religious orientation to predict the experience of Pakistani Muslims during Eid-ul-Azha, a celebration that marks the end of the Haj. They found that intrinsic orientation was an especially strong predictor of better religious adjustment while the extrinsic-social orientation predicted significantly poor religious adjustment. Likewise, working with four independent Christian samples, Ryan, Rigby and King [30] concluded that two types of internalization (the process through which an individual transforms a formerly externally prescribed regulation or value into an internal one) characterize the interplay between the individual and religion. The first, introjection, is similar to extrinsic religiousness (a partial internalization of religiousness based on self and other-approval-based pressures); the second, identification, is similar to intrinsic religiousness (beliefs based on personal values and volition). They found that higher levels of identification were associated with higher self-esteem, and less depression and anxiety, while higher levels of introjection were related to poorer outcomes on these variables. Taken together, these studies suggest that religiousness poses a greater risk for problems when it is pursued for reasons other than personal conviction.
4.4.4
PROBLEMATIC ATTACHMENT TO GOD
Building on the attachment theory of Bolwby [31], Lee Kirkpatrick [32] asserted that God can also serve as an attachment figure. Kirkpatrick’s assertion seems convincing given the similarities between the ways children perceive parents and God. First, in stressful situations, people often seek closeness to God as children do with parents. Second, God as well as parents can be a safe shelter in perilous times and situations and a secure foundation from which to explore the world with confidence in safer conditions. Third, when they experience separation from God, people often report reacting with distress similar to what the child experiences when separated from his/her parents. Fourth, as with their parents, people’s attachment to God can be insecure as well as secure. In fact, a number of studies show a correspondence between the nature of the child’s attachment to his/her
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parents and the child’s attachment to God [33–35]. For example, working with a college sample, McDonald et al. [34] explored the relationship between parent-child attachment and attachment to God. In addition, they assessed parental spirituality and religious emphasis in the home of participants. They found a correspondence between working models of parents and God. Participants who reported coming from homes that were emotionally cold or unspiritual exhibited higher levels of avoidance of intimacy in their relationship to God, a trend consistent with a Dismissing attachment style. Overprotective, rigid, or authoritarian homes were associated with higher levels of both avoidance of intimacy and anxiety over lovability in relationship to God, a trend characterized by the Fearful attachment style. Finally, like the attachment to parents, the individual’s attachment to God is tied to his/her health and well-being. In support of this assertion, a growing body of literature has linked insecure attachments to God and poorer health and well-being (see [32] for a review). Insecure attachments to God were associated with greater neuroticism and negative affect, and less positive affect [36], greater depression, psychosomatic symptoms, loneliness, and less life satisfaction [37], suicidality [38] and greater likelihood of panic disorder [39]. All in all, this literature suggests that an insecure religious attachment represents a risk factor for the individual’s well-being.
4.4.5
PROBLEMATIC RELIGIOUS INTEGRATION
As mentioned earlier, several theorists suggest that the efficacy of religion may depend not on specific forms of religious beliefs and practices, but rather on the degree to which the individual’s religion is well-integrated or poorly integrated [1, 13, 17]. Below we draw attention to some signs of religious dis-integration.
4.4.5.1
Religious dis-integration
Religious rigidity and inflexibility According to Allport [17], religion is a heuristic, a ‘working hypothesis . . . it can act wholeheartedly even without absolute certainty. It can be sure without being cocksure’ (p. 81). On the contrary, dis-integrated religion is rigid and inflexible, unable to respond to changing individual needs, times, and circumstances. Of course, there are some benefits for rigid systems of belief, one of these is their potential to provide people with a sense of absolute certainty and conviction. On the other hand, they may also push people to extreme undertakings when they feel their beliefs are threatened. For example, Altemeyer and Hunsberger [40] found links between a less flexible religious faith and greater prejudice towards homosexuals as well as other minority groups.
Religiousness that lacks depth and breadth Mature systems of religious belief and practice are capable of providing overarching frameworks of meaning that help people come to terms with the full range of life experiences. In contrast, poorly integrated religious systems lack depth and richness. People can be comforted by the belief in a higher power which insures that good things will happen to good people. Without a richer theology, however, these individuals can be
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thrown into a crisis of spiritual meaning when they face suffering and injustice. William James [16] described this kind of faith as ‘healthy-minded religion’, but criticized it for its narrowness: ‘There is no doubt that healthy-mindedness is inadequate as a philosophical doctrine, because the evil facts which it refutes positively to account for are a genuine portion of reality; and they may after all be the best key to life’s significance, and possibly the only openers of our eyes to the deepest levels of truth’ (p. 160). Conversely, some systems of religious belief focus on the dark-side of life and allow no place for penitence or redemption. Consider for example the ‘religious melancholy’ displayed in the words of Bunyan, ‘I was more loathsome in my own eyes than was a toad; and I thought I was so in God’s eyes too. Sin and corruption, I said, would as naturally bubble out of my heart as water would bubble out of a fountain . . . I thought none but the Devil himself could equal me for inward wickedness and pollution of mind’ (cited in [16], p. 155). Some empirical evidence links a spirituality that lacks breadth and depth with undesirable outcomes. For instance, in a study that speaks to the negative implications of narrow systems of religious belief, Watson, Morris and Hood [41] found that Christian college students who reported higher levels of religious guilt experienced more depression and anxiety. However, when the effects of a measure of grace (e.g., ‘My sins are forgiven’) were considered the effects of religious guilt were diminished. Other studies show that people with a less extensive history of religious and spiritual involvement are less likely to find their spirituality helpful to them in stressful times. For example, among individuals diagnosed with a serious mental illness, those who reported a shorter history of religious coping showed higher levels of symptomatology, including depression, hostility, obsessive-compulsiveness, anxiety, paranoid ideation and psychoticism [42]. After finding similar results in a longitudinal study of religion and life satisfaction, one group of researchers likened religious involvement to a sound investment strategy: ‘Long-term investment in religious capital yields dividends that can compensate for subsequent declines in other human stock’ [43]. Another set of studies indicates that people who compartmentalize spirituality from other aspects of their lives are more vulnerable to psychological problems. For instance, as part of a larger study of religious integration, Weinborn [44] asked members of liberal and conservative churches about the extent to which they agreed with statements such as ‘Religion is only one part of my life’ and ‘There’s a time and place for religion, and a time and a place for other things in life’. Greater religious compartmentalization, Weinborn found, was associated with less life satisfaction, poorer problem solving skills, and lower religious well-being. Overall, these studies suggest that a spirituality lacking scope and depth is less able to serve important psychological functions and can, in fact, contribute to psychological trouble. Not only that; a ‘shaky’ spirituality can lead to still other spiritual problems, for the disparate bits and pieces of spiritual life may clash and collide, resulting in further disintegration.
Religious extremism The problem that emerges when religious means become disproportionate to religious ends, religious extremism, has concerned theorists for a number of years. Violence in the name of the sacred, self-degradation in the pursuit of sacred goals, or scrupulosity that interferes with
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the accomplishment of religious ends are some of the forms religious extremism can take. For example, Greenberg, Witztum and Pisante [45] recounted the case of one scrupulous, Orthodox Jewish man who was tremendously fearful of violating the religious injunction to be ‘clean at all orifices’. To avoid the risk of this transgression, he would spend 20 minutes in the toilet cleaning and checking his anal area before each of his three daily periods of prayer. As a result of the scrupulous attention to his cleanliness, however, he was often late to prayer and failed to fulfill a religious obligation of greater importance than the cleanliness of orifices. Unfortunately, even though it is a central topic of concern today, religious extremism has received little research attention.
4.4.5.2
Problematic ways of coping
Despite the fact that almost all human beings experience life stressors, empirical studies have shown that the relationship between exposure to major life stressors and subsequent physical and mental health is relatively modest [46]. In an attempt to explain these modest associations, coping theorists assert that people are not passive reactive creatures. Rather, they are proactive, goal-directed beings who search constantly for meaning and significance in their lives. When people encounter life events, major as well as minor, they appraise them with regard to their important goals and strivings [13, 47]. A substantial body of research (e.g., [48–49]) has supported the assertion that the impact of life stressors on health and well-being depends at least partially on how people appraise and cope with these critical events. According to Pargament [13], religion can be a vital ingredient of both appraisals and coping. Stressful events have the potential to influence the lives of people spiritually as well as psychologically. Consider for instance the reactions of survivors of clergy sexual abuse. For many of these survivors, the trauma is inherently spiritual. One survivor described the decision she reached after being sexually abused in her church using the following straightforward words, ‘I don’t think I’ll ever step foot in a church again . . . I lost my religion, faith, and ability to trust adults and institutions’ [50, p. 8]. When people appraise life events, they do not overlook the implications of these events for their spirituality. Stated differently, the sacred is a part of the appraisal and coping process. Religious coping methods, ways of understanding and dealing with negative life events that are related to the sacred, are preferred methods of coping for many people [11]. Although empirical studies have shown that religious involvement in coping is mostly helpful [51–58], a growing body of studies has identified religious risk factors in the coping process [51, 58–62, 64]. Below we draw attention to two of these risk factors: appraisals of life events as losses or violations of the sacred and religious struggles.
4.4.5.3
Appraisals of sacred loss and desecration
When people perceive that negative life events impact a sacred aspect of life, they may be particularly vulnerable to distress, for we are talking about events that are more than traumas or major life stressors; words like these cannot do justice to the spiritual character of these experiences. Elkins [65] puts it nicely: ‘some violations and betrayals . . . wound so deeply that they can only be called abuses to the soul’ (p. 91). Two types of spiritual appraisals of negative events seem to be particularly problematic: the perception that a sanctified object
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has been lost (sacred loss) and the perception that a sanctified object has been violated (desecration). A growing body of research has examined the ties between perceptions of spiritual loss and desecration and subsequent physical and mental health. The results of these studies have been consistent. Appraisals of sacred threat, loss, and violation have powerful ties to psychological well-being [66–70]. Consider the following examples. In a study of college students in Ohio and New York City after the 9/11 attacks, students who perceived the attacks as desecrating sacred values were more likely to experience depression, anxiety and symptoms of post-traumatic stress disorder [67]. Working with 117 adults selected randomly from the community, Pargament et al. [68] found that people who experienced life events that were perceived to be sacred losses or violations of the sacred (i.e., desecrations) reported higher levels of emotional distress. More specifically, sacred loss was predictive of intrusive thoughts and depression, and desecration was tied to more intrusive thoughts and greater anger. Furthermore, sacred loss was linked to greater posttraumatic growth and positive spiritual change; in contrast, desecration was associated with less posttraumatic growth. Magyar-Russell [69] conducted a longitudinal investigation of the implications of religious/spiritual appraisals and coping strategies on mental and physical health following unexpected physical trauma. Fifty-four inpatient medical rehabilitation patients who sustained a variety of unanticipated traumas (e.g., stroke, spinal cord injury, traumatic brain injury, amputation, neurological syndromes) were orally administered a series of questionnaires at three assessment periods: admission, discharge, and 6–8 weeks’ post-discharge. Participants who experienced their accident, illness, or injury as a sacred loss at admission reported greater depression at discharge and six weeks following discharge. Greater appraisals of desecration at admission were predictive of higher levels of anxiety at admission and greater depressive symptoms six weeks post discharge. At the six-week follow-up period, greater perception of both sacred loss and desecration were significant predictors of decreased spiritual well-being. The results of this longitudinal study suggest that appraisals of sacred loss and desecration significantly affect adjustment following trauma.
4.4.5.4
Religious struggles
Over the course of their lives, people encounter different challenges that impact many domains: the personal, the interpersonal and the social. The religious domain is no exception. In the past decade, researchers have begun to address the spiritual struggles that arise in response to critical events. Research has demonstrated that individuals are susceptible to religious or spiritual challenges that overpower their spiritual resources in times of stress [13, 59, 71–73]. Major life events (e.g., loss of a beloved one, sexual abuse) can shake or shatter previously held assumptions about the benevolence, justice and meaningfulness of the world [74]. These events can also disrupt religious assumptions, such as the belief in a benevolent and loving God. When this ‘spiritual upheaval’ occurs, people may respond with religious struggles. Spiritual or religious struggles are ‘expressions of conflict, question and doubt regarding matters of faith, God and religious relationships’ [64; p. 1470]. Researchers have identified three types of spiritual struggles: divine, intrapsychic and interpersonal. Divine struggles refer to tension in the individual’s relationship with the divine. This tension might be
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manifested in questions about the benevolence and power of God, feelings of divine abandonment and anger toward God. Intrapsychic religious struggles are characterized by questions and doubts about spiritual beliefs and issues, such as the belief in the afterlife and the applicability of religious doctrines to the modern times. Interpersonal spiritual struggles include spirituality-related conflicts with family, friends and congregations. Spiritual struggles are not uncommon. For example, Johnson and Hayes [75] surveyed over 5000 college students. Twenty-five percent of these students reported significant distress associated with their religious and spiritual concerns. In a study of patients with different types of illnesses (diabetes mellitus, congestive heart, oncological problems), 15% of the total sample reported moderate to high levels of spiritual struggle [76]. Spiritual struggles may be rooted in various causes but are notably associated with life crises [77]. Smucker [78] refers to these events or circumstances as ‘breaking the web of life.’ Physical health problems that threaten one’s sense of mortality can serve as especially powerful precipitants of spiritual struggles [62, 79–80]. For example, Sherman, Simonton, Latif, Spohn and Tricot [62] studied 213 multiple myeloma patients and found that negative religious coping (a measure of religious struggle) was associated with a variety of indices of poorer health: fatigue, pain, clinician and self-rated depression, distress and mental health. Manning-Walsh [79] reported that spiritual struggle, as measured by the negative religious coping subscale of the Brief RCOPE, was significantly linked to lower quality of emotional and spiritual life and lower life satisfaction in a sample of women who had recently undergone surgical intervention for breast cancer. Results of studies of religious struggles are strong and consistent. Religious struggles, in all forms (i.e., divine, intrapsychic, interpersonal) have been associated with poorer health and well-being, even mortality. In a two-year longitudinal study of medically ill, elderly patients, Pargament, Tarakeshwar and Hahn [72] found that, after controlling for other variables (illness severity at baseline, mental health status, demographic variable), negative religious coping was associated with a significantly greater risk of dying. Specifically, people who felt that God had abandoned them, who questioned God’s love and care, and who felt that the devil was at work in their illness had a 19 to 28% increased risk of dying. This was perhaps the first study that has established a tie between certain forms of religious expression and risk of mortality. Signs of religious struggles have been linked to declines in physical health. For example, working with 96 medical rehabilitation inpatients, Fitchett [81] found that negative spiritual coping was predictive of poorer physical recovery (limited recovery in activities of daily living, such as walking, cooking, bathing) over a four-month follow-up period, even after controlling for demographic factors, social support, depression and level of independent functioning at admission. One type of negative spiritual coping, feeling anger toward God, was a particularly powerful predictor of compromised physical recovery in this patient sample. In a longitudinal study of religious struggles among 596 medically ill patients age 55 and over, negative religious coping at baseline predicted increases in depressed mood and declines in physical functional status and quality of life over a two-year period after controlling for selective attrition, mortality, demographic factors, and baseline physical and mental health [82]. Numerous studies have linked signs of religious struggle to poorer mental health and even psychopathology [38, 51, 58–64, 69, 83–85]. Below we draw attention to some examples. Cole [63] compared the efficacy of spiritually-focused therapy for people diagnosed with cancer to a no-treatment control condition. One of the major findings of her study was that
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negative religious coping was correlated with greater depression, anxiety, pain frequency and severity, and poorer overall physical well-being. Studying a large sample of racially diverse female trauma survivors, Fallot and Hackman [85] reported that negative religious coping was linked to more symptoms of posttraumatic stress and overall severity of mental health problems. Exline and her colleagues [38] found that both college students and adults in outpatient psychotherapy who reported higher levels of alienation from God also indicated higher level of depression. College students who expressed difficulty forgiving God reported higher levels of depression, anxiety, trait anger, and difficulty forgiving oneself and others [60]. McConnell and Pargament et al. [64] investigated the relationship between spiritual struggles and various types of psychopathology symptoms. As they predicted, negative religious coping was significantly linked to various forms of psychopathology, including anxiety, phobic anxiety, depression, paranoid ideation, obsessive–compulsiveness, and somatization, after controlling for demographic and religious variables. The vast majority of spiritual struggles studies cited earlier were conducted with Christian samples. However, a few empirical studies of non-Christian samples generated similar results, testifying to what may be the universality of spiritual struggles. For example, working with a sample of 75 Jewish 6th-8th graders, Dubow, Pargament, Boxer and Tarakeshwar [86] reported that connectedness to religion and culture among Jewish adolescents may increase their likelihood of experiencing stressful life situations such as exposure to anti-Semitic comments and peer conflicts. These religious stressors were associated with spiritual struggles in the form of questioning the omnipotence of God and His care, and wondering ‘What I did for God to punish me?’ Tarakeshwar, Pargament and Mahoney [87] developed a measure of religious coping among Hindus living in the United States. Factor analysis of the measure yielded three factors, one of which was ‘religious guilt, anger and passivity.’ They found that more use of strategies based on religious guilt, anger and passivity was associated with lower life satisfaction and greater depressed mood. Working with a sample of 340 Muslims from all over the world, Abu Raiya, Pargament, Mahoney and Stein [58] developed a valid and reliable Psychological Measure of Islamic Religiousness. Factor analysis of the measure yielded seven factors, one of which was Islamic religious struggle. This factor was a strong predictor of poorer health and wellbeing, including greater levels of negative outcomes (angry feeling, alcohol use, depressed mood) and lower levels of positive outcomes (positive relations with others, purpose in life). Hence, the authors coined the Islamic religious struggle factor the ‘negative predictor’ of Islamic religiousness. Ai, Peterson and Huang [55] collected information about religiousness, war-related trauma, religious-spiritual coping, optimism and hope from a sample of 138 Muslims who escaped from Kosovo and Bosnia and settled in the United States. Using a path model, they found that negative religious coping was negatively associated with hope and positively associated with more severe trauma. It seems that religious struggles symbolize the ‘dark night of the soul’ [88]. Their negative impacts are found across different religious groups and cultures. Initially, these findings surprised us. After all, from Abraham to Moses to Buddha to Jesus to Muhammad to Mother Teresa, illustrious religious figures have experienced their own religious struggles only to come out the other side steeled and strengthened. How can these findings be explained? One key may be whether the individual is able to resolve his or her struggles. Some recent analyses suggest that those who are unable to solve their struggles over time are at greater risk of poorer mental and physical health, while people who experience these struggles
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temporarily do not face the same risk [82]. Another key may be the degree to which religious struggles are socially acceptable [58]. Finally, it is important to recognize that religious stress and turmoil offer the possibility of growth, as Exline and Rose [89] noted: ‘Perhaps . . . the opportunity for struggle is actually one of the greatest gifts that religion and spirituality have to offer’ (p. 325). Nevertheless, even though some studies suggest positive links between religious struggles and growth, the weight of the evidence is clear and leads to a straightforward conclusion: certain forms of religion can pose a significant risk to health and well-being.
4.4.5.5 Problematic types of religiousness and poorer health and well-being – potential mediators In an attempt to clarify the workings of religion, many researchers are examining questions about potential mediators of the relationship between religion and well-being. For example, can the relationship between church attendance and lower rates of mortality be explained by the social support members receive from the church or the sense of meaning received from religious doctrine? Can the relationship between religious struggles and negative outcomes be explained by the degree to which the individual is able to work struggles through or the extent to which the individual’s community accepts these struggles? Identifying the mechanisms through which religion and spirituality exert their impact on health and well-being is one of the most critical areas of inquiry for social scientists who study associations between religion and health. Although evidence is limited, especially with regard to the manner in which specific forms of religiousness lead to negative health effects, recent empirical and theoretical work has begun to shed some light on these fundamental questions. Different mechanisms and variables have been proposed as potential mediators between religiousness in general and problematic types of religiousness in particular, and health and well-being. Some of these variables are social and psychological in nature. For instance, the relationship between religious involvement and poorer health may be due to members feeling judged or criticized when their behaviors, attitudes and opinions differ significantly from the teachings and the ideals of their religious congregation. Some members may also experience deep resentment and discontent with regard to the behavior of other members of their religious or spiritual communities who do not share their sacred ideals. The ties between religious risk factors and poorer health outcomes may be also mediated through fundamental cognitive and emotional disorientation (e.g., low self-confidence and selfworth, lack of meaning in life, hopelessness, feelings of guilt, shame, and fear) associated with these religious risk factors. Furthermore, some personality traits may act as mediators between religious risk factors and poorer health and well-being. For example, working with a sample of college students, Exline et al. [60] found that trait anger linked difficulty forgiving God with negative emotion. A growing body of empirical research has generated some evidence which suggests that proximal religious variables may be strong mediators of the relationships between more general measures of religiousness and health outcomes [13, 70, 90]. For instance, in their studies of spiritual appraisals, Pargament et al. [90] consistently found that the links between spiritual appraisals and outcomes were partially mediated by positive and negative methods of religious coping. More specifically, perceptions of sacred loss and desecration were more
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likely to predict negative mental and physical health when negative religious coping strategies were used. On the other hand, participants were more likely to report personal and spiritual growth and positive affect when they engaged in positive religious coping strategies in response to appraisals of sacred loss and desecration. Abu Raiya, Pargament, Trevino & Mahoney [70] found that the links between the perceptions that Muslims desecrate Christian values and teaching and anti-Muslim attitudes were partially mediated by religious coping. Specifically, perceptions of desecration were likely to predict less antiMuslim attitudes when positive religious coping methods (i.e., learning from Islamic spiritual models) were used, and more anti-Muslim attitudes when negative religious coping methods were used (i.e., punished by God, demonization). Religion has also been found to exert its impact on health through physiological and biological mechanisms. In the past decade we have witnessed enormous improvements in technology and the sophistication of measurement of physiological parameters. Studies utilizing these technological advances have indicated a positive relation between religious functioning and physiological systems, such as the immune system, blood pressure, neuroendocrine functioning and regional brain activity (see [91–92]). Almost all studies conducted in this area of research thus far have demonstrated links between physiology and biology and desirable psychological and physical well-being [71, 92–95]. Negative effects of religious involvement on well-being may also be mediated by undesirable physiological and health consequences. Koenig et al. [96] speculated that the association between negative types of religiousness (e.g., internal religious conflict, distressing interpersonal interactions and struggles with the Divine) and the increased susceptibility to illnesses over time might be mediated through increased psychological and physiological stress. Future research on the interrelations between physiological, biological and neurological mechanisms of action, specific types of religious involvement and undesirable health outcomes will certainly advance the scientific understanding of the religion-health connection. We close our discussion about the potential mediators between religious risk factors and poorer health and well-being with a few words of caution. As mentioned earlier, efforts to identify potential mediators are needed to explain how religion works at the psychological and social levels. This is part of our job as researchers and practitioners. Nonetheless, there is an important difference between explaining religious risk factors and explaining them away. A few studies [39, 97–98] have testified to the distinctiveness of religious risk factors with respect to distress. These studies have shown that some problematic types of religiousness may exert direct effect on health and well-being. For example, Trenholm, Trent and Compton [39] investigated the role of religious conflict in individuals with panic disorder. Working with a sample of 60 adults women in one of three groups (panic disorder without therapy, panic disorder in therapy, and therapy patients without panic disorder), they found that religious conflict was a unique predictor of panic disorder, even after controlling for anxiety state, hypochondriacal beliefs, and abnormal illness behaviors and irrational thoughts.
4.4.6
RELIGIOUS RISK FACTORS – CLINICAL IMPLICATIONS
Problematic forms of religiousness are not uncommon. They seem to occur at relatively high rates in the populations studied thus far (approximately 10% to 20%). And as we
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showed earlier, there are some theoretical reasons and a growing body of empirical evidence to suggest that these problematic forms of religiousness, chronic religious struggles particularly, are linked to poorer well-being and greatest risk for declines in health status. However, our goals as psychologists of religion are not limited to describing, explaining and understanding religious phenomena. Our ultimate goal, perhaps, is converting abstract knowledge to practical applications that can benefit people in their communities. What are some of the clinical implications of these findings? One important implication of our findings has to do with the need for early identification of religious risk factors before they become chronic and contribute to poorer health. The assertion that individuals who struggle with these religious risk factors will seek out resources or professional help on their own to address their religious concerns is not supported empirically. For example, working with a sample of 200 newly admitted medical and surgery patients, Fitchett [81] found that compared to patients with less need of spiritual intervention and high spiritual resources, those who were high in need and had a few spiritual resources were less likely to request spiritual help. Therefore, strategies are needed to screen for religious risk factors in healthcare settings and religious congregations. In this vein, Fitchett et al. [59, 76] recommended brief and direct screening questions that address some religious risk factors (e.g., anger at God, fear of punishment by God, disappointments in faith or religious institutions) to determine whether an in-depth spiritual assessment may be warranted. This leads us to the second practical implication of our findings, namely spiritual assessment. As with other important domains in the life of clients, spirituality should be assessed during the intake phase of psychotherapy. However, a dry set of intake questions or a few formal tests of spirituality in the first session or two will not provide the clinician with the information that is needed to move from assessment to intervention; it takes a process to know a process. Spiritual assessment evolves over the course of therapy as the relationship between client and therapist develops. Therapists need to communicate to their clients that they are open to learning and sharing. After setting the stage for ‘spiritual dialogue,’ psychotherapists should address four important areas: the salience of spirituality to the client, the salience of a religious affiliation or community to the client, the salience of spirituality to the problem, and the salience of spirituality to potential solutions. Manifestations of the religious risk factors that we pointed to in this chapter (e.g., religious struggles, problematic attachment to God, religious introjection) and lack of spiritual resources and support should be considered as ‘red flags.’ They should be assessed in depth and addressed comprehensively in the intervention phase of psychotherapy. The third clinical implication is related to intervention. Mental health professionals may be able to intervene effectively at the level of cognitive and spiritual appraisals, as well as assist in modifying potentially maladaptive religious coping strategies in response to adversity. ‘Spiritually integrated interventions’ (see [1, 77, 100] for reviews) in which religious issues and concerns are the focus of clinical attention, have just begun to be scientifically developed and empirically tested. Psychotherapists are also increasingly incorporating a variety of spiritual and religious elements into their work with clients with promising results [9, 97, 100–107]. Below we draw attention to some examples. Genia [107] developed ‘interreligious encounter groups’ that target intrapsychic religious conflict. In such groups, members share, listen to and discuss their internal religious struggles. One interesting fact about this intervention is that it is not exclusive. Rather, its format is inclusive of various faith traditions. This group intervention focuses on enhancing
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religious development through the exploration of religious conflict, the resolution of internal distress, solidification of a spiritual sense of identity and meaning, and the development of personal spiritual goals. Cole and Pargament [108] developed an intervention that focused on religious struggles with the Divine. Specifically, they implemented an intervention to address feelings of spiritual disconnection and conflict with God for cancer survivors. Pargament et al. [101] carried out an 8-week psychospiritual intervention designed to help women draw on their spiritual resources in coping with the challenges of HIV, including spiritual struggles. Similarly, Murray-Swank & Pargament [98] developed a spiritually-integrated intervention to help survivors of sexual abuse come to terms with the psychological, social and spiritual concerns raised by their trauma. The development of interventions for interpersonal religious conflict represents an important area for future research. Forgiveness interventions may be especially promising for people dealing with the profound distress and disillusionment that is triggered by religious and spiritual violations occurring within faith communities (e.g., abuse of privileges, power, and money, clergy sexual abuse) [109]. Finally, several studies have found that different forms of religious psychotherapy were effective with Muslim clients who suffered from anxiety, depression and bereavement [104–106]. In these studies, clients in the groups receiving psychotherapy that included Islamic components (i.e., prayer, expressing repentance and forgiveness, relying on Allah and supplicating to Him in times of needs) responded significantly faster to therapy and manifested better adjustment than those receiving standard treatment. Additional basic and applied research is necessary to advance the development of effective and appropriate interventions for people of various religious faiths and spiritually-oriented belief systems. Like other psychological interventions, spiritually oriented interventions should be tailored to particular groups dealing with particular problems in particular contexts.
4.4.7
CONCLUSIONS AND FUTURE DIRECTIONS
Much of the scientific research on the interface between religion and health has relied upon global measures of religiousness. This body of research, by and large, has shown that religious involvement enhances health and promotes well-being. However, when we take a closer look, we find that religion has its dark, harmful side. In this chapter, we have focused exclusively on religious risk factors for poorer health and well-being. In attending to the dark side of religion, however, we did not aim to challenge the positive role of religion and spirituality. In fact, we believe religion is largely helpful. Instead, our intent is to identify aspects of religiousness that may be problematic, build on this knowledge to enhance our more general understanding of what it means to be human and, in turn, apply this knowledge to our efforts to enhance the lives of people in their communities. Based on diverse theoretical frameworks, we have articulated some religious risk factors for poorer health and well-being. These religious risk factors are idolatry, extrinsic religiousness and religious introjection, insecure (avoidant and anxious) attachment to God, poor fit between religion and the situation, religious rigidity, lack of religious depth and breadth, religious extremism, appraisals of sacred loss and desecration, and religious struggles. They can be grouped within four global categories: problematic religious motivation, problematic attachment to God, problematic religious integration and problematic ways of religious
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coping. An accumulating body of empirical evidence shows that problematic forms of religiousness are not uncommon and confirms the assertion that religion can heighten risks for psychological, physical and spiritual distress. The strongest support comes from studies of religious struggle (e.g., negative religious coping) and religious motivation. We also specified some of the social, psychological and physiological variables that might account for the links between religious risk factors and poorer health and well being. Finally, we pointed to some of the ways to identify, assess and deal with these religious risk factors in clinical settings, and specified ‘spiritually integrated psychotherapy’ as one of the most promising practical implication of our findings. We close this chapter by pointing to some gaps in the literature on religious risk factors that should be addressed in future research. First, empirical research is needed on the impact of idolatry on health and well-being. Further, studies of religious attachment and process theory are still emerging. These are promising areas for future investigation. Second, the explanatory mechanisms that might account for the links between religious risk factors and poorer health are still largely unclear. Studying the impact of religious risk factors on measures of psychological and social functioning that have already been linked to poorer health (e.g., pessimism, hopelessness, low levels of control, meaning, self-esteem, coherence, social support), conducting brain imaging studies of individuals in the midst of spiritual conflict, assessing and comparing the immune functioning of individuals who do, and do not, engage in negative religious coping following a negative life event, and continuing to develop more proximal measures of religiousness and spirituality are needed to advance knowledge in this area of study. Third, the majority of studies on religious risk factors have used psychological and physical outcome measures. One type of outcome, the spiritual, has been particularly neglected. Because religion is designed primarily to serve spiritual functions, the effects of religious risk factors on spiritual outcomes (e.g., spiritual maturity, commitment to faith, religious stewardship, and spiritual security) seem crucial to consider. Finally, and perhaps most importantly, the vast majority of studies of religious risk factors have been conducted among Christian samples. The prevalence and consequences of problematic types of religiousness among members of other faiths have not been adequately studied, with a few exceptions (e.g., [55, 58, 86–87]). Hence, we should investigate religious risk factors among different cultures and religions, especially non-Western religious traditions.
REFERENCES 1. Pargament KI (2007) Spiritually Integrated Psychotherapy: Understanding and addressing the sacred. New York, Guilford Press. 2. Magyar GM, Pargament KI (2006) The darker side of religion: Risk factors for poorer health and well-being. In McNamara P (ed.). Where God and Science meet: How brain and evolutionary studies alter our understanding of religion (Vol 3): The psychology of religious experience. p. 105–131. 3. Koenig HG, Larson DB (2001) Religion and mental health: Evidence of association. International Review of Psychiatry 13, 67–78. 4. Princeton Religion Research Center (1996) Religion in America. Princeton, NJ, Gallup Poll. 5. Baetz M, Larson DB, Marcoux G, Bowen R, Griffin R (2002) Canadian psychiatric inpatient religious commitment: An association with mental health. Canadian Journal of Psychiatry 47, 159–166.
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6. Lazar A, Kravetz S, Frederich-Kedem P (2002) The multidimensionality of motivation for Jewish religious behavior: Content, structure, and relationship to religious identity. Journal for the Scientific Study of Religion 41, 509–519. 7. Khashan H, Kreidie L (Fall, 2001) The social and economic correlates of Islamic ReligiosityStatistical Data Included. World Affairs. 8. Tarakeshwar N, Pargament KI, Mahoney A (2003) Measures of Hindu pathways: Development and preliminary evidence of reliability and validity. Culture Diversity and Ethnic Minority Psychology 9, 316–332. 9. Al-Issa I (2000) Religion and psychopathology. In: Al-Issa (ed). Al-Junun: Mental illness in the Islamic world. Connecticut, International Universities Press, pp. 3–42. 10. Miller WR, Thoresen CE (2003) Spirituality, religion, and health. American Psychologist 58, 24–35. 11. Pargament KI, Abu Raiya H (2007) A decade of research on the psychology of religion and coping: Things we assumed and lessons we learned. Psyke and Logos 28, 742–766. 12. Yinger JM (1967) Pluralism, religion and secularism. Journal for the Scientific Study of Religion 7, 104–118. 13. Pargament KI (1997) The Psychology of Religion and Coping: Theory, research, practice. New York, Guilford Press. 14. Pargament KI (2002) The bitter and the sweet: An evaluation of the costs and benefits of religiousness. Psychological Inquiry 13, 168–181. 15. Pargament KI, Mahoney A (2002) Spirituality: Discovering and conserving the sacred. In: Snyder CR, Lopez, SJ (eds.). Handbook of Positive Psychology. New York, Oxford University Press, pp. 646–659. 16. James W (1902) The Varieties of Religious Experience. New York, Modern Library. 17. Allport GW (1950) The individual and his religion: A psychological interpretation. New York, Macmillan Publishing Co. 18. Strunk O (1965) Mature religion: A psychological study. New York, Abingdon Press. 19. Butter EA, Pargament KI (2003) Development of a model for clinical assessment of religious coping: Initial validation of the Process Evaluation Model. Mental Health, Religion & Culture 6, 175–194. 20. Sheldon KM, Ryan RM, Deci EL, Kasser T (2004) The independent effects of goal contents and motives on well-being: It’s both what you pursue and why you pursue it. Personality and Social Psychology Bulletin 30, 475–486. 21. Emmons RA, Cheung C, Tehrani K (1998) Assessing spirituality through personal goals: Implications for research on religion and subjective well-being. Social Indicators Research 45, 391–422. 22. Mahoney A, Carels RA, Pargament KI, Wachholtz A, Leeper LE, Kaplar M, Frutchey R (2005) The sanctification of the body and behavioral health patterns of college students. The International Journal for the Psychology of Religion 15, 221–238. 23. Palmer PJ (1998). The grace of great things: Reclaiming the sacred in knowing, teaching, and learning. The Sun, pp. 24–28. 24. Nelson JB (2004) Thirst: God and the alcoholic experience. Louisville, Westminster John Knox Press. 25. Jung CG (1945/1964) After the catastrophe. In Jung CG (1964). Civilization in transition. R.F.C. Hull (Trans.). The Collected Works of C.G. Jung (Vol. 10). Bollingen Series XX. Princeton, Princeton University Press. 26. Allport GW, Ross JM (1967) Personal religious orientation and prejudice. Journal of Personality and Social Psychology 5, 432–443. 27. Donahue MJ (1985) Intrinsic and extrinsic religiousness: Review and meta-analysis. Journal of Personality and Social Psychology 48, 400–419.
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28. Bergin AE, Masters KS, Richards PS (1987) Religiousness and mental health reconsidered: A study of an intrinsically religious sample. Journal of Counseling Psychology 34, 197–204. 29. Khan ZH, Watson PJ (2004) Religious orientation and the experience of Eid-ul-Azha among Pakistani Muslims. The International Journal for the Psychology of Religion 43, 537–545. 30. Ryan RM, Rigby S, King K (1993) Two types of religious internalization and their relations to religious orientation and mental health. Journal of Personality and Social Psychology 65, 586–596. 31. Bowlby J (1969) Attachment and loss: Vol. 1. Attachment. New York, Basic Books. 32. Kirkpatrick LA (2005) Attachment, Evolution, and the Psychology of Religion. New York, Guilford Press. 33. Birgegard A, Granqvist P (2004) The correspondence between attachment to parents and God: Three experiments using subliminal cues. Personality and Social Psychology Bulletin 30, 1122–1135. 34. McDonald A, Beck R, Allison S, Norsworthy L (2005) Attachment to God and parents: Testing the correspondence vs. compensation hypothesis. Journal of Psychology and Christianity 24, 21–28. 35. Beck R, McDonald A (2004) Attachment to God: The Attachment to God Inventory, tests of working model correspondence, and an exploration of faith group differences. Journal of Psychology & Theology 32, 92–103. 36. Rowatt WC, Kirkpatrick LA (2002) Dimensions of attachment to God and their relation to affect, religiosity, and personality constructs. Journal for the Scientific Study of Religion 41, 637–651. 37. Kirkpatrick LA, Shaver PR (1992) An attachment-theoretical approach to romantic love and religious belief. Personality and Social Psychology Bulletin 18, 266–275. 38. Exline JJ, Yali AM, Sanderson WC (2000) Guilt, discord, and alienation: The role of religious strain in depression and suicidality. Journal of Clinical Psychology 56, 1481–1496. 39. Trenholm P, Trent J, Compton WC (1998) Negative religious conflict as a predictor of panic disorder. Journal of Clinical Psychology 54, 59–65. 40. Altemeyer B, Hunsberger B (1992) Authoritarianism, religious fundamentalism, quest, and prejudice. International Journal for the Psychology of Religion 2, 113–133. 41. Watson PJ, Morris RJ, Hood RW Jr (1988) Sin and self-functioning: Part 3. The psychology and ideology of irrational beliefs. Journal of Psychology and Theology 16, 348–31. 42. Tepper L, Rogers SA, Coleman EM, Malony HN (2001) The prevalence of religious coping among persons with persistent mental illness. Psychiatric Services 52, 660–665. 43. Wink P, Dillon M (2001) Religious involvement and health outcomes in late adulthood. In Plante TG, Sherman AC (eds.) Faith and Health. New York, Guilford Press, pp. 75–106. 44. Weinborn M (1999) A rhetorical approach to the religion-mental health connection: Initial exploration of the religious orienting system. Unpublished doctoral dissertation, Bowling Green State University. 45. Greenberg D, Witztum E, Pisante J (1987) Scrupulosity: Religious attitudes and clinical presentations. British Journal of Medical Psychology 60, 29–37. 46. Rabkin JG, Streuning EL (1976) Life events, stress, and illness. Science 194, 1013–1020. 47. Lazarus RS, Folkman S (1984) Stress, appraisal, and coping. New York, Springer. 48. Aldwin CM (1994) Stress, coping, and development: An integrative perspective. New York, Guilford Press. 49. Mullen B, Suls J (1982) The effectiveness of attention and retention as coping styles: A metaanalysis of temporal differences. Journal of Psychosomatic Research 26, 43–49. 50. Matchan L (1992, June 8) Ex-priest’s accusers tell of the damage. Boston Globe, pp. 1, 8. 51. Smith BW, Pargament KI, Brant C, Oliver JM (2000) Noah revisited: Religious coping by church members and the impact of the 1993 midwest flood. Journal of Community Psychology 28, 169–186.
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52. Tarakeshwar N, Pargament KI (2001) Religious coping in families of children with autism. Focus on Autism and Other Developmental Disabilities 16 (4), 247–260. 53. Narin R, Merluzzi T (2003) The role of religious coping in adjustment to cancer. Psychooncology 12, 428–441. 54. Smith TB, McCullough ME, Poll J (2003) Religiousness and depression: Evidence for a main effect and the moderating influence of stressful life events. Psychological Bulletin 129, 614–636. 55. Ai AL, Peterson C, Huang B (2003) The effects of religious-spiritual coping on positive attitudes of adult Muslim refugees from Kosovo and Bosnia. The International Journal for the Psychology of Religion 13, 29–47. 56. Meisenhelder JB, Marcum JP (2004) Responses of clergy to 9/11: Posttraumatic stress, coping, and religious outcomes. Journal for the Scientific Study of Religion 43, 547–554. 57. Ano GG, Vasconcelles EB (2005) Religious coping and psychological adjustment to stress: A meta-analysis. Journal of Clinical Psychology 61, 461–480. 58. Abu Raiya H, Pargament KI, Mahoney A, Stein C (2008) A psychological measure of Islamic Religiousness: Development and evidence of reliability and validity. The International Journal for the Psychology of Religion 18 (4), 291–315. 59. Fitchett G, Rybarczyk BD, DeMarco GA, Nicholas JJ (1999) The role of religion in medical rehabilitation outcomes: A longitudinal study. Rehabilitation Psychology 44, 1–22. 60. Exline JJ, Yali AM, Lobel M (1999) When God disappoints: Difficulty forgiving God and its role in negative emotion. Journal of Health Psychology 4, 365–380. 61. Pargament KI, Zinnbauer BJ, Scott AB, Butter EM, Zerowin J, Stanik P (1998) Red flags and religious coping: Identifying some religious warning signs among people in crisis. Journal of Clinical Psychology 54, 77–89. 62. Sherman AC, Simonton S, Latif U, Spohn R, Tricot G (2005) Religious struggle and religious comfort in response to illness: Health outcomes among stem cell transplant patients. Journal of Behavioral Medicine 28, 1–9. 63. Cole B (2005) Spiritually-focused psychotherapy for people diagnosed with cancer: A pilot outcome study. Mental Health, Religion & Culture, 8, 217–226. 64. McConnell KM, Pargament KI, Ellison CG, Flannelly KJ (2006) Examining the links between spiritual struggles and symptoms of psychopathology in a national sample. Journal of Clinical Psychology 62, 1469–1484. 65. Elkins DN (1995) Psychotherapy and spirituality: Toward a theory of the soul. Journal of Humanistic Psychology 35, 78–98. 66. Magyar GM, Pargament KI, Mahoney A (2000, August) Violating the sacred: A study of desecration among college students. Paper presented at the 108th Annual Convention of the American Psychological Association, Washington, DC. 67. Mahoney A, Pargament KI, Ano G, Lynn Q, Magyar GM, McCarthy S, Pristas E, Wachholtz A (2002, August) The devil made them do it: desecration and demonization and the 9/11 attacks. Paper presented at the annual meeting of the American Psychological Association, Chicago, IL. 68. Pargament KI, Magyar GM, Benore E, Mahoney A (2005) Sacrilege: A study of sacred loss and desecration and their implications for health and well-being in a community sample. Journal for the Scientific Study of Religion 44, 59–78. 69. Magyar-Russell (2005) Sacred loss and desecration: A longitudinal study of spiritual appraisals among patients in rehabilitation hospitals. Unpublished doctoral dissertation, Bowling Green State University. 70. Abu Raiya H, Pargament KI, Mahoney A, Trevino K (2008) When Muslims are perceived as a religious threat: Examining the connection between desecration, religious coping, and antiMuslim attitudes. Basic and Applied Social Psychology 30, 311–325. 71. Koenig HG, Pargament KI, Nielsen J (1998) Religious coping and health status in medically ill hospitalized older adults. Journal of Nervous and Mental Disease 186, 513–521.
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72. Pargament KI, Koenig HG, Tarakeshwar N, Hahn J (2001) Religious struggle as a predictor of mortality among medically ill elderly patients: A two-year longitudinal study. Archives of Internal Medicine 161, 1881–1885. 73. Pargament KI, Smith BW, Koenig HG, Perez L (1998) Patterns of positive and negative religious coping with major life stressors. Journal for the Scientific Study of Religion 37, 710–724. 74. Janoff-Bulman R (1992) Shattered Assumptions: Towards a new psychology of trauma. New York, The Free Press. 75. Johnson CV, Hayes JA (2003) Troubled spirits: Prevalence and predictors of religious and spiritual concerns among university students and counseling center clients. Journal of Counseling Psychology 50, 409–419. 76. Fitchett G, Murphy PE, Kim J, Gibbons J, Cameron JR, Davis JA (2004) Religious struggle: Prevalence, correlates and mental health risks in diabetic, congestive heart failure, and oncology patients. International Journal of Psychiatry in Medicine, 34, 179–196. 77. Pargament KI, Murray-Swank N, Magyar GM, Ano G (2005) Spiritual struggle: A phenomenon of interest to psychology and religion. In Miller WR, Delaney HD (eds.) Judeo-Christian perspectives on psychology. Washington D.C.: American Psychological Association. 78. Smucker C (1996) A phenomenological description of the experience of spiritual distress. Nursing Diagnosis 7, 81–91. 79. Manning-Walsh J (2005) Spiritual struggle: Effect on quality of life and life satisfaction in women with breast cancer. Journal of Holistic Nursing 23, 120–140. 80. Rippentrop AE, Altmaier EM et al. (2005) The relationship between religion/spirituality and psychical health, mental health, and pain in a chronic pain population. Pain 116, 311–321. 81. Fitchett G (1999) Screening for spiritual risk. Chaplaincy Today 15, 2–12. 82. Pargament KI, Koenig HG, Tarakeshwar N, Hahn J (2004) Religious coping methods as predictors of psychological, physical, and spiritual outcomes among medically ill elderly patients: A two-year longitudinal study. Journal of Health Psychology 9, 713–730. 83. Koenig HG, George LK, Hays JC, Larson DB, Cohen HJ, Blazer DG (1998) The relationship between religious activities and blood pressure in older adults. International Journal of Psychiatry in Medicine 28, 189–213. 84. Krause N, Chatters LM, Meltzer T, Morgan DL (2000) Negative interaction in the church: Insights from focus groups with older adults. Review of Religious Research 41, 510–533. 85. Fallot RD, Hackman JP (2005) Religious/spiritual coping among women trauma survivors with mental health and substance use disorders. Journal of Behavioral Health Services and Research 32, 214–226. 86. Dubow EF, Pargament KI, Boxer P, Tarakeshwar N (1999, April) Religion is a source stress, coping and identity among Jewish adolescence. Paper presented at the biennial meeting of the Society of Research in Child Development, Albuquerque, NM. 87. Tarakeshwar N, Pargament KI, Mahoney A (2003) Initial Development of a measure of religious coping among Hindus. Journal of Community Psychology 31, 607–628. 88. Flower JW (1987) Faith development and pastoral care. Philadelphia, Fortress press. 89. Exline JJ, Rose E (2005) Religious and spiritual struggles. In Paloutzian R & Park C (eds.). Handbook of the psychology of religion and spirituality. New York, Guilford Press, pp. 295–314. 90. Pargament KI, Magyar GM, Murray-Swank N (2005) The sacred and the search for significance: Religion as a unique process. Journal of Social Issues 61, 665–687. 91. Seeman TE, Dubin LF, Seeman M (2003) Religiosity/spirituality and health: A critical review of the evidence for biological pathways. American Psychologist 58 (1), 53–63. 92. Koenig HG, Cohen HJ (2002) The link between religion and health: Psychoneuroimmunology and the faith factor. New York, Oxford University Press. 93. Ironson G, Solomon GF, Balbin EG, O’Cleirigh C, George A, Kumar M, Larson D, Woods TE (2002) The Ironson-Woods Spirituality/Religiousness Index is associated with long survival,
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health behaviors, less distress, and low cortisol in people with HIV/AIDS. Annals of Behavioral Medicine 24, 34–48. Sephton SE, Koopman C, Schaal M, Thoresen C, Spiegel D (2001) Spiritual expression and immune status in women with metastatic breast cancer: An exploratory study. The Breast Journal 7, 345–353. Woods TE, Antoni MH, Ironson GH, Kling DW (1999) Religiosity is associated with affective and immune status in symptomatic HIV-infected gay men. Journal of Psychosomatic Research 46, 165–176. Koenig HG, McCullough ME, Larson DB (2001) Handbook of religion and health. New York, Oxford University Press. Richards PS, Bergin AE (1997) A spiritual strategy for counseling and psychotherapy. Washington, DC, American Psychological Association. Murray-Swank NA, Pargament KI (2005) God, where are you? Evaluating a spirituallyintegrated intervention for sexual abuse. Mental Health, Religion, & Culture 8, 191–203. Pargament KI, Murray-Swank N, Tarakeshwar N (2005, eds.) Spiritually-integrated psychotherapy. Special Issue of Mental Health, Religion, and Culture 8, 155-238. Pargament KI, Murray-Swank NA, Tarakeshwar N (2005) An empirically-based rationale for a spiritually-integrated psychotherapy. Mental Health, Religion & Culture 8, 155–165. Pargament KI, McCarthy S, Shah P, et al. (2004) Religion and HIV: a review of the literature and clinical implications. Southern Medical Journal 97, 1201–1209. Freedman SR, Enright RD (1996) Forgiveness as an intervention goal with incest survivors. Journal of Consulting and Clinical Psychology 64, 983–992. McCullough ME, Worthington EL Jr (1994) Encouraging clients to forgive people who hurt them: Review, critique, and research prospectus. Journal of Psychology and Theology 22, 3–20. Razali SM, Hasanah CI, Aminah K, Subramaniam M (1998) Religious sociocultrual psychotherapy in patients with anxiety and depression. Australian and New Zealand Journal of Psychiatry 32, 867–872. Azhar MZ, Varma SL, Dharap AS (1994) Religious psychotherapy in anxiety disorder patients. Acta Psychiatrica Scandinavica 90, 1–2. Azhar MZ, Varma SL (1995) Religious psychotherapy with depressive patients. Psychotherapy and Psychosomatics 63, 165–168. Genia V (1990) Interreligious encounter groups: A psychospiritual experience for faith development. Counseling and Values 35, 39–51. Cole B, Pargament KI (1999) Re-creating your life: A spiritual/psychotherapeutic intervention for people diagnosed with cancer. Psycho-Oncology, 8, 395–407. McCullough ME, Pargament KI, Thoresen CE (eds.) (2000) Forgiveness: Theory, research, and Practice. New York, Guilford Press.
CHAPTER 4.5
Religious Practice and Mental Health: a Moroccan Experience Driss Moussaoui Professor of Psychiatry, Morocco
Nadia Kadri Professor of Psychiatry, Morocco
4.5.1
HISTORICAL OVERVIEW
The word Morocco (Marruecos in Spanish) derives from the name of the city of Marrakech, capital of the Moroccan empire under the Almoravid, Almohad and Saadian dynasties. The name of the country in Arabic (Al Maghrib Al Aqsa) means extreme west, the country of the sunset. Morocco’s religion has been for 13 centuries essentially Islam. Its present 32 million population is almost 100% Muslim; as a matter of fact, only 2500 Moroccan Jews are left, and a few hundred Muslims were recently converted to Christianity. The Muslim rite is Sunnite in its Maliki version. Morocco is situated in the North-Western part of Africa, only 7 miles from Europe. Because of its geographical proximity, for centuries it has had a disturbed relationship with its European neighbors for religious reasons, being on the front line with countries such as Spain, Portugal and France. Some historians consider that, during the Middle Ages, Morocco exported to Europe, mostly Southern Spain (Al Andalus), soldiers and administrators, and attracted scholars and craftsmen to build beautiful cities such as Marrakech or Fez, the latter being the spiritual capital of Morocco. Among the above mentioned scholars, some had a considerable impact in Morocco, but also in Europe such as Ibn Rushd (Averroes), Ibn Tufail (Abentofal), Ibn Bajja (Avenpace) or Ibn Zuhr (Avenzoar). Morocco had also great travellers such as Ibn Batouta and exported a well-known geographer to the Norman kingdom of Sicily (Achcharif Al Idrissi). Many other scholars lived in Morocco such as Ibn Khaldun (founder of sociology in the fourteenth century), Lissan Dine Ibn Khatib, and Hassan Al Wazzan also named Leo Africanus. The latter worked in the maristan (psychiatric hospital) of Fez [1] at the beginning of the sixteenth century. After his capture by pirates, he was offered to the pope Leo X because of his vast culture. He was christianized and was adopted as a son by the pope. He was asked to write a book describing
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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Africa (Cosmographia Dell’ Africa), which was the only source of information of Europe on the southern part of the Mediterranean region at that time. Ibn Rushd, who was a physician and a judge, played a leading role in discussing thoroughly the philosophical corpus of Aristotle at the request of the Moroccan Almohad emir Abu Yaqub Yusuf. This request was motivated by the theological disputes among various factions in Islam, and for which, the philosophical method was applied. Ibn Rushd was, among a vast diversity of topics, most interested in the relationship between faith and reason, and had a very modern way of dealing with both. Considered to be ‘The Commentator of Aristotle’, his books were studied for centuries in European universities, even after having been criticized one century later by St. Thomas Aquinas. The latter and Ibn Rushd were both Aristotelian and tried to build up a synthesis between rationality and religious faith. An important religious characteristic of Morocco is that its king is the recognized religious leader, ‘Commander of the faithful’ (Amir al Muminin). This title was transferred to Morocco in the eleventh century from Cordoba, Spain, where the Umayyads established a caliphate hostile to the Abbasids of Bagdad, after Muslim Spain became part of the Moroccan empire. This title is not merely honorific, and impacts considerably on the life of the country. For example, in 2006, the king suggested very significant changes in the family law towards more gender equality. The Moroccan parliament voted on this revolutionary text, despite the opposition of the most conservative political forces in the country. Two years before the king decided to take a stand about this issue, an attempt to pass that law led to a resounding failure. For the past 1200 years, religion has played a central role in Moroccan history and identity. All seven Moroccan dynasties were established under the assumption of religious return to the purity of Islam. The fight against various European invaders was always made in the name of Islam. This did not prevent Muslims from having a peaceful and mutually beneficial relationship with Moroccan Jews. For example, during World War II, King Mohamed V refused to let the Vichy government deport 350 000 Moroccan Jews to Nazi concentration camps and succeeded in saving their lives. Among other things, he sent a message explaining his refusal to be read in all mosques of Morocco during the Friday prayer.
4.5.2
SOCIAL OVERVIEW
This quick historical overview explains the strength of religion in Morocco and its impact on the daily life of people. It is true that this is also the case for many other countries. For example, a survey reported by the newspaper USA Today in 2003 in various countries of the world showed that 80 to 90% of people worldwide considered religion to be an essential part of their life. It seems, however, that in Morocco it is even more the case: In 2007, Mohamed El Ayadi et al. conducted a survey on perception and practices in Moroccan Islam: 91.7% of the interviewed people considered themselves as practicing Muslims at the age of 60 or more (vs. 52.6% from 18 to 24). Concerning identity, a majority considered themselves to be Muslims before perceiving themselves as Moroccans. In this sample, only 11.3% of young adults and 2.1% of elderly considered themselves as being ‘non-religious’ [1]. Under this heading, there are in fact two kinds of Islamic perceptions and practices: the official one which is promoted by scholars, and a more popular one, with beliefs and
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practices which go back to the pre-Islamic era. Among them is the importance of marabouts or tombs of saints, which are visited daily by thousands of people asking for favors or help, including when they are ill. Beliefs in evil eye, sorcery and possession belong to the same para-religious domain. Another Islam, which was historically important and which has experienced a strong revival is the one of Sufism, promoted by Zaouias. It plays a spiritual but also a local political role, by organizing hierarchal religious life. Powerful branches of such Zaouias exist in many different countries in Sub-Saharan Africa. Moreover, the religious discourse has always been and is still very present in the daily life of the vast majority of Moroccans (2). Since 1979, after the Iranian Islamist revolution, extremist perception and action started to grow in all Arab and Islamic countries. Some Moroccans, in search of a ‘true religious identity’, have gone far enough to commit terrorist attacks in 2003 and 2006, but they remain a very tiny minority, with no popular support.
4.5.3
RELIGIOUS PRACTICE AND MENTAL HEALTH
Concerning care issues, and following the popular perception of Islam, many mental patients and their families prefer to seek help and relief from religious leaders (fqih, taleb) or tombs of saints (marabout). This has nothing to do with medicine during golden ages. As a matter of fact, Hippocratic medicine was predominant in Morocco in various maristans, where humanly treatment was implemented during the Middle Ages [3]. At the present time, traditional healing, which can be considered as a degenerate form of this medical tradition, is the path 75% of patients follow before, during or after having consulted a health or a mental health worker [4]. On the other hand, it has not been easy to introduce the idea of doing research on the interface of religion and psychiatry/mental health. Reluctance towards such an approach was strong even among academic psychiatrists. ‘Faith cannot be studied, and should not become subject of research; it is a kind of disrespect towards religion’ they said when the ‘Hassan II Foundation on Ramadan and Health’ was created 18 years ago [3]. Moreover, for a number of reasons, some studies mentioned in this chapter were presented in various scientific meetings, but were not published. The articles published in this field by Moroccan researchers were mostly in French. All of the studies mentioned were conducted in the University of Casablanca, most of them in its Ibn Rushd University Psychiatric Centre.
4.5.3.1
Traditional healing and mental health
Traditional healing is not specific to mental patients; those suffering from somatic diseases (including fractures or tumors) often seek help from traditional healers. However, it is more the case for mentally ill patients. For example, a recent TV programme in Morocco (First Channel, October 2008) showed that more than 1200 mental health patients were ‘hospitalized’ in a marabout called ‘Bouya Omar’ 100 km north of Marrakech. These patients were in fact semi-abandoned by their families, many of them abused physically and chained. The government reacted promptly to halt such abuse on this systematized and large scale. However, the official reaction was less sharp than it should be (closing the
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marabout site), preferring a law forbidding the chaining of mental patients. The reason for that is the existing confusion between religion and marabouts in the mind of most people in the country. It is true that the 350 existing psychiatrists cannot treat all mental patients of Morocco. In 2007, the results of the National Epidemiologic Survey were released to the press, with a point prevalence of 40.5% for 25 different mental disorders. If traditional healing may help some mild mental difficulties, in no way does it represent a solution for major mental disorders, and the growing numbers of mental patients seeking help from psychiatric institutions is a good indicator that a more rational approach will finally prevail. It is also true that financial restrictions do not allow easy access to quality care for mental health patients. However, a study conducted on the cost of treatment of people with schizophrenia showed that it was higher in traditional settings than in modern psychiatric ones [2]. Another interesting aspect is the introduction of modern instruments to disguise old concepts [5], such as using modern buildings to host branches of marabouts in the middle of a city, or the delivery of ‘exorcism certificate’ written on typing machines.
4.5.3.2
Ramadan fasting and mental health
The late King Hassan II of Morocco gave his name to a foundation investigating the relationship between health and Ramadan fasting [6]. He personally helped organize a number of national and international meetings and congresses in Morocco and elsewhere in the world, bringing together physicians and theologians. Research studies were conducted, consensus statements were produced by this foundation, as well as a number of publications.
Ramadan fasting and bipolar disorders A study by Kadri et al. [7] was conducted in order to reply to bipolar patients who ask if they can fast without harm for their health. Twenty euthymic bipolar patients fasted for at least 3 months, treated with mood stabilizers, mostly lithium, were included. The main result was that 45% of patients relapsed, mostly in a depressive form, especially during the second week of Ramadan month, despite the fact that there was no difference in lithium plasma level. The main question was whether the relapse was due to the different social rhythm adopted during that month. This is why we recommend to bipolar patients not to fast during Ramadan month, but also to maintain their usual social rhythm in sleep, food intake and physical activity as much as possible.
Ramadan, sleep and cognitive functioning A number of studies conducted in Casablanca by Farid Hakkou et al. [8–10] showed that there is a cognitive impairment in healthy fasting volunteers during the day, especially the first week, which may increase the risk of traffic accidents, and which decreases economic productivity. Daytime oral temperature, subjective alertness and mood were all decreased during Ramadan.
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The most probable risk factors for the cognitive impairment are: reduction in total amount of sleep, disturbance of the day-night cycle, and maybe dehydration.
Ramadan and substance use and abuse Another study conducted by N. Kadri et al. (1997, unpublished) showed that the period of 40 days before Ramadan, traditionally ‘dry’ (without alcohol intake) for alcohol users, was not respected by 58.5%. It showed also a decrease of cannabis use at the beginning, but an increase at the end of Ramadan. It is interesting to mention that no delirium tremens is observed among alcohol abusers in the weeks before or during Ramadan month, though they abruptly stop such consumption.
Ramadan and irritability The first study [11] was conducted in 100 healthy and fasting volunteers during the month of Ramadan for two successive years, measuring objective and subjective irritability, describing its various modes of expression and examining risk factors for this irritability. Results showed that it was significantly higher in smokers vs. non-smokers before the beginning of Ramadan. It was higher during the Ramadan month for both groups. It increased continuously during Ramadan and reached its peak at the end of the month. Consumption of psychostimulants and anxiety level followed the same pattern. Smokers and non-smokers had a similar pattern of irritability over time, but irritability increased more in smokers than in non-smokers.
Ramadan and sexual activity In 2007 Berrada et al. [12] studied sexual activity during 6 months prior to Ramadan and during the 2nd and the 4th week of the fasting month. For religious reasons, the interviews were conducted during the night, after breaking the fast. The results showed a negative impact of the Ramadan month on sexual activity. Moreover, physicians see more sexual infections in their patients during Ramadan month as compared to other months. No study is available on this topic to our knowledge.
Ramadan fasting and religious obsessions Kadri, Khoubila and Chiboub conducted a study on this topic in 2008 (unpublished). In a group of 1500 psychiatric outpatients, 144 met DSM IV criteria for OCD. Forty-four of them had religious obsessions and compulsions. Thirty-four of them were investigated before, during, and after Ramadan month. A worsening of symptoms happened in 32% of cases during the month of Ramadan, but an improvement occurred in 32% of cases after the end of Ramadan. Another aspect of the same study, conducted by Khoubila and Kadri, showed that in 1500 psychiatric patients, 9.6% had an OCD diagnosis. Religious obsessions were the most
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frequent (31.3%) and the patients with this kind of obsession had more obsessions, as compared to OCD patients without religious obsessions.
4.5.4 4.5.4.1
CLASSIFICATION, PSYCHOPATHOLOGY AND RELIGION Psychiatric classification and religion
One of the authors (DM with M.Touhami) published in 1984 a paper on ‘Anthropological classification of depressions’ [13], classifying societies in four different cultural groups, hypothesizing that the way religion is perceived in the community is important for the clinical expression of depression.
Premonotheistic or polytheistic Because everything in nature (mountains, rivers, trees or stones) may be a habitat of souls of dead ancestors, depressive episodes will express themselves with predominant possession ideas, the patient becoming the habitat of angry or bad souls of ancestors; in this case of persecution by spirits, there is no suicidal ideation or behaviors. This happens in purely rural communities.
Monotheistic with strong community ties Bigger communities such as villages and small towns, lead to a concentrated power in the almighty group, as compared to a dependent individual; depression expresses itself with predominant persecutory ideas from the group (evil eye, sorcery), and sometimes with hetero-aggressive behavior from the depressed patient.
Monotheistic with weaker community ties In big cities, anonymity weakens the strength of the group, and moral police is then internalized; hence, depression expresses itself with predominant guilt feelings and sometimes delusions; in this case, increasing suicidal thoughts and behaviors are seen in these patients.
Technological and individualistic societies More and more, self-diagnosis of depression is done through the internet and through the information given by the media; high anomie leads to higher suicidality. What we have witnessed in the past three decades in our daily practice in Casablanca is a progressive switch from possession and persecutory ideations (and sometimes delusions) towards more guilt feelings in depression, but also towards more modern behaviors, the patient coming to the doctor with a self-diagnosis of depression, and discussing various therapeutic possibilities. Moreover, suicidal ideation and behavior increased significantly in the two last decades (Chakly et al. 1997, unpublished).
4.5
4.5.4.2
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Suicidality and religion
Caruso and Moussaoui [14] studied 65 patients who tried to commit suicide, as compared to a control group who did not. Religious practice (meaning: doing the five prayers a day and fasting Ramadan, at least) was significantly more encountered in the non-parasuicide group: 84.6% vs. 70.7%. But on the other hand, the social life of the non-parasuicide group showed stronger ties than the parasuicide one. The question hence is what is more important: religious practice or community links, or both, knowing the intertwining of the two? In fact, it is highly probable that religious practice is part of a corpus of behaviors which fight the Durkheim’s anomie, known for a long time to be a risk factor for suicidal behavior. Another study was conducted by Agoub et al. [15] in a representative sample of the adult general population of Casablanca, using the suicidality module of the M.I.N.I. (Mini International Neuropsychiatric Intervew). The one-month prevalence of suicidal ideation was 6.3% and 2.1% reported at least one suicidal attempt. The following were positively associated with suicidal ideation: non-married status, subjects with history of psychiatric disorders, and subjects without children. At least one mental disorder was present among 88.2% of subjects with suicidal ideation. Major depressive disorder was the most prevalent one (23.5%). It is important to see that suicidality exists in a society where religion is paramount and very present in daily life.
4.5.4.3
Religious delusions in mental patients
In our daily practice, there are numerous delusional patients (with schizophrenia, schizophreniform disorder or mania . . .) who do present with a religious content of their delusions. One of them is to consider oneself Al Mahdi Al Mountadar, a kind of prophet for the end of times. A surprising thing is that this concept is historically specific to Shiite Muslims, while Moroccan Muslims are 100% Sunni. An interesting clinical picture was seen a number of times in males presenting exactly the same delusions as the President Schreber [16], believing that they are progressively transformed into women, wives of God, pregnant to millions of human beings in order to save humanity from destruction. The interesting aspect in the first case reported by Moussaoui and Sayeh [17] is the fact that that the Moroccan patient was young, living in a rural area, with low socio-economic status, illiterate, from a completely different cultural and religious background, and still, 80 years later, presenting exactly the same kind of delusional system as President Schreber who was middle-aged and from a high socio-economic strata. This means probably that we should relativize the cultural relativity we usually give to form and content of delusions from one country to another.
4.5.5
CIRCUMCISION AND MENTAL HEALTH
Male circumcision is an ancient practice, documented in Pharaonic papyri. It became part of the Jewish religion, before being adopted by Islam. In fact, it was a pre-Islamic tradition, and not a single word of Kuran mentions this practice. It is therefore not an absolute obligation for Muslims, but only a Sunna Muakkada (a recommended behavior). No female circumcision exists in Morocco.
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Two studies conducted by Kadri and Bouchikh in 1996 and Kadri and Jabrane in 1997 (both unpublished) showed that 30% of 500 male medical students had no memory at all of their circumcision, despite the fact that it occurred between 3 and 10 years of age. On the other hand, 50 boys were followed-up for 6 months, interviewing them and their parents before circumcision, the day after, 3 and 6 months later. The main result of that prospective study is that age was positively correlated with higher disturbances in sleep and behavior. The interesting part here is that coming back to the history of circumcision, we found that the Prophet Mohamed circumcised his two grandsons Hassan and Hussein at the age of 8 days, while in Morocco it is done between 3 and 10 years of age. What we discovered also is that Muslims circumcise their boys in the Middle East at the age of 8 days. With this information in hand, we went to the media, we made a number of lectures to pediatricians and pediatric surgeons. The tradition is still what it was, but it is definitely changing in the medical community, as a start for a change in the entire country.
4.5.6
CONCLUDING REMARKS
It would have been a pity not to have done the studies we conducted on religious practice and mental health in Casablanca, because they all answered practical questions asked by patients or by the community. The sacred aura of religious (or supposedly religious) practices is so strong in society, that many doctors do not dare to use science to help patients overcome difficulties created by a wrong interpretation of religion. It is clear that we are at the dawn of a mental revolution which needs to be started as soon as possible in all Muslim countries.
REFERENCES 1. El Ayadi M, Rachik H, Tozy M (2007) L’Islam au quotidien. Enqu^ete sur les valeurs et les pratiques religieuses au Maroc. Editions Prologue, Casablanca. 2. Ferhat H (2003) Le soufisme et les Zaouias au Maghreb, merite individuel et patrimoine sacre. Editions Toubkal, Casablanca. 3. Chakib A, Battas O, Moussaoui D (1994) Le Maristane Sidi Frej a Fes. Histoire des Sciences Medicales 28, 171–174. 4. Moussaoui D, Tazi I, Boussaid F (1999) Cost management of mental patients’care: is traditional healing an alternative in developing countries? In: Guimon J and Sartorius N (eds.) Manage or Perish. Kluwer Academic/Plenum, New York, pp. 233–237. 5. Touhami M, Moussaoui D (1991) Le marabout dans l’immeuble. Psychologie Medicale 23, 29–31. 6. Hakkou F, Tazi A, Iraki L, El Otmani S, Moussaoui D, Chraibi N (1994) Proceedings of the First International Congress on Health and Ramadan. Hassan II Foundation on Ramadan and Health, Casablanca. 7. Kadri N, Mouchtaq N, Hakkou F, Moussaoui D (2000) Relapses in bipolar patients: changes in social rhythm? International Journal of Neuropsychopharmacology 3, 45–49. 8. Rachida R, Chapotot F, Hakkou F, Taoudi Benchekroun M, Buguet A (2001) A-Sleep during Ramadan intermittent fasting. Journal of Sleep Research 10, 319–327.
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9. Roky R, Chapotot F, Benchekroun M, Taoudi Benchekroun M, Benaji B, Hakkou F, Elkhalifi H, Buguet A (2003) Daytime sleepiness during Ramadan intermittent fasting: polysomnographic and quantitative waking EEG study. Journal of Sleep Research 12, 95–101. 10. Roky R, Iraki L, HajKhlifa R, Lakhdar Ghazal N, Hakkou F (2000) Daytime alertness, mood, psychomotor performances, and oral temperature during Ramadan intermittent fasting. Annals of Nutrition & Metabolism 44, 101–107. 11. Kadri N, Tilane A, El Batal M, Taltit Y, Tahiri S, Moussaoui D (2000) Irritability during the month of Ramadan. Psychosomatic Medicine, 62, 280–285. 12. Berrada S, Dorhmi S, Bouhaouli L, Kadri N (2007) Sexualite durant le mois de Ramadan. Sexologies - European Journal of Sexual Health, 17, 83–89. 13. Moussaoui D, Touhami M (1984) Classification anthropologique des depressions. Annales Medico-Psychologiques 142, 1125–1129. 14. Caruso M, Moussaoui D (1995) Tentatives de suicide, pratique religieuse et insertion sociale. Journal of the World Association for Social Psychiatry 2, 37–40. 15. Agoub M, Moussaoui D, Kadri N (2006) Assessment of suicidality in a Moroccan metropolitan area. Journal of Affective Disorders 90, 223–226. 16. Schreber, DP (1955) Memoirs of My Nervous Illness (Ida Macalpine and Richard A. Hunter, trans.) Dawson, London, 1955 (Original work published 1903). 17. Moussaoui D, Sayeh A (1987) Un cas Schreber au Maroc. Evolution Psychiatrique 52, 799–802.
CHAPTER 4.6
Religious and Spiritual Considerations in Psychiatric Diagnosis: Considerations for the DSM-V David Lukoff Professor of Psychology, United States of America
C. Robert Cloninger Professor of Psychiatry, Psychology and Genetics, United States of America
Marc Galanter Professor of Psychiatry, United States of America
David M. Gellerman Assistant Clinical Professor of Psychiatry and Behavioral Sciences, United States of America
Linda Glickman Research Assistant Professor in Psychiatry, United States of America
Harold G. Koenig Professor of Psychiatry and Behavioral Sciences, United States of America
Francis G. Lu Professor of Clinical Psychiatry, United States of America
William E. Narrow Psychiatrist, Research Director DSM-V Task Force, United States of America
John R. Peteet Associate Professor of Psychiatry, United States of America
Samuel B. Thielman Adjunct Assistant Professor of Psychiatry and Behavioral Sciences, United States of America
C. Paul Yang Associate Clinical Professor of Psychiatry, United States of America Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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4.6.1
RESEARCH ISSUES
INTRODUCTION: V62.89
In 1994, DSM-IV (1) included a new V-code entitled Religious or Spiritual Problem: V62.89: This category can be used when the focus of clinical attention is a religious or spiritual problem. Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of other spiritual values which may not necessarily be related to an organized church or religious institution. (p. 685; also DSM-IV-Text Revision, 2000, p. 1393).
The acceptance of this new category by the American Psychiatric Association Task Force on DSM-IV was based on a proposal documenting the extensive literature on the frequent occurrence of religious and spiritual issues in clinical practice, the lack of training provided mental health professionals, and the need for a diagnostic category to support training and research in this area of clinical practice [2]. The DSM-IValso included an Outline for Cultural Formulation that required clinicians to consider cultural idioms of distress, explanations of illness and preferences for care, as well as the role of religion in providing support. The inclusion of this cultural formulation and the acceptance of a religious or spiritual problem as a new diagnostic category in DSM-IVare a reflection of the increasing sensitivity to cultural diversity and world view [3] in the healthcare professions that can be enhanced in the DSM-V. Workgroups have already been formed for a planned 2012 release of the DSM-V. In view of the publication of the 2002 monograph A Research Agenda for DSM-V [4] and a followup volume focused on age and gender issues [5], the Corresponding Committee on Religion, Spirituality and Psychiatry of the American Psychiatric Association (APA) proposed a review of these innovations and of relevant recent research, as well as the development of an agenda for future research on religious and spiritual issues in diagnosis. The Spirituality White Paper Group was formed including a distinguished roster of authors who are wellknown researchers and clinicians with expertise in spiritual and religious aspects of psychiatric disorders (Table 4.6.1). Another focus of this group has been to expand the current DSM text on ‘Age, Gender and Cultural Considerations’ and ‘Differential Diagnosis’ for the major categories of mental disorders to include the impact of religious/spiritual factors on phenomenology, differential diagnosis, course, outcome and prognosis. The work of the Spirituality White Paper Group will be published as an edited book by American Psychiatric Publishing, Inc. (APPI) entitled Religious and Spiritual Issues in Psychiatric Diagnosis: Considerationsfor a Revised DSM [6]. The chapters review the spiritual and religious aspects of major diagnostic categories including psychotic disorders, depression, anxiety and substance use disorders, PTSD, and disorders of childhood and adolescence (Table 4.6.1) and suggested wording for a revised DSM-V. The chapters also consider the unique challenges of distinguishing spiritual experiences and practices from psychopathology, examine the V code for Religious and Spiritual Problem’s impact on diagnostic practice, and consider the importance of religious and spiritual factors in the Guideline for a Cultural Formulation. This chapter summarizes the major findings and recommendations from The Spirituality White Paper Group for religious and spiritual problems, personality disorders, PTSD, substance abuse and psychotic disorders. Religion and spirituality have been distinguished in a multitude of ways including definitions where religion subsumes spirituality and vice versa [7, 8]. The scientific and
4.6 Table 4.6.1
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Chapter Topics and Authors
Personality Disorders
C. Robert Cloninger, MD
Adjustment Disorders and PTSD Anxiety Disorders Depression Psychotic Disorders Substance Use Disorders
Samuel B. Thielman, MD Gerrit Glas, MD Dan G. Blazer II, MD Harold Koenig, MD Marc Galanter, MD Linda Glickman, PhD Alex Mabe, PhD Mary Lynn Dell, MD Allan Mark Josephson, MD David Lukoff, PhD Francis Lu, MD C. Paul Yang Francis G. Lu, MD David Gellerman, MD Bill Fulford, MD John Sadler, MD
Disorders of Children and Adolescents Religious and Spiritual Problems Outline for Cultural Formulation Philosophical Considerations
healthcare databases such as Medline and PsycInfo distinguish between religion and spirituality along the lines delineated in the DSM-IV definition of religious or spiritual problem. The Thesaurus of Psychological Index Terms [9] defines religion as ‘associated with religious organizations and religious personnel’ (p. 184) whereas spirituality refers to the ‘degree of involvement or state of awareness or devotion to a higher being or life philosophy. Not always related to conventional religious beliefs’ (p. 208). Thus religious problems involve a person’s conflicts over the beliefs, practices, rituals and experiences related to a religious belief system or community. In contrast, spiritual problems involve distress associated with a person’s personal relationship to a higher power or transcendent force that may or may not be related to a religious worldview.
4.6.2 RELIGIOUS OR SPIRITUAL PROBLEM [10]: USE OF RELIGIOUS OR SPIRITUAL PROBLEM V CODE One study of 258 psychologists found that: 44.7% were familiar with the criteria for the category religious or spiritual problem whereas 55.3% were not; 11.2% reported using the diagnosis within the past year; and 19.2% had used it at some time in the past [11]. Another survey of 333 psychologists found that 6.2% had used a religious or spiritual problem as part of a diagnosis: 4.5% of those in independent practice; 0% at university specialty clinics; 75% in military settings. This is despite the fact that 92% had noted changes in patients’ religious/spiritual functioning over the course of psychotherapy. The researchers concluded that, ‘Although the religious/spiritual domain may not be entirely neglected, it does not appear to be receiving an adequate level of clinical attention in routine practice. Assessment of client should become a more familiar part of the clinical landscape’ (p. 103). Reasons for underutilization reported by participants included lack of reimbursement, the thought that the diagnosis was superfluous, and lack of training in spiritual assessment.
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While these statistics are low, this represents an increase in training from 1990 when almost no psychologists reported training in religious and spiritual issues [12] to 34% reporting training in the 2003 study. Medical schools and psychiatric residencies have also increased their level of training in religious and spiritual issues [13–15]. Harter [16] surveyed 100 psychologists (60 women and 40 men, 84% of whom were in private practice) as to their experiences with religious and spiritual problems in psychotherapy. She found that the psychologists tended to consider the DSM-IV category a necessary and valuable contribution to their diagnostic practices. Sixty-five percent indicated that they would use the V-code religious or spiritual problem more frequently but third party reimbursement was a barrier.
4.6.2.1
Types of religious and spiritual problems
Most religious and spiritual experiences and changes in beliefs and practices do not become a focus of clinical attention. However polls have shown the U.S. religious marketplace is extremely volatile, with nearly half of American adults leaving the faith tradition of their upbringing to either switch allegiances or abandon religious affiliation altogether [17]. There has also been a dramatic increase in people reporting mystical and near-death experiences, contact with the dead, extrasensory perception, visions, out-of-body experiences, UFO abductions, and other unusual experiences. About 75 percent of Americans hold some form of belief in the paranormal, such as extrasensory perception, ghosts, telepathy, clairvoyance, astrology, communicating with the dead, witches, reincarnation or channeling [18]. During the last 25 years there has also been a significant increase in participation in spiritual practices such as meditation, Tai Chi, yoga, sweat lodges, drumming circles, and other spiritually-oriented new age groups, all of which can induce intense spiritual experiences [19]. The majority of these experiences are not problematic, do not disrupt psychological/social/occupational functioning, and do not lead to mental health treatment. But with participation in spiritual practices and reports of intense spiritual experiences increasing [19, 20] and individual spirituality gaining prominence on the cultural landscape [8], it seems likely that the incidence of religious and spiritual problems will be increasing [21]. Anomalous experiences include a variety of unusual experiences which appear to challenge our understanding of the world, such as mystical experiences, near death experiences, alien encounters, psychic experiences, lucid dreaming and psychedelic drug experiences. These non ordinary experiences have often been ignored or ridiculed by mainstream psychology, even though interest in exceptional mental states dates back to William James on Exceptional Mental States: The 1896 Lowell Lectures (22). The more recent Varieties of Anomalous Experiences: Examining the Scientific Evidence, published by American Psychological Association [23], examined ten types of anomalous experiences and found little relationship between anomalous experiences and psychopathology. Indeed, many of these experiences have been associated with claims of positive life changes following the experience. Many anomalous experiences such as mystical experiences, psychic experiences and near death experiences include religious and spiritual content. Yet they can be distressing and lead to contact with mental health professionals [23]. Four anomalous experiences are included as spiritual problems in the chapter for the White Paper Group’s book:
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mystical experiences, near-death experiences, alien abduction experiences and psychic experiences. The typology below is based on systematic and ongoing literature reviews of Pubmed (Medline) and PsycInfo as well as theology and anthropology reference databases to identify case studies and other research as well as clinical articles that address religious and spiritual problems [24–26]. In the definition of Religious or Spiritual Problem published in 1994 in the DSM-IV, two types were mentioned: * *
loss or questioning of faith; conversion to a new faith.
The typology of religious problems below has been updated in this chapter to reflect new studies reported in the databases of healthcare and scientific literature since 1991: * * * *
loss or questioning of faith; changes in membership, practices and beliefs (including conversion); New Religious Movements and cults; life-threatening and terminal illness.
The original definition proposed to the Task Force on DSM-IV included two types of spiritual problems that had been identified through literature searches: near death experiences and mystical experiences. The DSM-IVadopted a more general definition for spiritual problems: ‘questioning of other spiritual values which may not necessarily be related to an organized church or religious institution.’ The typology below reflects recent studies and cases reported in the databases of healthcare and scientific literature: * * * * * *
mystical experiences; near-death experiences; psychic experiences; alien abduction experiences; meditation and spiritual practice-related experiences; possession experiences.
The definition for the V-Code category religious or spiritual problem should be updated to reflect current peer-reviewed research on religious and spiritual problems by including mention of the additional types of problems identified in the literature. V62.89: This category can be used when the focus of clinical attention is a religious or spiritual problem. Examples of religious problems include loss or questioning of faith, changes in membership, practices and beliefs (including conversion), New Religious Movements and cults, life-threatening and terminal illness. Examples of spiritual problems include mystical experiences, near-death, psychic experiences, alien abduction experiences, meditation and spiritual practice-related experiences, possession experiences and questioning of other spiritual values which may not necessarily be related to an organized church or religious institution.
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While each type and each individual case of religious or spiritual problem presents unique therapeutic challenges, there are some basic principles that apply to all cases. The most important task is to provide patients with a positive context for their experiences. If they express fears of ‘going crazy’ or are having anxiety about the experience, this would include sharing the diagnostic assessment of a religious or spiritual problem, and normalizing the experience for the patient by providing background information. For example, Near-death Experiences (NDEs) often produce profound changes which, treated as an ICU psychosis, are now being normalized as nopathological, even positive experiences for many patients. ‘The inclusion of this new diagnostic category in the DSM-IV permits differentiation of NDEs and similar experiences from mental disorders and may lead to research into more effective treatment strategies.’ [27] Interventions can include referral to a spirituality group [28], support for a time-limited crisis, intensive psychotherapy and the involvement of relatives and friends [29]. Collaboration with religious professionals and spiritual teachers should also be considered, as well as referrals.
4.6.2.2
Research on religious on spiritual problem category
One of the original objectives listed in the diagnostic category proposal was to stimulate clinical research. Research has greatly expanded in the past 14 years with a 2001 review summarizing the findings of 1600 research articles [7]. The acceptance of the diagnostic category doesn’t account for this increase but is as much a reflection of the new acceptance of this domain for psychiatry and psychology. In addition to the Hathaway and Harter studies cited earlier about use of the diagnostic category by psychologists, two other studies have focused on the diagnostic category of religious and spiritual problem. One study [30] measured the evaluations of three vignettes of presenting problems with religious content: schizophrenia (mental disorder), mystical experience (religious or spiritual problem), and mourning (‘pure’ religious problem). A national, random sample of rabbis (N ¼ 111) and clinical psychologists (N ¼ 90) rated the religious etiology, helpfulness of psychiatric medication, and seriousness of these three cases. The rabbis and psychologists both distinguished between the three categories of presenting problems and concurred in their distinctions. The authors conclude that, ‘The results provide empirical evidence for the construct validity of the new DSM-IV category religious or spiritual problem (V62.89). Use of the V code allows for more subtle distinctions among the variety of problems that persons bring to clergy and mental health professionals. (p. 608). Another study [31] investigated whether and how psychologists (members of the American Psychological Association) are using DSM-IV V-Code Category Spiritual or Religious Problem, V62.89 in their work with clients. Each participant was sent an anonymous questionnaire. Of the1000 psychologists who received research packets, 25.8% completed and returned the two survey instruments. The study found that although 44.7% of the respondents were familiar with V62.89, only 7.3% of the psychologists had courses or were trained in areas related to religious and spiritual issues. Of the 19.4% (50) respondents who indicated use of V62.89, 66% (33) reported using it to indicate confusion about a religious issue, 40%(30) reported using it to indicate anger at God, and 54% (27) reported using it to indicate loss of faith. The questionnaire responses showed that
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two-thirds of respondents (61%) did not use V62.89 in diagnosis of their clients due to non billable insurance coverage. Eleven percent indicated that they refer to clergy for these issues.
4.6.2.3
Assessment of religious and spiritual problems
A recent consensus conference co-directed by Christina Puchalski with the Association of American Medical Colleges concluded that it is the ethical obligation of physicians to know how to respond to patient suffering, and to know how to respond to patient’s spiritual/ existential issues [13]. Several studies suggest that many patients desire their physicians to be accepting and attentive to their religious or spiritual beliefs. A large survey of 456 patients revealed that two-thirds of the participants felt that physicians should be aware of their patients’ religious and spiritual beliefs [32]. Patient preferences regarding three different spiritual interventions (asking about beliefs, silent prayer and prayer with the patient) varied depending on the medical seriousness as well as the medical setting. Only one-third expressed a preference for physicians to inquire about their religious beliefs during a routine office visit, but when in the context of dying, preference for physician inquiry increased to 70%. Likewise, only a minority endorsed a preference for prayer with their physician during a routine office visit, but up to half of the participants endorsed a desire to pray with their physician if dying. In North America, the Joint Commission for Accreditation of Health Care Organizations mandates that the assessment of spiritual needs be documented in each patient’s chart and that the spiritual component of a person’s life be considered in healthcare. When dealing with a spiritual problem, areas of assessment include how the patient uses spiritual coping, and how patients’ prayer life and religious practices give meaning to their life. Psychiatrists need to understand whether their clients’ religiosity or spirituality is intertwined with or contributes to problems and disorders. They should also attempt to determine whether their clients have religious or spiritual resources that could be used in therapy to help promote coping, healing and change [33]. Several brief instruments are available such as the FICA (acronymn for faith, involvement, community and how to address faith in the treatment) [34]. Introduction The inclusion in the DSM-IV and DSM-IV-TR of the ‘Outline for Cultural Formulation’ [Appendix I] (abbreviated in this chapter as ‘Cultural Formulation’) provides a standardized assessment tool that clinicians may utilize to describe cultural information relevant to the differential diagnosis and management of mental disorders. The 2000 text revision added additional language to emphasize the need for sensitivity regarding religious and spiritual issues. Examples of increasing sensitivity in the DSM-IV-TR are included in the Age, Gender and Cultural Consideration sections of the narrative descriptions of some mental disorders. For example, in the narrative description of Brief Psychotic Disorder, it is stated that hearing voices in a religious ceremony may not necessarily represent psychosis (APA, 2000, p. 330). Similarly, voluntarily induced depersonalization or derealization as a part of trance or meditation practices could be confused with Depersonalization Disorder (ibid., p. 531).
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RESEARCH ISSUES
In addition, the American Psychiatric Association’s Practice Guidelines for the Psychiatric Evaluations of Adults, Second Edition, which incorporates the Outline for Cultural Formulation, specifically commented on potential cultural, religious and spiritual factors which may be important to consider in psychiatric assessments (APA 2006). While the Outline for Cultural Formulation provides a concise clinical method to incorporate religious and spiritual information within the broad framework of culture, religious factors are only mentioned once in this section of the DSM-IV-TR. Yet religion and spirituality could be the primary identity in a person’s culture and heritage (Lukoff et al. 1995).
4.6.2.4
The cultural formulation [35]
As described in Appendix I of the DSM-IV-TR, the Cultural Formulation contains five categories of information which may be important in clinical care: cultural identity of the individual, cultural explanations of the individual’s illness, cultural factors related to the psychosocial environment and levels of functioning, cultural elements of the relationship between the individual and the clinician, and the overall cultural assessment as it relates to diagnosis and care (APA p. 897–898). All of these overlap with religious and spiritual issues as discussed below (Lewis-Fernandez and Diaz 2002).
Cultural identity The influences of various cultural and ethnic groups upon the individual’s sense of self as well as self-described affiliations are documented and described in this category. While factors such as ethnicity, acculturation and language are explicitly stated in the Outline for Cultural Formulation, religion and spirituality can offer meaning and purpose in an individual’s life, and religious or spiritual affiliation can be an essential part of one’s individual identity. Religious and spiritual belief systems and faith communities can play an important part in transmitting culturally held values, social behavior, and meaning even in the early stages of psychological development [36]. Such beliefs and values may be challenged when one’s perceived identity is threatened or distorted at times of crisis or transition [33], contributing significantly to a person’s distress. In the last two decades, the importance of religious faith and identity in patients with mental disorders has been increasingly recognized.
Cultural explanations of illness and help-seeking pathways This section asks the clinician to explore those cultural factors which contribute to the patient’s and family’s experience and understanding of illness, such as idioms of distress and explanatory models. Such factors not only impact the relationship between clinician and the individual and family and hence the diagnosis and treatment, but also the relationships between the patient and the family and community at large. It includes beliefs regarding causation of suffering; perceived severity and impairment, as well as help-seeking choices, preferences and expectations regarding treatment. The individual or family may describe or explain their illness experience from a religious or spiritual framework that the clinician should assess for a possible diagnosis of Religious or Spiritual Problem.
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Cultural factors related to the psychosocial environment Religious and spiritual beliefs and practices can be one of several important factors contributing to a patient’s ability to cope with psychosocial stressors, as explicitly stated in this section of the Cultural Formulation (APA 2000). The degree to which religious coping strategies are effective or harmful for individuals has been studied extensively by Pargament and his colleagues [37]. In cross-sectional studies examining the relationship between different means of religious coping and psychological adjustment to a variety of health stressors and trauma, some specific types of coping were found to be relatively healthy while others appeared to generally harmful. Examples of helpful or positive coping strategies included perceptions of spiritual support and guidance, congregational support, and attributions of negative life events to the will of God or a loving God, while negative coping strategies related to poorer outcomes included spiritual discontent, either with the congregation or with God, and perceiving negative life events as God’s punishment. Thus while some forms of religious coping may be protective and healthy, other forms of religious coping may contribute to poor spiritual and health outcomes. ‘Religious struggle’ can contribute to increased physical and psychological stress as well social isolation.
Cultural elements in the relationship between the clinician and the individual Culturaldifferencesandsimilaritiescanhaveasignificantinfluenceontherelationshipbetween the patient and the clinician. Awareness of the patient’s religious or spiritual beliefs and practicesallowsthetherapisttoaccommodatesuchbeliefsinthecaseformulationofthepatient, including the patient’s struggle to find meaning, means of relating to others, impact on the transference relationship between the patient and therapist, and the capacity to make appropriate referrals when religious or spiritual questions extend beyond the therapist’s expertise [38]. The American Psychiatric Association’s resource document, ‘Religious/Spiritual Commitments and Psychiatric Practice,’ [39] emphasizes that psychiatrists should inquire into and respect their patient’s worldviews and religious/spiritual beliefs, and includes several examples of clinical problems that may arise when psychiatrists are unaware of or violate treatment boundaries around religious and spiritual beliefs and practices. At the same time, clinicians should reflect on their own religious and spiritual development so they can effectively understand and empathize with the individual’s beliefs and practices as well as not inadvertently adversely affect the relationship.
Overall cultural assessment and conclusion The final component of the Cultural Formulation summarizes the information regarding the patient’s cultural identity, explanatory models and help-seeking behavior, psychosocial stressors and coping strategies, and impact upon the clinician-patient relationship, with the goal of recognizing those cultural factors that contribute to the differential diagnosis and treatment planning and management. Assessing the degree to which religious and spiritual phenomena may be normative within that person’s cultural reference group, a Culture-Bound Syndrome, a Religious or
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Spiritual Problem, a sign or symptom of a mental disorder or a mixture of these possibilities begins with the clinician’s use of the Outline for Cultural Formulation. This process can be aided by consulting with the patient’s family, friends and pastoral counselors, chaplains, or clergy. Under such circumstances, pastoral counselors, chaplains, or clergy may be considered a ‘spiritual or religious broker’ similar to the ‘cultural broker’ described by Kirmayer [40].While a religious or spiritual ‘match’ between the clinician and patient may minimize misunderstandings regarding religious beliefs, practices and experiences, such a match also potentially risks ethical violations of role boundary violations, displacing religious authority, and incorrectly assuming shared values [41]. While a knowledge base of various cultures, religions, and spiritual beliefs and practices is helpful to the clinician, comprehensive information is not always available to provide spiritually or religiously competent and sensitive care. Rather, a knowledge of the differential diagnosis of religious and spiritual phenomenology as described above, an ability to listen for and be aware of religious and spiritual themes, and an ability to comfort in performing a sensitive cultural and spiritual assessment may allow clinicians to incorporate religious or spiritually relevant information into the overall clinical assessment and treatment plan of the patient [41]. Actively listening for religious or existential themes may reveal the use of metaphors and narratives by the patient to describe spiritual experiences and ideas otherwise difficult to articulate [42]. By routinely obtaining religious and spiritual information as part of the Cultural Formulation, the clinician can better understand the patient’s personal coping and social resources, as well as allow the patient to express and explore religious, spiritual and existential issues which may contribute to the patient’s suffering. Considering the prominent role of religion and spirituality in the values, attitudes, and beliefs of different cultures and ethnicities, this information can easily be organized using the Cultural Formulation as outlined in the DSM-IV-TR.
4.6.2.5
Recommendations for DSM-V
Outline for cultural formulation revised The Outline for Cultural Formulation should be revised to include religious and spiritual factors.
Cultural identity of the individual Note the individual’s ethnic or cultural reference groups, including religious/spiritual affiliations, changes or development in religious or spiritual faiths, and the relative importance of religion/spiritual to the client.
Cultural explanations of the individual’s illness The following may be identified: the predominant idioms of distress through which symptoms or the need for social support are communicated (e.g., ‘nerves,’ possessing
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spirits, somatic complaints, inexplicable misfortune, testing or punishment from God), the meaning and perceived severity of the individual’s symptoms in relation to norms of the cultural, religious and/or spiritual reference group, any local illness category used by the individual’s family and community to identify the condition, the perceived causes or explanatory models that the individual and the reference group use to explain the illness, and current preferences for and past experiences with professional and popular sources of care. Note if a cultural, religious, or spiritual leader has been consulted regarding the symptoms, the degree to which this was found helpful, and the potential value of collaboration with such leaders.
Cultural factors related to psychosocial environment and levels of functioning Note culturally, religiously, or spiritually relevant interpretations of social stressors, available social supports and levels of functioning and disability, as well as the use of religious or spiritual coping strategies which may provide relief from or contribute to suffering.. This would include stresses in the local social environment and the role of religion and kin networks in providing emotional, instrumental and informational support.
Cultural elements of the relationship between the individual and the clinician Indicate differences in culture, religious and spiritual backgrounds, and social status between the individual and the clinician that may affect diagnosis and treatment (e.g., difficulty in communicating in the individual’s first language, in eliciting symptoms or understanding their cultural significance, in negotiating an appropriate relationship or level of intimacy, in determining whether a behavior is normative or pathological).
Overall cultural assessment for diagnosis and care The formulation should include a discussion of how cultural, religious and spiritual considerations specifically influence comprehensive diagnosis and care.
4.6.3
PERSONALITY DISORDERS [43]
A holistic spiritual perspective is different from the egocentric view that is consistently found in patients with personality disorders: individuals with personality disorders think of themselves as fundamentally separate, like Newtonian billiard balls, and consequently are vulnerable to fears that lead to psychopathology. A spiritual perspective recognizes that all things are inseparably interdependent parts of a whole, even though he or she can also recognize and respect the individual identity of the component parts. Recovery from personality disorders involves developments in character, self-awareness, spirituality, virtue and well-being. The treatment of personality disorders involves the
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facilitation of a change in a person’s worldview and life style, just as the diagnosis rests on an assessment and understanding of their worldview and life style. Consequently, religious activity and spiritual development are crucial components of the diagnosis and treatment of personality disorders. Accordingly, biological, psychological, sociocultural and spiritual perspectives are complementary in assessment and treatment. There need be no competition or incompatibility between contributions that can be made to the evaluation and treatment of personality disorders by psychiatrists, other mental health professionals and experts in spiritual development. Regarding the general diagnostic criteria for a personality disorder (DSM-IV-TR, p. 689), it is noteworthy that the criteria systematically avoid reference to spirituality despite the crucial feature of a personality disorder being a deficit in the person’s character. The manifestations listed are each non-essential indicators of an underlying lack of integration in the perspective taken on life. The criteria suggest an anti-spiritual bias in describing disorders that are essentially spiritual deficits. The general criteria are most important because the most commonly diagnosed personality disorder in clinical practice is ‘not otherwise specified.’ The avoidance of the spiritual features of personality disorders limits the utility of the criteria for both diagnosis and treatment, which are key motivations for DSM. A conservative solution to this deficiency in DSM-IV would be to add language that notes that a personality disorder is: A. An enduring pattern of perspective, inner experience and behavior that deviates markedly from the expectations of the individual’s culture. B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations as a consequence of the person’s perspective on life that does not integrate sexual, material, emotional, and intellectual situations into a coherent spiritual whole in his or her self-aware consciousness. C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, religious, spiritual, or other important areas of functioning. D, E, F. (no change) Introducing these proposed simple changes in the diagnostic criteria will acknowledge the compatibility of biopsychosocial approaches with spiritual approaches to diagnosis and treatment of mental health. It could refocus treatment on the development of well-being, including happiness, love and virtues. Such a change would move DSM along with the developments in the third generation of psychotherapies that now emphasize the importance of the cultivation of strengths of character and self-awareness by use of meditation, mindfulness and other activities that facilitate positive mental health [44–46]. The facilitation of well-being can be accomplished in ways that are compatible with fundamental psychobiological principles of spirituality without entering into subjective judgments about religious dogma. The investigation of the psychobiology of self-aware consciousness is an important challenge in modern neuroscience. Personality disorders can play a key role in psychiatry’s learning to understand and to appreciate the mystery of self-aware consciousness if the criteria are allowed to reflect the central issues about self-awareness and spirituality [46–48]. It is essential that the field dedicated to the ‘healing of the soul’ recognize the importance of self-awareness and a spiritual perspective in the disorders that include spiritual deficits regardless of what terminology that may be used.
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PTSD [49]
Many cultures place little emphasis on individual psychological experiences, focusing instead on issues of family, religion, and meaning within a larger social context [50, 51]. Clinicians working in settings involving war, political uncertainty, or natural catastrophe should be cautious when educating survivorsabout the emergence of PTSD. PTSD may not be as prevalent in non-Western settings as in the West since the intact extended social networks that often exist in non-Western settings may be protective against the development of PTSD. In a carefully thought out paper on psychological responses to civilian populations affected by war, Derek Summerfield [52] observed that an excessive focus on individual psychological syndromes can detract from appreciation of the larger social contexts that lead to, cause and perpetuate the alienation and anxiety associated with catastrophic events. He noted that in the West, the language of medicine and psychology have ‘displaced religion as the source of explanations for the vicissitudes of life, and of the vocabulary of distress,’ and that this narrative language may be used by Western mental health professionals to substitute for local narratives that incorporate biblical, legal, ideological, humanist, or liberation themes. This insight helps us adopt a more humble approach toward our own knowledge base. The moral context of the traumatic event, as well as the patient’s moral stance during an event, should be taken into consideration when a diagnosis and prognosis of PTSD are formulated. The DSM’s indication of the need for clinicians to consider the moral significance of a traumatic event may be vital in pointing the clinician in a therapeutic direction that may secure healing for the patient, though this is an issue that remains to be fully explored. At the very least, the DSM should acknowledge that PTSD is sometimes experienced by people who have committed morally reprehensible acts, with the implication that this guilt needs to be acknowledged and addressed in a therapeutically meaningful way. The PTSD section ‘Associated Features and Disorders: Associated descriptive features and mental disorders’ could adopt the following change in wording: ‘Individuals with Posttraumatic Stress Disorder may describe painful guilt feelings about surviving when others did not survive or about things they had to do to survive. Some may experience guilt related to the perpetration of a violent event and the moral implications of their actions.’ The DSM-V presentation of posttraumatic stress disorder might profitably be framed in such a way that it does not facilitate the exportation to other cultures of a purely technological worldview that describes experiences of distress in technical terms and offers a technical solution. Such an approach will avoid draining local narratives of their meaning and preserve alternative approaches to understanding that are steeped in local tradition and promote connectedness. In this way the DSM will promote a way of understanding that helps traumatized individuals to use readily available resources to grapple with and grow through the stressful circumstances. While the DSM focuses on the symptoms of the individual, these larger social considerations should also enter into the weight a clinician places on the presence of PTSD and the effectiveness of proposed treatments (i.e., securing basic needs such as food and shelter may be much more important than pharmacological treatment in some situations). Future research directions in the relationship of PTSD to religious and spiritual concerns will need to include a focus on contextual factors that shape PTSD, to use cross-cultural comparisons to highlight how divergent worldviews might affect the presentation and course of PTSD, and to explore how religious and spiritual factors might ethically be included in treatment strategies.
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SUBSTANCE USE DISORDERS [53]
Substance use may be normative within a religiously-grounded subculture, and may be confused by a diagnostician with a pattern of abuse. Such patterns of use may result in conflict with close relations or authorities because of cultural differences. The text of the DSM-V can make this distinction clear so it is not considered a sign of pathology. The following two sections refer to DSM-IV-TR diagnostic categories. Phrases in italics illustrate options to addressing the intersection between substance use and abuse and spirituality. deux) 297.3 Shared psychotic disorder (folie a The following diagnostic criterion is listed in DSM-IV-TR: ‘. . . is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or a general medical condition.’ The following could be added: but could result from a consensual belief system of a religious movement. Substance abuse The following material is included in the narrative preceding the diagnostic criteria: ‘The person may continue to use the substance despite a history of undesirable, persistent or recurrent social or interpersonal consequences (e.g., marital difficulties or divorce, verbal or physical fights).’ The following could be added: This aspect of substance abuse should be distinguished from difficulties encountered by individuals who are members of a religious group whose practice of ritualized substance use may lead to conflict with non-members or legal authorities (e.g., culture-bound use of agents such as khat or peyote). Substance dependence With regard to remission: ‘The following specifiers apply if the individual is on agonist therapy or in a controlled environment’ or in ongoing attendance at a mutual support program. In a mutual support group: This specifier is used if the individual is in voluntary regular attendance in an abstinence-oriented mutual support program or religious sect, and no criteria for dependence or abuse have been met for at least the past month. Examples of this are spiritually-oriented Twelve-Step groups such as Alcoholics Anonymous and abstinence-oriented religious groups. Religious/cultic experiences associated with substance use Some behaviors included as diagnostic criteria within the DSM structure may emerge in response to experiences associated with membership in an intensely affiliative religious or cultic group. These behaviors may appropriately qualify a person for a pathologic diagnosis. Others, on the other hand, may be incorrectly construed as pathologic as they may be normative in such groups. Descriptions of a number of the diagnoses in the DSM-V can therefore be qualified accordingly. For example: 300.15 Dissociative disorders not otherwise specified ‘Example 3. States of dissociation that occur in individuals who have been subjected to periods of prolonged and intense coercive persuasion (e.g., brainwashing, thought reform, or indoctrination while captive)’ This could be added: Such states, which remit, may take
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place during induction into a cultic group or the experience of an intense religious experience (possibly substance-induced), and should not be termed pathologic. 309 Adjustment disorder In the context of the description of this syndrome, the following is included in the DSM-IVTR: ‘Individuals from disadvantaged life circumstances experience a high rate of stressors, and may be at increased rate for the disorder.’ This could be added: Persons leaving religious movements with intense affiliative ties (which may be related to spiritually oriented substance use) under adverse circumstances are also at increased risk.
4.6.6
PSYCHOTIC DISORDERS [54]
Severe and persistent mental disorders with psychotic symptoms (SPMDP) in DSM-IV-TR include delusional disorder, schizoaffective disorder, schizophrenia, schizophreniform disorder, and shared psychotic disorder; major depression may be severe and persistent and present with psychosis, as can bipolar disorder. Religious content in the psychotic symptoms of persons with SPMDDP is present in 22% to 39% of patients [7], and is sometimes difficult to distinguish from culturally sanctioned beliefs and experiences. Religiousness in actively psychotic persons appears to be of a different nature than that in non-psychotic persons, and there are ways to identify when religious expressions become pathological. There may be an increase in religiousness near the time of illness onset, and religious conversion, particularly if sudden, may increase the risk of psychotic decompensation in vulnerable persons. However, persons with SPMDP commonly use religion to cope with the stress of their illness [55], which may confuse the diagnostic picture. This is especially true in religious areas of the world and for members of certain religious groups. There is some evidence that religious beliefs and activity may reduce frequency of hospital admission, improve compliance with medication and reduce suicide rates. Spiritual interventions – particularly when implemented in a group format – may benefit persons with SPMDP by providing support, addressing their spiritual concerns, and increasing their ability to connect with others. Clergy and the faith community can play an important role in the care and support of those with SPMDP, although some religious communities may shun persons with mental disorders because of fear and/or lack of knowledge.
4.6.6.1
Future research
Research on religion and mental health in persons with severe mental illness has lagged far behind that in non-psychiatric or medical populations. This represents a serious gap that interferes with the ability to differentiate psychotic symptoms from normal religious beliefs and experiences, and clouds the understanding of how religion can be a resource or a risk factor in this population. The lack of carefully designed and executed research on religion, spirituality and SPMDP (diagnosis, impact on outcome, role in treatment) is a major barrier to diagnostic assessment and future clinical applications. So the possibilities in terms of future studies are almost limitless and present a unique opportunity for investigators.
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In order to understand the relationship between religion and SPMDP for diagnostic purposes, further systematic research is critical. Areas of particular need for persons with SPMDP can be divided into three areas: (1) understanding the religion-SPMDP relationship in general, (2) understanding the religion-SPMDP relationship in special populations (children and adolescents, older adults, minority populations, HIV-AIDS, co-morbid substance abusers), and (3) assessing the effectiveness of spiritual interventions (individual, group, and community) on treatment and relapse-prevention.
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What are the effects of religious beliefs and practices on the etiology and the course of SPMDP? (i.e., schizophrenia, delusional disorder, bipolar disorder, etc.) How is the expression of religiousness different in persons actively symptomatic with SPMDP from (a) those with SPMDP whose symptoms are controlled and (b) those without SPMDP? Are there specific biological and/or psychodynamic causes for religious delusions and how do they influence the expression and course of illness? Can religious conversion experiences influence the presentation or exacerbation of SPMDP? Are certain types of conversion experiences particularly likely to do this? Are certain religious groups more vulnerable? Why? Do religious beliefs or practices influence burnout rates in family members or mental health professionals (nurses, social workers, therapists, psychologists, psychiatrists) caring for those with SPMDP?
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Religion-SPMDP relationship (general)
Religion-SPMDP relationship (special populations)
Does the religious training of children or adolescents either increase or decrease later susceptibility to SPMDP? Does type of religious training make a difference? Does age of religious training make a difference? Does the religiousness and type of religious belief of parents increase or decrease a child’s susceptibility to SPMDP? What is the relationship between religious beliefs and practices and SPMDP in older adults, especially elders with chronic medical illness, those who are socially isolated with few other resources, or the institutionalized? Do religious beliefs or activities reduce agitation in older patients with SPMDP? Does it help their caregivers to cope (or hinder it)? Is there a particularly strong relationship between religiousness and SPMDP in certain minority populations? (African-Americans vs. Hispanics vs. Asians vs. Middle-Easterners); does this relationship vary by type of religion or type of religious practice? What is the relationship between religiousness/spirituality and SPMDP in homosexuals and others with alternative lifestyles that may conflict with traditional religious doctrines? What about in persons with HIV/AIDS? Does the cause of HIV/AIDS influence the relationship between religiousness/spirituality and SPMDP? How does religious involvement affect the risk of co-morbid substance abuse in persons with SPMDP? How does it affect the course of illness in this population?
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Effectiveness of spiritual interventions
What is the efficacy and effectiveness of religious or spiritual interventions in persons with SPMDP? When are they most effective (i.e., during an acute episode of exacerbation, after symptoms are controlled, etc.)? Is individual or group therapy more effective? What interventions are more acceptable to persons with SPMDP? Does type of religion make a difference in the effectiveness of spiritual interventions in persons with SPMDP? What are the dangers of spiritual interventions in terms of worsening psychotic symptoms or reinforcing religious delusions? What is the role of spiritual interventions in children with SPMDP? Are there particular approaches that are more helpful? What about spiritual interventions for other special populations (older adults, minority groups, those with alternative lifestyles, HIV-AIDS)? What is the role of spiritual treatments (including Alcoholics Anonymous or Narcotics Anonymous) in persons with SPMDP and co-morbid substance abuse? How can religious communities best support those with severe mental illness? What are the limitations of such support? What are roles that persons with SPMDP can serve in faith communities, and how can they best be integrated into the life of these communities? Why are faith communities resistant to include those with SPMDP? How can these resistances be overcome?
4.6.6.5 Text suggestions for DSM-V section on schizophrenia and other psychotic disorders regarding religious/spiritual considerations Religious/spiritual ideas that appear delusional in one setting (e.g., sorcery and witchcraft) may be considered normal or even encouraged in another. Likewise, visual or auditory hallucinations with a religious content may be a normal part of religious experience (e.g., seeing the Virgin Mary or hearing God’s voice). The diagnosis of schizophrenia or other psychotic disorders should never be made in the absence of other symptoms and signs of the diagnosis. The religious/spiritual person without schizophrenia usually recognizes the extraordinary or unbelievable nature of their experiences (insight), shares their experiences or ideas with another group of people (inter-subjective reality), has no disturbances in thought processes (conceptual disorganization, looseness of associations, thought blocking), is able to handle every day commonsense tasks (maintain a job, stay out of legal problems), is not dangerous to others or self (low risk), and usually has a positive outcome over time [21]. Persons with schizophrenia, however, may have healthy religious/spiritual ideas and experiences. Prospective studies suggest that religious/spiritual activities (religious affiliation, worship, regular church attendance, satisfaction with religious belief) predict fewer admissions for psychotic exacerbations, less rapid deterioration over time, and reduce the risk of suicide in persons with schizophrenia. In contrast, religious delusions (held by 25–39% of psychotic patients with schizophrenia) may portend a worse prognosis, although further research is needed [7].
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SUMMARY AND CONCLUSIONS [56]
Since the introduction in DSM-IV of religious, spiritual and cultural factors in the diagnostic process, research in these areas has proliferated and matured. A clearer view is now possible of several specific areas of research needed to establish a firm evidence base for future revisions. Fortunately, findings to date substantiate several proposed modifications that can take the importance of religious, spiritual and cultural factors into fuller account in DSM-V. I. The revised DSM should provide clearer criteria for distinguishing intense religious/ spiritual experiences from psychopathology. Qualifications based on religious and spiritual factors may also be indicated in definitions of substance use. A broader understanding of the patient’s religious and cultural context, such as through the use of the Outline for Cultural Formulation, can help to understand and interpret to what extent observed phenomena represent manifestations of cultural norms, a Religious or Spiritual Problem, a Culture-Bound Syndrome, signs and symptoms of a mental disorder, or a combination of any of these diagnostic possibilities. Experiences such as hearing God’s voice or engaging in the use of mind-altering substances are normative in certain religious contexts. More research (including philosophical field work and phenomenological studies) is needed to determine how current psychiatric categories are actually being used, and to what effect. Where data is available, DSM-V should incorporate it into the diagnostic criteria for such disorders. II. Religious and spiritual categories may provide a better way of conceptualizing certain phenomena than categories of mental disorder. This may be true for sub-syndromal or sub-threshold forms of anxiety or depression that are related to existential or spiritual concerns. It may also be true in the case of personality disorders. Patients with personality disorders can be most clearly understood as having deficits in the coherence of their fundamental assumptions and schemas about life – i.e., deficits that can be considered spiritual. This proposed change is based on both the history of well-intentioned but unsatisfactory attempts to classify personality disorders without reference to virtues and vices, and on modern needs for improved treatment planning. III. Religion and spirituality can be important factors in understanding the course of many disorders. For example, religion and spirituality may well have protective effects regarding the development of psychopathology in children and adolescents, and positive influences on coping with adversity. Participation in spiritual approaches such as Twelve Step Programs could be added as qualifiers of the process of recovery from addiction. Religious institutions and professionals may provide personal and social support, as well as harmful influences, as in the case of cults. Research is needed to better characterize these positive and negative effects on course and outcome. A patient’s religious or spiritual outlook also shapes, and is shaped by, post-trauma symptoms in a number of ways. These include the influence of religion and spirituality on worldview; religious or spiritual coping strategies; an individual’s perception of the moral meaning of the traumatic event; and social forces that contextualize the traumatic event. IV. Existential and moral dimensions of human experience and distress deserve more explicit attention in a revised DSM. The original definition of a V Code for a Religious or Spiritual Problem proposed to the Task Force on DSM-IV and published in the
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Journal of Nervous and Mental Disease [2] included four types of religious problems, but only two of these were included in DSM-IV: loss or questioning of faith, and conversion to a new faith. Evidence has accumulated since to support the inclusion of additional religious and spiritual problems such as those related to changes in membership, practices and beliefs (including conversion), New Religious Movements and cults, and life-threatening and terminal illness. Existential and moral concerns can also be significant sources of anxiety that may be a focus of clinical attention or treatment. V. The impact of culture on the presentation and course of psychiatric disorders is often mediated through religious and spiritual beliefs and practices. For example, nonWestern understandings of the meaning of trauma and depression can differ widely from those in the West. Epidemiologic research is needed to determine the prevalence of conditions such as depression, PTSD and obsessive compulsive disorder within populations that give them different meaning, as well as more focused studies to examine the ways that particular faiths and cultures interpret, discourage or legitimate expression of symptoms. VI. Finally, research is needed to answer remaining questions about the complex relationship between religion/spirituality and psychiatric disorders. Epidemiological studies establishing associations between measures of religiosity or spiritual well-being and psychiatric symptoms suggest that positive effects may be common. But is the mechanism of action strong beliefs, community support, mindfulness, spiritual engagement with a Higher Power, or some other factor? Studies such as Pargament’s [37] on the implications of positive and negative religious coping have begun to explore one such factor. Future studies within religious populations are needed to understand how other aspects of religion/spirituality assist or interfere with recovery from illness. What factors across traditions predispose to healthy or unhealthy maturation? Given the value-laden and culturally conditioned nature of psychiatric diagnosis, when is this process most vulnerable to unwitting distortion by the clinician’s own worldview?
REFERENCES 1. American Psychiatric Association (1994) Diagnostic and statistical manual, fourth edition. American Psychiatric Association, Washington, DC. 2. Lukoff D, Lu F, Turner R (1992) Toward a more culturally sensitive DSM-IV: Psychoreligious and Psychospiritual Problems. Journal of Nervous and Mental Disease 180, 673–682. 3. Josephson A, Peteet J (2004) Handbook of Spirituality and Worldview in Clinical Practice. American Psychiatric Publishing, Washington, DC. 4. Kupfer D, First M, Regier D (eds.) (2002) A Research Agenda for DSM-V. American Psychiatric Association, Washinton DC. 5. Narrow W, First M, Sirovatka P, Regier D (eds.) (2007) Age and Gender Considerations in Psychiatric Diagnosis: A Research Agenda for DSM-V. American Psychiatric Association, Washington DC. 6. Peteet J, Narrow W, Lu F (eds.) (in press) Religious and Spiritual Issues in Psychiatric Diagnosis: Considerations for a Revised DSM. American Psychiatric Association Press, Washington DC. 7. Koenig H, McCullough M, Larson D (eds.) (2001) Handbook of Religion and Health. Oxford University Press, New York.
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8. Shafranske E, Sperry L (2004) Addressing the Spiritual Dimension in Psychotherapy: Introduction and Overview. In: Sperry L, Shafranske E (eds.) Spiritually Oriented Psychotherapy. American Psychological Association, Washington DC. 9. Walker A (ed.) (1991) Thesaurus of Psychological Terms, 2nd edn. American Psychological Association, Arlington VA. 10. Lukoff D, Lu F, Yang P(in press) Religious and Spiritual Problems. In: Peteet J, Narrow W, Lu F (eds.) Religious and Spiritual Issues in Psychiatric Diagnosis: Considerations for a Revised DSM. American Psychiatric Association, Washington DC. 11. Scott S, Garver S, Richards J, Hathaway W (2003) Religious issues in diagnosis: the V-Code and beyond. Mental Health, Religion & Culture 6, 161–173. 12. Shafranske E, Maloney H (1990) Clinical psychologists’ religious and spiritual orientations and their practice of psychotherapy. Psychotherapy 27, 72–78. 13. Boston P, Puchalski CM, O’Donnell JF (2006) Spirituality and medicine: curricula in medical education. Journal of Cancer Education 21, 8–12. 14. Larson D, Lu F, Swyers J (1996) Model curriclum for psychiatry residency training programs: Religion and spirituality in clinical practice. National Institute for Healthcare Research, Rockville, MD. 15. Hathaway W, Scott S, Garver S (2004) Assessing Religious/Spiritual Functioning: A Neglected Domain in Clinical Practice? Professional Psychology: Research and Practice 35, 97–104. 16. Hartter DK (1995) The identification of spiritual emergencies in the practice of clinicalpsychology by frequency and ability of therapist to recognize. [Unpublished doctoral dissertation]. The Union Institute, Cincinnati, OH. 17. Pew Forum on Religion and Public Life (2008) U.S. Religious Landscape Survey. Pew Research Center, Washington, DC, http://religions.pewforum.org/. 18. Gallup G (2002) The 2001 Gallup Poll: Public Opinion. SR Books, Wilmington, Delaware. 19. Gallup G, Jones T (2000) The Next American Spirituality: Finding God in the Twenty-First Century. Chariot Victor Publishing, Colorado Springs, CO. 20. Fuller R (2001) Spiritual, but not Religious: Understanding Unchurched America. Oxford University Press, New York. 21. Lukoff D (2007) Visionary spiritual experiences. Southern Medical Journal 100, 635–641. 22. Taylor E (1983) William James on Exceptional Mental States: The 1896 Lowell Lectures. Scribner, New York. 23. Cardena E, Lynn S, Krippner S (eds.) (2000) Varieties of Anomalous Experience: Examining the scientific evidence. American Psychological Association Press, Washington DC. 24. Lukoff D, Provenzano R, Lu F, Turner R (1999) Religious and spiritual case reports on MEDLINE: A systematic analysis of records from 1980–1996. Alternative Therapies in Health and Medicine 5, 64–70. 25. Lukoff D, Turner R, Lu F (1992) Transpersonal psychology research review: Psychoreligious dimensions of healing. Journal of Transpersonal Psychology 24, 41–60. 26. Lukoff D, Turner R, Lu FG (1993) Transpersonal psychology research review: Psychospiritual dimensions of healing. Journal of Transpersonal Psychology 25, 11–28. 27. Greyson B (1997) The near-death experience as a focus of clinical attention. Journal of Nervous and Mental Disease 185, 327–334. 28. Kehoe N (2007) Spirituality groups in serious mental illness. Southern Medical Journal 100, 647–648. 29. Lukoff D, Lu F (2005) A Transpersonal Integrative Approach to Spiritually Oriented Psychotherapy. In: Sperry L, Shafranske E (eds.) Spiritually Oriented Psychotherapy. American Psychological Association Press, Washington, DC, pp. 177–205. 30. Milstein G, Midlarsky E, Link BG, Raue PJ, Bruce ML (2000) Assessing problems with religious content: a comparison of rabbis and psychologists. Journal of Nervous and Mental Disease 188, 608–615.
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31. Brown J (2005) Inquiry into the Understanding and applications of DSM-IV Category Religious or Spiritual Problem, V-Code 62.89 by American Psychological Association (APA) Psychologists, [Dissertation]. Institute of Transpersonal Psychology, Palo Alto, CA. 32. MacLean C, Susi B, Phifer N (2003) Patient preference for physician discussion and practice of spirituality. Journal of General Internal Medicine 18, 38–43. 33. Peteet J (2004) Therapeutic implications of worldview. In: Josephson A, Peteet J (eds.) Handbook of Spirituality and Worldview in Clinical Practice. American Psychiatric Publishing, Washington, DC, pp. 47–59. 34. Puchalski C, Romer A (2000) Taking a spiritual history allows clinicians to understand patients more fully. Journal of Palliative Medicine 3, 129–137. 35. Lu F, Gellerman D (in press) Outline for Cultural Formulation. In: Peteet J, Narrow W, Lu F (eds.) Religious and Spiritual Issues in Psychiatric Diagnosis: Considerations for a Revised DSM. American Psychiatric Association, Washington, DC. 36. Shafranske E (1996) Religion and the Practice of Psychology. American Psychological Association, Washington, DC. 37. Pargament K, Koenig HG, Tarakeshwar N, Hahn J (2004) Religious coping methods as predictors of psychological, physical and spiritual outcomes among medically ill elderly patients: a twoyear longitudinal study. Journal of Health Psychology 9, 713–730. 38. Lomax J, Karff S, McKenny G (2002) Ethical considerations in the integration of religion and psychotherapy: three perspectives. Psychiatric Clinics of North America 25, 547–559. 39. American Psychiatric Association Corresponding Committee on Religion Spiritualty and Psychiatry (2006) Religious/Spiritual Commitments and Psychiatric Practice. http://www. psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/ResourceDocuments/ 200604.aspx. 40. Kirmayer L, Groleau D, Guzder J, Blake C, Jarvis E (2003) Cultural consultation: a model of mental health service for multicultural societies. Canadian Journal of Psychiatry 48, 145–153. 41. Richards PS, Bergin A (2000) Towards religious and spiritual competency for mental health professionals. In: Richards PS, Bergin A (eds.) Handbook of Psychotherapy and Religious Diversity. American Psychological Association, Washington, DC. 42. Griffith J, Griffith M (2001) Encountering the Sacred in Pychotherapy: How to talk with people about their spiritual lives. Guilford Press, New York. 43. Cloninger R. (in press) Personality Disorders. In: Peteet J, Narrow W, Lu F (eds.) Religious and Spiritual Issues in Psychiatric Diagnosis: Considerations for a Revised DSM. American Psychiatric Association Press, Washington, DC. 44. Linehan MM (1993) Cognitive-behavioral Treatment of Borderline Personality Disorder. Guilford Press, New York. 45. Hayes SC, Follette VM, Linehan MM (2004) (eds.) Mindfulness and Acceptance: Expanding the cognitive-behavioral tradition. Guilford Press, New York. 46. Cloninger CR (2004) Feeling Good: The Science of Well Being. Oxford University Press, New York. 47. Kandel ER, Schwartz JH, Jessell TM (2000) Principles of Neural Science. McGraw-Hill, New York. 48. Davidson RJ (ed.) (2003) Investigating the Mind: Studies of emotion. Mind & Life Conference, September 14, 2003. Massachusetts Institute of Technology, Cambridge MA. 49. Thielman S. Adjustment Disorders and PTSD (in press). In: Peteet J, Narrow W, Lu F (eds.) Religious and Spiritual Issues in Psychiatric Diagnosis: Considerations for a Revised DSM. American Psychiatric Association Press, Washington, DC. 50. Good CM (1987) Ethnomedical Systems in Africa: patterns of traditional medicine in rural and urban Kenya. Guilford Press, New York. 51. Beiser M (1985) A study of depression among traditional africans, urban North Americans, and Southeast Asian refugees. In: Kleinman A, Good B (eds.) Culture and Depression: studies in the
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52. 53.
54.
55. 56.
RESEARCH ISSUES anthropology and cross-cultural psychiatry of affect and disorder. Berkeley: University of California Press, Berkeley, pp. 272–298. Summerfield D (1999) A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Social Science & Medicine 48, 1449–1462. Galanter M, Glickman L (in press) Substance Use Disorders. In: Peteet J, Narrow W, Lu F (eds.) Religious and Spiritual Issues in Psychiatric Diagnosis: Considerations for a Revised DSM. American Psychiatric Association Press, Washington, DC. Koenig H (in press) Psychotic Disorders. In: Peteet J, Narrow W, Lu F (eds.) Religious and Spiritual Issues in Psychiatric Diagnosis: Considerations for a Revised DSM. American Psychiatric Association Press, Washington, DC. Lukoff D (2007) Spirituality in the recovery from persistent mental disorders. Southern Medical Journal 100, 642–646. Peteet J, Narrow W, Lu F Summary (in press) In: Peteet J, Narrow W, Lu F (eds.) Religious and Spiritual Issues in Psychiatric Diagnosis: Considerations for a Revised DSM. American Psychiatric Association Press, Washington, DC.
Part 5 Interdisciplinary Issues: Psychotherapy, Pastoral Care and Meaning Giving INTRODUCTION In this fifth part our scope is broadened toward the expertise of other members of the multidisciplinary teams that are commonplace in mental health institutions all over the world, although certainly not everywhere. Psychotherapy, pastoral care and spiritual care and meaning giving contribute without doubt to the care of psychiatric patients. But there is more to say. Their discipline-specific assessments can add specific observations and widen our understanding concerning the patient, diagnosis and treatment interventions. (Psychoanalytic) Psychotherapy and pastoral care deepen our understanding of the psychological and spiritual process of religious and spiritual life, more than psychiatry does. Psychiatrists are inclined to argue for unitary theories, although they disagree about the character of such a unity, and rather simple cause-and-effect relationships in a naturalistic worldview. The study of religion and spirituality has far more personalistic characteristics. The main concerns are intentions and experiences of persons in particular (sub)cultural contexts. In general, psychotherapies assume that the individual is suffering from a disorder, or psychopathology, or an inner problem. Religious traditions have developed relational strategies for guidance, spiritual growth and care (soul care), although the goal is formulated in a different way, e.g., a spiritual integrative process, personal transformation, a more
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promising view on the meaning of life. In psychotherapy patients usually do not embark on such a quest. In the three chapters that follow the main point of interest will be that of religious, spiritual and meaning giving concerns in relation to psychopathology or inner problems. At the end it will be clear that the patient’s religiosity or spirituality has a crucial role in the solution of her problem. It is obvious, not many people can do without any ‘material’ to help make narrative sense of their existence. Putting oneself within a religious or spiritual narrative context and ordering one’s experiences within that context is what religion is about. In that sense religion and spirituality do have transformative power. 5.1 Gods of the Horizon: The Therapist’s and the Patient’s Religious Representations and the Inevitability of Countertransference Moshe Halevi Spero 5.2 Assumptions About Pastoral Care, Spirituality and Mental Health Peter J. Verhagen & Adamantios G. Avgoustidis 5.3 Coming to Terms with Loss in Schizophrenia – The Search for Meaning Hanneke (J.K.) Muthert
CHAPTER 5.1
Gods of the Horizon: The Therapist’s and the Patient’s Religious Representations and the Inevitability of Countertransference Moshe Halevi Spero Professor of Clinical Psychology, Social Work, and Psychoanalysis, Israel
And I will visit in that day upon every one that entereth arrogantly over the threshold. —Zephanaia, 1:9
The highly focused topic of this chapter is an effort to straddle a mind-bending paradox that exists between the comfortable sense of relative objectivity psychotherapists enjoy after hours of work with the representational version of all that is human or material in the subjective experience of our patients versus the sudden sense of having traveled into an uncharted terrain of uncanny emotional experiences and psychic impressions, positive or otherwise, associated with the entity known as God. In the latter terrain, the true Object behind the object representation remains elusive, and its identity and works can never be completely fathomed or ascertained. Freud himself expressed the uncanny feeling best, in a manner that has always struck me as neither disrespectful nor cynical ([1], p. 72): The origin of the religious attitude can be traced back in clear outlines as far as the feeling of infantile helplessness. There may be something further behind that, but for the present it is wrapped in obscurity [aber das verhullt einstweilin der Nebel].
Hence, I cannot imagine writing about ‘religious beliefs’ or ‘God representations’ in any sort of scientific way without first acknowledging this strange existential-clinical tension.
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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The acknowledgment is necessary because of another conflict, which I will elaborate upon below. In brief, it is this: when themes, beliefs, and ‘objects’ pertaining to God enter the analytic frame, the religious point of view contends that the patient’s or the psychotherapist’s human interpersonal neuroses alone are no longer sufficient to explain psychic conflict and unease since an additional party is at play. Yet an opposing point of view insists that deliberations of this kind are in themselves philosophically tautological, regressive and clinically obtuse, a misguided attempt to restore all of the idolatries that Freud had painstakingly dissolved. Thus, as a psychoanalyst who is also a religious believer, I am fully aware that the abyss that I and many colleagues regard with awe – within which we search for meaning and from whence we actually anticipate some sort of response or meeting – is regarded by other colleagues as a meaningless neuropsychological blind spot.1
5.1.1 THE EPISTEMOLOGICAL QUESTIONS AND ASSUMPTIONS REGARDING THE IMAGE OF GOD This chapter concerns the idiosyncratic forms of religious imagery, emotion and enactment that occur within or surrounding the psychotherapeutic framework as a result of the cross-influence of the patient’s and the psychotherapist’s God representations and religious belief structures.2 It is focused upon the psychotherapist’s unconscious reactions to archaic or fragmentary representations that are hidden within the transference (there may be more than one) that develops within the ‘penumbra’ of either or both of the participants’ mental representations of the divine [3–5]. That is, I do not believe that the resistances or transformations of chief clinical significance have all that much to do with the participants’ manifest religious beliefs or images as such – it is, in fact, all too easy to deal with these quite respectfully. Clinical significance begins primarily when beliefs and images reverberate around the analytic frame or boundary, motivating the deepest levels of transference. Moreover, whether or not the analyst is a religious believer or sympathetic to the concept of God, he or she, too, possesses God representations of one kind or another. The activation by the patient of the therapist’s own latent dimensions of God representation will inevitably take the form of countertransference imagery or enactment. In turn, this imagery or enactment may have special value for the patient’s (and sometimes the analyst’s) religious development. The current openness to the far-reaching importance of the internalized relationship with one’s representations of God has reawakened perennial questions about the nature and ontological status of the sources of this specific representation in the intersubjective as well as intrapsychic world. Since Winnicott’s well-known contributions in the area of play and transitionality, there has been increased praise of the beneficial and creative quality of illusion and the sense of ‘irreality’ [6–8],3 and the current attitude towards religious belief and its non denominational cousin, spirituality, is prevailingly sympathetic. Nevertheless, as Simmonds 1
See most recently [2] Anderson-Thomson. Throughout, the psychotherapeutic framework I have in mind is essentially the psychoanalytic one, but what I write herein applies generally to most variations of intensive psychodynamic psychotherapy. 3 Since Winnicott, the dilemma of whether or not God is the epistemological equivalent of the transitional teddy bear continues to be discussed, most recently by Black [9], Blass [10], Britton [11], Corveleyn and Luyten [12], Field [13], Fischer [14], Grotstein [121], Issroff [15], McDargh [16, 17], Meissner [18], Smith and Handelman [19], Spero [20], and Symington [21, 22]. 2
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has recently shown [23–25], religious belief in general – including the non-anthropomorphic, non-image-bound concept of God typical of spirituality in general – is still a dead zone for a great number of psychotherapists, one they increasingly sense ought to be relevant to treatment, yet also one they cannot define well, and whose role in treatment they can only vaguely define.4 The real problem here is not simply that the ‘good news’ of Winnicott’s epistle regarding religious illusion has failed to reach some of the outlying practitioners of psychoanalysis. As I [20] and more recently Blass [10] have noted,5 the enhanced sympathy concerning the genetic path of the development of religious belief and its clinical management tends to elude rather than directly reverse Freud’s central critique regarding the value of maintaining belief in any kind of representation, including God representations, whose sources cannot be objectively confirmed. Consider, for instance, this comment by Odilon de Mello Franco ([31], p. 114), quite representative of the sympathetic postclassical attitude: From [the contemporary] point of view, the religious faith of our analysands should be seen not only in terms of its infantile determinants but also as the result of transformations of vital experiences into continuous, progressive processes open to the attribution of new meanings. Vis-a-vis the religious experience, [the implementation] of psychoanalysis should constitute not a factor that reduces it to its originating fantasies but a possibility of reorganization and revision of the representation of the image of God in the analysand’s subjective universe.
De Mello Franco does not take the matter further, but note that (a) the representation of God has been confined to the patient’s intrapsyche and (b) the analyst’s internal representations are not deemed pertinent to the discussion. But this would have limiting effects on the range of the analyst’s empathic resonance and on the potential meaning of the countertransference experience. In a more recent essay, Meissner offers a very unambiguous portrait of the central methodological dilemma ([18], p. 539): God [at least, as defined by mainstream Judeo-Christian traditions] is not a function of selfobject needs, nor can he be defined as a relation construct. These approaches show little recognition or regard for the distance and disparity of context separating religious and theological terms from the psychoanalytic. Analytic conceptualizations of the deity in subjective or relational terms do not meet the exigency of God as transcendent and beyond the reach of human cognitive capacity. . . . When we address the concept of God as a 4
This finding is noted again most recently by Tummala-Narra [26], yet it is disconcerting to find that the author has a very incomplete grasp of the great amount of progress that has taken place within the field, especially as concerns clinical intervention. One example of the kind of work she neglects are the essays by Randall L. Sorenson [27, 28] who found that psychotherapists’ lifelong personal God representations exerted less impact upon the analytic process than those specific God representations and experiences which were brought up during these therapists’ own personal analyses or subsequent to them. Here the desired level of analysis of the countertransference issue is writ large. Sorenson’s results strongly suggest that the patient’s and analyst’s perception of each other’s spiritual dimension is actively influenced not only by the representational and psychosexual qualities of the patient’s beliefs and rituals (and related psychopathology, etc.), but by the representational and psychosexual qualities of the analyst’s beliefs and rituals – and perhaps also by the degree to which an observing ‘third’ has at some point been internalized into these resident internal states. 5 See also Black [9], Jones [6, 29], and Roland [30].
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transcendent transference object, or cast his imagery in representational terms, or conceive of him as a supreme selfobject, we are defining him in human terms. These formulations are relevant only to our experience of God, our God-representation, and have nothing to say about God himself in his transcendent existence.
As cogent as this portrait is, I do not agree that our representations ‘have nothing to say about God himself,’ as Meissner states and as de Mello Franco implies, and it would seem as if we need to be able to make room for the possibility that they occasionally do say something ‘about God himself.’ The problem is so troubling to the professional mind that most clinicians prefer to adopt the even-handed stance expressed, with a dash of irony, by Wilfred R. Bion, in an intriguing discussion in his Memoirs ([32], pp. 242, 275): I spend a great deal of my time trying to show people which particular god they are currently worshipping. Whether they are right or wrong is for the individual to decide for himself. . . . All I purport to do is to give the individual a chance of observing his God-like assumption of God-like properties. It is not surprising that a patient finds it difficult to be awe struck by God, though not doubtful about his own God-like properties.6
Yet, as Stanley Leavy, another religiously-committed psychoanalyst, writes, the clinical dilemma at the heart of the disturbing paradox cannot be addressed by even-handed attitudes ([33], p. 55, emphasis added): For all the increased generosity and vision in the later views [of contemporary psychoanalysts toward religion], they do not succeed, cannot succeed, in representing religion as it appears to believers. The anthropological grasp that these authors represent is not a small thing in itself, but it is one that holds at a distance the idea of the transcendent reality, God. I call it ‘anthropological’ because it can include the idea of God only as a man-made symbol. Contrariwise, at the heart of religion is the conviction that the symbol is not totally man-made, not a golden calf, not just the product of the yearning soul, but is a point in which the encounter with a self-revealing transcendent Other is made concrete.
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De Mello Franco [31] would refer to this as an instance of man-as-God identifications overweighing the man-withGod identifications within personality. Judith Issroff [15], another psychoanalyst of Winnicottian bent, writes sensitively about religious experience during psychotherapy, yet, at bottom, adopts the oppositional view. For Issroff, the concept of God is itself essentially a metaphor of the unknowing mind, connotative not only beyond itself but beyond thought – not satisfactorily definable. She posits (p. 104): All that can be said of it has to be in the way of an “as if” observation, philosophically and theologically. Inexpressible, problematic, the concept of God remains plausible, useful and satisfying – probably necessary for us humans at this stage in our development. Yet it is not a totally necessary concept. Her way of putting the matter is sobering, and makes a significant point that ought to enhance the need to be aware of the dangers as well as the bounty inherent in the analyst’s countertransference. That is: any God concept or representation is so phenomenally constricted that one must always be aware of the degree to which it expresses so little of what its intended referent is all about, no matter what point of view one adopts on the matter. Pathology on the patient’s part, I dare say, generally inheres in failing or refusing to accept this; pathology on the analyst’s part inheres in over- or underemphasizing this.
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The opposing view, if one may call it that, comes through full force precisely when its subtleties are not immediately denounced. Consider an important observation by David M. Black [34], which at first blush might strike the reader as vintage Freud, ‘The religionist has to “believe” in his objects, because only in this way can he keep them in being’ (p. 617). Now it is necessary to accept Black’s point as valid in a certain sense. That is to say, many religions would acknowledge the fact that man does lend God a certain quality of intrapsychic character and ‘being,’ an examinable, discussible, accountable sense or quality of being (see Ref. [127], pp. 94–95, 100–101). At the same time, these anthropomorphic contributions are neither the equivalent of, nor do they delegitimize other levels of divine being that may in fact transcend human perception. Having indicated where Black and I agree, I must also indicate the sense in which I believe his assertion to be fundamentally wrong. One of the most elementary tenets of psychoanalytic object relations theory is that objects, or object representations, exist or have being whether or not one actively believes in them, as is the case, for example, with repressed representations, or poorly representationalized autistic objects, whose perceptual existence is marginal to the psychic system yet whose actual existence is nevertheless confirmed (or, at least, inferred) through symptoms, aesthetic products, countertransference, and the like. Indeed, it would seem to be an immature level of belief that leaves one feeling obligated to have to believe in one’s god in order to maintain its existence; this is generally what differentiates the fetish, and a fetishistic god, from something more authentic. By the time one is sentient enough to experience one’s belief as belief, or certainly to inquire into belief critically, the objects of one’s belief have already been established in ancient ground (itself a universal religious metaphor, not accidentally). Moreover, contra Black, ceasing to believe in such objects, or adopting an agnostic or atheistic stance toward them, does not make them suddenly cease to be, any more than a complete psychoanalysis makes a ‘bad’ breast cease to be a breast of some kind. Thus, despite my appreciation for the thrust of Black’s idea, his comment might actually encounter greater difficulty from the psychoanalytic point of view than it does from a theological point of view. The theoretical challenge for psychotherapists, therefore, is how to evolve new models that enable one to conceptualize the relationship between God and the human mind while juggling the unavoidable ontological disparity or paradox outlined above. We are in search of an alternative spatiotemporal domain to ‘clinical distance’ that, at the same time, does not require a simplistic concrete acceptance of the believing patient’s faith, does not automatically dilute the very immediacy and certainty that the patient seems to seek, and, to put it most dangerously perhaps—permits desire and anticipation of a ‘face’, ‘voice’, or ‘hand’ that has no source in anything human. I think such an alternative space exists, though we might only notice or occupy it momentarily. I have no special name for it, though I have borrowed one – the event horizon – and I believe that it ‘resides’ within the domain of the countertransference, whose characteristics in each idiosyncratic instance are suited for the ontological paradox that we have described.
5.1.2 THREE CLINICAL IMPLICATIONS OF THE PSYCHOLOGICAL GOD My contention that countertransference is the inevitable modus for welcoming the significant representational dimensions of God into the analytic room is an extension
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of a theoretical presumption that has been developed elsewhere.7 The presumption, condensed, is: Mental representations of God (or any form of divinity), of one qualitative level or another, exist within the mind of every sentient being, whether such representations are linked experientially (i.e., manifestly) to a broader and vibrant sense of religious belief and spiritual feeling and practice, or are latent, or even seem to not exist at all.
That is to say, as long as the term God exists in our semantic structures – be it deeply embedded in the most devout meditations and acts of faith or superficially tacked onto the angry expletives one might scream mindlessly after stubbing one’s toe – a vast range of emotions, wishes and concepts from a variety of sources will become attracted to and be enveloped by this term. The mind’s experience with that-which-we-call-God gradually achieves some form of representation – strong or weak, concrete or symbolic, manifest or latent – thus giving ‘God’ form, character, power and intentionality which may emanate wholly from language usage and may emanate from sources that are totally independent to material or human conditions. This view neither bypasses nor ignores Freud. On one hand, it accepts the legitimacy and validity of much that Freud and subsequent psychoanalysts had to say about the ontogeny and quality of some kinds of religious beliefs and images of God, which in some part are endopsychic exactly as Freud said. On the other hand, it does not rule out the possibility of the actual existence of an entity called God behind – Freud said, ‘obscured by’ – the ‘God’ representation.8 If it is the case that a God representation of some kind is a basic rudiment of the human psyche – if only as an equivalent to the unconscious [48] or the Real [46] but certainly if an actual residuum of an existing God—it most likely will exert influence on both analytic partners at crucial junctures of the intersubjective therapeutic process. Moving forward, the presumption of ‘God as basic mental structure’ sustains three important developmental and clinical implications. First, if we accept that both the therapist’s and the patient’s representational apperceptions of God – i.e., ‘God’ as psychologically experienced, ‘God’ as the representational dimension of God – do not exhaust the possibility of other levels of direct or immediate experience with a real divine entity, then we are obliged clinically to make room for this possibility. The character of this ‘room’ needs to be suitable to whatever might be valid about God-human experience.9 In a section to follow, I will characterize this kind of ‘room’ by identifying it as a sort of event horizon, as the term is used in astrophysics. 7 This presumption was originally developed by Ana-Maria Rizzuto [35–37] and has since been upheld and further elaborated by many different researchers [16, 17, 20, 38–40]. Much of the pertinent literature in support of this view, as well as opposing views – including reviews of earlier reviews – has been recently gathered by Spero and Cohen [41]. 8 Many writers from many disciplines have discussed the major epistemological and philosophical concerns that emanated from Freud’s stance toward faith and the notion of God, the most comprehensive and novel of which include Black [9, 34], Blass [10], Corveleyn and Luyten [12], Kernberg [42]; Kung [43], Meissner [7, 18, 44], McDermott [45], Richardson [46], Siggins [47], Smith and Handelman [19], and Spezzano and Gargiulo [124]. 9 Contemporary research suggests that an anthropomorphic definition of God may, under certain conditions, be no less developmentally mature than an abstract, ‘spiritualized’ one – contrary to James Fowler’s [49] long unquestioned assumptions in his model of the stages of faith (see the discussions in Cohen [50], Kegan [51], Stone [125] and Strieb [52–54]. This finding makes it even more clear that there is no compelling reason to consider an amorphous postmodern concept, such as Bion’s ‘O’ ([55], pp. 139–140, 147–148), to be a more accurate (or, as is sometimes claimed, a less ‘schizoid’ [21]) portrait of divinity than an image-specific one.
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For instance, when psychoanalyst Kenneth Wright ([56], p. 53; [57]) entertains the possibility that the object known as God must have a face,10 one can choose to understand him as emphasizing a religion-friendly metaphor drawing from the maternal roots of early mirroring, aesthetic, or awe-evoking experience. Alternatively, he may be emphasizing some unique facial or reflective surface that is essentially non-metaphoric, not reducible to representational dynamics alone, maternal or otherwise, something true of God. To be sure, such a face would still need to be a representation (for even God, according to most definitions, doesn’t have a real face but, rather, ‘facial attitudes’), yet in the newer view it would be a representation that draws from human-and-divine experience and not solely a projection of human-and-maternal experience. And while this kind of clarification may not reveal God as such, in a concrete sense, it respects the significance of an other-than-humanmaternal or other-than-human-paternal dimension of the interaction between the mind and the Real, a dimension that might be of God. The second implication is that, as a representational resident of the mind, God representations must be subject to the entire gamut of intrapsychic and intersubjective dynamics. As such, the clinician needs to not only be concerned, simply, with the existence or non existence of manifest religious imagery or sentiments. Rather, the clinician ought to be sensitive to any kind of shared experience within the therapy that has religious-like characteristics – e.g., the sense of providence, divine intentions, awesome and mysticaltype encounters – and then, instead of reducing such experience to wholly human terms, the clinician looks for the God-oriented endowments within the latent representational dimension of these experiences. Ideally, the therapist explores the quality of these latent representations, examining whether such representations are linked experientially to a broader and vibrant sense of religious belief or spiritual feeling and practice, whether they exert a shadowy, conservative and latent influence, or whether they have ceased to develop at a certain point. We can focus even more finely upon the degree to which the patient experiences him- or herself as being in relationship with God or as being identified with God, creating an all-too-godlike self structure that impedes healthy intersubjective and intrasubjective relationship [31]. Finally, with an even finer focus – as refracted by the subtle, fluctuating gradients of the transference-countertransference – it is possible to study the degree to which the internalized substructures of the God representation and self representation from different periods of time converge or diverge [60, 61]. Third, given the special characteristics of the analytic frame (the fundamental rule, the qualities of the room, the role of time) as a partly symbolized representation of the limnal or transitional zone where ego meets non-ego, semantic meets non-semantic, and knowable meets unknowable, it is plausible that the frame itself, as it influences and is influenced by the analytic partners, functions as an attractor around which divine representations will seek expression. God representations enter into this important intersubjective-intrasubjective fray as they become attracted to or intricated within the event horizon of the analytic frame, testing the patient’s and the analyst’s capacities to perceive them and contain them. The gods of the event horizon, so to speak, make certain forms of countertransference inevitable; and the peculiar semantic and prosodic qualities that characterize communication at the height of the transference-countertransference matrix well might be spoken of as the language of these gods. In this sense, one could say that countertransference entails a most rigorous test of faith in God, whether it is the patient’s image, the analyst’s, or a third image belonging tentatively to 10
See also Akhtar and Parens [58], Field [13], and Stein [59].
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both partners, mutually discovered and also created – like Winnicott’s transitional object – within the analytic frame, a unique representation of the religious-like developments taking place within the therapeutic process.11 To my mind, there is no way to successfully avoid his potentiality, nor ought one to (cf. [65, 66]). Indeed, under certain circumstances, the apparent lack of any countertransference signal when religious or spiritual issues are expressed or hinted may point to a powerful countertransference-derived insensitivity, vacuum or bulwark. James Grotstein (67, 68), for example, describes a variant of this ‘test of faith’ (he does not use that phrase) when he identifies what he refers to as the pieta transference and countertransference mode. In Grotstein’s clinical portrait, a patient who was not avowedly religious, unconsciously deployed the passionate and tragic relationship between the stoic yet hapless mother and the resigned sacrificial victim – gradually bringing the therapist into the dynamic, as both became entrapped within this great religious epic-mythic paradigm – which disguised the patient’s deeper need to project his own anger into the helper, arousing intense helplessness and guilt. As Grotstein shows, during such moments in psychotherapy each of the analytic partners gets a turn on the cross and beside it, looking down from the cross and looking up to the cross, or being held lifeless in the arms of the sorrowful mother even as one is thereby gaining new life. Grotstein seeks neither to ‘reduce’ nor ‘idealize’ the therapeutic process by appeal to theological or ethicomoral terms. Rather, by using biblical myth (in the spirit of his mentor, W. R. Bion), and without losing sight of the elementary dynamics of sadomasochism, Grotstein helps identify certain universal structures that have long become unconscious. In this manner, the therapist’s awareness is opened to the possibility that additional personae are involved in the analytic experience, whose full identity might be essentially anthropomorphic and more or less completely representational or transcendent and incompletely representational.12 Nothing in what Grotstein suggests prevents us from further refining the pieta countertransference mode in terms of, say, Heinrich Racker’s categorization [71] of concordant and complementary representations, in order to better understand which representation has been projected toward the therapist and which is active within the patient. The obverse is also important: it is entirely possible that Racker’s perspective 11
Elsewhere I offer a very detailed case analysis which portrays just such a development during psychoanalysis [62, 63] and Meissner [64] and Spero and Cohen [41] have published numerous illustrations, highlighting pitfalls and progress in this domain. 12 Grotstein [67, 68] is especially adept at speaking about God and other ‘sacred objects’ as if they were fully alive or real elements of universal ontology – not just autochthonous, subjective products of the mind – without losing his grip on the essentially psychological identity of these objects as they are presented to and appear in our representation-dependent minds. In Grotstein’s unique elaboration of Bion’s views ([69], pp. 142–143, [121]), God is the newborn infant who believes that he has created everything and everyone he opens his eyes to as he discovers them, including himself! As his own creator and as the creator of his parents Adam and Eve, once ‘God’ learns that it was their intercourse that created him, he is ousted from his Edenic paradise of omnipotence and becomes a normal dependent infant who now envies the parental primal scene from which he is excluded – anger, envy, murderous rage, and the need for the Law of the Father. One finds a similar form of description recently in Langs [70]. This kind of portrait can be seen as reductionistic – a poetic way of fleshing out the essentially unknowable realm that Bion called ‘O,’ without having to truly take a stand on whether or not one believes in an actual God. Indeed, Grotstein warns that we ought not to incarnate God – this, he states, is psychosis – but instead must allow the deity element or ‘O’ to incarnate us. The latter, in Grotstein’s view, is transcendence. Thus stipulated, we have here another fine example of using ‘God’ as metaphor, with no further ontological commitment. Nevertheless, I favor this way of conceptualizing because it helps the therapist to delineate the complexity of religious experience, and because it may, for all we know, pertain in some way to the actuality of God’s ‘mind’ and the way He relates to man.
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could clarify a certain dimension – one hesitates to suggest this – of the relationship between Jesus, as man or divinity and his mother and disciples.
5.1.3 THE INEVITABILITY OF COUNTERTRANSFERENCE IN THE CONTEXT OF RELIGIOUS REPRESENTATIONAL MATERIAL AND ITS OBJECT A few words are in order about how I view countertransference and its singular significance as a potential sacred space. As stated, a concept or representation of God (or deity-like imago), internalized and organized at various levels and qualities, is part and parcel of the human mind whether or not an individual directly espouses belief in such concepts, and whether or not the individual is aware of such belief. These representations may be lively or inert, profound or simplistic, rational or magical, concrete or abstract, and may have a completely different ontological status within analytic space than they have (or represent) outside of analytic space. Thus, when the patient brings declared, consciously-understood conditions of belief to psychotherapy, we engage these announced conditions with the conditions of the analytic relationship. Divine representations, and their innumerable unrecognized or not-fully representational forms, become perceivable and relevant to analysis when the conditions are ripe for the self to entertain experiences and objects of belief in a state of uninhibited unconscious flux. These conditions – including conditions for believing and conditions for ceasing to believe – are predicated upon the nature of the analytic frame and the matrix of transference and countertransference, and might be different in many ways than the ‘surface’ conditions that originally enabled or disabled religious representation and belief. It is often the case that the foundation of religious experience includes undigested images, archaic existential anxieties, unmentalized losses, and poorly internalized affect states that have achieved only quasi-representational status (not to mention so-called higher-order, post repression conflicts among more fully representationalized states which have regressed to, or become linked to more archaic states). Recent clinical reports highlight extremely early, uncanny types of feeling states that serve as the core of religious experience, some of which are highly sensory and not yet representational in the formal sense of the term, such as awe, rhythmicity, aniconic imagery, the sense of membranous engulfment and the oceanic experience [72–76].13 As an example, Wright [56, 57], to whom we referred above, has 13
See Ahlskog [77], Corte [78], Jones [6], Kegan (1980), Laor [79], McDargh [128], Spero [20], and Rizzuto [35, 80] who were among the first to clarify the preoedipal foundations of religious experience that Freud and the classical writers had tended to miss. Ahlskog’s concept of ‘latent theology’ is an especially important contribution because it steers the analyst’s focus toward these earliest levels of religious experience when one is attempting to move beyond the rigidities and concretisms of the manifest religious belief or practice – including, I want to emphasize, the occasionally over-valorized illusional quality of religious belief, in Winnicott’s sense, which can be as clinical blinding, cloying, and unfruitful as Freud’s earlier dogmatic perceptions. In Ahlskog’s view (p. 68), latent theology overlays (or is) a ‘space carved out during childhood for a pre-sanctified meaning system,’ which, he adds, speaking of treatment, ‘if not analyzed will be filled.’ By ‘filled,’ Ahlskog seems to allude to a saturated state, as in Bion’s sense, in which newness and growth are stymied. If such ‘space’ is not thoroughly analyzed, especially when such zones intersect with a prevailing transference configuration, there exists the seductive potential for the analyst to play a god-like role, or to abscond and abandon one’s transference role owing to some unanalyzed anxiety that has been generated within the analyst during his encounter with such a space.
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written very effectively about the relationship between the sense of the sacred and the preverbal perception of the maternal face, Meltzer and Harris-Williams [81] have outlined unique qualities of early prementational experiences and the aesthetic conflict (that is, plundering versus respecting the spatial integrity of the inside of the loved object), insisting that these serve as a central basis for deeply spiritual experience. In pragmatic clinical terms, then, the transference-countertransference matrix may be our best response to the kind of mental availability that religious ‘preobjects’ and quasirepresentations require for a chance at creative contraction, expansion and transformation. Countertransference facilitates the kind of shifting states that safeguard the self’s capacity to experiment with different forms of religious consciousness without ‘being had by it,’ thus creating a state or place that might accommodate ‘God’ as a self who is also a non self ([45], pp. 35–38). Within this zone, religious and ‘areligious’ representations and identifications are always diverging and converging, traversing different levels of symbolization, and negotiating the broad spectrum between intrasubjective and intersubjective presence and absence [61]. These are precisely the kinds of states that are most likely to awaken intensely peculiar transference-countertransference dynamics within the analytic field or frame.14 We know that the dynamics of the transference and countertransference interaction can be of symbolizing or non symbolizing quality since these are dependent upon the quality and dynamic of the mental experience within the patient and to some degree within the analyst that is being projected and introjected during the clinical work [86, 87]. It is thus inadequate simply to speak of being increasingly “aware” of the potential for countertransference ‘pitfalls’ with religious patients. Rather, countertransference experiences need to be retraced – though the several phases of the analyst’s and patient’s linguistic influence upon each other [88, 89] – in order to determine just how the countertransference enactment, frame violation, or aberrant perception got set up, exploring not only the contents but also the mental pathways that lead to religious beliefs. In working with patients who hint to religious imagery under these conditions, I may sense at some point that I have become the mental host to temporary states of confusion, apathy and disbelief as well as atypical spiritual imagery and reverential emotion whose chief focus is the object called ‘God,’ crossing all denominational boundaries. These states may appear to be induced by the patient’s latent belief states or possibly by my own. The only way out of what might otherwise deteriorate into an interminable tango – whose ‘God’ is talking? – is sober analysis of the countertransference. It also requires awareness that these ‘states,’ and the objects they entail, actually exist somewhere between the analyst’s and the patient’s minds. Within these intra- and intersubjective vortices, the conditions of a divine representation’s presence and absence, its splendor or hollowness, and its potentially transformative capacity, may eventually be recognized, or symbolically articulated for the first time. It is within this third,15 transitional or intermediary dimension – which always contains far more than we can or need to imagine – that the most valuable psychological transformations occur. In my view, we only really engage God when this image emerges
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Regarding which a substantially well-documented literature has developed, whose representatives are Alhanati [82], Baranger, Baranger and Mom [83], Mitrani [84], Mitrani and Mitrani [85], Racker [71], and Tustin [126, 130]. 15 See Ogden [90].
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within the intermediary space of psychoanalysis, where it may reveal the true psychological conditions of its existence, and its true merits as an object of belief, love, fear, awe, or disbelief.
5.1.4 THE EVENT HORIZON, THE ANALYTIC FRAME AND THE CREATION OF THE REPRESENTATIONAL GOD In order to sharpen our mental hospitality toward God representations, and in order to enrich our use of the idiosyncratic countertransference experiences of individual analytic partners, I will now add the following hypothetical ideas. In the previous paragraphs, I attempted to show that our countertransference experiences with religious patients often reach into that zone which lies closest to the earliest differentiation of protorepresentational mentation from an even earlier, premental state which precedes representation and to a large degree remains unknowable. It is a state that at one point was not, and then, at some subsequent given point, becomes, inaugurating the never-ending cycles of loss-and-gain that mental representation and symbolization always entail on some level. Eric Rhode [91, 92] hypothesizes that this kind of limnal state may be one of the Janus-faces of the contact barrier so fruitfully hypothesized by Freud.16 In dense prose packed with insight, Rhode shows that a vast amount of humankind’s cross-cultural religious imagery and myth expresses the paroxysms of the budding representational mind along this barrier. He adds, following Bion ([95], pp. 17, 22; [96], [120]), that these myths, even when denuded of their original religious connotations, persist as latent universal structures because they continue to embody and articulate the unique psychic experiences at the contact barrier between psyche and soma, between consciousness and the unconscious, and between symmetrical and asymmetrical qualities of thought and emotion. Such images are usually an index of catastrophic change or flux at the shores of some former threshold of representation, of that which only a moment before was unknown or unthought. In Rhode’s perspective, the contact barrier itself is represented in the mind far more often than we tend to notice – primary examples of which are religious (or religious-like) images of eternity, utter silence, awe, the sacred, exquisite somatic apperception (such as synesthesia), the oceanic, and the luminescent. Now Rhode might be prepared to consider ‘God’ as essentially one among many representations for the contact barrier itself, yet, as reviewed in the introduction, this would not completely satisfy the religionist’s search for the God who precedes all contact barriers. Nevertheless, from a clinical psychoanalytic point of view, Rhode has mapped out a better location in which to seek and experience God than economic theory, classical object relations, or self-psychology have provided. At the same time, I suggest a small refinement of the territory Rhode otherwise describes so well. I am interested in the domain that contemporary astrophysics refers to as an event
16
Rhode is not careful with nomenclature on this point, but for the sake of precision, Freud ([93], p. 306; 1920, p. 8) referred to this function as the stimulus barrier (Reizschutz) or protective barrier. When he began later to speak of it as a writing barrier or field ([94], p. 231), the notion of a contact barrier began to take on a more broad sense.
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horizon. I am speaking of the peculiar domain or ‘membrane’ that forms around, and in some way envelopes and even protects the so-called black holes in the universe. The few psychoanalytic authors who refer to this conceptualization [97–101] focus primarily on the well-known omnivorous maw of the black hole itself and its abjectly total emptiness, and seem less interested in the relatively better documented properties of the event horizon.17 I believe, however, that the paradoxical qualities of the relationship between the event horizon and the black hole, taken together (as they must), provide an analogue to the relationship between religious experience, the presence of God, and psychoanalysis. Let me first state that a ‘black hole’ – the name given by John Archibald Wheeler in 1971 to Kurt Schwarzchild’s theoretical entity, postulated in 1916 (the metaphor appears earlier in poetry – is not so much a place or site as a set of events caused by the massive collapse of a hydrogen-depleted dying star of a certain minimum size (that is, the hole’s hypothesized temporal and spatial properties render it as virtually no place and outside of time). Eventually, as the star shrinks to a certain critical radius of infinitesimal size and almost infinite density (known as the point of singularity), the resulting gravitational field becomes strong enough to engulf light, lending to the appearance of a stark black hole. According to the theory of relativity, nothing travels faster than light; therefore, if light cannot escape, neither can anything else, ‘producing a region of space-time where infinitely strong gravitational forces literally squeeze matter and photons out of existence’ ([103], p. 142). At the boundary of the black hole, forming a domain that is itself still visible, lays an expanse known as the ‘apparent event horizon.’ The event horizon is formed by the paths in space-time created by light rays that have managed to not be drawn into the black hole but which also cannot travel further, hovering forever on its edge. Scientists tend to agree that the event horizon acts like a one-way membrane or skin around the black hole, clothing the point of singularity as it were, and, as Penrose put it, ‘censoring’ anyone from being able to see the destruction of physics within the increasingly more narrow circumference of the hole [104]. I believe that this function is analogous to the shroud of mist that Freud intuitively portrayed as if it ‘enveloped’ (verhullt) the deeper tributaries of religious 17
Horizons and thresholds are dangerous spaces, and the anxieties that surround these marginal locales are ancient. Biblical and Greek myth emphasizes the threshold. The Greeks referred to the threshold gods or penate and in Jewish law the doorway is protected by the mezzuzah. The doorway to the house became a forbidden and sacred dividing line. In Roman mythology, the Penates were originally patron gods of the storeroom (from which we have the word penus, pantry, or ‘household provision’), but by extension their protection reached the entire household. Freud stated that thresholds are critical for the establishment of boundaries, safe or otherwise ([102], p. 197): The dangers which the anxious man believes to be threatening him never appear more vivid in his expectation than on the threshold of a dangerous situation, and then, too, is the only time when protecting himself against them is of any use. These sentiments were continuations of Freud’s thoughts regarding the contact barrier, where the hallucinatory images can be seen, and it is not surprising that the analytic frame might be one such threshold area at which the god experiences of patients and analysts become awakened. Grotstein [97–99] was the first to utilize the concept of the event horizon to explain the emergent sense of omnipotence, overwhelming bounty, ultimate badness or satanic feelings, and he also notes that the stimulus barrier may be especially sensitive to psychological experiences that we attribute to concepts such as God’s dwelling place. In some sense, the contact barrier or event horizon becomes equated with God in and of itself.
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representational experience ([1], p. 72). If so, then Freud anticipated the important cloaking/ containing function of the event horizon as guardian of the actual and logical unfathomability of God’s nature. It is often said, by lay and professional people alike, that anything that falls through the event horizon will be instantly torn apart and crushed, yet it is equally correct to say that anything drawn into the black hole will quickly reach the region of infinite density and the end of time and in that sense can never be crushed ([105], pp. 98–99, 110 [122]). This oddity introduces a series of additional paradoxical or semi-paradoxical qualities. For example, light at the event horizon is curved in such a manner that stars alongside the black hole appear to counter-rotate; light here is in fact so deeply curved that photons can reach the stationary observer from behind the black hole, despite the principle that light that is claimed by the black hole disappears. At the outer edge of the event horizon, furthest from the black hole, lies a ring known as the photon sphere, in which one finds photons that have succeeded in not being sucked into the hole, yet which cannot escape the event horizon; these photons are trapped forever. In theory, photons that are not so trapped would travel in circles along the edge of the event horizon, and would appear to (and perhaps they actually do) enter and exit the back of the observer’s head, go once around the black hole and still be seen by the observer’s own eye – as if one were able to see the back of one’s head without mirrors [106]. As well, consider the fact that any star that might seem to be on an ineluctable trajectory into the black hole, at least as we perceive it as it passes along the event horizon, would at some point seem to become suspended in time and never actually collapse since as it approaches the end of the event horizon there is less and less light to enable us to perceive speed and time ([107], pp. 119–123; [108], pp. 117–130). Using clinically relevant language, the paradoxical properties of the event horizon help us to better appreciate the sense in which meaninglessness and meaningfulness share a rotating or binary relationship, as do the states of ‘no-thingness’ and ‘nothingness’ emphasized by Bion [55] and the neo-Kleinians [97, 98]. Whereas the state of no-thingness is defined as the concrete negative ‘something’ which positively obtrudes the space or gap of separation from the object, disabling thought and hope, the relatively more mature state of nothingness designates the infant’s capacity to contemplate an abstract emptiness that representationalizes the absent object that stands ready to welcome the return of the object. The infant’s ability to tolerate the empty nothingness of the gap allows for proper filling, but also enables (and requires!) an act of faith that the object will return [109, 123]. We have learned that nothingness, in the sense that psychoanalysts use the term, is necessary to support the return of the departing object so as to provoke the development of object constancy through gradual processes of repeated cycles of departure, empty anticipation, and return, first of the concrete object itself and eventually of its fantasy representation. When the mind cannot tolerate this gap or hiatus, or has not achieved sufficient mentalization to accommodate ‘useable’ empty nothingness, the wobbly semistructures of the mental apparatus regress and become trapped in a state of sterile nothingness and deadness. Here the impoverished structures of the mind are subjected to increased storms of predatory anxiety that traditionally take the hallucinatory form of the bad breast, or, in religious language, Satan, omnivorous demons, mystical cataclysm, endless purgatory or stultifying limbo. Indeed, all of our traditional characterizations of divine omniscience, irreversibility, atemporality, omnipresence and so on are approximations or illusions that are made possible by the mind’s event horizon in order to contend
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with an otherwise incomprehensible domain of experience. Hence, neither a concrete, theistic nor symbolic, non-theistic portrait of faith can ever really be valid for long, certainly if it is not articulated at some level with its complimentary dimension. In summary, and borrowing from the work of Cesar and Sara Botella ([110], pp. 90, 99), we can also say that a truly transformative divine representation will be one that covers a domain whose conditions are governed by a mysterious but necessary paradox: Reality testing has to involve the paradox of disowning reality. In the animistic world, the [concrete] perception of the object, a factor facilitating non-distinction [i.e., the indistinct blur between perception, motor movement, and representation—MHS] has to be disavowed energetically so that ‘belief’ can be maintained in its existence simply as a representation; without which, its control is uncertain and the distress of absence, the animistic equivalent of the subject’s own disappearance, is a constant threat [p. 137].
That is, only by wish-fulfilling negation of the perception of the merely concrete object can the self be assured of a sense of fullness and constituency within its own internal boundaries, with its own indigenous or autochthonous objects. However – and contrary to all simple minded stage theories of the development of cognition in general and religious faith in particular – even after this early phase is transcended, our overall sense of what is real and what is not real continues to be maintained, on the one hand, by a constant balancing between the disavowal of the perception of the object in order to be able to invest it inward through representability, and, on the other hand, by reproducing it in the representation in order to find it again in the perception. The same paradox occurs in treatment. On one hand, we want the patient, or religious believer, to struggle with the regression to memory (tradition), or to whatever psychic dimension memory seems to reveal, as a refreshing and necessary force against overinvestment in the present and potentially hallucinatory ‘perception.’ On the other hand, we need the patient, or religious believer, to allow for a transference fixation – for example, a narcissistic or homosexual investment in the analyst-as-self (as the ‘real’ other) – as an impediment to becoming trapped in repetition, static memory, or frozen, unmourned-for objects. Our sense of God, it seems to me, straddles the same two paradoxical representational boundaries (and there may be more than two!). It is not just in order to prevent a collapse of the delicate relationship between psychoanalysis and religion that we must modify our stance toward divine objects. Rather, we have located a certain collapsible quality inherent in the constant effort of the human mind to sustain any and all object representations, and that is most endemic to the God representation. I am referring to a need to respect certain god-like or divine qualities that are inherent in the mental operations that characterize the evolution of the psyche along the delicate perimeter of the contact barrier or event-horizon and their maintenance. Hence, the countertransference experience in the shadow of the God representation may uphold the capacity for representation as a whole, and for this reason needs to be welcomed into the therapeutic process. I hold that this stance enables us to be better prepared during treatment for the emergence of clearly demarcated paternally- or maternally-oriented God representations, or for a complete absence of divine representations, or even for wholly abstract, non iconic ‘spiritual’ representations. But the larger significance of this stance is that it invites us to conceptualize ‘the religious encounter with a sense of the divine’ as one of the irreducible
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ways in which the mind continuously approaches, without seeming to approach, the contact barrier or event horizon of the mind. This in turn allows for a more flexible suspension of the analyst’s imagination over the full range of paradoxical vicissitudes of the divine potential and its impact upon the analytic framework.
5.1.5 CLINICAL ILLUSTRATIONS OF THE COUNTERTRANSFERENCE PITFALLS AND CONTRIBUTIONS DUE TO SENSITIVITY TO RELIGIOUS REPRESENTATIONS We can now devote our attention to some clinical portraits of the conflicts and conceptions that I have highlighted in the preceding sections. When psychoanalytic authors of the post-Winnicott era finally began to struggle with the implications of countertransference for the patient’s religious beliefs, the approach was largely aimed at isolating a potential impediment to treatment. In effect, the psychotherapist was advised to prevent his religious representations from interfering with the patient’s – and if the therapist was agnostic or neutral to the topic of faith, all the better. We now consider this approach naive. At the same time, numerous insights emerged from this literature and I wish to offer a few examples. Kochems [111] warned of the dangers of ‘isolating’ religious material during treatment in any manner which falls along a spectrum between completely ignoring such material, or devaluating it, and, at the other extreme, treating it in a specially positive way, rooted in idealization, curiosity, or other dynamics. His lengthy case report, and an excellent essay by Kehoe and Gutheil [112] (the first author is a nun and a psychotherapist), offered what was at the time a rare discussion of countertransference issues, mostly pertaining to the therapists’ conflicts in manifest professional-religious identifications in the face of their patients’ manifest religious conflicts and fragmented God representations. Later, Knoblauch [113], reporting a psychoanalytically-oriented psychotherapy, tried to help a terminally ill patient to ‘utilize a developmental mature selfobject experience precipitated by the therapist’s understanding and acceptance of her sense of God’ (p. 47). Perplexingly, despite the fact that the patient entered the therapy with a powerful idealization of the therapist and both were of the Jewish faith, Knoblauch does not indicate any dynamically relevant countertransference sentiments or conflicts that one might have thought likely to have occurred. Tillman [5] subsequently enriched the clinical complexity of the countertransference perspective by demonstrating that bringing the God concept or representation into the consulting room can be an attempt to weaken the dyad by introducing a Big Third or superego introject who presides over the treatment, inhibiting the therapist, or creates a ‘retreat’ where the patient and his God hide. Alternatively, it may enrich the dyad by fleshing out the dimensions of its potential closeness to a symbolized third. Tillman’s ideas are stimulating; however I am less prone to leave the matter to numbers: dyadic or triadic relationships must be further examined to ensure that their qualitative potentiality is, in fact, truly three-dimensional, i.e., post-depressive, reparative, mutual, and fully symbolized. In the case of many individuals, fantasy content that seems to present a triadic relation between the patient, the analyst, and a God representation turns out to be a mere
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trace, shadow, or hint to a failed or pseudo-mature oedipal aspiration. Also, there exist monadic and even autistic-like religious representational states – null-gods or nether-gods, as it were – aside from dyadic and triadic ones.18 At some point, the therapeutic partners might need to explore the influence of a negativized God in the room, especially since it is likely to be the case that, to the degree that the patient’s God representations are kept out of the analytic frame, other critical aspects of self- and other- object representations are probably being sequestered from the analyst’s view as well, diluting the depth of the transference. And the same would apply to the apparent lack of God representations in the therapist’s experience. I would offer as a slightly more detailed example a fine description by Marilyn Charles [116] of how a disordered linking process took religious expression in a way that touched on both the patient’s and analyst’s religious identities. She reports how her patient, Philip, becomes entrenched within a psychotic process as his identification with God becomes more and more complete on a concrete level, to the point that ‘reality’ is excluded. Eventually, the only way he can relate to his psychotherapist is to conceive of her as his (or God’s) wife. We are told that Philip was born Jewish and adopted a Christian faith in later life. Charles, who is Jewish, is struck by the fact that the patient, like many other of her patients, has misidentified her as non-Jewish (we really don’t learn why; was there a presumption about physical appearance or her name?), yet, she adds, she is no less able ‘to identify with the Christian virtues of acceptance, forgiveness and redemption.’ The analyst herself had at some point in life moved away from a God and belief system that promised optimistic solutions and a coherent logic to all problems and presumably moved on to beliefs that were conceptually and emotionally more suitable for her. But Charles does not offer us a window on the nature of her current religious representations, which I think marks a significant aporia in the countertransference processing of the religious event horizon. At one point, Charles states (p. 26): Thus, with Philip, I found myself in the odd position of internally identifying with the cast-off Jewish identity of my patient while it seemed just as likely that he would presume that I was mutually disposed to identify with the Christian identity of his adulthood. 18
I cannot go into detail here about my notion of null-gods, nether-gods and negativized God representations. But a few words of commentary are required. Britton [114, 115]; Harrison [74], Meltzer and Harris Williams [81], Ogden ([90], p. 83), and Wright [56, 57] have each highlighted certain primordial levels of mental development which they refer to as the bedrock of sacred experience, which they believe continue to impart a ‘sacred’ quality to psychological experience whenever there is some activation of those representations that are based upon this sacred mental bedrock. This idea is very important. Against this background, I add that there must also exist ‘negative sacred experiences’ – such as a sense of satanically seductive suffering or fatefully, omnivorously overpowering fright (as opposed to awe), harpy-like timelessness (as opposed to beneficial divine providence within time), and paranoid judgmental influence. We might refer to these kinds of negative sacred experiences and topographies, imitating Bion [55, 95], as –S. Further, bearing in mind Bion’s distinction between a no-breast symbol and the abject non-breast, the presence of –G (that is, a negative God concept) might refer to some demonic, megalomaniacal paranoid object that destroys religious faith and renders the mind fanatically antipathetic toward the subtleties of belief, faith and spiritual wonderment and also includes the capacity to comprehend concepts such as the deus absconditus. On the other hand, the utter lack of a God representation – if there is such a thing in any absolute sense (total lack being rare in the mind – might refer to the failure to internalize any of the foundational symbols of the mind. Even the sense of nothingness, much adored by many idealists and spiritually oriented writers who would prefer to not contend with a specific entity known as God, could not be put to creative philosophical use were these authors not somehow possessed of a healthy capacity to work with –G.
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Gradually, Philip’s pretence of compliance with the overall therapeutic regime became apparent, effectively sabotaging the entire treatment. Ultimately succumbing to regression, he needed to be protected from total loss by becoming psychotically self-enveloped with a God representation that overtook all else. So the following question must be posed at the epicenter of the countertransference as the author presents it: Might not the patient’s subtle facade of treatment compliance have been in some way a negative parallel to Charles’s willingness to allow her true faith to be misidentified? This is not to say that Charles ought to have concretely corrected the patient – that would be a simple technical error, unlikely to yield much. Rather, we want to inquire more about what motivates the analyst to adopt this stance. A hint to the possible activation of an unconscious pocket of unresolved conflict surrounding religious identifications or God-definitions is Charles’s comment that she felt unhampered to identify with ‘the Christian values of acceptance, forgiveness and redemption,’ without qualifying whether these values are in fact the same for a Christian, Moslem, a Jew. One wonders: what manner of divergent or convergent identification is masked by the therapist’s declaration, and what divine characterization lies behind her denominational assumptions and the patient’s? It is noteworthy that Charles seemed willing to barter her ability to ‘internally identify with the cast-off Jewish identity of my patient’ and, as a result, perhaps, failed to explore Philip’s perception of her as Christian or, more importantly, as not-Jewish, despite the fact that the deeper representations behind these religious assumptions – pertaining to sheer being or not-being – were rapidly encroaching upon the territory of his fragile self. Inadequate attention was paid to the quantum differences between the quality of the cast-off identifications of each of the analytic participants – foreclosed, frozen, relinquished, split, abandoned, mourned? –and to the question of just how much of the therapist’s and patient’s respective self-representations were cast-off (or mourned or frozen) in the process? The question would then be: Could Philip perceive of Marilyn Charles as sharing his mental state via empathy, or did he introject her absconded God as absent, hiding, or somehow attacking his attempt to link to her mind? Bereft of options, it seems that Philip offered dissociated identity fragments of himself to the analyst and to the therapeutic milieu, split along the lines of some form of demonic melange of Jewish-Christian images of God that had not been fully explored. The rest of his own collapsed God-self core he sequestered beyond human reach. Another case presentation by an avowedly religious psychoanalyst, capable of detailed scrutiny of her own God representation, is Patricia Holliman’s [117] psychoanalytically oriented psychotherapy with Debra. This troubled patient continued for a long time to demand from herself, the therapist, and God that she be seen and heard genuinely and that she be enabled to find something to hold onto in life. Holliman is aware of the undesirability of serving in an apostolic-didactic role, though one can sense the tension between her loyalties, as tends to be the case with clinicians who are strongly identified with a pastoral psychological context. Holliman also informs us that she has undergone a shift toward a more mature perception of God – man assumption that, in my view, psychotherapists must be more willing to interrogate further – and, indeed, we do not learn how this ‘shift’ came about on the deeper representational level (just as we are not told much about Charles’s ‘casting off’ of previous religious identifications). This makes it more difficult to study just how the therapist’s internal transformations might have enabled her to feel more secure or less secure to meet her patient’s philosophical expectations as transference expectations and not primarily as real theological wishes that the therapist might be religiously obligated to meet.
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Holliman provides an important description of the patient’s intrusive phone call to her, ostensibly to gain some sort of immediate assurance, at which occasion the therapist, for perfectly realistic reasons, was unable to be exclusively available to the patient. In her personal work, Holliman sought to carefully balance her own religious experience of learning to pull away from a sense of a controlling God and the need to always mollify the shame of other, weaker objects in her life. In the context of the analytic frame as activated uniquely by Debra, Holliman consciously allowed herself to be reached by phone, yet ‘inadvertently’ allowed herself to be distracted even as she did her best to offer Debra a bit of extra time and support. The therapist thus acted out her impatience with Debra’s control but at the same time evaluated the matter in terms of both hers and Debra’s God representations, and was thus able to be comfortable not being an omniscient, ever-available deity, for herself and for her patient.
5.1.6 THE EMERGENCE OF LATENT RELIGIOUS REPRESENTATIONS IN THE HORIZON BETWEEN ENACTMENT AND COUNTERTRANSFERENCE: THE CASE OF ‘KAREN’ Some details from one of the analytic treatments I am conducting might provide a contrasting way of experiencing and interpreting the countertransference experience. The segment that I offer here is one of many in my experience which support the view that the most clinically significant religious representational dynamics take place at the margin or horizon of the analytic field. A female patient, ‘Karen,’ married with several children, sought psychoanalysis at a relatively advanced stage of a successful career as a mental health professional and, to all appearances, a satisfying personal life. She had had some personal therapy during earlier stages of life, and had learned a good deal about herself during years of analytically oriented supervision, but knew that she had not come to terms with certain uncanny feelings, to be described below, that troubled her from time to time. Alongside a strong sense of commitment to her marriage and her husband, Karen detailed a very varied sexual life as an adolescent and young adult until her marriage, and several instances of torrid sexual escapades outside of her marriage, most without her husband’s awareness. During early phases of our work, the patient expressed minimal regrets and only mild embarrassment about these entanglements, maintaining a firm split between ‘sex’ and ‘love,’ and protesting that it would not bother her if her husband conducted himself the same way. I indeed had the sense that Karen loved her husband and certainly her family quite deeply, despite her secret sexual activities, and for the while I accepted at face value (i.e., from her point of view) Karen’s conception of distinct and separate needs. As we worked during this period, it seemed that Karen experienced her mother as somewhat cold and distant, coarse in touch, uncreative, perhaps not an intellectual equal. Her father, a professional, was portrayed as a bon vivant, active in many circles, often not home, but also as a caring, ‘good’ husband, and also willing to do anything for his children. With further progress, I began to have the impression that Karen was somewhat trapped between her avatars of the childhood desire to grow up fast and be perceived as a sensually strong, even irresistible woman – perhaps, it seemed, so as to drive a wedge between herself
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and some dangerous oedipal yearning for father and fear of mother – and the desire, later in life, to remain youthful and never-old. The intensity and ‘style’ of Karen’s sexual adventures also hinted to a powerful, if unconscious, incestuous fantasy. As the patient described herself and her own professional work, I got a clear sense of her competency and reliability, but we also uncovered many areas that were conflict-bound that in turn became areas of difficulty in her relationship with some of her own clients. In particular, Karen tended to be empathic with ‘standard,’ gender-consistent oedipal configurations, but could not quite grasp some of her female clients’ homosexual transference to her. In addition – and I heard this from the outset as a sort of warning signal – she was vexed by one client of whom she was ‘genuinely fond’ who sent the therapist a great deal of cellular phone text messages and also expected responses from her. Now the following sentences might ordinarily not have been written if not for eventual developments. While psychotherapists listen to all cases with an ear poised for the emergence of any and all kinds of material, we do not always know whether religious themes will be relevant. But I have argued that we should be no less prepared for such developments than we are prepared to learn about latent homosexual conflicts, preoedipal dynamics, hidden family secrets, and so forth. With this in mind, let me now state that during the first year of analysis, religious beliefs or imagery did not seem relevant, though Karen mentioned as a marginal ‘aside’ – as many patients do – that she had once been more religiously committed to Judaism, even more so that her semi-affiliated parents, but gave this up as she got older. At the time, Karen gave no further clue as to the depth or content of her religious beliefs. In addition, Karen wondered at one point in the middle of the first year whether it troubled her that I was apparently a religious individual (I wear a small knitted skullcap), and joked whether my religious orthodoxy matched my reputed Kleinian orthodoxy. She acknowledged quickly that while she really knew little about either of my ‘orthodoxies’ she had, after all, felt the need to utter her ironical jibe, but she wasn’t able to do much with it at the time. Gradually, during the first and second years of analysis, it became clear that one of the driving forces of Karen’s seeking analysis was to deal with a nagging sense of having missed out on something important in life, which she couldn’t yet define or describe. Objectively, she was able to acknowledge, she had accomplished so much and lacked for very little. And yet she dreaded that she would grow older and only to learn that she had continued to ‘miss out’ on this special something. The sense of missing out, missing something, or being missed was a very uncanny and anxiety-provoking experience for her, increasingly difficult to quiet. In the Hebrew language in which the analysis was conducted, the contemporary (not quite slang) term for ‘to miss out,’ le-fas‘fes (noun: fes‘fus), was rooted etymologically to many additional dimensions of her inner representational world of fantasy and desire: le-hach‘metz, to tarry, be late, or delay, e’fes, nothingness and worthlessness, and le-a‘pes, to balance, to recalibrate (i.e., to reset at zero), and it was not long before all of these words began to turn up repeatedly during her associations. During the middle of the second year of work, I began to be dimly aware that an incipient countertransference was forming. For all of the consistent work and fresh ideas – new issues in almost every sessions, which was itself somewhat irritating, for it came at the expense of continuity – I had the sense that we were all the time ‘missing’ something during Karen’s hours. Eventually I had the sense that Karen was hiding during our hours, to the degree that, despite my genuine interest in her and the analysis, I found myself often feeling somewhat unconnected, or even bored.
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The sessions came and went, leaving me with a false sense of ‘moving forward’ that I typically feel when there is always something new and very little that once might have been. Karen as well sensed that she was avoiding, and was unhappy. I could only comment that perhaps we were suspended over that odd dimension she referred to as fes‘fus, ‘missing out,’ in which case it was both an active state as well as a position to be dreaded. Karen said nothing at first, but tears rolled down her sad face for the first time, as she muttered in an aggravated voice that what she had dreaded for a long time, and had tried to avoid, was the thought of crying in front of me. ‘Here,’ Karen added, ‘at the end of the hour [al saf hadelet; lit., at the door’s threshold], it all bursts out.’ I said to her, ‘Sof and fes ‘fus are related terms, yes? Perhaps that’s a paradox we need to feel: maintaining a strong appearance so as to not miss out [le-fas‘fes], but thereby you miss out; at the same time, you leave the hour not quite as you preferred, missing out, or messing up, but a bit more aware of the presence of the feeling.’ And thus ended that hour, the last of the week. On Friday night of that weekend, whilst attending Shabbat evening services, I found myself distracted. I am always somewhat distracted, as the congregation sings or celebrates and I attend to my books and reflections upon the Torah reading for the week or to whatever other thoughts are floating through my mind. I personally disdain repetition of the same, and although religious ritual has that element within it, lending it its frame, I am always looking for something new that evokes fresh insight and vitality. As a haunting tune latched on to my mood, I was conscious that I was thinking about Karen and her face – it was lovely, intelligent and sensually exciting as always, but, alas, soiled by her tears. I was alarmed and curious. Was I prematurely ‘converting’ her, bringing her back to the synagogue, my synagogue? I immediately viewed this thought as superficial, and was able to sense something somewhat deeper: I wondered if my ‘enactment’ – my distraction from the more appropriate focus that I evidently found less inspiring than my patient – had been somehow unconsciously evoked by some memory of Karen’s that a synagogue was not an entirely safe place. This, too, seemed to venture much further than anything for which I had evidence, but I was glad as well, since I believed that this reverie stemmed from potential stirrings in Karen’s world, despite her unhappy exit from the last hour. Maybe, I thought finally, we had not ‘missed out’ this time after all. Upon entering my office following the weekend break, I found that Karen had sent me an email in between sessions. In it she expressed immediate awareness that she was risking acting out in order to share something of importance. First, she stated that she had written the letter on the Shabbat, which posed no problem for her but wondered if it did for me. She had composed it Friday night, while cooking for her family, during the hour when she imagined I’d be attending services in my synagogue. It struck her as odd, she continued, that I would be wrapped in my prayers – many of which she still knew by heart, and recalled either enjoying or not enjoying – while she was at home cooking, preparing for the traditional but non orthodox (‘not even kosher’) family meal, and, as on many evenings, thinking of making love to her husband. By the time she finished meditating, imagining and then writing the letter, she surmised that I’d be walking home to my home, though she had no idea if I attended synagogue prayer or not. The desire to write to me had simply overwhelmed her, and, in fairness, she thought, she needed to send it then and there, yet she paused and did not send the letter until after Shabbat, so as to not offend me. Naturally, this fascinating development raised technical questions of management – whether to acknowledge having read the letter, to bring it into the session or await the
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patient’s initiative (I chose the latter), and the like. In and of itself, the letter writing and sending was a sexual enactment yet, essentially, it had the form of a dream, a mix of concrete and hallucinatory happenings, rich with assertions and negations, possibilities and impossibilities. And it had taken place on the Shabbat, and in that sense, it was a religious experience as well and I knew that Karen understood this. After a brief silence, redolent of embarrassment and passion, Karen brought up her letter. She did not ask if I had read it, but assumed so, referring to it as a shared event. She spoke of the manifest themes in the letter as well as the somewhat deeper ones – an indirect invitation to join her in the warm spirit of a Shabbat evening sexual embrace, rich in sacred and perverse, ‘non kosher’ feelings – and she then revealed, with an air of genuine surprise, her awareness of a split similar in quality to her famous split between ‘sex’ and ‘love.’ Tripping over her own double negatives, Karen said that she was not quite so certain that her feelings on Friday night weren’t ‘deeply sexual and also loving, erotic and fatherly.’ I told Karen that the way she turned that last phrase conveyed a double impression, as if she meant to carry forward a contrast – sexual and erotic, on one hand, loving and fatherly, on the other hand – and a convergence – erotic and also pertaining to father. I then said to Karen, ‘Perhaps this is why you needed to share this creation with me only at the border or saf of the treatment hours, in a marginal place where it was simultaneously Shabbat and not Shabbat, and [here my tone became inquiring] reflecting your current desires as well as powerful memories, when mothers are at home and fathers go to synagogue?’ New deliberations entered Karen’s associations during the next sessions. There was a renewed sense of vitality, as well as pain, as she shared her dread of crying, and her fear that her tears would lead her to dealing with difficult memories, until now only hinted at in shadowy images and themes that were intentionally missed in her earlier therapy. As it turned out, much of her father’s vivacious, temperamental spirit and powerful opinions she did not see at home, as he worked late hours, but rather in the local synagogue, among his male friends. Here, in contrast to the boring atmosphere at home, was an identity that she could enjoy, and a latent form of sexual play which was in a sense ‘legitimized’ by its taking place in a ‘safe’ context but which, at one and the same time, aroused intense sexual conflict within, dread over her mother’s envy, and guilt over her feelings vis-a-vis both parents. Karen now understood that the natural erosion of interest in the synagogue, and the convenient disposal of God, was a screen for the inauguration of intense, often delirious sexual explorations with dangerous male friends. As we explored the intensity of her transference, partly enhanced by my own countertransference-augmented sensitivity, Karen could experience the kinds of intoxicating feelings that were covered over by her emphasis on the ‘safety’ of the august synagogue, much as the conventionality of her marriage masked her secret passions, and as the complexities of clinical work absorbed her deeper perverse feelings. In our current work, far from complete, Karen has spoken with increasing awareness that her image of God, and the early fantasies of fatherly prowess, had not ceased to exist or to exert influence, but were expressed in a clandestine way in several important areas of her life, including a heightened sense of intense mutuality that was coming closer to consciousness at the peak moments of sexual orgasm (too complex to take up in this chapter). Karen missed God – now she used the Hebrew term ga’a‘gu’a for anxious yearning – and her father, which until now had been disguised by her preoccupation with ‘missing out’ (fes’fus) or of being missed. At some point, I commented, in words to this effect, that, at the edge of the sessions – or in the margin or saf between them – Karen had encountered a fresh sense of what she had
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missed or even absented (le-a‘fes) in her feelings toward her father. Karen agreed that, of late, she expressed this yearning in her secret longings for me during and between our sessions, eluding me as she had eluded God, father, and the synagogue. Karen also understood that as long as her repressed feelings for her father had rendered all but the most ‘photo album’ type characterization of him unacceptable, God as well would remain a frightening image, one needing to be artificially normalized. This normalizing effect had taken expression in the arid atmosphere in the therapy room as well, until I had the good fortune to comment on Karen’s importing her sense of fes‘fus directly into our relationship. But ‘fortunate’ interventions are usually an elaboration of significant, unconsciously directed communications already in progress. This deeper link had been forged during the reign, of her forcefully nullified God image, but it was stimulated either from the direction of the father/analyst transference toward the father-like elements in her dormant divine representation or from the direction of a hidden stirring within the God representation toward the father/analyst. We cannot know which at this time, if ever, yet the creative impetus for change gained its first expression in the parallel between my reverie in the synagogue and the developments that took expression in Karen’s Shabbat letter to me. I do not wish to offer more material as I think I have amply illustrated my point. The therapist does not intentionally bring God into the analytic field when such an image or representation has not yet been announced or activated by the patient’s internal dynamics, generally as expressed along the deeply obscure zone of the analytic frame. At that point, the therapist may also experience a stirring within his or her own representational field, one which can create artificially splits within religious experience, quicken gods long deceased, or freeze living gods, in concert with the needs of the patient or therapist.
5.1.7 AN EXEGESIS WITHIN JUDAIC SOURCES REGARDING THE EVENT HORIZON AND THE REPRESENTATION OF GOD I would like to end this chapter with a midrashic-like reflection that compares the concepts outlined above to an older analogy drawn specifically from Judaic sources. At the beginning of the chapter I alluded to one of Freud’s comments about religious experience ([1], p. 72): The origin of the religious attitude can be traced back in clear outlines as far as the feeling of infantile helplessness. There may be something further behind that, but for the present it is wrapped in obscurity [aber das verhullt einstweilin der Nebel].
This entire chapter has been devoted to the concept of the obscurity or nebulousness (der Nebel) of the object ‘behind’ the representational ‘wrappings’ of religious imagery and belief, and how we might better accommodate its presence within the analytic frame. I would now introduce another comment by Freud that might seem unrelated at first glance. In his great commentary on dreams, Freud wrote ([118], p. 111n): There is at least one spot in every dream at which it is unplumbable – a navel, as it were, that is its point of contact with the unknown [dem Unerkannten].
Later in the same text, Freud writes ([118], p. 525):
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There is often a passage in even the most thoroughly interpreted dream which has to be left obscure; this is because we become aware during the work of interpretation that at that point there is a tangle of dream-thoughts which cannot be unraveled and which moreover adds nothing to our knowledge of the content of the dream. This is the dream’s navel [der Nabel des Traums], the spot where it reaches down into the unknown.
Here, again, are references to obscurity and to uncanny, unfathomable depths. Yet the umbilical concept (der Nabel) is not merely metaphoric. As Scalzone and Zontini [119] suggest, the dream navel can be seen as the chaotic link, or interface, between the unconscious wish – which constitutes an attractor as the term is used by contemporary physics – and the conscious thought. This attractor may be visualized as having an hourglass shape, the narrow mid-section being what Freud refers to as the dream’s navel, incorporating two dimensions in a super-condensed way. The dream’s navel is thus the center of a turbulent vortex connecting the dream to the unconscious magma that fuels it. Continuing with the metaphor, the dream navel is analogous to that point that once connected the fetus to the mother via the interface of the placenta. Scalzone and Zontini state ([119], p. 279): Even though the navel is a scar left by a physical relationship that no longer exists in reality – an absence – it continues to represent a virtual point of transition within the psyche, as is clear from Freud’s phrase ‘a navel, as it were, that is its point of contact with the unknown.’ This matrix, ‘the unknown,’ could be identified with the future id, because that structure is less organized than the topographical unconscious and because it affords a better representation of the realm of drive chaos situated in a timeless dimension.
Comparing the two Freud citations, we note that the German words Nabel (navel) and Nebel (clouds, obscurity) alliterate very closely and this is no accident. Like the dream navel, one might say, the nebulous experience of God within the analytic framework highlights a developmental reality, an innate human psychological struggle with the continuity and never-ending character of representation, with the fact that the full identity of the most archaic resident of our mind always appears just beyond our grasp. Over the years, I have been impressed by the conspicuous quantity and quality of literary references to the face or pan‘em in Exodus, 32:12–23, a small subsection of 11 biblical passages – an intimate dialogue between Moses and God – that contain what is perhaps the single most revealing and poignant expression of the desire for encounter between Moses, on behalf of himself and the Children of Israel, and God. The high point is reached when Moses expresses his desire to ‘see’ or to experience the glory of God’s own face. God replies: lo tu‘khal le’re‘ot et pa‘nei ke lo yer’ane ha-adam va-hai, ‘You cannot see My face, for no man shall see Me and live’ (Exodus, 32:20). The translation ‘cannot see my face,’ based on the ordinary meaning of the adverbial clause lo tu‘khal, accords with the general understanding of the impermeable barrier between man and the divine. However, one quickly notes that in almost all other applications in the Bible, the phrase lo tu‘khal clearly implies lack of permission as opposed to sheer inability. Indeed, the talmudic sage Rabbi Joshuah ben Kar‘hah (ca. 200 CE) adopts one instance of the phrase lo tu‘khal (see Deuteronomy, 12:17) in order to establish a general philosophical position: ‘You are, of course, able [to see], but are not permitted’ (Medrash Sif‘rai, ad loc). Any other interpretation, it would seem, would not be consistent with the belief in the capacity for free will that is fundamental to Jewish ethics. But could the same interpretation apply to the divine warning that Moses receives in the dialogue in Exodus 32?
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In fact, Rabbi Joshuah ben Kar‘hah himself was troubled by the passage in Exodus and interprets the phrase by creating the following imaginary conversation: Thus said the Holy One to Moses: When I was willing, you were unwilling [referring to Moses’s covering his eyes when God revealed Himself at the burning bush (Exodus, 3:2–4)]; now you are willing, but I am not’ (Talmud, Bera‘hot, 7a).
The general understanding of Rabbi Joshuah’s homily is that, in principle, it was conceivable that Moses could somehow see beyond the mortal-divine barrier, but that God wished at this time to reveal only a relatively limited portion of prophetic experience. The eleventh-century biblical commentary Rashi, in a gloss at Exodus, 32:20, adheres to this approach in his laconic paraphrase: ‘Even when I pass by your face in all My glory, I shall not give you permission to see My face.’ Once again, the implication is that, under the right circumstances, Moses might somehow have been able to apprehend that which generally seems beyond apprehension. Now, whatever Moses did or did not see, and however much he internalized all that he experienced sensorially, will remain a mystery. Yet we can appreciate that the myth captures the deep psychological truth – the Winnicottian paradox – that the human mind seeks, finds and creates God when man stands at the barrier between the unconscious and consciousness, when he or she is locked in an equal gravitational pull between no-thing and nothingness, between the lure of endless desire and the Real, one the one hand, and the somewhat more assuring plenipotentiality of the Symbolic, on the other hand. The term lo tu‘khal, with its potential dual meaning of cannot and may not, implies, at one and the same time, the censorship qualities of the event horizon referred to above alongside the bizarre moments where visions and sight seem possible beyond normal ranges and definitions, when a herniated event horizon reveals a naked singularity, the portal to other universes and to a reversal of time. I would take this analogy one last step further by comparing the obscure dream Nabel to the biblical cleft in the rock (nek‘rat ha-tzur), a portal that exists virtually in the sacred ma‘kom or space carved out by the man-God relationship (Exodus, 32:21–23), through which Moses was able to partake of a fraction of divine wisdom, and experience a bit of the radiance of the divine ‘face’ he clamored to see. The cleft is a window of sorts, and not a scotoma, yet like the navel (ombilicius ¼ omphalos), the cleft or gap only reveals a partial image, and symbolizes the exact spot where womb and mouth merge, and will separate; the gasp of birth pangs, laughter, orgasm and death. The cleft, as Freud says of the dream navel, doesn’t lead to nowhere. It is an intricate knot of threads which are too thick to unravel, an accumulation of quanta of desire too dense to surrender to a discrete representational form, and thus the navel, Janus-faced, smacks of the unknown itself rather than of anything knowable.19
19 This would also echo the Talmud’s opinion (Bera‘hot, 7a) that as God’s face eventually passed before Moses, with Moses secured in the cleft of the rock (Exodus, 32:22) – another event horizon or membrane? – Moses was enabled to see the back of God’s head, the knot of God’s phylacteries, from which it was possible to infer the experience of the front of God’s face. Put differently, the flux between human representations of the divine and the ‘reality’ of the divine – whether experienced as a preconceptual illusion at the edge of the Real, a complex psychological fantasy captured in myth, or an objective fact that we will one day discover in a parallel universe at the other end of a black hole – is a creative expanse of intensely contradictory and paradoxical dimensions; desired and dreaded, obtainable and destructive, inclusive and expulsive.
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I do not think that God’s reluctance, as per Rabbi Joshuah’s myth, is simply a case of pouting, a vengeful tit-for-tat maneuver with Moses. Instead, perhaps God cannot bear to look at Moses – for the promises He made regarding the process of redemption and the nature of His relationship with Israel had indeed been sorely tested, and Moses’s original hesitations at the burning bush might, for a moment, have seemed quite vindicated. Presciently, then, Rabbi Joshuah anticipated a truth of the analytic partnership during the throes of the transference-countertransference matrix. The analyst who, in a sense, implied at the outset of therapy that he could contain anything the patient had to tell, and encouraged the patient to explore more and more, finds now – as the repressed bares its darkest secrets, disturbing old conflicts within the analyst’s self, or as archaic, unmentalized elements within the patient impact deeply within the analyst’s own psychesoma – that he, too, has become symptomatic, confused, and begins to wonder, on behalf of the patient or on behalf of himself, whether their mutual ‘election’ can be maintained, whether their journey together can continue. And if it is the face of God that might be somewhat more present within the mortal analytic frame – as seems to have begun to be the case in Karen’s analysis – perhaps the analyst or the patient, each at different points, hesitates to return the glance? In the case of both the dream navel and the cleft at Sinai, the price of this kind of insight is joyous and painful, since the wished-for experience is necessarily limited by time, human language, and the inscrutability of the object of desire. All efforts to see beyond the light allowed by the cleft would be blinding, and lead to psychic death, but that is why humans transform much of what they desire into imagination. That we imagine, or fantasize, or engage in illusion, does not mean that what we desire does not exist! Thus, the mythic truth, universally internalized by religious believers and nonbelievers alike, is that mindedness, or mentalization, requires the capacity to be richly satisfied with the shifting balance between frustration, wishful fantasy, and symbolization. Might it be that the deepest level of paradox, common to our archaic heritage, is felt precisely at that point, if there is such a point, where the human mind confronts a real God who resides pristinely, beyond or distilled of other human representations, and who is experienced mentally only by virtue of our perceptual limitations? That is, a God who is not essentially the product of the unconscious. The fact that most of us would become psychotic, or cease to live, at that point – as Lacan warns of the search for total jouissance – does not in and of itself mean that there is no object present at that point. As physics has taught, the event horizon doesn’t imply an absolute nothingness; it shields, and even derives its own character from an entity that we call a ‘black hole’ which exists and has its own paradoxical properties. I have argued here that if such states exist, they might manifest during psychotherapy in the form of countertransference phenomena whose true source is suspended between the two participants, belonging to both and neither, and whose real or imaginary religious significance can never be fully determined. Gods, divine things, and sacred spaces might be found here.
REFERENCES 1. Freud S (1930[1929]) Civilization and its Discontents. In: Strachey J (ed. & trans.) The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vol. 27). London: Hogarth, London, 1961, pp. 57–146. 2. Anderson-Thomson J (2009) Who are we? Where did we come from? How religious identity divides and damns us all. American Journal of Psychoanalysis 69, 22–42.
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3. LaMothe R, Arnold J, Crane J (1998) The penumbra of religious discourse. Psychoanalytic Psychology 15, 63–73. 4. Shafranske EM (1992) God representation as the transformational object. In: Finn M & Gartner J (eds.) Object Relations Theory and Religion: Clinical Applications. New York: Praeger, New York, pp. 57–72. 5. Tillman J (1999) Religious language in psychotherapy: Dyadic and triadic configurations. Psychoanalytic Psychology 16, 389–402. 6. Jones JW (1991) Contemporary Psychoanalysis and Religion: Transference and Transcendence. Yale University Press, New Haven, CT. 7. Meissner WW (1984) Psychoanalysis and Religious Experience. Yale University Press, New Haven, CT. 8. Pruyser PW (1983) The Play of the Imagination: Toward a Psychoanalysis of Culture. International Universities Press, New York. 9. Black DM (2006) Psychoanalysis and Religion in the 21st Century: Competitors or Collaborators? Routledge, London. 10. Blass RB (2006) Beyond illusion: Psychoanalysis and the question of religious truth. In: Black DM (ed.) Psychoanalysis and Religion in the 21st Century: Competitors or Collaborators? Routledge, London, pp. 23–43. 11. Britton R (2005) The use of theological concepts in psychoanalytic understanding. In: Field N (ed.) Ten Lectures in Psychotherapy and Spirituality. Karnac, London, pp. 91–106. 12. Corveleyn J and Luyten P (2005) Psychodynamic psychologies and religion: Past, present and future. In: Paloutzian RF and Park CL (eds.), Handbook of the Psychology of Religion and Spirituality. Guilford, New York, pp. 80–100. 13. Field N (2005) Ten Lectures on Psychotherapy and Spirituality. Karnac, London. 14. Fischer RMS (2001) The God representation and the inner dialogue as transitional phenomenon. In: Akhtar S and Parens H (eds.) Does God Help? Developmental and Clinical Aspects of Religious Belief. Aronson, Northvale, NJ, pp. 53–74. 15. Issroff J (1999) Reflections about God (Yehovah) and religion. In: Stein SM (ed.) Beyond Belief: Psychotherapy and Religion. Karnac, London, pp. 99–117. 16. McDargh J (1983) Psychoanalytic Object Relations Theory and the Study of Religion. University Press of America, Lanham, MA. 17. McDargh J (1993) On developing a psychotheological perspective. In: Randour ML (ed.) Exploring Sacred Landscapes: Religious and Spiritual Experiences in Psychotherapy. Columbia University Press, New York, pp. 172–193. 18. Meissner WW (2005) On putting a cloud in a bottle: Psychoanalytic perspectives on mysticism. Psychoanalytic Quarterly 74, 507–559. 19. Smith JH and Handelman S (1990) Psychoanalysis and Religion. Johns Hopkins University Press, Baltimore, MD. 20. Spero MH (1992) Religious Objects as Psychological Structures: A Critical Integration of Object Relations Theory, Psychotherapy and Judaism. University of Chicago Press, Chicago. 21. Symington N (1994) Emotion and Spirit: Questioning the Claims of Psychoanalysis and Religion. Cassell, London. 22. Symington N (2001) The Spirit of Sanity. Karnac, London. 23. Simmonds JG (2004) Heart and spirit: Research with psychoanalysts and psychoanalytic psychotherapists about spirituality. International Journal of Psycho-Analysis 85, 951–971. 24. Simmonds JG (2006a) Being and potential: Psychoanalytic clinicians’ concepts of God. International Journal of Applied Behavioral Science 3, 221–241. 25. Simmonds JG (2006b) The oceanic feeling and a sea change: Historical challenges to reductionst attitudes to religion and spirit from within psychoanalysis. Psychoanalytic Psychology 23, 128–142.
5.1
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26. Tummala-Narra P (2009) The relevance of a psychoanalytic perspective in exploring religious and spiritual identity in psychotherapy. American Journal of Psychoanalysis 26, 83–95. 27. Sorenson RL (1994). Sea changes, interesting complements, and proselytizing in psychoanalysis: Commentary on ‘An interesting contradiction: A study of religiously committed, psychoanalytically oriented clinicians.’ Journal of Psychology & Theology 22, 319–321. 28. Sorenson RL (1997) Transcendence and intersubjectivity: The patient’s experience of the analyst’s spirituality. In: Spezzano C and Gargiulo GJ (eds.) Soul on the Couch: Spirituality, Religion, and Morality in Contemporary Psychoanalysis. Analytic Press, Hillsdale, NJ, pp. 163–199. 29. Jones JW (2002) Terror and Transformation: The Ambiguity of Religion in Psychoanalytic Perspective. Routledge, London. 30. Roland (2003) Psychoanalysis and the spiritual quest: Framing a new paradigm. In: Roland A, Ulanov B and Barbre S (eds.) Creative Dissent: Psychoanalysis in Evolution. Praeger/Greenwood, Westport, CT, pp. 219–229. 31. De Mello Franco O (1998) Religious experience and psychoanalysis: From man-as-God to manwith-God. International Journal of Psycho-Analysis 79, 113–131. 32. Bion WR (1977). A Memoir of the Future. Part II: The Past Presented. Karnac, London. 33. Leavy S (1990) Reality in religion and psychoanalysis. In: JH Smith and SA Handelman (eds.) Psychoanalysis and Religion. Johns Hopkins University Press, Baltimore, MD, pp. 43–59. 34. Black DM (1993) What sort of a thing is a religion? International Journal of Psycho-Analysis 74, 613–624. 35. Rizzuto A-M (1979) The Birth of the Living God: A Psychoanalytic Study. University of Chicago Press, Chicago. 36. Rizzuto A-M (1982). The father and the child’s representation of God: A developmental approach. In: Cath, SH, Gurwitt, AR and Munder Ross J (eds.) Father and Child: Developmental and Clinical Perspectives. Little, Brown and Co., Boston, pp. 357–381. 37. Rizzuto A-M (2003) Believing and personal and religious beliefs: Psychoanalytic considerations. Psychoanalysis & Contemporary Thought 25, 73–103. 38. Finn M and Gartner J (1992) Object Relations Theory and Religion: Clinical Applications. Praeger, London. 39. Randour ML (ed.) (1993) Exploring Sacred Landscapes: Religious and Spiritual Experiences in Psychotherapy. Columbia University Press, New York. 40. Vergote A and Tamayo A (1980) The Parental Figures and the Representation of God: A Psychological and Cross-cultural Study. Mouton, The Hague. 41. Spero MH and Cohen M (2009) Introduction to a symposium: The God representation in the psychoanalytic relationship: When is three a crowd? Journal of the American Academy of Psychoanalysis & Dynamic Psychiatry 37, 1–20. 42. Kernberg O (2000) Psychoanalytic perspectives on the religious experience. American Journal of Psychotherapy 54, 452–476. 43. Kung H (1979) Freud and the Problem of God. Yale University Press, New Haven, CT. 44. Meissner WW (2000) Psychoanalysis and religion: Current perspectives. In: Boehnlein JK (ed.) Psychiatry and Religion: The Convergence of Mind and Spirit. American Psychiatric Association Press, Washington, DC, pp. 53–70. 45. McDermott B (2003) Passing over yet being home: interrreligious encounter and the transformation of consciousness. In Meissner WW and Schlauch CR (eds.) Psyche and Spirit: Dialectics of Transformation. University of America Press, Lanham, MD, pp. 27–42. 46. Richardson WJ (1992) Love and beginning: Psychoanalysis and religion. Contemporary Psychoanalysis, 28, 423–441. 47. Siggins LD (1983) Psychoanalysis and ritual. Psychiatry 46, 2–15. 48. Bomford R (1999) The Symmetry of God. Free Association, London.
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49. Fowler JW (1987) The Stages of Faith: The Psychology of Human Development and the Quest for Meaning. Harper and Row, New York. 50. Cohen M (2003) The affirmation of religious (not merely spiritual) orientation in clinical treatment Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 31, 269–273. 51. Kegan R (1980) Where the dance is: Religious dimensions of a developmental framework. In: Fowler J and Vergote A (eds.) Toward a Moral and Religious Maturity. Silvert Burdett, Morristown, NJ, pp. 76–89. 52. Strieb H (2001) Faith development theory revisited: the religious styles perspective. International Journal of Psychology & Religion 11, 143–158. 53. Strieb H (2003a) Faith development research at 20 years. In: Osmer RR and Schweizer F (eds.) Developing a Public Faith: New Directions in Practical Theology – Essays in Honor of James W. Fowler. St Louis: Chalice, St. Louis, pp. 15–52. 54. Strieb H (2003b) Variety and complexity of religious development: Perspectives for the 21stcentury. In: Roelofsma, PHMP, Corveleyn, JMT and JW van Saane (eds.) One Hundred Years of Psychology and Religion: Issues and Trends in a Century-Long Quest. Amsterdam: Free University Press, Amsterdam, pp. 123–138. 55. Bion WR (1965) Transformations. Maresfield, London. 56. Wright K (2005) Have ‘objects’ got faces? In Field N (ed.) Ten Lectures on Psychotherapy and Spirituality. Karnac, London, pp. 41–60. 57. Wright K (2006) Preverbal experience and the intuition of the sacred. In: Black DM (ed.) Psychoanalysis and Religion in the Twenty-first Century: Competitors or Collaborators? Routledge, London, pp. 173–190. 58. Akhtar S and Parens H (2001) Does God Help? Developmental and Clinical Aspects of Religious Belief. Aronson, Northvale, NJ. 59. Stein SM (1999) Beyond Belief: Psychotherapy and Religion. Karnac, London. 60. Cohen M (2002) Convergence: Maturation and integration in the course of a religious conversion. Journal of the American Academy of Psychoanalysis & Dynamic Psychiatry 30, 383–401. 61. Spero MH (2004) What con-verges and what di-verges when religious object representations transform? An annotated critique of Cohen (2002). Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 32, 669–708. 62. Spero MH (2008) Touched by Grace during the psychoanalytic hour: The transformation of a religious resistance. Psychoanalytic Quarterly 77, 283–325. 63. Spero MH (2009) When the light shed by God is dimmer than the light shed upon God: Countertransference illumination of latent religious object representations of a Jewish patient in psychoanalysis. Journal of the American Academy of Psychoanalysis & Dynamic Psychiatry 37, 189–219. 64. Meissner WW (2002) The troubled seminarian. In: Reppen J and Schulman M (eds.) Failures in Psychoanalytic Treatment. International Universities Press, Madison, CT, pp. 153–178. 65. Langs R (2009) The role of religious imagery in Adaptive Psychotherapy. Journal of the American Academy of Psychoanalysis & Dynamic Psychiatry 37, 85–98. 66. Lijtmaer RM (2009) The patient who believes and the analyst who does not. Journal of the American Academy of Psychoanalysis & Dynamic Psychiatry, 37, 99–110. 67. Grotstein JS (1997a) Why Oedipus and not Christ? Part I: a psychoanalytic inquiry into innocence, human sacrifice, spirituality and the sacred. In: Grotstein JS (ed.) Who Is the Dreamer Who Dreams the Dream? A Study of Psychic Presences. Hillsdale, NJ: Analytic Press, Hillsdale, NJ, pp. 219–253. 68. Grotstein JS (1997b) Why Oedipus and not Christ? Part II: the numinous and spiritual dimension as a metapsychological perspective. In: Grotstein JS (ed.) Who Is the Dreamer who Dreams the Dream? A Study of Psychic Presences. Analytic Press, Hillsdale, NJ, pp. 255–279.
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69. Grotstein JS (2007) A Beam of Intense Darkness: Wilfred Bion’s Legacy to Psychoanalysis. Karnac, New York/London. 70. Langs R (2008) Beyond Yahweh and Jesus: Bringing Death’s Wisdom to Faith, Spirituality, and Psychoanalysis. Aronson/Rowman & Littlefield, New York. 71. Racker H (1968) Transference and Countertransference. Hogarth, London. 72. Andresen JJ (1999) Awe and the transforming of awesomeness. Contemporary Psychoanalysis 35, 507–521. 73. Epstein M (1995) Thoughts Without a Thinker: Psychotherapy from a Buddhist Perspective. Basic Books, New York. 74. Harrison IB (1975) On the maternal origins of awe. Psychoanalytic Study of the Child 30, 181–195. 75. Rhode E (1994) Psychotic Metaphysics. Karnac, London. 76. Werman DS (1986) On the nature of the oceanic experience. Journal of the American Psychoanalytic Association 34, 123–139. 77. Ahlskog G (1985) Latent theology: A clinical perspective on the future of an illusion. In: Stern EM (ed.) Psychotherapy and the Religiously Committed Patient. Haworth, New York, pp. 63–70. 78. Corte L (1997) Forms of the sacred. American Journal of Psychoanalysis 57, 337–358. 79. Laor N (1985) Psychoanalytic neutrality toward religious experience. Psychoanalytic Study of the Child 44, 211–230. 80. Rizzuto A-M (1993) Exploring spiritual landscapes. In: Randour ML (ed.) Exploring Spiritual Landscapes: Religious and Spiritual Experiences in Psychotherapy. Columbia University Press, New York, pp. 16–33. 81. Meltzer D and Harris Williams M (1988) The Apprehension of Beauty: The Role of Aesthetic Conflict in Development, Violence and Art. Clunie Press, Perthshire, Scotland. 82. Alhanati S (ed.) (2002) Primitive Mental States. Vol. II. Karnac, London. 83. Baranger M, Baranger W and Mom J (1983) Process and non-process in analytic work. International Journal of Psycho-Analysis 64, 1–15. 84. Mitrani JL (1996) A Framework for the Imaginary: Clinical Explorations in Primitive States of Being. Aronson, Northvale, NJ. 85. Mitrani JL and Mitrani T (eds.) (1997) Encounter with Autistic States: A Memorial Tribute to Frances Tustin. Aronson, Northvale, NJ. 86. Freedman N and Berzofsky M (1995) Shape of the communicated transference in difficult and not-so-difficult patients: Symbolized and desymbolized transference. Psychoanalytic Psychology 12, 363–374. 87. Freedman N, Lavender J (1997) On receiving the patient’s transference: The symbolizing and desymbolizing countertransference. Journal of the American Psychoanalytic Association 45, 79–103. 88. Bouchard MA, Normandin L and Seguin MH (1995) Countertransference as instrument and obstacle: A comprehensive and descriptive framework. Psychoanalytic Quarterly 64, 717–745. 89. Lecours S, Bouchard, M-A and Normandin L (1995) Countertransference in the therapist’s mental activity. Psychoanalytic Psychology 12, 259–279. 90. Ogden TH (1994) Subjects of Analysis. Karnac, London. 91. Rhode E (2003a) Notes on the Aniconic: The Foundations of a Psychology in Ontology. Apex One, London. 92. Rhode E (2003b) Plato’s Silence: A Study in the Imagination. Apex One, London. 93. Freud S (1950[1895]). Project for a scientific study of psychology. In: Strachey J (ed. & trans.) The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vol. 1). London: Hogarth, London, 1961, pp. 177–387. 94. Freud S (1925[1924]) A note upon a mystic writing pad. In: Strachey J (ed. & trans.) The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vol. 19). London: Hogarth, London, 1961, pp. 227–234.
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95. Bion WR (1962) Learning from Experience. Karnac, London. 96. Bion W R (1963) Elements of Psychoanalysis. Karnac, London (1987). 97. Grotstein JS (1990a) The ‘black hole’ as the basic psychotic experience: Some newer psychoanalytic and neuroscience perspectives on psychosis. Journal of the American Academy of Psychoanalysis 18, 29–46. 98. Grotstein JS (1990b) Nothingness, meaninglessness, chaos and ‘black hole’. I: The importance of nothingness, meaninglessness, and chaos in psychoanalysis. Contemporary Psychoanalysis 26, 257–291. 99. Grotstein JS (1990c) Nothingness, meaninglessness, chaos and ‘black hole’. II: The black hole. Contemporary Psychoanalysis 26, 377–407. 100. Eshel O (1998) ‘Black holes,’ deadness and existing analytically. International Journal of Psycho-Analysis 79, 1115–1130. 101. Arons J (2005) ‘In a black hole’: The (negative) space between longing and dread. The Psychoanalytic Study of the Child 60, 101–127. 102. Freud (1918[1917]) The taboo of virginity. In: Strachey J (ed. & trans.) The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vol. 11). Hogarth, London, 1958, pp. 193–208. 103. Gribbin J (1992) In Search of the Edge of Time: Black Holes, White Holes, Wormholes. Penguin, London. 104. Naber GL (1988) Spacetime and Singularities. Cambridge University Press, New York. 105. Hawking S (1988) A Brief History of Time: From the Big Bang to Black Holes. Bantam, New York. 106. Weinberg S (1972) Gravitation and Cosmology: Principles and Applications of the General Theory of Relativity. John Wiley, New York. 107. Herbert N (1988) Faster than Light: Superluminal Loopholes in Physics. Penguine, New York. 108. Nicholson I (1981) Gravity, Black Holes, and the Universe. David & Charles, London. 109. Eigen M (1981) The area of faith in Winnicott, Lacan and Bion. International Journal of PsychoAnalysis 62, 413–433. 110. Botella C and Botella S (2005) The Work of Psychic Figurability: Mental States without Representation. Brunner-Routledge, New York. 111. Kochems T (1993) Countertransference and transference aspects of religious material in psychotherapy. In: Randour ML (ed.) Exploring Religious Landscapes. Columbia University Press, New York, pp. 34–54. 112. Kehoe NC and Gutheil TG (1993) Ministry or therapy: The role of transference and countertransference in a religious therapist. In: Randour ML (ed.) Exploring Religious Landscapes. Columbia University Press, New York, pp. 55–80. 113. Knoblauch SH (1997) The patient who was touched by and knew nothing about God. In: Spezzano C and Gargiulo GJ (eds.) Soul on the Couch: Spirituality, Religion and Morality in Contemporary Psychoanalysis. Analytic Press, Hillsdale, NJ, pp. 43–56. 114. Britton R (1995) Reality and unreality in phantasy and fiction. In: Person ES, Fonagy P, Figuera SA (eds.) On Freud’s ‘Creative Writers and Day-dreaming’. Yale University Press, New Haven, Conn., pp. 82–106. 115. Britton R (1998) Subjectivity, objectivity, and triangular space. In: Belief and Imagination: Explorations in Psychoanalysis. London: Routledge, London, pp. 41–58. 116. Charles M (2009) Working with a patient claiming direct contact with God: Encountering otherness. Journal of the American Academy of Psychoanalysis & Dynamic Psychiatry 37, 21–34. 117. Holliman P (2009) Why bother with God? Journal of the American Academy of Psychoanalysis & Dynamic Psychiatry 37, 59–72. 118. Freud S (1900) The Interpretation of Dreams. In: Strachey J (ed. & trans.) The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vols. 4–5). Hogarth, London, 1960.
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119. Scalzone F and Zontini G (2001) The dream’s navel: Between chaos and thought. International Journal of Psycho-Analysis 82, 263–282. 120. Bion WR (1967) Second Thoughts. Maresfield, London. 121. Grotstein JS (2001) God and the unconscious: Eternal antinomies or long lost twins? In: Akhtar S and Parens H (eds.) Does God Help? Developmental and Clinical Aspects of Religious Belief. Aronson, Northvale, NJ, pp. 321–359. 122. Hawking S (1993) Black Holes and Baby Universes, and Other Essays. Bantam, New York. 123. Lemaire A (1979) The engendering of the unconscious by primal repression. Jacques Lacan, 2nd edn (Macey D trans.). Routledge, New York, pp. 95–131. 124. Spezzano C and Gargiulo GJ (eds.) (1997) Soul on the Couch: Spirituality, Religion, and Morality in Contemporary Psychoanalysis. Analytic Press, Hillsdale, NJ. 125. Stone C (2005) Opening psychoanalytic space to the spiritual. Psychoanalytic Review 92, 417–430. 126. Tustin F (1990) The Protective Shell in Children and Adults. Karnac, London. 127. Winnicott DW (1963) Morals and education. In: The Maturational Process and the Facilitating Environment. International Universities Press, New York, 1971, pp. 93–105. 128. McDargh J (1992) The deep structure of religious representations. In M. Finn J. Gartner (Eds.), Object Relations Theory and Religion: Clinical Applications. New York: Praeger, pp. 1–19. 129. Freud, S. (1920). Beyond the Pleasure Principle. In: J. Strachey (ed. & trans.), The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vol. 18). London: Hogarth, 1955, pp. 7–64. 130. Tustin, F. (1986). Autistic Barriers in Neurotic Patients. London: Karnac.
CHAPTER 5.2
Assumptions About Pastoral Care, Spirituality and Mental Health Peter J. Verhagen Psychiatrist and Theologian, The Netherlands
Adamantios G. Avgoustidis Psychiatrist, Priest and Associate Professor of Pastoral Theology and Psychology, Greece
5.2.1
INTRODUCTION
Our century is the era of multidisciplinarity and of co-operation between sciences and professionals. Modern therapy and healthcare at large are provided by a therapeutic team of different specialists. Then, why do we still face so many major problems in the relationships between some of the basic healthcare professionals? In fact, conflicts between psychiatrists and psychologists, psychologists and social workers, psychiatrists and chaplains, chaplains and nurses or between any other possible combination, including oppositions even between priests and chaplains, are undermining the outcome of a global approach of the suffering individual who needs all of them. Thus, if both theology and human sciences do not understand the substance and the underlying cause of all those difficulties, the development of an effective co-operation between them and of pastoral care itself will be a slow, difficult and not very optimistic process. The main scope of this text is to draw an outline of the differences between mental health professionals (psychologists, psychiatrists, psychotherapists, social workers, etc.) and priests or pastoral care professionals at large. It is also an attempt to make some assumptions especially on Hospital Pastoral Care and the ‘utility’ and role of spiritual care in healthcare. We chose to focus on the example of hospital pastoral care, as it shows more clearly the developments and the difficulties in the relation and co-operation between pastoral and psychological approach of the person who needs help or therapy. This chapter is constructed like a spiral staircase. First landing is history. Second landing consists of the recent definitions and the framing of each discipline. Third landing contains Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright 2010 John Wiley & Sons, Ltd
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the questions about the boundaries of pastoral care and of the priest’s or pastoral counsellor’s identity, referring also to some of their unconscious conflicts. Fourth landing is the topic of so-called spiritual concerns. Finally, arriving at the top of the staircase, we will attempt to formulate some conclusions and proposals on the issues discussed.
5.2.2
LANDING ON HISTORY I: WONDER
Pastor and psychiatrist both feel like a fish in water in the inner lives of human beings. At the same time they are both accustomed to the idea and daily practice of using their own language to describe and assess those inner lives. Unfortunately, they are used to the fact that they do not understand each other’s language. What are the origins of this dichotomy? Our survey will take us back to ancient Greek philosophy. It is the rather existential notion of ‘being astonished’, ‘wonder’ that will hold our attention. We are all used to the idea that there are quite a lot of differences between science and religion, between reason and faith. In literature, we find all kinds of descriptions of these differences and the consequences they have for the relationship between science and religion. It is not unusual to phrase these differences in terms of ‘dialogue’ and relational models. The relationship between religion and science, reason and faith, has long been a major concern, every time since scientists changed our world picture; since Copernicus argued that the earth revolved around the sun, since Darwin formulated his concept of natural selection and his theory of evolution, and so on. In addition we could put forward other questions causing trouble and difficulties in the relationship. For instance the question whether the theistic concept of a person – human or divine – can be squared with a scientifically acceptable conception of mind [1, p. 433]. When religion first met modern science, let us say from the sixteenth and seventeenth century on, the encounter was a kindly one. John Calvin, for instance, in his era valued the study of astronomy and medicine. He insisted that biblical statements with regard to God and the created world were accommodated to the abilities of their audiences. That the sun is rotating around the earth is simply such an accommodation to the worldview of its audience, and no scientific statement at all. On the other hand it would be foolish not to honor God for his splendid handiwork. Most scientists in those days were devout believers. In doing their scientific work they studied the created world, and therefore the work of the Creator. From the eighteenth century on scientists no longer needed the idea of or personal belief in a Creator and in divine guidance. The Deist model appeared. The world was seen as a watch, God as a watchmaker. God endowed the world with a design, and subsequently it could function on its own. ‘God created, Linnaeus organized’, as Carl von Linne, the famous Swedish eighteenth century scientist and botanist liked to say; he thought of himself as the second Adam. In the nineteenth century the relationship between religion and science became more strained and a more hostile attitude towards religion appeared, although not for the first time in history, and not among all scientists. Darwin maintained the design idea.
5.2.2.1
Common ground
However, despite these differences and the relational difficulties they cause, there is a kind of common ground, a common point of departure, or a common attitude to start with. This
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common ground we would like to refer to is the classical notion of astonishment, in Greek ‘thaumazo’. Philosophy, science, theology, reason and faith, they start with astonishment (see also Chapter 3.2, Section 3.1.4). The Greek verb means ‘to be astonished’ in a sense that it can express an attitude of criticism, doubt or censure, even rejection. On the other hand it expresses inquisitiveness and curiosity. It can also mean to look on with astonishment, and in that sense, it can mean to admire, to esteem, to honor. ‘Thauma’ can mean admiration, but also miracle. A miracle as a sudden phenomenon evokes astonishment, possibly a skeptical surprise, or a critical and receptive observation. However, there is also an element of fear and awe included, awe at the unknown, a respect for the mysterious. One can imagine that such an astonishment appears in travel accounts or in stories of extraordinary events. In the religious sphere it is the epiphany of deity which arouses astonishment, or miracles evoke the feeling; or the teachings of priests, or the revelations of prophets, like in prophecies and in dreams. In that sense astonishment is the basis of worship. The verb is also basic in philosophy. The verb denotes philosophical doubt that must be overcome. Astonishment is the beginning of philosophy! Whether science, philosophy or science, astonishment is its beginning. In so far as this astonishment is evoked by the fact and the meaning of his own being, man experiences his own existence as one great, and astonishing question; the anthropological question! We can differentiate several elements in this experience of astonishment. Firstly, there is the object that evokes my astonishment. It is my being there that fills me with wonder, because I cannot fully comprehend it. There is something strange about it, and this strangeness evokes wonder and consternation. In the second place, this strangeness of the object, my being there, corresponds with a certain retreat, a fall back facing this problematic, even mysterious fact in front of me, which happens to be myself, I have become more or less strange facing myself. However, this distance, in the third place, at the same time holds a fascination. It is not mere distancing or strangeness. Being puzzled as I am it intrigues me. It is far too interesting to let it disappear. This tension between distance and fascination and wonder evokes the desire to investigate this astonishing object or question. I want to grasp it. What is its secret? I want to understand. In such a way true to life questions arise.
5.2.2.2
A dichotomy
How fundamental this common ground of being astonished as attitude and point of departure might be, in fact a form of split, a dichotomy announces itself. The indication for this possible dichotomy, as a risk for a wished for or not wished for risk for future development can be traced back to the thinking of Aristotle. He acknowledges the idea of astonishment as a common starting point of philosophical or scientific thinking [2, 3, pp. 156, 274vv.]. However, the strangeness I mentioned, in his view holds an element of annoyance, or scandal, if you would like to use St. Paul’s expression. The motive for this annoyance is the fact that the issue I am being confronted with is something ‘out of its place’. It is ‘atopos’, which means out of place, and also unusual, uncommon. What science is doing, or philosophy in terms of Aristotle, is to restore order, to locate the proper place for the issue ‘out of place’ in that order. Or, in other words, the aim is to develop theory, ‘theoria’, which, again in the words of Aristotle, is contemplation of that order. As a result of this philosophizing, in a proper sense, the astonishment from the beginning
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becomes resolved, astonishment is brought to an end. The saying is attributed to Pythagoras: starting from astonishment (thaumazein), the fundamental movement heads towards disappearance of the astonishment (‘meden thaumazein’1) [5, p. 8].2 It is at this very point that we discover a principal difference between science and religion, reason and faith. Because in religion and spirituality, in faith and spiritual conviction the astonishment, again as common point of departure, never disappears, and stays far from any necessity of becoming resolved. On the contrary, theology starts with astonishment, and certainly that astonishment is evoked by something ‘out of place’. That is even to say, depending on the religious or spiritual tradition one is adherent to, evoked by something that has no place in this world altogether. Being a believer, whether in a religious or in a spiritual way, is being astonished. Believing, one experiences transcendence. Experiences of transcendence are a universal component of human life. Every human being is aware of a ‘before’, ‘after’, and ‘behind’ one’s ongoing experience. That knowledge is even part of common sense, and is not disappearing at all. So everybody knows of some kind of transcendence, be it other-worldly transcendences or intermediate (e.g. political) or even minimal transcendences (e.g. selfrealization, self-expression) as the inexhaustible mystery of oneself and of all things [8]. As the one who is, if we mean a supreme being, or as something that is surprising. The one who speaks of himself, absolutely singular, as eternal being, and/or who is (at the same time) full of becoming, most concrete. As Father in heaven, and at the same time/or as the brother or sister of humanity. So, whether we give an account of the monotheistic or prophetic religions, or the wisdom religions of the Far East, it is the mystery of greater selflessness in the midst of self-relatedness. And the more deeply one understands the mystery, the more mysterious it becomes. That is the very reason from a religious and spiritual perspective why astonishment or wonder is far from being resolved. On the contrary, it grows and deepens. So religious and spiritual knowledge, as philosophical and scientific knowledge, begin with astonishment at a mystery. And the goal is not to cease being astonished, but rather to understand and articulate it every now and again. In addition one could say that from the perspective of pastoral care and spiritual caregiving, a disappearance of this astonishment is a loss, and in that sense, one could say, religious and spiritual well-being ask for a rediscovery of this wonder. Spirituality and religious sensibility are shaped by the experience of wonder. Robert Fuller gives an exciting exploration of wonder in his ‘Wonder. From emotion to Spirituality’ [9, 10]. What kind of emotion is wonder? Is it a primary or secondary emotion? Hindu philosophers postulated wonder as one of the nine basic emotions, seventeenth-century philosopher Descartes postulated six basic emotions, one 1
Plutarch, De Recta Rationi Audiendi, 13, cited in [4, p. 29]. Dawkins seems to think in this direction [6]. It is an essential part of science to admit ignorance, ‘even to exult in ignorance as a challenge to future conquests’ (p. 151). Scientists are usually bored by what they have discovered already, ignorance drives them on. Ignorance and mystery give them something to do. ‘Admissions of ignorance and temporary mystification are vital to good science’ (5, p. 152; italics added PV). Religion, to the opposite, suggests, according to Dawkins, that ignorance is a virtue [6, p. 152]; piffle, I would say. Dawkins refers to what he calls ‘the worship of gaps’. The ‘God of the gaps’ was a figure in the eighteenth and nineteenth centuries, needed in order to deal with the gaps in a naturalistic approach to understand reality. McGrath in his critical discussion of Dawkins’s approach explains that this ‘God of the gaps’ approach failed as an apologetic strategy. In fact it is obsolete. He proposes, following Swinburne’s argument, that it is not the gaps but the comprehensibility of scientific understanding that requires explanation [7, pp. 29–31]. It is in fact this comprehensibility that evokes our wonder again and again. 2
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of them wonder [9, p. 29]. According to Fuller, wonder is probably more an emotional experience than an emotion. He defines: ‘A preliminary definition of wonder, then, is that it is the feeling state that accompanies the total organism’s response to something novel and unexpected (especially those things that strike us as especially powerful, real, true, and/or beautiful)’ [9, p. 33]. What might be the motivational adaptive function of wonder? Darwin postulated a defensive function of emotions like astonishment and amazement. However, as Fuller explains, more recent theorists identified distinct kinds of adaptive behavior(s): sustainment of constructive and creative interaction with the environment, engagement in life more fully and openly by exploration and learning. So wonder belongs to a family of emotions, each of which can motivate higher level conceptions of existence, exploration, creativity, and lively engagement in the environment [11]. Fuller concludes that ‘the temporary deactivation of our utilitarian striving and the creation of a sense of our participation in a more general order of life is crucial to understanding how wonder guides our adaptation to the wider interpersonal, moral, and cultural environments we inhabit’ [9, p. 41].
5.2.3
LANDING ON HISTORY II: TREES OF THE SAME WOOD
In the past, philosophy, psychology and medicine used to be trees of the same wood [12]. They belonged to a continuum of ideas and practice that tried to interpret and understand the universe. Originally, apart from their specific tasks and differences (i.e. research for the Science or salvation for the Church etc.) their common motivation and scope was to conquer the suffering and to comfort the human being. What they also had in common was an accepted experience of finiteness. For hundreds and hundreds of years priests played a major role in medicine, when psychiatry almost didn’t exist and psychology was an abstract part of philosophy [13]. Some centuries ago the big fire of the Enlightenment burned this ‘wood’. Today, the new formation looks totally different. We see several separated forests in the same wood. In the historic frame of modernity, psychology was separated from philosophy and became an empirical, experimental science [14]. This separation also led to the abandonment of the ontological speculation and to focus only on the behavioral and practical-therapeutic questions. Modern psychology and psychiatry are sciences with their own presuppositions, theories and practice, and, of course, – as good children of modernity – had to be more or less against religion [15]. Under the influence of Saint Augustine’s ideas, early Christianity tended to believe that psychiatric diseases came from the devil. The story of the ‘Malleus Maleficarum’ is very characteristic of the opposition between psychiatry and religion. In 1486 two German monks, Heinrich Kramer and Jacob Sprenger, published the famous book The Hammer of Witches (Malleus Maleficarum) [16]. This book was an attempt to codify all the theories and rules of demonology. According to those medieval ideas, mentally ill people were believed to be possessed by the Devil rather than having some form of illness. Having been approved by the Pope, the King of Rome and the School of Theology of Cologne’s University, the book was adopted by the Inquisition [13, pp. 436–437]. It is worth mentioning that some scientists reacted to those ‘dark’ ideas, for example Juan Louis Vives (1492–1540), a forerunner of Freud, writer of the book De Anima et Vita (Of Soul and Life 1538). In this book he describes the importance of psychological associations and their influence in forming emotions, and points out the need for a more humanistic care
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of the psychiatric patient [17, p. 2]. Very characteristic is the case of Johann Weyer (1515–588), writer of the book De Prestigiis Daemonum (The Deception of Demons 1564) in order to refute The Hammer of Witches. Weyer is mentioned as the first real psychiatrist and his book as a real textbook of psychiatry. Unfortunately, his name was included in the list of forbidden writers by the Roman Catholic Church and it was there until the beginning of the last century. Apart from those very visible oppositions, the relationship between psychiatry and religion was mutually disdainful. Indeed, the tension between pastoral care and psychiatry is not so strange if we take into account that ‘Augustine’s view dominated Christian Pastoral Psychology for over a millennium and traces remain today’ [18, pp. 57–58]. We have to keep in mind that psychiatry also needed to fight for a place in the spectrum of medicine. Even today psychiatrists are very sensitive about the fact that ‘their researches are often viewed as ‘soft’ science by research colleagues, or that they are compared with ‘shamans’, witch doctors, or clergy’ [19, p. 21]. For ages it was self-evident that patients with mental disorders not only needed physical treatment but also religious or pastoral care. However, the early nineteenth century modernization called for an increasing specialization and the development of a scientific worldview. That nineteenth century modernization heavily leaned on scientific and technical advances. It led to an engineering model in medicine and psychiatry. Specialization stimulated professionalism and secularization. Medical practice was reduced to the application of scientific insights and findings. The experience of illness, and values involved in medical practice became relegated to the realm of subjectivity and personal meaning construction. And so religion became relegated to the sphere of subjectivity and privacy. Summarizing the information from the landing of history, it is visible that the Enlightenment separated the religious and scientific worldview. Tensions between psychiatry, philosophy and religion took a new turn and we can still detect those traces (even) today.
5.2.4 LANDING ON THE SEPARATION OF PSYCHIATRY AND RELIGION While psychiatry wanted to be medical, i.e. to be free of any religious, metaphysical or superstitious influences, the new-born psychology was very keen on psychologizing everything in society. That happened since the beginning of the twentieth century, when psychology became the language to express human developments and encounters. In that climate new theological – or psychological? – sciences appeared. At first there was ‘Psychology of Religion’, which originally appeared as an attempt to interpret religion and religiosity at large psychologically [20]. ‘Pastoral Psychology’ appeared later as an attempt of some clergy to use and incorporate the psychological knowledge and experience in their pastoral work [21]. We should bear in mind the atmosphere and the circumstances of the beginning of the twentieth century. In Europe Reverend Oscar Pfister had been part of the psychoanalytic movement [22]. But, in spite of Freud’s and Pfister’s mutual respect and admiration, Freud insisted that those who would practise psycho-analysis shouldn’t be medicines or clergy men [23, p. 17]. In the United States of America, the ‘Emmanuel movement’ [24, 25], the ‘Social Gospel Movement’ [26, pp. 57–60], and mainly the initiatives of Anton Boisen [26, pp. 60–63],
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which finally led to the establishment of C.P.E. (Clinical Pastoral Education), were not simply personal achievements [27]. They also reflected the need of some Christian Churches to re-orient pastoral care in the new ‘modern’ reality. That is to say, to incorporate in their ministry the new scientific knowledge, especially in the area of human sciences [28]. The same separation process happened with the development of a new kind of care-givers named ‘social workers’. Ever since the welfare services became a duty of the State, i.e. of the secular institutions, the need for specialists to help people with their problems, such as practical discomforts or difficulties dealing with health problems, poverty, social or family life, became necessary. Obviously, for centuries this field had belonged to the religious orders and the clergy. So a new conflict and a new need for boundaries and clarifications came up. To make a long story short, the forest was burned and the new wood now consists of trees named Medicine, Psychiatry, Psychology, Science of Social Work etc., and certainly, Pastoral Care. Apparently, modern therapeutic teams also include nurses, music-therapists, art-therapists, speech-therapists and many other specialists, all with an approved level of training and skills and defined tasks and areas of work. The main idea behind the use of so many different professionals is to cover every patient’s need, scoping to the best therapeutic outcome of the services offered. But then, if we take into account all the changes in our even more secularized times, what is left for the priests and for pastoral care at large in the context of healthcare services? And furthermore, what could be a Christian Orthodox answer to all these questions?
5.2.5 LANDING ON THE BOUNDARIES OF PASTORAL CARE AND THE CLERGY’S IDENTITY All the aforementioned make clear that a priest, a pastoral counsellor or a chaplain cannot be a religious substitute for the psychiatrist, the psychologist, the social worker or any other specialist. Nevertheless, there are some crucial aspects characterizing modern psychiatry and medicine at large, which point to the need for ‘religious professionals’ in the healthcare context. The psychiatric ‘bio-psycho-social’ model, which in fact should be a model for all branches of medicine, cannot ignore the crucial role that religion or faith plays in social life, in personality formation [29], in adjusting to ordinary life difficulties [30, 31] to existential anxiety, to family and life values [32, p. 132] and so forth. The implementation of this model claims that, when psychiatry organizes its preventive or therapeutic methods, it must be aware of all the psychological, biological and social elements of the human being. Undoubtedly religiosity is one of those elements. Religiosity was always a serious and multilaterally influencing psychosocial factor in everyone’s personality construction and way of living [33]. Indeed, it constitutes a structural element of our civilization, either directly for the religious believers or indirectly for most others. The classical medical model is based on the treatment of a sick organ, for instance of the liver or of the heart, and not of the suffering patient as a person [34]. Thus, there is still a tendency, even in modern medicine, to neglect the psychological or social parameters and of course the spiritual ones which might have a positive or negative impact either in being ill or in recovering and being in a good health [35].
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What seems to be missing most of all is the importance of the existential issues for any patient. Everyone who suffers a physical illness, not even a terminal one, consciously or unconsciously goes through a vast experience of finiteness, of mortality. It is quite obvious that the more medicine and the healthcare system at large are aware of the patient’s every need as a person – and not as a carrier of a sick organ – the more room for priests and pastoral professionals they have to make [36]. In the new wood of healthcare the ‘tree of pastoral care’ has to gain its own space, in spite of all the differences it shows from all the other ‘trees’. That also raises questions about identity, scope and tasks. The most basic description of what a pastoral care giver does is tending to the existential, spiritual and religious needs of the patients. We can leave further descriptions to the specialists and concentrate on the ‘small plants’ and ‘grass’ that could prevent the ‘Pastoral Care tree’ from growing sufficiently and healthily and taking its own significant place in the new ‘wood’. In the past there was automatic respect for the clergy and consequently for all of God’s representatives. Unfortunately, this respect and the therapeutic context of the past led, at least for some in the priesthood, to feel like the only important and authorized therapists [37, pp. 5–9]; sometimes in a way that undermined or had no respect for medicine itself. Modern pastoral care professionals are paying now for the arrogance of some of our spiritual ancestors and they have to fight for their place in the healthcare context. They also have to prove as objectively as possible that their work is needed and beneficial to the patient. In fact priests, especially those who work in hospitals, need to understand that they are not there as medical therapists. They are there to look after the spiritual, the existential or even the simple needs of the human being as a person interrelated with other persons or with God. Undoubtedly, their intervention and specific religious care might also have a positive impact on the physical therapeutic process [38], but this is not a scope itself. The priest and the chaplain at large represent God and the Church as the Body of Christ. So both the main scope of spiritual guiding and the main concern of pastoral care are beyond the individual problem solving or the behavioral guidance. The ultimate purpose of the pastoral intervention is to assist and provide spiritual growth. That doesn’t mean in any sense to neglect the physical or psychological or practical needs and dimensions of the patient’s situation and do whatever possible about them. But in the end the major concern is the reaching of ‘God-like-ness’ of the human being, into which a person grows through his or her free choices regarding both God and other persons. We need to remember that the priest or the chaplain are not dealing with the physical (somatic) disease only but mainly with the ‘spiritual’ problem, which is what the patient will make of his/her physical problem, while his/her faith towards God or his/her loss of faith and bitterness against God may increase. So the pastor has to help the suffering person in seeking to discern a meaning in the unavoidable pain and sorrow. They have to help or guide the patient to discover that in the middle of the problem the meaning of his/her existence might be hidden. Spiritual growth and maturity means also getting rid of all the ‘idols’ we have created and discover what is truly necessary in order for us to ‘cooperate’ with God and recompose our self – image. And, as we all know, only in communion with God a person becomes him or her self. In the Christian Orthodox Tradition communion with God cannot be understood out of the sacramental life of the Church [39]. Pastoral care professionals need to be aware of the load that comes from the past. The ‘grass’ and the ‘small plants’, which represent the conflicts, the prejudices and the debates of
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the past, might not be visible but they bring on unconscious defences and they drive into mutual incomprehension or even to mutual disdain. It practically means that ministers need to be aware of not struggling to find their identity and fulfilment as professionals by implementing ’a ‘vital’, ‘dynamic’ church program that will exert a leadership and not a follow - ship’ [19, p. 21]. We always need to remember that the ‘savior’s syndrome’ or the need to ‘play God’ [40, p. 140] is not a ‘privilege’ of only the priests but of the other health professionals too. Nevertheless, pastoral care professionals need to be very much aware of it, more than any other healthcare worker. Over and above, we still work in the cultural context of modernity and the ideological conflicts between science and religion are spread all around [41]. Thus, the priests and pastoral workers need to be aware not to take any contestation as personal attack or assault. ‘These assaults strike the person himself and he responds with the antagonism appropriate to a personal attack. He is then no longer defending Freud or defending God – he is defending himself ’ [19, p. 21]. Focusing especially on hospital pastoral care, we have to keep in mind that chaplaincy is a new discipline which demands from the pastoral care giver to be aware of his inner motives for choosing this kind of work. For instance a hospital priest or a priest trained in psychology must be aware of what his vocation deals with psychologically, not being in conflict with his own vocation or with the other parish priests. Furthermore, it must be very clear that being a ‘chaplain’ means . . . being nothing but a ‘chaplain’. It doesn’t mean a superior priest or a modern ‘shaman’. Training, global education and openness are very important. We need to understand not only what the pastoral care field of work is but even more to understand what is not within the scope of the pastoral care giver’s work [42]. The theological principles and the ecclesiastical tradition are important to be the determinant elements of any pastoral or even psychological intervention of the pastoral counsellor [43].
5.2.6
LANDING ON THE TOPIC OF ‘SPIRITUAL CONCERNS’
It is a well-known fact that the DSM-IV has a category called Religious or Spiritual Problem. It is not clear whether there is any evidence for the usefulness of this category, but that is not our major concern in this chapter [44, 45]. Problems that are listed as examples of these religious or spiritual problems, for instance, are loss of faith, or neardeath experiences. It is possible to look at experiences like that as distressing events. On the other hand, it would also be thinkable to look for a more appropriate pastoral diagnostic evaluation. Such an approach would help clinicians and pastors in a more careful assessment of particularly religious and spiritual concerns. For within the realm of religion and spirituality, clinicians and pastors should be able to use their psychiatric and pastoral knowledge respectively and their experience of human relationships for analyzing a patient’s or a parishioner’s religiousness or spirituality. They should be able to recognize the dynamics of different types of religiousness and spirituality. They should also be able to identify the deep structure of religiousness and spirituality and the way in which such a personal religiousness and spirituality is formed by upbringing and life experience. And they should be able to use latent opportunities for therapeutic and pastoral interventions respectively that lie within the patient’s or the parishioner’s religious and spiritual frame of reference [9].
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5.2.6.1
INTERDISCIPLINARY ISSUES
Pastoral diagnosis
Generally psychiatrists are not very familiar with pastoral diagnosis. It is clear from clinical observations that psychiatric patients have religious and spiritual concerns. And it sounds reasonable to assume that a proper handling of these needs can be beneficial to the patient. There are several ways by which these concerns are formulated. Fitchett et al. used religious need items they found in earlier research [46]. By using a fivepoint scale subjects (51 adult psychiatric inpatients and 50 general medical/surgical patients) were asked to rate the importance of each of the needs during their hospitalization. In the study they conducted they found that for 72% of their subjects religion was an important source of comfort and resource. Eighty percent of these patients reported experiencing three or more religious or spiritual needs during their hospitalization. Fitchett et al. [46] divided the religious needs3 into three groups: religious beliefs needs, religious practice needs and religious social support needs. Religious beliefs needs included: knowledge of God’s presence, purpose and meaning of life and relief from fear of death. Religious practice needs were fulfilled by prayer and communion. Religious social support need was defined as the need to have a chaplain visit and pray, and care and support from another person. The most frequently expressed needs were care and support from another person, knowledge of God’s presence and prayer. Koenig and Pritchett [50] formulated another grouping of spiritual needs: needs related to the self, needs related to God, and needs related to others. In the first group needs for meaning, purpose and hope, acceptance and preparedness to die, and need for worthiness are meant. In the second group one finds need for knowledge of the existence and presence of God, and need for prayer, alone and with or for others. In the third group the need for the presence and care from other persons, and the need for confession and forgiveness are included. It is not difficult to see the overlap between these two and other divisions. They all go back to the multidimensional characteristics of religion and spirituality, and are comparable with the classical original operationalizing offered by sociologist Glock [51], who proposed five dimensions: the ritualistic (practice,
3
An important question concerns the exact nature and conceptual meaning of ‘religious or spiritual needs’. What exactly are needs within this context? Do religious needs belong to the class of innate, ‘biologically based needs and propensities that need to be represented in and “transformed” into personal aims and desires?’ [47]. It seems as if the needs according to Koenig en Pritchett include attachment, object seeking and object relational needs and tendencies, including a need for communion. Formulating these needs as related to self, to God and to others brings us also to the issue of the centrality of relationship themes in religious life. According to the object relations school conceptualization one can say that the way one relates to God mirrors the way one relates to others. It is from here that Kirkpatrick [48] takes the position that God psychologically functions as an attachment figure, according to the criteria formulated by Kirkpatrick that distinguish attachments from other kinds of interpersonal relationships. Our view on the concept of needs also depends on our concept of human nature. The history of our thinking on this issue dates back to antiquity. We can discern two lines of thinking. According to the anthropomorphic moralistic worldview good and evil belong to a given universal, cosmic order. These are forces that work upon nature and in humans. Hesiod tells in his theogony how the world became more or less ordered out of a frightening chaos, although still fragile and limited. Nature is depicted in moral pictures. And that is the stage on which humans understand their lives and their needs. The other line of thinking is the view of Democritus. His view seems remarkably ‘scientific’. There is nothing than just atoms and space without meaning, all the rest is opinion and anthropomorphic projection. Good and evil are in no sense cosmic realities, but moral imaginations. These two basic approaches are still two fundamental characteristics of human reasoning, sometimes conflicting, now and then taking turns [49].
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behavioral), the ideological (belief, convictional), the intellectual (knowledge, cognitive), the experiential (feeling, affective) and the consequential (effects, motivational). Another and so-called theological approach has been designed since the early 1960s and 1970s of the last century until recently. One could call it the approach of a ‘pastoral diagnosis’ in a narrower sense [52, 53]. The idea was based on the assumption that different disciplines have their own limited perspective on human development and functioning, including pastoral care and spiritual care giving. For that reason pastoral diagnosis is equivalent to other diagnostic approaches and has its own legitimacy. Pruyser formulated seven core themes as points for consideration: awareness of the Holy, awareness of providence, faith, grace and gratitude, conversion, community and sense of vocation. Pruyser also formulated several criteria to discern healthy religious functioning from ‘neurotic’ functioning. Neurotic religious functioning in his view causes decline of psychic energy, hindrance of healthy development, faulty compromises between drives and strives, and awkward manners to get one’s own back by imposing harsh demands or by being dependent, immature, or chagrined. The latest proposal of this kind we know of has been formulated by Wesley Brun in 2005 [54]. This more holistic approach is based on the idea that body, mind and spirit are in interaction with each other. So our assessment of a patient’s religious or spiritual concerns will be influenced by our assessment of the patient’s functioning in other areas (physical, psychosocial, psychodynamic, systemic). And this is not different for a psychiatrist than for a pastor. Diagnostic schema for religious and spiritual concerns proposed by Brun [54]: A sense of the Holy/Numinous, a capacity for reverence. An awareness of providence/grace, a capacity for dependence. An appreciation of the earth, and a capacity for stewardship. A sense of self, and a capacity for solitude. A desire for community, belonging and respect for authority. A sense of values, morality, ethics, and a capacity for guilt/repentance/forgiveness. A sense of vocation, and the capacity for meaning. A need for leisure/self-care, and the capacity to play. A desire for companionship, and a capacity for intimacy. An appreciation of Time/finitude, and a capacity to face Death. Religious/Spiritual Concerns Not Otherwise Specified. Brun tried to formulate positive and pathological expressions and even ‘diagnostic criteria’ in a DSM-IV like manner of each of these concerns. For instance, a sense of the Holy/Numinous and a capacity for reverence mean that persons with a healthy spirituality sense that they are finite and limited. They have a sense of perspective and mystery about the universe, and a sense of awe about life itself. In its pathological expression, according to Brun, people are not awed by mystery, limitation and finitude, they are confused and threatened by it. Another example is the sense of self and the capacity for solitude. In healthy religiousness and spirituality one has a positive sense of self, sees oneself as a valuable person. And they have the capacity to be alone, they use their solitude to rest or to recreate, to pray and to meditate. Persons with a damaged sense of self and/or capacity for solitude do not feel valued, and when left alone they feel abandoned or excluded. They feel uncomfortable with their own company, they feel a basic sense of shame and embarrassment. Brun went very far in his effort to approach a DSM-IV like system and even added a ‘Not
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Otherwise Specified’ type of religious/spiritual concern. His model cannot be used in a general way. It certainly lacks universality and validity. However, that is not the issue here. Religious and spiritual needs can be differentiated instead of being thrown all in a heap. Brun offers us a thoughtful model. Brun’s list is not necessarily exhaustive. And certainly, one could more or less easily rephrase the proposed categories. On the other hand one recognizes central religious and spiritual themes. One can also easily imagine the difference with the mere psychic or cognitive-emotional aspects of these categories. To phrase it in the words of James Fowler, these categories differ from DSM categories because another kind of ‘logic’ is involved [55]. Its aims are not objectivity in a demonstrable, measurable and replicable way. In these categories the self is continually being confirmed or modified by the religious and spiritual compositions. Conviction is involved. The self is involved and the self tries to be aware of its awareness of its ultimate concerns. The question is whether these categories, defined as religious and spiritual concerns, allow us to understand and articulate the astonishment which belongs to the religious and spiritual domains. And would that help us to see how this astonishment might grow beneficially, instead of being resolved, as faith or spiritual belief understand more of it?
5.2.6.2
Sense of self
Let us have a closer look at the proposed concern of a sense of self and the capacity for solitude. It is said that it is healthy to have a positive sense of self, to see oneself as a person of worth. A person feels loved and cared about. They are valued by their families, and others as well. Life has meaning and importance to them. They have energy to fulfill the potential they know they have. These characteristics all belong to a healthy sense of self, and capacity of solitude. However, what happens when in a certain way one becomes a stranger to oneself, let us say, caused by emotional stress? What happens when one becomes one astonishing question? Under such circumstances, under the burden of emotional stress, the astonishment evoked by these circumstances is not a pleasure in the first place. It might be an experience of being annoyed, of being skeptical about something one did not ask for, and still it is there. The astonishment becomes bewilderment or dizzying anxiety that needs to be rejected and avoided. One loses a healthy sense of uniqueness, and often feels inadequate or even inferior. One becomes confused about a sense of direction or purpose in life. Or one compares oneself negatively to others. Although it is difficult to name it, one feels a basic sense of shame or embarrassment. The self becomes a problem to oneself; the self becomes a stranger, or an object to oneself. And that is certainly not a healthy case, not even from a religious or spiritual point of view. For human beings are ordered toward recognition, and therefore mindful of that recognition. Human beings exist in a web of relations through which they come to themselves. It is essential for human beings to exist in relation to others. The human being is essentially a person in the presence of another human being, or in relation to another human being. So what happens to the self is something that has to do with a loss of this essential connectedness, which is characteristic of human beings. The modern answer to all this is self-realization. In our self-relation we can only fundamentally understand ourselves, if we have made ourselves [5, p. 228]. It is in working
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that human beings come to themselves. However, not so from a religious or spiritual point of view. Two illustrations of this religious or spiritual point of view are given here on what it means to be a person. First example: When the Buddha seemed to have come to a dead end, after all his efforts to reach the liberation of enlightenment, he recalled a childhood experience. It was an experience of ecstasy, of ‘standing outside the self’, which had come unexpectedly and without any striving on his part. Had the teachers been wrong, he wondered in a moment of endless efforts and despair. He reflected on that childhood experience, that he had attained without any exercise. And now it dawned on him again. Instead of ‘torturing our reluctant selves’ into the final release, we might be able to achieve it effortlessly and spontaneously [56, p. 68]. Second example: One of the fundamental Reformation insights is that the human being is not constituted by his acts, but through the very exclusion of human self-realization. ‘The work which I do, does not make me into the person I am, rather the person who I am makes the work; so the claim made by Luther is contrary to the claim made by Aristotle [5, pp. 216–240]. In other words: how foolish is it to be very concerned, from early morning until late at night, about the state of one’s property, position, and so on, and not at all about the health of one’s soul? In addition, if the person becomes the measure of all things, what kind of authority can decide what kind of person I am without ambivalence? Within the context of the world we remain exposed to the ambivalence of being human or inhuman. We cannot escape that ambivalence. This ambivalence indeed might turn out to be another source of estrangement in times of emotional distress and loss. That ambivalence is again expression of alienation from our selves. According to reformation insights human beings are constituted by faith, that is to say, by their total reliance on the word of God. According to reformation insights we are withdrawn from our selves for our own good [5, p. 231]. Man is not self-sufficient, not in becoming the person he is, not in understanding himself. And in fact, do not these transcendences we mentioned before pose this insufficiency of selfactualization and self-understanding? Because these transcendences, be it other-worldly or inner worldly transcendences, are so ‘dense and inexhaustible that we can never pretend to have fully appropriated them’. In that sense ‘transcendences’ give food for thought! So here we are again: mind the gap! We formulated some thoughts about the experience of astonishment as common point of departure for ‘thinking’ in philosophy and theology, in science and religion, for reason and faith. On the one hand we discovered that the experience of astonishment within the realm of religion and spirituality never ceases, on the contrary. On the other hand the scientific approach aims at bringing the astonishment to a scientifically appropriate end. Speaking about the self we tried to explain that both ways of thinking and experiencing seem to approach each other, or more carefully, seem to have common starting points. If we take these positions and the disciplines underlying them not as opposites, but as poles of a relational unity of these disciplines, we might be able to develop another view on a multilevel interdisciplinary dialogue as a relational paradigm. Our point of departure, the start of all thinking, places the disciplines as embedded in a broader relationality. This basic relationality is a hermeneutical category. And the necessity of such a hermeneutical perspective becomes evident. Self-understanding on different levels of abstraction, whether as a person, or as a scientific discipline, is the outcome of an encounter, of an interaction. Self-understanding depends on mediation. To understand oneself, to become a self is not possible with one’s eyes shut. Again this can be said with regard to selfunderstanding as a person, but also with regard to the self-understanding as a discipline, be it
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psychiatry, psychology of religion and theology. One has to open one’s eyes in order to have a distant view as far-sighted as the view of the horizon, instead of having a short-sighted view captured by interdisciplinary boundaries. If we would be able to take such a view on our disciplines, that we are ‘made’ for relational knowing, then the disciplines will shape each other [57]. Such a paradigm recognizes the value of data at multiple levels of analysis, and still making non-reductive assumptions concerning the value of spiritual and religious phenomena [58, p. 395].
5.2.7
CONCLUSIONS
Our laborious ascension through history and modern healthcare specialties to sketching out the boundaries of pastoral care and professional identity lead us to the top landing, that is to say to some conclusions and suggestions. Stephen Muse summarizes the recent reality as follows: ‘Over the course of the last century, until quite recently, religion slowly faded from the medical scene. Personals first became ‘patients’ and then, as both the healers and those seeking relief were managed and defined by forces that regulated our lives not according to wholeness, ecological harmony, depth and meaning in the light of Christ, but rather according to numerical efficiency and cost, ‘patient’ has given way to ‘customer’ or merely consumer. This is certainly not ‘spiritual’ progress, whatever face may be put upon it’ [59, p. 4]. In this particular context modern pastoral care has to find its own boundaries, identity and methods. It also has to fulfill a very demanding, complicated and delicate task. That is to find a modern and inclusive way to put some major aspects of religiosity and spirituality together with the scientific and the technical knowledge. Some of these crucial aspects are: * * * *
*
the spiritual and the ecclesiastical tradition theology the patient’s community principles and values the pastoral care giver’s skills of communication and of understanding the story of the individual some basic knowledge of both medicine and psychology, including the principles of the healthcare functions, like the way a particular ward in a hospital functions and so on.
All these need to be indivisibly incorporated into the formation of the pastoral care professional. In other words, the priest himself, as a mature person with his own spirituality and ability to implement all the aforementioned, has to become an existentially healing ’instrument’. He has to become a spiritual healer who must be integrated into the healthcare team as a professional of pastoral care, able to communicate with other team workers about his professional scope and approach. To communicate does not mean to ’preach’ but it means, instead of talking, making clear what he does and how he does it through his work with the patients. It also means that he must respect all the approaches and professionality of the others without letting them fill in his. The Christian pastoral ‘therapist’ always needs to remember that ‘apart of the fullness of the divine life, there will always be something incomplete in us, a kind of longing that
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cannot be satisfied in this world, but only on the next, and never alone, but only in relationship with God and others. Therefore we desperately need healers who treat us not only for ills in this world, but offer guidance and care for achieving health and citizenship in the other; healers who rely not on technology derived from humanly devised research protocols alone, but who themselves are struggling to enter into the fullness of relationship with God and the beloved community and so bring to the healing partnership humility, a loving awareness of the presence of God and the sanctity and mystery of every life’ [59, p. 10]. In any case, knowing that modern pastoral care is provided in the era of multidisciplinarity and co-operation between sciences and professionals, we should always be aware of the tensions between professions and protect pastoral work and above all the patient from any damaging conflicts, including professionalism [60]. Of course, a good start to understand what is happening, to prevent conflicts and be conscious of what we do and how we can be effective is to first look inside ourselves.
REFERENCES 1. Audi R (1997) Theism and the scientific understanding of the mind. In: Quinn PHL & Taliaferro Ch (eds.) A Companion to Philosophy of Religion. Blackwell Publishers, Oxford, pp. 433–441. 2. Aristotle (2003) Metaphysics Books I-IX. Loeb Classical Library (Tredennick H. trans) Harvard University Press, Cambridge, 982b 12f (first published 1933). 3. J€ungel E (2003) Ganz Werden. Theologische Er€orterungen V. Mohr Siebeck, T€ ubingen. 4. Bertram G (1965) Qayma. In: Kittel G (ed.), Theological Dictionary of the New Testament. Volume III (Bromiley GW trans). WmB Eerdmans Publishing Company, Grand Rapids. 5. J€ungel E (1995) Theological Essays II. T&T Clark, Edinburgh. 6. Dawkins R (2006) The God Delusion. Transworld Publishers (Black Swan edition published 2007), London. 7. McGrath A, McGrath JC (2007) The Dawkins Delusion? Atheist Fundamentalism and the Denial of the Divine. InterVarsity Press, Downers Grove. 8. Luckmann T (1990) Shrinking Transcendence, Expanding Religion? Sociological Analysis 50, 127–138. 9. Fuller R (2006a) Wonder. From emotion to spirituality. The University of North Carolina Press, Chapel Hill. 10. Fuller R (2006b) Wonder and the Religious Sensibility: a Study in Religion and Emotion. The Journal of Religion 86, 364–384. 11. Schreurs A (2006) Spiritual Relationships as an Analytical Instrument in Psychotherapy with Religious Patients. Philosophy, Psychiatry, & Psychology 13, 185–196. 12. Heitink G (1999) Practical Theology, History, Theory, Action Domains. William B. Eerdmans Publishing Co, Cambridge. 13. Hergenhahn BR (2001) An Introduction to the History of Psychology, 4th edn. Wadsworth/ Thomson Learning, Belmont. 14. Robinson DN (1986) An Intellectual History of Psychology. The University of Wisconsin Press, Madison. 15. Richards Gr (2002) Putting Psychology in its Place, a Critical Historical Overview, 2nd edn. Routledge, East Sussex. 16. Kramer H, Sprenger J (1971) The Malleus Maleficarum (trans. M. Summers). Dover Publications, New York (Original work published 1487). 17. Kaplan HI, Sadock BJ (1988) Synopsis of Psychiatry, Behavioral Sciences, Clinical Psychiatry, 5th edn. Williams & Wilkins, Baltimore, p. 2.
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18. Crapps RW (1990) Augustine of Hippo. In: Hunter RJ (ed.) Dictionary of Pastoral Care and Counseling. Abington Press, Nashville, pp. 57–58. 19. Draper E (1970) Psychiatry and Pastoral Care. Fortress Press, Philadelphia, p. 21. 20. Loewenthal KM (2000) The Psychology of Religion: A Short Introduction. Oneworld Publications, Oxford. 21. Pfister O (1944) Das Christentum und Angst. Eine religionspsychologische, historische und religionshygienische Untersuchung. Artemis-Verlag, Z€ urich. 22. Jones E (1961) The Life and Work of Sigmund Freud. Basic Books Inc., New York. 23. Freud S (1963) Psychoanalysis and Faith, The Letters of Sigmund Freud and Oscar Pfister. H Meng, EL Freud (eds.). Basic Books, New York, p. 17. 24. Cunningham RJ (1962) The Emmanuel Movement: AVariety of American Religious Experience. American Quarterly 14, 48–63. 25. Worchester E, McComb S (1931) Body, Mind and Spirit. Marshall Jones Co., Boston. 26. Gerkin CV (1997) An Introduction to Pastoral Care. Abington Press, Nashville, pp. 57–63. 27. Hall CE (1992) Head and Heart, The Story of the Clinical Pastoral Education Movement. Journal of Pastoral Care Publications Inc., Georgia. 28. Jacobs M (1982) Still Small Voice. An Introduction to Pastoral Counseling, 3rd edn. SPCK, London. 29. Oates WE (1987) Behind the Masks, Personality disorders in Religious Behavior. The Westminster Press, Louisville. 30. Dohrenwend BS, Dohrenwend BP (1984) Stressful Life Events and their Context. Rutgers University Press, New Brunswick. 31. Rabkin J, Struening E (1976) Life Events, Stress and Illness, Science 194, pp. 1013–1020. 32. Olson DH, DeFrain J (1994) Marriage and the Family, Diversity and Strengths, 2nd edn. Mayfield Publishing Company, Mountain View, p. 132. 33. Loewenthal KM (1995) Mental Health and Religion. Charman & Hall, London. 34. Cassel EJ (1979) Reactions to Physical Illness and Hospitalization. In: G. Usdin & Lewis JM (eds.) Psychiatry in General Medical Practice. McGraw-Hill, New York, pp. 103–131. 35. Koenig HG, Larson DB (2001) Religion and Mental Health: evidence for an association. International Review of Psychiatry 13, 67–78. 36. Moyer FS (1989) Pastoral Care in the Hospital, The Journal of Pastoral Care XLIII, 171–183. 37. Guggenb€uhl-Graig A (1971) Power in the Helping Professions. Spring Publications, Z€ urich, pp. 5–9. 38. Vanderpool H (1980) Religion and Medicine: A Theoretical Overview. Journal of Religion and Health 19, pp. 7–17. 39. Allen JJ. (2004) The Ministry of The Church, Image of Pastoral Care. St Vladimir’s Seminary Press, New York. 40. Jonson D (1961) Self – Understanding in Pastoral Counseling. In: Oates WE (ed.) The Ministers Own Mental Health. Channel Press Inc., New York, p. 140. 41. Carbine ME (1980) Religion, Psychology, and Mental Health: The problem of Partnership. Journal of Religion and Health 19, pp. 40–47. 42. Scherzer CJ (1971) Ministering to the Physically Sick. Fortress Press, Philadelphia. 43. Larchet JC (2002) The Theology of Illness. St. Vladimir’s Seminary Press, New York. 44. Scott S, Garver S, Richards J, Hathaway WL (2003) Religious issues in diagnosis: the V-code and beyond. Mental Health, Religion & Culture 6, 161–173. 45. Hathaway WL (2003) Clinically significant religious impairment. Mental Health, Religion & Culture 6, 113–129. 46. Fitchett GD, Burton LA, Sivan AB (1997) The religious needs and resources of psychiatric inpatients. The Journal of Nervous and Mental Disease 185, 320–326. 47. Eagle MN (1984) Recent Developments in Psychoanalysis. A critical evaluation. McGraw-Hill Book Company, New York.
5.2
ASSUMPTIONS ABOUT PASTORAL CARE
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48. Kirkpatrick LA (2005) Attachment, Evolution, and the Psychology of Religion. The Guilford Press, New York. 49. Safranski R (1999) Das B€ose und die Freiheit. Studium Generale Maastricht, Maastricht. 50. Koenig HG, Prichett J (1998) Religion and psychotherapy. In: Koenig HG (ed.) Handbook of Religion and Mental Health, Academic Press, San Diego, pp. 323–336. 51. Glock CY (1962) On the study of religious commitment. Religious Education, Research Supplement 57, 98–110. 52. Pruyser PW (1976) The minister as diagnostician. Personal problems in pastoral practice. The Westminster Press, Philadelphia. 53. Thomas K (1978) Religions-Psychopathologie. Archiv f€ ur Religionspsychologie 13, 65–76. 54. Brun WL (2005) A Proposed Diagnostic Schema for Religious/Spiritual Concerns. The Journal of Pastoral Care & Counseling 59, 425–440. 55. Fowler JW (1981) Stages of Faith. The psychology of human development and the quest for meaning. Harper & Row Publishers, San Francisco. 56. Armstrong K (2001) Buddha. Pinguin Books, New York. 57. Schults F. LeRon (2003) Reforming Theological Anthropology. William B. Eerdmans Publishing Company, Grand Rapids. 58. Emmons RA & Paloutzian RF (2003) The Psychology of Religion. Annual Review of Psychology 54, 377–402. 59. Muse S (2004) Raising Lazarus, Integral Healing in Orthodox Christianity. Holy Cross Orthodox Press, Brookline, MA, p. 4, 10. 60. Fosket J (2005) The Need for an Order of Pastoral Care Bound to End in Tears. The Journal of Pastoral Care and Counseling 59, pp. 279–281.
CHAPTER 5.3
Coming to Terms with Loss in Schizophrenia – The Search for Meaning Hanneke (J.K.) Muthert Spiritual Caregiver and Assistant Professor of Spiritual Care, The Netherlands
5.3.1
INTRODUCTION
The subject of loss and longing in the context of schizophrenia is probably best introduced by the practical expert Bjorklund with her quotation from Menninger: ‘It’s hard for a free fish to understand what is happening to a hooked one’ [1, 2]. This inability remains a fact, despite movies like A Beautiful Mind, through which viewers are directly confronted with the alienating psychotic experience. It is also in spite of the psychosis simulator tour that crossed the Netherlands, which offered a psychotic-like experience to caregivers, family members and friends of service users diagnosed with schizophrenia or related psychosis, obviously aiming at a better understanding of their patients and relatives. It is simply impossible to fully understand what someone goes through when diagnosed with schizophrenia. Nevertheless, at least the suffering – psychological and existential – is visible and can be partially experienced. Similarly, these elements can be seen and heard in the stories, behavior and experiences of people in the clinical psychiatric context, far from the movie scripts. Schizophrenia is widely recognized as a seriously disabling illness [3, 4]. Psychological and existential suffering is experienced by the patients themselves, their relatives and friends, and by many employed in psychiatry [5–8]. However, there is a striking lack of instruments and interventions that focus specifically on the existential suffering processes of people affected by schizophrenia in the clinical context. As a result, nurses, medical practitioners and affiliated health professionals feel powerless when faced with the existential suffering of their patients.
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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At the Psychosis Centre of the Foundation for Mental Health Care Drenthe in the Netherlands, these observations led to a close collaboration with the Trust’s team of spiritual caregivers. By working together and sharing mutual observations, the importance of the search for meaning as experienced by service users throughout the different stages of their illness became obvious [9–14]. It was also clear that patients often felt more at ease discussing their losses and suffering in the spiritual caregivers’ rooms than elsewhere. Following these observations we firstly tried to answer the following three questions. First, how do people diagnosed with schizophrenia handle losses and which coping processes do they adopt? Second, which caregivers offer the best support and how? Finally, what is the specific role of the spiritual caregiver in these processes? These questions cannot all be discussed thoroughly in this chapter. Therefore, this contribution will concentrate on some central findings of extensive research concerning clinical workers themselves [15]. The main questions addressed will be why caregivers at the Psychosis Centre of the Foundation for Mental Health Care Drenthe in Assen react as they do when encountering existential questions and answers, and how change can be brought about. These remarks will be illustrated by a case narrative, that of a twenty-two-year-old man called Peter. The case is about how Peter, who was diagnosed with schizophrenia, sees his illness. While reading, attention should be paid to the reactions of the other persons present in this case, as they are significant. Since an important part of our research concentrates on the question of how to support caregivers as they in turn support patients in the mourning processes, these are the precise reactions that are discussed later. Following Peter’s story, it is necessary to briefly elaborate on the model we used to integrate the existential-suffering-related processes of patients into the current framework of healthcare in schizophrenia. We refer to these processes as ‘coming to terms with loss’. Thirdly, a number of different categories of loss are illustrated by some more information about Peter. The fourth point is the main topic of this contribution and will stress four reasons in clinical practice why caregivers are currently not fully equipped to attend to patient’s existential and thus religious explanations. Although the research on which this article is based took place in Assen, we are confident that the situation in other hospitals in the Netherlands will not differ greatly. We also expect some similarities in foreign hospitals, at least in countries where rehabilitation and recovery are key concepts in treatment. Finally, the role of the spiritual caregiver is briefly addressed and this contribution will conclude by returning to Peter’s case.
5.3.2
PETER’S CASE
In the open discussion group, called Meet and greet – the art of living, service users of the Foundation for Mental Health Care Drenthe and two spiritual caregivers exchange ideas on a weekly basis on all kinds of existential topics relevant to the patient’s personal circumstances. All the participants are in some way related to the Psychosis Center due to their schizophrenia diagnoses or related psychoses. One day, the following discussion took place with ten participants present.
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After some general chat about this and that, the discussion gradually focused on how all these weird ‘psychotic’ things exactly started. Two participants are unable to explain anything. Their past appeared shrouded in mystery. Another is convinced that problems at work gave rise to his worsening condition. A woman mentions the breakdown of a relationship. If she had only handled things differently, she argues, her life would have been completely different. Another talks of being different. This feeling of alienation had simply always been there. It felt as though there was a yawning gulf between him and other people. Among those present, four or five nod approvingly. ‘I should have stayed away from those drugs,’ a young man says in a loud voice. He’s called Peter. And it is hard for him to keep his mouth shut while waiting for his turn. Again he raises his voice. ‘If I’d stayed away from those drugs and if I’d chosen the good path instead, none of all this stuff would have happened to me. It’s Gods punishment, you know. And it really is my own fault. I had the choice and I made the wrong decision. And I knew I did. God gave me new chances time after time. I myself messed things up.’ Some participants appear not to be affected at all by his words. Others look a little bewildered. One of them, a young woman, gets up to speak and says she sees things differently. It is simply bad luck. She describes herself as a believer; but God has nothing to do with her illness, that’s for sure. Some get schizophrenia and others don’t. More and more participants enter the discussion. Does God affect our lives directly? And if so, why don’t you hear or see anything from him when life is so hard. Why do some get all the troubles while others get hardly any. Crucial questions about theodicy and related topics are raised. Peter repeats his words once more. ‘If only I had listened carefully, everything would be all right. I made the wrong decision. God is right to punish me. I’ve had my chances.’ Then, time is up. As a conclusion, one of the spiritual caregivers carefully tries to modify Peter’s image of God a little by explaining something of her own image of God. As the others leave, Peter approaches the spiritual caregiver, and standing close in front of her, firmly grasps the collar of her jacket. He then tells her very insistently. ‘You can see what I mean, can’t you. That’s the way it has to be. God is punishing me with this illness. You must understand me. It has to be like that. If not, then I’ve got nothing left. I can’t bear that. You can see what I mean, can’t you!?’ [47]
In this case, named after Peter because of his leading role in the discussion, the essential aspects are loss and coming to terms with that loss in schizophrenia. What we see are themes that are recurrent and important in many other case studies, as well as the process of the search for meaning. We also see caregivers and other people not listening carefully to the specific answers offered by patients, partly because they are not in agreement with the caregiver’s own philosophies of life. This case illustrates the feeling of powerlessness experienced when confronted by the existential suffering of people affected by schizophrenia. It also tells us what it means to a person when no one really listens – it’s unbearable. Perhaps it is even more unbearable when the spiritual caregiver does not listen carefully to an existential answer. These topics will be further reflected on in the rest of this article in the light of Peter’s story. However, the current dominant framework of mental healthcare in schizophrenia in the Netherlands should be more closely examined.
5.3.3 THE INTEGRATION OF ‘COMING TO TERMS WITH LOSS’ IN THE CURRENT FRAMEWORK OF MENTAL HEALTHCARE As stated above, workers in psychiatry often experience feelings of powerlessness. One aspect which can partly explain these feelings is the depth and intensity of the
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psychological and existential suffering which people diagnosed with schizophrenia or related psychosis experience. The ongoing suffering of their patients affects them. It was also noted above that these patients illustrate the importance of their personal search for meaning. This view can also be found in the literature [9–15]. However, reality demonstrates that the clinical context lacks instruments and interventions that focus specifically on these processes [4]. This gap intensifies the caregivers’ feelings of being inadequately equipped for the task and therefore increases the feelings of powerlessness. Hence, the search for meaning should be clearly rooted in clinical practice, theoretically and methodologically. Considering the current framework of mental healthcare in the Netherlands and abroad, recovery and rehabilitation are key concepts in treatment. Schizophrenia is no longer viewed as an illness that can be cured. It is a chronic disease with lifelong consequences and therefore practitioners are required to focus on ‘how to make the best of it’. It is perceived that there is more to a person than just the illness. In this context, rehabilitation fits perfectly. The underlying ideas, methods and guidelines focus on care possibilities for patients with chronic psychiatric limitations, ultimately aiming at participation in society – and a paid job. Caregivers emphasize the capabilities or skills that remain available and which can be developed despite the handicaps and vulnerabilities patients have to contend with. The guiding principle is to enquire into what remains of the strengths of a person and/or personality and determine what remains in the domains of living, working, learning and leisure activities [3, 7, 16, 17]. In a nutshell, however, the mourning processes in schizophrenia focus on exactly the opposite. They concentrate on what is no longer there, what is not possible. Clinical staff, particularly those involved in rehabilitation, should realize that this focus on the absent is ever-present from the service user’s point of view. Even when asked about what remains possible, what springs to a person’s mind is what has been lost [15, 18]. The mentioned focuses for rehabilitation and these ‘coming to terms with loss’ processes seem diametrically opposed. However, it is this author’s view that these poles can be brought together in the concept of recovery. To put it another way, recovery will only succeed if these poles are interconnected. More specifically, this connection can be found in the meaning-making processes. Only once an individual becomes capable of connecting meaningfully between what is lost and what remains, does recovery have a chance. Therefore, in the model suggested, a central focus of recovery is meaning-making and, related to that, the individual’s philosophy of life [9, 15]. To sum up, it is felt that if we wish caregivers to feel less powerless when dealing with the existential suffering of their patients, and even more importantly, if we seek to do justice to the observed needs of patients in their search for meaning, we should pay greater attention to mourning processes in clinical treatment. This pragmatically means connecting this notion of ‘coming to terms with loss’ theoretically to the dominant concepts in treatment, both in rehabilitation and recovery. In our model, as presented in Figure 5.3.1, rehabilitation, recovery and ‘coming to terms with loss’ are viewed as mutually influential. According to this view, neither pole should be isolated or excluded.
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Rehabilitation - focus on what remains
Recovery - focus on meaning-making processes
Coming to terms with loss - focus on the absent
Figure 5.3.1 Suffering from and under schizophrenia – coming to terms with loss in relation to recovery and rehabilitation
5.3.4
BACK TO PETER – DIFFERENT LOSSES
When the ‘coming to terms with loss’ pole is considered more closely, the question of which losses are being addressed should first be answered. The loss of some or many of a person’s capabilities, feelings, skills and social activities is by nature different from coping with the loss of a loved one. Gradually, increasingly close attention has been paid in the literature to these specific kinds of losses, especially when focusing on the mourning processes that accompany physical diseases like cancer. Less attention is being paid, however, in cases of schizophrenia or other chronic mental health problems, though matters have recently improved somewhat [5–7, 15, 19–22]. Below, these specific processes are elaborated in the context of schizophrenia. First, the losses are described as they were presented by the service user group to the spiritual caregivers in Assen. For a couple of months two spiritual caregivers recorded the specific losses patients related. Hands-on expert literature was also studied. It should be stressed that each individual experienced different losses. These losses are multifarious but for the sake of practicality we classified them into the following six groups, a classification system which does not pretend to be exhaustive – 1) loss of health; 2) loss of activities or skills; 3) loss of dreams, longings and expectations; 4) loss of important relationships; 5) loss as a result of stigmatization; and 6) the losses of other service users [15]. Many of the losses related in a patient’s narrative can obviously belong to more than one of these groups, by virtue of their various characteristics. In choosing not explicitly medical terms to describe the different losses, we expected they would fit better with the stories told, which of course are not exclusively medical stories. The abovementioned losses will now be elucidated and illustrated by some background information on Peter’s case. The first loss mentioned, the loss of health, is very important. Health is one of the most keenly appreciated aspects of modern Western life. Being diagnosed with a chronic disease like schizophrenia has a considerable impact on a person’s self-image [23–25]. Peter accepts the idea of having a chronic illness. It is God’s punishment, and God is doing right in his opinion. However, he suffers greatly due to the feeling that he no longer can experience a self. Peter is no longer capable of managing his own mind. Thoughts may come and go. He cannot control them. Even worse, he is convinced that those thoughts which derive from his brain may seriously harm other people. He genuinely suffers from being incapable of stopping such harmful thoughts, feeling himself an instrument of the devil.
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Secondly, we listed the losses of activities or skills. Due to his immense fear, Peter is no longer able to do many of the things he used to, especially not in the company of friends. He is too frightened of hurting them. He is also too scared to leave the clinical boundaries. His world becomes a little world.
Thirdly, there is the loss of dreams, longings and expectations. Peter longs for a wife and a child but realizes that it will never happen, not to him in his present condition. He cannot make a living. He cannot find a woman who wants him. He cannot risk a child suffering the same disease. . . He also desperately longs to be a part of society, to be useful; but the world moves too fast, he says, and people are not willing to accept his otherness, he thinks.
Fourthly, the loss of relationships in general should be noted. Many existing relationships have changed or disintegrated, or have been broken off. This is also happening to Peter. He no longer meets many of the relatives and friends he used to see regularly before he went to hospital. Even the people who remain close are often very worried about him. ‘As if there’s a gulf between them and me. I can’t reach them. Even my mother doesn’t understand what I’m going through’, he explains.
The fifth category concerns losses as a result of stigmatization, reactions colored by inadequate knowledge and also by the fear evoked by the image of schizophrenics as being different [26, 27]. Peter experiences the world outside as hostile. They do not understand him and sometimes do not even try. Partly, this can be traced back to his own fears. However, his story has an element of truth. People of all kinds behave differently when confronted with a schizophrenic, for example, officials from the housing association. The media write articles about the huge number of ‘lazy’ youths drawing incapacity benefits. Papers write about those crazy, violent psychotics as though they are all like that. . . Peter takes such things personally.
Finally, the losses of other service users should be mentioned. More than other people, inpatients know a lot of fellow-sufferers who are experiencing their own losses. In addition, almost everyone loses at least one friend or roommate to suicide. Peter is a very sensitive young man, especially in sensing moods. When someone else is not feeling well he immediately senses it. It makes him feel guilty or bad. ‘If I had only thought things differently. . .’ Or he feels scared; perhaps he will be next in the isolation cell, just like one of his roommates. . . Looking back, he has also lost four close friends who committed suicide during the last five years.
This list of the various losses underlines the enormous impact of the illness. To be clear, this list is not meant to satisfy the service user’s needs. It is a tool for caregivers to aid them in understanding something of what could be going on in their patient’s lives. It should also help them realize that some of the patient’s reactions may be related to mourning processes connected with loss, rather than being manifestations of the development of a
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new pathological trait from a medical perspective. Owing to the impact of these losses, broad attention for these themes and related existential questions and answers is to be expected in clinical care. Unfortunately, there are some important obstacles in this respect.
5.3.5 WHY IS IT SO HARD TO LISTEN CAREFULLY TO EXISTENTIAL QUESTIONS AND EXPLANATIONS? In the conversation described in Peter’s case, the patients attempted to find answers to one of the questions which was obviously bothering them. Why do all these ‘psychotic’ things happen to them? How can they be explained? They wanted to look back to the very beginning of their illness and to try to progress in their search for meaning. One of them, Peter, actually found an answer. However, it is completely clear that in our case, Peter’s specific answer about the punishing God was not truly being listened to. The other patients and the spiritual caregiver obviously felt ill at ease with his answer, which was clearly a painful experience for Peter. Observations in clinical practice and our research clearly demonstrate that this experience is not an isolated incident. The same reactions can be observed for many other existential answers given by patients. Thus it appears that there are many existential answers which are not being recognized at all or which are not being listened carefully to in clinical practice. At least four interconnected reasons play a part.
5.3.5.1
A more subjectivistic approach
Firstly, it has already been noted that the current dominant framework of healthcare does not automatically provide for interventions that focus specifically on the existential suffering of people affected by schizophrenia. In short, the issue concerns the view held of the construct of schizophrenia itself, following methodologies, and thereby especially with the conception of the subject. A brief historical overview could explain why the search for meaning service users undergo fits better within the conception of schizophrenia inspired by Eugen Bleuler, who stressed the affective relationship, than with the description of schizophrenia offered by Emil Kraepelin, who focused on the organic defect [28–31]. Ultimately, the latter approach leaves little room for the meaning or content of what patients say, whereas the former approach does [15]. This can be explained further by relating those different conceptions to subjectivism and instrumentalism respectively, the two representing different but interconnected sides of modern thinking [32]. The so-called instrumentalistic approach dominates current debate and therefore also the recently published Dutch guidelines for the treatment of schizophrenia, which are founded on evidence-based interventions. Transparency and survey ability are central guidelines in the effort to monitor the condition. As long as the organic defect persists, acceptance of this defect and rehabilitation are the main focuses of treatment. However, a more subjectivistic approach is required to monitor the subjective experience, which is essential for coping with loss. People’s acts are often not that univocal, nor are their different images of the world. In the case of loss this disunity and the discordant dimension in the lives of human beings should be taken into account [32]. Nevertheless, the issue at stake is far more complex than the mere inclusion of a greater focus on the affective relationship to the current concentration on the organic defect. It is also about the way the construct of ‘subjectivity’ is used. Giovanni Stanghellini’s phenomenology
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theory of ‘common sense’ can illuminate this point [33, 34]. This Italian psychiatrist states that experiences should not be based on the analysis of isolated individuals. On the contrary, this egological perspective should be replaced by, or in my opinion complemented with, a specific social perspective, i.e. . . . the inescapable subjective peculiarity of sociality, adopting as its landmark the subjective dimension of social action and the forms of symbolic mediation operated during the process of interaction between individuals. The social world is the world made of meanings understood and shared by every individual [33].
This social world as seen by Stanghellini is a fundamentally interpretative order. It is all about ‘common sense’. This point cannot be fully explored here; however, for the present purpose, an important phenomenon which underpins this social common sense theory is the so-called social attunement, i.e. the ability to make emotional contact and establish mutual relationships; perceive the existence of others and their mental structure as similar to one’s one own; understand intuitively the mental manifestations of other persons; communicate with others using the shared meaning structures [[33], p. 13].
Precisely here, in this web of social attunement, can the schizophrenic be seen to be impaired, and it is in finding a language to describe the patient’s loss in this socially colored context that important links are missing and medical terms simply do not fit. Service users clearly reach out for other language games (Wittgenstein [35]) when trying to explain what is happening to them. It is not surprising that in many cases the religious language, which offers transcendent symbols and views, fits much better. Religion, religare, has also inspired – through a psychodynamic view within the psychology of religion – everything to do with linking, connection and attachment. To summarize this first point, desiring to take patient’s experiences and utterances about loss and meaning-making processes seriously and to listen to them correctly, a more subjectivistic approach is required in addition to the current dominant methodologies in the clinical approach. In viewing subjective experiences thereby as fundamentally social and individual, it can be understood that existential images or religious language is required for expression in the absence of transparency.
5.3.5.2
Relearning the world
The second reason why it is difficult to listen to the answers in question in the clinical context concerns caregivers holding wrong presuppositions about mourning processes. Inspired by the models of phases or tasks of K€ ubler-Ross, Bowlby, Parkes & Weis, Lindeman & Worden [36–40], caregivers tend to focus on the process of accepting illness. Patients need to admit that they have an illness because as a result they will take their medicines. Naturally, compliance with their treatment regimes is very important. However, ‘accepting’ in this context essentially means that patients are asked to subscribe to the medical point of view and accept that they have defects. Given the importance of the personal search for meaning as described previously, we can conclude that this view of the suffering process will not be
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satisfactory for many patients. In addition, such a point of view can easily be abused by judging patient’s reactions as pathological grieving [15, 18, 41–43]. Our approach stresses that although many patients have to deal with a great many losses, as has already been observed, these processes as such are often very normal. Because of the huge number of losses and given the fact that the character of the illness fluctuates, a longlasting coping process is not that strange either. In any case, mourner activity in the coping processes should be acknowledged. In short, when diagnosed with schizophrenia, ‘coming to terms with loss’ cannot properly be modelled in standard phases or tasks as is usually performed in different cases of loss and bereavement. A constructivistic model would fit much better because it stresses the search for meaning [18, 42, 44, 45]. In the words of the philosopher Thomas Attig ‘coming to terms with loss’ is all about relearning the world [18]. Attig firmly holds to a holistic view of reorientation in cases of loss. Everything changes. Such an overall reorientation indicates that these processes demand a great deal of attention from the people involved. Coping with one or many of the losses mentioned is akin to being confronted with mysteries. No one can ever definitely answer questions such as why is this happening to me, why is God not able to interfere, why is he interfering like this, why am I different, etc. These questions are raised in response to the fact that life is no longer the same. The losses simply do not fit the picture, the personal view of life. The whole means of experiencing life psychologically, socially, emotionally and spiritually is disrupted. According to Attig, three processes are involved in this reorientation. First, the search for understanding; second, the search for respect for the unique experience; and third, more or less realizing or accepting that there is something like a loss. This third process is mainly stressed in the clinical context as stated above. However, the other two are also vital to meaning-making processes. It is also important to emphasize that these processes will not always keep pace with each other. Together, these three processes focus on reorientation. Loss brings about chaos in the mind. Where that loss is the loss of control over the mind, the chaos is often unbearable. Inevitably, an answer is required, and thereby some balance is regained. The whole person is involved in responding to the chaos, as can be seen in Figure 5.3.2, even though this is limited by personal vulnerabilities. Therefore, ‘coming to terms with loss’ should be stressed as a very active and exhausting process. It is hard to find answers that will last for life. After a while, patients usually need to find fresh answers and the process repeats itself again and again. A patient is brought to the closed ward of our hospital. ‘Why have they put me here? They should take my wife. She’s crazy, not me.’ Instead of describing this reaction as reality avoidance, I prefer to view his words as an answer, perhaps the only answer he is capable of in coping with his new circumstances. That answer is truly exhausting because everything around him denies it. He is in a strange room, his wife is at home, people around him say they are psychiatrists, nurses and so on. Other people sitting around tell him that they are ill and that they have been there before as patients. His thoughts spin in his head, he stops enjoying his food, his body is like a stranger to him. . . after a while he explained his situation. ‘It’s my head. It’s overflowed you know. It simply ran over. I’ve been far too busy.’
The answers patients construct will be challenged in their social environments, in their minds, on special occasions and so on. As such this can be compared to other cases of great loss. Loss colors life from that day forward [15, 18].
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I the search for understanding
+
II the search for respect
+
III more or less realizing/accepting that loss is there
formulating an answer (reorientation): * the whole person is involved in answering (psychological, emotional, social, biological & physical spiritual, intellectual, behavioral) * in all spheres of life (physical world, social world, world of self, world of the loss) * limited by personal vulnerabilities
Figure 5.3.2
Coming to terms with loss: Relearning the world
An integration of this constructivistic theory of answering into current healthcare provides three advantages. Relevant existential questions and answers will be better signalled by caregivers. Caregivers will be more cautious in attaching pathological terms to these processes. Finally, caregivers will be more careful with their own moral judgments [15, 18, 42]. These advantages will be elaborated in the next two subsections.
5.3.5.3
Recognizing the existential dimension
Returning to our discussion of the obstacles in the clinical context which prevent caregivers from adequately supporting reactions in cases of loss, we arrive at our third point. It is apparent that many caregivers find it hard to recognize the existential dimension in their patient’s stories. There is a huge difference between questions concerning the facts and questions concerning the whys and wherefores of our existence. However, it appears to be much easier to pay attention to the facts [15]. Treatment aims at offering help, and what is more comfortable for a caregiver than to give straight answers? Questions concerning the whys and wherefores cannot be answered that simply. If a patient discovers an answer to a very important existential question – for example related to suffering processes in schizophrenia, as Peter did – such an answer likewise expresses far more than just a concrete cognitive fact. Our research in Assen showed that those existential utterances are very often dealt with as though they were only meant to be expressing something about what that particular person believes to be true, especially when religion is involved [15]. Caregivers
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react as though they have to judge these utterances as ‘true’ or ‘not true’. This is a striking and simplistically one-sided way of regarding religion, but unfortunately this view is in general use in clinical practice and in many religious coping theories and enquiries [46, 47].
5.3.5.4
Connecting with the philosophies of life
Finally, the fourth reason why existential answers are not adequately approached in the clinical context, strongly connected with the former reasons, is based on a conflict. An utterance like ‘God is punishing me with schizophrenia’ clashes with the caregiver’s own philosophy of life. Of course, people can clash at a cognitive level. However, when a person’s philosophy of life is at stake – i.e. when deeply held beliefs are affected – very passionate reactions can be provoked. It is more than mere leaping to conclusions. This primary reaction appears to be counter transference simply out of control. For example, in the case of a punishing God: ‘Well actually I don’t believe anything at all but if there were a God, he would be a loving and caring and merciful one, that’s for sure.’ Or another reaction: ‘That someone still believes all that stuff. Come on, it (schizophrenia) is just something in the brain. He definitely needs more education about his illness!’ These reactions are not only regularly observed in clinical practice but were also found in the evaluation of the training course we developed on this subject [15]. This training course, ‘Loss and longing. Coming to terms with loss in schizophrenia’ based on best practices, comprising a textbook and three workshops, was developed to support caregivers in their reactions to patients. It is based on the constructivist model of ‘coming to terms with loss’, as presented earlier. The training course first focuses on consciousness-raising processes among caregivers, then on learning supporting skills. The consciousness-raising processes relate to loss, existential questions, the caregiver’s own mourning experiences in coping with loss and suffering, and the caregiver’s own philosophy of life. In addition, four skills were trained – ‘hearing’ (careful listening to detect precise existential questions related to loss), ‘recognition’ (to recognize the impact of a certain loss), ‘support’ (to support patients in their answering processes according to the constructivistic answering theory) and ‘making connections’ (to seek connections with the patient’s philosophies of life in order to support them in finding ‘good enough’ answers). The course evaluation was based on semi-structured interviews conducted before and after the training course. Participants were asked to respond to two sets of case narratives concerning loss in which five different themes were described. Fourteen respondents from three different training groups participated in the evaluation. Two hypotheses were tested. First we anticipated an improvement in the supporting skills trained in the course. The second hypothesis concerned the participant’s philosophies of life. We expected a decrease in reactions dominated by the participant’s own philosophies of life in favor of listening to the ‘answers’ provided by patients. Both hypotheses proved to be true. However, as can be seen in Figure 5.3.3, only the first two skills really improved among the participants as a result of the training, whereas the latter two changed only to a lesser degree or not at all. This result is closely connected to the second hypothesis. Participants encountered difficulties in distancing themselves from their own philosophies of life, especially when tricky themes were mentioned in the cases, such as guilt (‘My disease is a punishment from God’). Furthermore, it should be noted that although participants succeeded in better signalling the elements of suffering in the case stories, it proved
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Skills
T 1 (before)
1a 1b 2 3 4
Hearing as fact Hearing as question Recognition To offer support Making connections
Figure 5.3.3
number 56 28 17 9 3
T2 (after) % 82 41 25 13 4
number 30 59 52 29 3
% 43 84 74 41 4
Evaluation of training course ‘Loss and longing’
difficult to name the existential questions precisely. These shortcomings obviously interfere with adequate support. Despite its methodological shortcomings, this evaluation at least indicates restrictions in what can be expected of caregivers when confronted with coping processes concerning loss in cases of schizophrenia. These empirical observations correspond with previous theoretical findings.
5.3.6
THE SPIRITUAL CAREGIVER
Although coming to terms with loss in schizophrenia is regarded as an important subject in the clinical context owing to the existential suffering of patients and because of the observed caregivers’ feelings of powerlessness in these situations, it must be concluded there are a number of barriers obstructing adequate support. Of course, these observations fit in a situation that transcends clinical boundaries. It should be noted that Dutch society is dominated by a secular paradigm. This results in there now being fewer widely accepted or institutionalized social (cognitive-affective) representations in which human vulnerability is presented as ‘normal’, representations which can be found in more religious views [48, 49]. Increasingly, remarkable aspects of human life are coming to be regarded as abnormal and targeted for removal, thus focusing on the makeable individual [48]. In this respect, coping with serious loss has also increasingly become an individual struggle or challenge outside the clinical setting. Returning to the clinical context, it should be recalled that the required supporting skills in cases of loss demand a primarily subjectivistic approach. This approach accords the spiritual caregivers a pivotal role. After all, not only is the affective relationship their most important instrument, but meaning-making processes in relation to all kinds of different philosophies of life constitute their object of interest [50]. Embarking upon a relatively new field of research, we mainly focused on case narratives to define the competences and interventions spiritual caregivers employ in contacts related to loss and longing in schizophrenia. This research resulted in a list of 12 core skills with a therapeutic and a hermeneutic component. A complete discussion of these skills is beyond the scope of the present article. However, considering this package of skills and competences along with the issues of subjective meaning, coping with loss, longing, and all the different kinds of socially shared philosophies of life as a whole, the essential characteristics of the spiritual caregiver profession can be defined [15]. It is noteworthy in this context that most of these competences relate to the ‘support’ skills, especially to ‘support’ and ‘making connections’, which (as described in the evaluation section) were exactly the skills that other professionals find more challenging
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to learn and practise. The attitude and language games of spiritual caregivers seem to fit with the important themes of human vulnerability and utopical longings in the face of loss.
5.3.7
BACK TO PETER AND HIS PUNISHING GOD ANSWER
By describing some of the highlights of the results of our research on loss and longing processes in schizophrenia, we can understand now why Peter’s existential answer evokes so much resistance in the situation he found himself. Among other reasons, the resistance derives from feelings of powerlessness; the current dominant framework of healthcare based on thinking in terms of defects; a specific way of looking at the subject and his or her experiences in relation to the social context; difficulties in signalling precisely the existential dimensions in patient stories and in their questions and answers; and, finally, wrong suppositions about coming to terms with loss. Is ‘God is punishing me with this illness’ a good answer? Is Peter coping well? Perhaps the question should rather be – what is a good way of looking at his answer? I have discussed how to analyze Peter’s answer in greater detail elsewhere [47]. For the present, I will remark that it is not simple to judge this kind of coping as purely negative, as can be seen in widely accepted religious coping theories, such as those recently published by Russell Phillips and Catherine Stein in the Journal of Clinical Psychology [51]. What a given answer means in its particular context should be considered very carefully. One thing is certain, to Peter, his answer is clearly one of support in his particular context, although it is evident that it is not an easy one [47]. To him it is also crucial that the spiritual caregiver acknowledges that his answer is important to him. Remember Peter’s words when approaching the spiritual caregiver and firmly grasping her jacket collar. You can see what I mean, can’t you. That’s the way it has to be. God is punishing me with this illness. You must understand me. It has to be like that. If not, then I’ve got nothing left. I can’t bear that. You can see what I mean, can’t you’!?
One thing the spiritual caregivers in Assen took note of very seriously after this case was to remind themselves that an existential answer cannot be changed nor can someone be forced to make such a change when there is no other answer left. However, in such cases it also appears to be very important that caregivers, spiritual or otherwise, are able to keep hold of the hope that a fresh answer will one day present itself. Spiritual caregivers can thus be an important complementary profession in healthcare, distinguishing themselves, and here I refer to the British psychoanalyst Wilfred Bion, by their specific ability to contain [52] many vulnerable answers. That patients do care about containers for their existential questions and answers seems obvious. Luckily, people are in general very creative in finding new answers. To conclude, in view of the existential suffering of people diagnosed with schizophrenia or related psychosis, this chapter concerns coping processes for their specific losses. We firmly hold the belief that most service user’s mourning processes can be viewed as normal coping processes. Nevertheless, it is recognized that people affected by schizophrenia often experience many losses. The ‘answering model’ presented here in brief helps service users in their coping processes and gives mental health practitioners a useful support framework. The kind of support needed depends on the existential questions related to loss raised by patients in a given context. Precisely because of the recurrence and prominence of existential
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themes in patient’s case narratives it is argued that nurses, medical practitioners and affiliated health professionals need to acknowledge the existential and spiritual dimensions attached to having a mental health disorder [15, 53, 54]. An improved understanding of the loss and longing that accompany a psychotic disorder will significantly improve the quality of mental healthcare.
REFERENCES 1. Bjorklund R (1998) First Person Account: Psychosocial implications of stigma caused by misdiagnosis. Schizophrenia Bulletin 24, 653–655. 2. Menninger KA (1992 [1930]) The Human Mind. Menninger Foundation, New York. 3. Slooff CJ, Appelo MT, Berkenbosch IM, Louwerens JW (1994) Trainingsmodulen voor revalidatie en rehabilitatie van mensen met een schizofrenie. Van Gorcum & Comp BV, Assen. 4. Multidisciplinaire richtlijn schizofrenie. Richtlijn voor de diagnostiek, zorgorganisatie en behandeling van volwassen cli€enten met schizofrenie. (2005) Trimbos Instituut, www.ggzrichtlijnen.nl 5. Eneman M, Sabbe BGC (2006) Hopeloosheid bij pati€enten met schizofrenie. Lijden aan en onder schizofrenie. Tijdschrift voor Psychiatrie 48, 373–382. 6. Appelo MT, Slooff CJ, Woonings FMJ, Carson J, Louwerens JW (1993) Grief: Its significance for rehabilitation in schizophrenia. Clinical Psychology & Psychotherapy 1, 53–59. 7. Appelo MT (1999) Van draaglast naar draagkracht. Bohn Stafleu Van Loghum, Houten/ Diegem. 8. Clarke DM, Kissane DW (2002) Demoralization: its phenomenology and importance. Australian and New Zealand Journal of Psychiatry 36, 733–742. 9. Pettie D, Triolo AM (1999) Illness as evolution: The search for identity and meaning in the recovery process. Psychiatric Rehabilitation Journal 22, 255–262. 10. Broekman JM (1997) Schizofrenie: het raadsel is de ander. In: Broekman JM, Milders CFA, Tilburg van W, Zoest van AJA Schizofrenie. Het raadsel opgelost?. Uitgeverij Peeters, Leuven, pp. 99–133. 11. Hutschemaeckers G, Festen T (2004) Waarover praten zij?: Over hulpvragen van cli€enten en antwoorden van hulpverleners. In: Hutschemaekers G, Festen T, Kal D, Bos C, Oosterholt D, Thomas E, Fijn P Vragen naar zin. Het perspectief van de GGZ-cli€ent. KSGV 2-64, Tilburg, pp. 15–20. 12. Pieper J, Uden van M (1996) Geloof en levensbeschouwing binnen de RIAGG-hulpverlening. Ex-cli€enten aan het woord. Psyche en Geloof 7, 115–127. 13. Pieper J, Uden van M (2000) Geestelijke verzorging op Van Gogh. Onderzoek onder cli€enten van het Vincent van Gogh Instituut naar hun geloof/levensbeschouwing en hun behoefte aan geestelijke verzorging. Vincent van Gogh Instituut, Venray. 14. Rose EM, Westefeld JS, Ansley TN (2001) Spiritual issues in counseling: Clients’ belief and preferences. Journal of Counseling Psychology 48, 61–70. 15. Muthert JK (2007) Verlies en verlangen: over verliesverwerking bij schizofrenie. Een kader, een training voor hulpverleners en de rol van de geestelijk verzorger nader belicht. Van Gorcum, Assen. 16. Pieters G, Gaag van der M et al. (2000) Rehabilitatiestrategie€en bij schizofrenie en langdurig zorgafhankelijke pati€enten. Bohn Stafleu Van Loghum, Houten/Diegem. 17. Farkas MD, Anthony WA, Cohen MR (1991) Psychiatric Rehabilitation: The Approach and Its Programs. In: Farkas MD, and Anthony WA (eds.) Psychiatric Rehabilitation Programs. The John Hopkins University Press, London, pp. 1–27. 18. Attig T (1996) How We Grieve. Relearning the world. Oxford University Press, Oxford.
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COMING TO TERMS WITH LOSS IN SCHIZOPHRENIA
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19. Lewis L (2004) Mourning, insight, and reduction of suicide risk in schizophrenia. Bulletin of the Menninger Clinic 68, 231–244. 20. Macias C, Jones D, Harvey J, Barreira P, Harding C, Rodican C. (2004) Bereavement in the context of serious mental illness. Psychiatric Services 55, 421–426. 21. Terry P (2003) Working with Psychosis. Part 1: Grieving the damage of a psychotic illness. Psychodynamic Practice 9, 123–140. 22. Mauritz MW, Meijel van B, Winter de CP (2001) Schizofrenie: leven met verlies. Pati€enten aan het word. Elsevier gezondheidszorg, Maarssen. 23. Charmaz K (1983) Loss of Self: a fundamental form of suffering in the chronically ill. Sociology of Health and Illness 5, 168–195. 24. Estroff SE (1989) Self, Identity, and Subjective Experiences of Schizophrenia: in search of the subject. Schizophrenia Bulletin 15, 189–196. 25. Davidson L, Strauss JS (1992) Sense of Self in Recovery from severe mental illness. British Journal of Medical Psychology 65, 131–145. 26. Haghighat R (2001) A unitary theory of stigmatisation. Pursuit of self-interest and routes to destigmatisation. British Journal of Psychiatry 178, 207–215. 27. Crisp A (2001) The tendency to stigmatise. British Journal of Psychiatry 178, 197–199. 28. Bleuler E (1911) Dementia Praecox oder Gruppe der Schizofrenien. (In: Aschaffenburg G. Handbuch der Psychiatrie, Teil 4) Franz Deuticke, Leipzig/Wien. 29. Bleuler E (1916) IX. Die Schizophrenien (Dementia praecox). In: Bleuler E. (1918) Lehrbuch der Psychiatrie. Verlag von Julius Springer, Berlin pp. 285–339. 30. Kraepelin E (1899) Zur diagnose und Prognose der dementia praecox. Allgemeine Zeitschrift f€ ur Psychiatrie und psychisch-gerichtliche Medicin 56, 254–263. 31. Kraepelin E (1901) Vorlesung III Dementia praecox und Vorlesung XXI Endzust€ande der Dementia praecox. In: Kraepelin E. Einf u€hrung in die Psychiatrische Klinik, Johann Ambrosius Barth Verlag, Leipzig, pp. 21–30; 213–223. 32. Mooij A (2002) Psychoanalytisch gedachtegoed. Een modern perspectief. Boom, Amsterdam. 33. Stanghellini G (2004) Disembodied Spirits and Deanimated Bodies. The psychopathology of common sense. Oxford University Press, Oxford/New York. 34. Stanghellini G (2000) At issue: Vulnerability to schizophrenia and lack of common sense. Schizophrenia Bulletin 26, 775–787. 35. Wittgenstein L(1992 [1953]) Filosofische onderzoekingen. Boom, Meppel. 36. K€ubler-Ross E (1969) On Death and Dying. The Macmillan Company, New York. 37. Bowlby J (1961) Processes of mourning. International Journal of Psycho-Analysis 42, 317–340. 38. Parkes CM, Weiss R (1983) Recovery from Bereavement Basic Books, New York. 39. Lindemann E (1944) Symptomatology and management of acute grief. American Journal of Psychiatry 101, 141–148. 40. Worden W (1991) Grief Counseling and Grief Therapy: a Handbook for the Mental Health Practitioner. Springer Publishing Company, New York. 41. Kleber RJ, Brom D (1992) Coping with Trauma. Theory, prevention and treatment. Swets & Zeitlinger, Amsterdam/Lisse. 42. Neimeyer RA (ed.) (2001) Meaning Reconstruction & the Experience of Loss. American Psychological association, Washington. 43. Wortman CB, Silver RC (1989) The myths of coping with loss. Journal of Consulting and Clinical Psychology 57, 349–357. 44. Attig T (2001) Relearning the world: making and finding new meanings. In: Neimeyer RA (ed.) Meaning Reconstruction & the Experience of Loss. American Psychological association, Washington, pp. 33–54. 45. M€onnink de H. (1999) Verlieskunde. Handreiking voor de beroepspraktijk. Elsevier/de Tijdstroom, Maarssen.
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46. Vandermeersch P, Westerink H. (2007) Godsdienstpsychologie in cultuurhistorisch perspectief. Boom, Amsterdam. 47. Muthert H. (2008) Een straffende god bij schizofrenie: een ongezond, gek verlangen? Reflectie van een geestelijk verzorger. In: Maeckelberghe E, Westerink H (eds.) Gekke verlangens. Opstellen in ethiek en godsdienstpsychologie voor Patrick Vandermeersch. Kok, Kampen, pp. 35–48. 48. Dehue T (2008) De depressie-epidemie. Augustus, Amsterdam/Antwerpen. 49. Lans van der J (1991) Zingeving en zingevingsfuncties van religie bij stress. In: Lans van der J. (2006) Religie ervaren: godsdienstpsychologische opstellen. KSGV, Tilburg, pp. 72–127. 50. Beroepsstandaard voor de geestelijk verzorger in zorginstellingen. Vereniging voor Geestelijk Verzorgers in Zorginstellingen 2002 (www.vgvz.nl). 51. Phillips RE, Stein CH (2007) God’s will, god’s punishment, or god’s limitation? Religious coping strategies reported by young adults living with serious mental illness. Journal of Clinical Psychology 63, 529–540. 52. Bion WR (1962) Learning from Experience. Heinemann, London. 53. Mohr S, Brandt P-Y, Borras L, Gillieron C, Huguelet P (2006) Toward an integration of spirituality and religiousness into the psychosocial dimension of schizophrenia. The American Journal of Psychiatry 163, 1952–1959. 54. Wagner LC, King M (2005) Existential needs of people with psychotic disorders in Porto Alegre, Brazil. British Journal of Psychiatry 186, 141–145.
Part 6 Controversial Issues: Religion and the Brain INTRODUCTION The study of the relation between religion, spirituality and physiological and neurological changes is not completely new. A classic theme is the connection between religion and epilepsy. Individuals reported religious and spiritual experiences during abnormal temporal lobe activity. This is an intriguing topic, but the strict localization theory is no longer compatible with recent neuroscientific understanding. At present research on biological factors in religion and spirituality has broadened its scope. A new scientific discipline made its appearance: Neuro-Theology (although it is no Theo-logy at all). It is called an ‘emerging discipline’ that tries to integrate religious and spiritual concepts with neurological and neuropsychological insights. Thus a broad scale of approaches and findings pass by: neuroimaging techniques, physiologiocal studies, neurochemical correlates of meditation, neurotransmitter findings, heritability, and so on. Besides that, it is very interesting to see and to discover how the authors in this sixth part approach their topic. It will turn out to be a clear illustration of what has been explained in the light of the fourfold typology of Barbour in the General Introduction (p. 6). Mark the phrases that are used: misuse of data, triumph of theism over atheism, demasque of religions, proof. Obviously the spirits disperse. However, since we try to argue beyond boundaries throughout this volume, the following could be stated. The neuroscientific revolution has broken down the dualistic barrier or intellectual fissure between observation and behavior and the activation of brain structures, between neuroscientific statements and the language of faith. There seems to be no mental function that is not orchestrated by processes activated in the brain. And still mind matters. Philosophical-theological language is needed to explain why. However, the challenge is to do so not in opposition to neuroscience, but in the light of it. For the mind is both embodied and rational.
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6.1 The Limits of Scientific Understanding and their Relevance for the Role of Religion in Psychiatry Robert H. Belmaker 6.2 Seat of the Divine: A Biological ‘Proof of God’s Existence’? Herman M. van Praag 6.3 Neuro-Theology: Demasque of Religions Dick F. Swaab & Wilma T. P. Verweij
CHAPTER 6.1
The Limits of Scientific Understanding and their Relevance for the Role of Religion in Psychiatry Robert H. Belmaker Professor of Psychiatry, Israel
6.1.1
PSYCHIATRISTS’ MINDSET
Two seemingly contradictory belief sets have been very common and perhaps even dominant in Western psychiatry for the last 100 years: On the one hand, there is a strong sense of psychiatry as the profession that deals with the whole patient, that respects the patient’s inner experiences and his complaints, and takes into account the patient’s subjective perception of external events that have occurred to him in the past including his childhood. On the other hand, psychiatrists have been convinced determinists who believed that all mental and behavioral activity is part of a causal chain explainable by strict scientific principle. A minority of psychiatrists felt that these principles might always remain psychological but the great majority of psychiatrists, including Freud himself, believe that ultimately all mental behavior and activity could be reduced to neurochemistry. This belief system among psychiatrists in my view has had a powerful and often negative effect on the progress of psychiatric research, or psychiatric treatment and on the worldview that we as psychiatrists have projected to our patients. Immanuel Kant made his famous statement ‘Two things fill me with awe: The starry skies above and the moral law within’. The sense of awe has been a critical part, and perhaps the essential part, of religious thinking. This feeling of awe can aid a person to see his place in the universe and aid him in overcoming difficulties of living, illness, tragedy and setback. The sense of awe can imply that we as individual beings and we as a species are part of something larger than ourselves and that our own judgment and own perspective are not enough to know what purpose and fate ultimately involve us. By contrast, the belief that all is clearly part of a causal chain that begins in our psychological environment of childhood or in
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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Figure 6.1.1 Three Body Problem. The gravitational attraction between any two bodies is directly proportional to their mass and inversely proportional to the square of the distance between them. The relations of three bodies, however, are unpredictable despite this simple law. This is not merely a theoretical fact and asteroids in our solar system often fly out of their orbits in surprising and unpredictable ways.
our neurochemical mechanism suggests that there will be little to cause awe. The sense that all can be understood, given the knowledge of all of the factors involved, promotes not a sense of awe or of positive curiosity but of aloofness. If every human emotion can be traced to its origin, it is difficult for a humanist to find a proper balance between pride in our individual and species’ accomplishments and concern for our individual and species’ defects. However, the aloofness that may derive from an entirely deterministic outlook is no longer a necessary part of psychiatry’s adherence to the scientific model. Physics, mathematics and other sciences have rapidly modified their adherence to a strictly deterministic model. Figure 6.1.1 illustrates the three-body problem, which is quite well known in physics and astronomy. While the basic laws of gravitational attraction are simple, having been known essentially since Newton, and slightly modified by Einstein, it is not well known in psychiatry that these simple equations do not yield simple solutions for more than two bodies possessing mass and gravitational attraction. Mathematical solutions do not allow perfect prediction because they lead to complex differential equations that can only be approximated and never fully calculated or predicted. The three body problem is an example of the new science of chaos [1–5]. As illustrated in Figure 6.1.2 only a tiny minority of equations are of the kind that we all learned about in high school that have specific and calculable solutions. Most differential equations or sets of differential equations do not have simple solutions. Iterative equations, which are like algorithms where we use input from the previous value of a variable to define the next value of the variable, may often lead to bizarre, chaotic results. See the famous
6.1
THE LIMITS OF SCIENTIFIC UNDERSTANDING
517
Xnext = r*x (1-xprevious)
Alternation
Period Oscillation
Chaos
Figure 6.1.2 Simple equation that generates chaos. As values of the constant r are changed and depending on the starting value of x, this simple equation alone can yield alternation, more complex period oscillation, or never repeating chaos. No one believes this until they try it for themselves (use values of r from 1 to 4).
logistic equation illustrated in Figure 6.1.2. The equation depicted in Figure 6.1.2 came to my attention via ecology. It is well known that the population of a prey, say rabbits, is affected by the population of a predator, say wolves. If in one season there are many rabbits the next season wolves will have more surviving pups, since they have more prey. Because there are more wolves, there will be more predation and the next year fewer rabbits and the following year fewer wolves. In the concept we were taught in college algebra this situation was thought to reach within a defined period of time an ‘equilibrium’ based on the number of rabbits and wolves and other constants. However, the new mathematics of chaos has shown that most of the time these situations do not reach equilibrium. If you have an x as in Figure 6.1.2 that depends on an x in a previous iteration and given a constant r, for many r’s and many x’s no equilibrium will ever be reached and in addition the kind of oscillation will become unpredictable. This is not an issue of statistical probability, which most of us were exposed to in college, but of a new science called chaos that changes the basis of determinism in a way that can greatly affect psychiatric thinking in my opinion. Chaotic systems have been likened to the effect of a butterfly flapping its wings in the Caribbean causing an eventual hurricane in Britain because in differential iterative equations as illustrated in Figure 6.1.2 small changes in initial conditions can have huge effects after amplification by iterative processes. Moreover, these effects are not predictable in a simple mathematical way without actually going through the millions of iterations. For example in billiards the simple laws of physics, mass and momentum clearly apply to all the balls but a very tiny difference in the acceleration of one ball or in its mass or in the tremor of the player’s hand can affect whether the ball goes slightly to the right of the pocket or slightly to the left. This difference will, after several iterations of the game, eventually lead to a completely different playing field.
6.1.2
CHAOS THEORY: RELEVANCY TO PSYCHIATRY
How is this relevant to psychiatry? The time that a particular environmental event affects the brain can cause the effect to have completely different consequences that after years could lead to brain biochemistry and behavior entirely out of proportion to the say one month difference in the timing of the same event. The timing of an antidepressant or antipsychotic effect in the evolution of an illness could have not a linear effect but an entirely nonlinear different effect. The effects of genes on behavior could be, and most likely are, entirely non linear and the interaction of different genes to produce behavior may be far more complex
518 Table 6.1.1
CONTROVERSIAL ISSUES: RELIGION AND THE BRAIN Coincidental constants
1. If ice were heavier than water, the oceans would freeze. 2. If the cosmic constant were different by as much as 0.1%, the cosmos would collapse on itself too quickly for life to evolve or expand too quickly for heavy elements to ever have been formed. 3. If the ratio of electron to proton size were different, no atoms could form larger than hydrogen. 4. If the inverse square law of gravitation involved a power other than exactly 2, no stable rotation of one body around another could occur (such as a planet around the sun).
than it will be possible to unravel [6]. In physics, there is considerable discussion about the limits of knowledge: The limits of knowledge at the level of the galaxy, of the origin of the universe and at the microlevel of quantum uncertainty [7]. Unfortunately this spirit of accepting that there may be limits to knowledge has not penetrated psychiatry. Exposure to physics gives a feeling of awe that physicists are quite familiar with [8] but psychiatric researchers seem to be quite suspicious of. The issue of coincidence is common in modern philosophy of science, especially physics, but has not seemed to affect psychiatry. Table 6.1.1 lists just a few coincidental constants discussed widely in physics. If ice were heavier than water, which is the case regarding most solids and their corresponding liquids, the ice that accumulates in most oceans at different times of the year would sink to the bottom of the ocean. This ice would gradually accumulate and only the top most layer of ocean would be liquid. This is not speculation but can be shown by mathematical models. Life could never have developed in such a situation and the development of life is quite dependant on the physical anomaly that ice is lighter rather than heavier than water. The cosmic constant is a term used in cosmology that relates to the nature of gravitation. The cosmic constant is such that our 15 billion-year-old universe expanded at a particular rate that allowed on the one hand enough time for the development of heavy atoms such as iron necessary for life but on the other hand did not cause implosion of the universe back on itself too quickly for a phenomenon such as life to evolve (at least a couple of billion years). Another coincidental constant relates to the ratio of electron to proton size. If it were different, no atoms could form larger than hydrogen and clearly complex molecules could never have evolved. The fact that these constants seem to have been necessary for the formation of life engenders a sense of awe in many of us although my experience in discussing it with many of my psychiatrist friends is that they shrug their shoulders in lack of belief in what I am saying and state that they are clearly convinced that there will be a scientific explanation for these constants someday if not soon. This belief in a scientific explanation of the value of a constant may be meaningless at best but at worst is a symptom of what I call scientism: The belief that science will explain everything. Certainly, science has had many accomplishments and there is still much reason to be devoted to science as an empirical enterprise. However, we have no proof that science will eventually explain everything in terms of simple equations. G€ odel’s theorem [9] is another mathematical discovery universally accepted by mathematicians and acclaimed but very little known by psychiatrists. G€odel’s theorem states that any mathematical system (a system based on clear postulates with a logical method of deriving additional theorems from them) will have statements within it that are true but cannot be proven. This theorem in my experience seems to go against the grain of my
6.1 Table 6.1.2
THE LIMITS OF SCIENTIFIC UNDERSTANDING
519
Emergent Properties
1. Water’s slipperiness cannot be predicted from H2 and O2 properties. 2. Computer experts looking at a complex program cannot tell what it does until they run it. 3. What emerges from 10 billion neurons in network?
colleagues who studied geometry between 50 and 10 years ago and seem to believe that the only possible essence for truth is provability. G€ odel clearly showed that there can be many true theorems in any mathematical system that cannot be proven. This may be relevant to the limits of science and the sense of awe. Table 6.1.2 illustrates the concept of emergent properties. In its easiest form, although perhaps most profound, it is difficult for a physicist or chemist to predict that the property of ‘slipperiness’ will be a property of water, based on what we know of hydrogen and oxygen. More familiar to those of us who use computers is that machine language programs can be unbelievably long and even the best computer expert looking at it cannot tell what it will do when you run it on a computer. It is well known that the world’s best computer scientists were not sure whether there would be bug Y2K or not. The incredible complexity of 10 billion neurons with many times that number of synaptic connections may lead to the emergence of physical forces that we have no idea of today. At the level of subatomic particles forces exist that are not familiar to us at our usual scale and these forces emerge only when subatomic physics began looking at the interactions of extremely small particles [10]. It is of course speculation that new properties such as consciousness or moral choice evolve when 10 billion neurons are connected in specific ways and it may not be true. However, to be sure in advance that it is not true is to believe in scientism, not science. We do not know yet whether there are such forces in the brain beyond the present laws of neurochemistry that we are aware of. Roger Penrose, distinguished professor of mathematics at Oxford University, in his classic book The Emperor’s New Mind [11] discussed his theory that at the level of subatomic neurochemistry in brain neurons quantum decoherence is avoided and emergent properties affect quantum processes that can eventually influence the firing or non firing of whole neurons. Jeffrey Gray, in his marvelous book on consciousness [12], criticized the Penrose theory on the basis of physical and mathematical computations that I am not capable of judging, but Gray did not deny that this approach may be worthwhile in another variation. Gray, a distinguished psychologist and empirical researcher at Oxford University, discussed at length the empirical evidence for the existence of consciousness in humans and perhaps some other animals as an independent function for which it is difficult to find a clear psychophysiological utility. For instance, the famous phenomenon where a colored dot is presented on a screen followed at various numbers of milliseconds later by a colored dot a short distance away on the screen. Up to 100–300 milliseconds difference between the two dots leads the observer to report that he saw a moving dot between the two points rather than two individual dots. This subjective perception can in the case of human beings be verbally ascertained. In the case of monkeys it can be shown to be similarly perceived by training the monkeys to respond differently to two dots than to a moving line and to show that when less than 100–300 milliseconds separates the presentation of the two dots the monkey responds as if it perceived a moving line. The key point in this phenomenon is that the perception of a line or two dots occurs only after the second dot is presented. Thus, the consciousness of a line is created retroactively by the brain. Other experiments reviewed by Gray confirm that
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consciousness seems to occur after most complex motor processes have already made critical decisions. The purpose of our consciousness therefore is not clear and could well be seen as a subject of awe but also for further empirical study. It is difficult to understand it as other than an emergent process. Yet it continually surprises me how few psychiatrists are interested in consciousness and how few make efforts to help patients and society revel in joy and pride at this incredible gift we have. Carl Sagan in his wonderful posthumously published lectures [13] describes at great length and conviction his belief that our planet Earth is an unimportant backwater in the universe; that billions of stars similar to our sun exist and that millions of planets similar to Earth exist and that therefore life has probably evolved in many places and perhaps an almost infinite number of places in the universe. He uses this argument to emphasize the ridiculousness of man’s sense of meaning and self importance. Yet over two decades have gone by since Carl Sagan actually gave these lectures and, at least partly due to his urging, considerable funds have been expended with high technology equipment to detect any messages from civilizations in other parts of the galaxy. Given the knowledge that the universe is about 15 billion years old and the many stars and planets that Sagan calculated should be within a few thousand light years of our own Earth, there is no reason to think that some of these many civilizations did not develop a few thousand years before ours. There is also no technological reason to think that, if as advanced as Carl Sagan predicts, they would not send a simple radio message perhaps coded in a universally understood way such as a Fibonacci series. No such messages have arrived. The recent book The Privileged Planet [14] and the corresponding DVD offer opposite arguments. They argue that our Earth is in a very particular place in our galaxy and that it is very unlikely that planets supportive of life could have developed closer to the center of the Milky Way galaxy or further out and that numerous other factors suggest that large numbers of extraordinarily rare coincidences were necessary for the development of life on Earth and that we may be unique in the universe and perhaps fulfill some purpose. The Privileged Planet was funded by the Discovery Institute, an Intelligent Design supportive institute close to groups that have denied Darwinism and that often promote theological thinking that we as scientists know to be destructive of open experimental scientific progress. However, human history has shown that there are often truths scattered in unlikely places and it seems a shame to make the science/religion debate into a zero sum game because of the politics of Intelligent Design and public school Darwinism in the United States. The possibility that man is unique in the universe and that various coincidences suggest some purpose for him is a core belief of religions around the world and may be a crucial facilitator for a truly humanistic optimistic psychiatry.
6.1.3 OUTLOOK: SCIENCE AND RELIGION SEVEN DAYS A WEEK The position of some scientists that religious belief is orthogonal to the scientific enterprise leads, in my view, to a dichotomy that will bring us to a dead end. A scientist may do science during the week on an entirely empirical basis but believe in an orthodox religion on Friday, Saturday or Sunday with truths that he feels are revealed by belief and are entirely unrelated to the empirical work that he does during the week. This will in my view not contribute to a future worldwide human religious sensibility. The scientific discoveries of the limits of
6.1
THE LIMITS OF SCIENTIFIC UNDERSTANDING
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knowledge in physics and mathematics and emergent properties in complexity theory give us the opportunity to develop a science based religious belief where awe, humility and feeling of purpose derive support from scientific discovery rather than existing in isolation from it. Psychiatrists are responsible for the greatest achievement of the human species, and perhaps all of creation, the human mind. We must avoid oversimplifying it, in either biological or psychological directions.
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Brown C (1995) Chaos and Catastrophe Theories. Sage Publications, Inc., Thousand Oaks. Cohen J, Stewart I (1994) The Collapse of Chaos. Penguin Books, New York. Gleick J (1993) Chaos: making a new science. Viking Press, New York. Gribbin J (2004) Deep Simplicity. Penguin Books, London. Ruelle D (1991) Chance and Chaos. Princeton University Press, Princeton. Mazzocchi F (2008) Complexity in biology. Exceeding the limits of reductionism and determinism using complexity theory. EMBO Reports 9, 10–4. NewsFocus (2008) A singular conundrum: how old is our universe? Science 317, 1848. Davies P (1983) God & the New Physics. Simon & Schuster, Inc, New York. Hofstadter DR (1999) G€odel, Escher, Bach: An Eternal Golden Braid. Basic Books, New York. Deutsch D (1997) The Fabric of Reality. Penguin Books, London. Penrose R (2002) The Eemperor’s New Mind: concerning computers, minds, and the laws of physics. Oxford University Press, New York. Gray J (2007) Consciousness: creeping up on the hard problem: Oxford University Press, New York. Sagan C (2007) The Varieties of Scientific Experience. Penguin Books, New York. Gonzalez G, Richards J (2004) The Privileged Planet. Illustra Media, La Habra, CA.
CHAPTER 6.2
Seat of the Divine: A Biological ‘Proof of God’s Existence’? Herman M. van Praag Emeritus Professor of Psychiatry, The Netherlands
(This chapter is partly included in the Dutch book by the writer entitled: God en Psyche. De redelijkheid van het geloven (God and Psyche. The reasonableness of faith). Boom, Amsterdam, 2008.) So-called neurotheology does research into the cerebral substrate of spirituality c.q. religiosity. There is evidence that such a substrate indeed exists. The relevant findings have been received with great acclaim by atheists. They see it as a triumph of their conviction. Religious faith is nothing but a ‘brain state’. Believers are bewildered: religion and religiousness biological phenomena? That sounds blasphemous. Is the triumphant atheist right or is the believer mistakenly bewildered? That is the theme of this chapter.
6.2.1
OBJECT OF RESEARCH
Is there a connection between religiousness and the functioning of the brain? On the face of it a peculiar research theme. Religiosity is the foundation of religion. Religion is a philosophy of life, whose essence is the concept of God, being a pure abstraction. The brain, however, is a concrete object; an organ consisting of 10 billion neurons with 1000 times as many contact points (synapses), 200 billion gliacells and 100 000 kilometres of axon (nerve fibres). So a pure piece of matter. How can there be any connection between these two unequal quantities? This astonishment is not appropriate. Neither mind nor soul floats above the waters. Like all phenomena of life, they are solidly anchored in a biological substrate. Many people feel the need to give meaning to their lives. This can be done in an ‘earthly’ manner, for example by artistic, scientific or social activities or simply by trying to make the most of it, in their family, at work or in their social life. To some this is not sufficient. They have a need to add a vertical dimension to life, one that transcends earthly existence. They, or rather, their minds are looking for a concept which undoes the temporal, the arbitrary and the accidental nature of existence. Their minds are looking for a superhuman concept, a God-concept.
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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Without the brain this need would not exist. There would be no mind. Consequently this means that I would have been surprised if religiosity/spirituality had existed without the neural circuits required for this to have developed in the brain. Psyche and mind are constructs that are dependent on the existence of a functioning brain. These words seem to come from an unadulterated materialist. I am not. I consider myself a moderate dualist. I will make myself clear by means of an analogy which I derive from Oomen [1]. Suppose one has a coin. This is a piece of matter with definable and measurable qualities. It is also a valid means of payment. You can buy something with it. What is actually bought varies from individual to individual. One person will buy ice-cream, the other a book; one person a ticket for a football match, the other a ticket for a concert. Whatever is bought is not enclosed in the material qualities of the coin. In other words, the purchase is dependent on the coin, but the coin does not determine the nature of the purchase. A similar relationship exists between mind and soul on the one hand and the brain on the other. Mind and soul are dependent on a functioning brain, but these two quantities do not coincide. Mind and soul are not extrapolatable to the brain. The brain does not determine what soul and mind will be equipped with. That is determined by that enigmatic concept, which is so extremely difficult to define and not localizable in the brain: the self. So I am not an orthodox materialist, rather a liberal dualist. On the one hand I consider mind and soul attached to a material substrate, i.e. the brain, but on the other hand I allot these two domains a considerable degree of autonomy. I will first concisely discuss some results of neurotheological research. Subsequently I will go into the theological interpretation of these data. First the atheistic view. The neurotheological data are considered to be powerful arguments for the statement that ‘alle spreken over Boven van beneden komt’ [2] (‘all the Above comes from below’), that concepts like God and transcendence are no more than human products of fantasy; that we are dealing here with a series of chimeras that are finally exposed as such. I address the question whether this view is plausible, or whether the neurobiological data are improperly used in this way, in other words misused, to discredit a certain philosophy of life. I oppose the atheist interpretation against the theist and take the position that the neurotheological data are indeed powerful evidence in favor of theism. The present data show, I believe, that religiosity in the human existence is entitled to existential significance and is consequently firmly biologically anchored. Before I go any further, I will define the concepts that are central to this treatise.
6.2.2
DEFINITIONS
I interpret the concept of soul as a metaphor for all of the psychological faculties an individual has. Faculties that give him access to both his own inner world and the outer world, including the inner world of others. Faculties that enable him to orient himself in both worlds, to hold firm there and make his contributions. Psychological faculties (or functions) are measurable, some of them even quantitatively, for example cognitive functions. The concept of psyche is, although immaterial, concrete by nature. By mind I mean that domain of the human existence where the ‘what-for question’ arises. What is the meaning of my existence? Do I have to live up to somebody’s expectations and if
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so, whose? Only mine, or also those of a higher authority? This again raises the question of the conceivable existence of a metaphysical space within which the concept of God figures. Metaphorically speaking, I consider the mind as the ‘top layer’, also the most esoteric layer of the psyche. The mind is an immaterial, and in contrast to the psyche, an abstract concept. By religion I mean a system that has developed around the hypothesis of a supernatural authority, an authority that is not sensorily perceptible and cannot be studied empirically, and yet fundamentally influences the individual and the society in which he lives. This authority is called God. It is either experienced in a strongly anthropomorphical way, so as a person with human features, or more as an abstraction, as an impersonal, intangible, inconceivable force field. ‘The foundation of all foundations’. Out of respect for the God principle a ritualized worship has developed. I denote the affinity with the religious root idea as religiosity, or rather religious susceptibility. I prefer this last term. For the first implies that religiousness is an all-ornothing phenomenon. One is either religious or one is not. Nothing is further from the truth. Religiousness is a quality that varies individually, just like for example in the case of aesthetic susceptibility. The term religious susceptibility conveys this most accuratly. For brevity’s sake, however, I will often use the term religiosity. Religiosity contains three aspects: *
* *
Susceptibility – emotionally and cognitively – to the concept of God and the transcendental reality it represents. Affinity with the worship and rituals that have developed around the God principle. Acceptance – at least in broad outline – of the life- and worldview that religion stands for.
Spirituality is a much more indefinite concept. It refers to a want for the ‘higher’, for the ‘spiritual’, to a discontentment with the here and now and constantly having one’s feet firmly on the ground. Some people every now and then have a romantic need to escape from the everyday, commonplace of life; away from worries, ambitions and conflicts to a world in which one can find inner peace and ‘realize oneself’. Spirituality occurs in many shapes. In broad outline I distinguish three forms. In the first place the earthly: one feels the strong need to give meaning to one’s life; to devote oneself to more than getting culinary, alcoholic and sexual pleasure; to spend one’s leisure time on something other than indiscriminately watching TV, aimlessly browsing the internet or obsessively watching sports events; to pursue higher objectives than earning money, spending money, acquiring social influence and achieving success professionally. Those higher objectives could be of any nature: for example cultural or social; one takes a course – history of art is popular – joins a choir, takes drawing lessons, applies as a volunteer for social activities, collects money for charity etc.; or more everyday: one decides to devote more time to partner and children. ‘Meaning’ can also be understood as ‘purpose’. One tries to live a life which at the end of the ride justifies the conclusion that one has lived for a good reason. A second form of spirituality I call the lyrical. There is affinity with the ‘higher’, the superterrestrial with those (presupposed) domains of existence that escape sensory perception. One feels united with nature, with humankind, turns against ‘contra-spiritual’ elements in society, such as bio-industry, experiments on animals and nuclear energy. They preferably buy ‘organic products’, tend to be or are adherents of vegetarianism. They explicitly call themselves non religious, even though there is a great interest in Oriental philosophies (Buddhism, Zen, Tao, etc.) and they often do meditative exercises. Undoubtedly, lyrical spirituality represents a
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philosophy of life, but it is non committal. One can follow this path, one can leave it without any consequences. This attitude to life does not know of a God who has expectations, who makes demands, who is in this respect unrelenting and is expected to be able to impose sanctions. Finally, there is a mystical form of spirituality. Spontaneously or by elicitation (e.g. by a certain event, a certain perception or experience), or by a specific effort (e.g. through meditation or religious submission) one suddenly or more gradually goes into ‘higher spheres’. One gets away from oneself, away from the daily worries, from the material aspects of existence (‘nothingness-awareness’) and one can get ‘out-of-body experiences’. In other words, there will be a blurring of boundaries between the self and the outer world. Self-awareness reduction usually goes handin hand with themystical union with theUmwelt: nature, humankind, cosmos, universe. The ultimate state of blurring of the self is called unio mystica (mystical union of the soul with God) by the Christians and Nirvana by the Buddhists. In such states of mind all that is perceptible gets another, ‘deeper’ significance. The person involved believes to have neared the essence of life, even though it is impossible for him to make these kinds of experiences more explicit. Words literally fail him. Consequently this ‘new world’ remains blurred and unstructured. However, people do usually accept the existence of a transcendental reality and a higher authority or higher authorities that operate in that transcendental reality, even though there is a holding back from relating this authority (authorities) to the concept of God or the Divine. As in religiosity this higher authority has the quality of holiness, is generally worshipped and this worship can even be ritualized. However, there is no or little philosophical structure attached to it, no theology developed. Religion has given the spiritual needs of humankind a strong focus: God; a foundation: the theology and a bedding: religious practice. To the religiously susceptible person God is the very symbol of spirituality. All other expressions of spirituality are by definition of a lower order. Religious experiences and spiritual experiences of the mystical type have so far been the focal point for neurotheological research.
6.2.3 6.2.3.1
THE DATA Heredity: twin research
It has been found that spiritual orientation and susceptibility to experiences interpreted as spiritual are partly hereditary and therefore biologically determined. In the research in question spirituality was defined as a tendency: *
*
to reach across the boundaries of the self to a transcendent and therefore practically unattainable reality; and to experience the world as one coherent whole, the self being part of it.
Thus that definition contains both elements of what I called the lyrical and mystical forms of spirituality. Cloninger et al. [3] operationalized this concept of spirituality and developed a questionnaire to assess its various aspects systematically in a standardized manner. He does not speak of spirituality for that matter, but of ‘self-transcendence’. In this concept he distinguishes three components. Firstly, the faculty to become entirely absorbed by a particular activity, experience or perception (‘self-forgetfulness’). Secondly, the ability to evoke the feeling of being connected with all aspects of the world as they manifest
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themselves to us, with, as it is often called, the ‘all’ (‘transpersonal identification’). A third component (and sub-scale) concerns the affinity felt with the supernatural, the miraculous in this world, with a focus on the intuitive and on matters that can only be determined with a ‘sixth sense’ (‘spiritual acceptance versus rational materialism’). The evidence that spiritual sensitivity is partly genetically determined was demonstrated by means of twin research. Dizygotic twins are genetically similar to ‘ordinary’ brothers and sisters. They have 50% of their genes in common, in contrast to monozygotic twins who are genetically identical. If a certain feature is completely or partly genetically determined, this will occur to a larger extent in monozygotic than in dizygotic pairs of twins. Comparable scores on the self-transcendence scale were found twice as frequently in monozygotic than in dizygotic twins [4]. The scores in monozygotic twins, however, did not correspond anywhere near 100%. This means that also non-genetic factors – environmental influences during life – play a role in the development of spiritual sensitivity. In this respect one could consider factors such as upbringing, education and social ‘climate’. Hamer [5], following Dawkins [6], calls this transmission through ‘memes, self-replicating units of culture; ideas that are passed on from one individual to another through writing, speech, ritual and imitation’. Blackmore [7] defines the ‘meme’ even pithier: ‘instructions for carrying out behavior, stored in brains (or other objects) and passed on by imitation’. In this manner it has been demonstrated that the degree of religiosity is partly genetically determined. This particularly applies when religiosity is the guiding factor in somebody’s life. This is called intrinsic religiosity, or also ‘religious devotion’ [8, 9]. It applies to a far smaller extent when religiosity is assessed in terms of external criteria, such as regularity of church attendance and prayer, or when it appears that religiosity is strongly nurtured for reasons of usefulness, for example the social circle it provides, or the professionally remunerative network (the so-called extrinsic religiosity). The genetic make-up for religiosity is weaker than for spirituality [10, 11]. ‘Memes’ seem to play a larger role in the transmission of religiously tinted spirituality than ‘genes’ [5].
6.2.3.2
Heredity: gene research
Which genes could be involved in the transfer of personality traits that determine religious c.q. spiritual sensitivity? Hamer [5] lifts a corner of the veil that is covering this issue. He found an association between the degree of self-transcendence, measured with Cloninger’s instrument and a natural variant (a so-called polymorphism) of the VAMT2 gene. This gene encodes for a protein, involved in the transport of monoamines, the so-called ‘vesicular monoamine transporter’. Monoamines function as neurotransmitters. These substances transmit information from one neuron to the next. They are stored in vesicles, the so-called synaptic vesicles, to be found in the axon terminals. Axons are nerve fibres that transport information from the cell body of a neuron to the next neuron. This information is enclosed in an electrical current (action potential) that is generated when a potential difference between the interior and exterior of a neuron is depolarized. This current travels via the axon to the terminals of the neuron. However, neurons do not form a continuum. Between one neuron and the next there is a narrow gap, the synapse. Here information is transmitted through a chemical process. When an electrical current (so the ‘information’) arrives at the axon terminals of the presynaptic cell, some synaptic vesicles release their contents into the synapse. The neuro-transmitter – e.g. a monoamine – binds with certain protein molecules in the cell membrane of the
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CONTROVERSIAL ISSUES: RELIGION AND THE BRAIN Electrical impulse receiving nerve fibre
Electrical impulse transmitting nerve fibre (axon)
Storage synaptic vesicles for the neurotransmittor (in this case a monoamine) Pre-synaptic receptors
synapse
Post-synaptic receptors
Figure 6.2.1 Neurotransmission, i.e. the transfer of information from one nerve cell (neuron) to the next. For this, a chemical substance is needed, the so-called neurotransmitter. It is released from the end of a nerve fibre (the axon), diffuses through the synapse (the virtual cleft between two neurons), and binds to a protein molecule on the cell membrane of the next neuron (the receptor). (Schematic much simplified.)
following neuron, the so-called receptors. Due to this fusion the permeability of that membrane changes, and a complicated pattern of ion transport is activated. This again causes an electrical current, which is transmitted by the next neuron. This continues until the final destination of the impulse has been reached (Figure 6.2.1). After it has done its job, the transmitter, in this case the monoamine, must be removed from the synapse. A small part is broken down. The largest part is transported back to the synaptic (i.e. storage-) vesicles, where they are protected from the inactivating effect of enzymatic breakdown. In this way they remain available for information transfer (recycling). The transport happens by means of two active ‘pumps’. The first transporter pumps the monoamine through the exterior cell membrane of the neuron, the second through the membrane of the synaptic vesicle. For the synthesis of the second pump the VAMT2 gene is needed. A dysfunctional VAMT2 gene will consequently interfere with the storage of monoamines, such as serotonin and dopamine. They fall victim to enzymatic breakdown and less will be available for information transfer. So far so good. Subsequently, Hamer [5] begins to speculate. He hypothesizes that neuronal systems that use serotonin and dopamine for information transfer generate experiential states that together constitute the concept of spirituality. ‘The monoamines are the chemical mediators of emotions and values’. The atypical VAMT2 gene would make the individual in question more susceptible to spiritual experiences. All this is pure speculation. A possible relation between serotonin- and dopamine controlled systems and spiritual characteristics has not been proven with any certainty. Moreover, we do not know if the atypicality of the VAMT2 gene indeed results in changes in the activity of these monoaminergic systems. Hamer calls the atypical VAMT2 gene the ‘God gene’ (without attaching a spiritual monopoly position to it, though). This is no doubt a challenging flag, but not really coming through with flying colors.
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Does the ‘God gene’ offer adaptive advantage?
Hamer then wonders: ‘what are the selective advantages of having God genes’. In other words, he tries to place spirituality/religiosity within a Darwinistic, evolutionary framework. Attributes, so this theory states, develop because they offer individuals an adaptive advantage over individuals from the same species that lack this characteristic. Hamer sees adaptive advantage in the ‘God gene’: religiosity gives humankind ‘an innate sense of optimism’. Optimism is believed to give man the will to procreate, despite the fact that he is doomed to die. Physically, optimism would be a prescription for a better health and a greater chance of recovery from illnesses. For this latter there are indeed indications, both with regard to physical and mental illnesses [12]. Moreover, involvement in religious activities is correlated with lower mortality [13]. In this respect no metaphysical explanations are needed. The correlation is probably based on earthly factors such as healthier life style, support from fellow believers and hope drawn from faith in God. Hope and faith are potent therapeutic aids [14]. Religiosity, however, can also have a reverse effect: a detriment to health. Pargament et al. [15] showed that over a five-year observational period, elderly, hospitalized patients who thought that God had abandoned them had a higher mortality rate than patients who did not know these concerns. Additional evidence stems from ultra-orthodox Calvinistic communities firmly believing that man was born in sin, that consequently he is eternally sinful, that this sin cannot be redeemed and that it is entirely uncertain whether God will have mercy on him. The Heidelberg Catechism states that man is corrupt, incapable of any good and tempted into all evil. Such beliefs can result in a fundamental attitude of anxious doubt. In such communities depressions probably occur more frequently than among the population as a whole [16, 17]. ‘Probably’, because definite research has not been conducted yet. From the adaptational viewpoint, religiosity is therefore a double-edged sword. Consequently, the conclusion should be that not all features of the psyche can be interpreted effortlessly in an evolutionary sense.
6.2.3.4
Biochemical and pharmacological research
There has hardly been any biochemical research into brain systems related to religious/ spiritual susceptibility. To my knowledge, there is only one study, namely that by Borg et al. [18]. They studied the density of a particular serotonin receptor, the so-called serotonin 1A receptor in relation to ‘spiritual acceptance’, being a measure for the susceptibility to spiritual experiences and reflections. Serotonin 1A receptors make up a subsystem of the neuronal network that uses serotonin as a neurotransmitter. That subsystem is involved in the regulation of mood, anxiety and aggression [19]. Besides, there are indications that activation of this system plays an important role in the therapeutic effect of antidepressants, medicines that are prescribed for depressions. In addition, this neuronal system might function as a filter in the transport of stimuli from the outside world from lower to higher brain centers. The serotonin 1A receptor density in the brain can be measured with PET (positron emission tomography) scanning. For this purpose a radioactive compound – the ‘tracer’ – which binds selectively to the serotonin 1A receptors, is injected intravenously. By means of the scanner radioactive radiation is measured in the brain. Radiation intensity is a
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CONTROVERSIAL ISSUES: RELIGION AND THE BRAIN Raphe
Hippocampus
Neocortex
Spiritual Acceptance Score
Self-Transcendence Score
16
12
8
4
0 10 8 6 4 2 0
Figure 6.2.2 The correlation between two measures for religiosity – namely ‘self-transcendence’ and ‘spiritual acceptance’ – and the density of serotonin 1A receptors. In different areas of the brain – namely raphe nuclei, hippocampus and neocortex – the correlation is negative. The higher religiosity scores, the lower the density of serotonin 1A receptors. Reprinted from Borg et al. [18], with permission from the American Journal of Psychiatry, (Copyright 2003). American Psychiatric Association.
measure for the serotonin 1A receptor density. ‘Spiritual acceptance’ was found to be negatively correlated with the serotonin 1A receptor density. A possible, but explicitly hypothetical explanation is that due to the reduced activity in the serotonin 1A system the sensory filter weakens. As a result stimuli would be perceived that normally do not get through to consciousness. This would heighten the sensitivity to spiritual experiences (Figure 6.2.2). There are some pharmacological data that seem to point to the same direction – that of serotonin. We know of hallucinogens which can evoke a state the user describes as ‘awakening’ or as ‘consciousness broadening’. Experience and perception of the environment alters. All that is perceived gets a different, sometimes ‘deeper’ and ‘richer’ significance. Also the experience of the user’s own body changes. For example he may perceive his body as from a distance (out-of-body experiences). He may feel united with the cosmos, more than with his own body. In short, phenomena occur that we also know from the mystical forms of spirituality. Consciousness remains intact, so that one remembers very well what one has experienced as soon as the drug effect has worn off. These effects can be generated by substances such as LSD and psilocybine. They affect the functioning of the serotonergic system drastically. It is unknown whether the 1A-subsystem is particularly involved.
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In short then, there are some indications for a connection between spiritual susceptibility on the one hand and the functioning of (certain parts) of the serotonergic system on the other hand. However, the data are still scarce, need confirmation and are definitely insufficient for a well-founded hypothesis about the biological foundations of spirituality/religiosity.
6.2.3.5
Brain imaging during spiritual peak experiences
Newberg et al. [20] examined Buddhist monks from Tibet during meditation and Franciscan nuns during prayer. Through meditation the monk tries to rid himself of his desires; these are considered sources of human misery. Through prayer the nuns try to come closer to and eventually melt with God. When the test subjects indicated they had reached the spiritual peak experience, a brain scan was made by means of SPECT. SPECT, single photon emission computer tomography, is a method in which a radioactive tracer is injected into the blood stream, after which the radioactive emission in the brain is measured. Since the tracer is transported through the blood stream and on its way binds to the brain cells, the SPECT scan pictures the speed at which the blood flows through the brain. The larger the emission, the greater the blood stream, and blood flow is a measure for brain activity there where emission was measured. During the meditative peak experience (‘There’s a sense of timelessness and infinity. It feels like I am part of everyone and everything in existence’) and the religious peak experience (‘a tangible sense of closeness of God and a mingling with Him’) the blood stream in the brain had altered. Generally speaking: an increase in the prefrontal cortex and a decrease in the posterior parietal cortex were found. Prefrontal cortex activation is believed to be related to heightened and focused attention. The posterior parietal lobe is related to self-awareness: the ability to experience a boundary between the self and the outer world. Decreased activity in this area would limit this capacity. Reduction of self-awareness and strongly heightened and focused attention are prerequisites for the above-mentioned peak experiences. A connection between these two phenomena seems therefore plausible.
6.2.3.6
Temporal epilepsy and religious experiences
Temporal epilepsy is a form of epilepsy, in which the patient suddenly ‘feels as if he is not really there, like in a dream’, is no longer in the state he was before the seizure started and is no longer able to communicate normally. He is in a sort of dreamy state without being asleep. Motor seizures – muscle contractions – do not occur. With an electroencephalogram epileptic zones can be located in the temporal lobes. During such a seizure the way the world is experienced changes. Colors, sounds, smells change in nature. Distances, spatial dimensions are experienced as altered. In short, the patient lives in another world. In such a state visual hallucinations (visions), acoustic hallucinations (hearing voices) and delusions can occur. Those phenomena relatively frequently have a religious content [21, 22]. For example, one sees biblical scenes, hears heavenly voices, believes to be a figure with religious significance or with a Divine assignment. Apart from the seizures these people are often religious ‘fundamentalists’ with unshakeable beliefs. They can be called hyper-religious [23].
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There are obviously areas in the brain that evoke religious images and ideas during stimulation. Persinger’s [24, 25] observations confirmed that conclusion. On the heads of normal, non religious test subjects (psychology students) he placed a helmet that can transmit electromagnetic signals to specific parts of the brain. Activation of certain temporoparietal areas resulted in the feeling of a ‘presence’, interpreted by the test subject as God, a spirit, or another supernatural being. According to Persinger, spontaneous discharges in the temporo-parietal area – micro seizures not accompanied by motor phenomena – are the biological basis for spiritual/ religious/mystical experiences. Persinger believes he has traced the ‘God spot’. To conclude this section I would like to mention that within the neurosciences there are ‘diehards’ who turn up their noses at neuro-theological research. Thus in 2005 a group of 544 brain researchers lodged a protest against the participation of the Dalai Lama in the annual conference of the Society of Neuroscience. He had been invited to give a lecture on brain research and meditation. ‘By consorting with the Dalai Lama and research into spiritual matters supported by him, the society would throw away the status of the neurosciences’, as was the protest [26]. Spirituality was obviously considered a ‘no-go zone’ for ‘real’ scientists. To be a true neuroscientist, one has to distance oneself from an important domain of the human condition. A truly poor worldview.
6.2.4
DOES ATHEISM TRIUMPH?
Spiritual/religious experiences are accompanied by measurable changes in brain activity. Spiritual/religious susceptibility is partly genetically determined and biological determinants of that feature have been traced. Finally, activation of particular brain zones evokes experiences that can be interpreted as religious/spiritual/mystical. Neurobiologists think they have found indications for the existence of a ‘God gene’ and a ‘God spot’. These terms are not used as slightly mocking metaphors. They parade as research findings. ‘Gefundenes fressen’ for atheist diehards. They have interpreted these observations as evidence of being right. Religious and related experiences are literally chimeras. I quote some dyed-in-the-wool atheists. Joseph [27] – an American brain researcher – states that: ‘. . . . heightened emotional activity within these (limbic) nuclei could result in feelings of fear, foreboding, or religious awe, as well as activation of the neural networks that respond selectively to crosses, such that emotional and spiritual significance is attributed to objects such as crosses. . . . Indeed, it could be argued that the essence of God, and of our living soul, may be slumbering within the depths of the ancient limbic lobe, which is buried within the belly of the brain’.
Janssen [28] – Professor of Psychology of Religion, Nijmegen University – observes: ‘God is biologically anchored and in our genes.’ Pierre Vinken [29] (Professor Emeritus of Neurology, former CEO of Elsevier’s Publishing House) has stated in a recent interview: ‘believing is an indication of a wrong use of brain functions.’ When Plasterk [30] – Professor of Moleculary Biology and currently Minister of Health in the Netherlands – is asked whether advancing scientific knowledge will ultimately result
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in people abandoning the God-idea, he replies: ‘That would be possible . . . If at a certain point that vague soul is the only aspect that can keep religions alive, this would consequently mean a resounding victory for science. Actually, in that case we can consider the Science versus Religion conflict as ended’. Swaab [31] – Director of the Brain Institute in Amsterdam expresses himself as follows: ‘I see the spirit as a product of our brain cells. I see the soul, as some believe something immortal that lives on after our death, as a misunderstanding.’ So no transcendence whatsoever, immaterial reality: an illusion. No higher authority. God is a mystification. Religious experiences are private fantasies. There is no world beyond the perceptible and measurable, no world beyond the horizon. Religious belief is a primitive relic of an infantile past. It arises from and is a product of excessive, possibly pathological activity in certain neuronal networks. ‘Just that’. Basically, the phenomenon can be provoked or suppressed via direct, e.g. pharmacological, manipulation of the brain. Religion unmasked. Not the agnostic and atheistic views are deviations from the norm: on the contrary, the deviation is in the religiously gifted person: certain circuits in his brain function abnormally. I fundamentally disagree with this line of reasoning, with its premise and the interpretation of the neurotheological data.
6.2.5 6.2.5.1
APPARENT VICTORY An incorrect premise
The premise of these kinds of arguments is twofold. First: science is synonymous with natural sciences and second: science and religion are antipodal to each other. The first premise is a product of scientific narrow-mindedness. The humanities are no less scientific than the natural sciences. Both try to find truths. The methods used differ fundamentally. However, the insights gained by means of methods used by the humanoria are no less ‘true’ than the ones acquired with empirical-scientific methods. They are truths of an entirely different order. Natural scientists search for truths in the material world. Truths that can be measured in size and number and are generalizable. They refer to the how of existence, to the underlying mechanism. Scientists laboring in the humanities search for truths in the spiritual world. Generally speaking, they deal with the subject, or a subject, with the analysis of its structure, with the foundations of the world in which it moves, with the products of its creative faculties. Science of this nature produces subjective truths. Truths that, generally speaking, are not objectiviable, measurable in size or number, or generalizable. The degree of truth is based on the feeling of obviousness these truths evoke, to what extent they enhance and enrich our notion of the reality in which we live. Frequently, not everyone will acknowledge these truths as the ‘truth’. This, however, applies just as much to scientific ‘truths’. Observations may have been established more or less objectively, an important degree of subjectivity is enclosed in their interpretation. It is not uncommon to be able to draw different conclusions from the same dataset; fairly often they turn out to be multiinterpretable. Conclusions are fallible. This goes for both types of scientific practice, but once again conclusions derived in the humanities are not qualitate qua less ‘true’ than those from
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the natural sciences. Natural sciences are not the only key to knowledge. Subjectivity is not the antithesis of knowledge. I also object to the second part of the premise. Religion is not the antipode of (natural) sciences. Their basic assumptions of reality are totally different. As mentioned earlier, natural sciences explore matter and try to analyze that material reality and express results in size and number. Religion is a spiritual system that has developed from the human need to imagine a world beyond the material; a world in which one can satisfy one’s hunger for meaning, for spirituality. In this respect it is completely irrelevant if that world really exists, in material terms, and if it can (ever) be made perceptible, measurable, or verifiable. It exists for the person who experiences that immaterial world, for the believer, and it is of essential significance for him. When, theoretically speaking, that transcendent world could be defined materially, its spiritual value would be lost. The founding fathers of the religions and their successors have given form and content to man’s metaphysical need. These forms and contents are in themselves well worth studying, also for non theologians. For example, the question as to how they have influenced the development of our culture and the arts, the role they play in the individual’s psychological functioning; the grounds those spiritual needs have originated from and a lot more. By definition, metaphysical concepts are inaccessible for research with methods used in the natural sciences. Objective evidence for their correctness is therefore illusory. As said earlier, the significance and importance of these concepts is based on the measure in which they ‘enlighten’ realities. If that degree is high, the individual experiences the concept as true and real, or at least meaningful. He believes in it. He does not require objective evidence, no more than the satisfied concert-goer will require evidence for having enjoyed himself, or the lover for loving his beloved. Religion and even more religiosity are subjects to be studied by the humanities. The natural sciences have nothing to offer in this respect. Nevertheless, the atheist demands from the believer: give me evidence that this metaphysical world exists. The believer cannot do this. This is not a fiasco, for the demand is nonsensical. A fish cannot be asked to walk. It simply does not have the tools. If it had been able to walk, it would have lost its fish-nature. Still the atheist believes he has won a knock-out victory. As a matter of fact, his assumption is totally unfounded. It is not that religion and (natural) sciences are opposites: they are unequal quantities. They are not, however, independent quantities, as Gould [32] has stated. They interact, in particular in the life of the researcher who believes. Science only (and in this respect I think of both the scientist and the scientifically-oriented individual, so the unadulterated rationalist) provides a horizontal, two-dimensional, worldview. Both feet stay firmly on the ground. I call this a disenchanted worldview. Religion as the piece de resistance creates a worldview that is literally unreal. One is in danger of floating above the waters. The combined attitude to life keeps an eye on reality and provides room for imagination. This gives life its inimitable flavor [33].
6.2.5.2
Misuse of the neurobiological data
Religious perceptions are accompanied by measurable changes in the functioning of certain brain circuits. This would indicate that religion is a product of the brain. ‘I believe that, just like one’s mother tongue, religion is rooted in certain brain circuits . . . that what
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we call religious faith is a brainstate’ [31]. The changes in the brain might demonstrate that religious experiences are ‘real’. ‘Years of research have led Gene and me to believe that experiences like Robert’s (a Buddhist mystic) are real, and can be measured and verified by solid science’ [20]. Neurotheology could shed light on the origin of religiosity and all its attributes. ‘The ability to explore theology from a neurological perspective can help us to understand, in very powerful ways, the human urge for religion and religious myth. . . . this approach also helps us understand many theological notions in terms of the origin of the concepts of causality, wholeness, and justice, not to mention specific conceptions of ‘God’ [20]. I believe that such reasonings are based on misinterpretation of neurobiological data. It is suggested that ‘biology drives psychology’, whereas the reverse is true: biology in this case is driven by psychology. I will explain this in more detail. Manifestations of religiosity are accompanied by measurable changes in brain activity. To me that is self-evident. Religiosity is primarily an experiential state, an ability to experience. Experiencing depends on a functioning brain. Without the brain there would be no experiencing. Neurotheology is of course a legitimate field of research. However, furor in the newspapers on this issue is unfounded. (‘The publication of Why God Won’t Go Away [a book about neurotheology] has drawn widespread attention from the media, and has generated a tremendous amount of excitement and support, as well as controversy’. . . . [20] . . . ‘The religious impulse is rooted in the biology of the brain’ (Kirkus Reviews, in: Newberg et al, [20]). There would be cause for furor if religious experiences occurred without evidence of brain activation, so without any measurable changes in the brain. Basically, activation of those ‘religious circuits’ could (in the main) be the result of biological processes. Due to genetic influences they could be hypersensitive, being activated by very mild, c.q. not easily verifiable stimuli (or the opposite: there could be decreased sensitivity, making the individual concerned immune to religious experiences). A second biological option is that acquired processes, such as brain injury, tumors in or inflammations of the brain have made these circuits oversensitive. This, however, is rare. In most cases these areas will be activated and the accompanying feelings/experiences generated by psychological processes, not by a primary anomaly in structure or function of the brain. ‘Psychology drives biology’, as good as ‘biology drives psychology’ [19, 33]. This also goes for religious feelings and experiences. They are usually generated by spiritual needs, some of which I discussed in chapter 3.2 of this book, namely: the search for meaning in life, dependence need, emotional response need and the need to give expression to one’s existential astonishment. Spiritual needs arise at the psychological level, are products of somebody’s psychological make-up and living conditions. Gratification of these spiritual needs is effected by induction of religious feelings and expressions. This first of all requires availability and subsequently activation of certain neuronal systems in the brain. Gratification of spiritual needs is effectuated at the biological level. In other words: the brain is the instrument that makes gratification of religious needs possible. These needs do not originate in the brain. Janssen [28] states that God is ‘biologically anchored’ and is ‘in our genes’. This is partly a misunderstanding. The ability to have religious experiences is biologically determined and its intensity is possibly (also) genetically determined. The need for religiosity is primarily generated by the psyche.
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Let me illustrate this with an example from another sector of the psyche. The locus ceruleus is a cluster of nerve cells in the brainstem and an important center in anxiety regulation. Its stimulation arouses feelings of anxiety. Direct stimulation of this nucleus by a material process in the brain is basically possible, but very rare. It would present an example of non psychologically determined anxiety. In most cases anxiety originates from a psychological condition, such as an inner conflict or a threat from the outer world. The tension resulting from this activates the locus ceruleus, arousing feelings of anxiety. The statement ‘anxiety is a product of locus ceruleus activation’, though not incorrect in itself, would be a serious simplification and present a completely distorted picture of the way in which anxiety generally arises. A second analogy. The observation of a work of art can evoke aesthetic feelings. Without doubt these feelings are based on the activation of certain neuronal circuits, even though we do not know them yet. It is true that this activation is essential to trigger these feelings, but it says nothing about the source of these feelings, the work of art, nor about the aesthetic qualities of the individual, who is looking at this work of art. Research into this requires methods that have nothing to do with neurobiology. Just as, I presume, one has ‘aesthetic circuits’, nerve cells that evoke aesthetic experiences when stimulated, one similarly has ‘religious circuits’, nerve cells that, when activated, generate religious experiences. These religious circuits are a conditio sine qua non for the religious perceptions to arise. However, they do not give any insight into the roots of this phenomenon, nor into the role religiosity plays in the lives of the individuals concerned. To put it even more simply: the pen (alternatively the computer) is the instrument that records a thought, it is not the root of that thought. The true positivistic materialist believes that neurotheological research will give or has already given the final blow to religiosity. Religiosity is nothing more than a product of hypersensitivity of certain neuronal circuits; in the most literal sense of the word: imagination, a chimera. This is biological reductionism of the worst kind. About a hundred years ago this argument was already raised by God’s opponents, much to the indignation of William James [34]: ‘Medical materialism finishes up Saint Paul by calling his vision on the road to Damascus a discharging lesion of the occipital cortex, he being an epileptic. It snuffs out Saint Teresa as an hysteric, Saint Francis of Assisi as an hereditary degenerate. George Fox’s discontent with the shams of his age, and his pining for spiritual veracity, it treats as a symptom of a disordered colon. Carlyle’s organ-tones of misery it accounts for by a gastro-duodenal catarrh. All such mental overtensions, it says, are, when you come to the bottom of the matter, mere affairs of diathesis (auto-intoxications most probably), due to the perverted action of various glands which physiology will yet discover. And medical materialism then thinks that the spiritual authority of all such personages is successfully undermined’.
The word reductionism is actually too weak. Here neurobiology is misused to support a point of view that has nothing to do with biology, i.c. religious unbelief. No-one would think of appreciating a scientific theory or the analysis of a work of art on the basis of the cerebral activities that make up the material underpinnings of those considerations. They are assessed as thought-constructs in their own right. The same goes for religious
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systems. To the individual and to society they have a certain intrinsic philosophical and psychological value. These qualities are studied by theologians, philosophers, psychologists and sociologists. The neurobiologist cannot contribute to this at all, no more than the car mechanic can give any insight into the way the user will drive the car or what the vehicle means to him.
6.2.6
DOES THEISM TRIUMPH?
I repeat: neurotheological data provide information about the material substrate of religiosity; the substrate that determines that religious susceptibility can exist at all. Neurotheological data do not provide any insight into the origins of religiosity, nor into the significance religiosity has for a certain individual, a certain group or a certain culture. Religiosity, or rather the need for it, is generated by psychological and social factors. The brain provides the opportunities to satisfy those needs. From the atheistic point of view it has been argued that the neurotheological data demonstrate that religious susceptibility is nothing more than the product of an abnormal or at least unusual ‘brain state’. In this viewpoint a transcendental reality, occupying a central place in all monotheistic religions, is a grotesque misinterpretation of the experiential effects of that ‘brain state’. I consider this view a ‘terrible simplification’, which completely denies the significance of religiosity. I interpret the neurotheological data as a triumph of theism. The brain obviously contains a neuronal network that generates religious c.q. spiritual experiences, when activated. I assume that this network has developed because such experiences have come to play an essential and valuable role in human existence. From an evolutionary point of view, the ‘religious circuits’ provided psychological advantages. The ‘utility’ of religiosity can not only be understood in the psychological but also in the theological sense. This is most likely the believer’s viewpoint. He will accept, better: he believes, that his religious urge does not stem from his own psychic inner world but comes from ‘above’, from a metaphysical space. He does not consider the concept of God a symbol, a symbol of ultimate compassion and ultimate justice – paradoxically conveyed: a symbol of superhuman humanity – but a concrete reality. In his line of reasoning God does exist, there is a superhuman authority who wants to make himself known to man, to communicate with him. God in search of man [35]. He will believe that the cerebral circuits developed to make that contact possible. Whatever explanation is considered plausible, the psychological or the theological one, I believe that religious susceptibility developed and got firmly biologically anchored because this personality trait was beneficial to man. It developed by the grace of a need. The need did not arise because of disfunctioning brain circuits. ‘Psychology drove biology’. I cannot think of a more powerful argument for the existential significance of religiosity. Hence, I see the neurotheological data as a triumph of theism.
6.2.7
SUMMARY
Religiosity is above all an experiential ability. As such it cannot exist without a biological substrate, without neuronal circuits whose activation evokes religious experiences. Research
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into the nature of those circuits has already yielded some results. Is religiosity with this reduced to a purely biologically determined phenomenon? Definitely not. Religiosity is not rooted in these cerebral circuits. Its roots are to be found at the psychological level. The brain functions as an intermediary; an intermediary between religious needs and their experiential gratification. In other words, homo sapiens developed hardware that enabled the coming into existence of religiosity. I conclude that the neurotheological data do not give support to the atheistic viewpoint. Religious susceptibility cannot be seen as a sophisticated complex of chimeras. The neurotheological data, on the contrary, give support to the theistic viewpoint: religiosity is a normal and valuable component of the human psyche. It has been firmly biologically anchored, an anchorage that was genetically embedded.
REFERENCES 1. Oomen PMF (2003) On brain, soul, self, and freedom: an essay in bridging neuroscience and faith. Zygon 38, 377–392. 2. Kuitert HM (2005) Het zelfde anders zien. Het Christelijk geloof als verbeelding. Ten Have, Kampen. 3. Cloninger CR, Bayon C, Sravkic DN (1993) Measurement of temperament and character in mood disorders. Archives of General Psychiatry 50, 975–990. 4. Kirk KM, Eaves LJ, Martin NG (1999). Self-transcendence as a measure of spirituality in a sample of older Australian twins. Twin Research and Human Genetics 2, 81–87. 5. Hamer D (2004) The God Gene. How faith is hardwired into our genes. Doubleday, New York. 6. Dawkins R (1976) The Selfish Gene. Oxford University Press, Oxford. 7. Blackmore S (1999) The Meme Machine. Oxford University Press, Oxford. 8. Kendler KS, Gardner ChO, Prescott CA (1997) Religion, psychopathology, and substance use and abuse: a multimeasure, genetic - epidemologic study. American Journal of Psychiatry 154, 322–329. 9. Waller NG, Kojetin BA, Bouchard ThJ et al. (1990) Genetic and environmental influences on religious interest, attitudes and values. Psychological Science 1, 138–142. 10. Bouchard TJ, Lykken DT, McGue M et al. (1990) Sources of human psychological differences: the Minnesota Study of Twins reared apart. Science 250, 223–228. 11. Bouchard TJ, Lykken DT, Tellegen A (1999) Intrinsic and extrinsic religiousness: genetic and environmental influences and personal traits. Twin Research and Human Genetics 2, 88–98. 12. Ellison CG, Levin JS (1998) The religion - health connection: evidence, theory and future direction. Health Education & Behavior 25, 700–720. 13. Hummer RA, Bogers RJ, Nam CB et al. (1999) Religious involvement and U.S. adult mortality. Demography 36, 273–285. 14. Steptoe A, Wardle J, Marmot M (2005) Positive affect and health - related neuroendocrine, cardiovascular, and inflammatory processes. Proceedings of the National Academy of Science of the United States of America 102, 6508–6512. 15. Pargament KI, Koenig H, Tarakeshwar N et al. (2001). Religious struggle as a predictor of mortality among medically ill elderly patients. Archives of Internal Medicine 161, 1881–1885. 16. Van Scheyen JD (1975) Bezwaard gemoed in een regio: over relaties tussen endogene (vitale) depressies, religie en su€ıcide. Tijdschrift voor Psychiatrie 17, 775–788. 17. Schilder A (1987) Hulpeloos maar schuldig. Uitgever Kok, Kampen. 18. Borg J, Andree B, Soderstrom H et al. (2003) The serotonin system and spiritual experiences. American Journal of Psychiatry 160, 1965–1969.
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19. Van Praag HM, De Kloet R, Van Os J (2004) Stress, the Brain and Depression. Cambridge University Press, Cambridge 20. Newberg A, D’Aquili E, Ranse V (2001) Why God Won’t Go Away. Ballantine Books, New York. 21. Trimble MR (1991) The Psychoses of Epilepsy. Raven Press, New York. 22. Brewerton TD (1994) Hyperreligiousity in psychotic disorders. Journal of Nervous and Mental Disisorders 182, 302–304. 23. Ramachandran V, Blakeslee S (1998) Het bizarre brein. Wat fouten in de hersenen ons leren over de werking ervan. Kosmos-Z en K Uitgevers, Utrecht, Antwerpen. 24. Persinger MA (1997) I would kill in God’s name: role of sex, weekly church attendance, report of a religious experience and limbic lability. Perceptual and Motor Skills 85, 128–130. 25. Persinger MA, Tiller SG, Koren SA (2000) Experimental stimulation of a haunt experience and paroxysmal electroencephalographic activity by transcerebral complex magnetic fields: induction of a synthetic ghost? Perceptual and Motor Skills 90, 659–674. 26. Van Delft D (2005) Herrie om Dalai Lama. NRC handelsblad, 22 Oktober. 27. Joseph R (1996) The limbic system and the soul. Evolution and the neuroanatomy of religious experience. In: Joseph R (ed.) Neuropsychiatry, Neuropsychology, and Clinical Neuroscience. Emotion, evolutions, cognition, language, memory, brain damage, and abnormal behavior. Williams and Wilkins, Baltimore (Maryland). 28. Janssen J (2002) Religie blijft altijd bestaan. NRC Handelsblad 20 Augustus. 29. Van der List G (2007) Gelovige hersenen. Elsevier, 6 October. 30. Plasterk R (2003) Juist onder religieuzen heerst een gebrek aan ethiek. In: Visser H (ed.) Leven zonder God. Elf interviews over ongeloof. Uitgever L.J. van Veen. Amsterdam/Antwerpen. 31. Swaab D (2003) Evolutionair gezien zijn we weinig meer dan wegwerpartikelen. In: Visser H (ed.) Leven zonder God. Elf interviews over ongeloof. Uitgeverij L.J. van Veen, Amsterdam/ Antwerpen. 32. Gould SJ (1999) Rockes of Ages. Science and religion in the fullness of life. The Ballantine Publishing Group, New York. 33. Van Praag HM (2008) God en psyche. De redelijkheid van het geloof. Boom, Amsterdam. 34. James W (1902/2002) Varieties of Religious Experience. A study in human nature. Routledge, London, New York. 35. Heschel JH (1955) God in Search of Man: a philosophy of Judaism. Farrar, Straus and Giroux, New York.
CHAPTER 6.3
Neuro-Theology: Demasqu e of Religions Dick F. Swaab Professor of Neurobiology, The Netherlands
Wilma T. P. Verweij Scientific Secretary, The Netherlands
6.3.1
A FEW FIGURES
How so many absurd rules of conduct, as well as so many absurd religious beliefs, have originated we do not know;. . .. . .; but it is worthy of remark that a belief constantly inculcated during the early years of life, whilst the brain is impressible, appears to acquire almost the nature of an instinct; and the very essence of an instinct is that it is followed independently of reason. —Charles Darwin, The Descent of Man, Part I, p 99–100, 1871
Almost 64% of the world population is either Catholic, Protestant, Muslim or Hindu. For a long time the only belief allowed in China was the belief in communism; religion was viewed as ‘opium for the people’, as Marx had described it. However, in early 2007, onethird of all Chinese people of 16 years and older claimed to be religious. And as this figure comes from a newspaper controlled by the Chinese government, The China Daily, the estimation will certainly not be too high. Approximately 95% of Americans believe in God, 90% pray, 82% say that God can perform miracles and over 70% believe in life after death. What is remarkable is that only 50% believe in hell [1]. In the secularized Netherlands these percentages are lower. The ‘God in the Netherlands’ study of April 2007 showed an increase in secularization from 33% to 61% over a period of 40 years. Although in the Netherlands only 5% are regular churchgoers, the degree of spirituality is much higher. Over 50% of the Dutch have their doubts and may be considered ‘agnostic’ or to believe in ‘something’. Only 14% are atheists, and 14% are Protestants. There are slightly more Catholics (16%). At a symposium in Istanbul in 2006, Herman van Praag, Emeritus Professor of Biological Psychiatry, told me that my atheism could be considered an anomaly, which he based on the 95% of religious believers in the U.S. I replied that that would all depend on which Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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Americans you ask. In 1996 a questionnaire among American scientists showed that the percentage of religious believers among this group was much lower, namely 39%. Among the cream of National Academy of Science scientists in the U.S. only 7% turned out to believe in God [2], and there is hardly a believer to be found among Nobel Laureates [3]. Of the English Fellows of the Royal Society for Science only 3.3% are religious. A distinction could also be made for different disciplines: there tend to be fewer believers in God or a hereafter among biologists than among physicists [4]. Furthermore, meta-analysis showed a negative correlation of the occurrence of atheism with education and IQ. There are thus remarkable differences within a population, and it is clear that the degree of atheism in a society is connected with intelligence, education, scientific achievement and a positive interest in natural science [3]. It is not surprising that the large majority (78%) of eminent evolutionary biologists refer to themselves as ‘pure naturalists’ (¼ materialists). It is noteworthy that only 8% of this group adhered to the NOMA (No Overlapping Magisteria between evolution and religion) principle as posed by Stephen Jay Gould. The large majority (72%) of them considered religion as a social phenomenon that had developed alongside the evolution of Homo sapiens: as a part of, not in contradiction with, evolution [4]. And indeed, the most interesting question as far as I am concerned is not whether God exists, but why so many people are religious in spite of the immense damage that is inflicted by it – not only to outsiders but also to the members of the group by their own religious faith.
6.3.2
A BETTER WORLD WITHOUT RELIGION?
The Lord is a Warlord Exodus 15:3. I have not come to bring peace, but a sword. Matthew 10:34. We shall cast terror into the hearts of those who disbelieve because they ascribe unto Allah partners, for which no warrant hath been revealed. Their habitation is the Fire, and hapless the abode of the wrong-doers. —Qor’aan 3:151
According to the Oxford World Christian Encyclopedia there are currently some 10 000 different religions and billions of believers, all convinced that there is one fundamental truth and that theirs is the one true faith. Unfortunately, a hatred of the followers of other religions seems to be part of the deal – think of the centuries of Christians hating Jews, which led to the pogroms and made the Holocaust possible. And Martin Luther described the Jews as ‘a brood of vipers’. Another example is what happened in India after the British rule. The country was divided into India (for the Hindu population) and Pakistan (for the Muslims) and in the process over 1 million people were slaughtered. And nothing has changed: since the year 2000, 43% of all civil wars have been fought over religion. Like every religion, the Christian tradition, too, has always presented itself as a religion of freedom and humanitarianism. And of course religious believers have done and are doing excellent work, for instance for Jews who had to go into hiding during World War II, or in taking in foster children. But humanitarian behavior, perseverance and courage are properties that are most definitely not reserved for religious believers alone – these are characteristics also of socialists, communists and atheists.
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Would man be better off without religion? I think so. Let me tell you why. Christianity, like other religions, has a history of robbing many of their freedom in an inhumane manner, and has even taken lives in the name of ‘God’s peace’. Experimental psychological studies have shown that reading a Bible text in which God sanctions killing has an aggressionenhancing effect, particularly in people who are religious [5]. The Old Testament bristles with murders, but the New Testament, too, puts up a good show. After Pontius Pilate has washed his hands of the decision to have Christ crucified, Matthew 27:25 reads: ‘his blood be upon us and our children’, and this has been the justification for the Christian anti-Semitic attitude that brought discrimination, persecution and death to countless Jews. Pope John Paul II has – albeit reluctantly – apologized for the Crusades and for the persecution of the Jews. A public condemnation by the Catholic Church itself about the silence that Pope Pius XII maintained about the Holocaust during World War II, when he knew perfectly well what was going on, is long overdue, as are the apologies by the Catholic Church for the Inquisition, and for the Church’s involvement in the slave trade, for discriminating against women, homosexuals and transsexuals, and for forbidding contraception, condemning millions of South Americans to a life of poverty and millions in Africa to infection with AIDS. In 2005 another 3 million people died of AIDS, and 5 million were infected with HIV. And what does the Catholic Church do? It declares that it remains opposed to the use of condoms. ‘In 15 to 20% of the cases, not only do condoms encourage immorality, they are unreliable in the battle against AIDS’, the President of the Pontifical Council for the Family, Cardinal Lo´pez Trujillo claimed in 2004. In 2006, it seemed to have gotten through to Pope Benedict XVI that the Vatican’s ban on the use of condoms will ensure the African continent’s destruction through AIDS. However, if the rumor that the Church would condone the use of condoms for protection exclusively between marriage partners is true, this would still be a criminal guideline. The past couple of years have also revealed the extensive (worldwide) and structural sexual abuse of children by Catholic priests – something that was not a big secret, apparently. Driving somewhere in Switzerland, Alfred Hitchcock reputedly once saw a priest with his hand on a little boy’s shoulder and shouted out of the car window: ‘Run, little boy! Run for your life!’ It is commendable that Pope Benedict in 2008 unequivocally condemned the sexual abuse of children by American Catholic priests. But these kinds of reproaches are definitely not limited to just one religion, as almost every religion imposes its fundamentalistic and outmoded ideas as ‘truth’ on others, often at great cost, sometimes at too great a cost. Examples can be found in every religion, as appeared from the 169 deaths that extreme right-wing Christian Timothy McVeigh, ‘the Oklahoma bomber’ caused by blowing up a government building, or from the murder of 29 Muslims in the Patriarch’s Cave of Hebron by the right-wing Zionist and racist Dr. Baruch Goldstein in Israel, or the 9/11 Twin Tower dead by Osama bin Laden in 2001. The list is endless and timeless. Child sacrifice to the Gods has also occurred throughout history. Mexican history offers many gruesome examples. In 2007, for instance, a grave was found near Mexico City with two dozen skeletons of children between 5 and 15 years old, all neatly laid out, facing east. Somewhere between 950 and 1150 A.D. their throats had been slit by the Toltecs, as a sacrifice to their rain god Thaloc. But these practices are not a thing of the past. To this day, in the Netherlands, a strict Reformed Christian group, bible in hand, sacrifices children through polio, rubella, mumps and meningitis [6]. There is nothing in the Bible about inoculation, but it is deemed contrary to God’s Providence. Jehovah’s witnesses, forced by Church and religion, are not allowed to let their dying child have a
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blood transfusion. On her retirement, Judge Anita Leeser-Gassan told how grateful the parents were when in such cases a judge, in consultation with the physician, ruled that the child was to be given a blood transfusion after all. Is it not terrible when a religion forbids parents such an important, in these cases even lifesaving, decision? As far as Islam is concerned I should mention the maltreatment of women, particularly the practice of female circumcision, a maiming procedure that is still killing many young girls and makes the lives of countless women a misery. In Sudan almost 90% of girls under 10 are circumcised, and a WHO report of 2006 states a worldwide number of circumcised women and girls of 100 million. Strictly speaking circumcision is not an operation propagated by the Koran and indeed, in Egypt, many Christian women are circumcised. But female circumcision tends to be restricted to the Islamic world, and the archconservative clergy are strong advocates and do not hold back on letting us know why. The Egyptian scholar Yusuf-el-Badry of Cairo is of the opinion that female circumcision would solve many problems of the Western world: ‘Western women are not circumcised and behold the result: a licentious society. Women always want sex. Over 70% of the children are illegitimate. A large proportion of the Egyptian women have a clitoris of over 3 cm. They need to be circumcised, in order for them to be able to control their emotions and sexual desires. Otherwise they will be continually excited and frustrated, because they do not get satisfied’. The consequences of female circumcision are horrifying. It causes problems with menstruation and urination and sexual intercourse is torture in many cases. In Africa almost half the babies born to circumcised women die during or shortly after birth. The mothers themselves often suffer heavy haemorrhaging during the birthing process of their babies. And then there is honor killing, suicide bombers, cutting off the right hand and decapitations of hostages and people who convert to a different religion: just a few examples of actions sanctioned by a religion. In July 2007 a man was stoned to death for adultery, with the local judge throwing the first stone. At the slightest provocation Islamic governments orchestrate a public outcry. In September 2006, 12 witty cartoons were published in the Danish newspaper JyllandsPosten ridiculing some extremist Islamic manifestations. In one of these cartoons suicide bombers are stopped at Heaven’s gate because Heaven is running out of the promised virgins. This provoked the rage of Danish Muslims, and after an appeal from this community, Muslims in the Middle East took to the streets in protest. In Jordan and elsewhere in the Middle East Danish products were taken off the shop shelves. The Muslim Brotherhood, Syria, the Islamic Jihad, the ministers of Foreign Affairs of Arabic countries and the Organization of Islamic Conference all acted like they were models of tolerance and demanded apologies. The Editor-in-Chief of the newspaper apologized to any Muslims who felt offended by the cartoons, but this did nothing to calm the mood. Everywhere crowds took to the streets and the cartoons led to people being killed. In a lecture at the University of Regensburg in 2006 Pope Benedict gave an example of an aggressive religious quote of Muhammad, and in order to prove their love of peace Islamic fundamentalists burnt Christian churches in Jordan and killed the Italian nun Leonella Sgorbati in Somalia. Apparently the Islamic world is not yet ready for intellectual discussion. Extremist organizations, such as the Taliban in Afghanistan, Hamas in the Palestinian areas and Hezbollah in the Lebanon are quickly growing in number and popularity. And again it may be said that this is not a specific Muslim problem: what to think of the fundamentalist Christians in the US, with their fanatical pro-life organization, their
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anti-Darwinistic ideas and their homophobia? And what of the extreme right-wing Jewish factions in Israel?
6.3.3
THE EVOLUTIONARY BENEFITS OF RELIGION
The evolution of modern man has gone along with five characteristic behaviors that are found in all cultures, namely language, the making of tools, music, art and religion. The evolutionary advantages of religion have been manifold. (1) Religion served to unite the members of a group. The Jews, for instance, despite Diaspora, inquisition and holocaust, have remained a group through their religious belief. DNA properties, too, show that the roots of this group go back some 3000 years, which is approximately the time of the Exodus, when the Jews escaped from Egypt. There are genetic properties in the Cohen tribe that go back 2100 to 3250 years, somewhere between the Exodus and the destruction of the first temple: the Cohens were strict followers of the rules of the Bible and only Cohen sons were allowed to become priests [7]. For leaders, religion has always been an excellent instrument. As Seneca put it: ‘Religion is regarded by the common people as true, by the wise as false, and by the rulers as useful.’ Even today, social contacts within a group still have advantages for the members and are a very important factor for American churches. All religions have their own way of keeping their group together. * One of the universal mechanisms to hold a group of people together is the strong ‘meme’ (self-replicating piece of culture) that it is a sin to marry an unbeliever (¼ anyone with a different belief). This is a principle that is found in every religion, with its accompanying threats and punishments. Many languages have sayings along the lines of ‘religions do not mix’. Having separate schools for every religious movement unfortunately facilitates a hatred of anything different. * Religions tend to impose many social rules on the individual in the name of God, usually with unequivocal threats to offenders – just look at how the Ten Commandments are formulated. This, too, serves to bind the group together. Blasphemy was a very serious offence in the Old Testament and it is still a capital crime in Pakistan. Intimidation also helped make the various Churches rich and powerful. Just think of the mediaeval ‘indulgences’, vast amounts paid to guarantee a reduced number of days in purgatory. At the beginning of the twentieth century, Catholic clergymen were still absolved of a number of days of purgatory on the basis of their rank in the Catholic Church [3]. There is a Dutch Reformation saying that goes along the lines of ‘Your money into the church coffers buys your soul a place in heaven’. Even today threats and intimidation still work. In Colorado, a reverend has introduced ‘Hell Houses’, where Christian schools send children to scare them about what awaits them after death if they do not keep the religious rules [3]. * Every religion demands that members of the group are recognizable as such by wearing outward signs such as the kippah, the crucifix, the headscarf and the burqa, by physical characteristics, such as circumcision of boys and girls, and by knowledge of the holy writings, prayers and rituals. It is important that members of a group are identifiable as such so that they can be protected. Which is why trying to ban these identifying marks, such as headscarves, is nonsensical.
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For centuries, the ‘we’ feeling of any group has been reinforced by relics, devotedly worshipped. It does not seem to matter that there are cartloads of the ashes of Buddha in temples in China and Japan, nor does it matter that there are so many splinters of the Cross of Christ that Erasmus said a fleet of ships might be built out of them. All these things serve to keep the group together. The same goes for the 20 churches that claim to have the foreskin of Jesus, who, in the Jewish tradition, was circumcised at the age of 8. The claim of these churches is upheld despite the opinion of some theologians that the foreskin would have returned to Christ at the resurrection, or the opinion of the seventeenth-century theologian Leo Allatius that the Preputium Domini had ascended to heaven separately after the death of Christ to form Saturn’s ring. * Also, most religions have rules regarding the promotion of procreation. Even today, many, if not all, religions forbid contraception. * The faith is thus propagated by producing children and by their subsequent indoctrination. In this way the group grows in size and strength. Dawkins [3] gets really angry, and justifiably so, about the term ‘Christian’, ‘Islamic’ or ‘Jewish’ children. Young children do not have a religion. They just have Christian, Islamic or Jewish parents, who imprint something in their children in a very early stage of their development, when they are supersensitive to imprinting. He points out, also justifiably so, that society would not accept it if there was talk of atheist, humanistic or agnostic 4-year-olds, and he says that you should not be teaching children what to think but how to think. He does have a point there, and a strong one, but accepting it would also mean the end of religion. Dawkins [3] sees programmed religion as a byproduct of another property of the child’s brain, a property with a great evolutionary advantage. If children are to be safe they should obey orders from their parents or other figures of authority immediately and without question. The other side of the medal is that children tend to believe everything they are told and indoctrination at a young age is thus easily accomplished. This could explain the continued existence of the religion of the parents and a mechanism for the origin of religion. One might add that early indoctrination of children is fixed in their brains for the rest of their lives, in the same way as their mother tongue is fixed. Copycat behavior (echo-behavior), which is the basis of our (social) learning and draws upon a system of mirror neurons in our brain is a terrifically efficient mechanism. Religious ideas, such as the existence of a life after death, that when you die a martyr’s death you go to paradise and are rewarded with 72 virgins, that unbelievers should be persecuted, that believing in God is the highest good and so on and so forth, are transferred from one generation to the next as ‘memes’. In the same way that genetic properties evolve, some religious memes also evolve. Many of the natural and supernatural phenomena ascribed to God a couple of hundred years ago now have a generally accepted rational explanation. (2) The religious do’s and don’ts used to have clear evolutionary advantages that were partly to do with the protection a group could offer to the individual. However, some rules, such as eating kosher food, also contained elements to promote health. In 1987, within a day after eating mussels from Prince Edward Island, situated in the estuary of the River Cardigan on the Canadian east coast, some 100 people fell seriously ill. Not only did they suffer from nausea and vomiting, they also experienced severe neurological symptoms, such as confusion, headache and paralysis. Seven patients went into a coma, and some of the victims appeared to have severe memory disorders even one year later. They were unable to remember things that people tend never to forget, such as a daughter’s wedding day. A brain autopsy carried out on four people who died of this *
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mussel poisoning revealed considerable damage to the hippocampus and amygdala, two structures essential for memory function. There had been particular weather conditions in Canada that summer that had led to extreme algae growth. The algae (a diatom, Nitzchia pungens) were ingested by the mussels but contained domoic acid, which is toxic to the nervous system: it destroys brain cells by overstimulating them. This seems to be a good explanation for the worldwide advice to avoid eating mussels [8]. And it is not just human beings who are at risk. In 1961, the puffin population of Rio del Mar began to exhibit bizarre behavior. The birds flew into windows and lampposts at full speed. They pecked at people and vomited on them. Alfred Hitchcock reputedly asked for records of this strange avian behavior at the local newspapers and two years later made the film ‘The Birds’, not only as an adaptation of a short story by Daphne Du Maurier, but probably also inspired by the birds in Rio del Mar. After a similar epidemic in Santa Cruz, California, in 1991, where cormorants and pelicans started to behave in a peculiar way, it was shown that these birds, too, had high concentrations of domoic acid. It is an interesting question whether there might be more religious dietary laws that have a basis in public health. According to a number of studies, even today religiosity is accompanied by indicators of a better psychic health, such as a contentment with life, a better mood, being happy, and by fewer cases of depression, suicide and addiction [9, 10], although the causality of these correlations has not been proven and connections are not unequivocal. When you break up the numbers for depression for men and women the favorable effect only seems to apply to women: male regular churchgoers have a higher prevalence for depression [11]. Braam et al. [12] did not find a correlation between prayer frequency and symptoms of depression. Curiously enough, prayer appeared to be correlated with a higher frequency of depressive symptoms in nonchurch going individuals. Flannelly et al. [10], too, found that there is a positive correlation between prayer and psychiatric problems. But please do not stop praying on the basis of these correlations: it might well be that these non churchgoers are simply crying out for help in getting rid of this terrible disease by any means possible, even prayer. Another favorable effect is that religious upbringing reduces the genetic influence on sensation-seeking and disinhibition, especially in boys [13]. (3) A religious conviction offers comfort and help in difficult times, whereas atheists have to solve their problems without help from above. Believers may also reckon that God has given them misery for a reason. It may be a test, it may be punishment, but God is trying to tell them something. Because people tend to strive for something, they believe God, too, must have some sort of purpose, says De Spinoza. According to him, man has come to think of God in the shape of a man because we think that all the useful things in nature have been made to accommodate us by someone who knows what we need and has the power to arrange it. Subsequently all the bad things that happen in nature – earthquakes, accidents, volcano eruptions, epidemics and floods – are seen as punishment by the same ruler of everything. De Spinoza considered religion as a desperate attempt to avert God’s anger. (4) God has the answer to everything we do not know or understand, and having a religion gives a feeling of optimism (‘Clap your hands, shout hurray, Jesus is my friend today’). Being religious also means that you know that, however hard life may be now, it will all be better afterwards, in the hereafter. Strangely enough it is always claimed that an advantage of religion is that your life has ‘meaning’, although it is a mystery to me why one wouldn’t be able to give meaning to one’s life without assistance from God.
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(5) Another thing that religion does is take away a little bit of the fear of death by promising life after death. A belief in the afterlife was already common a hundred thousand years ago, judging by what the deceased were given to take with them in their graves – food, water, tools, hunting gear, and toys for children. Cro Magnon people and modern Asian man were even provided with lots of jewelry: apparently looking good is important in the hereafter as well. However, having a religion does not automatically lessen the fear of death. People who are moderately religious fear death more than people with a very strong or a very weak belief [14] – which is understandable when you see how every religion uses fear as a means to keep people with the group of believers. However, many people still retain a certain degree of uncertainty about the promised life after death. Dawkins [3] rightfully wondered: ‘If you seriously believe in a life after death, why then does not everyone react like the abbot of Ampleforth?’ When Cardinal Basil Hume told the Abbot of Ampleforth that he was dying, the Abbot said, delightedly: ‘Congratulations! That’s brilliant news. I wish I was coming with you.’ Does this mean that many religious believers do not really believe? (6) The right to kill members of other groups in the name of your God has always been a prominent feature of virtually every religion. The evolutionary advantage of the combination of aggression, a recognizable group through religion, and discrimination of others is clear. During millions of years human beings have developed in an environment that offered barely enough food for their group, so any other groups you met in the savannah posed a threat and had to be destroyed. A couple of generations with central heating does not polish away millions of years of evolutionary advantage of the combination of religion and aggression towards other groups. Xenophobia thus remains to this day for a large number of people and the world is full of religious hotbeds of unrest. Since time immemorial ‘God’s peace’ has been violently forced onto others, a situation that does not look as if it will end soon. It took a few sacrifices, but once you belonged to the group you enjoyed many privileges. The group offered protection against other groups, and thus your chances of survival increased. However, the damage that is inflicted – not only to outsiders but also to the members of the group by their own religious faith – is immense. But it is not all bad news: neither religion as a means to keep the group together, nor aggression with the purpose of eliminating the other group will remain advantageous in an evolutionary sense in our globalizing economy and our information society. Both will thus lose their significance in the next couple of hundred thousand years and true freedom and humanity will eventually become possible, also for dissidents and unbelievers, as humankind will break out of the straitjacket of outmoded religious rules. The British politician Evan Luard has written about the changing character of war since the Middle Ages and has calculated that the number of wars is decreasing. This is encouraging news.
6.3.4
SPIRITUALITY, RELIGION AND PSYCHOPATHOLOGY
In 1995 a new category was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) IVunder ‘Other conditions that might be a focus of clinical attention’ [15]. This category, with the topic ‘religious and spiritual problems’, better recognized cultural differences and the special reactions of the brain than the DSM had done until then. For
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instance, near-death experiences are no longer considered to be related to an underlying psychiatric problem, but as a normal reaction of the brain to hypoxia or to a major stressor. The result of a spiritual experience, such as a near-death experience, is often that one’s religious fervor increases. A terminal disease, too, is often accompanied by an increased interest in religious or spiritual matters. However, religious and spiritual problems may also be based exclusively on the belief itself, for instance when they are caused by the stress of losing or changing one’s religion. Changing one’s religion may cause a great deal of stress. In an Islamic country such as Afghanistan, a conversion to Christianity is still punishable by death; a fate only to be avoided if you are declared ‘insane’. The terms ‘spirituality’ and ‘religion’ are often used as if they are interchangeable. However, for the sake of clarity it would be better to use the term ‘religion’ for a religious faith and the practices of an organized church or religious institution. The term ‘spirituality’ may be used to describe the transcendent relationship between a person and a ‘higher being’ unconnected to churches or other organizations. Hamer [7] views spirituality as a property that every human being possesses to a certain extent, without there being question of a universal theology. Also in the Netherlands a growing number of people say they are no longer religious but still believe in a ‘spiritual force’ or in ‘something’, and these people, too, may have mystical experiences. Spiritual experiences may get out of hand and result in psychopathology. Also, it is not always easy to distinguish intense spiritual experiences from psychopathology. On Boxing Day 2005, Radio Rijnmond journalist Paul Verspeek asked a psychiatrist how he would be able to identify the real Christ if he were to return to earth. How would he recognize him among the patients he’d just interviewed and who all claimed to be Christ? The psychiatrist was unable to give a satisfactory answer. In the 1960s, meditation and an interest in paranormal phenomena were all the rage, substance abuse soared, and many people experienced psychiatric problems through spiritual experiences they were unable to control and that completely upset their psychological, social and professional functioning. However, there are cultures and religions in which voluntary meditation, trance, depersonalization and derealization are common practice and cannot be seenasdisorders according to the DSM.Practicesthatareviewedbyourcultureasdeceptionsor delusions, such as magic, voodoo or witchcraft, are perfectly acceptable in other cultures. Also visual or auditive hallucinations of a religious nature, such as apparitions by the Virgin Mary or hearing God’s voice, are a normal part of such religious experiences. But a large percentage of psychotic patients, too, are religious. In many cases their interest in spirituality has been fuelled by their psychosis but they also use religion as a means to copewith their disease [16]. Religious and spiritual problems tend to feature in manic psychoses. The psychotic episodes of former Dutch State Secretary Klein are an example and are described below. It is thus important to balance any religious problems of a culture and time against the accepted religious situation of a person’s environment in order to be able to distinguish the ‘purely’ religious problems from the neurological or psychiatric ones.
6.3.5
SPIRITUALITY AS NEUROLOGICAL BASIS FOR RELIGION
I believe in God, only I spell it Nature (Frank Lloyd Wright. Quoted by D. Hamer, 2004, p. 26). This statement by Frank Lloyd Wright is undoubtedly based on De Spinoza, according to whom God and Nature were one (Deus sive Natura).
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A number of neurobiological substrates play a role in ‘normal’ religious experiences and in the mechanisms that cause neurological and psychiatric syndromes to be accompanied by changes in religious experiences. Neuropsychological research and functional imaging show the importance of the ventromedial area and the temporal and frontal cortex for religious experiences. Neuropharmacological research has pointed out the great significance of activation of the dopaminergic system for such experiences. The clinic, too, provides relevant information. For instance, Alzheimer’s disease is accompanied by a progressive loss of religious zeal. The slower the progression of this disease, the lesser the degree in which religiosity and spirituality are affected [17]. Hyperreligiosity, however, is found in frontotemporal dementia, mania, obsessive-compulsive behavior, schizophrenia and temporal lobe epilepsy and a number of these disorders are known to be accompanied by a heightened activity of the ventromedial dopaminergic system, which is related to reward [1]. Yes, spiritual experiences can be visualized as brain activity. But so can everything we do, think and experience. It is not proof for or against the existence of God. During an fMRI test Carmelite nuns were asked to recollect their single most mystical ‘Christian’ experience. A mystical experience is characterized by the sense of being one with God. It may also involve the feeling of having found the one truth, to have lost all sense of space and time, to be one with humanity and the universe, and to feel peace and unconditional love. When these nuns called such experiences to mind, a complex activation pattern of brain areas occurred. There was an activation of (i) the medial part of the temporal lobe, which could have a relation with the feeling of being one with God (see temporal lobe epilepsy), (ii) the caudate nucleus, which may be related to the sensations of joy and unconditional love, and (iii) the brainstem, the insula and the prefrontal cortex, possibly to do with the somatovisceral and autonomic reactions inherent to these emotions and the cortical realization of it. Also (iv) there was an activation of the parietal cortex that may be connected with the feeling of changes in the body scheme [18]. Becoming a religious person or not is most certainly not a matter of free choice. The environment in which a person grows up is a determining factor. It ensures that the religion of the parents is fixed in the child’s brain circuits during early development. The environment also fixes the customs and rituals of a religion in our brain, in a way that is similar to the way our mother tongue is fixed. However, for an important part the susceptibility for religion is genetically determined. Twin studies have shown that genetic factors determine some 50% of the variance in religious interest [19]. It is therefore remarkable that the Intelligent-Designer (ID) Jitse Van de Meer (in Dekker et al.) [20], without giving numbers, claims: ‘There is a modest genetic influence of religious and moral values. Upbringing and tradition have the largest influence’. Apparently the ID-aficionados are not too fussy about facts. The degree of binding of a PET radioligand to the 5HT1A receptors has a negative correlation with scores for spiritual experiences. The serotonergic system could thus be a biological basis for these experiences. Another indication is the fact that substances such as LSD, mescaline (from the peyote cactus) and the serotonin agonist psilocybine may induce mystical and spiritual experiences. Even though the spiritual experiences caused by salvatorin A, which acts on the kappa-opioid receptor, show that the serotonergic system is not the only system involved [21], the monoamines are now the center of attention due to Dean Hamer’s research [7]. Hamer’s research does not focus on the question that cannot be answered, namely whether God exists, but on the question why people believe. After all,
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religions are found all over the world, and the objects that archaeologists encounter in graves show that a belief in the hereafter is not only universal but of all times. Hamer makes a distinction between spirituality and religiosity. Twin studies have shown that spirituality is transferred by our genes for about 50%. Religion is the local interpretation, transferred by ‘memes’. Dean Hamer’s ‘God’ gene is probably one of the many genes that determine our degree of spirituality. This gene codes for VMAT2 (the vesicular monoamine transporter-2). A combination of molecular genetics and psychological tests led Hamer to a clear association between VMAT2 polymorphisms and spirituality. It is a protein that packages monoamines in vesicles for transportation by which the effect of neurotoxins on the monoamines decreases. VMAT2 is decreased in the substantia nigra of Parkinson’s patients and is less able to protect these cells against toxic effects. Also, VMAT2 in the substantia nigra appears to be involved in the formation of Lewy bodies, typical for Parkinson’s disease [22]. These are not functions that call up an immediate association with religion, but maybe the function of the VMAT2 in relation to spirituality is mainly coupled with the dopaminergic (reward) system of the ventral tegmentum and the nucleus accumbens, or with the innervation of the caudate nucleus.
6.3.6 TEMPORAL LOBE EPILEPSY AND RELIGIOUS DELUSIONS: PEAK EXPERIENCES Do not consult the gods to discover the directing soul, but consult an anatomist. —Galenus, second century
The often deeply religious/cosmic peak experiences that patients with temporal lobe epilepsy go through, due to, for instance, a tumor or to mesial/hippocampal sclerosis, is where, intriguingly, religion and neuroscience meet. The few recently studied cases of ecstatic epileptic attack all involved a temporal or peritemporal substrate. One of the epileptic patients did not only see a bright light, but also a young, bearded man who looked like Jesus. This patient turned out to have a tumor on the front right-hand side of the temporal lobe, an astrocytoma, and when this tumor was removed, the ecstatic epileptic attacks disappeared [19]. Ecstatic experiences in temporal lobe epilepsy are rare [23]. Most temporal lobe epilepsy patients merely reach a dreamlike state and experience symptoms such as deja vecu (‘it’s like reliving an old memory,’ as one patient spontaneously described it) and deja vu, complex visual hallucinations with vistas and persons in it that give the patient the feeling of being in unreal surroundings. These patients may be able to look back to when they were children in a particular situation – hallucinations that appear to be based on real memories from the past. These epileptic attacks are caused by strong neuronal discharges, usually in the right temporal-hippocampal area. The amygdala, hippocampus and parahippocampal gyrus are involved in this type of disorder [24]. In some cases the epileptic activity triggers circuits involved in religious experience. The attacks may consist of ‘visitations from God’ and although they usually last only 30 seconds to a few minutes, they may change one’s personality forever. Electrical stimulation of this area in experimental animals (‘kindling’) may also have lasting effects. A number of arguments argue for the possibility that a defect in the glutamate transmission could be a neurobiological basis for the susceptibility to the genesis of such electrical discharges. The levels of this excitatory neurotransmitter are increased in patients with epilepsy.
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Patients with temporal lobe epilepsy due to hippocampal sclerosis produce less glutamate transporter but more alternative splice variants of this protein [25, 26]. During the attack the patients are often in a dreamlike state and have auditive and visual hallucinations that are frequently of a religious nature. They sometimes have out-of-body experiences, often undergo emotional changes and may turn hyperreligious. Approximately 23% of postictal psychoses has a religious content. In between attacks, these patients often display the ‘Geschwind syndrome’, a syndrome characterized by, among other things, hypergraphia, hyposexuality and hyperreligiosity [19, 27]. Hyperreligiosity as a psychiatric symptom that occurs in between epileptic episodes is probably rare. However, a number of founders of large religious movements, prophets and religious leaders, among whom were the apostle Paul, Muhammad and Joan of Arc, most likely had temporal lobe epilepsy. It is also likely that Dostoevsky and Vincent van Gogh suffered from this form of epilepsy [19].
6.3.6.1
The apostle Paul
A famous episode is the one Paul had on the road to Damascus, when he was still using his Hebrew name Saul and hunted early Christians. The description of this ecstatic event can be found in Acts of the Apostles 9 (1–9): 9:3 ‘And as he journeyed, he came near Damascus: and suddenly there shined round about him a light from heaven: 9:4 And he fell to the earth, and heard a voice saying unto him, Saul, Saul, why persecutest thou me? 9:5 And he said, Who art thou, Lord? And the Lord said, I am Jesus whom thou persecutest. . . And he was three days without sight.’ A temporary cortical blindness after a grand mal epileptic insult, as well as conversion, both of which happened to Paul, have been described regularly in temporal lobe epilepsy [28]. The apostle Paul also describes, in Corinthians 12: 1–9, in the third person, his periods of ecstasy, which were accompanied by visual and auditive hallucinations, in which he went to paradise, experienced an aura of depersonalization, and where he may have had an out-ofbody experience. These moments of ecstasy were followed by a grand mal epileptic seizure: ‘. . .I must boast; not that it is profitable, but I will go on to visions and revelations of the Lord. I know someone in Christ who, fourteen years ago (whether in the body or out of the body I do not know, God knows), was caught up to the third heaven. And I know that this person (whether in the body or out of the body I do not know, God knows) was caught up into Paradise and heard ineffable things, which no one may utter. About this person I will boast, but about myself I will not boast, except about my weaknesses. Although if I should wish to boast, I would not be foolish, for I would be telling the truth. But I refrain, so that no one may think more of me than what he sees in me or hears from me because of the abundance of the revelations. Therefore, that I might not become too elated, a thorn in the flesh was given to me, an angel of Satan, to beat me, to keep me from being too elated. Three times I begged the Lord about this, that it might leave me. . .’ The temporal lobe epilepsy diagnosis is not based upon just this episode. Paul had visual hallucinations more often than once, as his historian Luke says. In one of these hallucinations Jesus spoke to him in an encouraging way, in another one he went into a trance during prayer in Jerusalem and saw Jesus.
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Muhammad
Muhammad, founder of Islam, was born in Mecca in 570 and died in Medina in 632. He was an orphan and was raised first by his grandfather and then by his uncle, Abu Talib. When Muhammad was 6 years old he had his first experience of being ‘possessed’, after which he experienced a number of epileptic insults all accompanied by religious experiences. This is the reason why an Arabic author called epilepsy ‘The divine disease’ [29]. In 610 A.D. Muhammad has his first visions. Lying asleep in a remote place in the hills around Mecca, to where he often withdrew to meditate, he hears a voice, which he later ascribed to the Archangel Gabriel that orders him: ‘Read (Ikra)’. Muhammad answered: ‘I cannot read’. The voice repeated: ‘Read, in the name of your God the creator.’ Muhammad believes himself to be possessed and wants to throw himself off the mountain, but whilst running he hears a voice from heaven: ‘Oh, Muhammad, thou art God’s prophet and I am Gabriel.’ Muhammad stops and sees the angel in the sky around him, in the form of a man. After a while Gabriel disappears and Muhammad returns home. Muhammad kept having visions, from that first time in the Hira cave until his death. His attacks were accompanied by heavy perspiration and paleness, he moved like a drunkard and fell to the floor. During such attacks he had auditive and visual hallucinations. Muhammad said that the messages sometimes came to him from an angel in human form and sometimes as the sound of a bell. The latter statement makes it likely that he also had a musicogenic form of reflex epilepsy, just like Joan of Arc and Dostoevsky. After a number of years in which he repeatedly saw the angel Gabriel he began to think of himself as a prophet [29; 30; 31). His wife Khadija, a rich widow who owned a trading firm in Mecca whom he married when he was 25 and who was 15 years older than him, was the first – and for a long time the only one – to believe that Muhammad was a prophet. But he did not acquire followers in Mecca. The Koran says [11, 27]: So the chiefs of his people who disbelieved replied, we are not seeing that you are anything more than a man like us, and we are not seeing that any people have followed you except those who are the meanest among us, and we have not seen in you people any superiority over us; rather, we believe that you are liars. Because he is unable to find an audience in Mecca, he travels to Medina in 622 – the beginning of the Islamic calendar. He manages to put an end to the tribal wars in Medina and a Muslim community begins to grow. The Jews, who refuse to acknowledge him as a prophet, are persecuted mercilessly. He leads 26 battles, at long last conquers Mecca and dedicates the Ka’aba, reputedly founded by Abraham, to Allah. Upon Muhammad’s death in 632 almost the entire Arabic peninsula had been converted and the revelations of Gabriel were noted down and collected as the suras (chapters) of the Koran.
6.3.6.3
Joan of Arc
Joan of Arc was born in 1412 in the French village of Domremy as a farmer’s daughter and was burned at the stake in Rouen when she was only 19 years old, on 30 May 1431, for practicing witchcraft. Her life history, including her epileptic attacks, has been minutely documented by the Inquisition in the account of her trial, as well as by the Church when she was rehabilitated 25 years later.
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Joan was 13 when she first heard the voice of God. The first time she found it a frightening sensation. The voice came from the right and was usually preceded by a bright light from the same side. When she heard the voice for the third time she recognized it as that of an angel. From then on the attacks were always preceded by a voice, followed by the appearance of saints, who proceeded to advise her daily during her campaigns. A couple of times a week the voice instructed her to march to France, to the besieged city of Orleans, which she cleansed of the English. She then went on and liberated the area around the River Loire. On 16 July of that year Reims was freed and the Dauphin was crowned King Charles VII in the cathedral, with Joan holding her standard above his head. But she was consequently denied military support against the English, and was captured and delivered to the English. Charles VII did nothing. During the extraordinarily unfair trial held by the Inquisition, Joan eventually retracted hearing voices and declared herself willing to wear women’s clothes again. However, she was tricked and the women’s clothes were taken away and she was forced to dress in men’s clothes again, upon which she was sentenced to death for recidivism. On the request of her mother, Pope Callixtus reviewed the trial in 1450, which led to Joan’s rehabilitation in 1456. She was beatified in 1909, and declared a saint in 1920. Her epileptic attacks were sometimes characterized by a musicogenic form of reflex epilepsy, where her attacks were brought on by church bells, which had a profoundly emotional effect on her. The sound caused her to fall to her knees immediately, even when she was in the thick of the battle. The attacks were accompanied with ecstatic auras and with a strong sense of bliss that made her cry when it was over. A generalized epileptic attack of Joan of Arc has never been reported. In between the attacks she had all 18 personality traits of the Geschwind syndrome, such as, for instance, emotionality, euphoria, the notion of having a mission, loss of sense of humor, demureness, a strong morality, asexuality, impatience, aggression, depression, suicidal tendencies and deeply religious feelings. It has been suggested she had a tuberculum on the left temporal side, but any proof of this is lacking [31].
6.3.6.4
Vincent Van Gogh
Vincent Van Gogh was born in 1853 and committed suicide in 1890. Today, still, the medical literature is rife with speculations about the diseases Van Gogh might have suffered from: acute intermittent porphyria, epilepsy, manic-depressive psychosis, schizophrenia, neurosyphilis, lead poisoning, Meniere’s disease, alcoholism, all described with pros and cons. But whatever was ailing him, everyone seems to agree that his life style had a lot to do with it. He neglected himself as far as nutrition was concerned, had gonorrhea, used alcohol (absinthe), took camphor and was exposed to turpentine [32]. However, I agree with Voskuil [33] that the most likely diagnosis is temporal lobe epilepsy, which started in 1889 with an aura that was not only mentioned by Van Gogh himself, but was witnessed by another party as well. Van Gogh suffered from partial epileptic insults, without convulsions but with postictal psychosis and personality disorders. He was admitted in Saint-Remy-de-Provence in 1889 for epilepsy, a disease that ran in his family. During the psychotic attacks, he experienced visual and auditive hallucinations and bizarre religious and paranoid delusions. It was during one of these attacks that he cut off his own ear and sent it as a gift to Rachel, a local prostitute. He also had attacks that left him unconscious and of which he later had no memory. In between the attacks he had the
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characteristics of the Geschwind syndrome with an intact intellect, a hypergraphia that not only manifested itself in the writing of over 600 letters to his brother, but also in an enormous production of paintings. During his final six years he produced an average of one oil painting every other day. He also became more and more religious from his 20th year onwards and read and reread the Bible obsessively in 1886. He wanted to join the clergy, but was rejected on the grounds of his personal characteristics. In 1887 he worked on a Bible translation into French, German and English. He attended four different church services on Sundays and on the wall of his house in Arles he wrote: ‘I am the holy spirit. . .’. Trimble [30] concludes that Vincent Van Gogh suffered from psychomotor epilepsy with a medial temporal focus.
6.3.6.5
Dostoevsky
The Russian writer Dostoevsky (1821–1881) was arrested in 1849 and sentenced to death because of his membership of a radical political discussion group. He was facing the firing squad when the message came that his sentence had been commuted to four years’ hard labour in Siberia. He had never been robust and his health worsened dramatically during this period in his life. He suffered hundreds of complex partial epileptic attacks and in his book The Idiot wrote in lyrical terms about the religious experiences that occurred during the ecstatic auras, that he said he would not have missed for the world: ‘All of you, healthy people cannot even suspect what happiness is, that happiness which we epileptics experience, for a second before the falling seizure. Muhammad in his Koran assures us that he saw Paradise and was in it. All the wise fools are convinced that he is simply a liar and deceiver. But no! He doesn’t lie! He really was in Paradise during an attack of epilepsy, from which he suffered just as I do. I don’t know whether that blessedness lasts for seconds or hours or months, but trust my word, all the joys that life can bestow I would not take in exchange for it.’ The auras thus appear to last longer than they actually do, as they generally last between 20 to 30 seconds. Remarkably, the reference to Muhammad does not seem to have made it to many of the translations from the Russian (V. Goncharuk, pers. Communic.; Dostoevsky [34, 35]). Dostoevsky also wrote about the religious content of these auras: ‘. . . I felt the heaven was going down upon the earth, and that it had engulfed me. I have really touched God. He came into me myself; yes, God exists, I cried. And that is all I remember.’ This probably means he had a general epileptic attack to follow. The ecstatic auras that Dostoevsky experiences, sometimes every three days, sometimes once a week, are also described in his book Devils (The Possessed): ‘There are seconds— they come five or six at a time—when you suddenly feel the presence of the eternal harmony perfectly attained. It’s something not earthly—. . .—oh, there’s something in it higher than love—what’s most awful is that it’s terribly clear and such joy. If it lasted more than five seconds, the soul could not endure it and must perish. In those five seconds I live through a lifetime, and I’d give my whole life for them, because they are worth it.’ One of his general epileptic attacks was brought about by the ringing of church bells on an Easter Sunday – a musicogenic reflex epilepsy. At the time, Geschwind said that Dostoevsky’s attacks were typical of a temporal lobe epilepsy [36]. Tuberculosis has been suggested as a cause of epilepsy, but that is pure speculation [31]. The same goes for those that expressed a suspicion that he may have had syphilis.
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The exact nature of the Geschwind syndrome symptoms, the character of the person in between the attacks and the manifestation of the aura itself depend on the sufferer’s cultural background. Kumagusu Minakata (1867–1941) was a Japanese genius who suffered from this syndrome. He was author of an immense amount of publications, 1142 of which – on a large variety of scientific subjects – were in Japanese. He discovered new types of myxomycetes, published 50 articles in Nature and reputedly spoke 20 different languages. He documented his epileptic attacks in his diary and in between attacks he showed all the characteristics of the Geschwind syndrome. Fifty years after his death, MRI of his fixated brain established that his right hippocampus was atrophic, a characteristic of temporal lobe epilepsy [37]. Another Japanese patient who on several occasions called out: ‘I saw my God’ saw the image of God as it is known in a new Japanese religion [23]. Undoubtedly to the disappointment of many in the Western world there has never been a report of anyone with this syndrome in a non-Western environment seeing Jesus or a Western image of God. Apparently anything that is imprinted into our brain in early development comes out again during temporal lobe epilepsy. However, I would like to see more systematic transcultural studies about this subject.
6.3.7
RELIGIOUS DELUSIONS IN PSYCHIATRIC DISORDERS
When one person suffers from a delusion, it is called insanity. When many people suffer from a delusion, it is called Religion [3].
Twenty-three percent of postictal psychoses in epileptic patients have a religious content [19]. Religious delusions occur in 3% of schizophrenic patients and are also reported in other psychiatric disorders, such as mania and depression, and as a prodromal occurrence in frontotemporal dementia (chromosome 17-related) [19, 38). The assassination of Anna Lindh, the Swedish minister of foreign affairs, on 10 September 2003 was ‘ordered by Jesus’. The 25-year-old psychiatric patient Mijailo Mijailovic felt chosen by Jesus and was unable to resist the voices commanding him to commit murder. Near-death experiences (see later on) may also be accompanied by religious experiences. A woman with a pulmonary embolism said she had been sent back to earth from heaven by Jesus to look after her children [39]. Not only is the temporal lobe involved in ecstatic experiences, an activation of the prefrontal cortex, as well as mystical experiences as they are described in the Christian and the Jewish faith and in Buddhism, may go hand in hand with grandiose ideas and experiences and with hyperreligiosity [38]. There have been many examples of manic religious leaders throughout the centuries. In 1665, in Smyrna in the Ottoman kingdom, the manic-depressive mystic Shabbetai Tsvi was proclaimed King Messiah. His message was embraced by many and an enormous amount of Jews moved to Palestine. Less than a year later, however, he was forced to convert to Islam by the Sultan, who did not appreciate the amount of unrest it all caused. A Dutch example of a religious delusion accompanying a psychiatric disorder is the story of State Secretary Ger Klein. I first got to know Ger Klein when, in the summer of 1975, in his capacity as State Secretary of the Ministry of Education, Culture and Science in Prime Minister Joop den Uyl’s Cabinet, he was forced to cut back by 200 million guilders on his
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budget and in one stroke of his pen got rid of our Netherlands Institute for Brain Research (which was in the process of finding a new director), as well as of the Netherlands Institute for War Documentation (NIOD – then the RIOD), led by Professor Lou de Jong, the ANS space project, and a few other institutions. I was 31 years old at the time, had no administrative experience, but was set the task, together with the other researchers of the institute, of trying to reverse the decision of the Cabinet. After talks with all parliamentary parties and an extensive campaign, we were at last successful when on December 17, 1975, a motion and an amendment against the closure of the Netherlands Institute for Brain Research were accepted by the Second Chamber of the Dutch Parliament. But while the negotiations were still ongoing, Klein and I developed a rapport, despite our opposing interests, backgrounds and characters. On 6 November 1978, at a press conference, Lou de Jong made an emotional statement about the Waffen SS past of Willem Aantjes, the member of parliament for the (newly formed) CDA, the Christian Democratic party. This was a mistake, he had been a member of a different organization, the Germanic SS. Aantjes had to step down and Klein, who had been in Parliament for a year, but had gained experience in the previous years as State Secretary and had been responsible for the NIOD, was confounded by De Jong’s behavior, which went against all agreements and felt more like a summary execution. Klein was of the opinion that De Jong, with whom he had had run-ins before, when he was State Secretary, should have let the government deal with the investigation of this file. He got enraged and worked incredibly hard on the answers to the questions from the members of Parliament and the preparation of the debate. One morning he had already drunk three liters of strong coffee in the space of four hours. But Klein was passed over by the Labour Party PvdA as spokesman for the Aantjes debate and during the debate he was mercilessly cut down by education minister Arie Pais. Driving home after the debate of 17 November 1978 he felt an enormous thud in his forehead – the start of his manic episode, about which he wrote a fascinating book, Over de Rooie, in 1994 [40], in which he describes how he thought he had had a brain operation and that he was being controlled from the outside. A booming voice told him: ‘You are not just God, no, you are the God of Gods.’ He stood outside a supermarket and announced the humanistic blessing that awaited the passers-by. Klein was not at all surprised that people did not stop but hurried on, because his messages were so important they needed to be executed at speed. At one point he ran around outside in the nude in the freezing cold. After the manic episode he descended into a horrible depression on 16 February 1979. After reading Klein’s immensely fascinating book I wrote him a little note. I asked him if he remembered me and told him that, after 19 years, we once again had something in common: manic-depression. I enclosed some of our publications about research on postmortem brain tissue of patients who had suffered from this disorder. On 20 October 1994 I received a very nice, long letter, which I still keep in his book. ‘Of course I remember, almost every detail of, the discussions the ministry had with your delegation about the closing down of your institute. . . The forced compulsive economizing almost cost me my (political) head, but, also because of what I have heard from you, I am convinced that you are content with your achievement. . . Of course, the Manic Depression research interests me greatly. Perhaps we could meet in the near future so that I, a layman, may be enlightened about any scientific progress re. MD. Are you interested?’ Of course I immediately invited him over to the Institute, but he died in December 1998 without having taken me up on it. I do not know the circumstances of his death.
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6.3.8 NEAR DEATH EXPERIENCES: NO ‘PROOF’ OF AN AFTERLIFE Until recently, a near-death experience (NDE) was only of interest to physicians who attributed a spiritual meaning to it. NDEs have often been interpreted as proof of the existence of a hereafter, and people who have had a NDE reckon they have caught a glimpse of this afterlife. Some see NDE as proof of a consciousness separate from the brain [41–43). NDE is an actual, real, experience with a stereotypical content that feels so special that it cannot be easily discussed with others. It involves a sense of peace and rest, of painlessness and the feeling of being dead. One travels at high speed from a dark room through a tunnel with bright light at the end, arriving in a glorious landscape of brilliant colors and flowers. Sometimes there is music, sometimes an irritating noise. One sees deceased friends and family members, or mysterious strangers – either thought to be spirits or known religious figures. The religious figures that are seen tend to correspond with the particular faith of the person involved. Christians see Jesus and Hindus see the messengers of Yamraj coming to take them away [44]. Time appears to speed up, one sees one’s life flashing past, and one may see the future. A sense of understanding everything, of being one with the universe, floods in. Then a boundary is reached and one returns to one’s own body. Usually these experiences do not come across as frightening but rather as pleasant, and in many cases those who have experienced them develop a greater interest in spiritual movements and an increase in religious feeling. They also come to fear death less and may begin to believe in a hereafter. Not so strange, when you hear that a woman with lung embolism saw Jesus after a caesarian, as well as two deceased family members. Jesus himself ordered her to return from heaven to earth to look after her children [39]. NDEs may occur under all circumstances that cause the brain to cease to function properly, such as hypoxia due to cardiac arrest, severe blood loss, septic or anaphylactic shock, electrocution, coma due to brain damage or a cerebrovascular accident, suicide, neardrowning, or during a depression. A NDE may also be caused by excessive CO2 levels, by passing out, notably seen in fighter pilots when they accelerate too quickly, by hyperventilation, or by the use of LSD, psilocybine or mescaline. Such experiences have also been reported after the use of ketamine, an anaesthetic agent. A NDE may also occur when experiencing mortal fear, for instance in a near fatal car accident or in situations of isolation, for instance in a shipwreck, or during a mountaineering accident. That dangerous (life threatening) situations may lead to a NDE points to the possible role of an arousal system, such as the locus coeruleus, or of the stress system, the hypothalamo-hypophysioadrenal axis and its stress hormone cortisol. NDEs are not rare. A large study found that approximately 6% of Europeans has had an out-of-body experience and autoscopy [45]. Depending on the criteria employed, some 12–18% of survivors of cardiac arrest are reported to have had a near-death experience. Women have more frequent and more intense NDEs than men. Also, NDEs occur more often in young people than in elderly people. As these experiences are far from rare it has been suggested that they may have shaped the generally accepted view of the afterlife propagated by religions. Most people interpret their NDE as something they actually experienced. They are convinced that they did leave their bodies and actually went to the hereafter. One of my PhD students did not think so. When he had a cardiac arrhythmia and was lying on the floor he could hear the voices around him but was unable to answer. From above he saw himself
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lying on the ground. The remarkable thing about his experience was that he was aware at that moment that he merely thought he saw it, but knew he did not really see it. In his words: ‘I realized full well that it was not really so but that I was imagining that I was hovering. I heard my wife standing next to me, not below me. I mentally analyzed my situation: I am lying on the floor, the window is over there, the door is there, the sofa is some 3 m away, I am lying in front of the door, can hear but not see, cannot respond. The hovering is apparently projected partly visually. Very odd, but no panic or concern’. A genuine scientist, then, who cannot be tricked, not even during a NDE. Other evidence that a near-death experience is not a real experience is that some people who hovered above themselves and saw themselves lying there noticed they were wearing unfamiliar clothes, such as a woman who saw herself wearing boots she definitely knew she did not own [46].
6.3.8.1
Neurobiological explanations of NDE
Some patients who experienced a NDE while staying in a clinic were diagnosed as ‘clinically dead’, i.e. unconscious due to the halting of the circulation and respiration. Clinical death was sometimes even objectified by the absence of an ECG or EEG. Sometimes enlarged and unresponsive pupils are reported and irreversible brain damage will then occur within 5 to 10 minutes. The ‘certainty’ that this is based on the death of neurons due to oxygen deprivation must be revised, as it is possible to keep brain cells alive in culture for weeks as long as they have been obtained within 10 hours after death [47]. Apparently it is not the neurons that are so extremely sensitive to hypoxia, as we have come to believe. Probably endothelial cell swelling in the capillaries prevents recovery of the circulation. Of course it is curious that one is able to remember such clear images from a time when one was unconscious as far as bystanders were concerned. However, this does not mean that all brain cells stop functioning at the moment you become unconscious or regain consciousness. There is a sound neurobiological explanation for every aspect of a neardeath experience. It is unknown when exactly the near-death experience occurs and how short a time the brain needs to produce the experience. It may well be that this experience is initiated in the first stage of unconsciousness or in the recovery phase; both are phases when there is some oxygen flow to the brain. After all, temporal lobe epilepsy experiences are similar and also last less than 30 seconds. In the rat brain, the energy store drops to one third in half a minute, when there is a total lack of circulation [48]. The fact that patients are able to relate detailed memories about their surroundings from the time they were unconscious merely shows that it is possible to observe and remember even when the brain is not working at its best. There are other examples of this, too. Patients under full anaesthetic are sometimes able to remember the conversation among their surgeons [49]; apparently sensory stimuli manage to reach the cortex in patients under anesthesia. fMRI studies in comatose patients have also shown cortical activity. Seeing a tunnel with bright light and colors at the end of it during a fainting fit may be explained by the disappearance – within 5–8 seconds – of the peripheral blood flow of the retina. This mechanism was confirmed by creating a vacuum in diving goggles, which turned out to induce the same phenomenon [50].
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There are many similarities between REM sleep and a NDE. Nelson et al. [50] therefore suggest that a REM intrusion – a mixed state of awareness, brought on by a glitch in the circuitry, where the brain is both in REM sleep and partially awake at the same time – might contribute to our knowledge of NDE. REM intrusions also occur in healthy, fully conscious persons but tend not to be recognized as such. They may manifest as visual hallucinations on falling asleep or on waking up. Of the healthy population, 25–40% has experienced an isolated sleep paralysis with features of a NDE, such as sensing a presence, auditive or visual hallucinations, sleep paralysis, the feeling of floating or flying or of leaving one’s body [51, 52]. Sleep-related hallucinations occur in 19% of the healthy population. People who have experienced it have an arousal system that predisposes them to REM intrusions [45]. People who once had a NDE more often have REM intrusions than people who have not had a NDE. Seventy-six percent of those who did have a NDE also had an out-of-body experience and autoscopy. Apparently the arousal system in these people is predisposed to react in this way. It is assumed that the amygdala, which is strongly activated during REM episodes, plays a role in the out-of-body experience (45, 50). What is also important in relation to NDE is that cardiovascular problems may intrude on REM episodes. Some neurological disorders feature regular REM intrusions. Narcolepsy patients, for instance, have very frequent hallucinations on falling asleep or waking up, accompanied by sleep paralysis. REM episode intrusions also occur in Parkinson’s patients, and these are blamed on a narcolepsy-like REM disorder in this disease. And indeed: we have recently found a clear decrease of the number of orexin/ hypocretin-containing neurons in the lateral hypothalamus, and of the amount of this peptide in the cortex and CSF of Parkinson’s patients. These kinds of changes are found to a large degree in narcolepsy [53]. People with a lesion near the cerebral pedunculi may have complex visual hallucinations and may see a tunnel with a golden bridge at the end. They sometimes see angels and may have the feeling they are floating [50]. As only a part (6–18%) of ‘clinically dead’ patients experience a NDE, Van Lommel [43] says that this cannot be explained in a purely physiological sense (i.e. hypoxia), as all clinically dead patients have hypoxia. Which is of course true, but the conclusion he draws is incorrect, as for this hallucination to occur it is vital that the brain is stimulated in a specific way and in a particular location by a specific degree of hypoxia. Also, the memory must remain intact in such a way that the experience is remembered. And indeed, Van Lommel’s own research [42] reports fewer NDEs when the memory is damaged after lengthy resuscitation. A worsened memory function may also explain why these experiences occur less in older people. Also, some people are more sensitive to the occurrence of a NDE than others. In addition, autoscopy may be induced not only by hypoxia or epileptic activity, but also by a dangerous situation that is not a deadly threat in the medical sense [50]. Hypoxia is thus not the only trigger for a NDE. Much of the mysticism of a NDE disappears when one realizes that essential features of such an experience can also be called up by stimulating certain brain areas. Electrical stimulation of the temporal lobe, the hippocampus or the gyrus angularis, located on top of the parieto-temporal junction, may induce aspects of a NDE, for instance the sense of leaving one’s body [54, 55]. Blanke et al. [54] describe a patient who, while her gyrus angularis was being stimulated, said her legs were growing shorter and that she then felt her body rise up and float above the bed. Stimulation of this area caused by the brain itself may also cause such experiences. In six patients with a neurological disorder (five epileptics, one who had had a small brain infarction and suffered from migraines) who reported repeated out-of-body experiences, abnormal activity in that area was found. An out-of-body
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experience could also be repeatedly induced by stimulating a depth electrode implanted in the posterior part of the temporal superior gyrus. This also stimulated the angular gyrus [56]. These authors reported on a patient who underwent depth electrode treatment in the parietotemporal junction for tinnitus. The irritating ringing noise remained but a side effect of the stimulation of the electrode was that he had an out-of-body experience and felt as if he was standing half a meter behind his own body. The temporal lobe is known to be very sensitive to hypoxia, which may explain why this area is so often activated. The stimulated out-of-body experiences are accompanied by sensations such as floating, flying, elevation and rotation. It seems as if these ‘experiences’ are founded on a disintegration of brain mechanisms that normally occur in this brain area, i.e. the integration of somatosensory, proprioceptive and vestibular information, information that makes it possible to distinguish between ‘personal space’ and ‘extra-personal space’. NDEs also have a great deal in common with the mystical experiences that are a feature of temporal lobe epilepsy, a phenomenon caused by electrical discharges in the same brain area that may be stimulated to induce NDEs [55, 56]. A second brain area that plays a part in the sensation of being inside one’s body is the extrastriatal body area, an area that responds to human bodies and body parts and has connections with the visual system [57]. Also the precunneus and the posterior part of the thalamus are possibly activated in an out-of-body experience [56]. The feeling of bliss that accompanies a NDE might be caused by endorphins that are released by stress, as this feeling sometimes changes into the exact opposite when the opiate antagonist naloxone is administered. Serotonin is thought to play a role in the mystical hallucinations [44]. Also people with cortical blindness may have a NDE, which is a strong argument against the claim that the observations truly are of the outside world. This is not such a strange phenomenon when you consider that people with cortical blindness may actually dream with visual images and that, although everyone’s primary visual cortex is less active during REM sleep, the nearby extrastriatal cortex is more active. Also, the majority of people with cortical blindness have visual hallucinations when they faint [50].
6.3.9
WHERE IS THE PROOF?
Attempts are made to collect proof that our consciousness may leave our body and that we may observe things during a NDE without interference from our brain. Codes and objects have been placed somewhere high up in clinical departments where NDEs tend to occur, but so far any patients who felt like they had left their bodies have been unable to say what was on top of the cupboard [46]. Also, we should not forget that we are dealing with people relating what they think they experienced and not with experiences that are open to objectification. All in all no reason whatsoever to argue that NDEs prove that one may observe things without interference from the brain, or that one has experienced life after death. These patients have not been in the hereafter. Nearly dead is not dead, just like almost pregnant is not pregnant.
6.3.10
PRAYING FOR SOMEONE ELSE: A PLACEBO FOR ONESELF
Sir Francis Galton (1822–1911), a cousin of Darwin, was the first to study the effectiveness of prayer using statistical arguments. He pointed out that a daily dose of ‘God Save
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the King/Queen’, sung by enormous numbers of British people, had not lengthened the lives of the monarchs as compared to others. And although many prayers were said for the safety of missionaries and pilgrims on sea voyages, these ships still were not more immune to being wrecked than other ships. There are publications that claim an effect of prayer [i.e. [59]], but closer inspection shows that the tools used for this research are unreliable and that the statistics and test set-ups are open to serious doubt. Fundamental mistakes were made, such as at a coronary care unit where they prayed for the patients, and where the secretary who assigned the patients to the experimental or control group also filled out the prayer results (‘non-blind research’) and where the test group that was prayed for was a little healthier to start with (‘selection’). Also, many studies showed no effect of prayer on leukemia, rheumatism or dialysis patients. More recently, however, a large, well-controlled study was published that actually showed a negative effect of prayer. It concerned 604 patients who were to undergo a coronary bypass operation and who were divided into three groups. Groups 1 and 2 were not sure whether there was going to be prayer on their behalf. However, group 1 was prayed for and group 2 was not. Group 1 experienced complications in 52% of the cases, for group 2 this was 51%. Group 3 was justifiably sure that they were going to be prayed for. To everyone’s surprise this group had the highest number of complications (59%) [59]. One may speculate about the reasons for this unexpected negative effect. Perhaps the patients who were told that they were in the group that was definitely going to be prayed for concluded they were the most seriously ill [60]. Whatever the reason, on the basis of this particular study it may be better not to tell your loved one you are praying for their health. The authors of a metaanalysis of 14 studies in 2006 concluded that praying for the healing of others did these others no good. Fortunately no detrimental effects were found either. The same authors also pointed out that there is no basis in Christian theology for the idea that praying might have an effect [61, 62]. Praying via a headphone for a patient under anesthesia while on the operating table during open heart surgery had no effect [49]. Others have found that there is a positive correlation between praying and psychiatric syndromes [10]. However, I am not so malign as to think that the psychiatric symptoms of these patients were caused by praying. Obviously these people were desperately trying anything that might help them get rid of their psychiatric problems. But however the case may be, a convincing effect of praying for others has never been shown. And there has never been anyone who saw an amputated limb regenerate, even though that should not be too challenging a task for someone who created the universe. Despite the controversial literature on the effectiveness of praying, the majority does not have a shadow of a doubt: a Time/CNN survey in the United States of America showed that 82% of all Americans are convinced that prayer can cure serious illness, that 73% believe that praying for others could cure them and that 64% ask their physicians to pray for them [63]. But why would the majority of people believe in the effectiveness of prayer when there is no research to support this notion? I think it is because people who have learned the ritual of praying have found that it does themselves good. Prayer creates in believers a state that is opposite to stress, which is why it is sometimes referred to as a ‘relaxation response’. The first and foremost characteristic of this response is a lowering of the stress hormone cortisol in our blood [64]. Praying for someone thus mainly benefits the one who prays; it relaxes. This is not a new concept. De Spinoza, too, did not see the point of praying to ask for something. Not because he did not believe in God, but because he did not believe in a personalized God who rules from above and responds to prayer. He saw prayer as a means to achieve concentration
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and meditation. Which it does. But this does not mean that we need to pray to be able to relax. The same result can be reached with yoga, meditation, or listening to music. Incidentally, studies into the effectiveness of prayer are fraught with unique methodological snags that are different to the problems one encounters during a study into drugs [60]. First of all, sometimes only the first name of the person prayed for was given, sometimes only a photo was available. This may not be the most exact way for God to locate the intended receiver. Also, morally one is obliged to ask for permission from the person prayed for, if not because of the possible outcome (good or bad), then at least out of respect for the other person’s belief or religion. The participants of such an experiment will form a selfselected group and the next step is that a control group should have the same characteristics. Secondly, many people are already praying for a partner, a friend or an acquaintance in hospital while these people may also be taking part in the experiment. How do you control for the amount of ‘background prayer’ in such an experiment? And how do you prevent that the control patients are also being prayed for? Thirdly, one could wonder whether God’s ways are a legitimate subject of study. Also, one might reprove believers involved in the experiment for not having faith in God. Lastly, could not a believer who heard of the experiment pray to God to make the experiment go wrong? In view of all these methodological problems, the only way to answer the question is controlled animal research. Strangely enough I have not yet encountered such a study.
6.3.11
CONCLUSIONS
The question this chapter is dealing with is not whether God exists, but why so many people are religious in spite of the immense damage that is inflicted by religions. The damage done is so enormous that one may well wonder whether we would not be better off without religions. Having said that, the evolutionary advantages of religion have been manifold: (1) Religion served to unite the members of a group by forbidding to marry an unbeliever (i.e. anyone with a different religion), by imposing social rules on the group in the name of God, usually with unequivocal threats to offenders, by demanding that members of the group are recognizable as such, by reinforcing the ‘we’ feeling of the group through relics, by setting up rules regarding the promotion of procreation, and by indoctrinating children at an early age so that religion is fixed in their brains for the rest of their lives. (2) The religious do’s and don’ts had clear evolutionary advantages that had partly to do with the protection the group could offer to the individual and partly to promote health. (3) A religious conviction offers comfort and help in difficult times. (4) God is the answer to everything we do not know or understand, and having a religion gives a feeling of optimism. (5) Religion takes away a little bit of the fear of death by promising life after death. (6) Finally, the right to kill members of other groups in the name of your God has always been a prominent feature of virtually every religion. This has been of great evolutionary advantage in times of food shortage. Since neither religion as a means to keep the group together, nor aggression with the purpose of eliminating the other group will remain advantageous in an evolutionary sense in our globalizing economy and our information society I expect them to lose their significance over time. The term ‘religion’ is used for a religious faith and the practices of an organized church or religious institution. The term ‘spirituality’ is used to describe the transcendent
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relationship between a person and a ‘higher being’ unconnected to churches or other organizations. Spirituality is a property that every human being possesses to a certain extent, without there being question of a universal theology. Spirituality is the neurobiological basis for religion, and religion is the local interpretation of our spiritual feelings. Yes, spiritual experiences can be visualized as brain activity. But so can everything we do, think and experience. It is not proof for or against the existence of God. A number of neurobiological substrates play a role in ‘normal’ religious experiences and in the mechanisms that cause neurological and psychiatric syndromes to be accompanied by changes in religious experiences. Becoming a religious person or not is not a matter of free choice. The susceptibility for religion is for some 50% genetically determined. The serotonergic system is thought to be an important biological basis for spiritual experiences. Polymorphisms in genes seem to determine our degree of spirituality. A combination of molecular genetics and psychological tests led Dean Hamer to an association between the vesicular monoamine transporter-2 (VMAT2) and spirituality. The environment in which a person grows up ensures that the religion of the parents is fixed in the child’s brain circuits during early development, similar to the way our mother tongue is fixed. The often deeply religious/cosmic peak experiences that patients with temporal lobe epilepsy go through, due to, for instance, a tumor or to mesial/hippocampal sclerosis, is where, intriguingly, religion and neuroscience meet. As examples of this condition and the Geschwind syndrome symptoms, the apostle Paul, Muhammad, Joan of Arc, Vincent Van Gogh and Dostoevsky are described. Religious delusions occur in 3% of schizophrenic patients and are also reported in other psychiatric disorders, such as mania and depression, and as a prodromal occurrence in frontotemporal dementia (chromosome 17-related). A Dutch example of a religious delusion accompanying a psychiatric disorder is the story of State Secretary Ger Klein, who had a manic-depressive disorder. A near-death experience (NDE) is often interpreted as proof of the existence of a hereafter, and people who have had a NDE reckon they have caught a glimpse of this afterlife. However, there is a sound neurobiological explanation for every aspect of a neardeath experience. Moreover, so far not any of the patients who felt like leaving their body has been able to say ‘what was on top of the cupboard’. A convincing effect of praying for others has never been shown, yet the majority of people believe in the effectiveness of prayer. It is proposed that this may be due to the fact that prayer creates a ‘relaxation response’ in those who are trained in this ritual.
REFERENCES 1. Previc FH (2006) The role of the extrapersonal brain systems in religious activity. Conscious and Cognition 15, 500–539. 2. Larson EJ, Witham L (1998) Leading scientists still reject God. Nature 394, 313. 3. Dawkins R (2006) The God Delusion. Translated into Dutch as ‘God als misvatting’, by H.E. van Riemsdijk, Nieuw Amsterdam Uitgevers, Amsterdam. 4. Graffin GW, Provine WB (2007) Evolution, religion and free will. American Scientist 95, 294–297. 5. Bushman BJ, Ridge RD, Das E et al. (2007) When God sanctions killing. Effect of Scriptural violence on aggression. Psychological Science 18, 204–207. 6. Webbink E, Ultee W (2004) Van polio tot meningokokken-C. Mens en Maatschappij 79, 4–23.
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7. Hamer D (2004) The God Gene. How faith is hardwired into our genes. Doubleday, New York. 8. Teitelbaum JS, Zatorre RJ, Carpenter S et al. (1990) Neurologic sequelae of domioc acid intoxication due to the ingestion of contaminated mussels. New England Journal of Medicine 322, 1781–1787. 9. Moreira-Almeida A, Neto FL, Koenig HG (2006) Religiousness and mental health: a review. Revista Brasileira Psiquiatria 28, 242–250. 10. Flannelly KJ, Koenig HG, Ellison CG et al. (2006) Belief in life after death and mental health. Journal of Nervous and Mental Disease 194, 524–529. 11. Norton MC, Skoog I, Franklin LM et al. (2006) Gender differences in the association between religious involvement and depression: the Cache County (Utah) Study. Journal of Gerontology 61B, P129–P136. 12. Braam AW, Deeg DJH, Poppelaars JL et al. (2007) Prayer and depressive symptoms in a period of secularization: patterns among older adults in the Netherlands. American Journal of Geriatric Psychiatry 15, 273–281. 13. Boomsma DI, de Geus EJ, van Baal GC et al. (2006) A religious upbringing reduces the influence of genetic factors on disinhibition: evidence for interaction between genotype and environment on personality. Twin Research 2, 115–125. 14. Wink P, Scott J (2005) Does religiousness buffer against the fear of death and dying in late adulthood? Findings form a longitudinal study. Journal of Gerontology 60B, pp. 207–214. 15. Turner RP, Lukoff D, Barnhouse RT et al. (1995) Religious or spiritual problem. A culturally sensitive diagnostic category in the DSM-IV. Journal of Nervous and Mental Disease 183, 435–444. 16. Mohr S, Gillieron C, Borras L et al. (2007) The assessment of spirituality and religiousness in schizophrenia. Journal of Nervous and Mental Disease 195, 247–253. 17. Kaufman Y, Anaki D, Binns M et al. (2007) Cognitive decline in Alzheimer disease. Impact of spirituality, religiosity, and QOL. Neurology 68, 1509–1514. 18. Beauregard M, Paquette V (2006) Neural correlates of a mystical experience in Carmelite nuns. Neuroscience Letters 405, 186–190. 19. Saver JL, Rabin J (1997) The neural substrates of religious experience. The Journal of Neuropsychiatry & Clinical Neurosciences 9, pp. 498–510. 20. Dekker C, Meester R, Van Woudenberg R (eds.) (2005) Schitterend ongeluk of sporen van ontwerp? Over toeval en doelgerichtheid in de evolutie. Uitgeverij Ten Have, Kampen. 21. Borg J, Andree B, Soderstrom H et al. (2003) The serotonin system and spiritual experiences. American Journal of Psychiatry 160, 1965–1969. 22. Yamamoto S, Fukae J, Mori H et al. (2006) Positive immunoreactivity for vesicular monoamine transporter 2 in Lewy bodies and Lewy neurites in substantia nigra. Neuroscience Letters 396, 187–191. 23. Naito H, Matsui N (1988) Temporal lobe epilepsy with ictal ecstatic state and interictal behavior of hypergraphia. Journal of Nervous and Mental Disease 176, 123–124. 24. Vignal J-P, Maillard L, McGonigal A et al. (2007) The dreamy state: hallucinations of autobiographic memory evoked by temporal lobe stimulations and seizures. Brain 130, 88–99. 25. Hoogland G, Van Oort RJ, Proper EA et al. (2004) Alternative splicing of glutamate transporter EAAT2 RNA in neocortex and hippocampus of temporal lobe epilepsy patients. Epilepsy Research 59, 75–82. 26. Proper EA, Hoogland G, Kappen SM et al. (2002) Distribution of glutamate transporters in the hippocampus of patients with pharmaco-resistant temporal lobe epilepsy. Brain 125, 32–43. 27. Wuerfel J, Krishnamoorthy ES, Brown RJ et al. (2004) Religiosity is associated with hippocampal but not amygdala volumes in patients with refractory epilepsy. Journal of Neurology, Neurosurgery & Psychiatry 75, 640–642. 28. Landsborough D (1987) St Paul and temporal lobe epilepsy. Journal of Neurology, Neurosurgery, and Psychiatry 50, 659–664.
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29. Temkin O (1971) The Falling Sickness. A History of Epilepsy from the Greeks to the Beginnings of Modern Neurology. The Johns Hopkins Press, Baltimore and London. 30. Trimble MR (1991) The Psychoses of Epilepsy. Raven Press, New York, USA. 31. Foote-Smith E, Bayne L (1991) Joan of Arc. Epilepsia 32, 810–815. 32. Arnold WN (2005) The illness of Vincent van Gogh. Journal of the History of the Neurosciences 13, 22–43. 33. Voskuil PHA (2005) Letter to the Editor and Author’s Response: The illness of Vincent van Gogh. Journal of the History of the Neurosciences 14, 169–176. 34. Dostoevsky FM(1935 Dutch translation by J. Jac. Thomson) De Idioot. Van Loghum Slaterus’ Uitgevers Maatschappij N.V. Arnhem. 35. Dostoevsky FM (1959) Verzamelde werken. Boze Geesten. G.A. Van Oorschot Publishers, Amsterdam. 36. Hughes JR. (2005) A reappraisal of the possible seizures of Vincent van Gogh. Epilepsy & Behavior 6, 504–510. 37. Murai T, Hanakawa T, Sengoku A et al. (1998) Temporal lobe epilepsy in a genius of natural history. MRI volumetric study of postmortem brain. Neurology 50, 1373–1376. 38. Muramoto O (2004) The role of the medial prefrontal cortex in human religious activity. Medical Hypotheses. 62, 479–85. 39. Marty AT, Hilton FL, Spear RK et al. (2005) Postcaesarean pulmonary embolism, sustained cardiopulmonary resuscitation, embolectomy, and near-death experience. Obstetrics & Gynecology 106, 1153–1155. 40. Klein G (1994) Over de rooie. Uitgeverij Balans, Amsterdam 41. Parnia S, Fenwick P (2002) Near death experiences in cardiac arrest: visions of a dying brain or visions of a new science of consciousness. Resuscitation 52, 5–11. 42. Van Lommel P, Van Wees R, Meyers V et al. (2001) Near-death experience in survivors of cardiac arrest: a prospective study in the Netherlands. Lancet 358, 2039–2045. 43. Van Lommel P (2007). Eindeloos Bewustzijn, een wetenschappelijke visie op de bijna dood ervaring. Ten Have, Kampen. 44. French CC (2005) Near-death experiences in cardiac arrest survivors. In: S. Laureys (ed.) Progress in Brain Research 150, 351–367. 45. Nelson KR, Mattingly M, Schmitt FA (2007) Out-of-body experience and arousal. Neurology 68, 794–795. 46. Buzzi G (2002) Near-death experiences. The Lancet 359, 2116–2117. 47. Verwer RWH, Hermens WTJMC, Dijkhuizen PA et al. (2002) Cells in human post-mortem brain tissue slices remain alive for several weeks in culture. The FASEB Journal 16, 54–60. 48. Swaab DF, Boer K (1972) The presence of biologically labile compounds during ischemia and their relationship to the EEG in rat cerebral cortex and hypothalamus. Journal of Neurochemistry 19, 2843–2853. 49. Ikedo F, Gangahar DM, Quader MA et al. (2007) The effects of prayer, relaxation technique during general anesthesia on recovery outcomes following cardiac surgery. Complementary Therapies in Clinical Practice 13, 85–94. 50. Nelson KR, Mattingly M, Lee SA et al. (2006) Does the arousal system contribute to near death experience? Neurology 66, 1003–1009. 51. Buzzi G, Cirignotta F (2000) Isolated sleep paralysis: a web survey. Sleep Research Online 3, 61–66. 52. Cheyne JA, Rueffer SD, Newby-Clark IR (1999) Hypnagogic and hypnopompic hallucinations during sleep paralysis: neurological and cultural construction of the night-mare. Consciousness and Cognition 8, 319–337. 53. Fronczek R, Overeem S, Lee SYY et al. (2008) Hypocretin (orexin) loss and sleep disturbances in Parkinson’s disease. Brain 130, 1577–1585.
6.3
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54. Blanke O, Ortigue S, Landis T et al. (2002) Stimulating illusory own-body perceptions. Nature 419, 269–270. 55. Blanke O, Landis T, Spinelli L et al. (2004) Out-of-body experience and autoscopy of neurological origin. Brain 127, 243–258. 56. De Ridder D, Van Laere K, Dupont P et al. (2007) Visualizing out-of-body experience in the brain. New England Journal of Medicine 357, 1829–1833. 57. Arzy S, Thut G, Mohr C et al. (2006) Neural basis of embodiment: distinct contributions of temporoparietal junction and extrastriate body area. Journal of Neuroscience 26, 8074–8081. 58. Harris WS, Gowda M, Kolb JW et al. (1999) A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Archives of Internal Medicine 159, 2273–2278. 59. Benson H, Dusek JA, Sherwood JB et al. (2006). Study of the therapeutic effects of intercessory prayer (STEP) in cardiac bypass patients: a multicenter randomized trial of uncertainty and certainty of receiving intercessory prayer. American Heart Journal 151, 934–942. 60. Turner DD (2006) Just another drug? A philosophical assessment of randomised controlled studies in intercessory prayer. Journal of Medical Ethics 32, 487–490. 61. Masters KS, Spielmans GI, Goodson JT (2006) Are there demonstrable effects of distant intercessory prayer? A meta-analytic review. Annals of Behavioral Medicine 32, 21–26. 62. Masters KS, Spielmans GI (2007) Prayer and health: review, meta-analysis, and research agenda. Journal of Behavioral Medicine 30, 329–338. 63. Ameling A (2000) Prayer: an ancient healing practice becomes new again. Holistic Nursing Practice 14, 40–43. 64. Stefano GB, Fricchione GL, Slingsby BT et al. (2001) The placebo effect and relaxation response: neural processes and their coupling to constitutive nitric oxide. Brain Research Reviews 35, 1–19.
Part 7 Training Issues: Residency Training and Continuous Education INTRODUCTION Psychiatric residency training, continuous medical education and psychotherapy training lay the foundation of acquirement and improvement of knowledge, skills and attitude. The very same holds true in regard to religion, spirituality, worldview and the interface between psychiatry. However, a strange, although more or less understandable phenomenon occurs. The dissociation or split between religion and psychiatry we started with in Part 2 seems to be ineradicable. If one looks at the residency training programs, one can see that a lot has been accomplished. Yet, whether religion and spirituality are addressed more or less substantially still seems to be dependent on the personal worldview of residency training directors and their staff or the policy and culture of the institutions. This still seems to hold despite official declarations by education councils and national boards in favor of a professional ‘sensitivity and responsiveness’ to a diverse patient population, including a growing diversity in religious and spiritual orientations and worldviews. If this is still true, and again, it seems to be, something odd and quite puzzling is going on. In our view the discussion of whether religion and spirituality are important enough or not is past the age of childhood. There is more than average evidence that it is unprofessional to continue neglecting these findings. It is stated throughout this book that the evidence indicates the necessity and clinical relevancy of training and continuous education with respect to the interface between psychiatry and religion. However, at the end we have to acknowledge that religion and spirituality and their dynamics open up a world beyond the dissociation or split between subjective experience and objective facts. An annoyance is triggered, and highly likely resistance and bias are
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evoked. For we try to grasp phenomena that by their nature transcend the limits of psychiatry, psychotherapy and psychology. Denial would be an inappropriate selflimitation. In fact this ambiguity is typically one of the characteristics of religion (and spirituality): to mark the difference between the normal and transgressions on the normal. Religion poses a protective and health sustaining boundary to these infringements by its rituals, practices and beliefs. 7.1 Religion and the Training of Psychotherapists Allan M. Josephson, John R. Peteet & Allan Tasman 7.2 Multicultural Education and Training in Religion and Spirituality Peter J. Verhagen & John L. Cox
CHAPTER 7.1
Religion and the Training of Psychotherapists Allan M. Josephson Professor of Child and Adolescent Psychiatry, United States of America
John R. Peteet Associate Professor of Psychiatry, United States of America
Allan Tasman Professor of Psychiatry and Behavioral Sciences, United States of America
7.1.1
INTRODUCTION
Psychiatric literature of the past generation either neglected religion [1] or linked it almost entirely with psychopathology [2]. This perspective has shifted and, as an example, a recent study of psychiatric residents indicated that a majority were open to encountering and addressing religious and spiritual issues with patients [3]. Another study, however, suggests that historical tensions in the field may remain. In a survey of practicing physicians, Curlin and colleagues found that psychiatrists are less religious than other physicians [4]. They also noted that religious physicians were less willing than non religious physicians to refer patients to psychiatrists [5]. This suggests some medical professionals continue to believe that psychiatry has an antipathy toward religion. Even so, there have been significant shifts in the requirements to consider religion and spirituality in psychiatric training. A burgeoning clinical literature supports the impression of many that there is growing interest regarding religious and spiritual issues in the mental health fields. One recent computer search on this topic for the years from 1900 through 1959 yielded half the number of articles that were written in the past five years alone. For the 1960s, the search produced almost 1500 articles, whereas almost 8000 articles addressing the topic of religion, spirituality and mental health were identified for the years from 2000–2006 [6]. During the last decade, the Accreditation Council for Graduate Medical Education (ACGME) identified the need to address religious and spiritual issues in psychiatry training programs and mandated that all training programs address religious and spiritual factors that
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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influence physical and psychological development [7]. In 2001 the ACGME identified cultural diversity as important in psychiatric training, including religious and spiritual diversity. Religious and spiritual factors were seen as influential in physical and psychosocial development throughout the life cycle [8]. These mandates stimulated the development of literature which describes the knowledge, skills and attitudes regarding religion and spirituality that should be taught in a psychiatry residency training program [9]. While the knowledge base [10] and clinical skills [11] have been developing in this area, training remains a major challenge. This is even more the case with respect to training in psychotherapy. With respect to psychotherapy, residents should learn to provide appropriate psychotherapeutic interventions with an understanding of patients’ religious experience and to deal with transference/countertransference reactions. Apart from this expectation of the skill of the resident, there is very little in the literature that identifies what to teach with respect to knowledge and which attitudes to develop. Bartoli found that since 1980, only 10% of articles that address religion and spirituality in the psychological literature have discussed issues of psychotherapy specifically and that only 1% of these articles address clinical training in psychotherapy [6]. Psychiatric literature on religion and the training of psychotherapists appears similarly sparse. Thus, it appears the challenge is significant in identifying how to train psychotherapists to appropriately address religious and spiritual issues in treatment. This article will: comment on the historical context of training in psychiatry and religion; identify contemporary challenges in training psychiatrists in psychotherapy; indicate why religion and spirituality are important in psychotherapy; describe the knowledge, skill and attitudes that must be taught (what to teach) and identify important clinical processes that faculty must consider when teaching residents how to address religious and spiritual themes in psychotherapy (how to teach). It will end with brief comments on integrating this material into a curriculum and address specific challenges for the future. The terms resident and trainee, and therapist and psychotherapist, are used interchangeably in the manuscript.
7.1.2
DEFINITIONS
This article utilizes the following working definitions of spirituality and religion. Spirituality refers to an individual’s connection to the transcendent and comprises the perspective that life is more than the material. Religion involves specific traditions as well as the expectation of adherence to doctrines and sacred writings. Such traditions attempt to integrate the spiritual and transcendent with the cognitive (i.e. belief). Worldview, a term related to religion and increasingly used in the literature, refers to one’s beliefs about life or philosophy of life. This certainly includes religion but can also include any set of beliefs (e.g. atheism) which attempt to answer an individual’s important questions about life.
7.1.3
HISTORICAL BACKGROUND
Given the ground swell of interest in spirituality and psychiatry, integration into training has been a slow process. In 1990, Sansone and colleagues demonstrated that few residency training programs had didactic course work in religion and that clinical supervision also
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neglected this area [12]. They called for ‘an academic approach to the role of religion in psychiatry training’. Seven years later, a survey of five psychiatric residency programs explored the didactic and supervision experience of religious issues and demonstrated that while didactic exposure was still limited, those who received such exposure were more likely to believe religion was important in clinical care. This paper ended with a call to make residency programs ‘religiously hospitable places’ for residency education where the resident ‘should be taught to include the patient’s religious beliefs in his understanding of the whole person’ [3]. During the last decade, reports from other countries including Canada [13], the United Kingdom [14] and New Zealand [15] have identified the need for specific education of psychiatric trainees in religion and spirituality. Subsequent to these efforts, several organizational developments have facilitated training in this area. The National Institute for Healthcare Research (NIHR) was a non profit organization that was funded in 1991 to examine possible links between spirituality and health. This organization fostered the development of courses in medical schools on spirituality and health and over a decade saw a dramatic increase in the representation of these issues in medical school curricula through its efforts. In 1998 and 1999 the NIHR sponsored an award program for psychiatric residencies similar to their successful medical school program. Over the last decade, through support from the John Templeton Foundation, awards were given to training programs to develop psychiatric training experiences in this area. NIHR also developed a model curriculum for psychiatric residency training in religion and spirituality, reviewed in detail elsewhere. The George Washington University Institute of Spirituality and Health (GWish) now administers the award program. In all, 23 programs have received awards and the programs have been valuable in shaping a consensus in identifying the knowledge, skills and attitudes which should be taught to residents [9, 16, 17]. These developments have occurred in the context of a push towards multiculturalism and cultural competence in all mental health fields [18, 19]. Culture can be seen as the way that worldview is transmitted through beliefs, values and social institutions (e.g. educational, legal, religious), although an extensive discussion of the relationship between religion and culture is beyond the scope of this chapter. Because all patients exist in various social, religious, political and economic contexts, psychiatrists must understand the impact of these variables on individual behavior. As religion arguably touches all aspects of culture, its relevance is obvious.
7.1.4 CONTEMPORARY CHALLENGES IN TRAINING PSYCHIATRISTS IN PSYCHOTHERAPY Before we fully discuss religion and the training of psychotherapists, several general comments must be made about training in psychotherapy. Many see impediments to psychotherapy training in contemporary psychiatry [20]. Dramatic developments in the neurosciences and clinical interventions stemming from neuroscience research have captivated the field. This has shifted many psychotherapeutic efforts toward psychoeducation or educating patients about their disease(s). McHugh [21, 22] has argued that, in addition to ‘mental disease’, many of the clinical problems psychiatrists treat are related to self development, individual characteristics of the patient (i.e., personality) and problems in behavior. These areas require psychotherapeutic intervention. A vigorous
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discussion, and often rancorous debate, about the importance of psychosocial factors has continued in different forms for over a decade and in many ways defines contemporary psychiatry [23, 24]. Other developments create impediments to the effective teaching of psychotherapy: limited time spent with patients, particularly in North America where third party payor schemes increasingly discourage psychiatrists from providing psychotherapy; decline in the number of supervisors who can effectively teach psychotherapy and, in general, a less developmentally oriented approach to patients and their individual narratives [24]. One contemporary educator has commented that it is very difficult to teach clinical formulation, the basis for all psychotherapeutic interventions, because residents are not gathering enough information to make such formulations [25]. Basic psychosocial facts such as individual development and life experience, family structure and social context are often missing in psychiatric assessments, let alone information about spiritual and religious factors. Such challenges do not mitigate the importance of considering religion in the psychotherapeutic treatment of patients, but do underscore the difficulty in doing so. Even if not the beneficiary of formal psychotherapy supervision regarding religion, many clinicians adopt pragmatic ways of using religious explorations in cognitive treatments [11]. For example, helping shift a patient from a guilt evoking faith to one that is less punitive and more embracing of positive elements likely occurs in a number of clinicians’ practices. The term ‘biopsychosociospiritual’ has been proposed to help psychiatrists understand the origins of a patient’s spirituality and incorporate this into psychotherapeutic treatment of the whole patient [26, 27]. While psychiatry has developed a substantial curriculum in human sexuality, another area previously uncharted, only recently have prescribing religious or spiritual interventions been discussed in training programs.
7.1.5
WHY IS RELIGION IMPORTANT IN PSYCHOTHERAPY?
This most basic of questions must be addressed. Considering psychiatry is a branch of medicine, founded in the behavioral and biomedical sciences, religion and spirituality at first glance do not seem to fit. Yet there are strong clinical reasons to consider these factors in psychotherapy [28]. General themes of importance will be reviewed, followed by specific areas of knowledge acquisition relevant to psychotherapy practice. 1. The rapidly developing field of developmental psychopathology describes risk factors and/or protective factors in the development of disorder [29]. Within the consulting room, a careful understanding of positive religious coping [30] allows the therapist to facilitate positive coping. 2. Understanding patients’ religious and spiritual inclinations, or their absence, may facilitate the psychotherapeutic treatment alliance, foundational for all psychotherapeutic progress. When the clinician communicates an empathic interest in this area, the patient is much more likely to feel aligned with the therapist. 3. Psychotherapy frequently is delivered in the context of multimodal treatments and intervention services. Residents should know how to integrate other therapies (e.g. Twelve step programs in alcoholism treatment) which have spiritual components. Understanding a patient’s religious and spiritual resources may facilitate referral to other services, such as clergy, to support psychotherapy [31].
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4. When a patient’s presenting complaint is related to a religious issue, a full exploration of the issue is indicated (e.g., a religious patient presents with depressive symptoms after the death of a younger brother and subsequently wonders whether God exists). 5. Religion and spirituality are relevant in areas traditionally the province of psychotherapy, such as existential issues related to suffering and life’s meaning and also moral issues and their relationship to psychiatric symptomatology. Affective responses to an existential dilemma or a moral failing are common and any psychotherapeutic treatment of anxiety and depression must consider these issues. 6. Patients may cite religious reasons for their difficulty in accepting clinical interventions, such as psychopharmacology, and this reticence often requires psychotherapeutic exploration. 7. Raising children involves teaching values and moral codes and thus many parental behaviors have a basis in religious and spiritual tradition. As a result, psychotherapy of parents and family psychotherapy should address religion and spirituality.
7.1.6
WHAT TO TEACH?
Model curricula for psychiatric training in religion and spirituality are just developing and recommendations regarding psychotherapy are part of this process [9]. Psychiatric training must cover specific knowledge, skills and attitudes to prepare residents to effectively integrate religion into the psychotherapeutic practice.
7.1.6.1
Knowledge
1. Residents should understand the past bias in the psychiatric literature which emphasized the negative aspects of religion and spirituality. For example, DSM-IIIR was criticized for religious insensitivity as it used religion more than any other cultural factor to illustrate psychopathology [32]. This bias is receding and emerging research suggests that far more frequently religious commitments seem to offer protection against a number of psychiatric and medical disorders [10]. Given the strong influence of psychoanalysis in the development of various psychotherapies, residents should appreciate that Freud’s view of religion and his atheistic worldview influenced clinical literature for several generations [33]. 2. Residents must know the relationship of various religious risk and religious protective factors in psychopathology as they relate to specific disorders. Literature on depression, anxiety disorders, and substance abuse disorders and, in children, conduct disorders and sexual behavior problems identifies religious risk and religious protective factors for the disorders [10]. Understanding these factors allows the resident to form an effective formulation and plan treatment. 3. Residents must be aware of empirical research on psychotherapy outcomes. Studies suggest that spirituality and religion are related to greater marital satisfaction, greater life satisfaction and general well-being as well as associated with reductions in drug use, alcohol, anxiety, suicide and other mental health problems [10, 34]. The mechanisms of these improvements, and their relationship with psychotherapy, need continued study but
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4.
5.
6.
7.
residents need to be aware of the generally improved outcome when religious factors are addressed in clinical care. Complete knowledge of comparative religions is outside the scope of any training program and most resident’s experience. There is emerging psychiatric literature [26, 35] that offers succinct summaries of the worldviews of the major religions which can orient trainees in their psychotherapeutic treatments. If a resident does not understand a religion’s core tenets, and such understanding is relevant to patient care, he should allow the patient to teach him about the patient’s faith tradition. This knowledge should also include a perspective on a patient’s secular worldview if pertinent to individual and/ or family functioning. Residents should be aware that religious traditions frequently describe core features of personality, aspects of human behavior and remedies for improving human behavior. Although the language is different (e.g., sin vs. psychopathology), the concepts of religion often parallel psychiatric concepts. Understanding special spiritual and religious techniques, such as prayer and forgiveness, is less important for the resident. However, as will be described, when patients request a clinician to pray or inquire about forgiveness, this is a different matter. These types of requests will need careful clinical supervision on how to address such requests. The resident should be aware of specific literature regarding religious aspects of basic cognitive [36] psychodynamic [37] and family therapy [38]. Cognitive restructuring often involves reevaluating of religious beliefs. Psychodynamic work often involves ‘God images’ and how they effect internal object relations. Family work often involves evaluating parental attempts to inculcate moral codes in their children.
7.1.6.2
Skills
1. In order to conduct effective psychotherapy, residents must acquire comfort in learning to talk about spiritual and religious issues. This is difficult and the aphorism ‘one shouldn’t discuss religion and politics’ comes to mind. For many, it is awkward to discuss affect laden topics such as religion and thus often avoided. However, if this anxiety leads to ignoring an important component of patient care, it must be managed. One way to achieve this is for residents to develop familiarity in the types of questions to be asked and in how these issues manifest themselves clinically [39, 40]. 2. Once this basic interviewing comfort is established, the resident needs a strategy of questioning to help her gather the relevant information to prepare for psychotherapy. Koenig and Pritchett have described brief questions, summarized by the acronym FICA, to help screen for religious and spiritual issues [41]. These questions have to do with existence of religious faith (F), its influence (I), the role of a religious community (C) and how to address spiritual needs (A). As in any screening interview, if religious issues do not seem prominent, they are not an integral part of subsequent treatment. In depth interviewing regarding religion may be required with a positive screening result and in any presentation in which interviewing indicates a clear relevance of religion.
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A seventeen-year-old girl with medically unexplained psychosomatic symptoms was interviewed after a referral for possible anxiety and depression. She had attended a religious parochial school and when the examiner inquired during the initial interview about the family’s faith, she emphatically stated, ‘Faith! Faith! That’s my problem’. She subsequently expressed anger toward her priest ‘who taught me anger was bad, did not please God and was sinful’ A prolonged psychotherapy explored her internalization of affect and the family and religious contributions to its developmental origins. 3. Developing case formulations is a necessary skill necessary in preparing for psychotherapy. As the resident gathers religious information, she must move toward a differential diagnosis and understanding when, how and if religion and spirituality should be included in a treatment plan. As part of this formulation, residents need to develop a skill in determining whether religion is a positive resource, a protective factor, or contributes to the presenting psychopathology as a risk factor. 4. Finally, the resident should develop the skill of working/consulting with religious professionals. It is not uncommon to feel awkward, defensive or intimidated by professions outside the boundaries of medicine and psychiatry. Understanding the perspective of religious professionals is essential in negotiating this relationship.
7.1.6.3
Attitudes
In learning to conduct effective psychotherapy, an attitude of openness to the influence of one’s own perspective may be the most important for a resident to possess [6, 9]. Residents must be aware of their own spiritual and religious experience as well as their worldview. This ‘religious countertransference’ is not a topic which has received attention in the literature but can powerfully affect how therapy is conducted. Empathy and a non judgmental approach is critical in conducting psychotherapy. An attitude of open inquiry is helpful in to understand traditions with which the resident is unfamiliar. This will be further discussed in the next section.
7.1.7
HOW TO TEACH
7.1.7.1 Learning to deal psychotherapeutically with religion and spirituality Armed with an empathic attitude of inquiry and supported by the extent knowledge base, the resident must acquire the psychotherapeutic skill to explore religious themes in the therapeutic process. So far, we have focused on the tasks of helping the trainee to actively listen, ask screening questions and explore religion/spirituality more deeply. As the resident moves beyond understanding religion’s role in the patient’s presenting problems to addressing religious/spiritual issues psychotherapeutically, further challenges emerge: (1) recognizing when these should be a focus of the work; (2) appreciating the potential for spirituality to be helpful; (3) deciding among possible therapeutic approaches; (4) respecting boundaries; and (5) monitoring the influence of one’s countertransference.
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Recognizing when religious and spiritual issues should be a focus of the work Newly qualified therapists understandably hesitate to focus on sensitive areas such as spirituality without clearly understanding their goal in doing so. It can help to remind them that a clinician’s role includes relieving distress, directing individuals toward resources for living well, and addressing problems that interfere with clinical care. An example of distress could be the mother of a five-year-old with leukemia asking, ‘Why did God do this to me?’ An example of a spiritual need might be a professional trying to kerb his marijuana habit by better developing his inner life. Examples of interference with clinical care include a conservative believer who fears that taking an antidepressant represents a lack of faith in God to heal, and a psychotic patient who wants to talk about what God is saying to him, rather than about what he feels.
Appreciating the potential for spirituality to be helpful Therapists in training often find it easier to recognize the harmful than the helpful potential of religion and spirituality, for several reasons. Psychiatry residents usually learn first from patients with major mental illness, many of whom are too disturbed to feel comfortable in a typical congregation. Their patients may have turned to secular mental health providers after feeling that religion has failed, or even traumatized them. The early stages of therapy often focus more on explicitly psychiatric concerns than on larger ones. More therapists than patients are secular [42], with limited or possibly negative experiences with religion. They may be influenced by Freud’s view of religion as infantile wish-fulfillment, or merely by clinical work which exposes them to religious pathology more than religious health. Such therapists may find it difficult to imagine that spiritually oriented interventions could have a legitimate place in scientifically oriented, evidence-based medicine. Two approaches are potentially helpful here. One is to describe the place of spirituality in healthy human functioning. Most therapists, regardless of their theoretical orientation, recognize that there is often an existential dimension to their patients’ struggles in the areas of identity, hope, meaning/purpose, morality and autonomy/relationship to ultimate authority. When they can see spirituality as the form taken by the individual’s answers to existential questions, they can then consider what constitutes a helpful versus an unhelpful spirituality and how to foster the former, regardless of their own or the patient’s world view. Specifically, concerns about identity, common at points of change and stress, are more likely to be helped by a spirituality that is engaged, and transformative than by one which is static. Narrative approaches can help connect individuals with a broader context and their particular sources of inspiration. Concerns about hope, which are common in the wake of trauma, are more likely to be helped by a spirituality that is integrated rather than ambivalent. A clinician can foster an integrated spirituality by lending his own hope to work through trauma, and by encouraging helpful spiritual practices in the way that he might encourage a patient in AA to ‘work the program’. Concerns about meaning and purpose, common in depression, are more likely to be helped by a spirituality that is contemplative and attuned than by one that is distracted. Mindfulness is becoming a tool for treating both depression and self-destructive behavior (cf. dialectical behavior therapy). Concerns about morality, common in patients who struggle with guilt and troubled relationships, are more
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likely to be helped by a spirituality that is contemporaneous with an adult self than one that is developmentally arrested, for example at the level of ‘Sunday School’ learning. Patients can be helped to know what they should do, to realize when they do not need to feel guilty, and to find sources of forgiveness when they should feel guilty. This process helps them to think through what they really believe as adults. Concerns about autonomy and one’s relationship to ultimate authority, common in situations where patients are making major life decisions, are helped more by a spirituality in which one feels loved than by one in which one feels rejected by God (i.e. positive vs. negative religious coping). Therapists can foster a helpful relationship to ultimate authority by exploring what elements of their experience and outlook block their access to positive resources within their given tradition, and whether they need to question it, or even change their worldview. A second way to help trainees appreciate the helpful potential of spirituality is through examples. Having residents present their own cases to a class of peers and/or a consultant can lead to questions about potential sources of spiritual support for the patient such as a pastor, a small group, a ritual or prayer. What does the patient get out of going to church? Has the therapist considered talking with the patient’s pastor about how he approaches the patient’s religious concerns? Teachers and supervisors can also cite examples from their own practices, and bring patients to class for a group interview. As an example, a residency class interviewed a conservative Christian woman in her 20s who was being treated for PTSD stemming from physical and sexual abuse by her father, who had enforced his will by quoting scripture that children should obey their parents. She provided the group with a dramatic example of the destructive use of religion, but also described how her relationship with God and the support of her congregation motivated and facilitated her recovery. A videotape library of such cases would have obvious value.
Deciding among possible approaches A trainee who acknowledges the potential for spirituality to be helpful to his patients in dealing with their core concerns may nevertheless remain unsure what approach to take as a therapist. Should he focus on the psychological or the spiritual aspects of a patient’s anger at God, or attempt to help the patient integrate them? Try to deal with the problem in the therapy, or refer it elsewhere? Work only within the patient’s belief system, or draw on spiritual beliefs that he and the patient share? One suggested framework distinguishes four possible approaches [43]. In the most familiar and straightforward of these, a therapist would acknowledge the problem, but limit discussion to its psychological (or strictly medical) dimension. For example, he might focus on how the problem is interfering with the patient’s care, or address a patient’s anger at God by examining his relationship with other authority figures in the patient’s life. A second possible approach would be to clarify the spiritual as well as the psychological aspects of the problem, suggest resources for dealing with the former, and consider working with an outside resource such as a religious community or other authority. This might include enlisting a hospital chaplain or clergy person to offer needed spiritual help, or referring a patient to a therapist of a similar tradition. It could also include referral to organized programs that integrate beliefs and emotions, such as religiously/spiritually based cognitive behavioral treatment or Twelve Step programs.
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In a third approach, one would aim to address the problem indirectly using the patient’s own philosophy of life within the treatment. This might include exploring ways the patient can make better use of his resources and tradition (e.g., by examining a range of beliefs within the patient’s own denomination, or misconceptions about the spiritual nature of AA). A fourth approach would be to address the problem directly together using a shared perspective, ranging from the therapist’s agreement on the importance of hope, meaning, worldview or a caring community to the prescriptive use of shared values, beliefs or practices (e.g. meditation or scripture) in the treatment. This fourth approach requires particularly careful attention to transference, countertransference, boundary and consent issues. A number of factors bear on which of these approaches to choose. The first is the patient’s primary need – e.g. for growth, adjustment, or problem solving. This in turn influences the nature, aims and timing of the work – for example, psychological insight into a maladaptive pattern or resolution of a conflict. These in turn determine the degree of direct support indicated, and the amount of interpersonal closeness that is appropriate. Additional factors include the patient’s existential concerns – for example, related to hope or identity – and the spiritual options under consideration; the importance of spirituality in his life; his presenting problem and attitude toward treatment; the concern of the patient to integrate psychological with other perspectives; the availability of outside religious or spiritual resources; and the therapist’s own knowledge and preferred style. Dual relationships, for example being a therapist as well as a fellow member of the same religious community, can complicate the transference, countertransference and boundary aspects of choosing one or another approach. In addition to hearing case examples that illustrate each of these approaches, it can be helpful for trainees to identify which approach they are using in treating their own patients, and to articulate why. Hospital chaplains or clergy can also usefully be invited to describe examples of collaboration.
Respecting boundaries One of the most anxiety provoking aspects of dealing with religious and spiritual issues for trainees is to identify what boundaries are appropriate to their role as therapists – particularly if and how they should disclose their own worldviews [44]. An atheist or agnostic trainee may fear being asked by a religious patient if he believes in God. Or a religious trainee who recognizes in himself a desire to see his patient come to faith may bend over backwards not reveal his worldview, so as to avoid being seen as proselytizing. As in dealing with other kinds of self disclosure, a therapist should try to understand what the patient’s request means, and whether it serves the patient [37]. Answering a religious patient’s question about whether his therapist believes in God can be an important element in achieving informed consent, if he needs to know whether he can trust his therapist’s values. On the other hand, answering the same question from a provocative patient could serve to divert attention from an important therapeutic issue into an unproductive theological discussion. Should one ever treat a member of his own congregation? Agree to pray, or discuss scripture with a patient? Risks attend engaging in dual relationships and roles, but as Guthiel and Gabbard [45, 46] point out, a ‘boundary crossing’, a descriptive term, differs from a
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‘boundary violation’, which represents a transgression of a boundary harmful to the patient. As they further note, the specific impact of a boundary crossing can only be assessed by careful attention to the clinical context. For example, it may be coercive and unethical to suggest prayer, but depending on the clinical context it may be therapeutic to accept a patient’s request to pray together if a therapist can do so sincerely and with a clear understanding of how it advances the goals of the therapy. In dealing with situations in which the patient has another relationship with the therapist (e.g., is a fellow congregant), anticipating, discussing and maintaining confidentiality is crucial. Group discussion of these issues, and of relevant literature, such as the American Psychiatric Association’s Guidelines [47], gives trainees new ways of thinking about them, and options for responding to patient requests. Supervision should also be readily available for considering complex questions in more depth. A fourth year resident who was an evangelical Christian brought to supervision a dilemma presented by a young woman with borderline features whom he had been seeing in weekly psychotherapy for over a year. During this time, she became a Christian, and subsequently discovered that he was by asking him about books she noticed in his office. She then felt freer to discuss her problems in the light of her faith, and, as they approached termination of the therapy at the conclusion of his training, invited him to attend her baptism. He explored her expressed reasons (that he share this important moment of her life as an important person in her growth), his own conscious feelings (a wish to support her faith but a fear of losing his position in her mind as an evenhanded psychological resource, and of setting up special expectations for her next therapist), and the possibility that he was being influenced by being the son of a pastor who once planned to become one himself. Supervision with both his regular supervisor, who was Jewish, and with another one whom he sought out because they shared the same faith, helped him to consider all of these issues before eventually deciding not to attend.
Monitoring the influence of countertransference Recognizing the potential influence of one’s unconscious feelings evoked by religious or spiritual issues arising in a treatment is a vital psychotherapeutic task. Countertransference responses may be rooted in a therapist’s own worldview, experience (or lack of it) with other traditions, and own early formative experiences. Responses to patients can vary depending on whether the patient and therapist share the same worldview. For example, a clinician of a patient from the same tradition may unconsciously respond to his patient’s conservatism by reacting as he did to his fundamentalist father’s, or attempt to enlighten a younger patient with whom he identifies. On the other hand, the clinician may more easily identify where aspects of this tradition are growth promoting and, in supporting them, facilitate the therapeutic alliance. A clinician treating a patient from a different tradition may unconsciously recoil from religious beliefs he finds personally repugnant. On the other hand, the clinician through his lack of intimate knowledge of the tradition may more easily be objective in assessing how faith and symptomatology interact. Worldview related transference/countertransference interactions may be complementary (e.g., parent/child, or seeker/teacher), merging (e.g., as when a sense of religious intimacy leads to avoidance of needed confrontation), oppositional (with engagement of old conflicts with religious authority), or nuanced in even more complex ways [48].
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Teaching about countertransference possibilities is ideally done both by formally considering them within a didactic curriculum, and by modeling self-reflection in the discussion of the faculty member’s own clinical work.
7.1.7.2
Practical challenges in teaching
Finally, consider a few core challenges of faculty in teaching therapists to effectively address religious and spiritual issues: (1) engaging trainees; (2) balancing conceptual and experiential approaches; (3) presenting models of integrated practice.
Engaging trainees Trainees bring to religion and spirituality varying degrees of interest, a diversity of experience, and a range of beliefs. Biologically oriented psychiatry residents may question the value of psychotherapy itself, and the place of religion and spirituality within the curriculum. Psychoanalytically oriented residents may look for the dynamic, defensive functions of their patients’ beliefs, and atheists for how spirituality could convey evolutionary advantage. Religious residents may feel on the defensive in the classroom about the primacy they give to a spiritual perspective. Residents who do not work well together as a group may not feel safe enough to disclose and discuss deeply held differences, and vulnerabilities. They may find it easier instead to project onto the course leadership their fears of being criticized, or influenced, by a particular point of view. One of us (JP), from a decade of experience co-teaching a required course Religion, Spirituality and Psychiatry to PGIV psychiatry residents, has found the following strategies helpful in engaging them [49]: (1) demonstrating clinical relevance, by focusing on discussion by clinicians of cases and questions; (2) emphasizing diversity of perspective, in both core and invited faculty; (3) inviting ownership, by offering residents choices of invited presenters, and opportunities to present their cases; and (4) balancing conceptual and practical approaches.
Balancing conceptual and experiential approaches Given the range of ways of thinking about religion and spirituality with which residents enter training, a conceptual framework serves an indispensable orienting function. What are the basic assumptions of the faculty about the relationship between spirituality and mental health? What have others thought about these issues? What questions have been studied, and which remain to be? Providing an annotated bibliography, with handouts after discussion tend to be more accessible ways of conveying such information than lecturing from slides. But trainees also need the experience of relating theory to practice. One way to facilitate this in a classroom setting is to encourage presentation and group discussion of cases, with follow up from residents to the group about the outcome of their interventions. Another is to have students pair up, spend five minutes each taking a spiritual history from one another, and discuss what the experience was like. Still another is to invite them to interview a patient in class about the relationship between his faith and his psychotherapy. Ongoing, or ad hoc,
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individual supervision provides a context in which trainees can consider in greater depth their own responses to patient’s needs, questions that arise for them, and potential directions to take in the treatment. Trainees are more likely to read, and bring in for discussion, literature suggested by a supervisor if it is relevant to their questions.
Presenting models of integrated practice The ‘informal curriculum’ – what trainees learn from observing more senior trainees and mentors – is arguably more influential in shaping attitudes and behavior than formal didactic instruction or supervision, hence the value of opportunities to see how respected clinicians deal with spiritual and religious issues. Ways of offering such exposure include inviting such potential role models to co-lead a course or a class, or to participate in grand rounds devoted to these issues. Elective mentorship and ad hoc supervision with faculty provide other learning opportunities. The challenge for trainees is not only to integrate psychodynamic, cognitive behavioral and other approaches into their own work with patients, but to learn how to collaborate with providers of spiritual care. It can be very helpful to hear clinicians and hospital chaplains discuss how they work together, and to see examples of this – for example, in the care of patients at the end of life.
7.1.8
INTEGRATION INTO CURRICULA
The training of psychotherapists in religious and spiritual issues should occur in the context of a broad-based curriculum on religion and spirituality. In the current literature on this subject, there is some general consensus on important curricular components [13, 49]. In addition, one of us (AJ) has reviewed the GWISH program awardees and numerous other applications for the program awards. In these curricular proposals, general recurring curricular elements included: 1. 2. 3. 4. 5.
Religious and spiritual psychiatric interviewing. Religious and spiritual case formulation (’biopsychosocialspiritual’). Religion and spirituality in human development. Brief overview of selected major faith traditions. Religious and spiritual issues in psychotherapy (including transference/countertransference, boundary issues, consent). 6. Case conferences with religious and spiritual emphases. 7. Religion and spirituality in psychopathology. 8. Collaboration with clergy. Special topics included: 1. 2. 3. 4. 5.
Psychiatry medicine interface. Substance abuse. Religious issues in the treatment of women. Religious issues in the treatment of those who are abused. Introduction to cults.
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7.1.9
CHALLENGES FOR THE FUTURE
With continued ethnic multicultural and religious pluralism facing many nations, future psychiatric residents will need to be versed in all aspects of cultural competence. Religious faiths and traditions inform many aspects of culture. Once a curriculum is set, there will be a need for increasingly sophisticated and experienced clinicians who first and foremost understand the importance of worldview in their own lives and how it relates to clinical work. This attitude of openness will then translate to an understanding of how this worldview affects patient care. As educators, faculty then can model for residents how to be sensitive to religious aspects of their patients’ lives and include this, where relevant, in psychotherapy.
REFERENCES 1. Larson DB, Pattison EM, Blazer DG et al. (1986) Systematic analysis of research on religious variables in four major psychiatric journals. American Journal of Psychiatry 149, 329–334. 2. Larson DB, Thielman SB, Greenwold M et al. (1993) Religious content in the DSM-III-R glossary of technical terms. American Journal of Psychiatry 150, 1884–1885. 3. Waldfogel S, Wolpe PR, Shmuely Y (1998) Religious training and religiosity in psychiatry residency programs. Academic Psychiatry 22, 29–35. 4. Curlin FA, Lawrence RE, Odell S et al. (2007a) Religion, spirituality, and medicine: psychiatrists’ and other physicians’ offering observations, interpretations, and clinical approaches. American Journal of Psychiatry 164, 1825–1831. 5. Curlin FA, Odell SV, Lawrence RE et al. (2007b) The relationship between psychiatry and religion among U.S. physicians. Psychiatric Services 58, 1193–1198. 6. Bartoli E (2007) Religious and spiritual issues in psychotherapy practice: training the trainer. Psychotherapy: Theory, Research, Practice 44, 54–65. 7. Accreditation Council on Graduate Medical Education. (1994) Special requirements for residency training in psychiatry. ACGME, Chicago, IL. 8. Accreditation Council on Graduate Medical Education. (2001) Special Requirements for Residency Training in Psychiatry on Cultural Issues. ACGME, Chicago, IL. 9. Puchalski CM, Larson DB, Lu FG (2001) Spirituality in psychiatry residency training programs. International Review of Psychiatry 13, 131–138. 10. Koenig HG, McCullough ME, Larson DB (2001) Handbook of Religion and Health. Oxford University Press, New York. 11. Eichelman B (2007) Religion, spirituality, and medicine. American Journal of Psychiatry 164, 1774–1775. 12. Sansone RA, Khatam K, Rodenhauser P (1990) The role of religion in psychiatric education: a national survey. Academic Psychiatry 14, 34–38. 13. Grabovac AD, Ganesan S (2003) Spirituality and religion in Canadian psychiatric Residency Training. Canadian Journal of Psychiatry 48, 171–175. 14. Lawrence RM, Duggal A (2001) Spirituality in psychiatric education and training. Journal of the Royal Society of Medicine 94, 303–305. 15. Turbott J (1996) Religion, spirituality and psychiatry: conceptual, cultural and personal challenges. Australian and New Zealand Journal of Psychiatry 30, 720–730. 16. Lu FG (2000) Religious and spiritual issues in psychiatric education and training. In: Boehnlein JK (ed.) Psychiatry and Religion: The Convergence of Mind and Spirit. American Psychiatric Press, Inc, Washington, DC, pp. 159–168.
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17. Puchalski CM, Larson DB, Lu FG (2000) Spirituality courses in psychiatry residency programs. Psychiatric Annals 30, 543–548. 18. American Psychological Association (2003) Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist 58, 377–402. 19. Lukoff D, Lu F, Turner R (1992) Toward a more culturally sensitive DSM-IV: psychoreligious and psychospiritual problems. Journal of Nervous and Mental Disease 180, 673–682. 20. Josephson A (2006) Family therapy in an age of biological psychiatry. In: Graham LC, editor. Children in Family Contexts: Perspectives on Treatment. The Guildford Press, New York, pp. 71–89. 21. McHugh PR, Slavney PR (1998) The Perspectives of Psychiatry, 2nd edition. The Johns Hopkins University Press, Baltimore. 22. McHugh PR (2005) Striving for coherence: psychiatry’s efforts over classification. Journal of the American Medical Association 293, 2526–2528. 23. Luhrman T (2000) Of Two Minds: The Growing Disorder in American Psychiatry. Alfred A. Knopf, New York. 24. Kleinman A (1988) Rethinking Psychiatry: From Cultural Category to Personal Experience. Free Press, New York. 25. Drell MJ (2007) The impending and perhaps inevitable collapse of psychodynamic psychotherapy as performed by psychiatrists. Child & Adolescent Psychiatric Clinics of North America 16, 207–224. 26. Josephson A, Peteet J (eds.) (2004) Handbook of Spirituality and Worldview in Clinical Practice. American Psychiatric Publishing, Inc., Washington, DC. 27. Sperry L (2005) Integrative spiritually oriented psychotherapy. In: Sperry L, Shafranske EP (eds.) Spiritually Oriented Psychotherapy. American Psychological Association, Washington, DC, pp. 307–329. 28. Josephson A, Wiesner I (2004) Worldview in psychiatric assessment. In: Josephson AM, Peteet J (eds.) Handbook of Spirituality and Worldview in Clinical Practice. American Psychiatric Publishing, Inc., Washington, DC, pp. 15–30. 29. Josephson A, Peteet J (2004) Worldview in diagnosis and case formulation. In: Josephson AM, Peteet J (eds.) Handbook of Spirituality and Worldview in Clinical Practice. American Psychiatric Publishing, Inc., Washington, DC, pp. 31–46. 30. Pargament KI (1997) The Psychology of Religion and Coping: Theory, Research, Practice. Guilford, New York. 31. Dell ML (2004) Religious professionals and institutions: untapped resources for clinical care. Child & Adolescent Psychiatric Clinics of North America 13, 85–110. 32. Post SG (1990) DSM-III-R and religion. American Journal of Psychiatry 147, 813. 33. Nicholi AM (2002) The Question of God: C.S. Lewis and Sigmund Freud Debate God, Love, Sex, and the Meaning of Life. The Free Press, New York. 34. Worthington EL, Kurusu TA, McCullough ME et al. (1996) Empirical research on religion and psychotherapeutic processes and outcomes: a 10-year review and research prospectus. Psychological Bulletin 119, 448–487. 35. Richards PS, Bergin AE (2000) Handbook of Psychotherapy and Religious Diversity. American Psychological Association, Washington, DC. 36. Tan S, Johnson WB (2005) Spiritually oriented cognitive-behavioral therapy. In: Sperry L, Shafranske EP (eds.) Spiritually Oriented Psychotherapy. American Psychological Association, Washington, DC, pp. 77–103. 37. Peteet J (2004) Therapeutic implications of worldview. In: Josephson AM, Peteet J (eds.) Handbook of Spirituality and Worldview in Clinical Practice. American Psychiatric Publishing, Inc., Washington, DC, pp. 47–59. 38. Walsh F (ed.) (1999) Spiritual Resources in Family Therapy. Guildford Press, New York.
586 TRAINING ISSUES: RESIDENCY TRAINING AND CONTINUOUS EDUCATION 39. Josephson AM, Peteet JR (2007) Talking with patients about spirituality and worldview: practical interviewing techniques and strategies. Psychiatric Clinics of North America 30, 181–197. 40. Griffith JL, Griffith ME (2002) Encountering the Sacred in Psychotherapy: How to Talk with People About Their Spiritual Lives. Guilford, New York. 41. Koenig HG, Pritchett J (1988) Religion and psychotherapy. In: Koenig HG (ed.) Handbook of Religion and Mental Health. Academic Press, San Diego, CA, pp. 323–336. 42. Josephson AM, Larson DB, Juthani N (2000) What’s happening in psychiatry regarding spirituality? Psychiatric Annals 30, 533–541. 43. Peteet JR (1994) Approaching spiritual issues in psychotherapy: a conceptual framework. Journal of Psychotherapy Practice and Research 3, 237–245. 44. Psychopathology Committee of the Group for the Advancement of Psychiatry (2001) Reexamination of therapist self-disclosure. Psychiatric Services 52, 1489–1493. 45. Gutheil TG and GO Gabbard (1993) The concept of boundaries in clinical practice: theoretical and risk-management dimensions. American Journal of Psychiatry 150, 188–196. 46. Gutheil TG and GO Gabbard (1998). Misuses and misunderstandings of boundary theory in clinical and regulatory settings. American Journal of Psychiatry 155, 409–414. 47. Association AP (2006) ‘Religious/Spiritual Commitments and Psychiatric Practice.’ From http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/ ResourceDocuments/200604.aspx. 48. Abernathy AD and JJ Lancia (1998) Religion and the psychotherapeutic relationship. Transferential and countertransferential dimensions. Journal of Psychotherapy Practice and Research 7, 281–289. 49. McCarthy MK, Peteet JR (2003) Teaching residents about religion and spirituality. Harvard Review of Psychiatry 11, 225–228.
CHAPTER 7.2
Multicultural Education and Training in Religion and Spirituality Peter J. Verhagen Psychiatrist and Theologian, The Netherlands
John L. Cox Emeritus Professor of Psychiatry, United Kingdom
7.2.1
INTRODUCTION
In 2006 two Dutch psychiatric residents and their residency training director reported on a small qualitative survey of 13 psychiatrists currently working in a mental health service. The psychiatrists were each interviewed about their own attitude towards religious belief and spirituality. The interviewers were particularly interested in the possible role that religion played in the relationship between psychiatrists and their patients [1]. This theme is not new, and yet still evokes controversy, and in some people consternation. Consider, for example, the turmoil the well-known authority in this field, Koenig, provoked with his recent editorial in Psychiatric Bulletin [2, 3]. In this article, Koenig broadly considered the relevance of religion to psychiatric practice, and outlined the possible place, when there is shared understanding, of spiritual practices, such as prayer. The correspondents reacted to this article by suggesting that psychiatrists should remain as bio-psychosocial scientists, not generic healers. They thus re-awakened the debate about the nature of science in the world of quantum physics, as well as the place of values in medical practice, commonly derived from religious beliefs and personal world views. Reporting on countertransference issues, the Dutch interviewers quoted a typical statement from the psychiatrist’s interview, ‘If one learns that a patient is a believer, that patient’s estimated IQ will actually be rated 20 IQ points lower’. About half of the 13 psychiatrists interviewed attributed similarly negative qualities to the religious patient. Nevertheless, the psychiatrists also claimed to be on full alert for their negative countertransference. The purpose of this study was to obtain more information about the basic assumptions as part of the self-view and professionalism of these psychiatrists, and the possible religious origin of their values, Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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such as trust, hope, relatedness, validation and responsibility. Nine psychiatrists indicated that the therapeutic relationship was partly founded on religious ideas and principles. Thus the question Koenig posed in the title of his editorial: ‘What should psychiatrists do?’ could therefore be preceded by another: ‘What should psychiatrists and psychiatric residents try to learn’? There is little doubt that we can speak today of a renewed interest in the place of religion in psychiatry; and it is even contended that in the shadow of the enormous and welldocumented revolution in the neurosciences, there is a quiet revolution going on at this boundary. That the attitude of psychiatrists is changing [4, 5] may sound overstated. But the relevance of the patient’s religion and spirituality is certainly emerging in research and clinical care as a factor relevant for mental health, and for the delivery of a needs-based mental health service. Internationally, the professional associations of psychiatrists and psychologists have drawn attention to the need for developing sensitivity to the dimension of religion and spirituality in the patient’s life. This development in contemporary psychiatry has got a strong impetus from the development of cultural psychiatry and its current practice. The anthropologist Lewis [6], for example, regarded religion and language as core components of culture, which are transmitted between generations. Professionals need to be culturally competent, and to be more familiar with how to address the patient’s religion and spirituality in both clinical assessment and therapy. How to provide an equitable and accessible mental health service to a diverse multi-faith population is now regarded as a mainstream clinical priority in many countries. Cultural Psychiatry is thus no longer relegated as a fringe subject in basic training programmes, and is usually a component in Continuing Professional Development. It is therefore often within the field of Cultural Psychiatry, as well as Ethics, Values Based Medicine and Moral Philosophy that the boundary between religion and psychiatry is increasingly being explored in postgraduate training. Within the specialist training programmes, such as those in Learning Disability, Psychotherapy and Perinatal Psychiatry, the exploration of the relevance of faith traditions to clinical practice may be considered. In the practice of Forensic Psychotherapy, for example, Cox and Grounds [7] have outlined the congruence between a world view derived from Christian tradition and the understanding of the mentally abnormal offender; and also, as recently summarized by Gordon et al. [7a], Murray Cox found theological as well as Shakespearean insights helpful as a resource for his work at Broadmoor Secure Hospital. In this chapter, we will describe different components of concern with regard to the content and structure of education and training programs, and will also draw on our awareness that some of the most important initiatives in this field come at the present time from the nursing profession, clinical psychologists, and in particular from the User and Carer movement. Increasingly, undergraduate training is problem-based, and multi-professional. Thus small group teaching, when medical students are encouraged to explore their own values and to rehearse communication skills, can involve an exploration of their religious belief. At the new Keele Medical School in the United Kingdom, two first-year students are currently undertaking a Special Study Module on Spirituality and Medicine, and all students are encouraged to discuss the relevance of religious belief in a first year seminar on death and dying. Although Culliford [8] reported on a more ambitious 8-week, half day per week module for third year medical students on Spirituality and Health Care in Brighton, the extent and depth of such teaching in the United Kingdom at the present time is very limited [9].
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7.2.2 PROFESSIONAL ASSOCIATIONS AND PROGRAM REQUIREMENTS It was, however, the American Psychiatric Association that first stated in its Practice Guidelines for the Psychiatric Evaluation of Adults [10, 1995, 2nd edn. 2006], that important cultural and religious influences on the patient’s life should be collected as part of the evaluation of the psychiatric patient. ‘This psychiatric evaluation ought to be performed in a manner that is sensitive to the patient’s individuality, identifying issues of development, culture, ethnicity, gender, sexual orientation, familial/genetic patterns, religious and spiritual beliefs, social class, and physical and social environment influencing the patient’s symptoms and behaviour’ [10, 1995, p. 76, 2006, p. 25]. And ‘the case formulation must include information specific to the individual patient that goes beyond what is conveyed by the diagnosis, including issues related among other characteristics to religious and spiritual beliefs’ [10, 1995, p. 76, 2006, p. 37]. And regarding skills, the following was stated in 1995: ‘An awareness of one’s possible biases or prejudices about patients from different subcultures, and an understanding of the limitations of one’s knowledge and skills in working with such patients, may lead to the identification of situations calling for consultation with a clinician who has expertise concerning a particular subculture’ [10, 1995, 76, 2006, p. 26]. In the 2nd edition the following interesting and sensitive statement can be found on this particular point: ‘In this regard, it is important for clinicians to cultivate an attitude of “cultural humility” in knowing their limits of knowledge and skills rather than reinforcing potentially damaging stereotypes and overgeneralizations’ [10, 2006, p. 38]. In this 2nd edition attention is also paid to work with multidisciplinary teams. Other disciplines including pastoral care may perform discipline-specific assessments. Such assessments should be reviewed and integrated into the psychiatric evaluation and in developing and implementing plans of care [10, 2006, p. 36]. As part of this overall guideline, these are important statements, and a minimal standard seems to emerge with regard to religion and spirituality. As one might expect, such a standard as the state of the art asks for special attention in terms of education and training. And indeed, before this APA guideline was published in 1995, the American College for Graduate Medical Education (ACGME), including Residency Training in psychiatry, stated in 1994 and repeated since then [11] that all training programs should provide its residents with theoretical and empirical knowledge relevant to the role of cultural, religious and spiritual diversity. ‘All training programs should comply with the following: a didactic training in the presentation of the biological, psychological, socio-cultural, economic, ethnic, gender, religious/spiritual, sexual orientation and family factors that significantly influence physical and psychological development in infancy, childhood, adolescence and adulthood’ [12, p. 324]. In 2007 the program requirements for graduate medical education in psychiatry are very clear and straightforward: ‘residents must be able to provide patient care . . . [and] must have experience in the evaluation and treatment of patients . . . of different ages and gender from across the life cycle, and from a variety of ethnic, racial, socio-cultural, and economic backgrounds’; residents ‘should develop competence in formulating a clinical diagnosis for patients by conducting patient interviews, eliciting a clear and accurate history; . . . relating history and clinical findings to the relevant biological, psychological, behavioural, and
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socio-cultural issues associated with etiology and treatment’; residents ‘must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and socialbehavioural sciences . . . . The didactic curriculum must include the following specific components: the biological, genetic, psychological, socio-cultural, economic, ethnic, gender, religious/spiritual, sexual orientation, and family factors that significantly influence physical and psychological development throughout the life cycle;’ (italics added by authors). And concerning professionalism, residents must demonstrate ‘sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation’ [11]. The American Psychological Association committed itself to the same instruction. ‘Psychology training programs are required to include exposure to theoretical and empirical knowledge bases relevant to the role of cultural and individual diversity, which includes religion’ [12, p. 324]. The Royal College of Psychiatrists in the United Kingdom has generally adopted a more minimalist approach to the inclusion of religion and the understanding of spirituality, as being relevant to mental health. However, two past Presidents (Andrew Sims and John Cox) have more openly, and following the prompts of the Patron (Prince Charles), advocated the importance of considering spiritual and religious practice, if psychiatric services are to meet the needs of a multi-faith population. In 1992 the College recognized, with the support of the Trainees Committee, the need to ‘emphasise the physical, mental and spiritual aspects of healing in the training of doctors in general and psychiatrists in particular. Religious and spiritual factors influence the experience and presentation of illness’. The curriculum for basic specialist training of the Royal College was well received and stipulated the knowledge and competencies required. The trainee should for example be able to demonstrate awareness of, and a working knowledge of, for instance, ethical standards and differences in ethical, religious and other belief systems between cultures. The trainee should be able to demonstrate appropriate attitudes: attention and respect, openness, tolerance of complexity and uncertainty, and responsibility [13]. Interestingly, the Royal College has been reluctant to define more specifically a training program in ‘Cultural Competence’ – perhaps because of sensitivity to any na€ıve idea that it is only ethnic minorities that have culture, and any failure to realize fully that Transcultural Psychiatry begins ‘at home’. Thus the traditions and history of cultural psychiatry (with its earlier critique of biomedical reductionism), and awareness of ‘category fallacies’ [14], have been partially neglected. Understanding ‘diversity’ of gender, race and religious belief, and the advocacy of Values-Based Practice will be further strengthened by being incorporated into Transcultural Psychiatry and by acknowledging the specific contribution of Medical Anthropology to psychiatric practice. At about the time when the training curriculum for psychiatrists was first updated, the Spirituality Special Interest Group (SIG) was established within the Royal College, with Andrew Sims as its first chairman. This SIG now has over 1800 members and draws maximally on the multi-faith backgrounds of its members, and has an active and accessible website. At the present time, it has instigated a multi-author book on Psychiatry and Religion, which broadly reflects current levels of academic, clinical and user contributions. Dinesh Bhugra, the current College President, had earlier pioneered a conference at the Institute of Psychiatry in 1996 on Psychiatry and Religion, which was provocative at the time and innovatively included a multi-faith meditation [15].
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The Bio-psychosocial model of mental disorder was first conceived by Engel [16] as an explanatory model based on general systems theory for medicine and has also provided a useful framework over several decades for considering the social, psychological and biomedical facets of health care. However, the valances of personal and professional relationships,the meaningful spiritual facets of patient care as well as the philosophical ambiguities of the mind/brain interface can be overlooked in this model. As suggested by Powell [17], and also advocated by ourselves, this model could usefully be re-framed as a Bio social/Psychospiritual (BSPS) approach to relationship based Health Care provision (rather than as a ‘causal’ model), which could encourage optimal clinical judgment in the diagnosis, management and treatment of all medical disorders [18]. Another major event was the change in diagnostic nomenclature from DSM-III-R to DSM-IV, with the introduction of religious and/or spiritual problems as a diagnostic code for so-called additional ‘conditions’ that may be a focus of clinical attention. Worth mentioning in this regard is the attention paid to the cultural formulation meant to supplement the multiaxial diagnostic assessment. The cultural formulation is meant to provide a systematic review of the individual’s cultural background, the role of the cultural context in the expression and evaluation of symptoms and dysfunction, and the effect that cultural differences may have on the relationship between the individual and the clinician [19, p. 843]. The World Psychiatric Association declared through its then President, the Egyptian Ahmed Okasha, in 1999, that religion has remained an important factor in most patients’ lives, no matter where in the world they live. He urged trainees and practitioners to become more familiar with the vocabulary and concepts of religion. In 2003 the WPA scientific section on Religion, Spirituality and Psychiatry was set up. In the WPA core training curriculum for psychiatry, religion and spirituality are mentioned in the list of general aspects, but not listed as a seminar topic [20]. Typical of the then apparent espousal by WPA of the biosocial psychospiritual approach to mental health service, and its influence on training, was a remarkable conference organized by the Egyptian Psychiatric Association, in collaboration with the Hellenic Psychiatric Association, on ‘Spirituality, Religion and Mental Health’. This conference was organized largely by Muslim psychiatrists and held at St. Catherine’s monastery in Sinai, (one of the oldest Christian communities in the world and the traditional site of Moses’ encounter with Jahweh in the burning bush). It included a nocturnal ascent of Mount Sinai, and many other shared multi-faith reflections. The WPA Institutional Program on Psychiatry for the Person [21] represented a consensus that there was a need for new, more holistic, approach to psychiatric diagnosis and clinical management. This program, which had conceptual, training and clinical components, was controversial, and could be perceived as challenging to a biomedical supremacy. The debates as to the nature of evidence in medicine, and the role of psychiatrists, should both be constructively resolved. It is our opinion that such a resolution will come from a more full understanding of the nature of persons and an understanding of the healing content of the doctor-patient relationship. In 2003 the essentials of the WPA’s International Guidelines for Diagnostic Assessment (IGDA) were published [22]. Fundamental in this approach is the assessment of the psychiatric patient as a whole person. Such an approach assumes the exercise of more than just the medical and scientific competences. And if one takes the trouble to look carefully at these essentials, one can see that religion and spirituality are fully integrated in
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the different phases of the diagnostic process: in interviewing the patient, in using extended sources of information, in the evaluation of symptoms and mental state, in the assessment of social context, cultural framework and quality of life. Assessment according to these guidelines should lead to a comprehensive diagnostic statement and case formulation. The authors’ workgroup proposed a tetra-axial formulation, including contextual factors relevant to a disorder (axis I) on a third axis, and quality of life on a fourth axis. Besides this multi-axial formulation the workgroup formulated another necessary step in the diagnostic process. Something is lost if one is satisfied by just identifying a disorder. It is here that the wholeness of the person is at stake. The workgroup argues for a so-called idiographic diagnostic formulation. Three elements are involved: 1) identification of clinical problems and their contextualization, 2) the patient’s positive factors, 3) expectations about the restoration and promotion of health. Although religious and spiritual factors have their impact on all three issues they are explicitly addressed in the description of positive resources. Earlier, in 1995, the World Health Organization introduced the so-called WHO Quality of Life Assessment, in which six domains of quality of life are stipulated: the physical and psychological domains, level of independence, social relationships, environment, and spiritual, religious and personal beliefs. According to its view, the WHO stated that spirituality and religion might affect quality of life by helping people cope with difficulties in their life, by giving structure, ascribing meaning, and providing a sense of greater wellbeing. The World Health Organization Quality of Life – Spirituality, Religion and Personal Beliefs (WHOQOL-SRPB, 2002) Field-Test Instrument is an instrument developed to evaluate how spirituality, religiosity and personal beliefs are related to quality of life in health and health care [23].
7.2.3
BIAS AGAINST RELIGION AND SPIRITUALITY
There is also a reverse side to this renewed interest in religion and spirituality in psychiatry. Coyle [24] listed at least 12 myths or prejudices against religion. It has been known for many years, and the finding seems to be consistent during the last few decades, that there is a ‘religiosity gap’ between mental health professionals and the general population with regard to religious and spiritual beliefs. However, there is another interesting aspect to this finding. There seems to be, as we will see later, a great disparity between mental health professionals’ beliefs and their practice. On the one hand, as in the anecdote we started with, psychiatrists would state that their practice is based on their (religious) world view, and yet a small minority would be decided how to approach religion and spirituality in assessment and therapy. And it is a mistake to think that the patient does not care about it [25]. In the Netherlands there is the following threefold typology regarding the professional’s attitude towards the religious or spiritual patient: combating, confessing or avoiding. Nevertheless recent reports seem to indicate that the historical antagonism is no longer as strong as it used to be [5, 25, 26]. Is the interface of religion and psychiatry well studied, and are research conclusions clear? There are no straightforward answers to these questions. Research into the interface between religion and psychiatry is very complicated for several reasons (see Chapters 3.7, 4.1). Simple statements about the interface between religion and psychiatry, even Freud’s,
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are out-dated. What do we mean by mental health? According to Freud, the difference between health and neurosis was a matter of being able to enjoy and to achieve [27]. Obviously a person needs satisfaction and affirmation. Western individualism was enforced in this way. The individual yearns for love, and for self-esteem through paid work. There is a great difference here when compared with non-Western societies [28, p. 107]. The wellknown Belgian Professor of Psychology of Religion Vergote [29] reformulated these psychoanalytic criteria for health as follows: *
* * *
the ability to work in a broad sense (the way a person actively contributes to the composition of his milieu); the ability to communicate in common language; the ability to love others in a personal, non manipulative way; the ability to enjoy activities.
In the course of time, different possible relations between religion and spirituality were assumed. Pieper and Van Uden [30] refer to the proposal formulated by Spilka and colleagues, dated back to 1985. Religion can: * *
* * *
cure the pathological by working as a therapeuticum;1 repress the pathological by suppressing potential deviant behavior through religious socialization;2 hide the pathological when religion becomes a haven to the individual;3 express the pathological in a religious form;4 be a risk factor and cause the pathological.5
Far more important is the summary: the relation between religion, spirituality and mental health is a complex one and far from being unidirectional. Statistically positive and negative correlations between religious variables and clinical symptomatology or health indicators can be found. In the meantime one has to keep in mind that the influence of religion and spirituality, and the way it works, varies from culture to culture and across the person’s lifespan. Not all religion or spirituality is healthy, not all religion or spirituality is sick. Without doubt, religion and spirituality are powerful forces and may impart harmful as well as beneficial effects. And there is still a lot of controversy about how to use this knowledge and these findings in an appropriate way during assessment and therapy. For instance, how 1
Religious rituals, religious experiences as conversion can have curative effects. The religious community can have a fundamental influence by disapproving and even punishing unwished-for behavior, and encourage and reward desirable behavior. 3 Monastic life offered and offers such a safe sanctuary. Religious sects can attract people who for various reasons, e.g. personality weaknesses, are not able to cope with life. 4 Mystical experiences can be expression of psychopathological states. Religious leadership can be expression of severe personality disturbances. Phenomena like scrupulosity (see Chapter 3.1) can be expressed in all kinds of religious doubts and insecurity. Personality disorder features are associated with certain characteristics of the god image [31]; see Chapter 4.2. 5 All sorts of doctrines can have a disabling effect on vulnerable people. Religion can cause negative bias against mental health treatment to the patient’s detriment. Religion can cause all kinds of countertransference distortions. Disturbed religious leadership can cause severe harm to the individual. Certain religious traditions cause trouble with negative emotions, sexual feelings and/or prohibit fantasy. 2
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should one proceed if the patient wishes his religious or spiritual beliefs and practices not only to be respected, but also to be included in therapy? How does one develop spiritual interventions? It is not only a matter of knowledge and attitude, but also a matter of skills. In any case, it is a biased and somewhat prejudicial opinion to believe that religious and spiritual concerns can be separated from mental states. In fact, giving personal meaning to one’s own life is a general characteristic of human beings. Not everybody is fully aware of this process. Again, it varies across the lifespan and is often evoked by so called boundary experiences, e.g. a psychiatric disorder. So the separation between mental health states and religious or spiritual concerns is a rather vague return to a simple form of dualistic thinking. Coyle’s last, 12th myth runs as follows [24]: ‘The field of psychiatry can continue to ignore the influence of spirituality in mental health’. We fully agree with his conclusion: ‘The seemingly natural occurrence and prevalence of various forms of spirituality and religiosity6 in the global society further confirms the importance and relevance of including spiritual and religious factors in psychiatric care. Emotional and psychological care that excludes a spiritual and religious dimension is incomplete and thereby inferior. Furthermore, the very credibility of our profession lies in how we will ultimately come to integrate spirituality and religion into our understanding and treatment of the human psyche’.
7.2.4
ATTITUDE
These statements are important enough to take notice of. Especially because, at least until recently, the attitude of psychiatrists towards religion has been complex. That attitude has been labelled as an attitude of neglect, of scepticism and even overt hostility [32–34]. Neeleman and Persaud [32] formulated several reasons for this attitude. The neglect is partly related to psychiatry’s progress in elucidating the biological and psychosocial causes of mental illness, rendering religious explanations superfluous. In addition, it was until recently often assumed that religious attitudes were linked with phenomena such as dependence and guilt, which were and still are seen as undesirable. Furthermore it is well known that psychiatrists and psychologists tend to be less religiously orientated than their patients, which may further increase the professional’s idea that religious or spiritual beliefs are associated with disturbance. However, it has long been assumed that a positive relationship may exist between religion and mental health. Psychology of religion has provided empirical support for that idea. But psychiatry has still to accommodate this evidence into theory and practice. In another survey, Neeleman and King [35] studied the religious attitudes of 231 psychiatrists in London, United Kingdom, in relation to their clinical practice. Twenty-seven percent reported a religious affiliation, 23% a belief in God. Ninety-two percent felt that psychiatrists should concern themselves with the religious concerns of their patients. But there was no evidence that psychiatrists’ private religious beliefs had an important influence on their clinical practice. Although more than half of respondents reported regularly assessing the religious beliefs of their patients, interventions in this area, such as referral to and liaison with the clergy, were relatively rare. In their conclusion the authors noticed that psychiatrists were undecided about the role of religious or spiritual belief in the development of, or recovery from, mental illness. 6
The authors (PJV and JLC) added ‘religiosity’, ‘religious’ and ‘religion’ to the quotation.
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Larson and colleagues [36] demonstrated another example of this complicated or even skeptical attitude of psychiatrists towards religion. They reviewed appendix C of DSM-IIIR published in 1987, that is the glossary of technical terms. And what they found was very interesting and illustrative of insensitivity concerning religion and spirituality. What did they investigate? They reviewed all definitions in the glossary to determine the frequency with which religion was presented as a clinically relevant factor. Secondly, all definitions were further reviewed to determine how sensitively religious examples were used to illustrate psychopathology in each term’s brief, illustrative case examples. They evaluated how frequently 1) religion was presented as a clinically relevant issue, 2) other cultural issues were presented as clinically relevant issues, 3) religion was used to illustrate psychopathology, and 4) other cultural issues were used to illustrate psychopathology. They found 21 examples of clinically relevant issues, of which 6 had a religious content. Of the remaining 15 issues only 1 was related to ethnicity, and only 1 to sexuality. They found 45 illustrative case examples of psychopathology. Ten of these cases had religious content, for instance: ‘catatonic posturing: a patient may stand with arms outstretched as if he were Jesus on the cross’. In contrast, only two cases contained sexual content. Although none of the case examples would seem clinically implausible, the context in which they were given (the definitions section of a major document of psychiatric nosology) casts religious commitment in a negative and pathological light, which is rather insensitive to religion and spirituality. Indeed, as the authors noticed, the over-utilization of religion as case example of psychopathology supported the simplistic traditional mental health notion that religious commitment fosters psychopathology, and that religion is not associated with mental well-being. Obviously these findings and comments were taken seriously. Negative inferences about religion were removed from the glossary in DSM-IV, published in 1994, and the new V code ‘Religious or Spiritual Problems’ was added. Recent studies inform us about a changing attitude. Baetz and colleagues [25] found that, although psychiatrists report significantly lower levels of spiritual and religious involvement than their patients and the Canadian population in general, both psychiatrists and patients agree that religion and spirituality have their role in psychiatric care. Interesting and recognizable are the barriers to addressing religion and spirituality that the psychiatrists experience: lack of time, lack of familiarity, feeling it is inappropriate to do so, and feeling the patient is not interested. One-half of the psychiatrists indicated that they inquire routinely about spiritual issues; that is about the same figure as the one Neeleman and King [35] found among British psychiatrists. In another interesting survey, the investigators tried to compare the way psychiatrists and non-psychiatrists interpret the relationship between religion and spirituality and health, and how they address religious and spiritual issues in the clinical encounter [5]. More than a thousand physicians completed the survey. What appears? In this study 93% of the psychiatrists responded that it is ‘usually or always appropriate’ to inquire about a patient’s religion or spirituality, versus 53% of other physicians. More than 90% in both groups responded that it is appropriate to discuss religious or spiritual issues when a patient brings them up. What about discouraging barriers? Lack of time (35% of the psychiatrists versus 48% of other physicians), concern about offending patients (25 versus 41%), insufficient knowledge/training (25 versus 26%), and concern that colleagues will disapprove (3 versus 4%). The authors conclude that psychiatrists seem to be more open to interacting with patients about religious and spiritual issues, and they are more or less optimistic about this development. However, an explanation of possible reasons sticks by older literature and is therefore not clarifying enough. In
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the conclusions of these surveys, education about religious and spiritual assessment, and other related issues, is highly recommended [25, 26]. On the whole similar conclusions can be drawn with regard to the clinical practice of psychologists [37]. All these developments and data are significant because of their centrality to guidelines and residency training. Although these developments are significant and underline the importance of religion and spirituality to the patients in assessment, diagnosis, case formulation and therapy, psychiatrists rarely systematically seek information about their patient’s religiosity and spirituality, and the amount of training time allotted to the topic is probably severely limited. In our (PJV) training program, however, there are eight hours allotted to psychiatry and religion, and twelve hours to transcultural psychiatry in a threeyear curriculum.
7.2.5
DEFINITIONS
It is obvious that we should try to be as clear as possible about the terms and concepts we use. The concepts of spirituality and religion are no exception to this important rule. The importance of this rule can be seen on different levels of analysis. Clarity about what we mean when we use our concepts contributes to the understanding of what people mean when they tell us about their everyday experience, whether it is signs of religious or spiritual experiences or symptoms of a psychiatric disorder, or perhaps both. Clarity about the terms we use is also helpful on the more clinical level, when we try to discern a pattern in the story the patient tells us, when we try to identify a disorder, and when we try to summarize our findings in a case formulation. We also need to become clear, or try to reach out for more clarity on a scientific level. On this level affective, cognitive and social processes, disordered functions and relations are investigated and analyzed. Religion and spirituality, from a psychology of religion perspective, are about affective, cognitive and social processes. On a philosophical level – a fourth level of analysis – we try to become clear about our premises and the theoretical models we are using in our scientific and clinical work. At this level of explanation, one of the essential themes is the relationship between science and religion. The meeting of science and religion, or the science-religion dialogue is usually, especially in the Western world, not understood as a two-way traffic from science to religion and from religion to science. Indeed, it is our claim, without intending to become religious expansionists [38], that religion and spirituality are not just interesting enough for the ethical considerations, but also important for the core business of science. To formulate a definition of religion and spirituality is not an easy task to fulfil, because both concepts have many facets. Of course, many definitions have been formulated. Two strategies can be recognized in attempts to devise a definition: the substantive one and the functional one [39]. The substantive definitions define religion and spirituality by their essence. They refer to their ‘substance’ from a certain religious viewpoint. Frequently there is reference to a transcendent reality, e.g. religion as a relationship to the absolute. Usually, that transcendent reality can be depicted in different ideas: in its infinitude transcending finitude, in its otherness and distinctness transcending a mortal being and the limitations of our conceptual abilities (see Chapter 1.3). According to a famous description of that relationship to the absolute, or to the Holy, as the author calls it, it is said to be an incomparable experience of a ‘mysterium tremendum et fascinans’ [40]. Functional approaches look at the purposes religion and spirituality serve and the functions they fulfil. It is not just a theoretical question.
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The difficulty can be met on the different levels we mentioned before. It is not only expressed in the way people describe their religious and spiritual life, beliefs and practices, and in the way this is evaluated in clinical practice; it is also a returning problem in the operationalization for research purposes. On a meta-theoretical level we encounter the same problem. If we look at an example of an influential definition of religion proposed by Geertz, we can probably sense the kind of questions that are evoked. Geertz defined religion as: ‘a system of symbols which act to establish powerful, pervasive, and long-lasting moods and motivations in men by formulating conceptions of a general order of existence and clothing these conceptions with such an aura of factuality that the moods and motivations seem uniquely realistic’ [41].
Geertz looked at religion as a cultural system, which may be defined as the interaction of different elements of culture. His definition however has some of the characteristics and disadvantages of a particularly Western way of thinking, and therefore may have limitations from a multi-cultural perspective. It is nevertheless quite clear what elements are involved which include a system of symbols, conceptions of a general order of existence, and the functional interactions these elements have on mood and motivation in men. In that sense this definition is a typical mixture of an essentialist and functionalistic approach to religion. As such, this approach is not only dated back to the development of structural functionalism, but it is also a chosen approach for evolutionary psychology. A function-based approach would look at adaptation, goal-attainment, integration and pattern maintenance. And if we look again at the definition like the one proposed by Geertz, we could quite easily discern functions like these. Religion and spirituality are sources for adaptation, integration, goalattainment and pattern maintenance in confrontation and struggle with the unruliness of life. However, a concept of religion employed in this way namely as a generic term to denote the communality of all religions dates back to the 17th century (see also the Epilogue). In that sense, the Western concept of religion is a typical ‘modern’ concept. It might mean that there is no proper equivalent in other non-Western non-Christian cultures. In fact this is not a hypothetical case. It is said by expert scholarship that for instance Hinduism is not a religion in that typical Western modern sense. The term used analogous to religion is Dharma, but there are many differences, and in fact Hinduism is a collective term for a variety of ‘religious’ traditions. In any case, it is very clear that monotheistic religions have far more in common with each other than the Indian religions [28, 42]. A controversial issue is the relationship between religion and spirituality (see also Chapters 4.1, 4.4 and the Epilogue). We fully agree with other experts in the field that there is no reason whatsoever to define these two concepts in a rather dualistic framework [39]. It is absolutely not necessary to follow some sort of current mode to set off some kind of bad, destructive religiousness against a far more favorable good spirituality. It is in our view very important to keep in mind that it is a fundamental mistake to oppose religiousness and spirituality. Religion has a bad name because of its institutional and organized forms. However, personal, experience-based devotion is the core of religiousness as much as it is spiritual. Religion and spirituality are both best understood as multidimensional constructs including social, cultural, cognitive, affective, behavioral, neurobiological and existential dimensions. Understood in that way it is simply not correct to state that religion is cognitive and spirituality is emotional, or religion is static and spirituality is dynamic, or even religion is bad and spirituality is good. On the contrary, it is possible to be spiritual and religious,
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spiritual but not religious, religious but not spiritual, and neither spiritual nor religious. Although it certainly is not just a matter of words, and it is also true that religion and spirituality as terms became differentiated during the last century, one could say that spirituality is a central concern of religion, but not the only one [43]. Outside the context of religion, spirituality has many meanings.
7.2.6
MEDIATING FACTORS
We need a model that can help us to explain why and how religion and spirituality influence (mental) health. Such a model, of course, needs to do justice to the complexity of the mechanisms involved; on the other hand it needs to be simple enough to be understood by professionals of a variety of disciplines, and needs to consider accumulative effects over time and varying effects in different stages of the life cycle [44]. All kind of models and figures have been depicted; all kind of pathways, direct and indirect, have been described. However the question is why and how should religious beliefs and practices, like hymns, readings, prayer, and worship, effect mental health? One of the hypotheses is the idea of ‘buffering’. Religious and spiritual practices provide a buffer against the impact of life events and all sorts of stress. There is in a certain sense consensus about the following influential salutary mechanisms [45–47]: epidemiological and clinical studies support the impact of religious and spiritual involvement on an array of indicators of mental and physical health (such as positive self-perception and personal efficacy, positive emotions, reduced burden); religious and spiritual involvement influence lifestyle behaviors. Religious factors are associated with lower levels of behavioral risk (smoking, heavy drinking), and higher levels of health promoting behavior out of respect for
Common factors (e.g. social, physical, genetic, personality features)
Mediating factors • personal lifestyle and health behavior • social resources • self-esteem and personal efficacy religion/spirituality
• coping resources and behavior
distress, psychopathology
• positive attitudes, beliefs and emotions
Figure 7.2.1 Schematic outline of Common and Mediating factors in the interplay between religion/spirituality and (mental) health.
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the body; religious and spiritual involvement enhance effective coping with stressful life events, boundary experiences, illness and disabilities; religious and spiritual involvement provide larger and stronger social networks and greater availability of social support and social integration.
7.2.7
‘MODEL CURRICULUM’
The most extensive program ever written was the ‘Model Curriculum Religion and Spirituality in clinical Practice’ prepared by The National Institute for Healthcare research, edited by Larson, Lu and Swyers in 1997. In a little more than 100 pages, they formulated a very comprehensive outline of their course. In 2001 Puchalski, Larson and Lu published a short introduction and an overview of this model curriculum [49]. They described the development of the program. Its development started in 1995, and psychiatrists from different faith traditions became involved. The result of the process was first published in 1996. It is called a model because its first aim is to serve as an instrument for developing one’s own training program with regard to religion and spirituality, adjusted to the circumstances one has to deal with. Interesting is the way one can follow whether, and if so, how the model has been functioning. The John Templeton Foundation supported the development of the model curriculum and created an award for psychiatric residency programs that address spirituality and health. The award is administered by the George Washington Institute since 1998, originally every year, now every three years. When visiting the Institute’s website (www.gwish.org), one can find the descriptions of all awarded programs since 2005. Puchalski et al. listed the award winners from 1998 through 2000 [49]. The model has obviously been playing a stimulating and innovative role. The table of contents of the model curriculum still tells us a lot about issues that should be covered in an appropriate training and/or course on religion and psychiatry for psychiatric residents. The authors divided the program into core modules and accessory modules [48]. Core modules: *
*
*
an introductory overview of religion, spirituality and mental health, including history, research on the relationship between religion and spirituality and mental health, matters of definitions, ethical issues, religious and spiritual traditions and modern beliefs and practices; assessment of a patient’s religious or spiritual life, including interviewing techniques and strategies, differential diagnosis, transference and countertransference issues, assessing appropriateness of religious or spiritual interventions; religion and spirituality in human development and through the life cycle. Accessory modules:
* * * * *
the psychiatric interface with medicine; collaborating with clergy; religious and spiritual issues in connection with substance abuse; religious and spiritual issues in the treatment of women; religious and spiritual issues in the treatment of traumatized persons;
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an introduction to god images; an introduction to charismatic religious experiences; an introduction to cults and their relationship to mainstream religion.
Perhaps we would now rephrase things somewhat, given the way we are more or less accustomed these days to cultural assessment in its current form, but it is immediately clear that the main issues were already covered in these modules. The model curriculum included learning formats and appendices on questions for assessment, and for evaluating a religious biography. The model curriculum is completed with literature for further study. And most important, all topics are described in terms of knowledge, skills and attitudes the resident should demonstrate competence in! Several groups have formulated learning objectives for training courses on the interface between religion, spirituality and psychiatry, following the model curriculum [49–51]. In summary (core themes and subdivision): knowledge: ‘understanding the spiritual/religious factors that affect the course and treatment of psychiatric disorders’ T basic understanding of major faith traditions; T demographics of religious/spiritual beliefs in various populations; T defining religion and spirituality in their (unique variety of) aspects: experiences, attitudes, beliefs, practices; T understanding the role of spirituality and faith in coping with life events and illness; T understanding a differential diagnosis for religious/spiritual phenomena; T the role of religion and spirituality and religious/spiritual professionals in healing; T understanding of research into the relationship between religion/spirituality and health, and on neurobiology of religious/spiritual experiences; T understanding how religious and spiritual issues affect medical ethics. * skills: ‘diagnosing, assessing and formulating treatment plans for patients, with an understanding of spiritual/religious experiences’: T the ability to take a religious/spiritual history; T to recognize when a patient’s religious/spiritual views are harmful to the patient; T to recognize the differential diagnosis of spiritual/religious phenomena; T to provide appropriate (psycho)therapeutic interventions; T to recognize transference and countertransfence reactions; T to recognize possible biases against religious/spiritual issues in research literature and psychiatric literature in general; T the ability to work collaboratively with religious professionals. * attitudes: ‘non-judgmental attitude when eliciting a spiritual history’: T to be sensitive to the cultural and religious/spiritual needs of patients; T to respect and take seriously the religious/spiritual beliefs of patients; T awareness of one’s own religious/spiritual beliefs, experiences and view on (mental) illness; T awareness of one’s own attitudes and possible biases that could influence assessment, case formulation and treatment. *
It will be no surprise to discover that the clinical psychology programs show(ed) the same difficulties with regard to religion and spirituality. All kinds of official statements confirm
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this picture [52]. The growing awareness of the importance of religion and spirituality appears to go hand by hand with the growing interest in the research into positive factors, such as life satisfaction. Brawer et al. [52] investigated the extent of education and training in accredited clinical psychology programs. Ninety-eight surveys (out of 197) were included. Only 13% of the directors indicated that their programs offered a specific course on religion and/or spirituality, however, with great variability concerning the frequency by which the courses were offered. In fact, religion and spirituality were most frequently addressed in supervision (77%). Sixteen percent of the directors reported that religion and/or spirituality were not covered at all. A few years later another survey was published [53]. This time the investigators looked at training in religion and spirituality within APA-accredited psychology predoctoral internships. They could use 139 surveys out of 433. Only 35, 5% reported didactic training in religion and spirituality (in 49, 2% it is offered once a year). Religion and spirituality are most frequently covered in therapy supervision (90, 8%). These figures are much the same. In both publications the authors formulated a list of recommendations to remove constraints. We mention a few of these very useful strategies: * * * *
*
facilitate discussion of religion and spirituality in supervision; modify the curriculum and/or add didactic session(s); incorporate religion and spirituality as variable when training in cultural psychiatry; network with other professionals who have greater familiarity with religion and spirituality; add readings on religion and spirituality.
In addition to this the following ‘golden principles’ for designing training courses on the interface between religion, spirituality and psychiatry are very helpful [54]: *
*
*
*
*
*
create a clear educational goals list: this list would provide residents with a clear picture of what is going to be taught and trained; otherwise the risk of vagueness and softness when compared with other more substantial courses would be discouraging and open to suspicion of irrelevancy; emphasize the integration of knowledge, skills and attitude: residents should demonstrate competence in using the acquired knowledge while interviewing and diagnosing with an engaged, sensitive and non-judgmental attitude; be sure that supervision is safe enough for residents to feel free about talking about spiritual and religious matters to their supervisors; with regard to spiritual religious history taking (see next) it would certainly be helpful to model an interview: methods for raising the topic of religion and spirituality, the risks and benefits of self-disclosure, and in-depth exploration are important issues in modelling (and supervision); in our experience it is absolutely helpful and necessary to model history taking and interviewing. It is also helpful and necessary to train residents (and professionals) in formulating clinical cases: risk and protective factors should be included; trainees should be acquainted with standardized and idiographic diagnostic formulations. They should be aware of the tension between application of general concepts (standardized) on the one hand and the uniqueness of the individual patient on the other.
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Not much is known about the efficacy and evaluation of training programs. Most recently, Grabovac and colleagues reported on a pilot study and evaluation of a mandatory postgraduate 6-hour course on the interface between Psychiatry, Religion and Spirituality [51]. They developed a ‘Course Impact Questionnaire’ and administered the questionnaire three times to two separate groups of residents (N ¼ 30) and a comparison group (N ¼ 6). Despite the limitations of the pilot study, the results showed a change in the desired direction in perceived knowledge and skill base. Interesting to note are the changes that will be made in further improvements of the course. More case studies will be included, a change we highly recommend. Other surveys explored the religious life of residents and their didactic and supervision experience regarding religious issues [55], content and process as well as evaluation data of a module to increase skills, expand knowledge and deepen sensitivities about spirituality and religion when serving older adults and their families [56], or the understanding and handling of spirituality and religion in professional training of a sample of Muslim psychology students [57]. Without becoming overzealous, the general conclusion of these surveys can be summarized in rather simple words: the challenge for training programmes lies in what constitutes a religiously and spiritually ‘hospitable place’ [55] for appropriate education and training.
7.2.8
TAKING A SPIRITUAL/RELIGIOUS HISTORY
We are used to the experience that a lot of things are difficult enough to talk about in private, not to mention with strangers. It is even said that it is more difficult and intimate to talk about one’s religious or spiritual life than about one’s sexual experience. Psychiatrists are trained in interviewing, and they are well aware of the domains that should be assessed: history of the present illness, diagnostic regions, interviewee’s perspective, formal mental status examination, social history, family history, determination of suicidal/homicidal potential, past psychiatric history, developmental and psychogenetic history, and medical history [58]. It is not unusual, depending on the patient’s problems, to conduct a more global assessment in this area, and more in-depth assessments in other domains. Depending on the information gathered, the interviewer will proceed from global to more in-depth assessment. This strategy is of course also very useful with respect to religion and spirituality. It is therefore helpful to make a distinction between a more global and an in-depth investigation. As with the other domains or content regions, a global assessment is in fact always indicated. Examples of global questions would be like [59]: * *
* *
* *
What is the patient’s worldview? Which role did religion or spirituality play in the patient’s childhood (affiliation, experiences)? In what way is the patient currently involved in religion or spirituality? Does the patient think his religious or spiritual beliefs and lifestyle are contributing to the problems, concerns, and symptoms in any way? Does the patient have any religious or spiritual concerns? Does the patient expect his religious or spiritual concerns need to be addressed in therapy?
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Would the patient expect his beliefs and the community he belongs to, to be helpful and a source of support?
Koenig and Pritchett [12, p. 327; 2, 60] proposed the following screening questions known by the acronym ‘FICA’: * * * *
Is (religious) faith an important part of your life? How has your faith influenced your life (past and present)? Are you a member of a religious or spiritual community? Are there spiritual or religious needs that you would like to address?
During a global assessment one wants to get the information needed to decide whether a more in-depth interview will be appropriate and necessary. Several possible indications for such a more in-depth approach need to be considered [58, 59, 61, 62]: *
*
*
*
*
*
*
*
*
the patient’s religious or spiritual background is obviously relevant to the understanding of their complaints and problems; religiosity or spirituality may influence the development and course of complaints and symptoms in a positive and/or in a negative way; religiosity and spirituality may influence the choice and course of treatment or psychotherapy; religiosity and spirituality may influence the explanatory models of illness and therapy religion and spirituality may cause problems that need clinical attention and care as such, because of unresolved conflicts, concerns, etc.; the influence that religion and spirituality may have, could be a reason to refer to, or to consult with a religious or spiritual care giver; a religious or spiritual assessment could help to determine whether religious/spiritual interventions would be useful; religious and spiritual beliefs and concerns may be a critical component in suicide assessment (‘evaluating the allure of the hereafter’, [63]; an understanding of moral codes and values in relation to a variety of aspects of human relationships and ethics may, again, have an impact on the choice of a therapist and on the choice and course of any treatment.
In other words, an assessment is needed to understand the prognostic value of the patient’s religious and spiritual involvement, to understand the life context of the patient, to monitor outcome, and to develop appropriate interventions [64]. In case in-depth exploration is indicated, several areas could be touched upon [61]: * * * * * *
development and religious/spiritual upbringing, intrinsic and extrinsic orientation; belonging to a religious or spiritual community; beliefs, worldview; God(s): ultimate source of life, God image, relationship with God; religious or spiritual practices, rituals; religious and spiritual experiences and well-being.
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7.2.9
CASE FORMULATION
The clinician wants to report his assessment. Formulating his considerations, the clinician will evaluate the impact of a patient’s religious and spiritual background on his or her clinical presentation [10]. The case formulation often turns out to be more or less abstract, comprehensive, speculative, and dependent on specific theories and assumptions. One of the tools one could use is the cultural assessment according to DSM-IV [19, 65]. Another approach would be to formulate the way in which religion and spirituality are constructive or destructive [61]. A more idiographic narrative approach would be to look at the dynamics of religiosity and spirituality in the person’s life, as we discuss below.
7.2.10
BASIC DYNAMICS
Much has been said about what topics should be covered in religious and spiritual assessment, and again, most issues raised are Western-orientated, based on defining concepts like mental health, religion and spirituality. However, much can be gained by this basic approach. What is needed? We need a method that helps us to recognize the dynamics of religion and spirituality, without requiring detailed knowledge of all kinds of spiritual and religious beliefs and practices. It is far more worthwhile to identify the structure of a patient’s spirituality and religiosity, and its accompanying personal theology. It is more relevant to understand and identify how a patient constructs his religious or spiritual philosophy of life, based on what he has been taught, and on his life experiences. When the assessment leads to a better understanding in this full sense, it will enable the therapist to use latent opportunities that may lie within the patient’s religious and spiritual frame of reference [66]. Let us have a closer look at four basic elements in the religiosity of ordinary people, whether or not they are patients.7
7.2.10.1
Basic trust
In religion there is always a basic sense of trust or of fear, which colors life in a very fundamental way. This sense or feeling of trust or fear is very closely connected to a basic experience of security, safety, attachment or threat. It is the basic sense of having the ‘right to be’, bestowed on us in the acceptance, or even the love that others may have for us. There is always in a very basic sense the knowledge or awareness that others may have begun their spiritual journey with us. One could call this the (nostalgic) ‘smell of home’ of religion. Of course, the idea and the words we use in describing this basic element in personal religiosity may recall the work of Erik Erikson and his concept of basic trust, as well as the ideas of object-relations and attachment theorists. Nowadays, in mentalizing theory we would call it perhaps ‘epistemic trust’ or ‘mistrust’, by which we mean the (lack of) confidence in the
7
Based on an unpublished public lecture by Patrick Vandermeersch, Professor of Psychology of Religion at the University of Groningen, The Netherlands (2005). We acknowledge his valuable contribution to this particular field of inquiry.
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caregiver as (un)reliable [67]. It is also connected with the basic level of self-awareness according to Cloninger [68]: a (deficient) basic sense of being and permanence. A few things need to be added here. It is important for our image forming to realize that faith and trust are closely connected. Faith is never just a simple matter of acknowledging that this or that fact or statement is true. Faith is always implicating a capacity for trust and for acknowledgment of others.8 All religions have that in common. And in such a capacity for trust the whole person is involved [69]. In faith, trust finds its expression; and in that sense it is strongly connected with the believer’s life cycle. One can imagine that suffering in any shape can cause severe religious and spiritual struggle- especially when mistrust and negative feelings get the upper hand. If this is the case, special attention to religious or spiritual interventions might be necessary [70] (see also Chapter 5.3). A comment from the perspective of a theology of religion is appropriate. In a global context ‘faith’ does not necessarily imply a personal relationship with a personal God. Faith can be understood as an existential orientation towards an impersonal transcendent reality. Starting from this point one could expect that a soteriocentric, not a theocentric, understanding and evaluation of religion would be preferable. Not all religions for example are theistic in the sense that the transcendent reality is imagined as a personal God. However, in all religions deliverance, salvation and welfare are central [71]. It has also been argued by Rene Girard [72] that ritualized sacrifice, and thus the containment of communal violence, is another characteristic of many religions and is particularly central to Christianity.
7.2.10.2
Commandments and prohibitions
A second basic element in the dynamic configuration of religion is the issue of commandments and prohibitions. Every religious tradition is concerned with religious obligations and life style regulation in order to restore something like ‘holiness’. These rules relate to daily life, and to religious rituals and practices. There are dietary rules, rules with regard to sexuality, but also rules concerning daily religious obligations like prayers and reading or reciting holy scripture(s). Some of these rules or obligations are connected with stages of life and rites the passage. Most of the time people belong to a religious tradition by birth, but usually not only by natural birth. Initiation rites are the expression of membership in a religion. And usually it means that one takes the responsibility to study and learn and to live more or less according to this or that religious tradition – including its life style regulations. It is important therefore in a medical context to understand how a person relates to these rules. Obedience may be the religious virtue pre-eminently. However, in daily life this might be less clear cut, and ‘nature’ (daily life) might be stronger than nurture (religious doctrine)’. What is the relevance of these considerations to patient care? It is not unusual in some orthodox religious groups to hold the view that mental illness is a consequence of disobedience to God’s demands. On the other hand, in the same religious groups some people do not take these demands too seriously. What does that mean on a
8
The difference dates back to a medieval distinction: fides qua creditor: the faith by which is believed, fides subjectively considered, and fides quae creditor, the faith which is believed, the content of faith (beliefs), fides objectively considered [69, p. 107].
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personal level, with regard to guilt feelings, anxiety, and negative thoughts about oneself? What does it mean in the religious make-up of this or that individual?
7.2.10.3
Identity
Identity is unmistakably the third dynamic component in the religious and spiritual make-up of the person. Although a complex concept, differentiated in other concepts like person, personhood, personality, self, we understand ‘identity’ according to a rather plain definition. We take it as the authentic and secure sense of congruence within the self between a person’s meaning to self and to others. And given that sense of identity, a person is ready to commit him/herself to affiliations and partnerships in combination with the developing ethical and moral strength to abide by such commitments, despite sacrifices that might be asked for [73]. Our commitments and trusts shape our identity. The deeper the content is internalized, the more likely images and schemes will motivate attitude and action. No doubt Erik Erikson influenced significantly our thinking about the process of identity development. His approach also strongly influenced research and thinking about faith development. He described the process as a merger of personal and social identity into one. His model became increasingly idealized [74]. Nowadays we are more capable of realizing that there are important cultural differences with regard to identity and its proclivities. Utilitarian individualism is not the same as hedonistic individualism. They both differ in important aspects from intersubjectivity. The boundaries of the person are not the same in every culture [75]. Kirmayer draws our attention to the contrast between individualistic and collectivistic orientations, but other variations are equally important. He distinguished four cultural configurations of self, which, as we assume, can also be taken as different configurations of identity: egocentric, sociocentric, ecocentric and cosmocentric. We fully agree with Kirmayer that, whatever the configuration, the moral order and religious/spiritual convictions of the individual are not an appendix, but is anchored at the core of the process of identity development, and selfdefinition and valuation! Faith includes notions like perseverance and commitment. Erikson coined the term ‘fidelity’ in connection with identity to denote these notions [69, 76]; fidelity as ego-quality of identity. ‘Fidelity is the ability to sustain loyalties freely pledged in spite of the inevitable contradictions of value systems’ [69, p. 125]. In that sense fidelity is a characteristic component of identity development. It is nourished and endorsed by resources providing meaning. Nourishment that shapes one’s sense of identity, comes from (sub)cultures, societies, institutions, education, religions and spiritualities. Whatever terms one chooses, faith has the (psychological) capacity to enhance an enduring sense of identity or self. And people are very sensitive to their personal identity and faith. For that reason, religious or spiritual crises are not just a matter of doubts about certain convictions or beliefs, which one can change or abandon without any costs or suffering. On the contrary, religious and spiritual crises due to life events or any cause can evoke an uncertainty about one’s sense of identity. Kim [74] has drawn attention to an evolving shift in our conceptions of cultural identity toward greater multiculturalism. He calls it an intercultural identity and discerns two key elements: individuation and universalization. The theologian Schmidt-Leukel asks whether the same could hold true for a ‘multireligious identity’ [77]. This is a very thought provoking
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issue, because religion inevitably seems to be a non-mixable individual and personal stance. A multireligious identity even seems contradictory to what we called before the ‘nostalgic smell of home’ background of religious socialization. Should one not fear that this so-called multireligious identity is just a patchwork-religiosity? On the other hand more and more people grow up without any religious socialization. Between individuation and universalization Schmidt-Leukel argues for authenticity. Obviously the possibility of a multireligious identity seems to be an important issue for any interreligious peace building program and interfaith dialogue [78–81].
7.2.10.4
Relationship to authority
A fourth component of the basic dynamics in religiosity (and spirituality) is the relationship towards authority. All religious traditions have their authorities, especially those persons who have the position, the calling, the ordination to proclaim. We know them as religious leaders, medicine men, prophets, priests (p ujari in Hinduism), preachers, mediums, seers, rain-makers, Devadasıs (women as ‘servants of God’ in Hinduism), Brahmans, Messiahs [28, 82]. Followers certainly will set their heart on what is said, proclaimed or prescribed in a positive or negative way. Some will follow without any doubt or resistance, others will become fretful or become entrapped in an ambivalent relationship. Religious leaders are important and valuable persons to many people. It is a universal fact that men and women who have religious insights or special religious or spiritual experiences are the ones who lead others in religious knowledge, practices and rituals. The special position they have is often due to a view on intercession between God(s), spirits on the one hand and ordinary people on the other. These intermediary people are often gifted in certain ways. Their gifts, and the practices connected with them, underpin the specialness of their position. A distinctive kind of gifted religious people are medicine men, shamans, and healers. Across the world and across religious traditions and faiths, the devout have faith in the strength and the power of spiritual healers. People commonly look for spiritual healing alongside medical care (without necessarily telling their doctors), or when medicine falls short. If it turns out that the patient is also looking for spiritual healing, it is clearly important to identify the perceived causes or explanatory models the patient and his relatives use. Medical authority might be in conflict with religious or spiritual authority. It is remarkable however to see that, often at the same time across these religious traditions, an ambivalent relationship exists between the official tradition and popular beliefs. To conclude, in our view picturing these four dynamic components gives a clear unfolding narrative of the personal religious and spiritual development and life of the individual that is highly relevant to the timing and content of both education and training in this complex field.
7.2.11 CONCLUSIONS: EXAMPLES OF TRAINING AND EDUCATIONAL METHODS It is our opinion, shared by several educational and regulatory bodies, as discussed above, that psychiatrists should be exposed to training in the relevance of religion and spirituality to the causes, diagnosis and management of mental disorders, as well as in the wider
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philosophical assumptions underlying mental health. Taking a ‘Religious/Spiritual History’ from patients is therefore essential to modern psychiatric practice in a globalized multi-faith world. Training in this approach may be considered as part of a seminar series in medical ethics, in which facilitating the greater awareness of health professionals to their own values and beliefs is also an integral part. Seminars and small group teaching in cultural psychiatry, and the appreciation of a diversity of beliefs and values and multi-cultural societies are other possibilities. It is likely, however, that sensitivity to these aspects of clinical practice will also be optimally facilitated through good role models and as a result of apprentice learning. Seminars on integrative and person-centred psychiatry should include both a discussion of the Bio social/psychospiritual – approach to persons with a mental disorder, and also of the need to hold together these different perspectives by the health practitioner. Postgraduate students, who have a special interest in comparative religion or who are trained in theology, may have a particular contribution to make to this educational process. Likewise those psychiatrists who are also religious professionals can, through their writings and clinical example, exert an influence on the training of health practitioners that is very constructive. It is our experience that a person-centred bio-psychosocial approach to the understanding of mental disorder, which enables the brain/mind interface to be explored, is particularly appealing to many young psychiatrists. In this regard, the work of Fenwick [83] on the neuroscience of religious belief, and that of Deeley [84] on the nature of the religious brain, can be particularly stimulating. The teaching of descriptive psychopathology that is cogniscent of the belief systems of patients is also fundamental to the education programs in this field. Trainees should be alerted to the available research methods in the field of religion and mental disorder, which include several well validated questionnaires, e.g. The Royal Free Interview for Spiritual and Religious Beliefs [85], and published papers in scholarly journals, such as Mental Health, Religion and Culture. Of particular educational impact, in our experience, is the use of small group teaching, in which students discuss their own difficulties in considering religion and spiritual practices. In this regard, the availability of several structured materials, such as ‘A workbook for values-based practice in mental health care’ [86], is of great advantage to educators. Similarly, the study seminar designed by David and Susan Larson [87], ‘The forgotten factor in physical and mental health – what does the research show?’ is an excellent non-didactic introduction to this complex field. Other educational aids can include forms of health service provision that emphasize the personhood and dignity of patients. Harvey Chochinov’s [88] system of the A, B, C and D of dignity conserving care provides a useful framework for considering Attitudes, Behaviors, Compassion and Dialogue. For example, Chochinov asserts that one of the essential qualities of the clinician is an interest in humanity, and that the secret of the care of the patient is in caring for the patient. Undoubtedly, more innovative training programs will be following over the next decade. These are likely to utilize online CME programs, joint user/professional endorsed curricula, agreement about competencies within the field of spiritual and religious assessment, and assessment methods that encourage the professional development of the staff member. The ‘Guidelines on spirituality for staff in acute care services’ [89], supported by the National Institute for Mental Health in England, are particularly pertinent as they are
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guidelines for managers and health professionals at the very sharp end of mental health care provision. The training and experiential implications for mental health staff if the religious gap is to be closed are summarized by Peter Gilbert [89] who recommends the carrying out of certain ‘exercises’, mainly in the form of questions directed to the self, such as: * * * * *
* *
What makes you tick? What gives your life meaning? What is missing when you feel low and don’t have much hope? Reflect on what keeps you going when life gets tough. What is your personal and professional response to service users and carers speaking about their religious faith and secular spirituality? Consider an example of multidisciplinary or multi-agency working, including faith leaders. Does your organization assist you to be a whole person, working with people to recognize their full humanity?
We are aware that much of the material in this chapter reflects our particular experiences in Western Europe. Nevertheless it is likely that much of its content is relevant elsewhere in the world, where societies may be less secularized and where in Muslim, Hindu, Buddhist and animist cultures religions flourish. The etymology of ‘psychiatry’ is ‘soul healing’. What is now required are adequate contemporary education and training programs at all levels and for all health professionals – and the full evaluation of their effectiveness.
REFERENCES 1. Fiselier JA, Vander Waal AE, Spijker J (2006) Psychiater, pati€ent en religie: meer dan coping alleen [Psychiatrist, patient and religion: more than simply coping]. Tijdschrift voor Psychiatrie 48, 383–386. 2. Koenig HG (2008) Religion and mental health: what should psychiatrists do? Psychiatric Bulletin 32, 201–203. 3. Correspondence (2008) Psychiatric Bulletin 32, 356–358. 4. Josephson AM, Larson DB, Juthani N (2000) What’s happening in psychiatry regarding spirituality? Psychiatric Annals 30, 533–541. 5. Curlin FA, Lawrence RE, Odell S, Chin MH, Lantos JD, Koenig HG, Meador KG (2007) Religion, spirituality, and medicine: Psychiatrists’ and other physicians’ differing observations, interpretations, and clinical approaches. American Journal of Psychiatry 164, 1825–1831. 6. Lewis IM (1976) Social Anthropology in Perspective. Pelican Books, London. 7. Cox M and Grounds A (1991) The nearness of the offence: some theological reflections on psychotherapy. Theology March/April Issue, 106–115. 7(a). Gordon H, Rylance M and Powell G (2007) Editorial: Psychotherapy, religion and drama: Dr Murray Cox and his legacy for offender patents. Criminal Behavior and Mental Health 17, 8–14. 8. Culliford L (2009) Teaching spirituality and healthcare to third year medical students. The Clinical Teacher 6, 22–27. 9. Neely D and Minford EJ (2008) Current status of teaching on spirituality in UK medical schools. Medical Education 42, 176–182. 10. American Psychiatric Association (1995, 2nd edn. 2006) Practice Guideline for the Psychiatric Evaluation of Adults. American Psychiatric Association, Washington, DC.
610 TRAINING ISSUES: RESIDENCY TRAINING AND CONTINUOUS EDUCATION 11. American College for Graduate Medical Education (2007) Program requirements for graduate medical education in psychiatry. Available at: http://www.acgme.org/acWebsite/RRC_400/ 400_prIndex.asp. 12. Koenig HG, Pritchett J (1998) Religion and psychotherapy. In: Koenig HG (ed.) Handbook of Religion and Mental Health. Academic Press, San Diego, CA, pp. 323–336. 13. Royal College of Psychiatrists (2001) Curriculum for basic specialist training and the MRCPsych examination. Council Report CR95. Royal College of Psychiatrists, Gosport Hants. 14. Kleinman A (1988) Rethinking Psychiatry from Cultural Category to Personal Experience. Free Press, New York. 15. Bhugra D (ed.) (1996) Psychiatry and Religion. Context, Consensus and Controversies. Routledge, London. 16. Engel G (1977) The need for a new medical model: a challenge for bio-medicine. Science 196, 129–135. 17. Powell A (2007) Spirituality and psychiatry-crossing the divide. In: Coyte M, Gilbert P and Nicholls V (eds.) Spirituality, Values and Mental Health. Jessica Kingsley, London. 18. Montgomery K (2006) How Doctors Think: Clinical Judgment and the Practice of Medicine. Oxford University Press, New York. 19. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. American psychiatric Association, Washington, DC. 20. WPA (2002) World Psychiatric Association Institutional Program on the Core Training Curriculum for Psychiatry. WPA, Yokohama. 21. Mezzich JE (2007) Psychiatry for the person: articulating medicine’s science and humanism. World Psychiatry June, 1–3. 22. Mezzich JE, Berganza CE, Cranach E von, Jorge MR, Kastrup MC, Murthy RS, Okasha A, Pull C, Sartorius N (2003) Essentials of the World Psychiatric Association’s International Guidelines for Diagnostic Assessment (IGDA). The British Journal of Psychiatry 182, Supplement 45. 23. Department of Mental Health & Substance Dependence World Health Organization (2002) WHOQOL-SRPB Field-Test Instrument. Available at: http://www.who.int/mental_health/media/en/622.pdf. World Health Organization, Geneva. 24. Coyle BR (2001) Twelve myths of religion and psychiatry: lessons for training psychiatrists in spiritually sensitive treatments. Mental Health, Religion & Culture 4, 149–174. 25. Baetz M, Griffin, R, Bowen R, Marcoux G (2004) Spirituality and psychiatry in Canada: Psychiatric practice compared with patient expectations. Canadian Journal of Psychiatry 49, 265–271. 26. Lawrence RM, Head J, Christodoulou G, Andonovska B, Karamat S, Duggal A, Hillam J, Eagger S (2007) Clinicians’ attitudes to spirituality in old age psychiatry. International Psychogeriatrics 19, 962–973. 27. Freud S (1961) Introductory lectures to psycho-analysis. In: Strachey J (ed. and trans.) The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vol. 15 & 16). Hogarth Press, London (Original work published 1917). 28. Michaels A (2004) Hinduism. Past and Present. Princeton University Press, Princeton. 29. Vergote A (1988) Guilt and Desire: Religious attitudes and their pathological derivatives. Yale University Press, New Haven. 30. Pieper J, Uden M van (2005) Religion and coping in mental health care. International Series in the Psychology of Religion 14. Rodopi, Amsterdam. 31. Schaap-Jonker H, Eurelings-Bontekoe EHM, Verhagen PJ, Zock H (2002) Image of God and personality pathology: an exploratory study among psychiatric patients. Mental Health, Religion & Culture 5, 55–71. 32. Neeleman J & Persaud R (1995) Why do psychiatrists neglect religion? British Journal of Medical Psychology 68, 169–178. 33. Sims A (1994) ‘Psyche’- spirit as well as mind? British Journal of Psychiatry 165, 441–446.
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34. Lawrence RM (2001) Spirituality in psychiatric education and training. Journal of the Royal Society of Medicine 94, 303–305. 35. Neeleman J & King M (1993) Psychiatrists’ religious attitudes in relation to their clinical practice: a survey of 231 psychiatrists. Acta Psychiatrica Scandinavica 88, 420–424. 36. Larson DB, Thielma SB, Greenwold MA et al. (1993) Religious content in the DSM-III-R glossary of technical terms. American Journal of Psychiatry 150, 1884–1885. 37. Hathaway WL, Scott SY, Garver SA (2004) Assessing religious/spiritual functioning: A neglected domain in clinical practice? Professional Psychology: Research and Practice 35, 97–104. 38. Stenmark M (2004) How to Relate Science and Religion. A Multidimensional Model. William B. Eerdmans Publishing Company, Michigan. 39. Zinnbauer BJ & Pargament KI (2005) Religiousness and Spirituality. In: Paloutzian RF and Park CL (eds.) Handbook of the Psychology of Religion and Spirituality. The Guilford Press, New York/London, pp. 21–42. ¨ ber das Irrationale in der Idee des G€ 40. Otto R (1947) Das Heilige. U ottlichen und sein Verh€ altnis zum Rationalen, 1st edn. 1917. Biederstein Verlag, M€ unchen. 41. Geertz C (1993) Religion as a cultural system. In: Geertz C The Interpretation of Cultures: selected essays. Fontana Press, London, pp. 87–125 (First published 1966). 42. Rodrigues H (2006) Introducing Hinduism. Routledge, New York. 43. Miller WR (2005) What is human nature? Reflections from Judeo-Christian perspectives. In: Miller WR & Delaney HD (eds.) (2005) Judeo-Christian Perspectives on Psychology. Human Nature, Motivation and Chance. American Psychological Association, Washington, DC. 44. Koenig HG, McCullough ME, Larson DB (2001) Handbook of Religion and Health. Oxford University Press, Oxford. 45. Ellison CG, Levin JS (1998) The religion-health connection: evidence, theory, and future directions. Health Education & Behaviour 25, 700–720. 46. Chatters LM (2000). Religion and health: public health research and practice. Annual Reviews of Public Health 21, 335–367. 47. Oman D, Thoresen CE (2005) Do religion and spirituality influence health? In: Paloutzian RF and Park CL (eds.) Handbook of the Psychology of Religion and Spirituality. The Guildford Press, New York/London, pp. 435–459. 48. Larson DB, Lu FrG, Swyers JP (1997) Model curriculum for psychiatric training programs: Religion and Spirituality in clinical practice. A course outline. National Institute for Healthcare Research, Rockville. 49. Puchalski CM, Larson DB, Lu FrG (2001) Spirituality in psychiatric residency training programs. International Review of Psychiatry 13, 131–138. 50. Grabovac AD, Ganesan S (2003) Spirituality and religion in Canadian psychiatric residency training. Canadian Journal of Psychiatry 48, 171–175. 51. Grabovac A, Clark N, McKenna M (2008) Pilot study and evaluation of postgraduate course on ‘The interface between spirituality, religion and psychiatry’. Academic Psychiatry 32, 332–337. 52. Brawer PA, Handal PJ, Fabricatore AN, Roberts R, Wajda-Johnston VA (2002) Training and education in religion/spirituality within APA-accredited clinical psychology programs. Professional Psychology: Research and Practice 33, 203–206. 53. Russell SR, Yarhouse MA (2006) Training in religion/spirituality within APA-accredited Psychology predoctoral internships. Professional Psychology: Research and Practice 37, 430–436. 54. Shea SC, Gren R, Barney C, Cole S, Lapetina G, Baker B (2007) Designing clinical interviewing training courses for psychiatric residents: A practical primer for interviewing mentors. Psychiatric Clinics of North America 30, 283–314. 55. Waldfogel S, Wolpe PR, Shmuely Y (1998) Religious training and religiosity in psychiatry residency programs. Academic Psychiatry 22, 29–35.
612 TRAINING ISSUES: RESIDENCY TRAINING AND CONTINUOUS EDUCATION 56. Birkenmaier J, Behrman G, Berg-Weger M (2005) Integrating curriculum and practice with students and their field supervisors: Reflections on spirituality and the aging (ROSA) model. Educational Gerontology 31, 745–763. 57. Patel CJ, Shikongo AEE (2006) handling spirituality/religion in professional training: Experiences of a sample of Muslim psychology students. Journal of Religion and Health 45, 93–112. 58. Shea SC (1998) Psychiatric Interviewing. The Art of Understanding, 2nd edn. W.B. Saunders Company, Philadelphia. 59. Scott Richards P, Bergin AE (1997) A Spiritual Strategy for Counselling and Psychotherapy. American Psychological Association, Washington, DC. 60. D’Souza R (2003) Incorporating a spiritual history into a psychiatric assessment. Australasian Psychiatry 11, 12–15. 61. Josephson AM, Peteet JR (2007) Talking with patients about spirituality and worldview: practical interviewing techniques and strategies. Psychiatric Clinics of North America 30, 181–197. 62. Onedera, JD (ed.) (2008) The Role of Religion in Marriage and Family Counseling. Routledge, New York. 63. Shea SC (2002) The Practical Art of Suicide Assessment. A guide for mental health professionals and substance abuse counsellors. John Wiley & Sons, New Jersey. 64. Gorsuch RL, Miller WR (1999) Assessing spirituality. In: Miller WR. (ed.) Integrating Spirituality into Treatment. Resources for practitioners, American Psychological Association, Washington, pp. 47–64. 65. Campbell WHM, Rohrbaugh RM (2006) The Biopsychosocial Formulation Manual. A guide for mental health professionals. Routledge, New York. 66. Schreurs A (2006) Spiritual relationships as an analytical instrument in psychotherapy with religious patients. Philosophy, Psychiatry, & Psychology 13, 185–196. 67. Allan JG, Fonagy P, Bateman AW (2008) Mentalizing in Clinical Practice. American Psychiatric Publishing, Inc., Washington, DC. 68. Cloninger CR (2004) Feeling Good. The Science of Wll-being. Oxford University Press, Oxford. 69. Meissner WW. (2001) So help me God! Do I help God or does God help me? In: Akhtar S. & Parens H (eds) Does God Help? Developmental and clinical aspects of religious belief, Jason Aronson Inc., Northvale/London, pp. 75–126. 70. Exline JJ, Rose E (2005) Religious and spiritual struggles. In: Paloutzian RF and Park CL (eds.) Handbook of the Psychology of Religion and Spirituality. The Guilford Press, New York/London, pp. 315–330. 71. Schmidt-Leukel P (2005) Gott ohne Grenzen. Eine christliche und pluralistische Theologie der Religionen. G€utersloher Verlagshaus, G€utersloh. 72. Girard RPG (2005) Violence and the Sacred. Continuum International Publishing Group, New York/London (First publication 1972). 73. Fowler JW (1981) Stages of Faith. The Psychology of Human Development and the Quest for Meaning. Harper & Row Publishers, San Francisco. 74. Kim YY (2008) Intercultural personhood: globalization and a way of being. International journal of Intercultural Relations 32, 359–368. 75. Kirmayer L (2007) Psychotherapy and the cultural concept of the person. Transcultural Psychiatry 44, 232–257. 76. Erikson EH (1964) Insight and Responsibility. Lectures on the ethical implications of psychoanalytic insight. WW Norton & Company Inc., New York. 77. Schmidt-Leukel P (2008) Multireligi€ose Identit€at. Anmerkungen aus pluralistisher Sicht. In: Bernhardt R. & Schmidt- Leukel P. (eds.) Multiple religi€ ose Identit€ at. Aus verschiedenen religi€osen traditionen sch€opfen. Theologischer Verlag Z€ urich, Z€ urich, pp. 247–270. 78. Abu-Nimer M (2001) Conflict resolution, culture and religion: toward a training model of interreligious peacebuilding. Journal of Peace Research 38, 685–704.
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79. Ward K (2008) Christianity Among the World Religions. The Fourth Roy Niblet Lecture, University of Gloucestershire. 80. Tournier P (1986) A Listening Ear: Fifty Years as a Doctor of the Whole Person. Hodder and Stoughton, Sevenoaks. 81. World Council of Churches (2002) Guidelines for dialogue and relations with people of other religions. Available at: http://www2.wcc-coe.org/ccdocuments.nsf/index/gen-11-en.html. 82. Mbiti JS (1991) Introduction to African Religion, 2nd edn. Heinemann Educational Publishers, Oxford. 83. Fenwick P (1996) The neurophysiology of religious experience. In: Bhugra D (ed.) Psychiatry and Religion. Context, Consensus and Controversies. Routledge, London. 84. Deeley PQ (2004) The Religious Brain: Turning Ideas into Convictions. Anthropology and Medicine 11, 245–267. 85. King M, Speck P, Thomas A (2001) The Royal Free Interview for Spiritual and Religious Beliefs: development and validation of a self report version. Psychological Medicine 31, 1015–1023. 86. Woodbridge K & Fulford KWM (2004) Whose values? A workbook for values-based practice in mental health care. The Sainsbury Centre for Mental Health, London. 87. Larson DB, Larson SS (1992) The forgotten factor in physical and mental health. What does research show? National Institute for Healthcare Research, Arlington, VA. 88. Chochinov H (2007) Dignity and the essence of medicine: the A, B, C, D of dignity conserving care. British Medical Journal 335, 184–187. 89. Gilbert P (2009) Guidelines on Spirituality for Staff in Acute Care Services. National Institute for Mental Health in England; available at www.virtualward.org.uk.
Epilogue: Proposal for a World Psychiatric Association Consensus or Position Statement on Spirituality and Religion in Psychiatry Peter J. Verhagen Psychiatrist and Theologian, The Netherlands
Christopher C.H. Cook Consultant Psychiatrist, Theologian and Anglican Priest, United Kingdom
E.1
INTRODUCTION
In 2004, one of us (PJV) wrote a discussion paper entitled ‘Religion, spirituality and psychiatry: A field wide open for discussion and research’ [1] and in 2005, on behalf of the World Psychiatric Association (WPA) Section on Religion, Spirituality and Psychiatry (SRSP1), this was circulated amongst colleagues around the world as a basis for discussion. Amongst other groups, this paper was sent to the Spirituality and Psychiatry Special Interest Group (SIG) of the Royal College of Psychiatrists in London, United Kingdom. It was agreed by the SIG and the SRSP that there might be benefit in agreement by WPA on a shorter position paper on the same theme. In November 2006 the SIG and the SRSP agreed to work together on this important project. A position paper was duly drafted, also by one of us (CCHC), and approved by the Executive Committee of the SIG.
1
The section was founded in 2003 during a WPA conference in Vienna; Chairman Professor H.M. van Praag, Vicechairman Professor Driss Moussaoui (Morocco), Secretary Peter J. Verhagen. The sections, currently more than 60, play an important part in the WPA organization, since the sections include an assembly of experts and are obliged to develop activities (symposiums, research, training) aimed at drawing attention to the specific fields of expertise of these sections worldwide and regionally. Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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The SIG and the SRSP hoped that the content of its proposed position statement would facilitate discussion within the WPA about what might be agreed amongst psychiatrists concerning spirituality and religion. As a starting point, the SIG considered that the position statement should aim for clarity (as far as possible in a short document) about the nature of spirituality and religion. The SIG felt that the statement should say something about the place of spirituality and religion within psychiatric assessment, training and research, and also that it should emphasize the need for respect of patients’ beliefs, and affirm the need to work closely with faith communities. It also warned against proselytizing by psychiatrists amongst their patients. The position statement prepared by the SIG was presented in 2006 to the SRSP of the WPA. A revised version of that document is published here for the first time (see appendix to this Epilogue, PROPOSAL). Following debate by the SRSP committee, it was eventually re-named as a draft consensus statement (CS), although we shall see that eventually discussion returned once more to the possibility that it might best be referred to as a position statement. The draft CS was duly circulated to appropriate bodies for international discussion. In the present chapter we will report on the subsequent international response to this document and offer our commentary on it. Amongst others, the Religion and Psychiatry Corresponding Committee of the American Psychiatric Association (APA) and the Asian Federation of Psychiatric Associations (AFPA) have made valuable contributions to debate about the CS, for which we are most grateful. Difficulties arose in the process of international consultation which were unforeseen and unexpected. We will focus here on two important issues for debate: the relationship between religion and spirituality, and the significance of taking a spiritual history.
E.2
CONSENSUS STATEMENT: CRITERIA
Drawing up a consensus statement is one of the fundamental tasks set by the WPA, thus marking the great importance of such a document. What is its purpose? A consensus statement helps to express a consensus about a specific issue related to psychiatric practice, research and/or training within psychiatry worldwide. Therefore, before agreeing a consensus statement, all members of national psychiatric associations and organizations will be asked for their opinions and are invited to comment on the draft statement. Table E.2.1 gives an overview of the consensus statements which have been agreed to date. The titles give clear indication of the kinds of topics that have, for all kinds of reasons, been deemed worthy of such international attention. We personally believe that spirituality and religion in psychiatry is another such topic. The WPA does not accept just any proposal for a consensus statement. In order to be considered worthy of such attention, a topic needs to fulfil a number of conditions. The topic has higher priority if: 1. It is a concern relevant to the further development of psychiatry around the world. Topics of only national or regional interest are given less priority. Topics of concern to several members (nationwide associations and organizations) gain higher priority. 2. Scientific evidence is available to support the importance of the topic. Topics which involve very complex and long-term evidence, and intensive commitment from experts, may be broken down into sub-sections to facilitate the process.
EPILOGUE Table E.2.1
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List of WPA Consensus Statements
(Access to the text of these statements is available through WPA Online, www.wpanet.org) 1. Consensus Statement on Psychiatry of the Elderly (Approved by the General Assembly on 8 August 1999) 2. Consensus Statement on Psychiatric Rehabilitation (Approved by the General Assembly on 26 August 2002) 3. Consensus Statement on Neurasthenia (Approved by the General Assembly on 26 August 2002) 4. Consensus Statement on Preventive Psychiatry (Approved by the General Assembly on 26 August 2002) 5. Consensus Statement on Second Generation Antipsychotic Medication (Approved by the General Assembly on 26 August 2002) 6. Consensus Statement on Reducing Stigma on Older People with Psychiatric Disorders (Approved by the General Assembly on 26 August 2002) 7. Consensus Statement on Disasters and Mental Health (Approved by the General Assembly on 26 August 2002) 8. Consensus Statement on Globalization and Mental Health (Approved by the General Assembly on 26 August 2002) 9. Yokohama Declaration (Approved by the General Assembly on 26 August 2002) 10. Consensus Statement on Eastern Europe and the Balkans (Approved by the General Assembly on 12 September 2005) 11. Consensus Statement on International Women’s Mental Health (Approved by the General Assembly on 12 September 2005) 12. Consensus Statement on Interpersonal Violence Against Women (Approved by the General Assembly on 12 September 2005) 13. Consensus Statement on Physician Impairment with Mental Illness and/or Addictions (Approved by the General Assembly on 12 September 2005) 14. Consensus Statement on Psychiatric Prevention and Health Promotion (Approved by the General Assembly on 12 September 2005. This is a lightly edited version of the basic version presented in item 4 above) 15. Consensus Statement on the Use and Safety of Electroconvulsive Therapy (Approved by the General Assembly on 12 September 2005) 16. Cairo Declaration on Mass Violence and Mental Health (Approved by the General Assembly on 12 September 2005)
3. It is of greater public visibility and consequently likely to have more impact. 4. The absence of a consensus statement could be harmful to psychiatry or psychiatric patients. The SRSP believed that these criteria provided sufficient justification to proceed with work on the CS for Spirituality and Religion in Psychiatry. In fact, in the SRSP’s view, there seemed hardly any doubt about the relevance of the topic. Table E.2.2 gives an indication of the enormous numbers of people belonging to the world’s major religions. Atheists comprise only 2.5% of the world population and non-religious people 12.8% [2, p. 67]. This is quite apart from the almost infinite diversity and continuing emergence of new religious groups [3]. We will now consider the four above-mentioned requirements for a CS, to see if a CS on psychiatry and religion could be considered eligible.
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EPILOGUE Table E.2.2 This List Includes Only Organized Religions and Excludes More Loosely Defined Groups Such as Chinese or African Traditional Religions
E.2.1
Religion
Members
Percentage
Christianity Islam Hinduism Buddhism Sikhism Judaism Baha’ism Confucianism Jainism Shintoism
2.1 billion 1.3 billion 851 million 375 million 25 million 15 million 7.5 million 6.4 million 4.5 million 2.8 million
33.0% 20.1% 13.3% 5.9% 0.4% 0.2% 0.1% 0.1% 0.1% <0.1%
Significance of the topic
It has repeatedly been argued that religion is a forgotten or lost dimension in psychiatry, but it is now commonly said that there is a growing awareness of the importance of religion and spirituality among psychiatrists and in mental healthcare. Some even speak of a ‘silent revolution’ which is taking place [5]. Psychiatrists once more recognize that their patients’ spiritual experiences and religious practices are important. Religion and spirituality are again understood as positive sources of well-being, rather than pits of gloom-and-doom and psychopathological misery. Is this ‘silent revolution’ taking place in the Netherlands, the United Kingdom and the rest of Western Europe, or is it confined perhaps to North America or elsewhere? Indications that it is occurring in the Netherlands are scarce. In the United Kingdom, the situation is perhaps rather more complex and it may be of value here to consider an example of this in a little more detail. A recent editorial by Koenig [6] provoked a short, but rather fierce storm of correspondence in the Psychiatric Bulletin of the Royal College of Psychiatrists. What did Koenig argue? Firstly, he summarized data concerning two issues: that religion was said to be pathological, and that psychiatrists themselves are mostly ‘non-religious’ and often have a critical attitude towards religion. In his arguments he uses older, but also some relatively recent data [7]. These data provoked plenty of protests. For example, Koenig posits that ‘only’ 1.4% of the population in Great Britain are atheists. However, the ‘World Christian Database’ on which he relies for these figures is seen by some as ‘hardly an unbiased source of information’ [8]. According to Koenig’s opponents, the correct number lies somewhere between 15.5 and 36% [9], although we might note that the 15.5% figure actually represents those who identify with ’no religion’ rather than those who are actually atheists,2 and the 36% figure applies to those of age 18 to 34 years.3 2
http://www.statistics.gov.uk/cci/nugget.asp?id¼293 http://www.parliament.the-stationery-office.com/pa/ld200506/ldselect/ldbbc/128/5110211.htm. This website also shows that figures from some other surveys are even higher. For example, a Guardian poll of 16-year-olds in 2004 found that 45% did not believe in God. 3
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An interesting source for data, used by Lepping in his response, is the Religion Monitor (www.religionsmonitor.com) of the conservative German Bertelsmann Foundation [10]. These data indeed show that Great Britain is not the most religious country in a series of 18 countries surveyed. For example, on a scale of 1–5 concerning centrality of religiosity in life, Nigeria has the highest score (4.6) and Russia the lowest (2.4). Great Britain is the third lowest with 2.7; in comparison, the United States scores 3.9. [10, p. 160] So, religion would hardly appear to be as important a part of life in the United Kingdom as in the United States of America. More important, however, are the objections against the proposals made by Koenig. Koenig pleads for the regular taking of a religious/spiritual history, for respect for supporting religious and spiritual beliefs, for challenging beliefs that are interwoven with or contribute to psychopathology, for praying with patients, and for consulting pastoral carers. What are the objections to these proposals? Poole et al. [9] argue that a spiritual history can be considered ’intrusive and excessive’ and lacking in respect for ’non-believers’. Hilton [11] mentions that there is too little experience in taking a spiritual history, as opposed to a religious history. The process of supporting or challenging beliefs is also said to appeal too much to the norms and values of the physician, and to be incompatible with the ’therapeutic neutrality’ that the clinician should adopt towards such matters. The introduction of prayer, a ’completely nonclinical’ activity, into the clinical setting is said to represent a great danger of blurring boundaries and creating ambiguity around the therapeutic relationship [9]. All of these arguments are open to counter-arguments. It is not at all the case that a spiritual history is necessarily insensitive or disrespectful to those who do not hold a religious faith. Hilton herself notes that there is actually guidance about how to take a spiritual history on the Royal College of Psychiatrists website [12] and another correspondent [13], who declares himself an atheist, rightly suggests that taking a spiritual history is actually ’an easy task’. Koenig is cautious in his editorial about challenging belief and praying with patients, even if we might feel that his advice is more relevant to United States religious culture than in the United Kingdom, where there tends to be greater personal reserve about such matters. It also seems that the critics are not giving weight to the now large body of evidence that suggests a therapeutic benefit of taking account of spiritual and religious factors in mental healthcare [14]. However, the point here is not to detail the arguments for both sides so much as to acknowledge that there is a debate and that psychiatrists in the United Kingdom are not of one mind on these matters. Some correspondents expressed concerned that the then president of the Royal College of Psychiatrists apparently endorsed Koenig’s arguments [15]. However, it should be noted that two other past presidents are on record as expressing similar support for the need to conduct spiritual or religious assessements in clinical practice, and generally to take religion and spirituality more seriously [16, 17]. In the United Kingdom at least, the situation would appear still to be one of movement and plurality. But, if we accept for a moment that a change of some kind appears to be in process, what might the explanation for this change be? One possible answer might be found in increasing interest in and knowledge of transcultural aspects of psychiatry. Within this movement, religious beliefs and practices are an important part of understanding the patient in cultural context. However, a more important explanation might be found in the observation that, despite all predictions to the contrary, religion has simply not disappeared from secular Western society. Based on so-called theories of ’secularization’, which emerged in the late nineteenth century and became popular in the 1950s and 1960s, it had been assumed by some that
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religion would slowly but surely make way for a more secular social order, governed by more ’adult’ and ’rational’ ways of thinking. Whatever arguments sociologists may have about theories of secularization (and it would seem that there is much debate) the European Enlightenment has brought about a general separation of religion (now seen as a matter for private life) and public discourse. But now, more recently, the situation (as we have just seen exemplified by the debate amongst psychiatrists in the United Kingdom) appears to be changing. When and where did this change come about? According to some experts, the Islamic revolution in Iran at the end of the 1970s could be seen as such a turning point [2]. Whether or not such factors have influenced thinking about religion in Europe, secularization has not carried the day, and has not occurred in other parts of the world at all. Thus a new hypothesis has gained ground: the transformation hypothesis. This hypothesis suggests that religion does not return to the (public) stage unchanged. This becomes apparent from the fact that it is no longer adequate to speak about religion only, but always about religion and spirituality. In other words, the comeback of religion also implies a change in the concept we have of religion. Without going much deeper into this, an important element of that changing concept of religion seems to be that religion is no longer an all-encompassing phenomenon [18]. It is also possible to speak of a change in religious awareness, and change in understandings of the self. These changes, the transformation of religion instead of its disappearance and the place spirituality occupies, are significant to psychiatry. With them comes a risk of improper medicalization or ‘psychiatrizing’ of unusual experiences, which could result in improper or even harmful psychiatric interventions. They require a renewed impulse for empirical and conceptual research into the distinction between religious and spiritual experiences on the one hand and pathological (not only psychotic) phenomena on the other hand. In addition, research is needed into the significance and effectiveness of religious and spiritual healing practices around the world. There are important differences in the way these phenomena and practices are approached, interpreted and evaluated, depending on cultural and subcultural contexts, values and sources. Based on these considerations, the SRSP holds the view that the topic of religion and spirituality concerns psychiatry worldwide and that consequently a consensus statement deserves high priority.
E.2.2
Scientific evidence
Extensive research has been conducted and comprehensive data are available, but the relationship between religion, spirituality and mental healthcare is still disputed. Indeed, there are some clear examples of a negative effect of spirituality or religion on mental health. Nevertheless, a majority of experts seem to agree that in general the relationship can be qualified as positive. Within this framework Koenig can be regarded as the champion in collecting and evaluating research [19, 20]. In a total of 724 quantitative studies before 2000 Koenig et al. found 476 studies that reported a positive association between religious involvement and a wide range of indicators for mental healthcare. In his earlier mentioned short contribution [6] he states that studies after 2000 confirm this picture. Indicators of mental health employed in such research include: fear, depression, suicide, addiction, abuse and trauma, self-image and self-esteem. However much of this research has been conducted in the West (mainly in the United States of America) and in Judeo-Christian groups of subjects. Therefore, much more research is needed from other parts of the world, in which studies
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address subjects with different religious, spiritual and cultural backgrounds. Whatever the protests against Koenig’s editorial, clinical practice should be based on good research.
E.2.3
‘Public visibility’
Health is a political and public theme. Officially, religious and spiritual well-being are not part of the World Health Organization (WHO) definition of (mental) health.4 This is seen by many as a shortcoming of the definition, but arguably it is politically unrealistic to expect agreement on religious well-being. For, if governmental organizations were expected to pursue this, they would soon be accused of ‘meddling with’ religious issues. Besides, which religion(s) would be singled out? Such an approach would be likely to lead to hopeless complications. Yet, the religious domain is part of the ‘Quality of Life’ measures developed by the WHO. Religion and spirituality are sources of support and of coping in circumstances where life seems unmanageable. They can stimulate positive experiences such as hope and optimism, but also traditionally provide the means to cope with transitional phases in life such as birth, marriage, illness and death. There is, therefore, sufficient reason to learn to speak of a bio-psycho-socio-spiritual model.
E.2.4
And without a consensus statement?
Does it matter if there is no WPA CS on spirituality and religion in psychiatry? What should be underlined is that psychiatry is about more than just making a (DSM or ICD) diagnosis. In its programme ‘Psychiatry for the Person’ [22] the WPA pleads for the individual to be understood in his or her uniqueness and to be the focal point of clinical attention. Not to do so inevitably leads to deficient healthcare. But spiritual and religious concerns will often (even if, as some might argue, not always) be at the heart of that patient centred focus. A CS therefore provides important counterbalance in this programme to traditionalism and empiricism, and particularly the impoverished hyponarrativity of the DSM-tradition. The SRSP have no doubt that a CS about psychiatry and religion would meet the demands set by the WPA, both as far as psychiatry itself is concerned, and also politically and socially worldwide. They see such a CS as harmonizing very well with WPA’s ethical views [23]. This is not to deny that more scientific research is needed, or that there are cultural sensitivies to be addressed. (For example, in addition to the English language proposal of the CS, versions in other languages would need to be formulated: especially in Spanish, Arabic, and at least one Asian language). Notwithstanding the views of the SRSP, the draft CS has met with controversy. Two of the controversies that have arisen will be considered here in detail.
4
‘Health is a state of physical, mental and social well-being, and not merely the absence of disease or infirmity’ (WHO). The World Health Report 2001 about mental healthcare repeats that mental health care is more than the absence of a psychiatric clinical picture. However, a closer description is not ventured, since this would be hardly feasible from a transcultural point of view. Subsequently they focus on factors that influence (mental) healthcare [21].
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CONTROVERSY I: RELIGION AND SPIRITUALITY
The draft CS opens with the observation that religion and spirituality, although neglected for a long time, are increasingly recognized as being of relevance to the examination and treatment of patients, and also to the understanding of psychiatric disorders. This immediately invites debate concerning the proper definition of religion and spirituality. The draft CS offers a simple explanation of each of these terms but does not (by virtue of its brevity) engage with the huge literature debating how these terms should best be defined. The definition offered for spirituality is based on that proposed by Cook [24]. A definition for religion is not offered, as such, but the scope of traditionally employed definitions is briefly described. (In drafting the CS, CCHC had in mind the discussion provided by Bowker [25, pp xv–xxiv]). Even more problematic is the relationship between religion and spirituality, and this has proved to be important in relation to the international debate about the CS so far. A number of participants in this debate would rather see the concept of religion removed entirely in order to deal with spirituality alone.5 However, it is an issue which is also elaborately discussed in Geloven in het publieke domein [18]. In this interesting study by the Scientific Council for Government Policy (in Dutch: Wetenschappelijke Raad voor het Regeringsbeleid (WRR)) lots of studies and material can be found that all relate to the ‘return’ and transformation of religion in its relationship to spirituality. According to this point of view, the term spirituality is not merely inclusive of religion, but rather supercedes it.
E.3.1
Spirituality
There are multitudinous definitions of spirituality, arguably corresponding to each other in certain main points. The possibility of reaching a consensus would therefore seem to be a reasonable one. Recurring themes include the capacity for relationality and spirituality as a defining characteristic of being human. The general idea seems to be that spirituality implies a developed form of relationship to oneself, the other and the transcendent. This understanding of the transcendent is often but not exclusively an ‘inner-worldly’ one. Formulated in this way the transcendent is not primarily a capacity, but a form of relationality. How someone develops spiritually is just as unique and personal as the way someone develops with regard to personality. What does this concept of spirituality aim to achieve then? It is a quest ‘for attaining an optimal relationship between what one truly is and everything that is’ (Van Ness, quoted by 5
It is important to note here that the text was drafted by CCHC with help from members of the SIG Executive Committee. It therefore represents the views of that group. The approach taken by the SIG is outlined in a patient brochure entitled: Spirituality and Mental Health (www.rcpsych.ac.uk). The text makes clear that spirituality is indeed seen as the more comprehensive concept, inclusive of, but not confined to, that of religion. Spirituality is described as being universal and at the same time uniquely personal. Religion usually presupposes communal worship, along with beliefs and other sacred traditions. In Koenig’s editorial ([6], see above), it might be noted in passing that the concepts seem to blend rather differently. The title is: Religion and mental health. He speaks about taking a ‘spiritual history’, but subsequently talks about ‘religious background’, and ‘religious beliefs and practices’. Josephson and Wieser [26] introduce the even wider idea that religion and spirituality comprise the concept of a ‘world view, or philosophical outlook on life’ and in this way want to make the term inclusive of all ideologies, religious, spiritual or other.
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Schneiders [27, p. 166]). It concerns how the self as a whole relates to the cosmos as a whole. The advantage of such a definition is evident in its inclusiveness of both religious and secular forms of spirituality. More specific, but no less inclusive is the following definition of spirituality: ‘the experience of conscious involvement in the project of life-integration through self-transcendence toward the ultimate value one perceives’ [27]. These definitions are very consonant with the draft CS formulation. There are also similarities with Cloninger’s capacity of self transcendence and (expression of) spirituality [28]. By contrast, other definitions see spirituality as something at the heart of philosophy or religion [29], almost inverting the relationship proposed here between spirituality and religion. However, any direct reference to religion has disappeared from the definitions of Van Ness and Schneiders. Spirituality comprises an awareness, an experience of something that surpasses ordinary observation and perception. It is not simply an abstract idea, or theory. It includes an element of advancing movement, a quest. It is not a once-only experience or event. It contains an element of integration, unification and, consequently, unity. Spirituality is holistically oriented. Looking at specific (e.g. religious) spiritual traditions from that point of view, similarities can naturally be observed between them.
E.3.2
Religion
The concept of religion as we now employ it, namely as a term trying to denote the communality of all religions, dates back to the seventeenth century [18, p. 38]. Modern definitions of religion usually distinguish between essential and functional approaches. In the first approach one seeks to denote the core essence of religion. In the second approach the function of religion is formulated. The latter is perhaps more frequently encountered in research into religion and mental healthcare. The approach of looking for the evolutionary origin of religion also fits into the functional framework. The interesting feature of this approach is a reversal of the more or less usual argument, dictated by our ‘traditional’ thinking, which proceeds from the basis of there being one ‘true’ religion. Instead, diversity in religion is seen not as the result of diversification from a (presupposed) original religious unity, but a reduction of a (possibly infinite) multitude of religious ideas that occur in the human mind, and from which the most useful or functional remain and are passed on [30, 31]. Essentialist religion can be denoted as a fundamental attitude to life in relation to a transcendental reality (with or without God or gods), a dependence on the source of life accompanied by awe and gratitude, a desire to live in harmony with that, and transcendental faith in life and death [27, p. 168]. Thus formulated, religion also includes a number of spiritual traditions, for example Christian or Buddhist, even when people have turned away from organized religion. But religion also represents an institution, alongside other institutions in society. Religion as an institution recognizes official bearers of the institution, with its codes and practices. However, religion is not always visibly institutional. In some cultures it is entirely interwoven with daily life, and is not a social institution in the usually accepted sense, as for example in Japan (see below). It can also be formulated differently. Religion, as in the Judeo-Christian tradition, represents a type of culture in which certain beliefs or values are shared. But there is almost always some tension between religion as a living tradition and religion as an institution. Schneiders points out that institutionalization presents a great danger to authentic tradition. It potentially takes the place of that tradition, and its values,
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leaving a hollow shell, associated with empty ritualism, abuses of power, hypocrisy and other unattractive remnants. But Schneiders also warns that beheading is not the best cure for a headache [27, pp. 171–172]. The concept of religion as now employed in the West presupposes a partition of domains, between the profane and the sacred. In other cultures such a dichotomy does not occur at all, as we will see below.
E.3.3
Spirituality and religion: the relationship
How do religion and spirituality relate to each other? Schneiders [27] suggests three possibilities: 1. Religion and spirituality regarded as two completely separate domains that have no connection. Obviously, one can be spiritual without being religious, although the arguable possibility of religion without spirituality is a little more controversial. (Is not all religion associated with some kind of spirituality, even if it is unattractive or apparently ’empty’?). Spirituality might be perceived as the more personal domain, and religion the more social. 2. Religion and spirituality seen as rivals. According to this view, there are not two domains, but one domain where spirituality and religion are each fishing in the same metaphorical pond. Here we may either turn towards spirituality, as preferable to an empty, or meaningless, religion, or we may turn towards religion, in preference to a ‘disorderly’ spirituality that will not conform to institutional authority. 3. Religion and spirituality considered as two dimensions of the same quest, in a sometimes tense, yet mutually indispensable relationship with each other, but nonetheless sharing the same fundamental concerns. According to this view, religion and spirituality are partners. What might make (personal) spirituality appear more meaningful than (institutional) religion? Schneiders [27] suggests three factors. Firstly, religion(s) traditionally claim exclusivity. That exclusivity can be cultural, geographical and tribal, but also doctrinal (‘outside the church there is no salvation’). Some would argue that this is what has led to religious persecution, hatred and war. Secondly, and closely linked to this theme of exclusivity, is the ideological aspect of religion. If one belongs to the church, one commits oneself to its rules and practices. This could suggest a certain oppressiveness and constraint, and may be why many people rebel against aspects of doctrine and religious practices. Thirdly, there is the clerical factor. This does not relate to clergy who, for example, are engaged in meaningful work in worship or pastoral care, but rather to authority that is based on pretence rather than competence. Schneiders [27] pleads for a partnership of spirituality and religion in which religion provides the encompassing framework for spirituality, rather than the other way round. Her Roman Catholic background is presumably conducive to this view, but she is not alone.6 In 6 Van Praag, in his latest Dutch book, is remarkably critical towards the concept of spirituality. He calls it ‘vague’ and characterizes spirituality as a ‘leaning towards the higher’. Religion, on the other hand, has a distinct focus, a foundation and a bedding. ‘To the religiously susceptible man God is the symbol of spirituality. All other manifestations of spirituality are by definition of a lower order’ ([35, pp. 24–25]; curs. PJV).
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contrast, as we saw earlier, others take spirituality as the encompassing concept. But, if we assume for a moment that partnership of some kind will be essential to take forward something such as a CS on spirituality and religion in psychiatry, how may we deal with inter-religious, inter-spiritual dialogue in our own countries and worldwide, given that there is such religious and spiritual plurality? What might partnership look like within the doctorpatient relationship? Do we require a completely new type of spirituality? Schmidt-Leukel [32] who became intensively involved in the dialogue between Christianity and Buddhism, outlines such a new ‘inter-faith’ spirituality, based on seven virtues: confidence, humility, curiosity, friendship, honesty, courage, and gratefulness. Confidence (or faith) acknowledges a transcendent (yet also immanent) order that is of decisive importance to our understanding of reality and especially our relationships with our neighbors. Humility puts aside exclusivity claims. The Infinite surpasses our thinking and feeling so much that our understanding is acknowledged as being only partial. Yet the transcendent is also a part of the religious experience, and that makes us curious, and this curiosity or wonder might initiate dialogue. That brings about a different attitude towards one another: friendship, says Schmidt-Leukel. How else can we exchange and share each other’s beliefs? Such a friendship presupposes honesty which is not uncritical, but with the opportunity of ‘brotherly admonishment’. Courage and gratefulness complete this set of seven virtues that characterize ‘inter-faith’ spirituality. Is Schmidt-Leukel being over-idealistic, or even completely unrealistic? There is considerable criticism against this ‘dialogue-ideology’, not least from the side of secular liberalism [33]. However, we might note the theses that Hans K€ung once formulated: no world peace without religious peace, no religious peace without religious dialogue, no religious dialogue without research into the foundations of religion [34].
E.4
CONTROVERSY II: TAKING A SPIRITUAL HISTORY?
In two places in the draft CS the word ‘essential’ is used: religion and spirituality are said to be an ‘essential’ component of the spiritual history, and, knowledge of religion and spirituality are said to be an ‘essential’ part of psychiatric training. The use of this word, especially in the former context, appears to have been unacceptable to some participants in the international debate on the CS. What are the objections? From the perspective of Japanese Buddhism, it is said that it is totally unconventional for a psychiatrist to ask a patient about his or her religious beliefs. The question is either too private, or else not important enough to the immediate purpose in hand (ie psychiatric assessment and treatment). A doctor would only ask such a question, it has been argued, in such extreme circumstances as might apply, for example, in the case of terminal illness. Considerations here are that religion is understood as a part of daily life and not an ideological conviction. If the patient were to be asked about his or her religious beliefs, the most likely answer would be that he or she does not have any. Here, it would appear, the concept of religion as we know it and handle it in general international parlance (or perhaps merely in Western culture?) does not work for the purpose at hand. There is evidently no universally accepted phenomenon called religion [18, p. 38]. Of an entirely different order is the objection on the part of some psychiatrists from the former Soviet republics. There it is also said that a psychiatrist would not easily ask questions about religion. Here, the concern is that it would be too politically charged and far
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too risky. After all, not so long ago religion was not only scorned but was even politically prohibited.Therefore to talk about religion in a clinical consultation could be perceived as having potentially disagreeable political consequences and should not be done. These objections are interestingly paralleled within psychiatry in the United Kingdom. Amongst the objections to Koenig’s editorial [6] raised by Poole et al. [9], was an assertion that psychiatrists are ‘essentially applied biopsychosocial scientists, who work within a clear set of humanitarian values and ethical principles in order to get alongside service users and facilitate their recovery from a mental illness’. In this context, dabbling in matters of spirituality and religion is seen as breaking ‘the boundaries of our legitimate expertise’. This would appear similar to objections raised by Japanese psychiatrists concerning what is within the rightful domain of psychiatric enquiry. The implication may also be that spirituality and religion are either too private, or else not important enough, to be relevant to the role of the psychiatrist. Poole et al. [9] refer also to the dangers of ‘religious breaches of therapeutic boundaries’ which, although not of a political nature, would appear similar to the dangers perceived by Eastern European psychiatrists who fear that asking questions about religion may present a potential threat to the therapeutic relationship. These and other objections are understandable, but at the same time they are curious, given ‘state of the art’ transcultural psychiatric research. In the second version of the Practice Guideline for the Psychiatric Evaluation of Adults [36] it is argued that in the framework of the social and cultural history of the patient, cultural and religious influences should be considered both in terms of meaningfulness and goals in life, and in terms of sources of support or even stress. Attention to these influences plays a crucial role in developing a treatment relationship, coming to a treatment plan in terms of treatment goals and outcome measurements, and promoting therapy loyalty. To give such factors adequate consideration requires a respectful, empathic, non-judgmental attitude. Thus it is necessary to acquire awareness of one’s own prejudices, ‘biases’, and limitations with regard to expertise and related skills. This means that formulating a case and treatment contract requires much more than simply making a diagnosis. It requires careful consideration of social and cultural factors, including religious and spiritual beliefs. The transcultural perspective has thus become a fundamental framework for psychiatric practice, at least since the introduction of DSM-IV [37]. It comprises five aspects: the individual’s cultural identity, culturally determined ideas about disease, cultural factors related to the psychosocial environment, cultural influences on the doctor-patient relationship, and cultural influences on diagnostics and care. These five aspects always contain religious and spiritual elements.7 Viewed from this perspective, Asiatic and Eastern European objections to the CS come under the heading of cultural influences on diagnostic and therapeutic processes. They clearly need to be recognized as such. At the same time it has become clear that the concept of religion is itself a culturally sensitive construct. It is transculturally curious that certain subjects of enquiry (spirituality and religion) might be considered ‘off limits’ when taking a history. It is also curious that within any 7
It should be noted that the American guideline(s) do not necessarily have the final word. On the other hand, they are very influential. Similarly, American and British educational requirements have been very influential in psychiatry (see a recent special issue of International Psychiatry, April 2007). The American curriculum explicitly promotes attention to knowledge and skills with respect to religion and/or spirituality. The British curriculum, currently under revision, has long promoted attention to issues of culture, but (until recently) not specifically spirituality or religion. Proposals are under consideration for spirituality and religion to be integrated explicitly and fully into the new curriculum.
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culture a clinical speciality which legitimately enquires after the most intimate aspects of patients’ lives, in order to build a better bio-psycho-social understanding of their condition, might actually consider some matters too sensitive to discuss. If spirituality (or sex, or politics, or anything else) actually is too private, or else too unimportant, for discussion, where does this leave us? Firstly, we hope that the foregoing discussion has shown that spirituality and religion are in fact not unimportant to psychiatry. Research suggests that there are evidence based reasons for including spirituality and religion in the assessment process and in treatment planning. In any case if, as Poole et al. [9] argue, there are significant dangers surrounding inclusion of spirituality and religion in clinical history taking, the matter cannot also be unimportant. The reasons for not including this topic within clinical history taking must be based on some other grounds. It might be implied that there are issues which are so important to our patients that it is difficult to talk about them without fear of misunderstanding. However, this may be revealing of politically or culturally imposed barriers that have undermined the spirit of openness and trust which is fundamental to therapeutic relationships. Ignoring these barriers, let alone deliberately preserving them, is surely not in our patients’ best interests. It will surely reinforce both social conventions, and professional ignorance, which create a fear of discussing things that risk misunderstanding. Yet this is no different from many areas of clinical enquiry in which the patient is the expert from whom the clinician must learn. As Koenig points out [6], there are also clergy, chaplains and others whose help may be sought in support of this learning process. The important objections raised within the United Kingdom, Eastern Europe and Asia raise equally important questions about the nature of the therapeutic relationship, and how this may be restricted by cultural perceptions of particular subjects (such as spirituality and religion) which are felt to be ‘off limits’. But surely these perceptions, and their validity or lack of validity, must be a legitimate subject for professional and academic conversation within psychiatry? Or are they to remained unexamined secrets – something which psychotherapy has so often shown to be a cause of psychopathology?
E.5
FINDING A WAY FORWARD
The controversies encountered during the course of the debate on the CS became so heated that the WPA Executive Committee decided that it was impossible to introduce the CS proposal at the meeting of its General Assembly (the highest organ of decision making within the WPA), during the most recently held WPA world conference in Prague, 20–25 September 2008. The CS has therefore not yet been included in the list of CSs, to be submitted to WPA members for consultation. On the other hand, consultation within the SRSP yielded satisfactory interest and support. An impasse has thus been reached, and there would not appear to be an easy solution. Presently (March 2009), consideration is being given to the possibility of the draft CS being adopted as a position statement, rather than a consensus statement, since the WPA procedures for this are less rigorous. However, it would seem very unsatisfactory that such an important topic should appear to be reduced in significance in this way. We dare to hope that a solution might yet be found in the very process for which the CS was first drafted: that of encouraging international dialogue. Understanding between
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psychiatrists of different culture, spirituality and faith tradition may be every bit as sensitive as that between any psychiatrist and patient. It requires mutual respect, patience, empathy and a desire to understand the other better. But this is, in itself, a spiritual task – not unlike that defined within the new spirituality of Schmidt-Leukel’s seven virtues. We therefore continue to seek agreement, acknowledging respectfully that we need fully to acknowledge the perspective of Eastern European, Asian and other colleagues if we are to achieve anything worthwhile. This process has certainly instilled in us a curiosity as to how our understanding of psychiatric assessment can apparently differ so significantly according to cultural context. We hope that this curiosity will carry us forward, with colleagues from other disciplines (especially anthropology, theology and the study of religions), to a better understanding of what lies beneath our different views of spirituality and religion and their relationship to psychiatric practice. We have confidence also in the international friendships that our common vocation to psychiatry has established and, through these friendships, we hope to pursue honestly and courageously the possibility of an agreement that will transcend our differences. Finally, we are grateful to all colleagues who continue working with us towards this end when their personal convications oblige them to disagree with us. Are we, like Schmidt-Leukel, being over-idealistic and unrealistic? Perhaps we are, but we think that the benefits of succeeding, and the costs of failing to try, are so great that we must persevere in our efforts to find the way forwards.
ACKNOWLEDGMENTS We would like to thank Andrew Powell for his careful reading of a draft of this chapter and for the helpful comments which he made on it. We acknowledge also the valuable contributions to discussion on the CS which were made by other colleagues in various parts of the world, as outlined in the text.
REFERENCES 1. Van Praag HM, Verhagen PJ (2005) Religion, Spirituality and psychiatry. A field wide open for discussion and research. In: Christdoulou GN (ed.) Advances in psychiatry. Second Volume. World Psychiatric Association, pp. 251–258. 2. Schw€obel C (2003) Christlicher Glaube im Pluralismus. Studien zu einer Theologie der Kultur. Mohr Siebeck, T€ubingen. 3. Joas H, Wiegandt K (eds.) (2007) S€akularisierung und die Weltreligionen. Fischer Taschenbuch Verlag, Frankfurt am Main. 4. Information Please Almanac: Top Ten Organized Religions of the World. Available at http:// www.infoplease.com/ipa/A0904108.html. Accessed February 21, 2008. 5. Josephson AM, Larson DB, Juthani N (2000) What’s happening in psychiatry regarding spirituality? Psychiatric Annals 30, 533–541. 6. Koenig HG (2008) Religion and mental health: what should psychiatrists do? Psychiatric Bulletin 32, 201–203. 7. Lawrence RM, Head J, Christodoulou G et al. (2007) Psychiatrists’ religious attitudes in relation to their clinical practice. International Psychogeriatrics 19, 962–973. 8. Lepping P (2008) Correspondence. Psychiatric Bulletin 32, 357. 9. Poole R, Higgo R, Strong G, Kennedy G, Ruben S, Barnes R, Lepping P, Mitchell P (2008) Religion, psychiatry and professional boundaries. Psychiatric Bulletin 32, 356–357.
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10. Bertelsmann Stiftung (2007) Religionsmonitor 2008. G€ utersloher Verlagshaus, G€ utersloh. 11. Hilton C (2008) Religion, psychiatry and professional boundaries. Psychiatric Bulletin 32, 357. 12. Eagger S (2005) A short guide to the assessment of spiritual concerns in mental healthcare. Available at: www.rcpsych.ac.uk/pdf/drseaggeguide.pdf. 13. Carter P (2008) Religion, psychiatry and professional boundaries. Psychiatric Bulletin 32, 357–358. 14. Koenig HG (2005) Faith and Mental Health. Templeton Foundation Press, Philadelphia. 15. Hollins S (2008) Understanding religious beliefs is our business. Invited commentary on. . . Religion and mental health. Psychiatric Bulletin 32, 204. 16. Cox JL (1994) Psychiatry and religion: a general psychiatrist’s perspective. Psychiatric Bulletin 32, 673–676. 17. Sims A (1994) ‘Psyche’ - Spirit as well as mind? British Journal of Psychiatry 165, 441–446. 18. Donk WBJH van de, Jonkers AP, Kronjee GJ, Plum RJJM (2006) Geloven in het publieke domein. Verkenningen van dubbele transformatie. Amsterdam University Press, Amsterdam. 19. Koenig H, McCullough M, Larson D (eds.) (2001) Handbook of Religion and Health. Oxford University Press, New York. 20. Hackney ChH, Sanders GS (2003) Religiosity and Mental Health: A Meta-Analysis of Recent Studies. Journal of the Scientific Study of Religion 42, 43–55. 21. World Health Organization (WHO) (2001) The World Health Report 2001. Mental health: new understanding, new hope. World Health Organization, Geneva. 22. Mezzich JE (2007) Editorial. Psychiatry for the person: articulating medicine’s science and humanism. World Psychiatry 6, 103. 23. World Psychiatric Association (WPA) (2001) Madrid declaration on ethical standards for psychiatric practice. Available at: http://www.worldpsychiatricassociation.org/content/madridethic-engish.shtml. 24. Cook CCH (2004) Addiction and spirituality. Addiction 99, 539–551. 25. Bowker J (1999) The Oxford Dictionary of World Religions. Oxford University Press, Oxford. 26. Schneiders SM (2003) Religion vs. Spirituality: A Contemporary Conundrum. Spiritus 3, 163–185. 27. Cloninger CR (2004) Feeling Good. The Science of Well-Being. Oxford University Press, Oxford. 28. Josephson AM, Wieser IS (2004) Worldview in psychiatric assessment. In Josephson AM and Peteet JR (eds.) Handbook of Spirituality and Worldview in Clinical Practice. American Psychiatric Publishing, Arlington, pp. 15–30. 29. King M (2001) The measurment of religious and spiritual beliefs. Spirituality and Psychiatry Special Interest Group. Newsletter No. 5. Available at: http://www.rcpsych.ac.uk/college/ specialinterestgroups/spirituality/publications/newsletter5.aspx. 30. Boyer P (2001) Religion Explained. The evolutionary origins of religious thought. Basic Books, New York. 31. Dow JW (2007) A scientific definition of religion. Anpere. E-journal for the study of anthropology of religion, 1-15 (2007-02-19). 32. Schmidt-Leukel P (2004) A New Spirituality for a Religiously Plural World. Concilium 5, 62–68. 33. Dacey A (2008) The Secular Conscience. Why belief belongs in public life. Prometheus Books, Amherst NY. 34. K€ung H (1991) Global Responsibility: in search of a new world ethic. SCM Press, London. 35. Praag HM van (2008) God en Psyche. De redelijkheid van het geloven. Visies van een Jood. Boom, Amsterdam. 36. American Psychiatric Association (APA) (2006) Practice Guidelines for the Psychiatric Evaluation of Adults. Second Edition. APA, Washington. 37. American Psychiatric Association (APA) (1994) Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. APA, Washington.
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PROPOSAL Revised proposal for a WPA consensus statement on spirituality and religion in psychiatry Whereas spirituality and religion have often been neglected in clinical and academic psychiatry, they are increasingly recognized as being of importance in the understanding of psychiatric disorders, and in the clinical assessment and treatment of patients. Both terms lack a universally agreed definition. Spirituality is a distinctive, potentially creative, and universal dimension of human experience arising both within the inner subjective awareness of individuals and within communities, social groups and traditions. It may be experienced as a relationship with that which is intimately ‘inner’, immanent and personal, within the self and others, and/or as relationship with that which is wholly ‘other’, transcendent and beyond the self. It is experienced as being of fundamental or ultimate importance and is thus concerned with matters of meaning and purpose in life, truth, and values. Religion is usually defined more in terms of systems of beliefs and practices related to the sacred or divine, and definitions often refer to social institutions and communities within which such systems are agreed and held in common. However, the scope and variability of such definitions is enormous, with some people identifying spirituality and religion as virtually synonymous, or at least as overlapping concepts, whilst others see them as contrasting or opposed categories. Others would see religion as much more individual than social, and yet others would focus less on religion as being concerned with belief systems and more on its concerns with morality, praxis or faith. In many Western countries, both religion and spirituality are now often faced with the context of a secular society, in which most public discourse is conducted without reference to either religion or spirituality. In many other parts of the world religious tradition continues to provide a shared frame of reference for public life and discourse. Faith communities, and spiritual or religious practices, have the potential to influence the course of mental illness, and attitudes towards people suffering from mental illness, for good or ill. Whatever disagreements there might be on definition, spirituality and religion are concerned with the core beliefs, values and experiences of human beings. A consideration of their relevance to the origins, understanding and treatment of psychiatric disorders should therefore be a central part of clinical and academic psychiatry. Spiritual and religious considerations also have important ethical implications for the clinical practice of psychiatry. In particular, it is affirmed here that: 1. Spiritual well-being is an important aspect of health. 2. Empirical evidence reveals a largely positive relationship between religiosity/spirituality and different indices of health. However, religious and spiritual beliefs are powerful forces and may impart harmful as well as beneficial effects. 3. A tactful consideration of patients’ religious beliefs and spirituality should be considered as an essential component of psychiatric history taking. 4. An understanding of religion and spirituality and their relationship to the diagnosis, aetiology and treatment of psychiatric disorders should be considered as essential components of both psychiatric training and continuing professional development.
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5. There is a need for more research on both religion and spirituality in psychiatry. 6. Psychiatrists should be expected always to respect and be sensitive to the spiritual/ religious beliefs and practices of their patients, and of the families and carers of their patients, and not to use their professional position for proselytizing or undermining faith. 7. Psychiatrists, whatever their personal beliefs, should be willing to work with leaders/ members of faith communities, chaplains and pastoral workers in support of the wellbeing of their patients, and should encourage all colleagues in mental health work to do likewise. 8. Psychiatrists should demonstrate awareness, respect and sensitivity to the important part that spirituality and religion play for many staff and volunteers in forming a vocation to work in the field of mental healthcare. 9. Psychiatrists should, whenever appropriate, work for a better understanding between colleagues and patients of different religions and cultures, bearing in mind that social harmony contributes to mental health and well-being. World Psychiatric Association Section on Religion, Spirituality and Psychiatry Executive Committee of the Spirituality Interest Group (SIG), Royal College of Psychiatrists 11 August 2008
Notes on Contributors Hisham Abu Raiya is a Psychology Fellow at the Counseling and Behavioral Health Center in New York University. He received his PhD from Bowling Green State University in the United States. His dissertation research resulted in the development of a Psychological Measure of Islamic Religiousness (PMIR) that is currently being used in mental health research with Muslim populations. His research interest is the psychology of religion, with special emphasis on the psychology of Islam. He has conducted multiple research projects and written several articles and book chapters pertaining to these domains of inquiry. John, Lord Alderdice is a psychoanalytic psychiatrist who has been applying psychoanalytic principles in politics since the 1970s. For 11 years he was the Leader of Northern Ireland’s cross-community Alliance Party and was a key negotiator of the 1998 Good Friday Agreement. Elected to the new post-Agreement parliament he became the first Speaker establishing its innovative practices and procedures. After six years he retired and he was appointed by the British and Irish Governments as one of four international commissioners who monitor terrorist activity and security normalization in Ireland. He is the elected President of Liberal International (the worldwide federation of about 100 liberal political parties) and in 1996 was appointed a life member of the House of Lords (the upper chamber of the British Parliament). He also heads up the Centre for Psychotherapy in Belfast and is a Visiting Professor in Psychiatry at the University of Virginia. His main focus is on the psychology of terrorism and politically motivated violence and he takes a particular interest in the Middle East. Alan Apter graduated in medicine at the University of Witwatersrand, Johannesburg, Republic of South Africa. He completed his Child Psychiatry Fellowship at George Washington University, Washington DC, United States of America. He is Belfer Fellow in Biological Psychiatry, Albert Einstein College of Medicine, New York. He received the Brickel Award, Columbia University, New York and the Distinguished Investigator Ward, American Foundation for Suicide Prevention. He is Visiting Professor at the University of Pittsburgh and Yale University United States of America, and Foreign Adjunct Professor at the Karolinska Institute Stockholm. He is also Associate Editor-Archives of Suicide Research. He was Chairman of the Department of Psychiatry University of Tel Aviv Medical School (1996–2000) and at present he is Director of the Feinberg Child Study Center, Schneider’s Children’s Medical Center of Israel and Professor of Psychiatry, Sackler School of Medicine, University of Tel Aviv, Israel. Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
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Adamantios G. Avgoustidis is a graduate of the School of Medicine and the School of Theology of the University of Athens, Greece. His PhD is on Pastoral Psychology. He is a practicing psychiatrist and theologian. He is Associate Professor of Pastoral Theology and Psychology at the School of Theology, Faculty of Theology at the University of Athens. He is a protopresbyter (proto-priest) of the Orthodox Christian Church of Greece and serves the Metropolis of Thebes and Levadia. As a psychiatrist, Dr Avgoustidis is involved in establishing institutions and developing programs for mental health. He was a member of the “Board of Directors” of the “Hellenic Centre for Mental Health and Research”, the largest social and community provider of psychiatric services in Greece, and a member of the National Council of Mental Health of the Ministry of Health and Social Affairs. He is the President of the European Council of Pastoral Care and Counselling (ECPCC). He is consultant member of the WPA Section on Religion, Spirituality and Psychiatry. Robert H. Belmaker received his BA from Harvard College in 1967 and his MD from Duke Medical School in 1971. From 1972–74 he was a Clinical Associate at the National Institute of Mental Health in Bethesda, MD. Since 1974 he has held positions in academic psychiatry in Israel, first at the Jerusalem Mental Health Center 1974–84 and then at Ben Gurion University of the Negev 1985 to the present. Dr. Belmaker was a pioneer in biological psychiatry in Israel, and chaired the International College of Neuropsychopharmacology (CINP) meeting in Jerusalem in 1982. His research interests include affective disorders, especially mania, ECT, and second messenger mechanisms. In 1993 he submitted a grant request to National Alliance for Research on Schizophrenia and Depression proposing that TMS could be therapeutically useful in psychiatry, and was awarded the prestigious Distinguished Investigator Award to pursue this hypothesis. He has received the Anna Monika Prize for Research in Depression (1983), the Ziskind-Somerfeld Prize for Senior Research in Psychiatry (1993) and the European College of Neuropsychopharmacology Lilly Research Award (1996), and the National Alliance for Research on Schizophrenia and Depression Lifetime Achievement Falcone Award for research in affective disorder (2000) and the Research Prize of the World Federation of Societies of Biological Psychiatry (2004). He is President of the Collegium Internationale Neuro-Psychopharmacologium International College of Neuropsychopharmacology (CINP). Dianne A. den Boer-Wolters studied medicine at the University of Utrecht in the Netherlands from 2002–08. During her study she did literature research on the relation between obsessive-compulsive disorder and religion at GGZ Meerkanten in Ermelo. From January 2009 she has been working as a junior doctor at the emergency department at Beatrix Hospital in Gorinchem in the Netherlands. C. Robert Cloninger is Wallace Renard Professor of Psychiatry, Professor of Psychology and Genetics, and Director of the Sansone Family Center for Well-Being at Washington University School of Medicine in St. Louis. He is widely cited and honored for his innovative research in the genetics, neurobiology, development, psychology, brain imaging, and psychometric assessment of normal human personality and its disorders, as well as in the diagnosis and treatment of psychopathology. He received his BA with High Honors and Special Honors in Philosophy, Psychology, and Anthropology from the University of Texas at Austin, 1966. He received his MD from
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Washington University in 1970; and MD, honoris causa, from University of Umea, Sweden, 1983. Christopher C.H. Cook qualified in medicine from St George’s Hospital Medical School, London in 1981. He subsequently undertook postgraduate training in psychiatry at the United Medical & Dental Schools of Guy’s and St Thomas’s in London and then specialized in the field of addictions. His MD thesis was on the genetic predisposition to alcohol misuse, and he has published widely in the field of alcohol misuse and addiction. His more recent academic interests have focused on spirituality, theology & health. Chris was ordained as an Anglican Priest in 2001. Chris was a Senior Lecturer at the National Addictions Centre from 1994 to 1997 and was then appointed Professor of the Psychiatry of Alcohol Misuse at the University of Kent. He is currently Tutor in Pastoral Studies at Cranmer Hall, St John’s College, Durham and Professorial Research Fellow in the Department of Theology & Religion at Durham University, where he is developing a project for Spirituality, Theology & Health. He continues to work part-time as a consultant psychiatrist for Tees, Esk & Wear Valleys NHS Foundation Trust. He is a member of the Executive Committee of the Spirituality and Psychiatry Special Interest Group at the Royal College of Psychiatrists. John L. Cox has a longstanding interest in the relationship between religion, spirituality and mental health, and was the lead editor of a book based on the work of Paul Tournier. He is Professor Emeritus at Keele University and Visiting Professor at the Institute of Psychiatry, London. During his period as President and Dean of the Royal College of Psychiatrists, he encouraged greater emphasis on international mental health, and the bridging of arts and science. He is the Immediate Past Secretary General of the World Psychiatric Association. He co-authored Modern Management of Perinatal Mental Disorder, and has published widely in perinatal mental health and transcultural psychiatry. He and his wife now live in Cheltenham where he continues his interests in solo singing, and attends the local Methodist Church. Carissa Dwiwardani is a graduate student pursuing a PhD in Clinical Psychology at Rosemead School of Psychology and adjunct faculty at Biola University, La Mirada, California. She has cross-cultural research and teaching experience in Indonesia. Elisabeth H.M. Eurelings-Bontekoe (clinical psychologist/psychotherapist) is an Associate Professor at the Department of Clinical Psychology of Leiden University, The Netherlands. She is specialized in the psychodynamic assessment of personality pathology. Together with W.M. Snellen she developed and described a new method to assess structural personality pathology: theory driven profile interpretation of the Dutch Short Form of the MMPI. One of her research areas pertains to Religion and Personality. She edited two Dutch books on personality pathology and (co)authored several papers on the topic “Religion and Personality”.
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Bill (K.W.M) Fulford is a Fellow of St Cross College, Member of the Faculty of Philosophy and an Honorary Consultant Psychiatrist, University of Oxford; Professor of Philosophy and Mental Health in the University of Warwick Medical School; Professor of Philosophy and Psychiatry and Co-Director of the Institute for Philosophy, Diversity and Mental Health at the University of Central Lancashire; and Special Adviser for Values-Based Practice in the Department of Health, London. He founded and co-edits the journal Philosophy, Psychiatry, & Psychology and the book series from Oxford University Press on International Perspectives in Philosophy and Psychiatry. His research interests have focused on analytic philosophy in the Oxford tradition particularly as applied to the meanings and implications of value terms. It is this research that has been the basis of recent policy, practice and service development programs in mental health on which he has been leading for the Department of Health in London. He has played an active role in a number of WPA programs in particular as Chair of the Philosophy Special Section and as Co-Chair of the Conceptual Work Stream of the Institutional Program on Psychiatry for the Person (IPPP). The latter has been developed in partnership with a program on assessment in mental health in the United Kingdom’s Department of Health. Marc Galanter is Professor of Psychiatry at New York University (NYU), Founding Director of the Division of Alcoholism and Drug Abuse at NYU, and Director of the NYU Fellowship Training Program in Addiction Psychiatry. He is also a Division Director at NYU’s World Health Organization Collaborating Center, and Director of its national Center for Medical Fellowships in Alcoholism and Drug Abuse. He is editor of the journal Substance Abuse, the annual research book series Recent Developments in Alcoholism (Kluwer), and co-editor of the American Psychiatric Association’s Textbook of Substance Abuse Treatment (APPI). His research has been funded by the NIH and foundations with over $16 million. It has addressed family therapy for substance abuse, pharmacologic treatment for addiction, self-help treatment for substance abusers, spiritually-oriented recovery, and Alcoholics Anonymous. Among his awards are the Gold Achievement Award for innovation in clinical care, and the Seymour Vestermark Award for Psychiatric Education, both from the American Psychiatric Association; the McGovern Award for medical teaching from AMERSA; and New York State’s Award for Psychiatric Research. He currently chairs Committees on Twelve-Step Recovery for the American Academy of Addiction Psychiatry (AAAP) and the Association for Medical Education and research in Substance Abuse (AMERSA), and serves on their respective organizations’ Boards of Directors. Samuel G. Gatere graduated from the University of London in 1980 with Master of Philosophy degree in Psychiatry. He is a graduate of the University of Nairobi from where he did a Bachelor of Medicine and Surgery degree. He also holds a Diploma in Psychological Medicine from the Royal College of Psychiatrists. His career in psychiatry spans over thirty years during which time he has worked for the Government of Kenya as a Medical Officer and Consultant Psychiatrist. He also worked with the University of Nairobi as a Lecturer in Psychiatry between 1979 and 1989. He has also collaborated with the University of London as a Research Fellow. He is the author of several books and book chapters, and has published extensively in scientific journals on a variety of subjects including: culture, rural-urban migration,
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personality issues and marriage. He has done extensive research on Alzheimer’s Disorder and has co-authored several papers which have been published on “the genetic risk of Alzheimer’s Disorder in the African”. He is also a regular participant in regional and international meetings. He runs a private practice in Nairobi, and continues with his social responsibility through various speaking engagements locally and internationally on issues of mental health and religion. David M. Gellerman completed his psychiatric residency and fellowship in forensic psychiatry at the UC Davis Department of Psychiatry and Behavioral Sciences. In 2002, he was the recipient of a John Templeton Foundation for Spirituality and Medicine Award for the curriculum he developed along with Dr. Mark Servis, Training Director for Psychiatry at UC Davis, and in 2008 he was awarded an APA Annual Irma Bland Aware for Excellence in Teaching Residents. He is currently a staff psychiatrist at the Veterans Administration Sacramento Medical Center in Sacramento, California as well as an Assistant Clinical Professor at the UC Davis Department of Psychiatry and Behavioral Sciences. Linda Glickman is Research Assistant Professor at the Division of Alcoholism and Drug Abuse of New York University School of Medicine and Bellevue Hospital Center in New York City. Charles H. Hackney received his PhD in social/personality psychology from the University at Albany, SUNY. He currently serves as a Professor of Psychology at Redeemer University College in Ancaster, Ontario, where his research specializations include positive psychology, terror management theory, and the psychology of religion. He is the author of several scholarly articles, and of the book Living the Warrior Virtues (in press). Peter C. Hill is Professor of Psychology at Rosemead School of Psychology, Biola University, in La Mirada, California (United States of America). In 2006 he was a Visiting Senior Research Scholar on the Faculty of Divinity at Cambridge University, England. He has co-authored The Psychology of Religious Fundamentalism (2005), co-edited Measures of Religiosity (1999), and co-edited the Baker Encyclopedia of Psychology (1999). He is a Past President of Division 36 (Psychology of Religion) of the American Psychological Association (APA) and was elected Fellow of the APA in 1998. Allan M. Josephson is Professor of Psychiatry and Chief of Child, Adolescent and Family Psychiatry at the University of Louisville School of Medicine in Louisville, Kentucky, United States of America. He also serves as Associate Chair of Psychiatry for Child and Adolescent Programs at the University of Louisville. In addition to the interaction between psychiatry and religion/spirituality, his other areas of academic interest include the relationship of family function to child and adolescent psychiatric disorders, family therapy, psychiatric diagnosis and psychiatric education. He is Chair of the Family Committee of the American Academy of Child and Adolescent Psychiatry and co-edited the volume Handbook of Spirituality and Worldview in Clinical Practice, published by American Psychiatric Publishing, Inc, in (2004).
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Nadia Kadri is Professor of Psychiatry at the Casablanca University (Morocco), Ibn Rushd University Psychiatric Centre. She is in charge of university diplomas on human sexuality, on psychological medicine, and on cognitive behavioral therapy (CBT). Her main areas of interest are: psychiatric epidemiology, women’s mental health, perinatal psychiatry, stigma of mental disorders, liaison psychiatry, cognitive and behavioral therapy, sexual health, and mental health during Ramadan month. Kenji Kitanishi is Professor of Department of Social Welfare, Faculty of Integrated Arts and Social Sciences, Japan Women’s University and Director of Kitanishi Clinic, Morita Therapy Institute (private practice for neurotic and depressed patients in outpatient setting of Morita Therapy). He is the Chief Director of Japanese Society for Morita Therapy from 2004. He has published many scholarly articles and chapters on Morita Therapy and comparative psychotherapy. Harold G. Koenig completed his undergraduate education at Stanford University, his medical school training at the University of California at San Francisco, and his geriatric medicine, psychiatry, and biostatistics training at Duke University Medical Center. He is board certified in general psychiatry, geriatric psychiatry and geriatric medicine, and is on the faculty at Duke as Professor of Psychiatry and Behavioral Sciences, and Associate Professor of Medicine. He is member of the board of the WPA Section on Religion, Spirituality and Psychiatry. Dr. Koenig is co-director of the Center for Spirituality, Theology and Health at Duke University Medical Center, and has published extensively in the fields of mental health, geriatrics, and religion. His research on religion, health and ethical issues in medicine has been featured on many national and international TV news programs, nearly a hundred national or international radio programs, and hundreds of newspapers and magazines. Dr. Koenig has given testimony before the U.S. Senate concerning the benefits of religion and spirituality on health, and has been interviewed by James Dobson on Focus on the Family and by Robert Schuller on the Hour of Power. Dr. Koenig has given many seminars and workshops (see www.dukespiritualityandhealth.org), and his latest books are Faith and Mental Health (2005), Kindness and Joy (2006), Spirituality in Patient Care, 2ndedition (2007), and Medicine, Religion and Health (2008) (all by Templeton Press). Marı´a Ines Lo´pez-Ibor Alcocer is Professor of Psychiatry at the Department of Psychiatry and Medical Psychology of the Faculty of Medicine of the Complutense University in Madrid. She also holds the post of Secretary of this department. She is President of the Advisory Board of USP Hospitals and member of the Technical Advisory Board of the Public Defender for Minors of the Region of Madrid. From 2003 to 2005 she held the position of Counsellor to the Ministry of Health of the Region of Madrid. Dr Lopez-Ibor earned her MD and PhD degree in medicine and surgery in the year 1992 with the highest awards by the Complutense University of Madrid, specializing in psychiatry. She is a representative for Europe on the World Psychiatric Association Operational Committee on Meetings, Scientific Coordinator of the Program on Mental Health and Disasters of the World Health Organization, member of the editorial board of the journal Actas Espan˜olas de Psiquiatrı´a and member of the board of the Juan Jose Lo´pez Ibor Foundation, the Salto Foundation for the Integration to Work of Persons with
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Severe Mental Illness and of the International Health Fair (Fisalud). She is author of two books and of 10 chapter monographs by other authors and has published more than 70 papers and communications in scientific meetings. Juan J. Lo´pez-Ibor, Jr is Professor and Chairman of Psychiatry and Director of the Institute for Psychiatry and Mental Health of the San Carlos Hospital of the Complutense University in Madrid. He is also Director of the World Health Organization Collaborating Center for Research and Training in Mental Health, Spain, and Fellow of the Royal National Academy of Medicine of Spain, Corresponding Fellow of the Royal Academy of Medicine of Zaragoza, and Honorary Fellow of the Spanish Medical Chirurgical Academy. He has been Secretary General, President-Elect and President of the World Psychiatric Association. Dr Lo´pez-Ibor earned his MD and PhD degrees with the highest awards from the Complutense University of Madrid. He is a Specialist in Neurology and Psychiatry, with psychiatric training completed at the University of Frankfurt, Germany, and in the Maudsley and Saint Bartholomew Hospitals, London, and in Rives de Prangins, Switzerland. He is author, alone or in collaboration, of 53 books and of 219 chapter monographs by other authors. He has published more than 330 papers in scientific journals and has presented more than 1,500 papers and communications in scientific meetings. Francis G. Lu is Professor of Clinical Psychiatry, University of California, San Francisco (UCSF). He is also the Director of the Cultural Competence and Diversity Program, Department of Psychiatry at San Francisco General Hospital (SFGH), where he has worked since 1977. In July 2009, he will join UC Davis as the Luke and Grace Kim Endowed Chair in Cultural Psychiatry in the Department of Psychiatry and Behavioral Sciences. As a Distinguished Fellow of the American Psychiatric Association, Dr. Lu has contributed to the areas of cultural psychiatry, psychiatric education, media and psychiatry, and the interface of psychiatry and religion/spirituality through his presentations and more than 70 publications. David Lukoff is a Professor of Psychology at the Institute of Transpersonal Psychology and a licensed psychologist in California whose areas of expertise include treatment of schizophrenia, transpersonal psychotherapy, spiritual issues in clinical practice, and case study methodology. He is author of 70 articles and chapters on spiritual issues and mental health; co-author of the DSM-IV category Religious or Spiritual Problem; Co-President of the Institute for Spirituality and Psychology and of the Association for Transpersonal Psychology; maintains the Spiritual Competency Resource Center at www.spiritualcompetency.com Patrick Luyten is Assistant Professor at the Department of Psychology, University of Leuven (Belgium). His main research interest focuses on the role of personality, stress, and interpersonal processes in depression, chronic fatigue syndrome, and fibromyalgia. He is currently also involved in studies on mentalization-based treatment of patients with borderline personality disorder, and has published on the relationship between mental health and religion. He is a Visiting Professor at the Department of Psychology, University College London, London (United Kingdom) and a Visiting Research Scholar at the Yale Child Study Center, New Haven (United States of America).
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Gina Magyar-Russell is Instructor of Psychiatry and Behavioral Sciences at The Johns Hopkins School of Medicine (JHSOM), Baltimore, MD. She is a licensed psychologist who specializes in psychosocial adjustment following adverse health events, with particular emphasis on treatment of mood and anxiety disorders among patients with cardiovascular disease (CVD). She received her PhD from Bowling Green State University in 2005 and completed post-doctoral training at JHSOM in 2007. In her current position, Dr. Magyar-Russell conducts research and psychotherapy with individuals with cardiovascular disease and anxiety and depressive disorders, and instructs and supervises psychiatry interns in cognitive behavioral therapy (CBT) techniques. Dr. Magyar-Russell leads an inpatient psychology consultation service for CVD patients hospitalized at the Johns Hopkins Bayview Medical Center and maintains an outpatient psychotherapy practice focused on treatment for patients suffering from anxiety and depression. Harold J.G.M. van Megen graduated from medical school (University of Amsterdam) in 1986. In 1991 he was registered as a psychiatrist and in 1995 he finished his thesis On the role of the cholecystokinin-B receptor in panic disorder at the University of Utrecht. In 2004 he was appointed Associate Professor of Psychiatry at the University of Utrecht. Since 2004 he has been the Director of the residency program and Director of the Anxiety Research Department at Meerkanten GGz (Ermelo, The Netherlands). He is author of numerous international papers and book chapters on anxiety. He is a board member of the Dutch Psychiatry and Religion Association. His main domain of interest and expertise is in anxiety disorders, obsessive compulsive disorder and Roman Catholicism. Ahmad Mohit entered Tehran University Medical School in 1961, Graduated as MD 1968, Internship: Nazareth Hospital, Philadelphia, Pennsylvania, United States of America. 1972–73, Psychiatry Residency: Eastern Pennsylvania Psychiatric Institute. Philadelphia, PA, United States of America: 1973–76; Neurology Residency: Temple University Hospital, Philadelphia, Pennsylvania: 1976–78; Fellowship: Behavior Therapy: Eastern Pennsylvania Psychiatric Institute: 1978. American Board of Psychiatry and Neurology Exam, passed: 1978. He was Director of the Tehran Psychiatric Institute, Tehran, Iran: 1979–88. He was Professor and Chairman, Department of Psychiatry at the Iran University of Medical Sciences, 1988–93. He was Regional Adviser Mental Health, Eastern Mediterranean Regional Office, World Health Organization, 1993–2002, and Director, Department of Health Protection and Promotion, Eastern Mediterranean Regional Office, World Health Organization 2002–06. At present he is the Chairman, Department of Social Determinants of Health in High Institute of Public Health, Tehran University of Medical Sciences. He is also the Chairperson of the Section on Literature and Psychiatry, World Psychiatric Association. He is member of the board of the WPA Section on Religion, Spirituality and Psychiatry. Driss Moussaoui is the Founder and the Chairman of the Ibn Rushd University Psychiatric Centre in Casablanca, Morocco. The latter is a WHO Collaborating Centre in Mental Health since 1992. He is the President-Elect of the World Association of Social Psychiatry and a member of the French Academy of Medicine. He is the Vice-Chair of the World Psychiatric Association Section on Spirituality, Religion and Psychiatry. Driss Moussaoui has published (or edited) 10 books and hundreds of papers in international journals.
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R. Srinivasa Murthy, Emeritus Professor of Psychiatry, completed his postgraduate degree in Psychiatry (MD) in 1975 and has been a Postgraduate Teacher of Psychiatry from 1975. Professor Murthy was Professor of Psychiatry at the National Institute of Mental Health and Neurosciences, Bangalore, India, from 1987–2003. He was Head of the Department of Psychiatry, from January 1988 to February 1997 with over 50 postgraduates and 40 academic staff. Professor Murthy has worked with the World Health Organization (WHO) extensively. He functioned as Editor in Chief of the World Health Report 2001 during 2000–01. The report focused on Mental Health. Following retirement in 2004, he worked with WHO at the Eastern Mediterranean Regional Offices of Cairo and Amman. The last two years (2006–07) of work was as Mental Health Officer of WHO-Iraq. He is member of the board of the WPA Section on Religion, Spirituality and Psychiatry. Research contributions have been mainly in the areas related to community mental health. He has published extensively in national and international journals (over 200 publications). Currently, he is working (for two days a week) in Bangalore with a voluntary agency for mental handicap (Association for Mentally Challenged, www.amcin.org) to develop a community-based care program for persons and families with a mental handicap. Hanneke (J. K.) Muthert is a theologian, PhD and has studied in Groningen and Barcelona. Her thesis (2007) is about mourning processes in cases of schizophrenia. Other main areas of interest at the moment are spiritual care, religious coping and the life and work of the psychoanalyst W. R. Bion. She is a spiritual caregiver at the Drenthe Mental Health Trust in Assen and Assistant Professor of Master Spiritual Care at the University of Groningen, The Netherlands. William E. Narrow’s research interests are centered on the epidemiology of mental disorders, mental health services research, and child and adolescent mental disorders. He is also interested in issues of disorder thresholds, functional impairment, and disability. He received a bachelor’s degree (summa cum laude) with majors in biology and sociology from Boston University, a medical degree from Temple University, and a master’s degree in public health from the Johns Hopkins University. Dr. Narrow completed an internship in internal medicine at Michael Reese Hospital, specialty training in psychiatry at the University of Chicago, and a fellowship in epidemiology at the National Institute of Mental Health. Before his appointment at the American psychiatric Association (APA) in 2001, Dr. Narrow was Senior Advisor for Epidemiology in the Office of the Director at the National Institute of Mental Health (NIMH). He has participated in several collaborative research projects at the APA and NIMH, including the current NIH-funded conference grant to develop a DSM-V research agenda, for which he is Co-Principal Investigator, and the editorial board for development of the Diagnostic Interview Schedule for Children (DISC-IV). He is also an editor of the journal Social Psychiatry and Psychiatric Epidemiology. Noa Navot obtained her MD degree at Hebrew University of Jerusalem and is training as a child and adolescent psychiatrist at Zieff Medical Center, Zefat, Israel. Dr Navot completed a special interdisciplinary program at the Hebrew University focusing on theology, philosophy and literature. Anna Nguithi has been a Consultant Psychiatrist in private practice for the last 15 years. She is an associate member of the Royal College of Psychiatrists, United Kingdom, a
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member of the American Psychiatrist Association, Kenya Psychiatric Association, Kenya Medical Association and Kenya Medical Women’s Association. She graduated from the University of Nairobi with a degree in medicine in 1984 and a Masters in Psychiatry in 1990. She was granted Specialist Recognition in 1993 by the Medical Practitioner’s and Dentists Board in Kenya. Dr. Nguithi has published in various journals and contributed various book chapters. She has attended various local and international conferences. She was on the Organising Committee for the World Psychiatric Association Regional Conference held in Nairobi in March 2007 and she presented a paper on the local experience of ADHD. Armand Nicholi, Jr. is a Professor of Psychiatry at Harvard College, Harvard Medical School and the Massachusetts General Hospital. Dr. Nicholi teaches a course at the Medical School based on his book The Question of God: C.S. Lewis and Sigmund Freud Debate God, Love, Sex and the Meaning of Life. A Public Broadcasting System television series, contrasting Freud’s secular worldview with Lewis’ spiritual worldview, was based on this book. Frank G. Njenga is the current President of the African Association of Psychiatrists and Allied Professions and Treasurer of the Royal College of Psychiatrists, Africa Division. He is a member of the World Psychiatric Association’s Publications Committee and the lead editor of the recently published book, Essentials of Clinical Psychiatry for Sub-Saharan Africa. He is the author of several books and book chapters, and has published extensively in scientific journals on a variety of subjects including culture, post traumatic stress disorder (PTSD), themes on childhood disorders and policy development. He is a regular participant in regional and international meetings. He runs a private psychiatric hospital in Nairobi, and has hosted a weekly TV program properly titled ‘Frankly Speaking’ which helped to break stigma barriers in mental health in East Africa. His web page with the BBC is a popular avenue of global communications in mental health. Having graduated at the Maudsley Hospital in 1980, he is a Fellow of the Royal College of Psychiatrists, a member of the American Psychiatric Association and continues with the tradition of research and social responsibility. His areas of personal interest include health policy in Africa, mental health and the media, and ADHD in adults. Ahmed Okasha is Founder, Professor and Director of WHO Collaborating Center for Training and Research in Mental Health, Institute of Psychiatry – Ain Shams University, Cairo; President Egyptian Psychiatric Association, President Arab Federation of Psychiatrists, Immediate Past President World Psychiatric Association (2002–05), President of the Egyptian Society of Biological Psychiatry, of WFSBP, Chairman of WPA Review Committee (2008–11), Chairman of WPA Ethics’ Committee (1999–2002), Editorial Advisory Board of 20 international scientific journals, awarded the Golden Medal of ICAPAP (2004), Honorary Fellowship of the American College of Psychiatrists (2002), Fellow of Royal College of Physicians (Edinburgh, 1973), Fellow of Royal College of Psychiatrists (London, 1973), Honorary Fellow of WPA (2005), Presidential Commendation of APA (2006), has published more than 220 original articles in national and international journals, editor and contributor of 47 books, awarded the Egyptian State Prize in creativity in science 2000 and, state merit prize for medical sciences 2008. He is member of the board of the WPA Section on Religion, Spirituality and Psychiatry.
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Kenneth I. Pargament is Professor of Psychology at Bowling Green State University in the United States. He is a clinical psychologist who conducts research on religion, stress, and coping and spiritually integrated treatments. He is the author of The Psychology of Religion and Coping: Theory, Research, Practice and Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred. He is co-editor of Mental Health, Religion, and Culture. John R. Peteet, after receiving his MD degree at Columbia and a medical internship at UNC in Chapel Hill, trained in psychiatry at the Massachusetts Mental Health Center, and completed a fellowship at the Peter Bent Brigham Hospital, in Boston. He has served for over 30 years as a psychiatrist at Brigham and Women’s Hospital and Dana-Farber Cancer Institute, where he is an Associate Professor of Psychiatry at Harvard Medical School. Board certified in psychiatry and psychosomatic medicine, he has received awards for teaching and has published numerous papers in the areas of psychosocial oncology, addiction, and the clinical interface between spirituality/religion and psychiatry. In 2004 the American Psychiatric Association Press published his book Doing the Right Thing: An Approach to Moral Issues in Mental Health Treatment, and another that he co-edited, The Handbook of Spirituality and World View in Clinical Practice (2004). He is currently coediting a volume on religious and spiritual issues in DSM-V, and is a past Chair of the American Psychiatric Association’s Corresponding Committee on Religion, Spirituality and Psychiatry. Herman M. van Praag is Professor Emeritus of the Dutch Universities of Groningen, Utrecht, Maastricht, and the Albert Einstein College of Medicine, New York, United States of America. He established the first department of biological psychiatry in Europe (Groningen) and became the first European Professor of Biological Psychiatry in 1968. He is well known for his extensive research on the biological determinants of depression and depressive symptoms for which he was decorated many times. He chairs the WPA section on Religion, Spirituality and Psychiatry. Hanneke Schaap-Jonker, psychologist and theologian, is Lecturer in Psychology of Religion at the Protestant Theological University, Kampen, The Netherlands. Her research interests are relational psychoanalysis and the image of God in relation to personality and mental health. Her works include Before the Face of God: An Interdisciplinary Study of the Meaning of the Sermon and the Hearer’s God Image, Personality and Affective State (2008) and Schaap-Jonker, H., Eurelings-Bontekoe, E.H.M., Zock, H. & Jonker, E.R. (2008). Development and Validation of the Dutch Questionnaire God Image, Mental Health, Religion and Culture 11, 501–515. She is currently working on the God Image and autistic spectrum disorders and on the God Image in relation to personality structure and mentalization. Naotaka Shinfuku studied medicine at Kyusyu University School of Medicine, Fukuoka, Japan, and graduated in 1967. During his school years, he was interested in Zen Buddhism. He started his career as a psychiatrist in Japan. He continued his studies as a French Government Scholarship student in Paris from 1971 to 1974. He came back to Japan in 1974 and worked as Chief Psychiatrist at Hizen National Sanatorium at Saga prefecture. He had a brief experience as Deputy Director at the National Sanatorium Division of Ministry of Health, Tokyo, from 1977 to 1979 supervising the reorganization of national hospitals for
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chronic patients. Then he went to Manila (Philippines) to work as Regional Adviser in Mental Health and Drug Dependence at the WHO Office of the Western Pacific. During his assignment at the WHO Western Pacific Region for 13 years from 1981 to 1994, he collaborated with member states in East Asia, ASEAN and South Pacific to develop community-based mental health services. He came back to Japan in1994 as Professor at the International Center for Medical Research, Kobe University Graduate School of Medicine. He experienced the Hanshin Awaji Earthquake in January 1995 in Kobe. During his assignment in Kobe for 11 years from 1994 to 2005, he carried out several international collaborative research projects. He retired from Kobe University in 2005. He came back to his home town, Fukuoka, to teach psychiatry and mental health to young students at the Department of Social Welfare of Seinan Gakuin University. Since 2005, he has served as WPA Zonal Representative for Zone 17 (East Asia). Also, he is at present President of the Asian Federation of Psychiatric Associations (AFPA). Andrew C.P. Sims is Emeritus Professor of Psychiatry, University of Leeds. He is a past President and former Dean and Director of Continuing Development of the Royal College of Psychiatrists. He has served on the General Medical Council of the United Kingdom, with particular responsibility for sick doctors. He has published extensively on psychopathological and epidemiological aspects of psychiatry. He is the author of Symptoms in the Mind (3 editions) and Is Faith Delusion? – to appear in 2009. He previously chaired the Spirituality and Psychiatry Special Interest Group of the Royal College of Psychiatrists. Moshe Halevi Spero is Professor, School of Social Work and Director, Postgraduate Program of Psychoanalytic Psychotherapy, Bar-Ilan University; Senior Clinical Psychologist, Weinstock Oncology Day Hospital, Shaare Zedek Medical Center; Senior Clinical Psychologist, Department of Psychiatry, Sarah Herzog Memorial Hospital, Jerusalem; Scientific Associate, American Academy of Psychoanalysis and Dynamic Psychiatry. He is Editor-in- Chief, Ma’arag: Israel Journal of Psychoanalysis. Michael H. Stone completed his medical training at Cornell Medical School and his psychiatric training at Columbia Presbyterian Medical Center (the New York State Psychiatric Institute), both in New York City. He finished his psychoanalytic training at the Columbia Psychoanalytic Institute. He is currently a Professor of Clinical Psychiatry in the Columbia University Medical College: Department of Psychiatry. He is also an Attending Psychiatrist at the Mid-Hudson Forensic Psychiatric Hospital, where he teaches the Columbia forensic trainees. He is a member of the Personality Disorder Institute directed by Dr. Kernberg in New York City, and is a distinguished life member of the American Psychiatric Association. His latest two books are Personality Disorders – Treatable and Untreatable, and The Anatomy of Evil. Professor Stone’s interest in the subject of evil was stimulated by his work in the forensic area and by his having served as the host of the Discovery Channel’s series (2006–07) called “Most Evil.” He has lectured in Europe and America on evil as conceptualized by theologians and philosophers. Dick F. Swaab was Director of the Netherlands Institute for Brain Research from 1978 to 2005. Since 1979 he has been Professor of Neurobiology at the Medical Faculty, University of Amsterdam. In 1985 he founded the Netherlands Brain Bank and was Director until 2005. He is leader of a research team for neuropsychiatric disorders, Netherlands Institute for
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Neuroscience, an institute of the Royal Netherlands Academy of Arts and Sciences (KNAW). Allan Tasman has been Professor and Chairman of the Department of Psychiatry and Behavioral Sciences at the University of Louisville since 1991. He is a graduate of the Western New England Psychoanalytic Institute. He has received national awards for medical student and resident educational excellence. His research has focused on neurophysiology of cognitive processes. He is a fellow of the Royal College of Psychiatrists of the United Kingdom. He was President of the American Association of Directors of Psychiatric Residency Training, Association for Academic Psychiatry, and American Association of Chairs of Departments of Psychiatry. He was American Psychiatric Association President 1999–2000. In 2005, he was elected for a six-year term as Secretary for Education of the World Psychiatric Association. He is President of the Pacific Rim College of Psychiatrists, an international academic organization. He is senior editor of a comprehensive textbook, Psychiatry, called “the best current textbook of psychiatry” by the New England Journal of Medicine and the “gold standard” by the American Journal of Psychiatry. The third edition was published by Wiley in 2008. Samuel B. Thielman serves as Regional Psychiatrist for the U.S. Department of State at the U.S. Embassy in London. From 2004–06 he was the Director of Mental Health Services for the State Department. He has worked extensively in East Africa and his research focuses on the way culture shapes the expression and duration of post-trauma symptoms and depression. He holds adjunct faculty positions at Duke University School of Medicine and the Uniformed University of the Health Sciences. Opinions expressed are his personal opinions and do not represent an official position of the U.S. government. Pichet Udomratn received an Outstanding Research Psychiatrist of Thailand award from the Psychiatric Association of Thailand. He is presently Professor of Psychiatry, Faculty of Medicine, Prince of Songkla University in southern Thailand. He currently also serves as the Vice President of the Asian Federation of Psychiatric Associations (AFPA) and also the President of the Psychiatric Association of Thailand. Moreover, he also serves on the Board of Directors of Pacific Rim College of Psychiatrists (PRCP), the Executive Committee of the Royal College of Psychiatrists of Thailand and as a Chairperson of the Sleep Disorder Service and Research Center of the Faculty. Dr. Udomratn is a former Editor of the Journal of the Psychiatric Association of Thailand and he is now the Editorial Board of the International Journal of Mental Health System, Asian Journal of Psychiatry and the upcoming Asia Pacific Psychiatry Journal. He has more than 100 publications including books, research, reviews, and special articles. His major fields of interest and research are anxiety and mood disorders, schizophrenia, sleep disorders, psychopharmacology, geriatric psychiatry, medical education, culture and religion related to mental disorders. Ayala Uri served in the Israeli Defense Force as a psychological screener for new inductees. She graduated in medicine from Sackler School of Medicine in 2006 and recently commenced her fellowship in Child and Adolescent at the Schneider’s Children’s Medical Center in Israel. One of her major interests is the integration of mindfulness and yoga in clinical psychiatry.
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Peter J. Verhagen is a graduate from the School of Medicine (1983) and the School of Theology (1988) of the University of Utrecht, the Netherlands. In 1988 he was registered as psychiatrist. He is a practicing psychiatrist and theologian, group psychotherapist and Supervisor (2002) of the Dutch Association for Group Dynamics and Group Psychotherapy. He is Director of the Program for the Treatment of Personality Disorders, Meerkanten GGz Ermelo/Harderwijk. He is Co-Founder and Present Secretary of the WPA Section on Religion, Spirituality and Psychiatry, founded in 2003. He is also Secretary of the Dutch Foundation for Psychiatry and Religion. He is leading editor of a Dutch journal entitled Psyche & Geloof (Psyche & Faith). Wilma Verweij studied English Language and Literature at the University of Nijmegen, The Netherlands. After graduating she taught English at a secondary school and then took a position as coordinator at a translation agency. She has worked at the secretariat of the Netherlands Institute for Neuroscience for many years. C. Paul Yang received his MD from Taipei Medical College in Taiwan in 1982 and PhD in epidemiology from University of Washington in Seattle in 1986. He completed his residency training in psychiatry at Stanford University in 1996. He has been a team leader psychiatrist at the Asian Focus Unit at San Francisco General Hospital since 1998. He is currently an Associate Clinical Professor at University of California, San Francisco. His research interests lie in facilitating cultivation of mindfulness and therapeutic empathy toward patients among psychiatric staff. He has been writing articles and giving presentations at professional conferences and to the general public to promote spirituality, mindfulness and positive psychology.
Index of Names Aantjes, Willem 557 Abulafia, Abraham 29 Agnon, S. Y. 99–100 A Simple Story 100–101 In the Prime of her Life 101–102 The Doctor and his Divorcee 102 Alderdice, John (Lord) 33, 633 Allatius, Leo 546 Allport, Gordon 346, 392, 395 Aristotle 17, 65, 67, 218, 481–482, 491 Arjuna 169 Asaph 96 Attig, Thomas 505 Augustine (Saint) 18–19, 69, 483 Austin, J. L. 39, 40, 43, 55 Averro€es 21–22, 127, 413–414 Avicenna 21, 126 Bastami, Bayazid e 80 Batson, C. Daniel 347 Bayle, Pierre 24 ben Kar’hah, Rabbi Joshua 469–470 Benedict XVI 543, 544 Bergin, Allen 352 Bhagavad Gita 163, 169–170, 176 Bhugra, Dinesh 57, 590 Bialik, Haim Nachman 91–92 Barbour, Ian 6 religio-scientific typology 6–8 Bin Laden, Osama 543 Blacking, John 312 Boehme, Jacob 23 Bo€ethius 22 Buddha 16, 182, 195–197, 491 Cain and Abel 16 Callixtus 554
Calvin, John 480 Cantwell, W. S. 344 Cartwright, Samuel 348 Catherine of Siena 225 Charles, Marilyn 462–463 Charles VII of France 554 Columbo, Anthony 55 Confucius 16–17 Cowper, William 266–267 Dalai Lama 532 Daniel (Biblical figure) 257–258 Dante (Alighieri) 21–22 Darwin, Charles 26–27, 483 Davey, J. Ernst 306, 307, 308–310 David (Biblical figure) 91, 93 Dawkins, Richard 482, 546 Descartes, Rene 23, 64, 66, 482–483 Dilthey, W. 64–65 Donnolo, Shabbetai 96 Dostoevsky, Fyodor 555–556 Durkheim, E. 344 Edgar, James 306 Einstein, Albert 516 El Ghazali 126–127 Ellis, Albert 345, 350 Epicurus 17 Erikson, Erik 128, 292, 312, 604–605, 606 Ey, Henri 313 Ezekiel 16, 257 al-Farabi, Abu Nasr 20 Franco, Odilon de Mello 449 Frankl, Victor 344, 347 Fras, Alonso de 214
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
648
INDEX OF NAMES
Freud, Sigmund xii, 1, 4, 29–30, 98–99, 128, 214, 343, 468–469 Galen 123 Galton, Sir Francis 561–562 Gandhi, Mohandas 65 al-Ghazali, Abu Hamid 21 Girard, Rene 314 G€odel 518 Gould, Stephen J. 111 Gray, Jeffrey 519 Grotstein, James 454 Hamer, Dean 7, 550–551 Hegel, Georg 26 Heidegger, Martin 69, 218–219 Hippocrates 123, 212–213 Hitchcock, Alfred 543, 547 Hobbes, Thomas 23 Hopkins, Fredric Gowland 74 Hume, Cardinal Basil 548 Hume, David 25 al-Husayn ibn Sina, Abu Ali see Avicenna Hyman, S. E. 83 Ibn Bajja 413 Ibn Khaldoun 34, 127–128, 413 Ibn Khatib 413 Ibn Rushd see Averrho€es Ibn Zuhr 413 Ignatius Loyola (Saint) 22–23 Imhotep 122–123 Irenaeus, Bishop 18 Isaiah 16 Ishin, Yoshimoto 185 James, William 344, 346, 392, 536 Jaspers, Karl xi, 216, 256 Jentz, Terri 28–29 Jesus 546 Joan of Arc 553–554 John (Saint) 213 Jonathan (Bibilical figure) 93 Jung, Carl Gustav 29, 30–31, 75, 215, 394 Kant, Immanuel 25, 68, 212, 343, 515 Kierkegaard, Søren 27, 69 al-Kind€ı, Ab€u Y€usuf 19 Klein, Ger 556–557
Koenig, Harold 587, 618, 619, 637 Krishna 169 Kuhn, Thomas 68, 217 Lactantius 17 Legion (biblical figure) 260 Leibniz, Gottfried von 24 Lewis, Aubrey 83 Lewis, C. S. 287 Lindh, Anna 556 Linnaeus see von Linne, Carl Lucifer 16 Luther, Martin 65, 272, 542 McVeigh, Timothy 543 Maha Sattipathana Sutta 197–198 Maimonides 22, 95–96 Manji, Irshad 34 Masinde, Elijah 154–155 Meer, Jitse van de 550 Meissner, (work of) 287 Mencius 17 Mijailovic, Mijailo 556 Minakata, Kumagusu 556 Mitchell, Martha 217 Mohamed 124, 138, 139, 420, 553 Mohamed V, King of Morocco 414 Moore, Bishop John 227 Mora, Farrater 218 Morita, Shoma 183–184, 186 Moses 120, 470 Muhammad see Mohamed Muse, Stephen 492 Nash, John 220 Nebuchadnezzar 106, 259 Neiman, Susan 28 Newton, Isaac 516 Nicholson, W. P. 307 Nietzsche, Friedrich 27 Omer, Mullah Otto XI 596
312
Paisley, Ian 307–308 Pascal, Blaise 66–67 Paul, (Saint), The Apostle Pelagius 18–19 Penrose, Roger 519 Peterson, Scott 31 Petrie, Caroline xii
552
INDEX OF NAMES Pfister, Oscar 286, 484 Pius XII 543 Plasterk, Ronald 532–533 Plato 17, 222 Plotinus 18 Popper, Karl 219 Pushkin, Aleksandr 30 Pythagoras 482 Rao, Venkoba 176 Rhazes 20, 125–126 Rousseau, Jean-Jacques Rumi 79–80
649
Stenmark, M. 8–9 Stevenson, Robert Louis 30 Stewart, Lyman and Milton 310 Strunk, Orlo 392 Summerfield, Derek 435 Swaab, Dick F. 533 Szasz, Thomas 45 Thomas Aquinas, (Saint) 22, 414 Tsvi, Shabbetai 556 Twerski, Abraham J. 90, 96, 97–98
25
Sagan, Carl 520 Salanter, Rabbi Yisrael Lipkin Salanter 97 Salom, Lou Andreas 29 Samuel (Biblical figure) 92 Sarro´, R. 211–212 Sartre, Jean-Paul 69 Saul, King of Israel 91–94, 106, 258–259 and David 93 and the sorceress 94 Saul of Tarsus 18 Savage, George 265 Schleiermacher, Friedrich 343 Schmidt, Wilhelm 76 Schneider, Kurt xii Schopenhauer, Arthur 26 Scopes, John 307 Shinran 182 Siddharta, Gautama see Buddha Skinner, B.F. 345 Solomon 95 Spencer, Herbert 26 Spinoza, Baruch 23–24, 70, 547 Stanghellini, Giovanni 55–56, 503–504
Valentine (Saint) 213 van Gogh, Vincent 554–555 van Praag, Herman 541–542 Varela, Franscisco 199 Vergote, A. 593 Verspeek, Paul 549 Vetter, George 345 Vives, Juan Luis 23, 483–484 Voltaire 24–25 von Linne, Carl 480 al-Warraq, Isa 20 Watson, John 344 al-Wazzan, Hassan 413 Weyer, Johann 484 Wheeler, John Archibald 458 Wilber, Ken 5 Wilgefortis 224–225 Winnicott, D. W 291–292 Wittgenstein, Ludwig 28 Yajnavalkya 15 Yinger, J. Milton 390 Zi Si 17 Zubiri, Xavier
71
Index of Subjects References to tables are given in bold type. Cited texts appear in italic. A Simple Story 100–101 Abrahamic religions 32, 299 parallels 308 see also Christianity; Islam; Judaism; prophetic religions Accreditation Council for Graduate Medical Education (AGCME) 571–572, 589 Achte, Indonesia 134 addictive disorders 112 adjustment disorder 437 affective disorders see mood disorders African religion 261 colonial era 145–147 common themes 148–150 contemporary politics and 154–156 grief and 152–153 influence of Islam 145 marriage and 150–151 mental illness in 144 post-colonial era 147–148 pre-colonial 143–145 self-esteem 156–157 sexual practices and 151–152 see also Morocco African-American churches 115 afterlife evil and 14 evolutionary advantages for belief 548 Agag 92 Age of Anxiety 68 agnosticism 240–241, 299, 450 see also atheism Ahriman 16 Ahura-Mazda 16 Akamba people 154
alcohol abuse 204–205, 228–229 Islam and 138, 417 Alcoholics’ Anonymous 97–98, 112 Algeria 146, 156 alien abduction experiences 427 Alzheimer’s disease 55 amazement see astonishment American College for Graduate Medical Education 589 American Psychiatric Association 424, 431, 616 Practice Guidelines for Psychiatric Evaluation of Adults 430 program requirements 589 Amish 311 amygdala 560 analytic logic 65–66 anatta 196–197 Ancient Greece 228 anger 108 see also mood disorders Anglican Church 305 anguish 71 anicca 196 animals, moral status 15 anomalous mental experiences 426–427 anorexia nervosa 225 anti-Semitism 2, 543 antidepressant drugs 529 anxiety about death 70–71, 548 Christians 109 creativity and 69 religion and 133
Religion and Psychiatry: Beyond Boundaries Edited by Peter J. Verhagen, Herman M. van Praag, Juan J. Lo´pez-Ibor Jr., John L. Cox and Driss Moussaoui Copyright Ó 2010 John Wiley & Sons, Ltd
652
INDEX OF SUBJECTS
Apartheid 147 apologism 2 apperception 74 Arab countries, suicide rates 137 Arabic philosophy 19–22 see also Islam, philosophy archetypes (Jungian) 30 Aristotelianism 22 art 78 asceticism 20 ashramas 171–172 Asian Federation of Psychiatric Associations 616 assessment 602–603 lack of background 574 Assessment of Muslim Marital Satisfaction 331 astonishment 238–239, 481, 491–492 transcendent experience and 482 see also awe Asura personality type 165 At the Handles of the Lock 99–100 atheism 241–242, 248, 299, 524 arguments against 533–534 arguments for 242–243 brain activity and 532–533 correlated demographic factors 542 evangelical 243 prevalence 618 see also agnosticism; materialism Atman 77 atomoxetine 221–222 Attachment to God Inventory 326 attention deficit hyperactivity disorder 148–149 meditation and 200 attitude 577, 592, 594–595, 600 authority figures 607 awareness (values-based practice) 51–52 awe 515–516 see also astonishment axons 527 Ayurveda 163–164, 167 personality types 164–166 Aztec religion 213 Babylonian religion 76 Baha’ism 3, 353, 618 Bantu peoples 143–144, 153 Beck Depression inventory 350 belief see faith
Belief in Divine Intervention Scale 351 beta-blockers 222 Bible 543 see also New Testament; Old Testament biopsychosocial(spiritual) approach 73–75, 485, 574, 591, 608 Christianity and 106 bipolar affective disorder 255 diagnosis 264–265 in Old Testament 259 Ramadan fasting and 416 black holes 458 Borderline Personality Disorder 367, 375, 380 boundaries (therapeutic) 580–581 Brahma personality type 164–165 Brahman 77, 607 brain 531–532 atheism and 532–533 evil and 31–32 faith and 523–524 imaging 531–532 near-death experiences and 558, 559–561 spiritual experiences and 5, 242–243, 531, 550 causal relationship 535–537 see also neurons; neuroscience British Psychological Society 56 Buddha 16, 182, 195–197, 491 Buddhism 182 concept of evil 15, 16 core beliefs 16, 195–197 geographical extent 194 history 193–195 Japanese 182 number of world adherents xi, 3, 618 psychotherapy and 183–185, 201–204 spiritual illness 201 suicide in 205 see also Zen Buddhism buffering 598–599 Bushido 181 Cairo Declaration on Human Rights in Islam 128–130 Calvinism 529 Canada 389, 547 Canoon of Medicine 126 caregivers, presuppositions about mourning 504–505 case formulation 293–294, 574, 577, 604
INDEX OF SUBJECTS Catholic Church 543 see also Spanish Inquisition Catholicism 106, 276–277, 545 eating disorders and 225–226 cells 74 chaos theory 517–519 chaplains 486–487 children 546, 550 Chinese folk religion, number of people practising xi Christian Medical and Dental Association 112 Christianity Africa 149 colonialism and 146–147 Ethiopia 145 traditional religious practices and 149–150 alcohol and 229 attitudes toward psychiatry 278 concept of evil 17, 18–19, 22–23 core beliefs 105–106 delivery of care to believers 114–115 depression and 267 diversity of belief 105–106 eating disorders and 224–226 integration with psychology 112 internal attitudes and sin 108 measurement difference with Islam 322 mental health in 106, 483–484 obsessive compulsive disorder and 276–277 prayer 110–111 psychodynamics 114 science and 111–112 tensions with psychiatry 111–113 violence 543 world population xi, 3, 618 see also Anglican Communion; Catholicism; Protestantism circumcision 419–420 female 544 classification, 172, 418 clinical assessment conceptual difficulties 42–44 importance of enquiring into religious denomination 384–385 psychoanalytic 293 values-based approach 53–54 see also case formulation; diagnosis; spiritual assessment clinical significance 44
653
cognitive behavioural therapy Christians 114 compared with Japanese therapies 187–188 coincidence 518 collective unconscious 30 colonialism 145–147, 156–157 commandments 605–606 commitment (to religion) 324–325 communication skills 52 compartmentalization 397 compulsions 273 concrete thinking 257 conditioning 126 Confucianism concept of evil 16–17 number of world adherents 3, 618 consciousness evil and 15 see also dualism; reductionism contact barrier 457 Continens 125 contraception 546 conversion 427, 549 coping strategies 132, 398, 402–403 assessment and 431 corticoids 69 cosmetic pharmacotherapy 221–222 cosmic constant 518 countertransference 295–297 existential crises of schizophrenics 507 negative prejudicial 587–588 representation of God and 455–457 clinical examples 461–464, 464–468 training issues 581–582 creativity, anxiety and 69 criminality Africa 156 orthodox Protestantism and 373–374 crises of faith see religious crisis cults 32, 311–312, 436 cultural communication 82–83, 626–627 Cultural Formulation 430–432 proposed changes 432 cultural psychiatry 76 cultural sensitivity 353–354, 430–432 curricula 5, 583 NIMH Model Curriculum 599–602 Daily Spiritual Experience Scale Damascene conversion 552 Dark Night of the Soul 107
326
654
INDEX OF SUBJECTS
Darwinism, 520 de Passionibus 23 death 75 African religion and 152–153 ancient Egyptian conception 121 anxiety 70–71, 548 attitudes toward physicians and 429 clinical 559 Hinduism and 171 see also loss; near-death experience; suicide Declaration of Independence 17 delusion xii, 211–212, 219–220, 229–230, 556–557 African religion and 155–156 anxiety and 71 certainty 256–257 content 261–262 contrasted with religious belief 257, 262–263 definition 216–217 impossibility of beliefs 217 Morocco 419 spiritual experience and 41–42, 215 structure 217–218 suggested DSM-V criteria 439 truth and 220 see also psychotic disorders; revelation; schizophrenia; truth demarcation theory 7 dementia 172 demons xiv, 136, 212–213 African religion 144 see also jinn; possession denominational segregation 374 Department of Health (UK) 49 dependency (on God) 237 depressive disorders xii, 226, 266–268 African religion and 153–154 Buddhist treatment 203–204 Christianity and 109, 267 Dark Night of the Soul 107–108 Protestantism 383 culture and 418 in fiction 101, 102 Hindu diagnostic equivalents 172 Judaic approaches 98 Morocco 418 narrow religious frameworks and 397 overdiagnosis 268 religion and 132–133, 547
descriptive psychopathology 256 desecration 399 determinism 516–517 Deuteronomy 90 dharma 160, 161–162 diagnosis African religion and 154, 154–156 bipolar disorder 264–265 by pastoral care providers 488–490 Christians 113–114 classification systems 254 see also DSM depression 268 distinguishing symptoms from religious experience 255–257, 262–263, 265–266 Hindu 172 idiographic 592 personality disorders 375, 433–435 post-traumatic stress disorder 435 psychotic disorders 437–439 religiosity and 246–247 substance misuse 436–437 value judgements and 43–44 values-based approach 53–54 see also clinical assessment; spiritual assessment Diagnostic and Statistical Manual of Mental Disorders 43–44 for individial reivisions, see also DSM-III; DSM-IV; DSM-V Die Welt als Wille und Vorstellung 26 dietary laws 547 dignity 608–609 disinhibition 374 distributed research 55 domoic acid 547 dopamine 528 Dr. Jekyll and Mr. Hyde 30 drapetomania 348 dream analysis Freudian 29–30 Jungian 30 dreams, near-death experience and 560 Drenthe Foundation for Mental Health Care 498 drugs abuse, 137–138 antidepressant 529 cosmetic use 221–222 obsessive compulsive disorder 277–278 traditional Indian 167
INDEX OF SUBJECTS DSM-III classification system 120, 575, 595 DSM-IV classification system 219–220, 254, 367, 548, 591 assessment using 429–430 Cultural Formulation 430–432 delusion 216 obsessive compulsive disorder 272–273 Religious or Spiritual problem code 424–425, 487, 548–549, 591, 594 changes 426–428 research 428–429 use by psychologists 425–426 DSM-V classification system 424 recommendations for 432–433, 440–441 personality disorders 377, 385, 434 post-traumatic stress disorder 435 psychotic disorders 439 dualism 7, 64–65, 524 dukkha 195, 196 Dutch short form of MMPI 377 negativism subscale 377 Eastern philosophy 81 eating disorders 224–226 educational aids 608 ego 70, 188 ego psychology 291 Egypt ancient religion 121 the heart 121–122 suicide 122 treatment of mental illness 122–123 Christianity 135 suicide rate 137 Eightfold Path 16, 196 El Zar cult 135–136 embalming 121 embodiment 8 emergent properties 519 Emmanuel movement 484 emotion rationalism and 66–67 religious receptivity and 238 empathy 31, 256 empirical studies 350–351 meta-analysis 351–353 see also measurement Encyclopaedia of Religion xi endorphins 561 epilepsy medieval conceptions 213
655
in medieval Jewish thought 96 in New Testament 259–260, 552 religious delusion and 556 temporal lobe 531–532, 551–552 Dostoevsky 555–556 Joan of Arc 553–554 Mohamed 553 St. Paul 552 Vincent Van Gogh 554–555 epistemological pluralism 6 essentialism 67–68 ethics, medical 67 Ethiopia 145 evangelism atheistic 243 memory recall and 332–333 event horizon 457–458, 468–471 evil Arabic conceptions 19–22 brain state and 31–32 conceptions in 1st. Millennium CE 18–22 development of concept 14–15 human consciousness and 15 modern conceptions 27–34 natural selection and 26–27 origin of concept 13–14 philosophical conceptions 14, 16–17, 23–27 religious conceptions 14 antiquity 15–16 Judaic 97 Medieval Christian 22–23 Renaissance and Enlightenment 23–27 religious intolerance and 33–34 existential crises 212, 498–499 listening and 503–508 pastoral care and 508–509, 509 recognition 506–507 see also loss of faith; religious crises existentialism 69–70 Exodus 469–470 extrastriatal body area 561 extremism 397–398, 544–545 Morocco 415 see also fundamentalism extrinsic faith 293, 323, 395 extrinsic religiosity 246, 347 faith 605 adaptive advantages 529 anxiety and 133 benefits 132–134, 563, 620–621
656
INDEX OF SUBJECTS
faith (Continued ) brain functioning and 523–524 coagulation 243–244, 248 crises of 399–402 degree of see religiosity dependency on 237 depression and 226 evolutionary explanation 32 intrinsic and extrinsic 293, 323, 395 loss of 398, 399–400, 427 mania and 265–266 measurement see measurement obsessive compulsive disorder and 275–277 see also ritual prevalence of mental illness and 120 psychotic disorders and, research proposals 438–439 therapeutic effects 593 trust and 604–605 see also religiosity Faith Development Scale 325 Faith Maturity Scale 325 fasting 416–418 FICA 576, 603 fidelity 606 fluoxetine, cosmetic use 221–222 forensic psychiatry 28 forgiveness 111 Four Buddhist States of Consciousness 197 Four Noble Truths of Buddhism 195–196 free association 29 free will 22, 26, 98, 169 Christianity and 111–112 on obsessive compulsive disorder 271–272 views on religion 285–286, 344–345, 447, 575 Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale 328–329 fundamentalism 32–33, 397 defining characteristics 310–311 group psychology 311–313 intra-textuality 310 Northern Ireland 307–308 political conditions and 308 radicalization 315–316 temporal regression and 313–314, 314–315 violence 314 see also extremism Future of an Illusion 344
Gambia 261 Gandharva personality type 165 General Health Questionnaire 351 General Social Survey 329–330 genetics determinism 7 religiosity and 527–528, 550 genocides 14 George Washington University Institute of Spirituality and Health 573, 599 Germany, medieval 213 Geschwind syndrome 552, 554, 555, 556 Gikuyu people 143–144, 150 globalization 299 effects on spirituality and religion 9–10 fundamentalism and 314–315 Gnosticism 30 God arguments for existence 5 conceptions of 243–244, 362–366, 451 anthropological 449–450 ‘black hole’ analogy 457–459 as image of self 363 mystic 79–80 personal 362 personality disorders and 363–364 psychotherapy and 448–451, 461–464 countertransference and 451–455, 455–457, 461–468 therapeutic environment and 453–454 religious culture and 364–365 representation 287 evil and 17 human relation to 447–448 attachment 326, 395–396 dependence 237 schizophrenia and 499 identification with 462, 557 psychological attitudes toward 364 see also revelation ‘God’ gene 7, 529, 551 adaptive advantages 529 God Image see God, conceptions of G€ odel’s incompleteness theorem 518–519 gods primitive 76 see also God Good Friday Agreement 307 gossiping ape theory 32 grief 152–153 see also death; loss
INDEX OF SUBJECTS guilt 108, 267, 284–285, 397, 401 Islamic attitudes 139 hallucinations 439 St. Paul 552 see also epilepsy hallucinogens 530, 550 Hangat ha-Beri’ut 96 health 390 loss of 501–502 heart 121–122 hedonism 17 Helsinki Declaration 68 heredity 526–528, 550 heresy 305, 306 hermeneutics 55 Hinduism 159–161, 607 caste system 174 compared to other religions 161–162 crises of faith 401 death and 171 mental health in 174–176 Ayurvedas 163–164 Bhagavad Gita 163 Upanishads 163 Vedas 162–163 mental illness in 166–167 classification 172 number of world adherants xi, 3, 618 as philosophy 160 stages of life 171–172 suicide and 170 therapeutic practices 167 psychotherapy 168–170 yoga and meditation 168 history 65, 75 HIV/AIDS 151, 543 holism 81–83 Holocaust 14, 542 homicide 28 homosexuality 110, 151–152, 348 hope 578 hospitals 139, 488–490 human rights, Cairo Declaration 128–130 human sacrifice 543 humanism 63–64 medicine and 67 hygiene 2 hyperreligiosity 243–246 hypomania see mania hysteria, Islam and 135–136
657
ICD-10 classification system 254 identity 606–607 relationship between personal and group 312 idiographic diagnosis 592 idolatry 394, 406 immature religiosity 346 implicit measurement 332 impulsivity, religious orthodoxy and 367 India xiv, 159–160 ancient religion 77 epilepsy and 213 see also Hinduism indoctrination 126, 546 Indonesian Tsunami (2004) 134 Indra personality type 165 infidel 33 initiation rites 605 insurance 428–429 Intelligent Design 520, 550 International Classification of Diseases 42 International Guidelines for Diagnostic Assessment 591–592 interreligious encounter groups 404–405 interventions, spiritual 404–405, 439 interviews 576–577, 602–603 intolerance 33–34 intrinsic faith 293, 323, 347, 395 intrinsic religiosity 246, 527 Iran 77 Ireland 307–308 irritability (cellular) 74 irritability (mood) 417 Islam in Africa 145 alcohol and 228 Cairo Declaration of Human Rights 128–130 central texts 124 circumcision 419–420 concept of evil 20–22 concept of mental illness 131–132, 133–134 hysteria 135–136 obsessive compulsive disorder 134–135 Quranic 124–125 scholarly 125–128 substance abuse 137–140 suicide 136–137 crises of faith 401 fundamentalism 33, 312, 315 history 123–124
658
INDEX OF SUBJECTS
Islam (Continued ) measurement of belief 322, 330–331 number of world adherants xi, 3, 618 philosophy 78–80 pillars of 133 possession in 261 poverty in 130–131 view of personality development 128 women 130, 544 see also Arabic philosophy; Quran; Sufism Islamic Reflection Scale 331 Israel 89, 137, 389 iterative equations 516–517 Jainism 618 number of world adherents 3 Japan Buddhism 182 psychiatry 183 religious beliefs and psychiatry 190, 625 Shintoism 182–183 Japan Society of Psychiatry and Neurology 183 Japanese Society of Morita Therapy 189 Jehovah’s Witnesses 543–544 Jesus 546 Jews 89, 99, 545 jihadism 33 jinn 124, 136, 261 Joint Commission for Accreditation of Health Care Organizations (JCAHO) 114 Judaism 89 alcohol and 229 crises of faith 401 eating disorders and 226 evil in 16, 22 intrinsic vs. extrinsic religious orientation 323 medieval conceptions of mental illness 95–96 number of world adherents 3, 618 obsessive compulsive disorder and 278 Orthodox 278 psychoanalysis and 29, 90, 98–99 psychotherapy and 465–468 representations of God 468–471 see also Jews; Mussar; Old Testament; Talmud justice 14 Jyllands-Posten 544
Kalaoon Hospital 139 kamma see karma Kantakasodhana 170 karma 15, 161 karuna 197 Keele Medical School 588 Kenya 147, 149–150 Koran see Qur’an Krishna 169 Kubera personality type 165 language 74 see also linguistic analysis leadership 607 Lebanon, prevalence of religious practice 389 life mystic conception 80 origin 74 linguistic analysis 40–41 case study 41–42 limitations 57 see also values-based practice Lisbon earthquake 24–25 listening 502–503 logic 65–66 loss caregivers’ presuppositions 504–505 categories 501–503 mourning processes 500 as reorientation of worldview 505 schizophrenia and 498 social context 503–504 see also death; existential crises loss of faith 398, 399–400, 427 see also existential crises; religious crises love 18 Lucifer 16 Luo people 151, 153 lyrical spirituality 525–526 madness, Old Testament concept 90–91 Mahayana Buddhism 195 majnoon 124 major depressive disorder see depressive disorders Mali 145 mania 255, 264–266, 265–266 Ger Klein 556–557 see also bipolar affective disorder Maqaka fi’l Nafs 21 marriage, African religion and 150–151
INDEX OF SUBJECTS materialism (consumer) 130–131 materialism (metaphysical standpoint) 7, 241, 536 Matsya personality type 165 maturity of religion 396–397 Measure of Religious Coping 328 measurement 319–320 assessment and screening 331–332 cross-cultural differences and 322–323 memory recall 332–333 reliability 321, 382 sampling considerations 321–322 systems 323–324 choice 333–334 of commitment 324–325 of coping 327–328 of developmental maturity 325 functional 326–328 general 324 indigenous to particular religions 330–331 of motivation 326–327 multidimensional 329–330 not utilising self-reporting 332–333 of participation 327 of private practices 327 of quality of life 328–329 of support 327 technical considerations 321 theoretical considerations 320–321 medical ethics 67 medication see drugs meditation 168, 176 brain state and 199–200 Buddhist 197–199, 200, 205 brain activity 531 melancholia yoga as therapy 173 see also depressive disorders memes 527 memory recall 332–333 menstruation 135 Mental Health: New Understanding, New Hope xiii mental health 415–416, 593 Christianity and 106 definitions 347–350, 593 Hinduism and, 175 Islam and, 123–128 see also mental illness Mental Health Foundation 49
659
mental illness 2, 6, 222–223, 348 African religion 144 ancient Egyptian religion 122–123 Christian concepts 106–108 as God’s punishment 605–606 hedonic definition 350 Hindu concepts 166–167 Islamic concepts 124–128, 131–140 risk factors see risk factors as subjective experience 348–349 see also individual disorders and disorder types; mental health mental wellness 349 meta-analysis 351–353 metta 197 mimesis 315 Mini International Neuropsychiatric Interview 419 Minnesota Multiphasic Personality Inventory (MMPI) 377 Mohamed 124, 138, 139, 420, 523 monoamines 527 monotheistic religion xiv, 76 see also Christianity; Islam; Judaism mood disorders 226, 255 see also bipolar affective disorder; depressive disorders moral treatment xiv morality 27 Morita psychotherapy 183–185, 186, 189 compared with Western psychotherapies 187–188, 187 Morocco 413–414 academic tradition 413 circumcision 420 demographics 413 medical tradition 415 traditional healing 415–416 religious establishment 414 social overview 414–415 Mohamed 124, 138, 139, 420, 553 Moses and Monotheism 29, 98 Mother Goddess 76 motivational theory 394–395 mudita 197 multidimensional studies 329–330, 353 multidisciplinary approaches 54 Muhammad see Mohamed musicogenic epilepsy 553, 554 Muslim-Christian Religious Orientation Scale 323, 327
660
INDEX OF SUBJECTS
Mussar 96–98 mystic religions xiv, 299 see also Hinduism mystical spirituality 526 mysticism 79–80 mythologems 211–212 myths 75, 454, 457 Naikan therapy 185–186 compared with Western psychotherapies 187–188, 187 current state 189–190 Nairobi 157 narcolepsy 560 National Institute for Healthcare Research (US) 573 National Institute for Mental Health in England 50, 53–54, 608 values framework 51 natural disasters 13, 14 nature 78 near-death experiences 426, 427, 428, 556 content 558 neurobiological explanations 559–561 neo-Platonism 18 Netherlands mental healthcare approach 499–500 secularism 508 Netherlands Institute for Brain Research 557 neuro-theology see neuroscience neurons 519, 527–528 neuroscience 8, 68, 513 Buddhism and 199–200 evil and 31–32 key terms 524–525 reductionistic 534–537 reductive materialism 7 see also brain neurosis Morita therapy 184–185 religious functioning and 489 neurotransmitters 527–528 New Testament 18, 220, 259–260 9/11 attack 543 Nirvana 196, 526 no-ego 188 normal behaviour 239–240 Northern Ireland 307–308 nothingness 459–460 nuns 531
object relations theory 291–292 obsessive compulsive disorder 227–228, 272–273 Christians 135 cognitive strategies 275–277 epidemiology 273–275 Islamic conception 134–135 Ramadan and 417–418 ritual and 107–108 symptoms 272, 274 treatment 277–279 see also ritual obsessive neurosis 214–215 occupational dysfunction 43–44 Old Testament 90, 469–470 on evil 16 madness in 90–94, 257–258 see also Saul optimism 529, 547–548 Original Sin 19, 25 orthodox Protestantism, image of God 364–365 out-of-body experiences 530 pantheism 80, 418 see also Spinoza paranormal beliefs 426 paroxetine 221 pastoral care see spiritual care pastoral diagnosis 488–490 see also spiritual assessment pastors, authority 607 Pasva personality type 165 patient spiritual histories 246, 602–603, 607–608, 619, 625–627 Persian religion 77 person, see also whole person personality, 164–166 personality disorders 222, 377, 385 diagnosis 375 proposed changes for DSM-V 433–434 effect of religious upbringing vs. acquired religiosity 375–382 orthodox Protestants study 384–385 background variables 379 DSM-IV cluster B traits 379 procedure 378 statistical analysis 378–379 personal image of God and 363–364 religious orthodoxy and 366–368
INDEX OF SUBJECTS current faith 368 upbringing 367–368 religious upbringing and 382–384 upbringing and 382–383 phenomenology 55, 256 philosophy astonishment in 481 evil and 14, 16–17, 23–27 Arabic 19–22 existentialist 69–70 psychiatry and 211–212 phobias 202–203 see also anxiety physical health 400–401, 403 physicians, awareness of religious issues 429 Pirkei Moshe 96 Pisaca personality type 165 pluralism 6 polygamy 150–151 possession 261 Islamic concept 135–136, 261 see also demons post traumatic stress disorder 134, 227, 399 proposed changes for DSM-V criteria 435 postmodernism 298–299 poverty 130–131 Africa 156–157 powerlessness, caregivers’ feeling 500 Practice Guidelines for the Psychiatric Evaluation of Adults 626 prayer 110, 581 beneficial effects 562–563 effects of being prayed for 562 frequency measurement 320–321 Islam 133–134 Islamic 134–135 psychiatric symptoms and 562 Present State Examination 42 Preta personality type 165 Prince Edward Island 546–547 prohibitions 605–606 prophetic religion xiv Protestant Reformation 65 Protestantism denominational segregation 374 fundamentalist 310–311 in Ireland 307–308 orthodox, image of God 364–365 psychiatry antipathy toward religion 1–2, 575, 587–588, 592–594, 594–596
661
attitudes 600 Christianity and 111–113 cultural 76 history xiv–xv, 21, 80–81, 484 holistic approach 81–83 pastoral care and 480–481, 487 philosophy and 211–212 scientific approach 515–517 therapists’ spiritual attitudes 594, 595–596 see also countertransference see also psychoanalysis; psychotherapy; science psychiatry for the person 591 psychic experiences 41, 427 psycho-history 65 psychoanalysis xiv, 484 attitude to religion 286–288, 288–290 relationship perspective 290–292 Bhagavad Gita and 169–170 case formulation 293–294 clinical assessment 293 criteria for health 593 Davey, J. Ernst 308–310 dream analysis 29 Japan 183, 186 Judaism and 29, 90, 98–99 conception of God 468–471 postmodernism and 298–299 practitioners’ beliefs and practices 289–290 religion, spirituality and 284–285 transference 295–297 image of God and 456–457 treatment issues 294–295 as worldview 286–287, 297–298 see also countertransference; dream analysis; free association; Freud, Sigmund; psychotherapy; transference Psychoanalysis and Religious Experience 288–289 psychodynamics 114 psychopathology 253, 418–420, 548–549 psychopathy 31 psychosis 257, 261 psychosis simulator 497 psychotherapy Buddhism and 201–204 choice of approach 579–580 compared with Japanese approaches 186–188 Hindu 168–170
662
INDEX OF SUBJECTS
psychotherapy (Continued ) image of God and 448–451 ontological imbalance 450–451 importance of religion in 574–575 Japanese 183–187 Muslims 405 respect for boundaries 580–581 skills training 576–577 training see training see also Morita psychotherapy; Naikan therapy; psychoanalysis psychotic disorders 245–246, 419 Christians 109 in fiction 100 future research proposals 437–438 Islam and 136 proposed changes to DSM criteria 437–439 public understanding 497 religious delusions 556–557 spiritual experience and 42 spiritual interventions 439 see also schizophrenia quality of life 592 measurement 328–329 studies 353 WHOQOL-SRPB 353, 592 Quest Scale 326 Questionnaire God Image 362 Quran 78, 130, 136, 137 concept of mental illness 124 racism 156 colonialism and 146–147 radicalization 316 Rakshasa personality type 165 Ramadan 416–418 rationalism 66–67 reasoning (values-based practice) 52 reductionism 7, 64–65, 81 regression, fundamentalism and 313–314, 314–315 reliability (of a measurement) 321 relics 546 religion belief in see faith concepts of evil 14, 15–16, 20–27, 97 as corrupting influence 27 see also evil criteria for evaluation of efficacy 391–394
definitions 343–344, 390–391, 525, 596–598 as destructive influence 344–346 as helpful influence 346–347 WPA consensus statement 623–624 evolutionary benefits 545–548 function 598 as harmful influence 542–545 Japanese practice 190 major xi major strands xiv number of adherents 618 origins xi prevalence of belief 389, 541–542, 618–620 as process 392–394 psychoanalysis and 285 positive and negative influence 293–294 relationship perspective 290–292 psychotherapy and 574–575 as repressive influence 294 science and xiii, 5–6, 520–521 Barbour’s typology of interactions 6–9 integration 6, 8 social cohesion and 545–546 social conditions and 309 social support networks 132–133 sources of demographic data 618–619 spirituality and 624–625 DSM-IV 424–425 tension with psychiatry 2 trust in 605 see also culture; religiosity; religious belief; spirituality Religion Monitor 619 religiosity 236–237, 247–249, 523, 525 abnormal 240–243 basic dynamics 604–607 brain state and 242–243, 534–537 causal relation 536–537 diagnosis and 246–247 extrinsic and intrinsic 246, 347 genetic predisposition 526–527, 550 maturity 346 normal 239–240 obsessive compulsive disorder and 274 pathological 244–246 serotonin and 529–531 Religious Commitment Inventory 325 religious conflict (between communities) 32, 146, 548 religious conflict (personal) see religious crises
INDEX OF SUBJECTS religious crises 65, 107, 108–109, 399–402, 427, 431 personal image of God and 365–366 see also existential crises; loss of faith religious delusions 419, 551, 556 religious experience see spiritual experience religious fancy 244–245 religious maturity 325, 346, 418 Religious Maturity Scale 325 religious motivation 326–327, 394–395 Religious Orientation Scale 322–323, 326 religious obsessions 417 religious receptivity see religiosity religious risk factors see risk factors religious struggles see religious crises Religious Support Scale 327 religious tolerance 239 religious wars 542–545 Religious World View Scale 351 REM sleep 560 Res cognitans 64 Res extensa 64 research methods 620–621 distributed 55–56 empirical studies 350–351 general issues 341–342 into religion/psychiatry interface 592–593 Judaeo-Christian bias 620–621 measurement see measurement meta-analysis 351–353 prayer 563 values-based practice 53 residency training programmes 572–573 respect 580–581 revelation 245 revelations 245 delusion and 215 linguistic analysis 41 Revised Religious Orientation Scale 326 Rishi personality type 165 risk factors 393–394, 575, 593 clinical implications 403–405 idolatry 394 pathological attachment to God 395–396 prevalence 403–404 religious extremism 397–398 research needed 406 see also religious crises ritual 243, 398 Freud’s views 286 in Hinduism 341
663
obsessive compulsive disorder and 107–108, 134–135 rituals, African religion 149 Roman Catholicism see Catholicism rowalfia serpentina 167 Royal College of Psychiatrists 590–591 Royal Free Interview for Spiritual and Religious Beliefs 608 Royal Society for Science 542 sacred violations 398–399 sadism 31 Sainsbury Centre for Mental Health 49 saints, female 225 Sakuna personality type 165 Samadhi meditation 198 Santa Clara Strength of Religious Faith Questionnaire 325 Saracen Empire 124 Sarpa personality type 165 satvic personality types 164–165 scapegoating 314, 316 schizophrenia 229–230, 254–255 diagnosis 263 distinguished from religious belief 262–263, 439 existential suffering 497–498 listening and 503–508 recognition 506–507 Hindu diagnostic equivalent 172 intuitive diagnosis and conceptual framework 216–217 loss and 498 categories 501–503 Morocco 419 religious literalism 262–263 subjective feeling 499 science explanatory limits 287–288 as natural philosophy 480, 483 religion and 5–6, 9, 520–521 Barbour’s typology 6–9 Christianity 111–113 conflict 7 dialogue 8 independence 7, 533–534 integration 6, 8 specialisation 483–484 see also chaos theory; neuroscience; psychiatry scrupulosity 227–228, 276
664
INDEX OF SUBJECTS
secularization 239, 619–620 self psychology 292 self, sense of 490–492 self-esteem, African religion 156–157 self-image effect of diagnosis of mental illness on 501–502 God and 363 self-realization 491 self-report questionnaires 382 self-sacrifice 107, 109 selfishness 26 sensation 74 serial killers 31 serotonin 528 receptor density 529–531 Seventeen Article Constitution 182 severe and persistent mental disorders with psychotic symptoms (SPMDP) 437–440 sexual abuse 398, 543 spiritual intervention 405 sexual activity African religion and 151–152 Egypt 135 God image, countertransference and 464–465 Ramadan and 417 sexual offences 28 shared psychotic disorder 436 Shintoism 182–183 number of world adherents 3, 618 Shohood 80 Shona people 144 shoteh 95 Siddharta, Gautama see Buddha Sikhism, number of world adherents 3, 618 sin 19 see also evil; Original Sin Sinai, Cleft in the Rock 470–471 skills (patient’s) loss of 502 skills (practitioner’s) training 576–577, 600 values-based practice 47–49 Sky God 76 sleep 415–416, 560 smoking 137–138, 138 Social Aspects of Psychoanalysis 309 social functioning 42–43, 393 religion lacking breadth and depth 396–397
religious rigidity 396 schizophrenia 504 Social Gospel movement 484 social workers 485 sorrow 19–20 soul 107, 122, 524 Plotinus’ conception 18 South Africa 147, 312 Spanish Inquisition 214 speaking in tongues 107, 153 spiritual assessment culture and 430–432 DSM-IV and 429–430 risk factors and 404 Spiritual Assessment Inventory 326 spiritual care 607 existential questions and 508–509 psychiatry and 479–480, 480 common ground 480–481 as origin of psychiatry 484 requirements 492–493 role in therapeutic environment 485–487 sense of self and 490–492 spiritual diagnosis 488–490 see also spiritual direction spiritual direction 56 spiritual experiences 215, 244–245, 426–427, 549, 552 brain activity during 531, 550 causal relationship 535–537, 560–561 delusion and 41–42 Dostoevsky 555 epilepsy and 531–532, 551–552 Joan of Arc 553–554 Mohamed 553 normal 264 St. Paul 552 visitations 144–145 spiritual health, assessment 488–490 spiritual history 246, 602–603, 607–608, 619, 625–627 Spiritual History Scale 325–326, 331–332 spiritual integration 393 spiritual interventions 404–405, 439 Spiritual Transcendence Scale 324 Spiritual Well-Being Scale 324 spirituality 131 ancient world 76–78 contrasted with religion 283–284, 424–425, 597–598
INDEX OF SUBJECTS definition 75–76, 597–598 WPA consensus statement 622–623 heredity and 527 Hindu 175 inter-faith 625 lyrical 525–526 measurement see measurement mystical 526 neurotheological definition 525–526 non-religious 78 normal 236–237 religion and 624–625 Spirituality Special Interest Group (SIG) 590 stigmatization 502 stress 69, 490 Islamic attitudes 138–139 substance abuse 228–229, 417 Islam and 137–140 proposed changes for DSM-V diagnostic criteria 436–437 Sudan, civil war 146 Sudarshan Krishna yoga 173 suffering 109 Sufism 78–79, 127, 415 suicide 226, 419, 502 African religion and 153–154 in ancient Egyptian culture 122 in Buddhism 205 Hinduism and 170–171 Islam and 136–137, 419 suicide bombing 137 Sumerian religion 76 sunnata 203 supernatural phenomena 214–215 survival mechanisms 69 synagogue 467 synapses 527–528 synthetic logic 66 Taliban 312 Talmud 94–95 teaching 577–579 approach choice 579–580 conceptual frameworks 582–583 countertransference monitoring 581–582 curricula 583 engaging trainees 582 respect for boundaries 580–581 small groups 608 temporal lobe 561
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near-death experiences and 561 see also epilepsy Ten Commandments 120 terrorism 307, 415, 544–545 The Doctor and his Divorcee 102 The Eradication of Sorrow 19 The Privileged Planet 520 therapist countertransference see countertransference feeling of powerlessness 500 own religious views 455–457 Theraveda Buddhism 193–195 Thersites complex 221 Thesaurus of Psychological Index Terms 425 thought action fusion 276–277 three-body problem 516 Toltecs 543 Torah 95 torture 31 training appreciation of therapeutic effect of spirituality 578–579 approach choice 582–583 attitudes 600 biopsychosocial approach and 608 course design 601–602 curricula 583 National Institute for Healthcare Research 599–602 difficulties 573–574 evaluation 602 examples 607–609 future challenges 584 group discussion 581 history of spiritual integration 572–573 inclusion of religion 571–572 knowledge 575–576, 600 materials 608–609 ‘model curriculum’ 599 program requirements American College for Graduate Medical Education 589–590 American Psychiatric Association 589, 590 Royal College of Psychiatrists 590–591 World Psychiatric Association 591–592 recognition of appropriateness of spiritual approach 578 respect for boundaries 580–581 schizophrenia care and existential questions 507
666
INDEX OF SUBJECTS
training (Continued ) skills 576–577, 600 small group teaching 608 teaching areas, potential helpful effect of spirituality 578–579 trainee engagement 582 trust 604–605 values-based practice 50–52 see also residency programmes transcendence 11, 67–68, 482 psychopathology and 67–68 see also spiritual experience transcendental idealism 68 transcultural approach 626–627 transference 295–296 image of God and 464–468 treatment Christians 114–115 obsessive compulsive disorder 277–279 tribal religion xiv Tri-guna 164 Tripitaka 200–201 trust 604–605 truth 218–219, 391–392 delusion and 216–218 mathematical 518–519 scientific and religious 533–534 12-step programmes 97, 112 Buddhist 204–205 twin research 526–527 Ulster Defence Association 307 Ulster Volunteer Force 307 unio mystica 526 United Kingdom religiosity 239, 618–620 training program requirements 590–591 United States religiosity 239, 541–542, 618–620 religious affiliation volatility 426 training program requirements 589–590 Upanishads 15, 163 on suicide 170 upbringing 382, 547 upekkha 197 Vajyarana Buddhism 194 validity (of a measurement) values 45 judgements
321
diagnosis of mental dysfunction and 43–44 objectivity and convention 46–47 respect for 50 see also values-based practice values-based practice 47–49 assessment approach 53–54 development 49–53 key elements 48–49, 51–52 policy development 50 principles 53 religious traditions paralleling 56–57 research 53 training 50–52 values framework 51, 53 see also linguistic analysis VAM2 gene 528 VAMT2 gene see God gene Vanaspatya personality type 166 Varuna personality type 165 Vedas 162–163 violence 156–157, 543–544, 548 evil and 28 fundamentalism and 314, 315–316 see also anger Vipassana meditation 198–199 virtual environment 74–75 virtue 17 visionary exaltation see revelation wars 13, 32, 154 well-being, 389–390 whole person 73–75 Whose Values 50 wisdom psychotherapy 203–204 wisdom religions xiv witchcraft 213–214 Wolf Man 29 women African religion and 150–151, 152 Islam and 130, 544 saints 225 wonder 482–483 World Council of Churches, mental health strategy xiii World Health Organization xiii, 10, 592, 621 Quality of Life Assessment 329 World Psychiatric Association xiii, 1, 591 consensus statement criteria 616–618 definitions of religion 623–624
INDEX OF SUBJECTS definitions of spirituality 622–623 genesis 615–616 list of statements 617 relation of spirituality to religion 624–625 revised proposal 630–631 significance of topic 618–620 state as of March 2009 627–628 values-based practice and 49 worldview 284 loss and 505 religion as 297–298
Yama personality type 165 yetzer tov 97 yoga 168, 176 research studies 172–174 Yoruba people 144 zaouias 415 Zen Buddhism 181, 182 psychotherapy and 183–185 Zi Si 17 Zoroaster 16 Zoroastrianism 16, 77
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