CLINICAL HANDBOOK OF SCHIZOPHRENIA

594 VIII. SPECIAL TOPICSbe related to the frequency with which religious delusions are expressed in severe mentaldisorders. Those cultures in which religious self-understanding and ritual practices aremore prominent (e.g., the United States) seem to have higher rates of religious content indelusions. Religious content also varies with the predominant religious context and thecommitments of the individual. In short, religious content in psychotic experience reflectsto a significant degree the cultural context and the extent to which the individual participatesin and is shaped by that culture. For clinicians, then, interpreting religious contentaccurately and helpfully rests on an understanding of the person’s broader cultural settingand its characteristic beliefs—especially those regarding mental and physical health andillness, and their relationships to spiritual realities.Second, research has begun to examine whether the presence of religious delusionsor hallucinations predicts an individual’s likely response to treatment. Clinicians have frequentlynoted the especially high stakes associated with religious language and experiencein psychosis. Often highly publicized are reports of people who mutilate themselves (e.g.,by self-castration or by removing the eye that has “offended”), or who attempt suicide ormurder in response to command hallucinations (e.g., hallucinatory voices that tell theperson to kill a child labeled “evil” or “demon-possessed”). Some researchers have foundthat those individuals who identify themselves as strongly religious, or whose delusionsor hallucinations are overtly religious, have poorer treatment outcomes. Others, however,have not found this to be the case, indicating no difference in treatment response. Stillothers suggest that the positive role religiousness or spirituality may play in recovery isneglected in many, especially shorter-term outcome studies, and that the longer-term impactof religion is on the whole a positive one.The implication of these perspectives for the practicing clinician is to highlight theimportance of a culturally attuned, individualized, functional assessment of the role specificreligious or spiritual activities and beliefs play in the person’s life at a specific time. Itmay be the case, for example, that someone who is strongly involved in a religiouscommunity, and who understands religion to be especially important to his or her selfconcept,may in the midst of a psychotic episode voice religious delusions or be especiallydistressed by religiously based perceptions of guilt or sinfulness. However, this individualmay also be able to draw on religiously based resources in recovering from these acutesymptoms. Understanding these possibilities is a task for spiritual assessment.ASSESSMENT OF SPIRITUALITYAND RELIGION IN SCHIZOPHRENIACultural competence in assessment is particularly relevant for life domains such as religionand spirituality, precisely because these domains are so closely tied to culturalconcerns. The meaning of religious beliefs and practices depends on an understandingof the larger context in which they are expressed. DSM-IV has explicitly noted thedangers of pathologizing behavior and thoughts that, in the cultural setting of the consumer,may not be out of the ordinary and/or may have clearly prescribed meaningsand responses that differ from those of Western medicine. Some of these are especiallygermane to diagnostic judgments related to schizophrenia. For example, in some communities,people hold strong beliefs in the capacity of individuals to influence othersfrom a distance. Sometimes the influence is exercised by concrete means such as“working roots” or manipulating sacred likenesses or effigies; at other times, immaterialdemons or spirits are the media by which control is exerted. Insensitivity to theculture-specific implications of such beliefs may easily lead to premature, pathologizing