Religion and Spirituality in Psychiatry

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Religion and Spirituality in PsychiatryAlthough medicine is practiced in a secular setting, religious and spiritualissues have an impact on patients’ perspectives regarding their health and themanagement of disorders that may afflict them. This is especially true in psychiatry,because spiritual and religious beliefs are prevalent among those withemotional or mental illness. Clinicians are rarely aware of the importance ofreligion and understand little of its value as a positive force for coping with themany difficulties that patients and their families must face. This monographaddresses various issues concerning mental illness in psychiatry: the relationshipof religious issues to mental health; the tension between theological andpsychiatric perspectives; the importance of addressing these varying approachesin patient care and how to do so; and differing ways of treating patients usingChristian, Muslim, and Buddhist principles. This is a book specifically addressingthe challenges that mental health professionals face when seeking to considerand integrate spiritual, religious, and cultural issues relevant to patient care.Philippe Huguelet, MD, is lecturer in the Department of Psychiatry, UniversityHospital of Geneva and University of Geneva, Switzerland.Harold G. Koenig, MD, is professor of psychiatry and behavioral sciences andassociate professor of medicine at Duke University Medical Center and at theGeriatric Research, Education, and Clinical Center, Veterans AdministrationMedical Center, Durham, North Carolina.

Religion and Spiritualityin PsychiatryEdited byPhilippe HugueletUniversity Hospital of Geneva and University of Geneva, SwitzerlandHarold G. KoenigDuke University Medical Center and Veterans AdministrationMedical Center, Durham, North Carolina

CAMBRIDGE UNIVERSITY PRESSCambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São PauloCambridge University PressThe Edinburgh Building, Cambridge CB2 8RU, UKPublished in the United States of America by Cambridge University Press, New Yorkwww.cambridge.orgInformation on this title: www.cambridge.org/9780521889520© Cambridge University Press 2009This publication is in copyright. Subject to statutory exception and to theprovision of relevant collective licensing agreements, no reproduction of any partmay take place without the written permission of Cambridge University Press.First published in print format2007ISBN-13 978-0-511-53451-5ISBN-13 978-0-521-88952-0eBook (NetLibrary)hardbackCambridge University Press has no responsibility for the persistence or accuracyof urls for external or third-party internet websites referred to in this publication,and does not guarantee that any content on such websites is, or will remain,accurate or appropriate.Every effort has been made in preparing this book to provide accurate and up-todateinformation that is in accord with accepted standards and practice at the timeof publication. Although case histories are drawnfrom actual cases, every eff ort has been made to disguise the identities of theindividuals involved. Nevertheless, the authors, editors, and publishers can makeno warranties that the information contained herein is totally free from error, notleast because clinical standards are constantlychanging through research and regulation. Th e authors, editors, and publisherstherefore disclaim all liability for direct or consequentialdamages resulting from the use of material contained in this book. Readers arestrongly advised to pay careful attention to nformation provided by themanufacturer of any drugs or equipment that they plan to use.

ContentsList of Contributorspage vii1 Introduction: Key Concepts 1Philippe Huguelet and Harold G. Koenig2 Spirituality and the Care of Madness: Historical Considerations 6Samuel B. Thielman3 Theological Perspectives on the Care of Patients withPsychiatric Disorders 19Joel James Shuman4 The Bible: Relevant Issues for Clinicians 31Armando R. Favazza5 Religion/Spirituality and Neuropsychiatry 48Nader Perroud6 Religion/Spirituality and Psychosis 65Philippe Huguelet and Sylvia Mohr7 Delusions and Hallucinations with Religious Content 81Sylvia Mohr and Samuel Pfeifer8 Religion/Spirituality and Mood Disorders 97Arjan W. Braam9 Spirituality and Substance Use Disorders 114Alyssa A. Forcehimes and J. Scott Tonigan10 Religion, Spirituality, and Anxiety Disorders 128Harold G. Koenig11 Religion/Spirituality and Dissociative Disorders 145Pierre-Yves Brandt and Laurence Borras12 Self-Identity and Religion/Spirituality 158Pierre-Yves Brandt, Claude-Alexandre Fournier,and Sylvia Mohr13 Personality, Spirituality, Religiousness, and the PersonalityDisorders: Predictive Relations and Treatment Implications 173Ralph L. Piedmontv

viContents14 Religion, Spirituality, and Consultation-Liaison Psychiatry 190Harold G. Koenig15 Community Psychiatry and Religion 215Marcus M. McKinney16 Religious and Spiritual Assessment in Clinical Practice 232Sylvia Mohr and Philippe Huguelet17 Integrating Spiritual Issues into Therapy 244René Hefti18 Explanatory Models of Mental Illness and Its Treatment 268Laurence Borras and Philippe Huguelet19 Psychiatric Treatments Involving Religion: Psychotherapyfrom a Christian Perspective 283William P. Wilson20 Psychiatric Treatments Involving Religion: Psychotherapyfrom an Islamic Perspective 301Sasan Vasegh21 Psychiatric Treatments Involving Religion: PsychiatricCare Using Buddhist Principles 317Charles Knapp22 Teaching Religious and Spiritual Issues 332Elizabeth S. Bowman23 Conclusion: Summary of What Clinicians Need to Know 354Philippe Huguelet and Harold G. KoenigIndex 369

ContributorsLaurence Borras , MDDepartment of Psychiatry, University Hospitalsof Geneva and University of Geneva, Geneva,SwitzerlandElizabeth S. Bowman, MDClinical Professor of Neurology, IndianaUniversity, Consulting Psychiatrist, IndianaUniversity Epilepsy Clinic, Indianapolis,IndianaArjan W. Braam , MDDepartment of Psychiatry and the Instituteof Research in Extramural Medicine, VrijeUniversiteit Amsterdam, Amsterdam,The NetherlandsPierre-Yves Brandt , MDFaculty of Theology and Religious Studies,University of Lausanne, Lausanne,SwitzerlandArmando R. Favazza , MDDepartment of Psychiatry, University ofMissouri–Columbia, Columbia, MissouriAlyssa A. Forcehimes , PhDCenter on Alcoholism, Substance Abuse, andAddictions, University of New Mexico,Albuquerque, New MexicoClaude-Alexandre FournierFaculty of Theology and Religious Studies,University of Lausanne, Lausanne,SwitzerlandRen é Hefti, MDDepartment of Psychosomatic Medicine,Klinik SGM Langenthal, Langenthal,SwitzerlandPhi l ipp e Hu g u el e t , M DDepartment of Psychiatry, University Hospitalsof Geneva and University of Geneva, Geneva,SwitzerlandCharles Knapp MA, LPCCo-Director, Windhorse Community Services,Boulder, ColoradoHarol d G . Ko en i g , M DDepartment of Psychiatry, Duke UniversityMedical Center, and Geriatric Research,Education and Clinical Center (GRECC),Veterans Administration (VA) MedicalCenter, Durham, North CarolinaMarcus M. McKinney , Dmin, LPCDepartment of Psychiatry, Universityof Connecticut School of Medicine,Farmington, Connecticut, and PastoralCounseling, Saint Francis Hospital andMedical Center, Hartford, ConnecticutSylvia Mohr , PhDDepartment of Psychiatry, University Hospitalsof Geneva and University of Geneva, Geneva,SwitzerlandNader Perroud , MDDepartment of Psychiatry, University Hospitalsof Geneva, Geneva, SwitzerlandS amu el Pfei fer , M DPsychiatric Clinic Sonnenhalde, Basel-Riehen,SwitzerlandRalph L. Piedmont , PhDDepartment of Pastoral Counseling,Loyola College in Maryland, Columbia,Mar y l andvii

viiiJoel James Shuman , PhDCenter for Ethics and Public Life, King’s College,Wilkes-Barre, PennsylvaniaS amu el B. Thielman , MD, PhDDepartment of Psychiatry and BehavioralSciences, Duke University School ofMedicine, Durham, North CarolinaJ. Scott Tonigan , PhDCenter on Alcoholism, Substance Abuse, andAddictions, University of New Mexico,Albuquerque, New MexicoContributorsSasan Vasegh, MDAssistant Professor of Psychiatry, Departmentof Psychiatry, Ilam University of MedicalSciences, Ilam, Iran (Islamic Republic of)William P. Wilson, MDProfessor Emeritus of Psychiatry, DukeUniversity Medical Center, DistinguishedProfessor of Counseling, Carolina EvangelicalDivinity School, Greensboro, North Carolina

1 Introduction: Key ConceptsPHILIPPE HUGUELET AND HAROLD G. KOENIG1. WHY THIS BOOK?Patients facing illnesses may often use religion asa way to cope with the illness. What is problematic,however, is that sometimes symptoms havereligious elements (e.g., delusion with religiouscontent). However, clinicians involved in psychiatriccare may have noticed that for patientswith mental disorders, religion/spirituality alsorepresents an important way of making sense ofand coping with the stress that the illness causes.Despite these observations, clinicians often failto inquire about the religious beliefs, practices,and experiences of patients, sometimes missingan opportunity to help relieve the suffering thatpsychiatric disorders cause. Some clinicians mayhave expertise in the religious aspects of psychiatricillness and are knowledgeable enough inthis area to integrate it into their clinical practices;others may not know much about religion,may be reluctant to discuss issues related to it,and may completely avoid it in their encounterswith patients. Thus, it is necessary to build abridge between these two groups. This book triesto comprehensively and synthetically addresssuch issues and seeks to give psychiatrists andother clinicians the tools they need to integratereligious and spiritual issues into their daily workwith patients. A growing number of texts addressreligion, psychology, and psychiatry. The presentbook, however, seeks to give practical knowledgeto clinicians who are not familiar with theseissues and who may not a priori consider religion/spiritualitywhen they take care of patients.To provide a foundation for the chapters to follow,this chapter briefly discusses definitions ofkey concepts in this area.2. DEFINITIONSThere are many definitions for the words religionand spirituality . The scientific and theologicalcommunities are divided on how they definethese terms.(1) In this book, the term religion isused to indicate specific behavioral, social, doctrinal,and denominational characteristics. In particular,it involves belief in a supernatural poweror transcendent being, truth or ultimate reality,and the expression of such a belief in behaviorand rituals.Spirituality is concerned with the ultimatequestions about life’s meaning as it relates to thetranscendent, which may or may not arise fromformal religious traditions (but usually does).One may notice that spirituality’s definition ismore subjective, less measurable. From a clinicalperspective, having a term that is broad anddiffuse is good because this allows patients todefine what it means for them. Using the languageof spirituality helps to establish a dialoguewith persons who may or may not considerthemselves religious. From a research perspective,however, such lack of conceptual clarity isnot permitted.Some authors (2) distinguish extrinsic religion,that is, a means to nonsacred goals, such asincreasing social contacts or attaining other externalbenefits, and intrinsic religion, that is, religionthat is lived, internalized, and motivated forreligion’s sake, rather than for external benefits.3. NEW PARADIGMReligion is unique in the sense that it may involvebeliefs that a supernatural being has influence on1

2 Philippe Huguelet and Harold G. Koenighow things are. Research on religion and mentalhealth does not address the question of whetherGod exists. Rather, research on psychological processesinvolving religion is neutral with respectto the existence or nonexistence of God or anyother supernatural being. In the context of care,clinicians should have the same attitude: Facing apatient addressing a religious issue, the questionis not to determine whether it is true or false, butrather to consider it in terms of meaning, coping,and its relationship to current therapeutic goal(s).Addressing religion in the care of patients, oneshould recognize that religion involves multipledimensions, for example, religious beliefs, religiousaffiliation, organized religious activity, “private”religiosity, religious commitment, religiousexperience, and religious coping i.e., religiousbehaviors or cognitions designed to help peopleadapt to difficult life situations.(3) A paradigmis needed to serve as a framework for researchand patient care activity. Palouzian and Park (4)define a “multilevel interdisciplinary paradigm”as a framework that allows an accurate descriptionof religious phenomena by recognizing “thevalue of data at multiple levels of analysis whilemaking non-reductive assumptions concerningthe values of spiritual and religious phenomena.”As an example of the usefulness of thisparadigm, Palouzian and Park describe the caseof religious conversion, which can be examinedboth at a neuropsychological level and at a socialpsychologicallevel.The multilevel interdisciplinary paradigm canaccommodate subdisciplines of psychology, butalso other domains such as evolutionary biology,neurosciences, anthropology, philosophy, otherallied areas of science, and pastoral care.Clinicians need to keep this paradigm inmind, because many disciplines may have somethingto offer depending on the specific clinicalsituations.4. MODEL OF CAREPsychiatric care often involves a multidisciplinary/multilevelmodel of care. The overarchingparadigm that should be considered in thecare of patients with psychiatric conditions isthe bio-psycho -social model, (5) which aimsat addressing the whole person. This modelunderscores the need to consider disorders froma holistic perspective, thus avoiding a reductionisticview that considers only biological(e.g., pharmacological treatments) or psychologicalaspects of the person. Appling this modelincludes integrating religion/spirituality into thesocial part of this model or, preferably, includingthis dimension in all three areas, thus approachingpatients from a bio-psycho-social-religious/spiritual model. This is recommended becausereligion/spirituality affects social, psychological,and even biological aspects of human life,and all domains affect each other, including thespiritual.5. PLACE OF RELIGION/SPIRITUALITYResearch suggests that religion/spirituality can behelpful for persons with physical disorders. Forinstance, outcomes of heart disease have beenrelated to religious involvement.(6) This may bedue to the relationship between religious beliefsand cardiovascular risk factors such as highblood pressure, cigarette smoking, and diet andto the stress-reducing effects of religious coping.Religion may also influence cancer incidence, (7)notably through dietary and health practicesfostered by certain religious groups. The courseand outcome of cancer may also be favorablyinfluenced by religious involvement throughimproved health behaviors, but also by the use ofreligious coping that may instill hope and reduceanxiety.In the field of psychiatry, partly for “historical”reasons, the general attitude toward religion hasbeen ambivalent. Religious belief, practice, andexperience have often been considered neuroticby mental health professionals, at least in thepast. Religion offers a different way of viewingpsychiatric illness that may conflict with that ofpsychiatrists. Evidence also exists showing thatreligion may offer help to patients with psychiatricconditions, particularly those with substanceuse disorders. This led to the implementation

Introduction: Key Concepts 3of 12-step programs to facilitate the treatmentof patients with alcohol or drug problems (seeChapter 9 ). More recently, religious copinghas been shown to influence the outcomes ofbereavement and major depressive disorders (seeChapter 8 ). Concerning patients with psychosis,the diagnosis of “mystical delusion” has hinderedclinicians from recognizing the positive influencesof religion.(8) However, recent researchfrom Switzerland and other countries has documentedthe powerful benefits in terms of copingthat religion/spirituality can have for psychoticpatients.(9, 10)Thus, although further research on this topicis greatly needed, growing evidence demonstratesthat religion/spirituality is important forpatients with psychiatric conditions and maybe beneficial or detrimental to their illness. Wehope that providing updated information toclinicians about the research in this area anddescribing sensible clinical applications will helpto overcome the reluctance among clinicians toaddress these issues with patients. At a minimum,this book will make mental health professionalsmore aware of an important area ofpatients’ lives that is rarely addressed in clinicalsettings.(11)6. THE ROLE OF CLINICIANSThe role of the clinician is not an easy one. Cliniciansinvolved in psychiatry have many reasons fortheir reluctance to address spiritual/religious issueswith patients.First, clinicians’ own religious involvement (orlack thereof) may influence the value they placeon religious/spiritual issues. We are generally lessinvolved in religious activities than our patientsare (12) and are thus less likely to be interested indiscussing these issues.Second, there is widespread lack of knowledgeabout how to address religion or spirituality inclinical practice. Psychiatric training rarely devotesmuch time to such issues, as described later in thisbook (see Chapter 22 ).Third, as mentioned earlier, there has been historicalconflict between psychiatry and religion.Some authors (Freud) have referred to religionas an “illusion,” merely a neurotic defense againstlife’s vicissitudes.(13) Antagonism remains todaybetween clergy and psychiatrists, because theirdomains overlap and they often share the same“customers.”Fourth, some clinicians may fear that addressingissues pertaining to religion may representwalking into unknown territories, thus riskingharm to patients. In some areas of the world (e.g.,in Europe), clinicians may fear offending patientsby bringing up such issues, which patients maynot wish to address.Fifth, psychiatrists may feel uncomfortablebeing involved in a social/care network in whichroles are not well defined between clinicians, chaplains,and clergy. This is likely to be the case inareas where clinicians and clergy have not workedtogether before.A common factor at the root of most of theseconcerns is a lack of knowledge and tools, whichthis book is intended to help correct.7. WHO SHOULD READ THIS BOOK?Th is book seeks to give knowledge and practicaltools to clinicians taking care of patients withpsychiatric disorders. The goal is to cover issuespertaining to psychiatry and religion/spiritualityin a way likely to engage and maintain theinterest of readers who may not be particularlyinterested in religion. There is a large gapbetween those who are interested in religion,consider it when treating their patients, andare drawn by books or papers on this topic, andthose who have little or no interest in religion,do not broach this topic in clinical settings, andfeel reluctant to “waste time” learning about thistopic. The present text is designed to fill this gapby providing concise, detailed information thatwill help clinicians consider integrating spiritualityinto the care of patients, even if the clinicianis not religious.This book is written by psychiatrists, psychologists,theologians, and pastoral care experts andwill be of use to all clinicians treating patientswith psychiatric disorders.

4 Philippe Huguelet and Harold G. Koenig8. WHAT THIS BOOK IS NOTFirst, this book does not address claims about thesupernatural (i.e., whether God exists), whetherany particular religion is “true” or “false,” orwhether one religious tradition is healthier thananother. Rather, religion is considered to be animportant way of shaping human experience inthe context of psychiatric disorders.Second, this book is not a textbook on thepsychology or sociology of religion. We do notemphasize concepts, definitions, or particularmodels of care. This has been addressed elsewhere.(3,4) Rather, this book is focused on issuesthat are directly related to patient care.9. CONTENT OF THE BOOKTh is book presents (1) an overview of theoretical(2) a systematic description of specific psychiatricconditions and their relationship to religion/spirituality, and (3) psychosocial and curricularaspects of religion/spirituality in psychiatry,with an emphasis on clinical applicationsthroughout.First, we consider historical and theologicalfactors relevant for clinicians, neuropsychiatricaspects of religion/spirituality, and a brief commentaryon the Bible from a particular viewregarding its “psychological” aspects.Second, we discuss specific psychiatric disordersto provide a comprehensive update on recentresearch. This will include “Axis I” disorders, butalso conditions such as identity disorders, religiousdelusions, and personality disorders. Thesechapters have been written from a multiculturalperspective. Spiritual assessment will also bedescribed.Third, authors will address treatment inthe community, which may involve coordinationbetween clinicians, chaplains, and clergy.We include here three examples of treatmentapproaches involving Christian, Muslim, andBuddhist principles. Including these chaptersdoes not mean that we share or endorse all theviews presented here. The goal is to provide thereader with information on various religiousways of approaching the psychological needs ofpatients. As clinicians, we are confronted withpatients who wish to engage in these treatments.Therefore, although many of us may not adoptsuch approaches, we should at least have knowledgeabout them so that we can advise patientsabout their merit. Finally, an overview is presentedon what needs to be taught in psychiatricresidency programs about religion/spirituality toenhance the competency of future psychiatrists(and other clinicians) in this area.Thus, we welcome you on an informativeand fascinating journey into a critical area ofour patients’ lives that may represent a powerfulresource for healing or be intricately interwovenwith psychopathology, requiring bothprofessional psychiatric care and pastoral care toresolve and disentangle.REFERENCES1. L ars on DB , Sw yers J P , Mc Cu l lou g h M E : Scientificresearch on spirituality and health: A consensusreport . Rockville, MD : National Institute forHealth Research , 1997 .2. Allport GW , Ross JM: Personal ReligiousOrientation and Prejudice. Journal of Personalityand Social Psychology 1967 ; 5 : 432 –443.3. Ko enig HG , Mc Cu l lou g h M E , L ars on DB :Handbook of Religion and Health . Oxford : OxfordUniversity Press , 2001 .4. Pa louzi an RF , Park C L : Handbook of the Psychologyof Religion and Spirituality . New York : GuilfordPress , 2005 .5. Engel GL : The need of a new medical model: A challengefor biomedicine . Science 1977 ;196 : 129 –136.6. Goldbourt U , Yaari S , Medalie JH : Factors predictiveof long-term coronary heart disease mortalityamong 10,059 male Israeli civil servantsand municipal employees. A 23-year mortalityfollow-up in the Israeli Ischemic Heart DiseaseStudy . Cardiology 1993 ; 82 : 100 –121.7. Enstrom JE : Health practices and cancer mortalityamong active California Mormons . Journal of theNational Cancer Institute 1989 ; 81 : 1807 –1814.8. Mohr S , Huguele t P : The relationship betweenschizophrenia and religion and its implicationsfor care . Swiss Medical Weekly 2004 ; 134 : 369 –376.9. Mohr S , Brandt PY , Gi l l ieron C , B or r as L ,Huguelet P : Toward an integration of religiousnessand spirituality into the psychosocial dimensionof schizophrenia . American Journal of Psychiatry2006 ; 163 : 1952 –1959.

Introduction: Key Concepts 510. Yangarber-Hicks N : Religious coping style andrecovery from serious mental illness . Journal ofPsychology and Theology 2004 ; 32 : 305 –317.11. Huguelet P , Mohr S , Brandt P-Y , Borras L ,Gillieron C : Spirituality and religious practicesamong outpatients with schizophrenia and theirclinicians . Psychiatric Services 2006 ; 57 : 366 –372.12. Neeleman J , King MB : Psychiatrists’ religious attitudesin relation to their clinical practice: A surveyof 231 psychiatrists . Acta Psychiatrica Scandinavica1993 ; 88 : 420 –424.13. Gay P : A Godless Jew: Freud, Atheism, and theMaking of Psychoanalysis . New Haven : YaleUniversity Press , 1987 .

2 Spirituality and the Care of Madness: Historical ConsiderationsSAMUEL B. THIELMANSUMMARYSpiritual and religious issues are sometimes neglectedor misrepresented in histories of psychiatry.This chapter outlines a historical approach tounderstanding how spiritual and religious ideasare expressed in medical and religious writingsdealing with madness. Sacred writings, inscriptions,ancient architecture, commentaries, pastoralletters, medical texts, and religious andspiritual publications all reflect a range of ideasabout the role of spirituality and the supernaturalin the etiology and treatment of mental disorders.Beginning with ancient pagan and Jewishwritings, and continuing with the writings of theearly church fathers, medieval physicians andPuritan divines, the chapter describes ways inwhich spirituality influenced the care of emotionallydistressed patients. The chapter discusses theways in which both naturalistic and supernaturalisticviews of madness are reflected in practice inthe roots of modern medicine in the eighteenthcentury and how psychiatrists and others dealtwith religious issues during the more secularnineteenth and twentieth centuries. The chapterargues against the position that there has beensteady progression from a supernatural to a naturalisticunderstanding of madness and shows howreligious and spiritual ideas continue to affect thepsychiatric approach to mental disorders.INTRODUCTIONThe history of psychiatry has often been writtenas though the emergence of psychiatry involveda transition from superstition to reason, fromreligion to science, and that only in the modernera have we come to understand that madness isnot the result of the influence of spirits, demons,and curses. In fact, the relationship among ideasof madness and religion, medicine and theology,treatment and ritual is complex and varied.Although natural explanations seem to competewith religious explanations, in fact, peopleactually caring for the mad often (although notalways) held these explanations in mind concurrently,and doctors, clergy, and families used thisunderstanding as a basis for managing those forwhom they cared.Different religious traditions, of course, havehad different approaches to the mad. This chapterfocuses primarily on care given in the Christiantradition in Europe and North America because itis this tradition that has shaped modern psychiatry’sway of dealing with religious and spiritualissues. Historical accounts of the Islamic approachto the mad indicate a variety of ways of dealingwith madness – from the traditional Islamic methodsthat involved casting out the devil, to Koranbasedmethods, to an approach that involves anaturalistic understanding.(1, 2) Hinduism andBuddhism have their own approaches to madnessas well.(3–5)1 . THE BIBLE AND MADNESSFor a variety of reasons, including missionaryactivity, European colonialism, and the adaptablenature of Christian belief, Christians are presentin significant numbers in most parts of the modernworld.(6) The Bible is, arguably, the mostglobally influential of ancient religious texts, and6

Spirituality and the Care of Madness 7it has influenced the West, both physicians andlay people, since the time of Constantine, so it isimportant to understand how the Bible presentsmadness. The Bible has several sections that haveshaped views of madness – although in differentways at different times.Th e Bible was written and edited overmany centuries. The Old Testament (or HebrewScriptures), assumed its present form in about90 AD.(7) The New Testament canon wasestablished at the Council of Nicea in 325 AD.All Christian groups accept the parts of theOld Testament that Jews regard as canonical.Roman Catholic, Eastern Orthodox, and CopticChristians, variously, include additional edifyingJewish writings that were not accepted as canonicalby Jews.Madness is portrayed in the Old Testamentin several ways, sometimes in naturalistic terms,sometimes otherwise. Illustrative of the variousways madness is viewed in the Bible are theaccounts of madness in 1 Samuel. In Chapter 21,the young David, not yet king of Israel, findshimself in a dangerous situation in the presenceof Achish, a Philistine king, and his comrades.According to the Bible, “he changed his behaviorbefore them, and pretended to be insane in theirhands and made marks on the doors of the gateand let his spittle run down his beard” (1 Sam.21:13, NRSV). Achish was disgusted and declared,“Do I lack madmen, that you have brought thisfellow to play the madman in my presence? Shallthis fellow come into my house?” (21:15). Davidwas able to escape and carry on unharmed. In thissetting, madness is presented as a natural phenomenonthat is not unusual.The same book of the Bible, five chapters earlier,includes an account of Saul that describes asupernatural cause of madness or, in Saul’s case,despair. The writer records, “Now the Spirit ofthe Lord departed from Saul, and an evil spiritfrom the Lord tormented him” (1 Sam. 16:14).In this story, David was summoned to play hislyre for Saul, because David had musical talent,and David’s music greatly consoled Saul. Saulhired David to work for him, and “wheneverthe evil spirit from God was upon Saul, Davidtook the lyre and played it with his hand. So Saulwas refreshed and was well, and the evil spiritdeparted from him” (16:23).In the New Testament, madness is sometimesattributed to demons. In the Gospel of John,Jesus’s opponents at one point say, “He is demonpossessed and raving mad. Why listen to him”(John 10:20). In another incident, Paul tells therecipients of one of his letters, to make a point,that he is speaking as though he is mad, with noimplication of a supernatural aspect at all.These examples illustrate something that istrue throughout the Old and New Testaments:when madness is portrayed, it is often seen innaturalistic terms, but the Lord often has somethingto do with the madness (for example, Deut.28:28, Jer. 25:16 and 51:7, and Zech. 12:4).Not only does the Bible contain informationon an ancient way of viewing madness in spiritualterms, but it also contains large portions of wisdomliterature that is analogous to modern selfhelpliterature, although religious readers wouldconsider it help from God. Wisdom literatureexists in many writings from the ancient world,and there are parallels in the Bible to Egyptianwisdom literature. The books of Proverbs,Ecclesiastes, Wisdom, and Sirach all containadvice on how to live life and how to understandlife’s difficulties.2 . MADNESS AND RELIGION IN THEANCIENT WORLDTh e ancient world presents a wide range ofworldviews and a number of philosophies ofhealing. Religion, psychology, and medicinewere intertwined, for example, in the ancienthealing cult, the cult of Asclepius. The cult ofAsclepius was the most widespread healing cultin the ancient world, originating with the ancientGreeks and lasting until after the time of Christ.Asclepius was a god of healing whose templeswere places of healing. One of the principalmethods of healing in the temple was making avotive offering of a small replica of the diseasedorgan and waiting for healing. Healing oftencame through dreams in which Asclepius would

8 Samuel B. Thielmanappear. The Asclepian physicians were practitionersof rational medicine who, when they couldnot heal through rational medicine, directedthe sick to the Asclepian temple (p. xviii).(8)Certain psychological methods were attributedto the god Asclepius. Galen of Pergamum (c.130–216 AD), the well-known physician of thesecond century, offered this insight into howAsclepius, the deity, ordered psychologicalmeans to cure disordered emotions:And not a few men … we have made healthyby correcting the disproportion of theiremotions. No slight witness of the statementis also our ancestral god Asclepiuswho ordered not a few to [write] odes … heordered hunting and horse riding and exercisingin arms.… For he not only desired toawake the passion of those men because itwas weak, but also defined the measure bythe form of exercises” (pp. 208–209).(8)More significant for religion in the Westwere the Hippocratic writings and Plato andPlatonism. Hippocratic medicine is highly valuedin modern accounts of medical historybecause it encouraged observation over theory,and because it generally eschewed supernaturalexplanations of madness.(9)Early church writers generally respected thework of physicians and had a view of madnessthat incorporated a spiritual perspective,while acknowledging the physical influencesthat cause mental distress as well. The writingsof John Chrysostom (c. 347–407 AD) reflectthis approach. John Chrysostom was bishopof Constantinople, a highly regarded preacher,and a person with considerable skills as a pastor.In a series of letters to Olympias, a deaconesswho apparently suffered from bouts of despair,Chrysostom provided a wealth of informationabout his views on despair and its relationshipto physical illness. Melancholia per se is notmentioned. Instead, Chrysostom referred frequentlyto athumia and its relationship to illness.Olympias apparently suffered from a chroniccomplaint of unclear origin, and this conditionwas accompanied by a sense of despair and gloom.Chrysostom at times tried to comfort her by assuringher that physical illness often caused despair.“[Job] was not tortured by despondency [until] hewas delivered over to sickness and sores, then didhe also long for death” (p. 294).(10)As his correspondence with Olympias progressed,however, Chrysostom began to becomesomewhat more impatient. In rebuking her forpersisting in her state of dejection he told her thathe believed that her physical illness was causedby her sense of dejection:You lately affirmed that it was nothing butdespondency which caused this sicknessof yours. … I shall not believe that youhave got rid of your despondency unlessyou have got rid of your bodily infirmity(p. 296).(10)He then went on to rebuke her for taking pridein her sorrow:I …reckon it as the greatest accusation thatyou should say ‘I take a pride in increasingmy sorrow by thinking over it’: for whenyou ought to make every possible effort todispel your affliction you do the devil’s will,by increasing your despondency and sorrow.Are you not aware how great an evildespondency is? (p. 301) … Do not thennow desire death, nor neglect the meansof cure; for indeed this would not be safe(p. 296). (10)Finally, Chrysostom offered pastoral advicefor her dejected state: he suggested that she pray,that she read his earlier letter, and even that shememorize it. He also suggested that she comparethe blessings God had given her to her adversecircumstances to help her obtain consolation forher feelings of despair (p. 297).(10)To the despondent, John Chrysostom recommendedthe Christian faith as a remedy inhis homily on St. Ignatius: “If any is in despondency,if in disease, if under insult, if in any othercircumstance of this life, if in the depth of sins,

Spirituality and the Care of Madness 9let him come hither with faith, and he will layaside all those things, and will return with muchjoy.” (11) Yet his letter to Olympias, directed asit was to a more specific case of despondency, isnuanced and humane.Not all of the early church writers held abalanced view. Tatian (c. 160) was a disciple ofJustin Martyr, a skilled speaker and theologian.In Oration to the Greeks , Tatian asserted a viewthat demons follow sickness.(12) The cure ofmadness is from God, not from the amulets thatmadmen were apparently supposed to wear.A disease is not killed by antipathy, nor is amadman cured by wearing amulets. These[cures from amulets result from] visitationsof demons. … How can it be right toascribe help given to madmen to matterand not to God? [The] skill [of those whouse such means to cure] is to turn menaway from God’s service, and contrive thatthey should rely on herbs and roots.(12)Tatian, however, did not always hold viewsconsistent with orthodoxy, and his view of“herbs and roots” was probably not shared bymany early church leaders.3 . RELIGIOUS APPROACH TO MADNESSIN THE MIDDLE AGES IN EUROPEOf the few extant sources for learning about thespiritual side of the treatment of madness duringthe Middle Ages, perhaps the Leechbook ofBald is the most interesting. The Leechbook consistsof three books owned by Bald, presumably aphysician, and compiled in the ninth century inEngland.(13) The Leechbook contains remediesfor all sorts of ailments. Many of the remediesare plant remedies, but the book also containsincantations and rituals to be used in the treatmentof disease. Book I of the Leechbook ofBald contains several references to madness andinterestingly distinguishes between demon possessionand lunacy. Even for demon possession,the physician is to treat the demon-possessedman with an herbal concoction: “For a fiendsickman, or demoniac, when a devil possesses theman or controls him from within with disease;a spew drink, or emetic, lupin, bishopwort, henbane,cropleek; pound these together, add ale fora liquid, let it stand for a night, add fifty libcorns,or cathartic grains, and holy water” (p. 137).(14)This mixture is put into every drink that the possessedman will drink, and he is then directed tosing Psalms 99, 68, and 69, then drink the drinkout of a church bell and let a priest say mass overhim. For the lunatic the writer prescribes anotherherbal concoction of costmary, goutweed, lupin,betony, attorlothe, cropleek, field gentian, hove,and fennellet. A mass is to be sung over it, andthe lunatic is to drink the mixture for nine mornings,then give alms and earnestly pray to God formercy (p. 139).(14)Th ere is an additional instruction for lunaticsin Leechbook III, thought to be the mostrooted in contemporary Anglo-Saxon medicine.(13)“In case a man be a lunatic; take skinof a mereswine or porpoise, work it into a whip,swinge [beat] the man therewith, soon he willbe well. Amen” (p. 335).(15) There was also aformula for dealing with temptation: “Againsttemptation of the fiend, a wort hight red niolin,red stalk, it waxeth by running water: if thouhast it on thee, and under thy head bolster, andover thy house doors, the devil may not scathethee, within nor without” (p. 343).(15) Clearly,Anglo-Saxon medicine incorporated a religiousworldview, and they used for treatment bothmaterial means (the herbal remedies) and religiouslysymbolic means (drinking a concoctionout of a church bell, saying masses as part ofthe treatment, and singing psalms as a means ofreceiving healing).4 . EMERGENCE OF A MORENATURALISTIC CLINICAL APPROACHTO MADNESS AMONG ENGLISHPURITANSAlthough in some spheres there was an increasedinterest in the occult and the supernatural duringthe Renaissance, those dealing with themad moved even further away from relying

10 Samuel B. Thielmanon supernatural explanations. Reginald Scott’s(d. 1599) book, Discoverie of Witchcraft (1584)reflects a point of view that grew in the sixteenthcentury: that people who are sad or distressedsuffer from a natural malady and not from supernaturalinfluences. Scott was a surveyor, not aphysician, and was active in the county governmentof Kent, England. Discoverie of Witchcraftis primarily an extended and entertaining argumentagainst the notion that witches actuallyhave supernatural powers. In the process, Scottreveals a lot about charlatanism in the sixteenthcentury, and the book even explains a numberof card-and-ball deceptions that in our time areconsidered to be magic tricks. Scott also toucheson the treatment of the insane and, in so doing,reveals how religious reasoning was used byfamilies to help those suffering from religiousdelusions.Scott recounts the case of Ade Davie, wife ofSimon Davie, a farmer from Scott’s home countyof Kent, and a person known to Scott. At sometime in her early adulthood, Ade, who had noprior history of any sort of melancholy or madness,“grew suddenlie (as her husband informedme … ) to be somewhat pensive and more sadthan in times past.” Simon was worried, but didnot tell anyone for fear that he would be thoughtguilty of “ill husbandrie.” But Ade became worse.She could not sleep, she cried, she began sighingand “lamenting,” and although her husbandpressed her, Ade would not provide any reasonfor her sadness. Finally, Ade fell to her kneesand confessed to Simon that she was depressedbecause she had sold her soul to the devil. Herhusband replied, “Thou has sold that which isnone of thine to sell … Christ … paid for it, evenwith his bloud …, so as the divell hath no interestin it.” The husband reasoned with her in this fashion.His wife then told him, “I have yet committedanother fault and done you more injurie: forI have bewitched you and your children.” But herhusband reasoned with her, “Be content … by thegrace of God, Jesus Christ shall unwitch us: fornone evill can happen to them that feare God.”With time, Ade recovered, “and remaineth a righthonest woman … shamed of hir imaginations,which she perceiveth to have growne throughmelancholie” (pp. 31–32).(16)Scott’s account and his general view of melancholyand the supernatural indicate that bythe latter part of the sixteenth century, naturalisticexplanations for mental disorders wereprevalent even among educated laymen. In fact,naturalistic explanations for melancholy wereprevalent among physicians throughout theMiddle Ages, although spiritual/religious factorswere acknowledged as playing a role in mentaldistress as well.(17)By the seventeenth century, a rather sophisticatedpractical way of dealing with psychologicaldistress emerged from the thinking of Puritanwriters. These writers, because of their concernwith spiritual experience, conversion, andthe inner spiritual life, were often very attunedto the existence of states of mental distress anddespair. Many offered pastoral advice that reflectsa concern for the psychological well-being of theindividual and provides a variety of spiritualexplanations and remedies.Among the most influential of the Puritanwriters on emotional distress was Richard Baxter(1615–1691), an Anglican priest who, in thosetumultuous times, became a “dissenter.” Becausehe could not in good conscience comply with theBritish Act of Uniformity, he could not preach,and so he had a lot of time to write. Baxterwrote prolifically about many aspects of livinga Christian life, and he also wrote about depression.During the 1660s, Baxter wrote A ChristianDirectory (1673), a gigantic compendium ofthoughtful and well-organized spiritual counselon a range of topics, including marriage, businessethics, lawsuits, government, dealing with sicknessand dying, church government, recreation,and, most of all, how to lead a spiritual life.(18)In A Christian Directory , Baxter wrote alengthy set of instructions on identifying andtreating melancholy. He thought of melancholyas a “diseased craziness, hurt or error in imaginationand consequently of the understanding”(p. 294).(19) It was characterized by preoccupationwith having irreparably sinned, perplexingthoughts, and the inability to divert thoughts to

Spirituality and the Care of Madness 11pleasant subjects. He, like many other Puritanwriters, rejected the idea that the devil was primarilyresponsible for melancholy.Baxter counseled that those who were melancholyreduce the time spent in religious exercisesso that religious duties would become lessburdensome. He advised the melancholy toseek cheerful company, to oppose blasphemousthoughts with reason, and to avoid “thoughtsupon your thoughts.” In addition to many othersimilar pieces of advice, Baxter advised, “Commityourself to the care of your physician and obeyhim” for “I have seen [many people] cured byphysic; and till the body be cured, the mind willhardly ever be cured, but the clearest reasons willbe all in vain” (p. 267).(19)Timothy Rogers (1658–1728) took a similarlymedically oriented approach to depression,which nonetheless incorporates the religiousworldview of Christianity in a nonmagical way.Rogers was a Presbyterian minister in Englandwho became depressed in his early twenties.Although he subsequently was very effective asa preacher, he wrote extensively on the properspiritual approach to melancholy.(20) Not surprisingly,his most well-known book, Troubleof Mind and the Disease of Melancholy (1691),contains practical wisdom shaped by his ownexperience. In Rogers’ estimation, melancholywas a condition like gout or a gallstone, becauseit created great misery for the sufferer and thesufferer was helpless against it. Rogers advisedthose who cared for the melancholy person toeducate those who suffered about the natureof the “disease” (his term). Empathy was alsoimportant:Look upon those that are under this woefulDisease of Melancholy with great pityand compassion. And pity them the more,by considering that you yourselves are inthe body and liable to the very same trouble;for how brisk, how sanguine, and howcheerful soever you be, yet you may meetwith those heavy Crosses, those long andpainful and sharp Afflictions which maysink your spirits. (p. v) (21)He counseled against harshness, which onlypoured oil on the flames and would chafe andexasperate them. He advised reassuring thepatient that people recover from melancholy.He also pointed out that, although the devil wasat work in melancholy,Do not attributed the effects of meerDisease, to the Devil; though I deny notthat the Devil has an hand in the causingof several Diseases.… [I]t is a veryoverwhelming thing, to attribute everyaction almost of a Melancholly man to theDevil, when there are some unavoidableExpressions of sorrow which are purelynatural, and which he cannot help, nomore than any other sick man can forbearto groan (p. xv).(21)Like Richard Baxter, he valued medicaltreatment, writing, “I would never have thePhysician’s Counsel despised.” But he believedthat the physician and the minister should worktogether, because both the soul and the bodyneed attention in depression (p. iv).(21) Thephysician, by physic and diet and “harmlessdiversions” would prepare the troubled soul forthe more complicated task of dealing with spiritualtroubles. Clearly the Puritans, like manyChristian writers before them, valued bothmedical and spiritual methods of treatment andbelieved that the two together were needed totreat melancholy.Patients wrote of spirituality and the care ofmadness as well. The way in which spiritualitywas incorporated into thinking about madnessin the seventeenth century emerges clearly fromthe account of George Trosse (1631–1713) of hisown madness. Trosse was a Presbyterian clergymanwho left a very readable autobiographythat was published posthumously in 1714. Bornin Exeter, he purposed early on to travel, makemoney, and live a life of luxury. He drank a lot,flirted a lot, and had very little use for religion.(22) Then, in 1656, when he was 25 years old,he began to experience emotional distress andhallucinations.

12 Samuel B. ThielmanIf I walked in the Garden , (as there sometimesI took many distracted turns) Iwould fancy all about me Places of Burning ,and Torments , and Devils .… Thus I discoveredthe Confusion and Distraction of myMind where ever I went [Italics added].(pp. 98–99) (23)He was taken by friends to the house of a physicianwho specialized in the treatment of madpeople.But at length, thro’ the Goodness of God , andby His Blessing upon Physick , a low Diet ,and hard keeping , I began to be orderedand civil in my Carriage and Converse , andgradually to regain the use of my Reason[Italics added]. (p. 101) (23)Trosse read the Scriptures, memorized portionsof Scripture, began to “favor somewhatmatters of Religion ,” and prayed with a Christianwoman who was one of the employees of themad-house (p. 181).(23) He began to improve.Trosse suffered two relapses shortly afterward,but he recovered, attended university, and had anactive career as a Presbyterian minister until hisdeath at age 81.5 . DEVELOPMENT OF A MORESECULAR MEDICAL APPROACHTO MADNESS DURING THEENLIGHTENMENTDuring the seventeenth and eighteenth centuries,philosophers and physicians began to thinkof the soul less in religious terms and more inphilosophical or scientific terms. Likewise,those dealing with the mad began separatingreligious causes from other causes and religion/spirituality became a category of madness.This way of thinking about madness is mostclearly laid out in Robert Burton’s Anatomy ofMelancholy (1621), in which Burton coined theterm “religious melancholy” and wrote at lengthdescribing the condition and offering recommendationsfor cure.In the eighteenth century, Enlightenmentthought permeated the philosophical aspects ofmedicine, and the Reformation had created religiouschange all over Europe. A reform was alsotaking place within madhouses and asylums inEurope where the asylum began to be viewed ashaving a therapeutic as well as a custodial purpose.Although management and medicine hadbeen part of the regimen of madhouses for sometime (p. 8), (24) several physicians for the madbegan outlining the need for a particular regimenof management in the asylum and began to presentthe asylum as a therapeutic institution.(25)Several individuals instituted extensive reformsfor institutions for the mad. Sometimesthese reforms were driven by a religious motive,as in England at the York Retreat. Sometimesit was driven by a rationalist/secular reformmotive, as in the case of Philippe Pinel and hisreforms in France at the Salpetrière and otherhospitals. Sometimes the motives for humanereforms were a mixture of these things, as theywere at the South Carolina Lunatic Asylum inColumbia, South Carolina and at the EasternLunatic Asylum in Williamsburg, Virginia.(26)But whether reform motives were secular or religious,patients and their religious views had to beconsidered.In France, Philippe Pinel (1745–1826) institutedreforms at Biĉetre and Salpetrière, andthese reforms sprang from an Enlightenment/rationalistic motive (pp. 9, 47, 53, 78–81).(27)In fact, like his revolutionary contemporariesin France, Pinel did not have much use forreligion. Pinel was very much motivated by thepursuit of knowledge and by the need to treatmad patients humanely and with a degree ofrespect. He criticized physicians’ reliance oncontemporary theories of inflammation tounderstand the brain, advocating instead thatthey focus on the “management of the mind,”that is, moral therapy (pp. 4–5).(27) Pinel’sapproach to “religious enthusiasm” was to separatethe religiously delusional patient fromothers; encourage physical activity; removefrom view every book, painting, or other objectthat could remind them of religion; order them

Spirituality and the Care of Madness 13to devote time during the day to philosophicalreadings; and instruct them by “drawing aptcomparisons between the distinguished acts ofhumanity and patriotism of the ancients, andthe pious nullity and delirious extravagancesof saints and anchorites” (p. 78).(27) Pinelrecounts one instance when the directors ofcivil hospitals, in 1795, ordered that all religiousobjects be removed from hospitals. AlthoughPinel viewed this act as extreme, he did noticethat, when implemented with goodwill andevident good intention on the part of hospitalmanagers, it resulted in seeming improvementof many of the religiously delusional patients(pp. 80–81).(27)But in other places, asylum reforms grewout of religious motives, especially among theQuakers and the hospitals under their influencein England and America, and religiousexercises were an integral part of asylum management.The story of the reforms at the YorkRetreat is well known but inspiring. In 1790,a 42-year-old Quaker widow, Hannah Mills,died in the York Asylum in England six weeksafter she had been admitted for melancholy.Local Quakers, who had tried to visit her tooffer spiritual consolation, were denied accessto her by officials at the asylum. William Tuke,one of those concerned about the death, was somoved by the way the case had been handledthat he decided to establish a place of treatmentfor the mentally distressed that would providecare for Quakers. Although a physician wasemployed to provide medical treatment at theRetreat, laymen offered a gentle but religiouslyoriented therapy intended to calm those withmental disorders. Harsh management was notallowed, and patients were treated with dignity.In contrast to the authoritarian approach usedby Pinel, Tuke’s approach harnessed the gentlereligious outlook of Quakerism to push patientstoward wellness.In 1813, Samuel Tuke published an account ofthe way the Retreat was managed, A Descriptionof the Retreat, that became highly influential ininspiring similar reforms elsewhere (pp. 24 ff).(28, 29)The Tukes believed that religious influencescould be very helpful to the mad, and they werestraightforward in stating their view. SamuelTuke wrote:To encourage the influence of religiousprinciples over the mind of the insane,is considered of great consequence, as ameans of cure. For this purpose, as well asfor others still more important, it is certainlyright to promote in the patient, anattention to his accustomed modes of payinghomage to his Maker. (p. 161) (30)In the United States, especially, the modelprovided by the Retreat served as an inspirationfor many of the early asylum superintendents asthey established public and private institutionsfor the insane throughout the country in theearly decades of the nineteenth century.6 . EMERGENCE OF THE MODERNMEDICAL APPROACH TO RELIGIONAND MADNESSBy the nineteenth century, any notion that psychiatricdisorders were directly the result of supernaturalinfluence had vanished from medicalwritings and from most records of treatment. Butinterest in the influence of religion in mental disorderswas prevalent, and there was an interest inboth the positive and negative aspects of religion.Indisputably, the most influential Americanphysician who wrote about madness during thelate eighteenth and early nineteenth centurywas Benjamin Rush (1746–1813). Not only wasRush an experienced general physician, but hewas a prolific writer, a signer of the Declarationof Independence, and a firm advocate for reformof the care of mad people. Rush’s book, MedicalInquiries and Observations Upon the Diseases ofthe Mind (1813), was in some ways an Americancounterpart of Pinel’s Treatise on Insanity (1801;English version 1806). Both books were concernedwith the classification and treatment,medical and “moral,” of madness. Both booksadvocated humane treatment of patients. But

14 Samuel B. Thielmanphilosophically, they differ significantly in theirtreatment of religion, because Rush, unlike Pinel,was a devout Protestant Christian.Rush, like many physicians of his day, adopteda view of disease that placed heavy emphasison the role of inflammation as a primary causeof many diseases. In the case of madness, Rushbelieved that disordered blood vessels were toblame. But this did not exclude the possibility ofother influences, and religion was, in general, apositive influence.Rush’s book is sprinkled throughout withreferences to the Bible and to God and assumesthroughout the correctness of his mildlyCalvinistic perspective. For Rush, religion couldinfluence patients both for ill and for good. Onthe one hand, a patient’s madness might be precipitatedby overstudy of Biblical end-time prophecies(p. 37) (31) or by incorrect doctrine (pp. 71,83, and 115–116).(31) On the other hand, religionwas in many instances helpful to patients.“Let not religion be blamed for these cases ofinsanity,” Rush wrote. “ [Its] tendency is to prevent[insanity] from most of its mental causes;and even the errors that have been blended with[religion] produce madness less frequently thanlove” (p. 45).(31)Rush believed that there was a mental “believingfaculty” that was disordered, for example,when people would “propagate stories that areprobable, but false,” a sort of paranoia (p. 272).(31) He thought this faculty was impaired in“persons who refuse to admit human testimonyin favor of the truths of the Christian religion,[while] believing in all the events of profane history”(p. 274).(31)As to treatment, Rush recommended, amongmany other things, reading the Bible as a wayfor patients suffering from hypochondriasis(or depression) to help themselves. Rush foundthat when hypochondriacal patients obsessedabout having committed the unpardonable sin,reasoning with them seemed to help. In fact, Rushthought physicians should educate themselvesabout common religious problems of patients:“It is of consequence to a physician, to be fullyprepared upon the subjects of the two errors[of belief: unpardonable sin, and creation formisery] that I have named, for they are the twoprincipal causes of religious hypochondriasm”(pp. 115–116).(31) He also advised that physiciansenlist the support of the clergy in such instancesbecause “erroneous opinions in religion … mustbe removed, by advising the visits of a sensibleand enlightened clergyman” (p. 115).(31)Rush’s views reflect the general respect inAmerica for religious patients that existedthroughout most of the nineteenth century.Although some American asylum superintendentsand others who treated madness held to abroader view of religion, others held views verysimilar to those of Rush, and religion and experiencedclergy who were bereft of extremism werewelcome in American asylums.During the nineteenth century, the focuson religion began to disappear from most ofEuropean and American psychiatry, even in thecountries that had been affected by religiousreform.Johann Christian August Heinroth (1773–1843), a German physician, who wrote on mentaldisorders, viewed psychiatric disorders asconditions resulting from sin, but his approachwas exceptional.(32) More typical were theviews of physicians such as Wilhelm Griesinger(1817–1868) who wrote:Th e aid of religion in the treatment ofinsanity is not to be lightly estimated; theapplication of this remedy requires, however,great caution. Religious instructionshould not be withheld from any patientwho desires and requires it; it would, however,oppose the first principles of mentaltreatment to enforce such instruction, orattempt to interest in it any one who hasno religion at heart. It would show totalignorance of the nature and circumstancesof those diseases to aim at direct recoveryby reforming or converting the patientby religious instruction. All such meansshould only aim at imparting quietude,trust, and hope to direct attention fromthe morbid representations to an earnest

Spirituality and the Care of Madness 15and remarkable theme to revive the modesof thought and sensation of his healthystate. (p. 347) (33)In fact, Griesinger was concerned aboutthe possibility of developing various forms ofpsychiatry that were religiously oriented.Several medical psychologists would havethe whole treatment of the insane to bespecifically Christian. But Jews also requirethe aid of the alienist and his science, andthere is no abstract, only a confessionalChristianity. Therefore there would requireto be a special Protestant, Catholic, etc.,and again a Jewish, heathen, psychiatrie.Possibly even this may be yet desired(p. 348).(33)Griesinger’s concern was that physiciansneeded to treat patients who came their wayregardless of religious background, and a form ofpsychiatry that was too sectarian would not servethe field of psychiatry, or patients, well.There were those who had concerns about therelationship of religion to mental health for otherreasons as well. While Benjamin Rush, writing atthe beginning of the nineteenth century, believedthat religion tended to be a positive influence,others, even in the United States, did not sharehis view. Amariah Brigham (1798–1849), anAmerican asylums superintendent and the firstpresident of the American Psychiatry Association(then known as the Association of MedicalSuperintendents of American Institutions for theInsane), wrote an entire book about the effect ofreligion on mental health, Observations on theInfluence of Religion upon the Health and PhysicalWelfare of Mankind (1835). He was particularlyconcerned about the effects of “religious excitement”on mental health, observing, “It should,however, never be forgotten, that of all the sentimentsimparted to man, the religious, is the mostpowerful,” and, therefore, like other “excitinginfluences,” could cause insanity (p. 285).(34)Similarly, Isaac Ray (1807–1881), an Americanalienist known, among other things, for hisexpertise in forensic psychiatry, wrote in MentalHygiene (1863) that religious excitement couldbe a powerful force in creating mental imbalancein those predisposed to insanity. Because religioninvolved nothing less than a person’s eternaldestiny, it was bound to have a negative effect onpeople who were emotionally unstable (p. 190).(35) So Ray counseled that people should “carefullyavoid all scenes of religious excitement, andindulge their religious emotions in quiet and byordinary methods, always allowing other emotionsand other duties their rightful share ofattention” (p. 193).(35)7 . LATE NINETEENTHAND TWENTIETH CENTURYDuring the latter part of the nineteenth century,psychiatry itself in Europe and the UnitedStates tended toward a view of mental illness thatwas more pessimistic and focused on heredityand biology. The number of people in psychiatrichospitals increased substantially. In the latenineteenth century, however, there was also anincreased interest in hysteria and the effect ofthe mind on the unexplainable presentations ofdisease. This period also saw the increased professionalizationof medicine, medical specialization,and the beginnings of outpatient psychiatricpractice and psychotherapy. With the interest ofphysicians in milder forms of mental disorderand in psychotherapy came a concurrent interestin the role of religion in psychological development.In the United States, psychologist WilliamJames (1842–1910) of Harvard explored, inVarieties of Religious Experience (1902), the role ofreligion in the life of ordinary individuals seekingto make sense of existence. James saw religiousexperience as a major way through which humanbeings dealt with the emotional complexities oftheir lives. It was also the way people made senseof the good and the evil that they experienced asthey lived their lives.(36)For medicine, however, the most importantinfluence of the late nineteenth and early twentiethcenturies was the work of Sigmund Freud(1856–1939), who, more than anyone else, was

16 Samuel B. Thielmanresponsible for bringing psychiatrists out of thehospital and into the psychotherapy consultingroom. Freud was an unabashed atheist, andhis later works make very clear that he viewedreligion as a shared delusion, helpful for some,harmful for others, but ultimately something thatwas an indicator of psychological immaturity. Itwas a way through which humans came to termswith the fear of death and the concern aboutmeaninglessness.Freud’s thinking embodied the materialisticconception of medicine that continues to beinfluential and that, during Freud’s time, wastaught to him in London, Vienna, and Berlin.(37) In The Future of an Illusion (1927), Freudproposed that religion was a common but falsebelief and that God was a projection of internaldesires. In Civilization and Its Discontents(1929), he wrote that religion was a delusion ofthe masses that could relieve some anxieties, butthat fostered immaturity and restricted choice.Freud’s view of religion set the tone for the psychiatricview of religion in the West, particularlythe United States, during much of the twentiethcentury.But some analysts were uncomfortable withFreud’s hostility to religion (notably Carl Jung,but also Gregory Zilboorg) and, in fact, Freud’sthought could be adapted to the purposes ofreligionists. A number of American Protestantclergy, interested in applying the insights ofFreud to pastoral work, used psychoanalyticthought to enrich pastoral work. In 1906, theReverend Elwood Worcester (1862–1940) andthe Reverend Samuel McComb, both clergymen,set up an education and psychotherapy programthrough the Emmanuel Church in Boston andcollaborated with an early psychoanalyst, IsidorCoriat, as well as prominent Boston physiciansJoseph Pratt, James Jackson Putnam, and RichardCabot. This effort, which became known as theEmmanuel Movement, continued until 1929.The program was intended to counter the influenceof the new “healing cults” that were sweepingthe United States. However, as it developed,it foreshadowed the modern pastoral counselingmovement.(38–41)Psychiatry itself tended to relegate religion tothe province of hospital chaplains and clergy. Inthe United States, psychoanalytic thought andpsychoanalytic psychotherapy, usually somewhathostile to religiosity, became a major force in psychiatrythrough the 1960s.(42) Psychoanalysis,which in its early days had included practitionersfrom a range of disciplines, came to be comprisedlargely of psychiatrists, especially after 1938 whenthe American Psychoanalytic Association madepsychiatric training part of the requirementsfor membership.(25) (In Europe, psychoanalysiswas less influential, but more professionallyinclusive.)During the latter part of the twentieth century,the influence of psychoanalysis on clinicalpractice waned as psychiatry came to be influencedmuch more directly by the neuro sciencesand cognitive psychology. In addition, the spiritual,yet nonsectarian perspective of AlcoholicsAnonymous, which came to national prominencein the 1940s and 1950s, highlighted thepotential therapeutic benefits of spirituallyoriented programs.(43) With the lesseningphilosophical opposition to religion, somepsychiatrists and others interested in mentalhealth explored more fully the role of religionin mental health. In 1968, the Committee onPsychiatry and Religion of the Group for theAdvancement of Psychiatry published a reportnoting the positive as well as the negative influencesof religion on mental health.(44) In 1986,the American Journal of Psychiatry published aseminal review article by Larson and colleaguesdocumenting the lack of adequate literature onthe mental health effects of religion.(45) Duringthe 1990s and early 2000s, interest in religionand spirituality grew substantially and was evidentin many geographical regions. The RoyalCollege of Psychiatrists began the Spiritualityand Psychiatry Special Interest Group in 1999,the World Psychiatric Association recentlyestablished a Section on Religion, Spiritualityand Psychiatry, a journal of Muslim mentalhealth has been founded, and the number ofarticles on religion in peer-reviewed journalshas grown substantially.

Spirituality and the Care of Madness 17It seems likely that interest in religion andspirituality will continue to be a focus of psychiatry,even if it is not a central focus. The UnitedStates continues to be a religious country. Europe,though much more secular, has been indeliblyshaped by its religious heritage, and SouthAmerica, Africa, Asia, and the Middle East allhave populations for whom religion is a vital partof the fabric of life. As a result, it is very likelythat psychiatric patients will often have psychopathologyshaped by their religious beliefs andwill frame their understanding of their life andinner concerns in religious or spiritual terms.Physicians for the mad have been dealing withreligious problems for centuries, trying to reassurepatients, offer comfort, and work out waysto use their own religious/spiritual/philosophicalperspective to bring healing to their patients.The opinions expressed in this chapter representthe personal views of the author and do not representthe views of the U.S Department of State.REFERENCES1. D ols MW , Immis ch DE . Majnun: The Madmanin Medieval Islamic Society . Oxford: ClarendonPress ; 1992 .2. S engers G. Women and Demons: Cult Healing inIslamic Egypt . Leiden, Netherlands: Brill ; 2003 .3. Pach A. Narrative constructions of madness ina Hindu village in Nepal . In: Skinner D, Pach A,Holland D, eds. Selves in Time and Place: Identities,Experience and History in Nepal . L an ham ,Md. : Rowman & Littlefield Publishers, Inc. ;1998 : 111 –128.4. Bhugra D. Hinduism and Ayurveda: Implicationsfor managing mental health . In: Bhugra D (ed.),Psychiatry and Religion: Context, Consensus andControversies . New York : Routledge ; 1997 : 97 –111.5. Obeyesekere G. Depression, Buddhism, and thework of culture in Sri Lanka . In: Kleinman A ,G o o d B , e ds. Culture and depression: Studies inthe Anthropology and Cross-Cultural Psychiatryof Affect and Disorder . Berkeley : University ofCalifornia Press ; 1985 :134 –152.6. B ar rett DB , Ku r i an G T , Johns on TM . WorldChristian Encyclopedia: A Comparative Survey ofChurches and Religions in the Modern World . NewYork: Oxford University Press ; 2001 .7. Met zger B . The Canon of the New Testament: ItsOrigin, Development, and Significance . Oxford:Oxford University Press ; 1997 .8. Edelstein EJL , Edelstein L . Asclepius: Collectionand Interpretation of the Testimonies . Baltimore :Johns Hopkins University Press ; 1998 .9. Tem k in O . Hippocrates in a World of Pagans andChristians . Baltimore : Johns Hopkins UniversityPress ; 1991 .10. Chrysostom J. Letters to Olympias . In: Schaff P ,Wace H , eds. A Select Library of Nicene and Post-Nicene Fathers of the Christian Church . GrandRapids, Mich : Eerdmans ; 1978 :2d series, vol. 9.11. Chrysostom J. Homily on St. Ignatius . In: Schaff P ,Wace H , eds. A Select Library of Nicene and Post-Nicene Fathers of the Christian Church . GrandRapids, Mich. : Eerdmans ; 1978 :2d series, vol. 9.12. Whittaker M, ed. Tatian : Oration ad Graecos andFragments . Oxford: Clarendon Press ; 1982 .13. Cameron ML. Anglo-Saxon Medicine . Cambridge:Cambridge University Press ; 1993 .14. Leechbook I . In: Cockayne O , ed . Leechdoms,Wortcunning, and Starcraft of Early England .Bristol : Thoemmes Press ; 2001 :vol. 2.15. Leechbook III . In Cockayne O , ed. Leechdoms,Wortcunning, and Starcraft of Early England .Bristol : Thoemmes Press; 2001 :vol. 2.16. Scot R , Summers M . The Discoverie of Witchcraft .New York : Dover Publications, Inc. ; 1972.17. Gowland A . The problem of early modern melancholy. Past and Present . 2006 ; 191 : 77 –120.18. Keeble NH . Richard Baxter (1615–1691). OxfordDictionary of National Biography . OxfordUniversity Press ; 2004 . Available at: http://www.oxforddnb.com/view/article/1734. Accessed6/26/08 .19. Baxter R. The Practical Works of Richard Baxter .Morgan, Pa. : Soli Deo Gloria Publications ; 2000 .20. Wright S . Timothy Rogers (1658–1728). OxfordDictionary of National Biography . Oxford UniversityPress ; 2004 . Available at: http://www.oxforddnb.com/view/article/24002 . Accessed 6/27/08.21. Rogers T. A Discourse Concerning Trouble of Mind,and the Disease of Melancholy . London : ThomasParkhurst and Thomas Cockerill ; 1691 .22. Wright S . George Trosse (1631–1713). OxfordDictionary of National Biography . Oxford UniversityPress ; 2004 . Available at: http://www.oxforddnb.com/view/article/27758. Accessed 6/27/08.23. Trosse G. The Life of the Reverend Mr. George Trosse .Montreal : McGill-Queen ’s University Press ; 1974 .24. Parry-Jones WL . The Trade in Lunacy: A Study ofPrivate Madhouses in England in the Eighteenthand Nineteenth Centuries . London : Routledge &Kegan Paul ; 1972 .25. Shorter E. NetLibrary Inc.: A History of Psychiatryfrom the Era of the Asylum to the Age of Prozac .New York: John Wiley & Sons ; 1997 :xii, 436 p.26. Thielman SB. Madness and Medicine: The MedicalApproach to Madness in Antebellum America,with Particular Reference to the Eastern LunaticAsylum of Virginia and the South Carolina LunaticAsylum . Department of History , Duke University ,1986 : 244 .

18 Samuel B. Thielman27. Pinel P , Davis DD . A Treatise on Insanity . NewYork, published under the auspices of the Libraryof the New York Academy of Medicine by HafnerPublishing Co.; 1962.28. Cherry CL. A Quiet Haven: Quakers, MoralTreatment, and Asylum Reform . Rutherford, NJ :Fairleigh Dickinson University Press ; 1989 .29. Digby A. Madness, Morality, and Medicine: AStudy of the York Retreat, 1796 – 1914 . Cambridge:Cambridge University Press ; 1985 .30. Tuke S . Description of the Retreat, an Institutionnear York, for Insane Persons of the Society ofFriends. Containing an Account of Its Origin andProgress, the Modes of Treatment, and a Statementof Cases . York, England : W. Alexander ; 1813 .31. Rush B. Medical Inquiries and Observationsupon the Diseases of the Mind . New York , publishedunder the auspices of the Library of the New YorkAcademy of Medicine by Hafner Publishing Co. ;1962 .32. Steinberg H . The sin in the aetiological concept ofJohann Christian August Heinroth (1773–1843).Part 1: Between theology and psychiatry. Heinroth’sconcepts of “whole being,” “freedom” “reason” and“disturbance of the soul.” Hist Psychiatry. 2004;15(3):329–344.33. Griesinger W , Robertson CL , Rutherford J.Mental Pathology and Therapeutics . London: NewSydenham Society ; 1867 .34. Brigham A . Observations on the Influence ofReligion upon the Health and Physical Welfare ofMankind . Boston : Marsh, Capen & Lyon ; 1835 .35. Ray I , Curran FJ . Mental Hygiene . New York ,published under the auspices of the Library ofthe New York Academy of Medicine by HafnerPublishing Co. ; 1968 .36. Holifield EB. A History of Pastoral Care in America:From Salvation to Self-Realization . Nashville, TN :Abingdon Press ; 1983 .37. Gay P . A Godless Jew: Freud, Atheism, and theMaking of Psychoanalysis . New Haven, Conn. : YaleUniversity Press ; 1987 .38. Stokes A. Ministry after Freud . New York: PilgrimPress ; 1985 .39. Worcester E , McComb S . Body, Mind and Spirit .Boston: Marshall Jones Company ; 1931 .40. Worcester E , McComb S , Coriat IH . Religion andMedicine: The Moral Control of Nervous Disorders .New York : Moffat Yard ; 1908 .41. Cunningham RJ . The Emmanuel Movement: Avariety of American religious experience . A Q .1962 ; 14 (1): 48 –63.42. Hale NG. The Rise and Crisis of Psychoanalysis in theUnited States, 1917 –1985: Freud and the Americans .New York: Oxford University Press ; 1995 .43. Cheever S. My Name Is Bill: Bill Wilson: His Lifeand the Creation of Alcoholics Anonymous . NewYork: Simon & Schuster ; 2004 .44. Committee on Psychiatry and Religion. The psychicfunction of religion in mental health andillness. In Reports and Symposiums, Group forthe Advancement of Psychiatry; 1968;642–725.45. Larson DB , Pattison EM , Blazer DG , Omran AR ,Kapl an BH . Systemat ic ana lysis of res e arch onreligious variables in four major psychiatric journals,1978–1982 . Am J Psychiatry . 1986 ; 143 (3):329 –334.

3 Theological Perspectives on the Care of Patientswith Psychiatric DisordersJOEL JAMES SHUMANSUMMARYTh e inclusion of religious considerations inpsychiatry and clinical psychology affords bothclinicians and patients an important resourcein understanding and therapeutically addressingmental illness. Yet that inclusion also presentspotential difficulties that may be avoidedonly by careful theological reflection; that is,by critical consideration of religious belief andpractice from the perspective of one or moreof those historical traditions we call “religions.”To avoid theological reflection is to risk reducingreligion to a technique valued only for itstherapeutic utility, which clearly threatens theintegrity of most religious traditions. In thischapter, I1 offer an account of tradition and explain whatit means to think theologically from within areligious tradition;2 suggest the ubiquity of theological and atheologicalassumptions in the worldviews of everypatient and clinician;3 follow theologian George Lindbeck in likeningthinking theologically to being part of a“cultural-linguistic” system constituting anentire way of life;4 discuss two significant theological difficultieslikely to arise at the intersection of psychiatryand clinical psychology for persons shaped byparticipation in the Jewish and Christian biblicalnarratives;5 suggest the therapeutic significance of somereligious communities as resources to be cultivatedby clinicians.A cursory glance at recorded history suggeststhat conditions like those we now call “mental illnesses”have been with us for a very long time, ashave the attempts of various cultures to accommodateand care for their mentally ill members. (1)And while modern psychiatric medicine has madegreat strides in the recognition and effective treatmentof mental illness and the destigmatization ofthe mentally ill, the discipline arguably has also followeda pattern typical of the applied sciences inmodernity, a pattern characterized by an escalatingspiral of specialization, reductionism, fragmentation,and alienation.(2) Just so, while medicinenow knows more than ever about the neurochemicalaberrations associated with depression, anxiety,psychosis, and so forth, these conditions areincreasingly regarded as individualized pharmacologicalproblems to be resolved clinically, as efficientlyas possible. This slide toward reductionismis one reason the reintroduction into psychiatryand clinical psychology of religious considerationsis, from my perspective as a theologian, so promising,for it calls into question the ready division oflife, so characteristic of our time, into the respectivedomains of ostensibly discrete disciplines.It has become possible once again to see mentalillness as more than a matter to be dealt with bythe clinician and the individual patient in relativeisolation. Clinician and patient alike, along withthe members of their respective communities, maynow understand psychiatric illness as a theologicalmatter as well, one that may be addressed fully onlyin light of a measure of theological reflection.Psychiatrists and other mental health professionalswho wish to take seriously their patients’religious faith need to develop some sense of thetheological issues at stake in such consideration.19

20 Joel James ShumanBy “theological” I mean first of all having to dowith disciplined, critical reflection on religiousbelief and practice. Properly theological questionsabout matters at the intersection of religion withpsychiatry are not primarily questions about theplausibility of religious belief from the perspectiveof current psychiatric theories, nor are theyquestions about the psychotherapeutic efficacy ofreligious belief and practice. Questions of boththese sorts are clinically important and oftentheologically interesting, but neither accountsadequately for what it means to think theologicallyabout psychiatry and religion. Rather, theologicalquestions about psychiatric matters shouldbegin by critically examining a patient’s beliefsand dispositions in light of his or her association(or lack thereof) with the particular religious traditionof which she counts herself a member. Atheologically sensitive clinician, that is, attemptsto see and interpret a patient’s condition notsimply from the perspective of what course ofaction might be therapeutically effective in theshort term, but also from the perspective of whatwould, to the greatest extent possible, respect theintegrity of the particular religious tradition ofwhich a patient is a member. This is not to saythat the clinician should feel compelled to makethe internal coherence of her patient’s religioustradition the sole or even the primary arbiterof her judgment of that tradition or of her carefor that patient; clearly some religious traditionshave better stood the test of time, are more plausible,and more conducive to human flourishingthan others. Yet to make clinical judgments abouta religious tradition based solely on its therapeuticutility or its perceived threats to mental healthis to avoid thinking theologically and risk doingviolence, both to a particular patient and her religioustradition.1. THEOLOGY AND TRADITIONI have suggested that theological reflection isalways informed with reference to a particularreligious tradition. A tradition, in the sense I amusing the notion here, is best understood as along-standing communal conversation that isboth synchronic and diachronic, which is simplyto say that it is a conversation among membersof an historically continuous community that hasfor generations engaged voices from its past withrespect to matters of enduring significance, whilenever failing to ground itself in the present orlook toward the future.(3) A theological traditionis thus an enduring, never-completed argumentabout the nature of both proximate and ultimatereality and about the proper relationshipof humanity to divinity, which is to say a theologicaltradition is to a significant extent also anextended conversation about the human conditionand the best way for women and men to live.The possibility of such a conversation presumesthe sharing of what might be called canonicalnarratives – that is, venerable stories about theorigins of things, the way things are, and the waythings ought to be – by the conversants. To theextent people live under the authority of the samecanonical narratives, look to the same exemplarsof virtue, and engage in the common practicesevoked by those narratives, they may engage aswell in intelligible theological discourse.(4) Assuch, theology is a discipline usually undertakenfrom within a tradition, at least in the sense thatthe theologian – I use the word here loosely torefer to anyone engaged in informed theologicalreflection – has an adequate working knowledgeof the language, logic, and way of life characteristicof the tradition in question.(5)And yet, a somewhat-more-than cursoryunderstanding of a patient’s faith tradition is onlyone part of the theological task of the clinician.The clinician should also be aware of his owntheological situation, for even when the cliniciandoes not count himself a member of a religioustradition or has no faith in anything resemblinga god, his view of the world and of his patientsis nolens volens based on theological (or atheological)suppositions. Every person, religious ornot, lives with certain tacit and explicit assumptionsabout the way things are and the way theyshould be. A significant part of what it means tobe human is consciously to consider the worldone understands oneself to inhabit, and to orderone’s desire for the various goods one finds in

Theological Perspectives 21that world. Such assumptions and ordering areacquired and develop along with the languages weuse to describe our worlds; together, they constitutewhat are commonly called worldviews , all ofwhich are in some sense theological. As NicholasLash puts the matter, “It is taken for granted, insophisticated circles, that no one worships Godthese days except the reactionary and the simpleminded.This innocent self-satisfaction tells uslittle more, however, than that those exhibiting itdo not name as ‘God’ the gods they worship.” (6)Just so, clinicians should practice their craftnot only with a sensitivity to their own commitmentsand an awareness that the languages andlogic of their discipline are in a broad sense “theological,”but also with a conscious awareness ofthe genealogical connections of modern psychiatryand psychology to the Jewish and Christianfaiths, especially as those faiths were understoodand called into question by Continental thinkersof the mid to late nineteenth century, includingFeuerbach, Nietzsche, and Freud. Freudian psychologyhas long since died the death of a thousandqualifications, but the specter of Freud’saccount of religion continues to haunt psychiatryand clinical psychology, such that even thosemental health professionals who are themselvesreligious believers often carry with them theinfluence of Freudian categories, at the very leastassuming a clear boundary between the realmsof clinic and congregation. Yet, a clinician attentiveto such matters will see that these presumedboundaries are not so clear. She may even recognizesignificant family resemblances (to borrowa phrase from the philosopher Wittgenstein)among the modern taxonomy of psychiatry andthe recorded spiritual struggles of innumerablewomen and men of faith over the past threethousand years, discovering that religion hashistorically been far more than wish fulfillment,reality avoidance, or a less-than-optimal form ofcoping.(7)The possession of an informed theologicalperspective on a patient’s beliefs and dispositionsmay help the clinician better understandhow such beliefs and dispositions relate to a particularpatient’s religious tradition. Those beliefsand dispositions may follow “naturally” from thepatient’s religious commitments, or they may bepathological in nature. As I have indicated above,these are not mutually exclusive alternatives.Religious belief and mental health (or the lackof either) may coexist in a wide range of complexand ever-changing arrangements, very fewof which correspond in any uncomplicated wayto the traditionally pejorative psychotherapeuticview of religion, which maintains that religiousfaith is both a cause and sometimes a sign ofmaladaptive thinking. Religious faith may notbe a prerequisite for mental health, but neitheris it an indicator in se of mental illness; people offaith are by no means all delusional, neurotic, orsocially disabled.More, active mental illness of various kindsis not incompatible with generally orthodoxreligious belief. A patient may be or desire tobe profoundly faithful to his tradition even ashe is at the same time profoundly sick; in manycases mental illness is an occasion for or even acause of theologically problematic assumptionsthat factor into a patient’s inability to live well.At the same time, a theologically orthodox faithmay for many patients prove powerfully effectivein a broadly (albeit unconventionally) therapeuticsense, offering them the means, often inconjunction with more conventional therapies,to cope with even serious mental illnesses. Onethinks here of the protagonists in the novels ofthe American writer and physician Walker Percy;those characters’ struggles with melancholy andother disturbances of the mind proved notoriouslyresistant to the interventions of psychiatrybut were often responsive to the characters’immersion (or sometimes reimmersion) as acatechumens in an unfashionably orthodoxChristian faith. One might also consider therole of the Christian Daily Office – a traditionalregimen of daily liturgical prayer – as a usefuladjunct to medication and therapy in KathrynGreene-McCreight’s chronicle of her struggleswith major depression and bipolar disorder, or ofJeffery Smith’s discovery of the writings of ancientChristian monastics on the “Dark Night of theSoul,” which offered him an ultimately satisfying

22 Joel James Shumanway of understanding and coping with his longhistory of serious depression.(7–12)2. RELIGION AND RELIGIONSI have advocated shifting the focus on matters atthe intersection of religion and psychiatry fromthe individual patient’s beliefs and the therapeuticutility of those beliefs to the ways her beliefsare shaped by her membership in or associationwith a religious tradition. My advocacy is basedon the conviction that it is more descriptivelyaccurate, not to mention more clinically useful,to talk about psychiatry and a particular religion,such as Judaism, Christianity, or Islam, than totalk about psychiatry and religion in general.The truth is that it is impossible to say very muchabout psychiatry and religious faith in general,because there really isn’t any such thing as religiousfaith in general . The notion of a generic“religion,” as Nicholas Lash has shown, is inessence an epiphenomenon of the shifting philosophicalground of early modern Europe, oneaspect of which included an emerging suspicionof what traditionally had been a conspicuously“public” Christianity.(13) This is not to say thatthere are no resemblances among the traditionswe call “religions.” Certainly there are commonlyheld beliefs and practices among the adherentsof various traditions (or those of no traditionwho still call themselves religious or spiritual).More, the faiths we commonly call “Abrahamic”(Judaism, Christianity, and Islam) share a commonhistorical heritage and comparable canonicalnarratives.(14) Still, too easily associatingthe beliefs, practices, and narratives of eventhese traditions avoids, rather than encourages,theological scrutiny. It has become fashionablein recent years in a wide variety of medical specialties,psychiatry not excepted, to investigateand in some cases even to commend the therapeuticeffects of actions and dispositions broadlyregarded as “spiritual” or “religious.” (15) Theoperational assumption in most of this work hasseemed to be that the subjective act of belief ismore significant than the objective content ofwhat is believed, insofar as the various historicalreligious traditions are but ways of referring toa universal characteristic of human subjectivity,which we might name religious feeling or religiousbelief. The traditions, that is, are butspecies of a common genus named “religion,”or now, more commonly, “spirituality.” As such,they may be exchanged or hybridized accordingto therapeutic effectiveness and the needs of thereligious consumer.(13, 15)Such a view of “religion” corresponds towhat the theologian George Lindbeck hascalled “experiential-expressivism,” wherein thetheological focus is on interpreting the alwayspersonal, usually inward, and often privateexperience of the believer. The content of thebeliever’s experience, the raw material informingwhat theologians typically call doctrine , isseen from this perspective as “noninformativeor nondiscursive symbols of inner feelings,attitudes, or existential orientations.” (16) Thisway of understanding religion not only fits,but also emerges as part of, the contemporaryNorth Atlantic sociopolitical context. The worldinhabited by most mental health professionalsand their patients is characterized by radicalindividualism and a sharp egalitarian impulse,a paradoxically reactionary suspicion towardtraditional authority, and a belief that someform of scientific reason is the only legitimatearbiter of public truth. Subsequently, we tend toassume the existence of a deep division betweenthe public and private realms, whereby we supposethat religious belief is a private, individualmatter that cannot and should not be critiquedwith respect to its content.(15, 17)Yet such a highly individuated, private, experientiallygrounded understanding of religionfalls decidedly short of accounting for what ithas for most of history meant to “be religious.”Lindbeck argues that the traditions we call “religions”are better understood as entire ways oflife, which may be participated in properly onlythrough initiation, extensive training, and lifelongritual reinforcement. Here he draws on thework of Wittgenstein in arguing that religions arenot unlike languages, in that they make possible“the description of realities, the formulation of

Theological Perspectives 23beliefs, and the experiencing of inner attitudes,feelings, and sentiments.” Moreover, insofaras languages emerge from and are made intelligibleby their association with the ways of lifeof particular communities, theological languagecannot be dissociated from the practice of a commonlife. A religious tradition’s “doctrines, cosmicstories or myths, and ethical directives areintegrally related to the rituals it practices, thesentiments or experiences it evokes, the actionsit recommends, and the institutional forms itdevelops. All this is involved in comparing areligion to a cultural-linguistic system.” (16) Justso, a clinician can often assess the relationshipof her patient’s illness to that patient’s religiousfaith only by taking into account not simply thefact that her patient believes, but also the entirecultural-linguistic framework within which thatbelief is acquired and exercised. In accounting forthe cultural and linguistic history of her patient’sfaith, the clinician may be surprised to discoverthat her patient is part of a tradition that historicallyhas afforded a generous space to those wetoday call the mentally ill and that also possessesabundant resources for wrestling with the particulartheological and existential questions raisedby mental illness.3. PSYCHIATRY AND THEOLOGYIN TENSION AND IN CONVERSATIONThe kinds of theological challenges mentalhealth professionals are likely to face withrespect to their patients’ religious commitmentsdepend to a significant extent on the particularreligious tradition with which the patient isaffiliated. Mental illness and its treatment willpresent different kinds of theological challengesto different religious traditions. In what follows Iwant to discuss what I take to be two ultimatelyinseparable challenges that mental illness and itscontemporary treatment present to my own tradition,Christianity. Although adherents of othertraditions, Judaism in particular, may recognizeanalogies with my account, I do not presume tospeak here on behalf of any tradition other thanmy own.A first type of theological challenge the clinicianis likely to encounter at the intersection ofpsychiatry and religion is with the connotationelicited by the very category “mental” illness.Psychiatry’s traditional suspicion of religionis often greeted with a corresponding antagonismby religious believers. Psychiatrists andother mental health professionals may have tocontend with religious patients who are suspiciousof and even hostile toward the very ideaof modern psychiatry. Although this suspicionis clearly in part a defensive reaction, it is morecomplex than that. Judaism and Christianityhave for centuries recognized and wrestled withthe existence of melancholia, anxiety, and otherconditions that bear undeniable resemblances towhat modern psychiatry identifies as disorders ofmood, affect, and personality. In the world of theBible, such conditions are generally and for themost part understood as “spiritual” challenges,or perhaps as “sicknesses of the soul,” the appropriateresponses to which are similarly “spiritual,”which is to say, religious. The psalms andprophetic writings in particular are replete withboth communal and individual laments madeby women and men confronted by the apparentabsence of God from their lives and those oftheir communities. The “absences” lamented inthese texts range from existential despair overthe apparent meaningless of life, to expressionsof the real or imagined fear of imminent death,to expressions of remorse over the commission ofsins, to protests against God’s failure to meet hiscovenant obligations to the psalmist’s or prophet’scommunity. In many cases, these laments includenothing less than pointed demands that God givean account of godself. And yet in spite of theirintroductory tone, these texts linger neither inanger nor despair, but transition without fail toexpressions of praise and gratitude in response toanticipated liberation by the very God who at thetime seems totally absent. Given the undeniablyliturgical character of much of this literature (thatis, the fact that it appears to have been written tobe performed in the gathered public worship ofthe community), these transitions appear to correspondto declarations of forthcoming salvation

24 Joel James Shumanby “a trusted, authorized official… not unlike the‘fear not’ formula of Isaiah 43:1”:But now says the L ord,he who created you, O Jacob,he who formed you, O Israel:Do not fear, for I have redeemed you;I have called you by name, you aremine.(18)This suggests that the public, communal performanceof these texts was an important resourcethat sustained the community and its membership,not simply in extraordinary times, but alsoin the difficult conditions that characterize theebb and flow of everyday life. The psalmists andprophets seem to understand that, even at its mostpedestrian, life frequently presents us with tragiccircumstances that we cannot imagine resolved toour satisfaction, apart perhaps from the extraordinaryintervention of God, which in the shortterm, as the poet Michael Blumenthal says, is“oblique and obscure and not even assured.” (19)One might argue, of course, that it is the sense ofpenultimate pathos characteristic of the psalmists’and prophets’ worldview that is the problem,and that it is not necessary, much less healthy, toexperience the ebb and flow of everyday life asfundamentally tragic.(11) Yet in the view of thebiblical authors, this objection itself might be partof the problem. One prominent scholar of the OldTestament goes so far as to claim that one of theprimary purposes of the prophetic writings is tocall a people numbed by the comfortable socialand economic stability typical of life in a politicallypowerful state to move beyond their superficialcontentment and “engage their experienceof suffering to death.” The solution to the tragicand sometimes apparently absurd human conditionis not blissful sleepwalking, but a hopefulengagement with an emerging reign of peace andrighteousness secured by the love of God. Such anengagement can be sustained only by an imaginativecountercultural community devoted to themutual well-being of its entire membership.(20)But how is any of this threatened by the modernnotion of “mental” illness? There appears tobe a trajectory within modern psychiatry thatcalls into question the biblical embrace of pathos,and in particular the undeniably social characterof that embrace. On the one hand, this questioningtakes the form of identifying religious belief,and communal religious practice in particular, ascollective delusion; religious practice in this viewis, at best, a less-than-optimal means of copingwith the Sturm und Drang of life and, at worst,a dangerous avoidance of reality that needs to beunlearned by a rigorous course of therapy. (7) Amore contemporary and much more commonform of questioning, however, comes from therecent ascendancy of applied neuroscience andpsychopharmacology, which tends to reduce theexperience of mental illness to aberrations in theparticular brain chemistry of the individual. I donot wish to take issue with the efficacy of contemporarypsychopharmacology, which has provenitself, notwithstanding thoughtful social andphilosophical interlocution; rather, I wish to visitthe question of the theological significance of thisefficacy. (10, 11) What are the implications for biblicalfaith of psychoactive medications that can, ina remarkably short time, effect deep changes inmood, behavior, and even personality? (21) Whatdoes it mean to have a “soul” so profoundly susceptibleto chemical manipulation that personalityitself appears to be transformed, quite apartfrom a change in circumstance or the mutual helpand support of a faithful community?Inarguably, neuroscience and the diagnosticand therapeutic interventions it has spawnedchallenge much conventional thinking about thesoul. Some neuroscientists have gone so far as toclaim that, since what was once identified as “soul”can now be accounted for largely in terms of brainchemistry, the very notion of “soul” is no longertenable and should be regarded as one moredecrepit member in the crumbling edifice of anoutdated biblical worldview.(22) As it turns out,however, neuroscience and psychopharmacologyare much more serious threats to the legacy of Platoand Descartes than to Judaism or Christianity.Descartes, who is sometimes called the “fatherof modern philosophy” because of his emphasison the human subject as the ultimate arbiter

Theological Perspectives 25of meaning, is best known for his Discourse onMethod (1637). In response to the emergence ofa widespread dissatisfaction with the Aristotelianmethodology undergirding the intellectual discourseof that day, Descartes sought to developan alternative philosophical method based on afoundation of absolute certainty.(23) Beginningwith a determination to “reject as absolutelyfalse everything in which I could suppose theslightest reason for doubt,” Descartes set out toestablish an “entirely indubitable” remainder onwhich certain knowledge might be established.(24) Descartes believed he had found such afoundation in the human psyche ; his conclusionwas that he, Descartes, was “a substance, of whichthe whole essence or nature consists in thinking,and which, in order to exist needs no place anddepends on no material thing.” (24) Hence wehave Descartes’ nearly universally recognizeddictum: “I think, therefore I am.”Perhaps because much of what he says echoedthe then two-thousand-year-old legacy of Plato,Descartes’ ego – the “I” – came over time to beidentified with the soul. The human essence –the thing that made humans unique – was anineffable, immaterial, and immortal res cogitans, a “thinking thing.” The body, meanwhile,was ultimately nothing more than a temporary,passive extension of the soul, a res extensa . Inpart because of its explanatory power and inpart because of its surface resemblance to somestrands of biblical anthropology, Cartesian dualismbecame the dominant paradigm for thinkingabout what it meant to be human. Some versionof Descartes’ anthropology became axiomaticfor all fields of inquiry, including theology and,less directly, medicine. The suppositions of theCartesian model also shaped the translation andinterpretation of scripture and popular piety,such that it became common for Christians toassume that the biblical account of the humanperson was essentially dualistic – that humanswere immortal, immaterial souls temporarilyinhabiting mortal, material bodies.Yet, as biblical scholarship and theologicalscholarship have shown, Christianity has virtuallyno stake in defending Cartesian (or any othervariety of) dualism. Dualism was in fact at thecenter of some of the earliest and most persistentheresies faced by nascent Christianity. Theseheresies are collectively referred to as varieties ofGnosticism , which, generally speaking, maintainsthat the material creation, including the humanbody, is unimportant except in a temporary,strictly utilitarian sense. The limits inherent inmaterial corporeality are to be ignored, struggledagainst, or fled, as often, as intensely, and as soonas possible. This earthly life is ultimately illusory;many Gnostics have gone so far as to likenit to a fleshy prison. But Gnosticism is patentlyinconsistent with the biblical narrative, whichfrom the beginning insists on the goodness ofcreation and the significance of embodied humanlife, which the second-century Church FatherIrenaeus called “the glory of God.” Contrary tothe Gnostic insistence that women and men ultimatelyare immaterial souls, the biblical portrayalof humanity is conspicuously corporeal; from theperspective of scripture, we are in this life andthe next never less than our bodies. As WendellBerry so succinctly explains the biblical story ofthe creation of Adam:The formula given in Genesis 2:7 is notman = body + soul; the formula there issoul = dust [earth] + breath. According tothis verse, God did not make a body andthen put a soul into it, like a letter in anenvelope. He formed man of dust [earth];then, by breathing His breath into it, hemade the dust live. The dust, formed asman and made to live, did not embody asoul; it became a soul. “Soul” here refersto the whole creature. Humanity is thuspresented to us, in Adam, not as a creatureof two discrete parts temporarily gluedtogether but as a single mystery.(25)Thus, the categories so typical of modernthought, such as the distinction between thespiritual and the physical, or the body and thesoul, or the natural and the supernatural, arefrom the perspective of scripture deeply problematicand useful only in a limited heuristic

26 Joel James Shumansense. The mystery we name “human” (from theLatin humus , “earth”) is from the perspective ofscripture altogether consistent with what neuroscienceand the philosophy of mind call “nonreductive physicalism” in which the notions “souland mind are physiologically embodied,” andyet not exhausted by neurophysiological explanation.“Human mind and behavior have newemergent properties that cannot be exhaustivelyexplained by lower level physical phenomena.Thinking, deciding, willing, etc., are real and efficaciousproperties of embodied human life.” (26)As Berry puts the matter, “Creation is one continuousfabric comprehending simultaneouslywhat we mean by ‘spirit’ and what we mean by‘matter’.… The body, ‘fearfully and wonderfullymade,’ is ultimately mysterious both in itself andin its dependences. Our bodies live, as the Biblesays, by the spirit and breath of God, but it doesnot say how this is so. We are not going to knowabout this.” (27)Just so, the worldview of those who standwithin the biblical-Christian traditions shouldnot feel that the plausibility of their faith is threatenedby the fact that their illness has a neurophysiologicaspect that responds to psychoactivemedication. Because we are never less than ourbodies, we are never less than an extraordinarilycomplex constellation of chemical reactions.More, we are no less real, less human, becauseof this.(28) Although there may in rare cases begood theological reasons to question the pharmaceuticalmanipulation of the human mind,members of the biblical traditions may generallyand for the most part view them as gifts providedby God to facilitate human flourishing.4. SUFFERING: WHAT IS THEOLOGYGOOD FOR?As important as such assurances may be, theydo not address an older and more intractabletheological question with respect to mental illness,namely, the question of why such sufferingafflicts good and faithful people. In philosophy,this is one version of what is typically called theproblem of theodicy (from the Greek theos , “god”and dikē , “justice”), which is typically posed inthe form of a question: “Why does a benevolent,all-powerful God allow the innocent to suffer?”In a therapeutic culture like our own, whichteaches us to value individual happiness above allother goods, the long-standing human tendencyto reduce God to the role of being a dispenserof whatever we happen to want is multiplied.(15) Our bent is simplistically to assume thatGod wants us to have what we want and that religiousbehavior of various kinds is but a means ofachieving what has already been afforded. Insofaras suffering of various kinds is an impediment tothis kind of happiness, suffering becomes a problemto be solved rather than a mystery to be contemplatedor an affliction to be ministered to byfriends and neighbors. Thus, when we suffer, weare likely to begin by asking what we have donewrong to deserve suffering or what we need to dodifferently to rid ourselves of it.Of course, it is perfectly appropriate not towant to suffer and so to ask whether we maybe able to do something to escape or alleviatewhatever suffering we might be experiencing.More, the God revealed by the biblical narrativeis accessible and active as a healer. Yet fromthe perspective of scripture, “why” questionsabout sickness and suffering are almost alwaysthe wrong place to begin. For while it is absolutelythe case that the God revealed in scriptureintends the redemption of all creation, includingthe life of every person, that redemption must beviewed from the perspective of what theologiansoftentimes call “salvation history,” which includesan irreducibly eschatological (oriented towardan ideal future consummation) component.The human experience of suffering demands atheological response. From the perspective ofChristian tradition, such a response focuses onthe past, present, and future history of God’s savingactivity, which does not attempt to explain,but does account for, human suffering.It is important to note that scripture doesnot offer a single, univocal account of why wesuffer or what can be done about suffering. Yetneither are the scriptural voices addressing sufferingcacophonous. It is possible to discern a

Theological Perspectives 27kind of harmony among the scriptural accountsof suffering, which consists in five parts:1 Su ffering is not part of God’s original or ultimateintention for any member of God’screation.2 The world as we experience it is not the worldGod ultimately intends. Humanity has willfullyalienated itself from God, from itself, andfrom the rest of creation, one typically inscrutableconsequence of which is suffering.3 God’s activity toward creation is nonethelessfundamentally redemptive. God is sovereignover history – including the history of everyperson – and will ultimately consummate historyto the benefit of God’s creatures.4 Christians therefore must cultivate an “apocalypticsensibility” with respect to suffering,knowing that suffering has the penultimate,rather than the ultimate, word in their lives.5 In the interim, suffering should not surpriseus; indeed, it is in a broken creation in somesense inevitable. As such, it is an opportunityfor Christians to serve those who suffer anda possible means by which God may furtherGod’s purposes in history.Any account of suffering in light of the biblicalnarrative must begin with the insistence thatsuffering is part neither of God’s original nor ultimateintention for the creation. Rather, creationexists as an expression of the fundamental goodnessof God, for God is, according to scripture,love (1 John 4:8). A central tenet of Christiantheology is that God is an aseity , which is to saythat God is fully sufficient in and of godself ( a se ).God alone is self-sufficient; creation is thereforecontingent, rather than necessary. All that is hasbeen brought into existence and continues to existby virtue of God’s generous, playful, and totallygratuitous creative act – the overflowing of God’simmeasurable love. All of creation, women andmen in particular, exist joyfully to participate inGod’s love, to be God’s friends.(29)That God is love, and that God intends ourflourishing and the flourishing of all creation,is to most of us far from self-evident. The worldis full of suffering, as observation and personalexperience plainly demonstrate. This antinomy,between the prevalence of suffering and the presumedgoodness of God, evokes the theodicyquestion in its traditional forms. Yet this is a mistakeprecisely because it presumes that the existenceof suffering is evidence of some defect inGod. In fact, it is possible to see the existence ofsuffering as a function of God’s regard for humanity.Insofar as humans are created in God’s imageand likeness, we possess a measure of freedom.It is by way of this freedom, Thomas Aquinasinsists, that God “moves” us, which is to say thatGod is fundamentally noncoercive with respectto the human will; God’s activity toward us is toentice us by attraction rather than to push us frombehind. Of course, the correlative to the humancapacity to choose God’s intention is the freedomto choose against God’s intention. Christian traditioncalls the free human opposition to God’sintention sin and suggests that it is sin that is thecause of various forms of suffering.This is not so simple a claim as it would firstseem, for “sin” here describes the state of a creationalienated from its Creator more than itdescribes any one person’s discrete acts of oppositionto God and God’s intention. The two are ofcourse not unrelated; as the biblical story of the“fall” indicates, creation’s alienation from Godhas its origins in specific acts of human disobedience.More, certain “sinful” choices are quiteobviously self-destructive and so contribute inrelatively straightforward ways to the suffering ofthe sinner and those around him. Yet the biblicalnarrative, from the book of Job to the teachingof Jesus, for the most part rejects the idea thata given instance of suffering in a person’s life isthe result of a particular sin or sins that personhas committed. Rather, the cumulative effect ofgenerations of human disobedience is portrayedas a kind of collective centrifugal force that flingsall of creation away from God toward disorderand chaos, such that even in the presence of thebest of human intentions, nothing works quitethe way it is supposed to.Thus, suffering is one of the most obviouseffects of sin, not in the sense that God punishes

28 Joel James Shumansinners by making them suffer, but in the sensethat sin is in a variety of ways its own punishment.Insofar as it not only separates the personfrom God, but also distorts and renders dysfunctionalhis relationships to other persons and tothe earth on which his life depends, sin makeshim an often unwitting participant in the violentbrokenness of the world we all inhabit. As thetwentieth-century Protestant theologian DietrichBonhoeffer explains, with the first act of humandisobedience, “Man’s life is now disunion withGod, with men, with things, and with himself….Instead of seeing God man sees himself.” (30)Alienated from God and the creation, womenand men are destined to suffer.And yet, in spite of appearances to the contrary,God’s activity toward creation is fundamentallyredemptive, which is to say it is in opposition tochaos and suffering. God is sovereign over history,including the history of each person, suchthat although God allows innumerable proximatecontingent circumstances that can and do causesuffering, God ultimately consummates historyto a good that includes the restoration of all creation’soriginal well-being. Although this patternpervades the biblical narrative, God’s activity inthis regard is both ideally exemplified and perfectlyestablished in the life, death, and resurrectionof Jesus of Nazareth. Subjected to thehumiliation of false accusation, verbal and physicalabuse, and a sham trial, Jesus was eventuallysentenced by Roman authorities to death by crucifixion.From the cross he cried out the openinglines of Psalm 22, an extended, desperate lamentof God’s absence which begins, “My God, my God,why have you forsaken me?” In spite of his persistentlyhaving rejected the view that God visitsthe pious with prosperity and the sinner with suffering,Jesus’s declaration indicates that he associatedhis experience not simply with injustice,but also with his having been abandoned by thevery God whose imminent reign he had come toproclaim and make present. Thus, there is in thenarrative of the cross a dramatic tension createdby the disparity between the tenor of Jesus’s lifeand teaching and his fate at the hands of imperialpower. This narrative tension is resolved byJesus’s resurrection from death on the third day.According to John Howard Yoder, the resurrectionis to be understood as a vindication of Jesus’slife and teaching and an assurance of the sovereigntyof good in history, such that “the triumphof the right… is sure because of the power of theresurrection and not because of any calculationof causes and effects …. The relationship betweenthe obedience of God’s people and the triumphof God’s cause is not a relationship of cause andeffect but one of cross and resurrection.” (31)Jesus’s patient faithfulness in suffering isregarded by Paul as an example made possibleby the theological hope that his resurrectionforeshadows the general resurrection of the deadat the consummation of history (1 Cor. 15). Inthe interim, Christians are invited to cultivate an“apocalyptic sensibility” with respect to suffering,knowing that God is active in particular and unexpectedways invisible except to the eyes of faith.(15, 32) Thus, the biblical story, and the story ofJesus’s death and resurrection in particular, “insertsinto our present setting a fulcrum capable of beingleaned on to pry us away from the assumption thatthe world as we see it is the only way it can be.” (33)Suffering of whatever kind is not generally an indicationthat the sufferer has done something wrong,nor is it a sign that if she did things differently hersuffering would cease or never have occurred.Suffering is simply one of the inevitable consequencesof our habitation of a broken creation. AsPaul puts the matter, “The sufferings of this presenttime are not worth comparing with the gloryabout to be revealed to us. For the creation waitswith eager longing … in hope that the creationitself will be set free from its bondage to decay andwill obtain the freedom of the glory of the childrenof God.” (34) In the meantime, it is inevitable thatmost of us suffer and that some of us have the misfortuneto suffer the pain of mental illness.5. SUFFERING, HEALING,AND THE PEOPLE OF GODIt is extremely important at this point to notethat an acknowledgment of the ubiquity of sufferingis neither fatalism nor an abandonment of

Theological Perspectives 29the significance of this life in favor of a betterlife to come. Rather, from the perspective of thebiblical narrative, the significance of suffering isshifted, such that suffering becomes, in spite ofits potential horror, an opportunity for ministryand a means of faithful witness. According to theGerman theologian Gerhard Lohfink, the centraltheme in the biblical narrative is that God worksin the world through a particular people whomGod calls together for the purpose of bearingwitness. (35, 36) This suggests that one of the,if not the most prominent, places where God’shealing work may be seen is in and through thesocial ecology of God’s people. In and throughtheir common life, which proclaims God’s loveto the world, the people of God form a new societythat makes possible a distinct way of dealingwith suffering. They are given one another asfriends pledged to share all manner of burdens,including, and perhaps especially, illness.(37)Suffering thus paradoxically becomes an opportunityfor the people of God to care for eachother in a way analogous to God’s care for thecreation: by patiently and lovingly being presentto the brokenness and isolation suffering creates,by working to overcome the alienation endemicin a broken creation, and by proclaiming in sodoing the emerging reign of God.Thus, a mentally ill person who wants toknow why God is allowing him to suffer or whois frustrated that his prayers for healing seemineffectual may have his question redirected inthe same way that Jesus redirected the questionsof those who demanded to know whose sin wasresponsible for one man’s congenital blindness:“Neither this man nor his parents sinned; hewas born blind so that God’s works might berevealed in him” (38). God is infinite not simplyin mercy and compassion, but also in creativity.By bringing into existence a new communitywhose telos is to make God present to the worldthrough their common life, God gives to thosewhose work is healing a powerful resource. Bythe provision of various forms of caring hospitality,the religious community becomes a locusof healing. Without assuming that every clergypersonand every religious community mightbe legitimate therapeutic resources, the clinicianshould at least be free cautiously and judiciouslyto cultivate partnerships among the religiouscommunities of consenting patients.6. CONCLUSIONBy necessity this chapter is incomplete and fragmentary.I have tried here to account for some ofthe things at stake theologically in the incorporationof religious matters into the treatment ofthe mentally ill. In so doing, I hope that I haveachieved a medium somewhere between the tritesimplistic view that religious practice is a meansof getting what we want (whether God existsor not) and the hopelessly difficult perspectivethat because God (whether he exists or not) isbeyond our control, we are alone in the worldwith our medication and psychotherapy. Foralthough it is true that God is certainly wild anduncontrollable, it is also the case that God is atwork effecting our redemption. In the words ofthe morning prayer from the United MethodistHymnal , “New every morning is your love, greatGod of light, and all day long you are workingfor good in the world” (39).REFERENCES1. Fouc au lt M. Madness and Civilization: A History ofInsanity in the Age of Reason . New York , RandomHouse; 1965 (1988).2. Berry W. Discipline and hope . In: A ContinuousHarmony . San Diego : Harcourt Brace andCompany; 1970 : 95 .3. Wainw r ig ht G . Doxology: The Praise of God inWorship, Doctrine, and Life . New York , OxfordUniversity Press ; 1980 .4. MacInt y re A. After Virtue: A Study in MoralTheory, 2d ed. Notre Dame, Ind. , University ofNotre Dame Press; 1984 : 204 –225.5. MacInt y re A. Whose Justice? Which Rationality?Notre Dame, Ind., University of Notre DamePress ; 1988 :370 –388.6. Lash N. Reality, wisdom, and delight . In: TheBeginning and the End of “Religion.” Cambridge :Cambridge University Press; 1996 :49.7. Greene-McCreight K . Darkness Is My Only Companion:A Christian Response to Mental Illness . GrandRapids, Mich. , Brazos Press; 2006 :112 –127.8. Perc y W. Love in the Ruins . New York , BallantineBooks ; 1971 (1989).

30 Joel James Shuman9. Perc y W . The Second Coming . New York , BallantineBooks ; 1980 (1990).10. Elliot C. Pursued by happiness and beaten senseless:Prozac and the American dream . HastingsCenter Report . 2000 ; 30 :2, 7 –12.11. Kramer P. The valorization of sadness: Alienationand the melancholic temperament . Hastings CenterReport . 2000 ;30:2, 13 –18.12. Smith J. Where the Roots Search for Water: APersonal and Natural History of Melancholia. Ne wYork , North Point Press ; 1999 .13. Lash N. The beginning and the end of “religion”?On what kinds of things there are, hollow centresand holy places. In: The Beginning and the Endof “Religion.” Cambridge : Cambridge UniversityPress; 1996 :10–13, 93–111, 188–191.14. The Journal of Scriptural Reasoning . Available at:http://etext.lib.virginia.edu/journals/ssr/ (lastaccessed 6/18/08); A Common Word BetweenUs and You . Available at: http://www.acommonword.com/(last accessed 6/18/08).15. Shuman J, Meador K. Heal Thyself: Spirituality,Medicine, and the Distortion of Christianity . NewYork , Oxford University Press ; 2003 ;38, 19–43,80–93, 71–111, 109.16. Lindbeck G. The Nature of Doctrine: Religionand Theology in a Postliberal Age . Philadelphia,Westminster Press ; 1984 :16, 33 .17. Brooks D. The neural Buddhists. The New YorkTimes Available at: http://nytimes.com/ 2008/05/13/opinion/13brooks.html (last accessed 5/20/08).18. Brueggemann , W . An Introduction to the OldTestament: The Canon and Christian Imagination .Louisville, Ky. , Westminster John Knox ; 2003 :280 –282.19. Blumenthal M. The Wages of Goodness . Columbia ,University of Missouri Press; 1992 :54.20. Brueggemann , W . The Prophetic Imagination .2d ed. Minneapolis, Minn. , Fortress Press ; 2001 :39–57.21. Kramer P. Listening to Prozac: A PsychiatristExplores Antidepressant Drugs and the Remakingof the Self . New York , Viking ; 1993 .22. Wolfe T. Sorry, but your soul just died. Forbes.1996;158(13):210–223. Available at: http://www.orthodoxytoday.org (last accessed 5/20/08).23. Sutcliffe F. Introduction. In: Descartes R . ed.Discourse on Method and the Meditations . NewYork : Penguin ; 1968 :7–23.24. Descartes R. Discourse on Method and theMeditations ; 1968 :53, 54.25. Berry W. Christianity and the survival of creation.In: Sex, Economy, Freedom & Community . NewYork : Pantheon; 1991 :106.26. Brown W. Human nature, physicalism, spirituality,and healing: Theological views of a neuroscientist .Ex Auditu. 2005 ; 21 : 114.27. Berry W. Health as membership. In: Another Turnof the Crank . Washington : Counterpoint; 1995 :91.28. Flanagan O. The Science of Mind , 2d ed. Cambridge,Mass., MIT Press ; 1991 .29. Waddell P. Friendship and the Moral Life . NotreDame, Ind. , University of Notre Dame Press ; 1989 .30. Bonhoeffer D. Ethics . New York , Collier ; 1949(1986): 20 .31. Yoder J. The Politics of Jesus . Grand Rapids, Mich. ,Eerdmans ; 1972 :238.32. Toole D . Waiting for Godot in Sarajevo: TheologicalReflections on Nihilism, Tragedy, and Apocalypse .Boulder, Colo. , Westview ; 1998 :205–266.33. Yoder J. Ethics and eschatology . Ex Auditu .1990 ;6 :119 ; Quoted in Shuman and Meador, p. 110.34. Romans 8:18–21, NRSV.35. Lohfin k G. Does God Need the Church? Collegeville,Minn. , Liturgical Press; 1999 .36. Yoder J. A people in the world. In: TheRoyal Priesthood: Essays Ecclesiological andEcumenical . Grand Rapids, Mich. : Eerdmans ;1994 :65–101.37. Shuman J. God does not wear a white coat: ButGod can, does, and will heal us all. In: LaythamB. e d. God Does Not . Grand Rapids, Mich. :Eerdmans; Forthcoming 2009 .38. John 9:3, NRSV.39. The United Methodist Hymnal, United MethodistPublishing House; 1989:877.

4 The Bible: Relevant Issues for CliniciansARMANDO R. FAVAZZASUMMARYThe Bible is the most globally influential andwidely read book ever written. Both directly andindirectly, it has been a major influence on thebehavior, laws, customs, education, art, literature,and morality of Western civilization. This chapterpresents basic facts about the Bible itself becauseit is such a vast and complicated book that is confusingto many readers. The concept of the biblicalGod is explored because it is not uncommonfor manic, schizophrenic, and depressed psychiatricpersons to proclaim the delusion that theyare God or Jesus Christ and to put themselvesin harm’s way. Further, high- functioning charismaticpatients who believe they are God cando enormous damage by becoming cult leaders.Many religions, including those based onthe Bible, use sin and guilt as methods that controltheir members’ behavior but may result indepressive and obsessive-compulsive disorders;also, the notion that women must be submissiveto their husbands may be used by men to rationalizeabusive behavior. The chapter discusseshomosexuality, an issue that divides societies andfamilies because the Book of Levitical Laws condemnshomosexual behavior. Christians are notobligated to follow these laws, yet many continueto despise homosexuality even though psychiatryno longer considers it to be a mental disorder.The history of Christian religious healing isreviewed and demonstrates that sick persons whoparticipate in religious healing rituals may feelbetter temporarily and that some self-proclaimedChristian healers may be charlatans. Despite itscomplexity, the Bible has for more than two millenniaprovided solace and hope to the vexed andthe hopeless. Psychiatrists should know about theBible because of its importance in the lives of somany mentally ill persons and their families.The Bible is the most globally influential andwidely read book ever written. Judaism andChristianity are Bible-based religions, and neithercould have survived by oral tradition alone.Judaism’s impact on the world mainly has comethrough the brilliant accomplishments of individualJews. Christianity’s impact has been muchgreater because of its mission to convert all personsinto Christians and because it became themain religion of the European continent whosesoldiers, merchants, settlers, explorers, andpriests traveled throughout the world bringingtheir Bibles and their religion with them.Both directly and indirectly, the Bible hasbeen a major influence on the behavior, laws,customs, education, literature, art, and moralityof Western civilization. Its views on topics suchas God, sin, guilt, gender, sexuality, homosexuality,and healing are especially relevant to psychiatristsin their clinical interactions with patientsand are the subject of this chapter.The United States is unique in the world forhaving both a high level of religious belief andof formal education. An estimation from numeroussources is that one-third of Americans watchreligious television each week, and one-thirdbelieves that God speaks to them directly. Amajority say they are church members, attendreligious services at least once a month, and readthe Bible at least once a week, while 25 percentattend weekly Bible study groups.(1) The world’s31

32 Armando R. Favazzalargest publisher of Bibles found that most readersare frustrated in reading the Bible because itis difficult to understand, too long, boring, andcontains contradictory messages. In fact, mostreaders hold false beliefs about the Bible.1. BASIC FACTS ABOUT THE BIBLEThe Bible is composed of many individual bookswritten by men whom Jews and Christians believewere divinely inspired. Each book was written tostand alone with no mention that one day theywould be brought together to form one book.The Bible is divided into two parts. The first part,properly called Hebrew Scripture, was renamedthe Old Testament (O.T.) by second-centuryChristians. None of the authors, with one exception,is known. Neither Moses, nor David, norSolomon wrote any Biblical books; their nameswere used to lend authority to the texts.(2)Jewish Scripture was written on multiplescrolls starting in 900 BC using sources from pastmillennia. The order in which they are presentedis not the chronological order in which they werewritten. It is divided into the Torah (the firstfive books), the Books of the Prophets, and theWritings. All the books have been edited many,many times until they reached a form that is verylike what appears in modern Bibles in 150 BC. Itwas not until about 90 AD that a council of rabbisdecided exactly which books were holy enoughto be included in the O.T. Jewish Scripture wasoriginally written in Hebrew but was translatedinto Greek starting in 250 BC. It was translatedinto Latin by St. Jerome in 400 AD, and his versionbecame the official O.T. portion of the Bibleof Christianity for more than a thousand years.Between 150 BC and 50 AD, no religiousmaterial was written that entered into the Bible.The New Testament (N.T.) was written between50 AD and 150 AD, and the content was derivedfrom multiple sources such as thousands of Greekmanuscripts and material written on piecesof pottery. In fact, the text of the N.T. containsmore variations than any other body of ancientliterature. It was not until 367 AD that a finalofficial list of books was compiled as the N.T. byan influential bishop. None of the Gospel writers,with the possible exception of John, knew Jesuspersonally. In fact, evidence for the existence ofJesus is based solely on the Bible (the same is trueabout Moses, the central character of the O.T.),and the biblical Gospels about the life of Jesuswere written more than twenty-five years afterhis death. He is not mentioned in any officialRoman documents, and there are no drawings,coins, statues, letters, or any artifacts about Jesusfrom the time in which he lived.Because there never has been a single originalset of biblical scrolls or books, there is great variabilityin the thousands of editions of the Bible.This problem is complicated further because ofthe translations of the Bible into almost everylanguage of the world and into versions that caterto special audiences, for example, people withlimited vocabularies, politically correct persons,and teenagers. Despite these obstacles, ChristianFundamentalists and Evangelicals – who, accordingto a Gallup poll conducted in May 2006,comprise 30 percent of the American population –believe that every word in their version of the Bibleis literally true and that the earth, for example, wascreated in 4004 BC, that the sun revolves aroundthe earth, and that a pair of every animal on theearth was rescued on Noah’s boat during a worldwideflood.(3) Christians regard both the O.T. andthe N.T. as divinely inspired sacred Scripture butbelieve that the N.T. fulfills the O.T.2. PROBLEMATIC BIBLICAL THEMESThe Bible is a vast, complicated, and often confusingbook.(4) For more than two thousand years,scholars have continued to debate the meaningof many passages and even entire books. TheBook of Job, for example, has been interpretedin many ways but none is convincing. Job wasan honest, God-fearing, and moral person aboutwhom God inquired during a heavenly counsel.A satan, a type of prosecutor as well as an agentof God, said that Job was righteous only becausehe was so prosperous. God agreed to test Jobby causing the loss of his possessions and thedeath of his children. God was pleased that Job

The Bible: Relevant Issues for Clinicians 33remained righteous. The satan then urged Godto take away Job’s health by covering his entirebody with scabs and wounds, betting that hewould then curse God. God agreed, and Jobsat in a pile of dung ash and was so thoroughlymiserable that his wife urged him to “curse Godand die!” Some of Job’s friends told him that hemust have sinned because God is just and onlypunishes sinners. Yet Job proclaimed his innocence,begged for mercy, and said that he wouldremain righteous even though God had made hissoul bitter. God then spoke with Job and listedhis mighty works. Job replied, “Behold, I am vile:how shall I answer you?” God again humbledJob with more examples of his power. Job said, “Iabhor myself, and repent in dust and ashes.” Godthen restored Job’s possessions by twofold andallowed him to have seven sons and three daughtersand to live for 140 years. The story ends wellfor Job. But why would a just God punish such arighteous man? It puzzled Job, and it still puzzlesreaders.Many people turn to the Bible for solace andfor both spiritual and behavioral guidance, especiallyin difficult times. It is not surprising thatmentally ill persons may be influenced by whatthey have read in the Bible and by what they havebeen taught about it. Sometimes this turning tothe Bible has positive results, but at other times,the opposite occurs. This chapter considers someproblematic Biblical themes that may affect thelives of patients.2.1. GodWhen the O.T. was written, there were manygods in the area we now call the Holy Land. Forthe Jews, however, the God Jehovah emergedas the supreme God. In the passage of time, theother gods disappeared, were forgotten, or werechanged into different supernatural beings suchas angels, principalities, powers, Sons of God,cherubim, and seraphim. God selected the Jewsas his chosen people and made a covenant thathe would look after them, allow them to prosper,and to rule the Holy Land as long as theykept his commandments and followed his laws.In the O.T., God intervened many times in thelives of the Jewish community and often punishedthem when they did not follow the rules of theholy covenant. In the beginning, God appeared toMoses at Mount Sinai, but afterwards only sometimesrevealed himself in visions and dreams. Hethen let his prophets speak for him until, finally,at the end of the O.T., he totally disappeared.He let his chosen people be forced into exile inBabylon, but then he allowed them back hometo rebuild the destroyed Holy Temple. His peoplevowed again to follow his commandments andlaws. He made no appearance but simply had theprophet Ezra read from a scroll that containedeverything of importance that he had to say.Throughout the centuries, Jews have beenpersecuted, especially by Christians who hatedthem for their role in Christ’s crucifixion. In fact,the N.T. contains many anti-Semitic passages.Throughout all the terrible persecution of the pasttwo thousand years, however, the community ofJews has demonstrated to the world that sufferingcan be made redemptive and a promise of betterthings to come. Then came the Holocaust wherethe Nazis methodically exterminated millions ofJews. This led to a crisis of faith not only amongJews but also among Christians who could notunderstand why God did not intervene. Manypersons felt that God was no longer a real presence,that maybe he was dead, and that humanbeings were responsible for their own fate.In the N.T., the God of the Jews is still presentbut is composed of three “persons”: theFather, the Son, and the Holy Spirit, each onebeing uncreated, omnipotent, eternal, co-equal,and unalterable. Jesus Christ, the Son of God,was sent to earth in human form to educate themasses and then to be crucified to wash away thesins of the world and to save humankind. Jesuson the Cross of the Crucifixion is the most iconicimage of Western civilization. His voluntary suffering,crucifixion, and resurrection, accordingto Christians, both fulfilled and transcended theprophecies of the O.T.It is not uncommon for manic, schizophrenic,and depressed psychotic persons in Christian cultureareas to proclaim the delusion that they are

34 Armando R. FavazzaGod or Jesus Christ. Many of these patients arealienated from their families, have no home, andare penniless. Their delusion elevates them froma downtrodden to an exalted state, from beingpowerless to being the most powerful person inthe universe. Psychiatric treatment that consistsof bringing these patients back to their oftenmiserablereality is usually unwanted by them.Their reluctance is understandable, but they mustbe committed to a mental institution in manycases and treatment must be forced on them toprotect them from harming themselves or others.Because God is all powerful, patients who believethemselves to be God may jump off high buildingsthinking that they can fly, or they may putthemselves fearlessly in perilous situations, orthey may rarely kill innocent people (althoughkilling is more often the result of a perceived vocalor visual command message from God).High-functioning, charismatic patients whobelieve they are God can do enormous harm bybecoming cult leaders. Over the centuries, it hasbeen impressive that so many people have comeunder the influence of delusional leaders whorelentlessly twist the words of the Bible to justifytheir beliefs. In 1993, American federal forcestragically burned the ranch of a Christian cultcalled the Branch Davidians. Fifty-four adultsand twenty-one children died in the fire. The cultleader had convinced the cult members that hewas Jesus Christ and that he was entitled to 140wives as queens and concubines and to have sexwith as many young girls as he could get his handson. The destruction of the cult was a botchedattempt to rescue its members, especially whenit became known that the cult leader was sexuallyabusing female children. On a much largerscale, Jim Jones, a delusional, charismatic leaderof a Christian Apocalyptic cult convinced his followersto move from San Francisco to the remotejungles of Guyana, South America. In this captivesetting, he played the role of God, demandedtotal allegiance, and preached that the Americangovernment was trying to exterminate African-Americans. His delusional grandiosity and abusivenessescalated. He forcibly drugged manymembers of his cult. When a U.S. congressmancame to inspect Jones’s camp and four members ofthe cult decided to leave with him, Jones becamefloridly psychotic. He convinced more than ninehundred cult members to drink poison and to dieby telling them that they would be “translated” toanother planet where they would live blissfully.Some patients consciously, but often unconsciously,feel a strong identification with the sufferingChrist of the Passion. Indeed the N.T. statesthat “Christ also suffered for you, leaving you anexample, that you should follow in his steps. …Do not be bewildered by the fiery ordeal that isupon you. … It gives you a share in Christ’s sufferings,and that is cause for joy” (1 Pet. 2–4). Thisidentification may be encountered in patients whorepeatedly self-injure themselves. The psychiatrist,Edward Podvoll (5) was correct in noting thatThe self-mutilator can incorporate intohis actions patterns which, to a greater orlesser degree, remain unarticulated in mostof us. That is, such patterns already exist inmuted intensities within the patient’s socialfield. As such, he may even perform a serviceto his culture in his dramatic expressionof those patterns which are felt to beintolerable within the self. Still other patternsinvoked are those which elicit silentlevels of admiration and envy. The historyof these images reaches at least as far backas the Passion of the Cross and has prevailedamong some of the most respectedmembers of our culture. (p. 219)In the N.T., Jesus established several rules forChristian behavior that have resulted in relativelyrare but horrible acts of major self- mutilation.(6)The Gospel of Matthew 5:28–30 states, “Anyonewho looks lustfully at a woman already has committedadultery with her in his thoughts. If yourright eye is your trouble, gouge it out and cast itfrom you. … And if your right hand causes youto sin, cut it off and cast it from you; for it is moreprofitable for you that one of your body parts perish,than for your whole body to be cast into hell.”Almost the exact words appear in the Gospel ofMark 9:43–48.

The Bible: Relevant Issues for Clinicians 35Case ExampleA 39-year-old single man took out hisright eye with his fingernail in obedience toMatthew’s biblical injunction. He claimedthat voices of devils, angels, and personshe had formerly known commented on hisbehavior in an accusatory tone and commandedhim to injure his remaining eye.He believed that he had stolen the soul ofa nurse seven years previously and that sheexerted great control over him. He alsobelieved that he possessed both male andfemale sexual organs and that he producednumerous babies daily.(7)In another passage, Jesus told his disciples thatdivorce was permissible only in cases of adultery.They commented that if a man’s wife committedadultery, “It is better not to marry.” Jesus replied,“All cannot accept this saying, but only those towhom it has been given. For there are eunuchswho were born thus from their mother’s womb,and there are eunuchs who were made eunuchsby men, and there are eunuchs who have madethemselves eunuchs for the kingdom of heaven’ssake. He who is able to accept it, let him acceptit” (Matt. 19:11–12). What exactly is meant bythis passage has been debated for two millennia.A small number of Christian groups have used ithistorically to justify the castration of its members(within the Eastern Orthodox tradition,for example, the sect known as the Skoptsi, oreunuch, was widespread in eighteenth and nineteenthcentury Russia, and the Catholic Church’spractice of castrating young boys to preservetheir high-pitched voices for the Vatican choirendured until 1880), and some psychotic patientshave used it to justify their self-castration.Case ExampleA shy, withdrawn man with an excellentwork record was constantly afraid thatpeople would consider him a homosexualbecause of his gentleness. At the age of 35years, he suddenly developed deep religiousfeelings. His work deteriorated ashis religious preoccupations increased. Hewas hospitalized and received electroshocktreatment. He dwelled on the Bible andon outer space. He then decided that hemust renounce “the sex life of the world.”After reading passage 19 in the Gospel ofMatthew, he castrated himself with a razorin the belief that this act of purificationwould qualify him to serve as the pilot whowould carry the godly to outer space.(8)Although it is difficult to anticipate acts ofmajor self-injury, ominous signs in a psychoticor pre-psychotic person include intense religiosity,a focused interest in the Bible, and a markedchange in physical appearance such as cutting offall of one’s hair or dressing bizarrely. It should benoted clinically that one act of major self-injuryputs a patient at very high risk for a second act.2.2. Sin and GuiltIn both Judaism and Christianity, sin refers to anybehavior that violates the moral codes of conductestablished by God primarily in the Bible but alsoin theological works by esteemed rabbis, priests,and church councils. The O.T. Book of Leviticuscontains 613 laws revealed by God to Moses concerningofferings, the priesthood, purification,the Day of Atonement, feasts, the tabernacle,blasphemy, the Sabbath years, and blessings forobedience and curses for disobedience. Althoughthe laws refer mainly to priestly legislation, allJews were expected to know and obey them. Amajor theme in Leviticus is atonement throughanimal sacrifice. “For the life of the flesh is in theblood, and I have given it to you upon the altar tomake atonement for your souls; for it is the bloodthat makes atonement for the soul (17:11). Thosepersons who atoned for their sins achieved holiness.“You shall be holy; for I am holy” (11:44).The O.T. also contains the Ten Commandments.Punishment for not keeping the laws and commandmentsinclude death, humiliation, loss ofpossessions, and all sorts of bodily ills such asinsanity, scabs, boils, and famine.Animal sacrifice has long been abandoned byJews who note that the O.T. prophets said that

36 Armando R. Favazzaatonement and a return to holiness were alsopossible through prayers and repentance. Thus,Samuel 15:22 states, “Does the Lord delight inburnt offerings and sacrifices as much as in obeyingthe voice of the Lord? To obey is better thansacrifice, and to heed is better than burnt offerings.”And Hosea 6:6 states, “For I desire mercy,not sacrifice, and acknowledgment of God ratherthan burnt offerings.”In the N.T. Jesus overthrew the Levitical lawsand expanded on the Ten Commandments in hisSermon on the Mount (Matt. 5–70) as well as onthe concept of sin. For him, the one unpardonablesin was blasphemy against the Holy Spirit.The N.T. Epistle of Paul to the Romans notes,“For the wages of sin is death, but the gift of Godis eternal life in Christ Jesus our Lord.” The N.T.firmly established the concepts of hell and heaven.Differing interpretations of the N.T. by variousChristian groups hold that heaven can be reachedonly by the grace of God, or by a combination ofgood works in addition to the grace of God, orby being fortunate enough to be a person predeterminedby God for heaven. People can be reconciledwith God through baptism, following hisrules, prayers, and acts of contrition.A common result of sin is guilt, the remorsefulfeeling of having done something wrong leadingto self-reproach and even self-hatred. Becausehuman beings are imperfect, it is impossible forthem to consistently fulfill the expectations ofJudaism or Christianity, for example, one of theTen Commandments states that it is sinful tocovet a neighbor’s wife or possessions. Thus, evenfantasies may be sinful. Both religions rely partlyon a guilty conscience to control the behaviorof its members. People regard their conscience,which in psychodynamic terms is the consciouspart of their superego, as if it were a guide or ajudge that is better than themselves and evenseparate from themselves. It reflects a society’sethical and moral standards that, in great part,derive from religious teachings. Behaviors, suchas committing a sin, that are disapproved of byone’s conscience result in anxiety, guilt, and loweredself-esteem. A saying commonly attributedto the Jesuit Order of Catholic priests is, “Giveus control of a child until he is six years old andhe will be ours forever.” The reasoning here isthat the basic structure of the conscience is set inearly childhood but will affect people for the restof their lives.The conscience is an important stabilizer inpeople’s lives. Persons with a limited conscienceare sociopaths and moral monsters, but personswith an overly strict conscience may experiencechronic guilt. Dythymic persons experiencetheir guilt by feelings of inferiority, depression,and worthlessness, while obsessive-compulsivepersons experience their guilt by attempting todeny and to magically counteract it through theirsymptomatic rituals that, like a religious service,must be performed flawlessly. People whose consciencesare unbearably harsh may develop apsychotic depression with suicidality and cometo regard themselves as truly great sinners whoare condemned to hell.Because the conscience reflects a society’smoral and ethical standards, cultural changesover the past century have diminished thepotency of sin as a regulator of behavior and ofhell as an actual, eternal reality. True sin is basedon the notion of a free will choice, but this notionhas been undermined by alternative explanationsfor behavior, for example, genetics, chemicalimbalances in the brain, defective neuralcircuitry, child-rearing practices, peer pressure,and the influence of advertising. As far back as1850, the incredulous congregation in NathanielHawthorne’s novel The Scarlet Letter had alreadylost its ability to comprehend the heartfelt confessionof their adulterous minister. “Ye, that havedeemed me holy! Behold me here, the one sinnerof the world.”The reality of hell was based on the visions andaccounts of persons who claimed to have seen it,but this was undermined when the two greatestevocations of hell were described centuries ago inDante’s Inferno and Milton’s Paradise Lost, whichwere published as poems that sprang from thewriters’ imaginations. Today, sin has been transformedinto mental illness and criminality, whilehell has been transformed into accounts of toxicdumps and drug-induced stupors, and in the

The Bible: Relevant Issues for Clinicians 37Nazi concentration camps there was much wailingand gnashing of teeth.2.3. Women’s IssuesThe Judeo-Christian tradition has been the mostsignificant force in defining the “natural” role ofWestern women. The unifying core of this traditionis the Bible, which provides numerousexamples of proper and improper female comportment.Unfortunately the Bible was writtenand edited over the course of more than a thousandyears so that no consistent “model” womanemerges. Although the Catholic Church has longoffered Mary, the mother of Jesus, as the idealwoman because of her attributes of virginity andsuffering, the Protestant Revolution did away withveneration of Mary, and the twentieth centuryfeminist revolution devalued both female virginityand suffering. Additionally, for several thousandmore years, rabbis, priests, and ministersin endless writings and sermons have providedsometimes contrary interpretations of biblicalstatements about women. Many Orthodox Jews,for example, demand that a woman’s head shouldbe practically bald and that wigs should be worn,while some Fundamentalist Christian groupsdemand long, uncut tresses on female members.St. Paul clearly states that women should covertheir heads while in church; some congregationsfollow this thinking, others don’t. If such diverseinterpretations of the Bible exist on the simplematter of a woman’s hair, then there is littlechance that more significant and complex issueswill be understood identically by all readers.Creation stories usually have great prestigein a culture. The story of Adam and Eve surelyhas enormous implications for male-femalerelationships, yet, once told, it is never mentionedagain in the Old Testament except fora momentous interpretation in the apocryphalbook of Ecclesiasticus (about 180 BC): “Froma woman sin had its beginning, and because ofher we all die. Allow no outlet to water and noboldness of speech in an evil wife. If she doesnot go as you direct, separate her from yourself” (25:24–26). Ecclesiasticus appears in theGreek Orthodox and Catholic Bible but not theProtestant. Neither is it included in the JewishBible, although its exposition of traditionalHebrew wisdom and advice for men made it afavored text by many rabbis. What advice andwisdom about women were offered? From awoman’s perspective, the high point comes earlyin Chapter 3: “Whoever honors his father atonesfor sin, and whoever glorifies his mother is likeone who lays up treasure.” Everything then rapidlygoes downhill. “Do not give yourself overto a woman so that she gains mastery over yourstrength” (9:2); “Taking hold of an evil wife islike grasping a scorpion” (27:7); “Keep strictwatch over a headstrong daughter lest, when shefinds liberty … she will sit in front of every postand open her quiver to the arrow” (26:10–12);“A wife’s charm delights her husband, and herskill puts fat on his bones. A silent wife is a giftto the Lord. … Like the sun rising in the sign ofthe Lord is the beauty of a good wife in her wellorderedhome” (26:13–16); “He who acquires awife gets his best possession, a helper for himand a pillar of support” (36:24).The portrayals of woman as a man’s possessionwhose role is to cook, keep a neat house, andbe silent and of woman as the seductive scorpionwho can make men miserable are found throughoutthe “wisdom” literature of the Hebrews. Thispopular type of literature, found in many culturesand often offering the same advice, wasdeveloped by sages who spoke from experience;priests and prophets ended their comments withthe definitive phrase “thus saith the Lord.” Thebiblical book of Proverbs, several centuries olderthan Ecclesiasticus, contained many of the sameideas. “For the lips of an immoral woman driphoney, and her mouth is smoother than oil; butin the end she is bitter as wormwood, sharp asa two edged sword. Her feet go down to death,her steps lay hold of hell” (5:3–5); “The mouthof an immoral woman is a deep pit; he who isabhorred by the Lord will fall there” (22:14); “Donot give your strength to woman” (31:3). Thevirtuous wife (31:10–31) arises before dawn toprepare food, helps the poor, brings in money byinvesting in land and by selling the garments that

38 Armando R. Favazzashe makes, is wise and kind, and does not eat thebread of idleness.Overall, women in the Old Testament werevalued primarily as mothers. Some of the mostpoignant moments describe the grief of mothersfor their dead children, especially their sons.“A voice was heard in Ramah; lamentation andbitter weeping, Rachel weeping for her children,refusing to be comforted for her children,because they are no more” (Jer. 31:15). Afterthe Gibeonites hanged her sons, “Rizpah tooksackcloth and spread it for herself on the rock,from the beginning of the harvest until the laterains poured from heaven on their bodies. Andshe did not allow the birds of the air to rest onthem by day nor the beasts of the field by night”(2 Sam. 21:10).Secondarily, women were valued as wives. Inthe early days, polygamy was the norm. By theeighth century BC, monogamy was standard andwas a metaphor for Jewish acceptance of oneGod. Women could not file for divorce, but menhad little problem. “When a man takes a wifeand marries her, and it happens that she findsno favor in his eyes because he has found someuncleanliness in her,” the husband merely had tohand her a written certificate of divorce (Deut.24:1). Because a woman, even after marriage,owed some allegiance to her family of birth, theproblem of divided loyalty was always present.Also, wives could become contentious, spiderlike,and even bovine. Amos 4:1 refers to them ascows. The presence of concubines – unmarriedwomen who lived with the family at the pleasureof the husband – undoubtedly made life easierin some ways by taking the edge off things. Theultimate state of degradation into which womenmight descend is depicted during a famine inSamaria. One woman says to another, “Give meyour son, that we may eat him today, and we willeat my son tomorrow” (2 Kings 6:29).In contrast to images of women as motherand wife, the O.T. contains a bevy of prostitutesand adulteresses who intrigued the Israelites. Theexpression “to play the harlot” is used throughoutthe O.T. to describe the act of abandoning one’sfaith. “Yet they would not listen to their judges,but they played the harlot with other gods, andbowed down to them” (Judg. 2:17). In a powerfulmetaphor Israel, the bride of God, became aprostitute. “You have polluted the land with yourharlotries and your wickedness. … You have hada harlot’s forehead; you refuse to be ashamed”(Jer. 3:2–3). An elaboration of this theme formsthe drama of the book of the prophet Hosea whowas ordered by God to marry a prostitute andhave children of prostitution “for the land commitsgreat harlotry by forsaking the Lord” (1:2).Hosea obeyed. Just as his wife pursued her lovers,so too did Israel pursue false gods. But Hoseareclaimed his wife and God reclaimed Israel.In the N.T., Jesus stirred up problems in hisdealings with women. He broke one of the TenCommandments when he neither honored noreven acknowledged his mother when she calledout to him, concerned for his safety. Rather, helooked at the crowd around him and said, “Hereare my mother and my brothers! For whoeverdoes the will of God is my brother and my sisterand my mother” (Mark 1:30–31). He even healeda woman with a chronic vaginal flow – the essenceof Jewish uncleanliness – who touched his robe.He elevated the status of women by declaringthat the only legitimate reason for divorce wasadultery. Until then a man was free to divorce hiswife, according to the great Rabbi Hillel, even ifher major fault was that she spoiled the soup. Hisrelationship with Mary Magdalen was distortedby interpreters of the Bible who made her out tobe a penitent prostitute instead of venerating heras the first person to see the resurrected Christ.In the Gospel of Thomas, one of the many gospelsnot selected for inclusion in the Bible, Peterthe disciple said to Jesus, “Let Mary Magdalenleave us, for women are not worthy of life.” Jesusreplied, “I myself shall lead her in order to makeher male, so that she may become a living spiritlike you males.”She became the perfect foil for Mary, thevirgin mother of Jesus, the greatest woman inChristendom.(9) The Bible actually says littleabout Mary but the early church fathers madeher out to be the perfect model of womanhoodeven though, when a woman in a crowd called

The Bible: Relevant Issues for Clinicians 39out to Jesus, “Blessed is the womb that bore youand the breasts that you suckled,” he replied,“Blessed rather are those who hear the word ofGod and keep it” (John 11:27–28). The church’svehement defense of her virginity is based on amistranslation of the word for “a young woman”in Matthew’s Gospel. Virginity was a majortheme in early Christianity and was seen as apathway to heaven. In the fourth century, St. JohnChrysostom noted that virgins did not have toworry about being “split apart by labor pains andwailings,” and that “the virgin is not obligatedto involve herself tirelessly in the affairs of herspouse and she does not fear being abused.”In order to buttress their argument for theideal of virginity, the church fathers declared thatwomen were problematic because they inspiredmen to lust. St. Bernard, for example, wrote thata beautiful woman was like a temple built over asewer. The Witch’s Hammer , an erudite, medievalguide book about the detection and persecutionof witches that influenced European witch trialsfor several centuries, concluded, “All witchcraftcomes from carnal lust, which in women is insatiable.See Proverbs 30. The mouth of the wombnever says ‘enough.’ Wherefore for the sake of fulfillingtheir lusts they consort even with devils.”Attitudes such as these posed great problemsfor Catholic women. The closest approximationto being like the Virgin Mary was to become anun and to marry Christ. Thus, in the fourteenthcentury, the pious Margery Kemp wrote whatJesus supposedly told her when she went to bed,“Take me as thy wedded husband, as thy dearworthydarling, and as thy dear son, for I will beloved as a son should be loved by the mother, andI will that thou lovest me, daughter, as a goodwife ought to love her husband.” With dazzlingvirtuosity the virginal, ascetic Margery simultaneouslybecame Christ’s mother, daughter, andspouse.Married women were in a bind because it wasimpossible to be both a virgin and a mother. Thecompromise that resulted in a great deal of maritaldiscord was for a wife to fulfill her marital sexualobligations but not to enjoy them. Anotherproblem was that the Virgin Mary was veneratedfor her maternal sufferings. In many images she isshown as Our Lady of Sorrows with seven swordspiercing her breast. In trying to emulate the sufferingMary, female ascetics, such as St. Catherineof Siena, whipped themselves, pressed thorns intheir skin, ate cat vomit and dead rodents, andeven developed skin wounds like the stigmata ofJesus. However, the foremost method of sufferingwas self-starvation, whose deepest goal was tofacilitate a divine union with Jesus by subsistingon a diet of communion wafers. Thus, anorexiawas approved as a saintly behavior. Some modernanorexics believe that there is no fat in heavenbecause the gate to enter paradise is very narrow(Matt. 7:14).2.4. MarriageThe most common type of marriage in the Bibleis the patriarchal kind in which the father/husbandis the supreme authority as establishedin Genesis. God said to Eve, “In pain you shallbring forth children; your desire shall be for yourhusband, and he shall rule over you.” David’sand Solomon’s many wives exemplify polygamy,although usually just two wives was more typical.By the eighth century, monogamy had becomethe prevalent form of marriage. The bride andgroom entered into a covenant that involved notonly them but also their families. On a largerscale, monogamy represented the covenantbetween God and Israel. Isaiah’s chapters 61and 62 compared the bride’s and bridegroom’sclothing with “the garments of salvation” and“the robes of righteousness” and promised thatthe desolate forsaken land of Zion would attainsalvation through marriage with the Lord, andjust as the bridegroom rejoices over the bride,“so shall God rejoice over you.” In 2 Corinthians2, Paul betrothed the church to Christ “as a purebride to her one husband.”Marriage in Christianity has been somewhatproblematic beyond the issue of the husband’sdomination over the wife. Although the Catholiccatechism states that Jesus established marriage asa sacrament, most scholars disagree. In fact, bothJesus and Paul tolerated marriage but hardly gave

40 Armando R. Favazzait glowing reviews. Marriage for them was “a formof this world [that] is passing away” because theend of the world was approaching, “So that hewho marries his betrothed does well; and he whorefrains from marriage does better” (1 Cor. 7).That Jesus attended a wedding at Cana, where heperformed his first miracle by changing water intowine, is not particularly significant. It would bea totally different story if he had consecrated thecouple’s marriage with a nuptial blessing.With a few exceptions, the early church fatherswere not terribly high on marriage. Ambrosewrote, “Even a good marriage is slavery. What,then, must a bad marriage be?” For Jerome,“Marriage is only one degree less sinful than fornication.”The church adopted the Roman conceptthat a valid marriage simply required theconsent of the bride and groom. Marriage was asecular contract and the church recognized thevalidity of all marriages, including those amongslaves, that followed local civil laws. A priest couldattend a marriage as a witness. At the Council ofElvira in 309 AD, many rulings were made aboutthe necessity for control over sexual matters; itwas in this century that priests began to intrudecautiously into the marriage ceremony by blessingthe newlyweds. In the sixth century, marriageswere often associated with a mass but theirvalidity was still based on a secular contract. Itwasn’t until the Council of Trent in 1563 that thechurch officially proclaimed marriage to be a sacrament.The current Catholic catechism states,“In the Latin Church, it is ordinarily understoodthat the spouses, as ministers of Christ’s grace,mutually confer upon each other the sacramentof matrimony by expressing their consent beforethe Church.”In modern times, just about all Christianchurches, some more reluctantly than others,have modified their position on divorce becausesecular divorce is so prevalent. Even in thosechurches that might excommunicate persons whoget divorced, members of the church usually willaccept divorced persons as new members. TheCatholic Church still has a hard-line policy aboutdivorce, but each year new records are being setby couples who have their marriages annulled bythe church, sometimes on a flimsy pretext. Manyparish priests do not withhold communion fromremarried persons even though they technicallyare acting against church policy. I might add that,for a long time, psychiatrists considered divorcea sign of emotional immaturity. However, whenenough psychiatrists themselves divorced theirspouses, they changed their position. Now,divorce may indicate a mentally healthy actiondepending on the circumstances. Psychiatryreflects the times in which we live and the customsof the people.The period of the exile of many Jews in Babylon(587–538 BC) marks an important historicaldivision. Before the exile, women, although subordinateto men, had a certain status. Along withconcubines, slaves, precious metals, and animals,wives belonged to a man, but they could not bepurchased or sold. Women could participate inreligious ceremonies. They could be prophetessesor wise persons or sorceresses. They could beheroines, like Deborah, or agitators, like Jezebel.When the Israelites returned from their exile,they were determined to avoid the circumstancesthat caused God to treat them so harshly. Theirsolution was a back-to-the-basics focus on purity,which meant keeping within the boundariesof divine order. There was a renewed emphasison the covenant established between Abrahamand God. “And you shall be circumcised in theflesh of your foreskins, and it shall be a sign ofthe covenant between me and you” (Gen. 17:11).Because circumcision was an option only formen, females could enter into the covenant onlythrough their relationship with men. To emphasizethe importance of sacrificial blood, whichmade atonement possible, other forms of bloodwere deemed impure. Thus, a menstruatingwoman was unclean and so was everything shesat on. Slowly but surely, the social and religiousstatus of women declined. A special court wasconstructed in the temple to keep women in theirplace away from the sanctuary. The period of awoman’s impurity was seven days following thebirth of a boy, but fourteen days after the birth ofa girl. Ecclesiasticus noted that only one man ina thousand is wise, “But a woman among these I

The Bible: Relevant Issues for Clinicians 41have not found” (7:28). A man could have a trialmarriage with a female captive. “And it shall be, ifyou have no delight in her, then you shall set herfree” (Deut. 21:14).Ezra was so distressed by the iniquities of hisfellow Jews that he tore his clothes and pulled outhis hair. At a great assembly he said that the wrathof God would continue until they rid themselvesof impure, pagan wives. Shechaniah spoke up,“Let us make a covenant with our God to putaway all these wives and those who have beenborn to them, according to the advice of my masterand of those who tremble at the commandmentof our God; and let it be done according tothe law” (10:3). Nehemiah was even more zealous:he slapped people around, cursed a lot andforced them to swear by God that they would notintermarry (13:25). In modern times, polls showthat half of American Jews marry outside theirfaith and that only one-third of their children arebeing reared as Jews.In the N.T., Jesus recognized that peoplemarry but noted that “those who are consideredworthy of participating in the coming age,which means in the resurrection from the dead,do not marry” (Luke 20:35). On the road to thecrucifixion he said to the daughters of Jerusalem,“Behold, the days are coming when they will say,‘Blessed are the barren, and the wombs that nevergave birth, and the breasts that never nursed aninfant’” (Luke 23:29). Paul never met Jesus, yetdeveloped a working theology based on hisinterpretation and development of Jesus’s words.In 1 Corinthians he wrote, “It is good for a mannot to touch a woman … I say to the unmarriedand to the widows … if they cannot exercise selfcontrol,let them marry. For it is better to marrythan to burn with passion … but he who refrainsfrom marriage does better.” He also wrote, “Thehead of every man is Christ, and the head ofevery woman is her husband.” The Letter to theEphesians, which has been attributed to Paul,contains the warning, “Wives, submit to yourhusbands, as to the Lord. For the husband is thehead of the wife. … Just as the church is subjectto Christ, so let the wives be subject to their ownhusbands in everything.” The warning is softenedby requiring husbands to love their wives as theirown bodies. Paul was very clear about the inferiorstatus of women, even forbidding them to speakin church but rather to speak to their husbands athome if they wanted to know something.This attitude has persevered throughout thecenturies and has been used by men to condonespousal abuse. It is not uncommon for psychiatriststo encounter women who believe they mustendure abuse because the Bible commands themto submit to whatever their husbands do.Case ExampleA psychiatrist was asked to examinean attractive woman who had been hospitalizedfollowing a life-threatening overdose.She reported that she was a devoutChristian but her husband was an alcoholicwho often beat her. On weekends he wouldbring home women he had met in a barand have sex with them after forcing hiswife to leave the bedroom and to sleep ona couch. She had complained to her pastorbut was told that she needed to becomea better wife who could sexually meet herhusband’s needs. After years of enduringsuch abuse and deciding that she was stuckin a hopeless situation, she had tried to killherself. The psychiatrist, after determiningthat she had a great deal of personalstrength and that she was demoralized butnot mentally ill, utilized a forceful therapy.He told her that since her husband did notrespect her, as stated in the Bible, she wasnot obligated to submit to him. He urgedher to stand up for herself and to leave herhusband immediately and to go to a localwomen’s shelter. When she expressed dismayover what the church members wouldthink of her, he advised her to find a newchurch. She followed his advice, divorcedher abusive husband, moved to anothercity, and decided that she would wait beforeseeking another church. A year later shewrote to tell the psychiatrist that she wasdoing well, had made new friends, found ajob, and was enjoying her freedom.

42 Armando R. FavazzaUnfortunately, not all such cases turn out sowell. Many abused women may give in to guiltevokingpressure from their husband, theirfamily, their pastor, and even members of theirreligious congregation to return to the abusivesituation because “it’s against the Bible not tosubmit to your husband.” This argument is mostcommonly encountered among Orthodox Jews,Fundamentalist Christians, and Mormons.The rise of secular feminism and of femalebiblical scholarship in the twentieth century haselevated the status of women in both Judaism andChristianity. In many cases, women can now beordained as ministers and rabbis, but the CatholicChurch still reserves the priesthood only formen. Women today often hold prominent positionsin their congregations and are more apt toreceive support for the decision to leave abusiverelationships, although some orthodox and fundamentalistreligious groups still hold on to thebelief of female submission to their husbands inevery circumstance.2.5. HomosexualityCondemnation of homosexuality, a sociallydivisive issue, is often based on several biblicalcitations. The Book of Leviticus containsmyriad laws, such as prohibitions against trimmingone’s beard, eating shellfish or pork, andwearing garments made of a mixture of linenand wool; in addition, adulterers, fortune tellers,and male homosexuals should be put to death.Although Christians are not obligated to followthe Levitical laws, most groups have selectivelychosen to uphold the prohibition against homosexualbehavior.Another source commonly cited in favor ofthis prohibition is from the book of Genesis,which tells the story of two angels dressed as menwho came to the city of Sodom. A man namedLot allowed them to stay in his home. A group oftownsmen surrounded the home and asked aboutthe two men, saying, “Bring them out to us thatwe may know them.” Frightened, Lot told themto leave his guests alone and offered his virginaldaughters in their place. The townsmen failedto break down the door and left. The next day,God rained fire and brimstone on the city, killingall its inhabitants, although Lot and his childrenescaped. The earliest interpretations of this storyfocused on the Sodomites’ arrogance and rudenessto strangers; God killed them for incivilityto his angels. The theme of sexuality emerged fullforce in the first century BC writings of Philo ofAlexandria, a Jewish historian. Rabbinical writingsabout Sodom generally did not mentionhomosexuality. Although some church fathersagreed with Philo, others did not, pointing to aparallel story in Chapter 19 of the Book of Judgesin which homosexuality was not implicated. TheSodomite townsmen wanted “to know” the men;the verb “to know” is used 943 times in JewishScripture, and in only ten places does it clearlyrefer to sexual intercourse. However, over time,the homosexual interpretation won out: the KingJames Bible translates the townsmen’s request,“that we may know them carnally,” whereas theNew English Bible says, “so that we can have sexualintercourse with them.” Some scholars refutethese translations and note that Lot was not a fullcitizen of Sodom. The townsmen were suspiciousbecause he had allowed two strangers to stay inthe city at night without asking permission of theproper officials and, thus, they wanted “to know”who the two men were.Jesus does not mention homosexuality.However, he did link Sodom with the inhospitalitythat his disciples might encounter whenpreaching (Matt. 10:14–15). St. Paul, who barelytolerated marital sexuality, seems to have disapprovedof homosexual behavior, but the exactmeaning of the specific words he used is unclear.In 1 Corinthians 5:11, for example, he includesin his list of the unrighteous who will not go toheaven people who are malakoi and arsenokoitai .The translations of these words vary widely andinclude effeminate, child molesters, homosexual,masturbators, immoral, sexually immoral,depraved, and male prostitutes.Paul’s other reference to homosexuality occursin chapter one of his Epistle to the Romans. Paul’smajor points here are that the just shall live byfaith and that the worship of idols in the image of

The Bible: Relevant Issues for Clinicians 43corruptible humans, birds, animals, and creepingthings has resulted in God’s wrath as manifestedby decaying moral standards and vile passions.Paul then lists examples: same-sex sex para phusin(against or in excess of nature), sexual immorality,wickedness, covetousness, envy, murder,strife, deceit, evil mindedness, back-biting, hatingGod, violence, pride, boasting, inventing evilthings, disobedience to parents, and being undiscerning,untrustworthy, unloving, unforgiving,and unmerciful.Paul clearly disapproves of homosexual acts,but what does the phrase para phusin mean? In11:24, Paul says that God could para phusin grafta wild olive tree onto a cultivated olive tree. Godsurely could not act immorally, but he could actin a way that is “unexpected, unusual, or differentfrom what would occur in the natural orderof things.” (10) Even the conservative Interpreter’sBible notes that Paul’s purpose in this section “is topoint not at sins, but to judgment.” It is likely thatPaul is not condemning homosexuality itself butrather mainstream Gentile men and women whohad overstepped their normal sexual practices. Infact, St. John Chrysostom’s fourth-century homilyon Romans stated that Paul’s disapproval ofhomosexual practices pertained only to peoplewho fall in lust and not to those who fall in love.Although homosexual behavior was commonthroughout the ancient world, the designationof a person as a homosexual did not occur untilthe eleventh century AD when St. Peter Damiancoined the word sodomia , thus establishing anabstract essence. Persons who indulged in sodomiawere thereafter referred to as sodomites(homosexuals).Homosexuality was listed as a mental disorderin the early editions of the American PsychiatricAssociation’s Diagnostic and Statistical Manualuntil 1973. In that year, a vote was taken by theassociation’s members, and a majority decidedto remove homosexuality from the official list ofmental disorders. Despite this action, the overwhelmingmajority of Christian churches havemaintained their positions that homosexualbehavior is sinful and a threat to social morality.In contrast, the general public has become muchmore tolerant as demonstrated by broad acceptanceof homosexuality on popular televisionshows and movies. Although some Christianchurches have ordained homosexuals as priests,the issue remains troublesome and has causedmajor conflicts. While the Catholic Church hasbeen disgraced in recent years by revelationsabout widespread priestly pederasty, it has beenlong known that many priests have a homosexualorientation. A study of homosexual priests foundthat 4 percent were celibate while the others averaged227 partners each.(11) In another study, of62 percent of priests who responded, 32 percenthad exclusively male sexual partners.(12)Case ExampleAn agitated, anxious, and guilt-ridden18-year-old man sought psychiatric help.He and all his family were born-againChristians. The patient confessed a lifelongattraction to men. He knew that this waswrong and said that he prayed and cried toJesus for help but that his feelings did notchange. When he told his family membersthey became furious with anger and hismother even called him an abominationwho had given himself over to the devil. Thepsychiatrist reassured the patient that hisfeelings did not constitute a mental illnessand discussed various interpretations of thebiblical passages regarding homosexualitywith a particular focus on the fact that Jesusoverthrew the Levitical laws, including theone ordering the death of homosexuals.The psychiatrist also met with the patient’sparents who, after discussing the matter,were somewhat less angry. He told themthat their son’s homosexuality was inbornand not a deliberate choice, and that therewas no treatment that could change a person’ssexual orientation. The parents agreedto send their son to a distant college andto allow him to return home for holidaysas long as he did not mention his homosexuality.They said that they would try toshow him Christian love but that it wouldbe difficult.

44 Armando R. Favazza2.6. HealingThe O.T. attributed most disease to God’s revengeagainst sinners. In Deuteronomy, God threatenedthe disobedient with all sorts of physicalills including insanity, blindness, severe fever,tumors, boils, and scabs. Because God causeddiseases, it seemed only logical to look to Godfor cures. Exodus 15:17 is the definitive OldTestament statement on God the healer. “If youdiligently heed the voice of the Lord your Godand do what is right in his sight, give ear to hiscommandments and keep all his statutes, I willput none of the diseases on you which I havebrought on the Egyptians. For I am the Lord whoheals you.”The most common acceptable “treatment”for sick Hebrews was prayer. The Hebrews led aspiritualized life in which God’s handiwork wasimplicit in every event. He was seen as the primemover in everything from famine and war tofamily discord and diseases. Because they diminishedGod’s position, formal medical practiceand magic were disdained by the early Hebrews.To remain healthy and to have a good heart, thebest approach was to follow God’s rules as writtenin the code of Moses. Many of the rules were,in fact, incidentally beneficial to public health.Rest one day a week. Eat vegetables with impunitybut avoid pork (pigs probably were sacredto some Semitic group; Moses didn’t know thatpork is often infested with parasites). Don’t pollutethe water supply. No incest. Wash frequently.Bury human excreta. Obey these rules and younot only stay on God’s good side, but you alsodecrease the possibility of getting sick.Things started to change in about the fourthcentury BC after the Hebrews returned fromtheir exile in Babylon. The priestly writers whoreedited the Bible put such an emphasis on puritythat physically “impure” humans, such as lepers,the blind, and the lame, were treated badly andexcluded from the Holy Temple (Lev. 13–14;2 Sam. 5–7). Perhaps it is purely coincidental,but the attitude toward physicians began tochange as handicapped and chronically ill personswere increasingly stigmatized by the priests.By 180 BC, Jesus the Son of Sirach wrote thatphysicians are needed and should be honored(Ecclus. 38). Likewise, sensible persons shouldtake medicines that heal and take away pain.When you are sick, you should pray to the Lordfor healing, but “there is a time when success liesin the hands of a physician.”In the N.T., Jesus revolutionized the approachtoward the sick. He actually welcomed the sickas well as socially marginal and even despisedpersons such as the blind, eunuchs, hunchbacks,dwarfs, cripples, tax collectors, and prostitutes.He immediately healed all the sick people whoapproached him, even on the Sabbath day. Hedid not take a medical or social history and didn’trequire confessions or a therapeutic relationship.Most important, he didn’t blame the sick forbeing sick. The early Christians accepted Christas the Messiah in great part because of his healings,which fulfilled O.T. prophecies.Almost 20 percent of the Gospels are devotedto Christ’s forty-one healing encounters. Hisusual technique was to say a few words and totouch the sick person. What types of illness didhe heal? The list includes the fever of Peter’smother-in-law; eleven lepers; a man with palsy,and one with dropsy or edema; the severed ear ofthe High Priest’s servant who had arrested him;a crippled man; a boy and a girl on the brink ofdeath; the woman with vaginal bleeding; a man’swithered hand; a centurion’s paralyzed servant;the dead son of a widow; four blind men; theblind and lame in the Temple; a blind, mute man;and, most of all, people who were possessed withdemons. He passed on the power to cast out(exorcise) demons to his twelve disciples and toall believers.For several centuries, healing through bothexorcisms and prayer was common in earlyChristianity and was effective in recruiting membersto the new church. However, once the churchwas officially recognized by the Romans, healingsgreatly diminished. This change was facilitated in400 AD when St. Jerome made an error in histranslation of the Bible into Latin. The classicN.T. model for healing was the text from James5:13–26. James wrote that sick people should call

The Bible: Relevant Issues for Clinicians 45the elders of the church to pray at their bedsideand anoint them with oil in the name of the Lord.They should confess their sins and pray for oneanother and “they will be healed.” Jerome madea mistake and translated the phrase as “they willbe saved.” Thus, spiritual salvation displaced thehealing of illness.Another major factor in the church’s neglectof healing was the increasing importance givento the biblical writings of Paul, who basicallyreclaimed the old Jewish concept that sick personsare sinners. Sickness itself was a consequenceof demons, idols, false gods, and all thehosts of wickedness in the universe. Paul himselfhad a sickness (probably epilepsy). He askedGod to cure him three times but God refused.According to Paul, God then said, “My grace issufficient for you, for my power is made perfectin weakness.” This was truly a brilliant, new idea:a handicap was transformed into an asset by perceivingit so. Instead of regarding an infirmitymerely as a defect or liability, declare it an opportunityto receive the power of Christ and makethe most of it. The upside of this reformulation isthe enhanced sense of self-worth that it providesto the disabled and chronically ill. The downsideis the potential for persons to accept their infirmitieswith passivity or even to harm themselvesdeliberately in pursuit of a higher, spiritual goal.The glorification of suffering has influencedChristian attitudes toward illness for almost twothousand years, and medical treatment was devalueduntil the eighteenth century. However, thechurch did encourage devotion to sacred relicssuch as the bones of saints and ascribed healingpowers to them. Specific saints were associatedwith differing body organs and diseases. St. Lucy,for example, supposedly enucleated her eyes tocalm the ardor of a suitor who had praised theirbeauty and, thus, became the patron saint of personswith eye diseases. St. Dymphna of Belgiumwas the patron saint of the mentally ill. Churcheswere built to display these relics and becamehealing shrines that attracted pilgrims.Relics lost their power to heal as medical practicebecame more scientific and effective. The onlymajor healing shrine today is in Lourdes, France.It was established in 1858 when a young girl hadvisions of a lady subsequently identified as theVirgin Mary. Several million pilgrims each yeartravel to Lourdes in search of healing, althoughthe Catholic Church has certified only about 100miraculous cures. Sick visitors to Lourdes returnhome uncured but usually feeling better. Patientsbenefit from the support of the family memberswho accompany them on their pilgrimage; fromsharing expectations for improvement with thousandsof like-minded patients; from participationin emotionally charged and spiritually upliftingceremonies that include fervent praying, hymnsinging, and a formal parade of children, priests,nuns, bishops, nurses, and physicians; and froma sense of expectant excitement. In the words ofJerome and Julia Frank (1991), (13) “The improvementprobably reflects heightened morale,enabling a person to function better in the faceof an unchanged organic handicap. Fully documentedcures of unquestionable and gross organicdisease are extremely infrequent – probably nomore frequent than similar ones occurring insecular settings.” Improvement seems to belinked with the intensity of the faith of patients.According to Cranston (1995), (14) those who feelbetter are “almost invariably simple people – thepoor and the humble; people who do not interposea strong intellect between themselves and theHigher Power.”The rebirth of interest in healing began in NewEngland at the end of the nineteenth century withthe development of the mind-cure movement. In1875, Mary Baker Eddy founded the Church ofChristian Science, which preached that sicknessis only a belief that can be destroyed by the divineMind, and that disease is simply fear made manifeston the human body. She considered medications,surgery, and hypnotism to be examplesof false beliefs and mortal illusions. Harvardpsychologist William James published his masterpiece,The Variety of Religious Experience , in1902.(15) He noted that mind-cures replacedmorbid beliefs with healthy-minded attitudes.“The whole matter can be summed up by onesentence: God is well and so are you. You mustawake to the knowledge of your real being.”

46 Armando R. FavazzaThe actual rebirth of Christian healing startedin Topeka, Kansas, in 1900 when a Methodistminister rediscovered the practice of speakingin-tongues(glossalalia) and was able to healsick people. His inspiration was a passage in theGospel of Mark (16:17), which states that believerswill not only speak in tongues but also lay handson the sick who will recover. His experience waswarmly embraced by the Pentecostal Church andled to the rise of preachers who became famousfor their healing sermons. Eventually, televangeliststook over the movement, which has grownto enormous proportions not only in the UntiedStates but also throughout Christian cultural areasaround the world. Today it is not uncommon for100,000 people to attend faith healing services atlarge arenas. While some of the so-called healersundoubtedly believe they are doing God’s work,many are charlatans who make a lot of money.Originally they focused on demon possession, butas people have become more sophisticated, theynow focus on demonic oppression, especially forpersons with impulse control disorders. Follow-upstudies have not found any long-lasting practicalresults from this type of “healing.” (16, 17)Many persons, including the mentally ill,engage in intercessory prayers to overcome theirillness. On three occasions in the Gospels Jesuspromises, “Whatever things you ask in prayer,believing, you will receive” (Matt. 21:22); “Ask,and it will be given to you” (Luke 11:9); and“Whatever you ask the Father in My name, He willgive you” (John 16:23). Unfortunately, intercessoryprayers are rarely, if ever, effective. If a persondoes recover from an illness, it is impossible toprove that prayers are responsible. Studies comparingsick persons who are prayed for at a distanceand without the knowledge of the patientshave failed to show better results than for controlgroups for whom no prayers are offered. A problemwith such studies is that people in the controlgroup may pray for themselves or may be prayedfor by relatives or hospital staff. When prayersare not answered, patients may be told that evenJesus’s prayer to his Father asking to be sparedfrom the crucifixion was not answered. In otherwords, God’s will takes precedence over individualdesires. He only answers prayers that are part ofhis own plan, which cannot be known in advance.Thus, whatever happens is God’s will.There is no harm in praying for healing, andparticipation in prayer-healing ceremonies fostershope and positive feelings that may help bothpatients as well as family members and friendsfeel better. This, in turn, may energize a sick person’snatural recuperative powers, perhaps byaffecting the immune system or by increasingmotivation in a rehabilitation program.Case ExampleAn obviously depressed woman soughtpsychiatric help. She described herself as adevoutly Christian woman whose 10-yearolddaughter had died six months earlier inan automobile accident. She said that shehad prayed at her daughter’s bedside dailyasking for God to cure the girl. She had aBible and even read aloud to the psychiatristthe passages cited above in which Godpromises to give believers what they askfor. She was angry with God and with herreligion. She had already heard the usualclichés, for example, “She’s in a better placenow”; “God had a special plan for her”; “Thegood die young.” The psychiatrist acknowledgedher loss and then told her that shewas depressed. He urged her to take antidepressantmedications and to enter therapyso that she could overcome her depressionand honor her daughter’s memory appropriately.He explained that depression is anillness that interferes with clear thinking. Heexplained that she should not come to anymajor decisions about God, her religion, orthe apparent senselessness of her daughter’sdeath until her depression had lifted and shecould then enter into meaningful dialogueswith God and her pastor.3. SOLACEIn the dullness of a fool, the Bible can seem foolish.In the grips of a zealot, it can suffocate thehuman spirit. In the hands of a psychopath, it can

The Bible: Relevant Issues for Clinicians 47rationalize greed, lust, and all the antisocial vices.It has been used to justify religious wars, slavery,racism, self-castration, anti-Semitism, and countlessother behaviors. But artists, authors, architects,and composers have been moved by the Bible toproduce some of the most sublime, beautiful, andmarvelous works ever created by humankind.Countless deeds of mercy and charity have beenperformed over the centuries in the pursuit of biblicalholiness and in imitation of Christ. And formore than two millennia, the Bible has providedsolace and hope to the vexed and the hopeless.Because the Bible is so vast and complicated,it can be interpreted to suit many purposes. If itwere an easy text, there would not be so manydivisions among both Christian and Jewishgroups. Yet many persons, including the mentallyill, often read the Bible to reaffirm their faith in aGod that personally cares for them and is alwayspresent for them. In their reading, they may discovera passage or bit of wisdom that has specialmeaning and allows them to continue living andto follow a certain course in life. Some patientsattend Bible study groups through their churchor through online or correspondence courses.For some, just holding the Bible in their hands orlooking at it on their bed table offers some measureof reassurance.Psychiatrists should have some knowledge ofthe Bible because it may be so important to someof their patients. It may be useful to remind religiouspatients who are noncompliant with theirtreatment that Jesus healed everyone who soughthelp, and that it is their Christian duty to recoverfrom their illness.REFERENCES1. Wur t hnow R . Sharing the Journey: Support Groupsand America’s New Quest for Community . NewYork , Free Press ; 1994 .2. Fox RL. The Unauthorized Version: Truth andFiction in the Bible . New York , Knopf ; 1992 .3. Wills G. A country ruled by faith . New York TimesBook Review Nov. 16, 2006 ;53.4. Favazza A . PsychoBible: Behavior, Religion, andthe Holy Bible . Charlottesville, VA , PitchstonePublishing ; 2004 .5. Podvoll E . Self-mutilation within a hospital setting. Br J Med Psychol . 1969 ; 42 : 213 –221.6. Favazza A. Bodies Under Siege: Self-Mutilationand Body Modification in Culture and Psychiatry .Baltimore, MD , Johns Hopkins ; 1996 .7. Ananth J , Kaplan HS , Lin K-M . Self-enucleationof the eye . Can J Psychiatry. 1984 ; 29 : 145 –146.8. Kushner AW. Two cases of auto-castrationdue to religious delusions . Br J Med Psychol .1967 ; 40 : 293 –298.9 . War n e r M . Alone of All Her Sex: The Myth andthe Cult of the Virgin Mary . New York , RandomHouse ; 1976 .10. Boswell J. Christianity, Social Tolerance, andHomosexuality . Chicago , University of ChicagoPress ; 1980 .11. Wagner R. Gay Catholic Priests . San Francisco,CA , Institute for the Advances Study ofHomosexuality ; 1980 .12. Murphy A. Delicate Dance: Sexuality, Celibacy andRelationships Among Catholic Clergy . New York ,Crossroads ; 1992 .13. Frank JD , Frank JB. Persuasion and Healing , 3ded. Baltimore, MD , Johns Hopkins UniversityPress ; 1991 .14. Cranston R. The Miracle of Lourdes . New York ,Popular Library ; 1955 .15. James W. The Varieties of Religious Experience .New York , Modern Library ; 1902 .16. Nolan W. Healing: A Doctor in Search of a Miracle .New York , Random House ; 1974 .17. Pattison EM , Lapino NA , Doerr HA. Faith healing. J Nerv Ment Dis . 1977 ; 157 : 397 –400.

5 Religion/Spirituality and NeuropsychiatryNADER PERROUDSUMMARYIn this chapter, we review the neurobiologicalbasis of spirituality and related religious experiences.We first focus on regions of the brain associatedwith mystical and spiritual experiencesshowing that increased activity in the frontaland temporal lobes is a key component of suchpractices. We then explore serotonergic and dopaminergicsystems in measures of spirituality. Inthis field, we mainly explore association studiesbetween genetic polymorphisms and spiritualityas a personality trait. These studies stronglysuggest a higher activity of serotonergic and dopaminergicsystems in individuals with high spirituality.We then propose a model encompassingboth religious activities and measures of spiritualityin connection with serotonergic and dopaminergicsystems. This explanatory model couldhelp to understand the complex link betweenpsychiatric disorders and spirituality.1. INTRODUCTIONSpiritual experiences, religion, and rituals may beviewed as the result of the evolutionary changesin the brain that have led humans to socializeand to form communities and societies. Withinthe evolutionary perspective, spirituality or religiousnesscould be seen as an advantageous toolfor human beings over other species. This couldbe understood as a complex neurochemical processoccurring in the brain. This view has ledresearchers to explore the brain’s neurochemicalactivity to explain some of the spiritual processeswe experience. However, dealing with the neurobiologyof religious and spiritual experiencesis a complicated and difficult task. A new way oflooking at the above would perhaps give us anopportunity to draw a biological picture. Here,we will discuss the neurobiological basis of spiritualexperiences and spirituality and also therole played by neurotransmitters. We will focuson the serotonergic and dopaminergic systems.The effect of genes and their possible interactionwith environmental factors in the understandingof spirituality will be tackled. As clinicians, ourthinking is driven by an attempt to understandthe possible impact of spirituality and its neurobiologicaland genetic effect on psychiatric diseases.Within this perspective, we will also linkspiritual neurobiological hypotheses to thesedisorders.Research has sought to understand spiritualityand religious experiences through twomain approaches: One has been concentratedon religious practices and meditation andtheir relationship with activities in the brain.The second has been based on the relationshipbetween genes and spirituality as a personalitytrait. In this chapter, we will briefly discussboth approaches.But first we will discuss serotonin and dopamineneurotransmitters, which have been specificallyinvestigated in terms of spirituality.2. SEROTONIN (5-HT) AND OTHERNEUROTRANSMITTERSNeurotransmitters are chemicals that relay messagesbetween the neurons in the brain acrossa gap called a synapse. These neurotransmitters48

Religion/Spirituality and Neuropsychiatry 49are distributed widely in the brain and coverspecific regions. They are synthesized in thepre-synaptic neuron and are released from thisneuron into the synaptic gap to act on a specificneurotransmitter receptor. They can bindonly to this specific receptor, and their effect isdetermined by this receptor. Several types ofneurotransmitters cause either excitement orinhibitory impulses. For example, glutamate isthe most important excitatory neurotransmitterin the brain, whereas gamma-aminobutyricacid (GABA) and glycine are inhibitory ones.However, we will focus on serotonin and dopamine,because they are the most investigated ofthe neurotransmitters in our subject area. Theycover the brain activities of both those whoare involved in religious practices and thoseinvolved in spiritual activities.5-HT are located in the brainstem in an areacalled the raphe nuclei. Their axons project inmany areas of the brain, notably the cerebralcortex, hypothalamus, limbic system, and thestriatum. These neurons modulate the activityof several brain regions by their inhibitory orexcitatory action on brain receptor subtypes. Inaddition, 5-HT is believed to play an importantrole in several psychiatric conditions includingdepressive disorders, anxiety disorders, suicidalbehaviors, aggression and anger-related traits,and even schizophrenia and similar disorders.Particularly, low levels of 5-HT have been associatedwith aggression, violent behavior, suicidaltendency, and clinical depression in humanstudies. As we will discuss below, 5-HT has alsobeen directly implicated in meditation and religiousexperiences.2.1. Serotonin or 5-hydroxytryptamine(5-HT)If both sympathetic (norepinephrine, adrenaline)and parasympathetic (acetylcholine)systems have been shown to be stimulated inmeditation and other related experiences (seebelow), serotonin (5-HT) and to a lesser degreedopamine have been the focus of geneticistsand neuroscientists. The involvement of the5-HT system in spiritual-like experiences issupported by observations that drugs (LSD, psilocybin)can induce spiritual experiences. Thesedrugs are known to perturb the 5-HT systemin several brain regions. They produce perceptualdistortions, illusions and hallucinations,and sometimes a sense of insight and spiritualawareness, mystical experiences, and religiousecstasy. These effects can resemble the perceptionsand ideation described by subjects whohave experienced spirituality. Some benefits or“side effects” of praying and meditation on psychiatricdisorders could be explained by a modulationof this neurotransmitter (see below).Although 5-HT can be found mainly in thegastrointestinal tract, 5-HT is also a monoaminethat serves as a neurotransmitter in thebrain. Serotonergic neurons that synthesize2.2. DopamineDopamine is produced in several areas ofthe brain. It is the primary neurotransmitterinvolved in the reward pathways and is commonlyassociated with the pleasure systemof the brain. Drugs that increase dopaminesignaling (like cocaine), particularly in thenucleus accumbens, may produce euphoriceffects. Psychostimulants, such as amphetamineand cocaine, induce dramatic changes indopamine signaling; large doses and prolongeduse can induce symptoms that resemble schizophrenia.Moreover, in the mesolimbic pathway,dopamine increases arousal and goal-directedbehaviors.Given its importance in many personalitytraits or dimensions such as anger-relatedtraits (1) and the main role of this neurotransmitterin the function of the frontal lobes, dopaminehas also been investigated in spirituality.Moreover, from a psychiatric point of view,perturbation of dopaminergic systems has beensuggested in psychiatric disorders includingschizophrenia, Parkinson’s disease, and drugand alcohol dependence. Of note, dopaminergicneurons are also under the control of the5-HT system.

50 Nader Perroud3. NEUROBIOLOGICAL BASISOF MEDITATION AND SPIRITUALEXPERIENCES: ANATOMICALPATHWAYS AND STRUCTURESMany of the major sources concerning the neuroanatomyof spirituality in humans are studies thatmeasure brain activity during deep religious ortranscendental practices such as meditation. Forinstance, the neuroscientist Andrew Newbergstudied the brain functions of subjects as theywere meditating or praying using several imagingtechniques.(2–4) Based on neuroimaging,neurochemical, hormonal, and physiologicalstudies, he examined several types of spiritualexperiences and practices. He proposed thatmystical and meditative experiences are measurableprocesses, and could be described a complexanatomical pathway that he implicated in spiritualand meditative experiences. Newberg foundseveral regions and pathways involved in meditativeactions (defined as a specific state characterizedby sustained attention, focus on an object, achange in the body’s spatial orientation and deafferentation,arousal, emotion, and relaxation).Some key cognitive functions such as abstractionof generals from particulars were, from his pointof view, crucial in the experience of meditationand spiritual experiences. As a result, Newbergstated, “These functions allow us to automaticallygenerate a causative construct such as spirits, godor power when no ‘observational or scientific’causal explanation is found.” He suggested thatconstruction of myths, spiritual powers, or godsis the only choice human beings have to explaintheir world or understand their environmentwhen no other explanation exists.3.1. Frontal Lobe, Limbic System,and Parietal LobeThe frontal lobe is one of the regions that hasbeen most implicated in religious activity.(5)Newberg (2–4) focused on the prefrontal cortexand its connections with the thalamus, posteriorsuperior parietal lobe, and limbic system (mainlythe amygdala and hippocampus). By measuringcerebral blood flow, he determined that thedeeper people descend into meditation or prayer,the more active the frontal lobe and the limbicsystem become. His observation was consistentwith other studies that found a higher activityof the frontal lobe during meditation or religiousrecitation.(6–9) The frontal lobe is the seatof concentration and attention; the limbic systemis where feelings, emotions, and behavioralemotional states such as ecstasy are processed.Interestingly, it seems that, at the same time thefrontal lobe and the limbic system are activated,the parietal lobe, which is responsible for temporal-spatialorientation, becomes less activated.(2, 6, 10 , 11) Taken all together, these findingsgive us a nice picture of a profound meditativepractice.3.2. The Temporal LobeTo a lesser extent, the medial temporal lobe hasalso been involved in religious activity, and individualswho were more spiritual have reportedstronger beliefs in paranormal phenomena.(12–15) These studies were in agreement withfour other studies (measuring brain activityeither by topographical electroencephalogram,cerebral blood flow, or cerebral metabolism)that found an activation of the temporal lobeduring religious practice.(6, 11, 16 , 17) Themedial temporal lobe comprises the hippocampus,which seems to be particularly importantfor memory function and is also part of the limbicsystem.3.3. Autonomic Nervous Systemand Other Related SystemsSystems such as the autonomic nervous system(sympathetic and parasympathetic systems)were also found to go through a significantchange in terms of activity during meditationand spiritual experiences.(18) Activation of theautonomic system creates a reduction in heartand respiratory rates, which in turn bringsabout a sense of relaxation. Although there havebeen many studies on the effect of religious and

Religion/Spirituality and Neuropsychiatry 51spiritual activity on the parasympathetic andsympathetic systems, it is not clear if both systemsare affected equally or not.It has also been proposed that the activationof the autonomic nervous system has an impactdirectly on the 5-HT level in the brain as demonstratedby higher urinary excretion of metabolitesof 5-HT during meditation.(19) This observationcould be linked to a higher level of 5-HT duringthese practices. However, in other studiesit appears that inhibition of 5-HT activity or atleast 5-HT deficiency is associated with spiritualityand religious beliefs and practices.(20, 21)Noradrenalin is also involved in such experiencesand is highlighted by a decrease in stimulation ofthe locus coeruleus, which produces and distributesthe noradrenalin throughout the brain.(22)Some studies also found increased activity inserum GABA (the main inhibitory neurotransmitterin the brain) during meditation. This possiblyreflects increased GABA activity in the brain linkedto the deafferentation observed during meditationpractice.(23) Finally, still other neurotransmittershave been shown to be involved during meditation,such as dopamine or glutamate.(22, 24) For example,Kjear et al., (24) in a functional imaging study,found an activation of the dopaminergic receptorsin the striatum during meditation, which reflecteda much higher level of dopamine in this region.However, a clear picture does not seem to emergefrom all these studies. Meditation and its relatedpractices are probably too complex to be simplyexplained by the way neurotransmitters performand change in the brain. Probably the main andmost consistent findings in all the above studiesare the increased activation of prefrontal temporalcortices and the limbic systems during meditationor religious experiences (versus parietal or occipitallobes). This should also be the easiest way tounderstand the possible link between psychiatryand spiritual experiences.3.4. Meditation, Spiritual Experiences,and PsychiatryMany studies have shown an association betweenaggressive behavior and frontal lobe braindamages.(25) Moreover, individuals showing avery high degree of aggression display low baselineactivity in their frontal cortex.(26, 27) It is postulatedthat the frontal cortex provides inhibitoryinput to the circuits in the thalamus and amygdalethat promote aggression.(28) Thus, higher activityin the frontal cortex is linked to reduced aggression.This observation is of particular interest inthe possible link between religious practices suchas meditation and psychiatric disorders.It has also been shown that prayer and meditationcan improve both physical and psychologicalstates.(29) Recently Mohr et al.(30) foundthat religious practice was significantly correlatedwith better coping among schizophrenic subjects.This information may be useful for clinicians inpsychiatric practice. In a recent study, Borras etal.(31) found that two-thirds of schizophrenicpatients considered spirituality very importantor essential in everyday life. They concluded thatreligion and spirituality contributed to the waytheir illness manifested itself and patients’ attitudetoward treatment. In another study, it wasfound that religion may play a protective roleagainst suicide attempts among patients withschizophrenia and schizoaffective disorder.(32)These results could be linked to a reduced aggressivenesspossibly associated with religious practice.This reduced aggressiveness may be causedby activation of the frontal lobe during religiouspractice. By helping individuals to meditate andso to increase the activity of their frontal lobe, wemay reduce the risk or magnitude of aggressivebehavior such as suicide attempts.Of note, numerous studies have demonstratedthat reduced levels of impulsivity and aggressivenessare associated with higher levels of5-HT. (33) This observation could also be linkedto the above-mentioned findings of higher levelsof serotonin during meditation. If this werethe case, spiritual practice (meditation or intensepraying) could act as a selective-serotonergicantidepressant. The latter acts on a specific transporter(see below) in the brain to enhance thelevel of 5-HT. This not only can treat depressivedisorders but also reduce aggressiveness. Butserotonergic antidepressants are also known,

52 Nader Perroudbecause of their action on 5-HT levels and secondarilyon dopamine systems, to enhance psychoticsymptoms in schizophrenic patients.Does the intensive practice of meditation havethe same effect on schizophrenic patients? Thisissue requires clarification, and further researchis needed before encouraging patients to performsuch practices.Finally, as discussed above, other neurotransmittershave been involved in spiritualexperiences, and most of them have been implicatedin different psychiatric disorders or endophenotypes(see below) such as those associatedwith aggressiveness or suicidal behavior. We willhere mention, for example, that dopamine andnoradrenalin have been involved in aggression.It seems that blocking D2 receptors (for example,with risperidone, an antipsychotic used totreat schizophrenia) can reduce aggression. Inthe same way, noradrenalin by enhancing arousalseems to be linked to aggression. The reports ofelevated dopamine levels during meditation orreligious trances (22, 24) could also be linkedto the dopaminergic hypothesis of schizophrenia.This hypothesis suggests that schizophreniais the result of overactivity or at least disturbedregulation of dopamine in the frontal lobe. Theobserved increase of dopamine during religiousactivities may have a deleterious effect on thesesubjects, because it may highlight or enhance psychoticrelapses.What is really the link between religious practicesand psychiatric disorders from the neuropsychiatricpoint of view is not very clear. It seemsthat, on one hand, it can reduce aggression. On theother hand, it can, as a side effect, enhance psychoticfeatures in schizophrenic patients. Cliniciansshould consider this issue and always discuss withtheir patients their religious practices. It is importantto know not only if they are believers, but alsothe intensity of their religious feelings.4. GENES, PERSONALITY,AND SPIRITUALITYGod, spiritual powers, or spirits are concepts wecan find all around the world in human culture.This is a strong indication that this concept issomehow preloaded in the human genome.Within the neuroscience and evolutionary perspective,a provocative question can be raised:Were human beings inspired by gods, spirits,or messages sent from above to create religionor did evolution bring about a sense of spiritualityor religiosity to bring together people incommunities and societies to help the evolutionof the species? If the second answer is the rightone, there might be a genetic background behindthis behavior. In other words, is it possible tofind genes for spirituality in humans, becausegenetic selection will have chosen individualswith higher beliefs to hold groups together? Is itnature or nurture that makes some people morespiritual than others?4.1. Spirituality as a PersonalityTrait or EndophenotypeThe first step in genetic studies is to find intermediatetraits called endophenotypes. An endophenotypeis an intermediary measure betweena gene-effect and a disorder. Endophenotypesare thought to be more influenced by genes thanwould be a complex disorder. For example, in thepath leading from genes to schizophrenia, onecould look at the association between one givengene and paranoid delusions, auditory hallucinations,or aggressiveness, which are all connectedto endophenotypes. The association betweenDNA variants and psychological phenotypes giveus the potential to find more easily which genesinfluence heritable psychological traits such aspersonality. For instance, in the path betweengenes and spirituality or religiousness, investigatorsfocused on personality dimensions.Classic genetic analysis emphasizes mendeliantraits. In mendelian diseases, such as cystic fibrosis,there is a strong correlation between the genotypesomeone carries and his or her phenotype/disease. In other words, a single gene is responsiblefor that condition within a family. But mostbehavioral traits are multigenic; it means thatthey are determined by several genes interactingtogether and with environmental factors. In

Religion/Spirituality and Neuropsychiatry 53contrast to single-locus mendelian traits, multigenictraits do not have a simple recognizablepattern of inheritance, and thus the relative contributionsof several genes to one trait are difficultto analyze. Nevertheless, determining whichgenes contribute to complex human traits hasprofound implications for the care and treatmentof human diseases.Convincing evidence shows that psychologicaltraits, including spirituality, are stable in timeand influenced by genetic factors to a significantdegree. Indeed, several family, twin, and adoptionstudies have shown that genetic factorsunderlie at least some individual differences inpersonality traits. This heritability is estimated tobe around 40 to 60 percent.(29, 34, 35) Most ofthese reports also suggested that genetic variationcould contribute to as much as 40 to 50 percentof the individual variation in terms of a person’sreligiosity. Based on this assumption, someresearchers focused their analyses on genes andgenetic polymorphisms mainly related to 5-HTand dopaminergic systems. They postulate thatreligious belief could be genetically driven andconsider spirituality as a personality component.Of note and contrary to spirituality, genetic analysesindicate that religious affiliation is primarilya culturally transmitted phenomenon.(34) In thesame way, how faithfully an individual practicesany religion (rituals such as attending services orthe degree to which he observes it) is dependentmore on environmental factors.Of particular interest is Cloninger’s descriptionof personality.(36, 37) Using theTemperamental and Character Inventory (TCI),he described the main temperamental dimensionsassociated with human behavior. From hispoint of view, differences in temperament arethought to be associated with activity in specificcentral neurotransmitter systems. Amongthese, the self-transcendence scale encompassesseveral aspects of religious behavior, subjectiveexperience, and the way an individual perceivesthe world. It has been found to be an importantcorrelate with an individual’s sense of coherence,self-esteem, hope, and emotional well-being inadults. It is considered as the most stable TCIdimension over time. Self-transcendence consistsof three subscales: spiritual acceptance, transpersonalidentification, and self-forgetfulness.High scorers on spiritual acceptance (or opennessto things not literally provable) endorseextrasensory perception and ideation, whetherit has to do with named deities or a commonunifying force. Low scorers, by contrast, tend tofavor a reductionistic and empirical worldview.Transpersonal identification has to do with atendency to feel connected to a larger universe,whereas self-forgetfulness refers to the ability toget entirely lost in an experience. Geneticists andneuropsychiatrists were therefore highly interestedin this personality trait and tried to understandit either from a genetic point of view orfrom a biological one. In the next part, we brieflylook at what a neurotransmitter receptor is andthen focus on the 5-HT receptor and studiesdone with spirituality traits. Then we will turnto the genetic aspect of the link between genesand spirituality.4.2. Neurotransmitter ReceptorA neurotransmitter receptor is a protein onthe cell membrane that binds to a specific neurotransmitterand initiates the cellular response.There are a thousand different receptors in thehuman brain, each specific for one neurotransmitter:5-HT, dopamine, cannabinoids, norepinephrine,and so on. For example, more than fivedifferent receptors have been discovered for dopamine:dopamine receptor 1 (DRD1), dopaminereceptor 2 (DRD2), and others. Neurotransmitterreceptors can be localized either postsynaptically,where their action is the recognition of specificneurotransmitters and the activation of effectorswithin the cell to give a specific message, or presynaptically,where they act as autoreceptors tomodulate the firing of the neuron, either inhibitingor exciting it.4.2.1. The Serotonin Receptor 1A (5-HT1A)As for dopamine receptors, several 5-HTreceptor subtypes have been identified in the brain.Among them, the 5-HT1A receptor has been the

54 Nader Perroudmost studied. These receptors are located bothpost- and presynaptically. Presynaptic 5-HT1Aautoreceptors are highly concentrated on cellbodies in the raphe and modulate the cell firingand release of several neurotransmitters in allbrain areas. Thus, the 5-HT1A receptor may havea role as general regulator of neurotransmitteractivity such as 5-HT and dopamine.In a recent positron emission tomography(PET) study, Borg et al.(20 ) found an associationbetween 5-HT1A receptor binding potentialand self-transcendence scores (a personalitytrait associated with spirituality, see previously)in healthy, male subjects. This association, however,depended completely on the subscalespiritual acceptance, which measures an individual’sapprehension of phenomena that cannot beexplained by objective demonstration. Whetherthe low 5-HT1A receptor density observed insubjects scoring high on a measure of spiritualityreflects low or high activity in 5-HT cortical projectionareas is not clear, and literature providessupport for both interpretations. Interestingly,several studies have found an abnormal densityof brain and platelet 5-HT2A and 5-HT1Areceptors in subjects suffering from some psychiatricdisorders. For example, it has been proposedthat 5-HT receptors may be up-regulatedin depressive disorder or in subjects displayingsuicidal behaviors as a compensatory responseto chronic low levels of 5-HT.(38 ) Followingthis hypothesis, low 5-HT1A receptor densityshould reflect higher 5-HT activity in the brainof subjects with high spirituality or at least ahigh efficiency of the 5-HT system. The resultscould be linked to the observed higher activityof 5-HT system during meditation and relatedexperiences. These findings could have importantimplications for the pathophysiology ofmany psychiatric disorders and the role of spiritualityin these conditions. However, it also hasto be stated that lower 5-HT1A receptor densityhas been linked to greater anxiety and chronicstress. The findings of Borg et al. are thereforealso consistent with the notion that those whoare more spiritual are biologically more prone toanxiety.(39 , 40 ) Understanding the complex linkbetween spirituality, the 5-HT system, environmentalfactors, and symptoms such as psychoticfeatures could help to find new ways to reducethe morbidity associated with several neuropsychiatricconditions. For example, activationof 5-HT1A receptors (by eltoprazine and other5-HT1A-receptor agonists) reduces aggressivebehavior.(41 ) Globally this observation adds tothe possible effect of religious practice on aggression.This should be taken into account in clinicalpractice.4.3. A Genetic PolymorphismA polymorphism is a genetic variant that appearsin at least 1 percent of a population, but in genetics,the term is reserved for variation in a population’sDNA. Genetic polymorphisms provide us with thepossibility to predict interindividual differencesin susceptibility to clinical disease. There are severaldifferent types of polymorphisms. The singlenucleotide polymorphism (SNP) refers to a variationof a single nucleotide (A, T, C, or G) within theDNA sequence between members of a species. Forexample, the following two DNA sequences fromdifferent individuals, AT T AGCC and AT CAGCC,differed by a single nucleotide, a C allele in place ofa T allele. The other polymorphism we shall consideris the insertion-deletion polymorphism. Aninsertion-deletion polymorphism is an insertion ordeletion of a part of the DNA that is found in somepeople but not in others. The sequence with theinsertion is normally called the long allele, whereasthe one with the deletion is called the short allele.Finally, short tandem repeat polymorphisms and/or variable numbers of tandem polymorphisms(VNTR) are short sequences of DNA that arerepeated numerous times in a gene.Polymorphisms may fall either within a codingregion or in a non-coding region. In the sameway they can change the amino acid sequenceof the protein. However, even if these polymorphismsare located in a non-coding region ordon’t change the amino acid sequence, they couldstill have great impact on the expression of theprotein. Given that, these variations in the DNAsequences can affect a number of diseases.

Religion/Spirituality and Neuropsychiatry 554.3.1. Insertion-Deletion in the PromoterRegion of the Serotonin Transporter Gene(5-HTTLPR)One important target of antidepressants,namely selective serotonin reuptake inhibitors(SSRIs), is the 5-HT transporter (5-HTT). It hastherefore widely been studied in depressive disordersbut also more broadly in several psychiatricconditions. Like many other neurotransmitters,5-HT is removed from the synaptic cleft by neurotransmittertransporters in a process calledreuptake . During the reuptake process, 5-HT istaken back into the axon terminal that released itso it cannot bind to its receptors. This reuptake isperformed by the 5-HTT.A forty-four-base pair (bp) insertion-deletionin the promoter region (a regulatory region ofDNA located upstream from a gene, providing acontrol point for regulated gene transcription) ofthe 5-HTT gene (5-HTTLPR) has been describedand shown to be functional (the short allele isassociated with reduced expression of the 5-HTtransporter and lower 5-HT reuptake activity).Nilsson et al. recently found that homozygosityfor the long 5-HTTLPR allele was associatedwith high scores of spiritual acceptance. The associations,however, were only found in boys.(42 )Interestingly, the long allele has been negativelyassociated with depression, anger- and aggression-relatedtraits, suicidal behavior, and otherpsychiatric conditions. Furthermore, homozygosityfor the long 5-HTT allele has been associatedwith high CSF levels of the 5-HT metabolite5-HIAA in nonhuman primates.(43 ) This resultadds weight to the hypothesis of a higher activityof the 5-HT system in spirituality. Interestingly, ithas been recently shown that 5-HTTLPR modulatesthe effect of stressful life events in severalpsychiatric outcomes.(44 ) This polymorphism hasalso been found to modulate the neuronal activityof the amygdala in response to fearful stimuli inhumans.(45 ) Indeed, homozygosity for the longallele of the 5-HTTLPR has been associated with adecreased amygdala reactivity and high capabilityto process environmental threat and to adaptivelycope with persistent stress. The Nilsson et al. findings,therefore, suggest a better function of the5-HT system in individuals with high spirituality.Given the role of this polymorphism and moregenerally of 5-HT in religiosity and spirituality, itcould be interesting to further investigate genesinvolved in 5-HT systems and religious behaviors.Why this association was observed only inboys remains a question to be debated. It remindsus of the association between 5-HT1A bindingpotentials and spiritual acceptance that was carriedin male subjects only. Gender differences inreligious behavior have been reported in the literature.(46) Taken together, these results indicatethat other uninvestigated variables such as environmentalor hormonal factors could govern thephenotypic expression of spirituality differentlyamong men and women. For instance, it has beenrecently found that the estrogen receptor alphagene may influence various aspects of personalityin women.(47 )Interestingly, Bachner-Melman et al., (48 )in an intriguing study analyzing genetic backgroundof dancers, found that the 5-HTTLPRgene was associated with spiritual facets of creativedance. They found that dancers carryingthe short allele of 5-HTTLPR scored high on theTellegen Absortion Scale, a questionnaire thatcorrelates positively with spirituality and alteredstates of consciousness. They unfortunately donot discuss why the short allele was linked to thisscale. It is not unusual to see discrepant geneticassociations with any one given trait in geneticstudies. They mainly reflect some undetectedbias such as ethnicity or gender. Nevertheless,these results, as well as those from Nilsson et al.,suggest an involvement of the 5-HT system inmanifestation of spirituality.4.3.2. Single Nucleotide Polymorphisms inthe 5-HT Receptors and SpiritualityBorg et al.(20 ) identified, as mentioned above,a relationship between self-transcendence and5-HT1A receptor binding potential. Someinvestigators were therefore interested in singlenucleotide polymorphism (SNP) within thegene’s coding for 5-HT receptors. These authorsreported associations of genotypes of the 5-HT1Areceptor and the 5-HT2A and 5-HT6 receptors

56 Nader Perroudwith self-transcendence. A functional variant inthe promoter region of the gene coding for the5-HT1A receptor has been reported. It is a C toG substitution, which was demonstrated to beinvolved in modulating the rate of transcriptionof the 5-HT1A gene.(49 ) The 5-HT1A G variant issupposed to result in an enhanced 5-HT1A autoreceptorexpression, whereas the C variant resultsin a lowered 5-HT1A receptor expression and inconsecutive enhanced 5-HT activity. Lorenzi et al.(50 ) found that individuals with two copies of theC allele had lower self-transcendence scores thancarriers of the G allele. Their results support theinvolvement of 5-HT1A receptors in human spiritualimplications. However, Borg et al. found lower5-HT1A receptor binding potentials in subjectswith high self-transcendence scores. Based on thatfinding and due to a lower 5-HT1A receptor density,they suggested that high self-transcendencescores were possibly linked to high 5-HT release.Given this hypothesis and the functionality of the5-HT1A polymorphism, the C variant should normallyhave been found to be associated with highself-transcendence scores. These conflicting resultsare difficult to explain and several reasons couldbe given. We refer to the explanations given byLorenzi et al. in their article. We will just say thatthe path between a given SNP in a gene and a givenphenotype such as the 5-HT1A receptor densityin the human brain is far more complex than inanimal or laboratory studies. A polymorphismthat is supposed to enhance 5-HT1A expressionin cell culture could have totally different implicationsin the human beings. As highlighted byLorenzi et al., “Molecular genetic studies cannotcover and explain subsequent biological, developmental,and environmental modulating process,which ultimately produce a definite phenotype.”Nevertheless, taken together these results providefurther evidence of the involvement of serotoninergicsystem in the self-transcendence charactertrait. Interestingly abnormal 5-HT1A receptorsignaling in brains of psychiatric subjects includingdepressive subjects and suicide victims and/or attempters has been found.(51 ) The functional5-HT1A C-1019G (rs6295) variant in the promoterregion of the gene has been associated with majordepression, anxiety-related traits, and suicide.(30)More broadly, 5-HT receptors haven been implicatedin a large range of psychiatric conditions.Given the implication of 5-HT receptors in spirituality,researchers should try to better understandthe complex links between spirituality and psychiatricconditions, not only from the clinical point ofview, but also from the genetic perspective.The function of the 5-HT6 receptor is notwell understood. It is abundant in the limbic systemand thus should have some involvement inmood disorders and personality traits. Ham etal.(52 ) studied two other polymorphisms: onein the gene coding for the 5-HT6 gene, a silentpolymorphism that consists of a T to C substitution(C267T), and another functional one locatedin the promoter region of the 5-HT2A gene, theA-1438G. In a Korean sample, they found thatsubjects heterozygous for the A-1438G polymorphismof the 5-HT2A receptor and/or those carryinga C allele of the C267T scored significantlylower on the self-transcendence scale. Of note, theA allele of the A-1438G polymorphism has beenassociated with suicide and impulsive traits.Interestingly, the psychotropic effects of LSDare attributed to its strong partial agonist on5-HT2A receptors. Given the mystic-like experiencesobtained when taking this drug and theimplication of 5HT2A receptors in spirituality, arelative hyperactivity of the 5-HT system shouldbe suspected.4.3.3. Other Polymorphisms Associatedwith Measures of Spirituality: The DopamineTransporter and the Activating Protein-2(AP-2)4.3.3.1. Dopamine receptorsDopamine receptors are distributed throughoutthe central nervous system and are involvedin many processes such as motor control, learning,pleasure, motivational behavior, and rewardseeking. As mentioned above with 5-HT receptors,there is more than one dopamine receptor,and dopamine receptors are also located in preandpostsynaptic levels. DR2 are, for instance, thetarget of antipsychotics.

Religion/Spirituality and Neuropsychiatry 574.3.3.1.1. Polymorphisms in the DopamineReceptor 4 gene (DRD4)The gene coding for the Dopamine Receptor4 (DRD4 ) is highly polymorphic, although mostof the research in psychiatry and personalityfocused largely on a variable number of tandem(VNTR) polymorphisms in exon 3. These polymorphismshave been shown to be functional.(53 ) Following the Cloninger hypothesis, whichsuggested an involvement of dopaminergic systemsin some dimensions of personality, (36 , 37 ,54 ) Commings et al.(55 , 56 ) were intrigued bythe considerable role of dopamine genes, and theDRD4 gene in particular, in spiritual transcendence.As already said, dopamine receptors, andespecially DRD4, play an important role in thefunction of the prefrontal cortex. The DRD4 geneis indeed expressed in a high level in the frontalarea and the nucleus acumbens, (57–59) regionsassociated with affective and emotional behaviors.(57) Because spirituality may especially usethe prefrontal cortex, it should use dopaminergicsystems. From this perspective, Coming etal., (55 , 56 ) in two consecutive studies investigatingseveral polymorphisms (including theVNTR) in the DRD4 gene, found a significantrelationship between spiritual transcendence andDRD4 receptor polymorphisms. At a lesser level,Comings et al. also found other dopamine receptorsto be associated with spiritual transcendence.Their results suggest an involvement of DRD4in the personality trait of spiritual acceptance.Their authors concluded that this may be a functionof the high concentration of the dopamineD4 receptor in the cortical areas, especially thefrontal cortex. Dopamine is thought to increasecreative drive of idea generation. This involvementin creativity could be linked to spirituality.Indeed, as previously mentioned, creative dancecorrelated positively with spirituality and alteredstates of consciousness. So better dopaminergictone in people carrying particular genotypes ofthe DRD4 gene could lead people to seek spiritualityand religious practices to give them pleasureor euphoria through higher effectiveness ofDRD4 receptors and also because these practiceshave been shown to enhance dopamine levels(see upstream). It has effectively been argued thatthe activation of the dopaminergic system duringmeditation and other religious activities may berelated to the seeking of these activities.(4 )However, the link with spirituality is far morecomplex than this single association would tell us,because it has been shown that the dopaminergicsystem is under the control of 5-HT1. Indeed,stimulation of 5-HT2A and 5-HT1A receptors –half of the dopaminergic neurons in the medialprefrontal cortex (mPFC) express 5-HT2A receptors– can elicit dopamine release.(60 , 61 )4.3.3.1.2. Activating protein-2 (AP-2)Transcription factor AP-2 (activating protein-2[AP-2]) is a specific DNA-binding transcriptionfactor family. In one sense, it participates in andregulates specific neural gene expression and hasbeen shown to be involved in neural survival,death, and development.(62 , 63 ) In particular,gene coding for dopamine transporter and5-HTT displays multiple AP-2 binding sites intheir regulatory regions. It has been proposedthat AP-2, by its regulation of monoaminergicgenes (dopamine and 5-HT), could affect therelease and metabolism of 5-HT and dopaminein the frontal cortex. Because dopamine receptorsand 5-HTT have been implicated in personalitytraits and spirituality, one might speculateAP-2 could interactively influence these traits.Different isoforms of the AP-2 family have beenidentified, including the AP-2β. One polymorphismof interest for spirituality in the gene codingfor the transcription factor AP-2β is a four basepairrepeat polymorphism in the second intron(CAAA,) which has been associated with anxiety,binge-eating disorder, and levels of homovanillicacid. Homovanillic acid is a metabolite of majorcatecholamines like dopamine. Nilsson et al., (42 )in the same paper investigating 5-HTTLPR, founda significant association between this repeat polymorphismand Self-Transcendence. Again andas observed for 5-HTTLPR, this association wasobserved only in boys and showed that carriersof the short allele (less repeat) had higher selftranscendencescores. Interestingly, this observationwas also completely explained by the subscale

58 Nader Perroudspiritual acceptance. However, in girls and not inboys, they found an interactive effect of the genotypesfor 5-HTTLPR and AP-2β. Indeed the presenceof the LL genotype of 5-HTTLPR and theshort allele of the AP-2β polymorphism resultedin low scores in self-transcendence whereas highscores were associated with a short allele of 5-HT-TLPR and a short AP-2β allele. The inverse patternwas observed for the homozygous of the longallele of the AP-2β.AP-2 and other transcription factors regulatethe expression of a number of monoamineneurons during development and also a varietyof candidate genes involved in psychiatric disorders.These transcription factors are thereforegood candidates for explaining interindividualdifferences in temperament and psychiatric vulnerability.For instance, it has been proposed thathomozygosity for the long AP-2β allele couldbe associated with low central 5-HT activity. Inother words, the results of Nilsson et al. suggestedthat low self-transcendence/spiritual acceptanceare linked to low central 5-HT activity throughthe AP-2β genotype. This hypothesis is concordantwith the above results showing not only aninvolvement of 5-HT in spirituality but also thehigher activity of 5-HT system during meditationsand related experiences.4.3.3.1.3. The cytochrome P450 2C19(CYP2C19) polymorphismThe gene coding for the CYP2C19 enzymemainly involved in the metabolism of sex hormonesis also highly polymorphic. Of interest inour subject, this enzyme has been implicated inmultiple brain functions and also catalyzes themetabolism of 5-HT.(64 ) One study in a Japanesesample (65 ) found that in females, scores of selftranscendencewere lower in those consideredas poor metabolizers (given their genotype)than those considered as extensive metabolizers.Because these results were based on womenonly, we may assume an involvement of sexhormones, and especially, a higher testosteroneconcentration.Considering the progress in gene-environmentinteraction studies and its effect on complex traitssuch as spirituality, it would be of interest to takeinto account environmental factors in furthergenetic studies on spiritual traits. The importanceof gene-environment interactions in research andespecially in psychiatric research will be discussedb elow.5. GENE-ENVIRONMENTINTERACTION AND CORRELATION5.1. Gene-Environment InteractionRecently, research has paid attention to the geneenvironmentinteraction as a new and differentcomprehensive model of psychiatric disorders.(66 ) Classical approaches in genetic psychiatricresearch assume a direct path between genesand behavior. The goal of this approach is toassociate psychiatric disorders or intermediatephenotypes (or endophenotypes such as spiritualtranscendence) with individual differencesin DNA sequences. However, many studieshave failed to replicate previous findings, andbecause of inconsistent findings, many scientistshave abandoned this approach. A recentand promising approach is the understanding ofcomplex disease and personality traits throughthe gene-environment interaction approach, orGxE. GxE typically occurs when the effects ofone given environmental factor on one individualis dependant on his or her genotypebackground. For example, exposure to cannabisis a well-known environmental pathogenthat elicits the development of schizophrenia.However, not all individuals smoking cannabiswill develop schizophrenia, only those whohave a genetic vulnerability will. Another classicalillustration of GxE is the phenylketonuria.Children with two abnormal copies of the genethat codes for phenylanaline hydroxylase, a keyenzyme that converts the amino acid phenylanalineto another amino acid thyrosine, express thedisease. Accumulation of phenylanaline in theblood of children who lack both functional copiesof the gene leads to abnormal developmentof the brain and mental retardation. However,a simple reduction of phenylanaline intake by

Religion/Spirituality and Neuropsychiatry 59a restricting regimen completely prevents themental retardation. Phenylketonuria is a particularlyclear example of GxE. The environmentalfactor (diet) is necessary for the expression ofthe disease. In contrast to the main-effects studies,GxE studies do not necessarily expect anassociation between gene and behavior/disorderin the absence of an environmental factor.Measures of spirituality and religiousness aretypical examples of complex traits that could beunderstood by GxE studies. As with complexdiseases, the absence of perfect concordance inmonozygotic twin studies indicates a nongeneticcontribution to spirituality. Moreover, fromthe previous findings (see above), environmentalfactors such as hormonal levels (as a reflection ofgender effect), diet, drugs, region of origin, andso on seem to play a key role in the comprehensionof this trait.A great deal has been learned about the role ofgenetic influences on personality in recent years,but this has raised many additional questions,including those concerning the influence of environmentalfactors and the nature of their interactionin spirituality. How environmental factors,such as diet, drugs, hormonal levels, and parentalcare, and developmental adversities, such aschildhood trauma or stressful life events, interactwith genes to modulate measures of spiritualityshould be a subject for further research.5.2. Gene-Environment CorrelationFollowing recent findings of genetic sensitivity toenvironmental factors, most studies investigatinggene-environment interplay focused on GxE.However, few of them were interested in geneenvironmentcorrelation (rGE) or even tried toidentify one in their samples. rGE typically reflectsgenetic differences in exposure to particular environments.As mentioned above, GxE refers to theinfluence of environment on the expression of onegiven gene. rGE, in contrast, refers to the geneticinfluences on environmental exposure. As earlyas the 1960s, personality researchers discussedthe role of the person in producing her or hisenvironment.(67 ) The person’s behavior was notseen as a consequence of solely situational contexts.In their view, it was suggested that people’spersonalities influence the way others respond tothem and, in this way, influence the choice of how,where, and with whom they were going to interact.As previously discussed, and based on severalstudies showing the importance of the geneticcomponent on individual differences in personality,we suggest that the genetically driven wayan individual is going to behave will influencethis individual’s exposure to a particular environment.In the end, such interactions betweengene and environmental influences could makecertain environmental influences heritable. Thisis referred to as rGE.(68 )If we take the example of spirituality, there arethree different types of rGE.5.2.1. The Passive rGEPassive rGE refers to the interaction betweenthe environment in which a child is raised and thegenes he inherits from his parents. For example,a child carrying a gene susceptible to spiritualitymay grow in a family with high spirituality, whichwill in turn elicit the expression of genes of spiritualityin that child. Because parents who showa sense of spirituality (which has been shown tobe heritable, see above) tend to elicit spiritualityin their children, a highly religious environmentmight be a marker for the genetic vulnerabilityparents transmitted to their child rather than acausal risk factor for child spirituality.5.2.2. The Evocative rGEEvocative rGE refers to the association betweenthe individual’s genetically influenced behavior andthe reaction of others to that individual’s behavior.For example, an individual who is geneticallydriven to behave in a spiritual way will attract theattention of other like-minded people. The latterwill then bring him into a spiritual environment.For example, one can find that good copingamong schizophrenic subjects is the result of aninteraction between a genetic polymorphism anda religious environment. This interaction couldbe, in fact, the reflection of a hidden evocativerGE. In the latter, a schizophrenic subject may,

60 Nader Perroudby his behavior, elicit a spiritual environmentbecause of his or her particular genotype. This inturn will enable the individual to cope better.5.2.3. The Active rGEActive rGE refers to the association between anindividual’s genetically influenced traits and theenvironmental niches selected by this individual.For example, individuals who are highly spiritualmay seek out religious community to expresstheir spirituality. Here the individual, becauseof his genetic background, will actively seek anenvironment that will enhance the expression ofhis genes. Contrary to the latter, with the evocativerGE, the individual will be “discovered” bythose around him.All these examples illustrate how, in some cases,a genetic effect can be detected or have a differentimpact on a trait only when an environmentalvariable is taken into account. The major questionin studies dealing with spirituality is this: Whichenvironmental factor should one study in relationto this trait? Personality seems to be influencedby parenting style. The intensity of parental careor the intrusiveness of parents should probablybe important environmental candidates. Otherenvironmental factors are presupposed. It hasbeen found that religiousness has a large sharedenvironmental component (that is, environmentalfactors shared by close relatives), especially inchildhood and adolescence. For example, heritabilityfactors for religiousness may have less influencein childhood than in adulthood, showingthat age is an environmental moderator of theheritability and should be taken into account.(35 )As mentioned above, hormonal levels (partiallyunder genetic control also), ethnicity, and drugsare also putative environmental factors.The demonstration that early environmentalfactors could considerably strengthen or even highlightassociations between genes and personalityis a promising new area of research in complexbehavior. The publication by Caspi and his coworkers(66 ) showed what was widely hypothesizedbut rarely demonstrated. This important workstated that both nature and nurture contribute tothe shaping of behavior. Many studies have sincetried to find such interaction in psychiatry. Forexample, it has been shown that individuals sexuallyabused in their childhood displayed higherrisk of making a violent suicide attempt only ifthey were carrying a particular genotype.(69 ) Suchstudies should be promising in the understandingof spirituality. However, human personality andspirituality are complex traits and require a moreencompassing view to understand their geneticand molecular architecture.5.3. Religious Activity asan Environmental Factor?Contrary to spirituality, religious activities, whichare supposedly less heritable and so less underthe influence of genes, could be seen as environmentalfactors. Given the impact of meditationon 5-HT, dopamine levels, and the functioningof the brain, it would be surprising if religiousactivities did not have an impact on the geneexpression. Within this perspective, Timberlakeet al.(70 ) investigated the moderating effects ofthree styles of religiosity (religious affiliation,organizational religious activity, and self-ratedreligiousness) on the genetic and environmentaldeterminants of smoking initiation. They foundthat self-rated religiousness moderated geneticinfluences on the likelihood for smoking. Thiskind of study could also have a huge impact onpsychiatric disorders. If we consider religiouspractice as an environmental factor, it would beinteresting to know, based on an individual’s genotype,which individual is susceptible to respondfavorably and which is not.6. CONCLUSIONThe results from the present review might suggestthat a high degree of spirituality is linked to5-HT and dopaminergic systems. In the initialCloninger hypothesis, it was proposed that differentpersonality traits were influenced by genesrelated to 5-HT, and dopaminergic and noradrenalin-relatedgenes. The above studies of 5-HT anddopaminergic genes suggest higher levels of activityin both systems, not only in individuals with a

Religion/Spirituality and Neuropsychiatry 61DRD4CYP2C19Higher Dopaminelevels in the frontallobeAP-2β5-HTTLPRHigher levels of 5-HT in the brain5-HT1A and other5-HTHormones level,ethnicity, age,parental care,rearingenvironment…Higher concentration of Dopamine receptor(DRD4)Lower density of 5HT1A receptors and other5HT receptorsHyper-activity of DA systemHyper-activity of 5-HT systemDrugs: LSD,cannabis,cocaine,amphetamines…SpiritualityMeditation and religious practicesActivation of frontal, temporal and limbic systemsFigure 5.1. Serotoninergic and dopaminergic systems in spirituality and religious practices.high sense of spirituality but also during religiousactivities such as meditation. It can be speculatedthat, during the development of the midbrainneurotransmitter systems, early geneticallydriven modulation of the 5-HT and dopaminesystems participate in the formation of spiritualityin adults. We can now try to draw a biologicalpicture of spirituality and religious practices( Figure 5.1 ). In this model, individuals carryingparticular genetic polymorphisms within 5-HTT,DRD4, CYP2C19, 5-HT1A, 5-HT2A, 5-HT6,and AP-2B genes (either directly or interactingtogether) will have, through different pathways, arelatively higher level of 5-HT and dopamine inspecific areas of their brain. As a secondary sideeffect, this will enhance the sense of spiritualityin individuals and possibly religious practices.To be complete, this model should also includeenvironmental factors modifying either geneexpression or 5-HT and dopamine levels.These hypotheses are only speculations basedon limited research. The reality of spiritualexperiences and individual beliefs is far morecomplex than this simple model. Our purposewas only to review current knowledge onthe biology of spiritual experiences. “God onlyknows” if one day we will be able to explain allour thoughts and feelings by neurobiology.REFERENCES1 . B a u d P , C o u r t e t P , Pe r r o u d N , Jo l l a n t F , B u r e s i C ,Malafosse A . Catechol- O -methyltransferasepolymorphism (COMT) in suicide attempters:a possible gender effect on anger traits .Am J Med Genet B Neuropsychiatr Genet .2007 ; 144 (8): 1042 –1047.2. Ne w b erg A , A l av i A , B ai me M , Pou rdehnadM , S ant anna J , d’Aqu i l i E . The measurement ofregional cerebral blood flow during the complexcognitive task of meditation: a preliminary SPECTstudy . Psychiatry Res . 2001 ; 106 (2): 113 –122.3. Ne w b erg A , Pou rdehnad M , A l av i A , d’Aqu i l i E G .Cerebral blood flow during meditative prayer:preliminary findings and methodological issues .Percept Mot Skills . 2003 ; 97 (2): 625 –630.4. Ne w b erg AB , Ivers en J . The neural basis of thecomplex mental task of meditation: neurotrans-

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6 Religion/Spirituality and PsychosisPHILIPPE HUGUELET AND SYLVIA MOHRSUMMARYPsychotic disorders such as schizophrenia arefrequent around the world and account for agreat amount of disability. Antipsychotic treatmentsimprove symptoms, but do not often allowpatients to regain their full social capacities. Inthis context, it is crucial to help patients recover,that is, to find ways to lead a fulfilling life andto develop a positive sense of identity foundedon hopefulness and self-determination. In thisperspective, it appears that religion/ spiritualitycan be an important component of recovery.Additionally, it can be an essential coping mechanism,helping patients to deal with the symptomsof illness, social difficulties, and so on. Even ifreligion/spirituality may cause distress to patientswith psychosis, studies show little evidence thatreligion/spirituality fosters or triggers psychoticrelapses. Psychosocial approaches (both individualand group) can address religious issuesthrough fostering social integration in patients’religious communities and working on identityand meaning. Individual treatments may alsoaddress spiritual crisis. Overall, the clinician’sgoal should be to negotiate a common worldviewwith patients in domains concerned withtheir care, integrating both their beliefs and secularpsychiatric knowledge. This is particularlycrucial in cultural contexts in which traditionaland/or religious healing may be of more importancethan in Western countries.1. THE RELATIONSHIP BETWEENPSYCHOTIC DISORDERS ANDRELIGION/SPIRITUALITYReligious issues have only recently been consideredin relation to psychiatry. This may be dueto several factors: an underrepresentation of religiouslyinclined professionals in psychiatry thatcan be observed among both North American (1)and European psychiatrists, (2, 3) a lack of educationon religion or spirituality for mental healthprofessionals, (4) and the tendency of mentalhealth professionals to pathologize the religiousand spiritual dimensions of life.(4, 5) The neglectof religious issues in psychiatry may also reside inthe rivalry between medical and religious professions,which issues from the fact that both professionsdeal with human suffering.(6, 7) Thingsmay be even more complicated when consideringpatients with psychotic disorders, mostly dueto entanglement of religion with the illness. Asdescribed later, some patients may present withsymptoms involving religious content; others (perhapsthe very same patients) may consider religionthe most important thing in their lives.Many questions arise about the relationshipbetween religion and psychiatry in individualswith psychotic disorders:■■Does religion affect the development ofpsychosis?Are there situations in which religion may beharmful to patients with psychosis?65

66 Philippe Huguelet and Sylvia Mohr■■■■■Are patients with psychosis more prone toengage in religious activities?Can religious coping help patients withpsychosis?Does religion have an effect on patients’outcomes?What about delusions with religious content(this point will be discussed in Chapter 7)?How can clinicians deal with the religious issuesbrought forth by patients with psychosis?The goal of this chapter is to answer thesequestions.2. OUTLINEAfter defining certain terms, the history of therelationship between psychosis and religion willbe briefly described. Some of the medical aspectsof schizophrenia and other psychoses will thenbe presented, that is, diagnostic and epidemiologicalissues, descriptions of known risk factorsfor schizophrenia, particularly the relativecontribution of biological versus psychosocialfactors. These aspects provide justification forthe paradigms that shed light on psychosis asa construct. Given the advantages of a holisticapproach to psychosis in its biological, psychological,and social dimensions, the role that religion/spiritualitymay play will be described.Studies on psychosis and the role religion mayplay – negative or positive in terms of coping andoutcome – will be described.Practical notions of how to deal with religious/spiritual aspects of the care of patients with psychosiswill be discussed, including assessment,individual and group treatments, and how towork with the clergy and religious leaders.Finally, we will describe a multicultural perspectiveon ways that psychosis is understoodand treated across countries, taking religious factorsinto account.3. DEFINITIONSPsychosis is not equivalent to schizophrenia. Infact, the term psychosis – and psychotic – is usedeither to describe symptoms (that is, psychoticsymptoms) or diagnoses, which can be definedas “mental disorder[s] in which the thoughts,affective response, ability to recognize reality, andability to communicate and relate to others aresufficiently impaired to interfere grossly with thecapacity to deal with the reality.” (8)In the present chapter, we use the term schizophreniawhen the aim is to discuss elements pertinentto this diagnosis. The term psychosis is used torefer to the broader group of psychotic disorders,that is, schizophreniform disorder, schizoaffectivedisorder, delusional disorder, brief psychotic disorder,and so on.Some patients may present with psychoticsymptoms such as delusions and hallucinationswithout suffering from psychotic disorders (forexample, in mood disorders). That’s why thisbook includes a special chapter, distinct fromthe present one, on delusions and hallucinationswith religious content.The definitions of religion and spirituality arefound in the first chapter. To simplify the reading,the term religion will be used to refer to both religionand spirituality, unless both terms are necessary.4. RELIGION AND PSYCHIATRYIN THE HISTORY OF PSYCHOSISLittle is known about how psychosis wasexpressed in very ancient times. The lack of literatureon this topic leads some authors to believethat psychosis was rare, if not absent, in antiquity.(9) This controversial view gives some weight tothe argument that psychosis may be – at leastpartially – due to infectious causes, that is, factorsthat may have become more salient whenhumans began to move across continents.Religions affect how the mentally ill areunderstood and cared for. In the early Christianchurches, mental illnesses were thought to becaused by possession by demons, and sacramentalhealing and exorcism were practiced. The Christiannotion of compassion for the poor and sufferingled to the creation of hospitals for the mentallyill. However, during the Inquisition, Christianchurches showed great cruelty toward the mentally

Religion/Spirituality and Psychosis 67ill. Overall, Christian views of mental illness oscillatedbetween the biological and the spiritual.(10) In Islam, mental illness was considered to bea medical condition, and care for the mentally illwas an intellectual and academic tradition datingback to the Middle Ages. The illness was consideredas a blessing to believers. The mystical traditionof Islam provided traditional religious healing.For instance, Islamic hospitals were built duringthe ninth and tenth centuries (11) that encouragedprayers and incantations as choice of treatment. TheKoran’s precepts were the source of medical practicesthat spread throughout the Islamic world.(12)This complemented Galenic approaches, togetherwith music therapy. Eastern traditions (Hinduism,Buddhism, Confucianism, and Taoism) provideddifferent models of mental illness, with a focus onexistential and transpersonal issues. Buddhismemphasizes compassion and the importance of lifein this world, which led to the care of the mentallyill in hospitals, monasteries, or families.(13)In Europe, asylums were built across the nineteenthcentury, leading – at least at the beginning – tohelp protect individuals with serious mental disorders.Unfortunately, due to financial constraints(among other reasons), these asylums becameplaces of seclusion, at least until the arrival ofantipsychotic medications. These medications ledto a “deinstitutionalization” which brought aboutreal improvement in the living conditions of somepatients and further neglect for others.A nosological distinction between psychosisand affective states (mood disorders) wasfirst made in 1874 by Kraepelin. In 1911, Bleulerintroduced the term schizophrenia . These authorsemphasized organic factors in the etiology ofschizophrenia.(14) Later, due to Freud’s work,schizophrenia was conceptualized as a psychologicaldisorder in which religion could play anegative role. Today, a general consensus givesprevalence to a bio-psycho-social model thatmakes it possible to understand psychosis in variousways. Each of these approaches completes theother rather than excluding it. In this perspective,both the positive and negative facets of religioncan be considered, complementing to other psychological,social, and biological aspects.5. THE CAUSES OF PSYCHOSIS –THE RELATIVE CONTRIBUTIONS OFBIOLOGICAL VERSUS PSYCHOSOCIALFACTORSMost research and hypothesis testing related tothe etiology of psychosis were conducted duringthe twentieth century. As mentioned above,we have moved beyond former controversies,and any valid model should include both psychologicaland biological factors. Biological factorsinclude not only genetics and infectious factorssuch as influenza, (15) but also early brain damagerelated for instance to starvation of the mother.(16) Recently, more emphasis has been given topsychological factors, especially social deprivation.(17)This factor is illustrated by the increasedrisk linked to immigration, at least through itseffect on social contacts. It appears (even if it isstill controversial) that early abuse (that is, sexual)may increase the risk of developing psychosis asan adult.(18) Additionally, some potential riskfactors, such as cannabis intake, include bothbiological and psychosocial components. Thereis evidence (19) that heavy cannabis intake may(1) foster acute psychotic episodes, (2) exacerbatechronic psychoses, and even (3) increase the riskfor developing a chronic psychotic condition.These elements related to the cause(s) of psychosisform the background for some hypothesesabout religion’s impact on the risk of psychosis.In the biological domain, one could note thatthe healthy lifestyle recommended by most religionsmay improve health, thus diminishing therisk of disease. Psychosocial factors such as socialcontacts may be enhanced by religious involvement,particularly among immigrants. Finally, factorsrelated to drug use/abuse may be diminishedbecause religion discourages this behavior.(20)6. THE IMPACT OF PSYCHOSESIN TERMS OF COST OF CAREAND HUMAN SUFFERINGSchizophrenia is a disorder characterized notonly by hallucinations and delusions, but alsoby apathy and social withdrawal. Long-term

68 Philippe Huguelet and Sylvia Mohroutcomes vary greatly, ranging from full remission(about a fourth of patients are able to leada “normal” life even after being diagnosed withschizophrenia at some point in time) to lifelongdisorders that require continuing assistance frommental health services. Overall, the majority ofpatients suffer from persisting interpersonal andsocial disabilities. With a lifetime prevalenceof about 1 percent, schizophrenia may accountfor 2.3 percent of all health-care costs in developedcountries and 0.8 percent in developingeconomies.(21)Before the arrival of antipsychotic medications,individuals with schizophrenia may have beenconsidered “insane,” that is, permanently incapableof thinking and behaving in appropriate ways.Unfortunately, this point of view has survivedin some places, leading (among other causes) toabuse in the care of these patients. However, thepast few decades have gradually witnessed theappearance of a more respectful attitude towardpatients with psychosis. This position incorporatesthe observation that although patients mayhave transient symptoms altering their ability tomake judgments (that is, the so-called “psychotic”symptoms), they are fully aware of what happensaround them and what they wish to do most of thetime. It is true that patients with psychosis oftenmake erroneous choices, such as taking drugs orwithdrawing from social interactions, but thesedecisions may be more accurately defined as waysto cope with emotional difficulties such as anxietyand discouragement. Moreover, subjects withpsychosis are far from being the only individualswho resort to such behaviors.The point is that most people withschizophrenia – as well as those who care for them–have to cope with a severe disease for many years(or in some cases, the rest of their lives). Theseindividuals must often dramatically change theirprofessional and personal plans in early adulthood,just as goals and dreams may be on the verge ofbecoming a reality. This disorder is associated withsome degree of cognitive impairment, vulnerabilityto stressors, and also a great deal of stigmatization(22), and the critical question is how to helppatients cope with such a weighty burden.7. A PARADIGM FOR UNDERSTANDINGPSYCHOSISSchizophrenia can be understood through thestress-vulnerability model.(23) This model perceivesschizophrenia as the result of a psychobiologicalvulnerability (that is, genetic and earlyenvironmental factors; see above). The onset ofthe disorder and its course is determined by theinterplay of biological and psychosocial factors.The most important biological factors are medicationand substance abuse. Psychosocial factorsinfluencing the course of schizophrenia are stress,coping skills, and social support.Comprehensive care for patients with schizophreniainvolves pharmacological treatment,which generally gets most “positive” symptomsunder control, and psychosocial treatment, thatis, psychotherapy, social skills training, familysupport, and orientation in the domains of livingconditions, occupation, and other factors affectingday-to-day life. (21) In the field of psychopharmacology,the enthusiasm for new-generationantipsychotics has been shown to be partiallyunfounded.(24) In this context, it has become necessaryto reemphasize psychosocial treatments,which remain the cornerstone of the treatment ofpatients with severe mental disorders. Thus, psychosocialapproaches should be given more importanceto provide patients with optimal chancesfor improvement. At this point, one may noticethat this model can easily accommodate the biopsycho-socialmodel.(25) Additionally, it justifiesan intervention based on the goal of recovery, whichinvolves an action aimed at improving psychosocialfactors. All these interventions are important, butthey do not meet the most basic need of these individuals:like every other human being, these peopleneed to find meaning in their lives.This is the point at which the treatment ofindividuals with psychoses such as schizophreniashould intersect with other resources that aren’tmentioned above. Resources such as involvementin peer support, work, art, and spiritual/religious activities can help patients. These goals,which focus on personal fulfillment rather thanon a complete restoration of a prior level of

Religion/Spirituality and Psychosis 69functioning, are part of the concept of recovery.(26) Over the past few years, recovery has beenrecognizedas an organizing principle for the systemsof care for the mentally ill that can replacepaternalistic, illness-oriented services.(27)8. INDIVIDUAL TREATMENTAND COMMUNITY PROGRAMSSchizophrenia and other psychoses affect allareas of a patient’s life. Consequently, treatmentsshould comprehensively cover all affectedareas. This should include individual, supportive,and cognitive approaches, (28) but it mayalso involve psychodynamic therapy (29) (evenif it may be difficult to integrate both behavioralinterventions and more psychoanalyticallyoriented approaches).(30)A comprehensive treatment also involves avariety of actions, for example, aggressive communitytreatment, family and individual psychoeducation,supported employment, social skilltraining, and integrated treatment for substancemisuse.(21)Recovery-oriented services should take theseaspects into account to obtain a better understandingof the meaning of what patients areexperiencing, and this from the perspective oftheir personal histories.(31) Guidelines have beendeveloped to facilitate the development of servicesaccording to this paradigm.(27) Beyond thecomprehensive approach briefly described above,treatment features should include a variety ofservices that support consumer self-sufficiency,encourage the use of advanced directives, provideculturally sensitive treatments, emphasize consumerchoice, limit the use of coercive measures,and address barriers to access. This is the frameworkthat allows us to study, assess, and interveneon spiritual and religious issues when treatingpeople with psychosis.9. THE ROLE RELIGION/SPIRITUALITYWe have described why religion/ spiritualityshould be incorporated within a recovery- orientedapproach to patients with psychosis.But how can we integrate this part of treatment?This is not an easy question to address.Indeed, the answer depends on various factors,the main one being the cultural context in whichclinicians work. Ultimately, the choice to bemade will be whether the clinicians should dealwith an issue by themselves, or whether it shouldbe delegated to a trained religious professional.In fact, we must admit that research is stillneeded on this topic to fully address some crucialquestions. The first is to know what patientswant us to do. Do they want us to discuss religionwith them? If we hypothesize that the answer tothis first basic question is affirmative, others arisebeyond that. What can we do, what are the issues aclinician could broach with his or her patient? Asmentioned before, some issues certainly fall withinthe domain of the clinician; others, however, maybest be addressed by a specialist in religion – achaplain, pastoral counsellor, or other member ofthe clergy trained in mental health care.If research is lacking on these issues, commonsense may suggest some indirect answers, whichare described later in this chapter.10. ASSESSMENT OF RELIGION/SPIRITUALITYBefore considering factors related to the interactionbetween religion/spirituality and psychosisin terms of coping and treatment, webriefly describe how to assess these elementsin patients with psychosis. Although more generalaspects of the assessment of religion andspirituality are discussed in Chapter 16, weemphasize here aspects specific to patients withpsychosis. The main issue (and maybe the mostdifficult for clinicians) is that these patients mayexpress themselves in ways that make it difficultto disentangle normal elements from pathologicalones.However, types of religious coping in schizophreniaand how they may affect clinical outcomesand adherence to psychiatric treatmentmust be assessed. No validated questionnairesexist that survey religion and religious coping forpsychotic patients. Wulff (32) pointed out that

70 Philippe Huguelet and Sylvia Mohrno assessment could be adapted to every kind ofreligious belief and practice.Mohr et al.(33) developed a semistructuredinterview, based on several different scales andquestionnaires, including the “multidimensionalmeasurement of religiousness/spirituality foruse in health research,” (34) the “religious copingindex,” (35) and a questionnaire on spiritualand religious adjustment to life events.(36)This clinical interview explores the spiritual andreligious history of patients, their beliefs, theirprivate and communal religious activities, andthe importance of religion in their daily lives. Italso explores the importance of religion as a wayof coping with their illness and the consequencesof illness, as well as the synergy versus incompatibilityof religion with psychiatric care. Thesalience of religiousness (that is, the frequencyof religious activities and the subjective importanceof religion in daily life), religious coping,and synergy with psychiatric care is quantified bythe patient by means of a visual analog scale.This questionnaire can be used by clinicianswho wish to get a comprehensive view of theirpatient’s situation. For patients whose religionmay be intertwined with their psychopathology,the most appropriate evaluation method is theclinical interview, which allows clinicians to adapttheir language to the beliefs of each individual.However, clinicians should act cautiouslywhen dealing with patients for whom religionis not important and who currently have no orfew religious practices. Any spiritual stance,including a professed absence of belief, shouldbe respected. Addressing religious coping withpatients with low religiosity could send the messagethat they are missing something, and thusbe harmful. This may be the counterpart of thedismissive message about spirituality that is sofrequently sent when the issue is not addressedwith patients for whom it is central.11. RELIGION AS A PRECIPITANTOF ACUTE PSYCHOTIC CONDITIONSClassification systems describe disorders characterizedby acute psychotic symptoms that cannotbe accounted for by schizophrenia (for example,hallucinations or delusions that last no more thanone month with eventual full return to premorbidfunctioning). It is possible that, at least in somecases, predisposed individuals could be destabilizedby intense religious experiences, which mayrepresent such a disorienting experience that itmay serve as a precipitant.Some case reports have shown that manic episodesmay be induced by religious practices.(37)Concerning acute psychotic conditions, religiousconversion may play a role in precipitating psychosisin vulnerable individuals.(38) Koenig (10)mentions the case of John Cuidad (consideredthe patron saint of psychiatric nurses) and AntonBoisen (founder of clinical pastoral education),who experienced episodes of psychosis followingtheir religious conversions.Further research is needed on the questionof whether religion acts as a stressor involvedin some brief psychotic disorders. Nevertheless,when clinicians are confronted with such a condition,they should examine religion as a possiblestressor. The fact that such a cause may be maskedby delusions with religious content warrants acareful assessment focusing on the temporal relationbetween events and symptoms.12. STUDIES ON RELIGION ANDPSYCHOSIS SHOWING A HARMFULINFLUENCEThere is some evidence that religion and spiritualitycan be harmful for patients with psychosis.Indeed, spiritual and religious concerns maybecome part of the problem as well as part of therecovery: Some people recount that they experiencedorganized religion as a source of pain, guilt,or oppression. For some patients, it was a positiveresource for recovery, and the faith communitywas welcoming and hospitable; for others, it wasstigmatizing and rejecting. Some felt uplifted byspiritual activities; others felt burdened by them.Some felt comfort and strength in religiousness;others felt disappointed and demoralized.(39)Religiousness may exert a harmful infl uencethrough religious movements/churches that

Religion/Spirituality and Psychosis 71discourage psychiatric care or amplification ofmorbid cognitions by religious considerations.It is difficult to obtain an exact picture reflectingthe extent to which patients with psychosismay be negatively influenced or abused by religiouscommunities. On one hand, people withpsychosis do not usually have much money, thusnot much to be taken, and they may have unpleasantand disruptive symptoms that cause religiouscommunities to reject them. On the other hand,their difficulties, both in terms of interpersonalties and cognitive experiences, may lead them totry to cope with these issues through religion ina way that may be harmful to them. It is difficultto find medical literature quantifying this issue.Psychosis itself may precipitate a change in affiliationto a less traditional religious group (40).But abuse may occur within both traditional andnontraditional religious groups. Anthropologyhas illustrated some examples of patients whowere negatively affected or abused by religiouscommunities.(41) However, a cross-sectionalstudy showed that among 115 patients, only 2had been negatively influenced (for a limitedtime) by religious communities.(42)The concern that religion exerts a deleteriousinfluence on patients with delusions can be supportedby the fact that patients who have delusionswith religious content may experience a worselong-term prognosis.(43) However, it is not possibleto conclude that a causal effect exists. Indeed,among other arguments, it appears unlikely thatdelusions with religious content constitute a unitaryphenomenon, because delusions themselvesproceed from different mechanisms. Research onmedication-free individuals with schizophreniaindicates that delusions can be separated intothree distinct factors: delusions of influence (forexample, delusions of being controlled, thoughtwithdrawal, thought insertion, or mind reading),self-significance delusions (delusions of grandeur,reference, religion, and guilt/sin), and persecutorydelusions.(44) Religious content may befound in each of these categories: A patient mayhave the conviction that he or she is controlledby a god or that a god puts thoughts in his or hermind; he or she may think that he or she is a god;or he or she may be convinced of being persecutedby the devil or some other religious figure.Delusions with religious content may be related toformer personal and social experiences and thusunderstood in the context of a person’s life andculture.(45) Rhodes and Jakes (46) suggest thatreligious experience could represent attemptsmade by patients to interpret their anomalousexperiences, i.e. a way to cope when facing distressingevents such as hallucinations. Delusionswith religious content are encountered in 25 percentto 35 percent of patients with schizophrenia,although they are not specific to that population.13. THE IMPACT OF RELIGIONON OUTCOMEAs mentioned before, when considering the stressvulnerabilitymodel, (23) every factor likely toincrease support and/or relieve stress may improvea patient’s outcome. Religion is likely to play rolesin this regard. Indeed, it can provide assistance incoping with the illness, difficult life experiences,and existential issues, as well as provide interpersonalsupport through peers and clergy.When considered in the light of the recoverymodel (that is, beyond aiming at symptomreduction), religion’s impact becomes even moreobvious. A vast majority of patients with schizophreniado not have work, and their activities andsocial contacts are restricted. Clinicians are confrontedwith the need of these patients for hope,self-fulfillment, and personal growth. Farkas (47)argues that positive psychology (for example,dimensions such as personal accomplishmentand self-esteem) is important for these patients.Keeping in mind the importance religion representsfor these patients, (42) it must be examinedas a resource for recovery. Qualitative researchindicates that religion and spirituality can be amajor resource in recovery, (48) as reported bypatients. To our knowledge, there are still no outcomestudies shedding light on the role religionmay play in the prognosis of psychoses such asschizophrenia (either in terms of symptom reliefor recovery). Neither is it known how religiousnessalone evolves over time in patients with psychosis.

72 Philippe Huguelet and Sylvia MohrPreliminary results of a study we conducted inGeneva, Switzerland indicate that continuouspositive religious coping improves the outcomein schizophrenia (in terms of symptoms, socialfunctioning, and quality of life). While awaitingmore data, cross-sectional studies can provideinformation pertinent to clinical practice.14. THE ROLE OF RELIGION IN COPINGCross-sectional studies have examined the roleof religion/spirituality in the process of copingwith mental illness.(49) Pargament (50)suggested that religious coping can serve fivepurposes: spiritual (meaning, purpose, hope),self-development, resolve (self-efficacy), sharing(closeness, connectedness to a community), andrestraint (help in keeping emotions and behaviorunder control). Religious coping may be adaptiveor not.But what about patients with severe psychiatricdisorders such as schizophrenia?A qualitative study of Bussema andBussema (51) found that patients with severemental disorders (not only psychotic conditions)used all of these five coping strategies. However,the “restraint” factor, that is, a way to keep themfrom undesirable actions, was the least effective forsymptom management. The authors also identifiednonadaptive religious coping that caused feelingsof guilt and hopelessness or of being ignored,judged, or condemned by the religious community,which at times hindered efforts to managenegative symptoms. Moreover, in the absence offellowship, faith and hope were difficult to sustainwhen confronted with persistent illness.In a recent quantitative and qualitativestudy, (42) we studied the role of religion/spiritualityas a coping mechanism among 115 stabilizedpatients with schizophrenia or schizo-affectivedisorders. For almost half the patients (45percent), religion was the most important elementin their lives. Religion was used as a positiveway of coping for 71 percent of subjects and as anegative way of coping for 14 percent of patients.Recently, we were able to replicate theses findingsin 123 patients living in Quebec, Canada.(52) Thesubjective importance of religion, the religiouspractices, and the rate of positive/negative copingwere remarkably similar to those found in theGeneva cohort.14.1. Positive Religious CopingAt a psychological level , religion gave thesepatients a positive sense of self (for example,hope, comfort, meaning of life, enjoyment oflife, love, compassion, self-respect, and selfconfidence).For two-thirds of these patients,religion provided meaning to their illness,mainly through positive religious connotations(for example, a grace, a gift, God’s test to inducespiritual growth, and spiritual acceptance of suffering),less frequently through negative connotations(for example, the devil, demons, andGod’s punishment). However, even if thosemeanings were negative in religious terms, theywere positive in psychological terms by fosteringan acceptance of the illness or a mobilization ofreligious resources to cope with the symptoms.For example, one patient said, “I think my illnessis God’s punishment for my sins; it gives meaningto what happened to me, so it is less unjust”(30-year-old woman, paranoid schizophrenia).For three-quarters of patients, religious copinghad a positive impact on symptoms (for example,by lessening the emotional or behavioralreactions to delusions and hallucinations and/orby reducing aggressive behavior). A patient whosuffered from delusions of persecution clearlyexpressed this by saying, “I always have a Biblewith me. When I feel I am in danger, I read it andI feel I am protected. It helps me to control myactions of violence” (26-year-old man, paranoidschizophrenia). A patient who had delusions ofcontrol said, “At some time during every day, Ifeel that other people can control me from a distanceand that they can do anything they wantwith me. However, I do not feel anxious like I didbefore. The Buddhist monk told me it was onlymy imagination and he teaches me how to meditate.In this way, I distance myself from this ideaof control; I tell myself that it is just a symptomof an illness, that there is nothing true about it

Religion/Spirituality and Psychosis 73and it has no meaning” (20-year-old man, paranoidschizophrenia).Religion may also help to reduce anxiety,depression, and negative symptoms. As onepatient said, “I am spiritual in my heart. Myway of meditating is to sing. There is a linkbetween breath and spirit. When I sing, I don’tfeel as depressed and I am more enthusiasticabout doing things” (44-year-old man, paranoidschizophrenia).At the social level , religion provided guidelinesfor interpersonal behavior, which led to reducedaggression and improved social relationships. Asthis patient said, “Believing in Jesus helps me tocontrol my actions. That means not striking myfellow man when he upsets me!” (31-year-oldman, paranoid schizophrenia).Unfortunately, in spite of the subjective importanceof religion, only one-third of the patientswho were using religious coping in a positiveway actually received social support from a religiouscommunity. Some patients didn’t receiveany support from their communities due totheir symptoms. As one patient said, “I’ve goneto church every Sunday since childhood; I listento the sermon; I don’t speak to anyone” (50-yearoldman, paranoid schizophrenia). More often,symptoms hindered religious patients from practicingwithin their religious communities.However, for some patients, religious communitiesprovided social support. One patient said,“I am a single woman; I have a lot of problems.At church, I meet a lot of people. It comforts me.I participate in every church activity: the serviceon Sunday, the intercession prayer group and Ising in the choir. The pastor and church memberspray for me” (39-year-old woman, paranoidschizophrenia).Religion may also play a role in decreasing orincreasing adherence to psychiatric treatment.(See Chapter 18 on this topic.)14.2. Negative Religious CopingFourteen percent of patients reported negativeeffects of religious coping. For those patients,religion was a source of despair and suffering.Four patients felt despair after the spiritual healingthey had sought was unsuccessful. As onepatient said “I didn’t get any comfort from psychiatry.So I turned to Christian Science, whichhas healed many people. Prayer is an assertionthat healing is already there and to see it. I triedfor years. It comforted me when it was new,but I didn’t succeed, so they told me that I wasa negative person and a bad influence on others.I was not worth their attention. Since then,I’ve been drinking alcohol” (41-year-old woman,hebephrenic schizophrenia). Others used religionto cope, but with a negative outcome. Asan example, one man said, “I suffer from beingso isolated. I wasn’t a believer, but I went tochurch in order to meet people. But when Iread the Bible, it disturbs me. I begin to think Ihave behaved wickedly and then I believe I amthe devil” (47-year-old man, schizo- affectivedisorder). Although religion was meaningfulfor these patients, it always carried negativereligious connotations. In some cases, religiouscoping increased delusions, depression, suiciderisk, and substance intake. One patient foundcommunity support, but this led to a loss of faithand increased medication compliance. “I wentto church to be healed and to meet a woman. Ibelieved Jesus would help me, but this is a lie.More problems came, like a curse. Evil has thepower on earth. God is a cruel God. I want todie because I suffer too much. It is not Jesus whohelps me, but people; at least, medication helpsme for anxiety” (43-year-old man, paranoidschizophrenia).14.3. Clinical CorrelatesAt the time of the study, sixteen of the patientswith positive or negative religious coping presentedreligious beliefs mixed with their delusionsor hallucinations. At a psychological level,they experienced religion either as negative (sixcases) or positive (ten cases). However, none ofthese patients actually participated in communityreligious practices.Overall, it appears that religion can serve asa powerful coping mechanism for patients with

74 Philippe Huguelet and Sylvia Mohrpsychosis, as it can for other, “healthy” people.The main difference is that patients with psychosismay find it difficult to develop social contactsin this area. This has important therapeuticimplications (see below).15. RELIGION’S INFLUENCE ON OTHERBEHAVIORSCoping may also be used to deal with other issuessuch as suicidal behavior and substance abuse.Religion may indeed play positive and negativeroles in the frequent comorbidities associatedwith schizophrenia.15.1. Suicidal BehaviorsReligion may protect against suicide attempts . Theaforementioned research showed that 25 percentof all subjects acknowledged that religion playeda protective role with regard to suicide, primarilythrough ethical condemnation of suicide andreligious coping.(53) However, one out of tenpatients reported that religion played an exacerbatingrole, not only due to issues with negativeconnotations but also due to the hope for somethingbetter after death.15.1.1. Protective Role of ReligionOne patient said, “When I feel such despairthat I want to jump out of the window, I thinkabout God. This helps me to live, even if life isso hard sometimes” (41-year-old man, paranoidschizophrenia).For patients who had previously attempted suicide(fourteen patients), the positive role of religionincluded not only religious coping and ethical condemnationof suicide, but also rediscovery of meaningin life through religion and, for one patient,a mystical experience after a suicide attempt thatrestored hope and the courage to live.Psychotic patients who had never attemptedsuicide (twenty patients) reported several aspectsthat played a protective role: religious coping thathelped them fight despair and suicidal thoughtsand restore hope, “finding the joy to live in God’slove” (six patients), finding a reason to live inreligion (three patients), and religious beliefs thatcondemn suicide (four patients).15.1.2. Exacerbating Role of ReligionOne patient said, “Spirituality is essential inmy life; I know that there is a life after death.Once, I took medication to die in order to experiencedeath and know what it’s like afterwards”(36-year-old man, schizo-affective disorder).The patients who had previously attemptedsuicide (nine patients) reported some negativeaspects of religion: suicide attempts followinga break with a religious community (threepatients), suicide attempts involving religiousdelusions and hallucinations (three patients),wishing to die in order to be with God or to liveanother life after death (one patient), the loss of afaith which was the meaning of life (one patient),and a mystical experience of death (the patientbelieved in life after death and wanted to experienceit) (one patient).Two patients who had never attempted suicidereported negative aspects of religion: wishingto die in order to be with God and angerwith God.15.2. Substance AbuseReligion provided guidelines for some patientsthat protected them from substance abuse .(54)Religious involvement was indeed significantlyinversely correlated to substance use and abuse.A content analysis showed that religion mayplay a protective role in substance misuse in 14percent of the total sample, especially for patientswho had stopped substance misuse (42 percent).It played a negative role in 3 percent of cases.Patients’ stories indicated how the various protectivemechanisms of religion worked or howreligion led them to use substances to cope. Onepatient said, “I felt bad. I smoked a lot of hashishevery day. Once I had a religious conversion aftera mystical revelation that the way I was behavingwas not what God wanted for me” (34-year-oldman, paranoid schizophrenia). Conversely, somepatients who misused drugs may have been lesslikely to participate in private and/or collective

Religion/Spirituality and Psychosis 75religious practices than abstinent patients becauseof the social impairment, inappropriate affects,and reduced motivation to cope with the outsideworld brought about by both their illnessand substance use and abuse. Some patientswith schizophrenia who were drug abusers saidthey had been rejected by their faith communitywhen they became ill, but others said that, evenif they could have found help and support inreligion, they lost contact because of their lackof motivation or because they lost their pointsof reference.16. TOWARD AN INTEGRATIVE VIEWReligion/spirituality can help patients with psychosisin the following ways:First, spirituality/religion may be used to copewith current difficulties, that is, symptoms andsocial and interpersonal problems.Second, it may help to prevent potentiallyharmful behaviors, such as interpersonal violence,substance abuse, and suicidal or parasuicidalattempts.Third, it can be a key element in the recoveryprocess that every individual with a severepsychiatric disorder should engage in. A personwithout long-term life goals is like a bicycle thatisn’t moving: It falls down. Religion and spiritualitycan play a role that goes beyond cognitivealterations, symptoms, and stigma by allowingeven patients with severe forms of schizophreniato experience personal growth (as part of therecovery process).Examining these issues unearths some cluesabout what to consider when treating patientswith psychosis. Before going into further detail,it must be emphasized that the context in whichthese elements are implemented should alwaysbe kept in mind. Indeed, cultural elements mustbe taken into account when considering religion/spiritualityin the individual care of patientswith psychosis, but the kind of therapeutic workunderway is also important. A therapist engagedin a psychoanalytically oriented approach will notproceed in the same way as a cognitive therapistor a clinician practicing supportive therapy.17. INDIVIDUAL TREATMENTSpecific therapies involving religion are discussedin Chapters 17 and 19 to 21. Aspects concerningillness representation and treatment adherenceare discussed in chapter 18. We would like tofocus here on elements to be considered principallywhen practicing behavioral-cognitive orsupportive therapy with patients with psychosis.To our knowledge, no specific guidelines existin the scientific literature on how to incorporatereligious issues in the individual care of patientswith psychosis. In fact, we do not even knowwhether patients want to speak about religiousissues or not. But, based on research on copingand religious involvement in patients who sufferfrom psychosis, we can tentatively examinesome issues that may be relevant for them.The first step is to assess the religiousnessof the patient (see above and Chapter 16). Thepatient may report no participation in any religiousactivity or some extent of involvement inspirituality and/or religion. The spiritual assessmentmay also reveal a problem(s) warrantingintervention.The following section describes which issuescould be components of individualized treatment.Research on coping in patients with psychosisshows that the personal dimension of religion isnot correlated with its social dimension, that is,that many patients have religious beliefs and prayalone but do not have social contacts related totheir faith. In fact, they replicate what happens inother areas of their lives because they have problemscreating and maintaining an interpersonaland social network. This area can be a focus oftreatment; these deficits should be overcome (orat least the goal should be made to overcomethem) through social skills training or individualcounseling.For any one of various reasons, patients maybe in a period of spiritual crisis. This can happento anyone, but in patients with psychosis,their crisis may be to some extent embedded indelusions or other “bizarre” thoughts. In suchcases, the situation cannot be resolved by sendingthe patient to a chaplain or member of the

76 Philippe Huguelet and Sylvia Mohrclergy. A thorough assessment should make itpossible to disentangle a “true” spiritual crisisfrom the expression of delusional thoughts.Finding the answers to the following questionscan help in this process: Is the patient experiencinga relapse? Is he or she in a moment ofhis or her life suggesting the possibility of sucha spiritual crisis? Things can be even trickierconsidering the fact that patients may be experiencingsymptoms and a period of spiritualcrisis as well. Generally, clinicians should assessand treat – if possible – such a situation beforereferring the patient to a chaplain or a spiritualleader. In this latter case, the clinician shoulddiscuss the patient’s medical context with himor her (with the patient’s consent).Identity building is also an issue of importance.Indeed, patients with psychosis often haveproblems related to identity, at least partly dueto the consequences of their disorder. Even ifmost of the therapeutic work with these patientsis now behavioral-cognitive based, there is agrowing trend to emphasize psychodynamicissues again.(30) In general, a psychodynamicapproach may be helpful in resolving conflictsand identifying recovery goals. As mentionedin Chapter 12 on self-identity, both the individualand social aspects of religion/spiritualitymay be key components of identity. Dependingon the time available and the skills and the orientationof clinicians, it should be possible tointegrate these aspects into individualized treatmentplans. Working on identity is not an easyprocess. The first step is to engage the patientin a narration of their story, making it possibleto reappraise certain elements of their identity,including the spiritual/religious components.Further steps may be envisaged, but a thoroughknowledge of the psychodynamic field isrequired at this point.Another issue pertaining – at least partly –to psychodynamics is the quest for meaning,not in a religious perspective, but in the senseof understanding one’s current reactions andemotions. In the field of religion, patients couldbegin to understand why they invest God as apaternal figure, in the light of the relationshipwith their parents. Different studies suggesthigher levels of insecure attachment in patientswith psychosis as compared to controls.(55)Based on research investigating attachmentstyles and spiritual coping in patients with psychosis,we identified a relationship betweenpatients’ compensation strategies in the processof constructing affective security and spiritualbeliefs. The first analyses suggest that patientsreproduce interpersonal parental experiencesthat are associated with a compensatory copingstrategy in the context of a relationship to aspiritual figure.(56)As mentioned below, all these interventionsshould be brought together with a common goalin mind: recovery. In particular, individualizedtreatment should help to provide culturally sensitivetreatments, emphasize consumer choice,and address barriers to access.18. IMPLICATIONS FOR GROUPTHERAPYRehabilitation is often implemented to progresstoward recovery. However, patients have reportedthat the services they received were least helpfulin achieving goals in spiritual and religiousdomains.(57) Nevertheless, moving beyondindividual treatment, group activities have beendeveloped in some places, mostly in the UnitedStates. A group format has some advantages overindividual treatment in terms of costs but also interms of the opportunities for interaction amongpatients.Some groups are less rigidly organized and/or psychodynamically oriented; others aremore structured, based on behavioral-cognitiveprinciples. Kehoe (58, 59) has been a pioneer inthe field, having run such a group for decades.This activity consists in weekly sessions involvingten to twelve patients for two to three yearsin general. The groups aim to foster tolerance,self-awareness, and nonpathological therapeuticexploration of a value system. Each new memberis asked to describe his or her religious/spiritualquest. Then, through interactions with peers,patients are given an opportunity to consider

Religion/Spirituality and Psychosis 77how their beliefs may help in their recovery and/or create conflicts. Interestingly, none of thepatients decompensated during the group meetings,and staff concerns about this issue thusseemed unfounded.Phillips et al.(60) developed a psychoeducationalgroup, a more structured format involvingseven sessions. This program is defined assemistructured; information is provided on specifictopics such as spiritual resources, striving,and struggles, followed by discussions. Theirresearch was based on the study of ten subjects,and the authors concluded that this interventionappeared to reach most of its objectives.Wong-McDonald (61) described the outcomeof an optional spirituality rehabilitation program,as compared with an ordinary program. Thisspirituality group, added to a psychosocial rehabilitationprogram, consists of discussing spiritualconcepts, encouraging forgiveness, listeningto spiritual music, and encouraging spiritual andemotional support among members. Comparedto the usual treatment, this additional groupallowed patients to achieve their goals in 100percent versus 57 percent of cases.Revheim & Greenberg (62) developed theSpirituality Matters Group (SMG) for hospitalizedpatients. SMG aims to offer comfort andhope through structured exercises focusing onspiritual beliefs and coping. These exercisesinvolve more activities with a specific orientation,such as reading from the book of Psalmsor reciting and writing prayers, in addition tocognitively oriented activities, such as emotionfocusedcoping. Created in the United States,this group is conducted both by clinicians andreligious representatives. It involves a mixtureof psychological and religious features, whichshould be implemented, at least in public facilities,with caution in other areas, such as Europe.According to reports in the literature, groupactivities involving spirituality are bourgeoning,at least in the United States. Other programsmay exist elsewhere, but without being reported.However, the development of such activities warrantsa careful evaluation of the social and culturalcontext in which they are implemented.19. A MULTICULTURAL PERSPECTIVEOur goal is not to describe health systems indeveloping countries where western-style careis implemented. Rather, we highlight somealternative ways of conceptualizing and treatingpsychosis, that is, integrating spirituality intopatient care.The first point to clarify is that developingcountries do not have a monopoly on attributingsupernatural causes to psychiatric disorders. Forexample, Pfeifer (63) showed that in a rural areaof Switzerland, more than a third of psychiatryoutpatients believed that an evil influence wasa possible cause of their problem. Moreover,30 percent of patients sought help through ritualssuch as prayer and exorcism. Those patientssuffering from schizophrenia reported the highestrate of rituals involving exorcism.Conversely, some research has shown thatmental illness may be recognized as such indeveloping countries. For example, Younis (64)reported that in Sudan, schizophrenia was identifiedin 76 percent of cases, both in urban andrural populations. Psychiatric treatment wasadvised for more than half of them.Nonetheless, spiritual factors in the treatmentof mental illness have a place of their ownin developing countries, as shown by Campion &Bhugra.(65) These authors report that in SouthIndia, almost half the patients seeking treatmentin a psychiatric hospital had previously solicitedhelp from religious healers. The highest rate wasin the group diagnosed with schizophrenia (58percent). Less than a third of patients reportedan improvement through these treatments,which consisted of chanting mantras, ingestionof holy water or ash, use of animal sacrifice, orother rituals. Ninety-nine percent of patients hadstopped any religious treatment at the time of thepsychiatric consultation.In Uganda, Africa, Teuton et al.(66) carriedout a qualitative investigation of the conceptualizationof “madness” across indigenous, religious,and “allopathic” healers. For indigenous healers,“madness” is seen as a sign of a deviation or aform of harm instigated by a jealous party. For

78 Philippe Huguelet and Sylvia Mohrreligious healers, it is attributed to the influenceof Satan. “Allopathic” healers (that is, psychiatristsand specialized nurses) have few resourcesand provide limited services, usually psychotropicmedication. The authors investigated healers’attitudes toward their peers who practice a differentapproach. Indigenous and religious healerswere often tolerant of “allopathic” medicine.Psychiatrists’ attitudes were characterized byboth tolerance and conflict.In Brazil, Redko (67) studied young peoplesuffering from first episodes of psychosis in poorneighborhoods. Religion allowed them to expresstheir personal and interpersonal re actions topsychosis through the manipulation of religiousreferents. Religious idioms and signifiers wereuseful to label or describe what they experienced,indicated attempts to cope with psychosis, andreflected the quest to reinforce one’s own existenceand sense of self. The authors discuss thefact that religion can heal, in terms of the descriptionsabove, but also can act in a “regressive” way,for instance, when patients remain absorbed bytheir delusions.Bilu and Witztum (68) report their experiencein Jerusalem with Jewish, ultra-orthodox,severely ill patients. These patients turn tothe clinic as the very last resort, after havingattempted – and failed – to employ religioushealing. They try to incorporate religiouslycongruent elements into their secular treatmentmodalities. The authors found that medicationssuch as antipsychotics, initially ineffective,turned out to be quite potent when accompaniedby a religiously informed intervention,when “drugs are presented to create a mysticalwall against demonic assault” (p. 208).Interestingly, ethnic minority groups maysearch for spiritual methods of healing whenbeing treated in Western countries. Khan & Pillay(69) reported that patients from South Asia withschizophrenia living in the United Kingdom preferredhome treatment, primarily so they couldpractice their faith and retain the possibility ofadding faith healing to their psychiatric treatment.The authors explain their motivationsnot only as a desire to maintain their culturalidentity, but also as a means of having access tomore holistic treatment.Overall, it appears that in developing countriesor in areas where religious paradigmsmay be applied to health issues, religious and“allopathic” care coexist for treating psychosis.Interestingly, some separation appears betweenthese approaches, as it does in more developedcountries (even if treatment of psychosis basedon religious principles is less common in theoccident). Without being naïve – by claimingthat religious worldviews can perfectly fit intoour medical model – there appear to be opportunitiesfor dialogue between “modern” psychiatryand religious healers.(66) As in Western countries,this could be done while keeping in mindthe principles of recovery. Both psychiatristsand religious healers should admit that patientsneed good medication, psychosocial counseling,and something more, something related to lifegoals but also to a sense of one’s identity, whichis sometimes strongly rooted in religion andculture.20. CONCLUSIONPsychosis is often associated with persistentsymptoms and/or social disabilities. In this context,recovery, which aims to achieve a life worthliving rather than a “cure” for all symptoms, maybe an important goal. That’s where religion/spiritualitycan come into play in the lives of individualswith psychosis. Research has shown thatreligion/spirituality, rather than triggering psychoticsymptoms, can provide powerful copingmechanisms. Indeed, it can help patients copewith symptoms such as hallucinations, depressivethoughts, and suicidal ideations; it may preventsubstance abuse; and it can help patientsto set life goals. Clinicians organizing individualand group treatments should integrate religion/spiritualityin nonjudgmental and neutralways. In particular, religious involvement mayhelp patients to socialize, and they should beassisted in that pursuit. Therapy may include atleast some religious components as they relate toidentity, relationships, contextual issues, and so

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7 Delusions and Hallucinations with Religious ContentSYLVIA MOHR AND SAMUEL PFEIFERSUMMARYDelusions and hallucinations with religious contenthave been a subject of interest in psychiatryover the last two hundred years. The prevalenceof these psychotic symptoms displays greatvariations across periods and cultural areas.Hallucinations and delusions with religious contentare not restricted to schizophrenia. They canalso be found in patients with mood disorders,that is, those presenting with depressive or manicstates. In some studies, religious delusions havebeen associated with a poorer prognosis. We discusspsychological explanations of delusions andhallucinations to point out that religion and psychopathologymay interact in complex ways.In order to disentangle the two, we (1) critiquethe category of religious delusion, that is, it is nota valid theoretical category, it is a stigmatizingcategory for patients and a confusing categoryfor clinicians; (2) provide guidelines to differentiatebetween functional or dysfunctional rolesof religion to disentangle religion from psychopathology;(3) examine implications for the cliniciansin the assessment of hallucinations anddelusions with religious content; and (4) discusstreatment issues.1. DESCRIPTION OF THE PHENOMENAN o area of psychopathology draws such publicattention and morbid fascination as religiousdelusions. The discrepancy between grandioserevelations and disorganized behavior, betweenholy words and unholy demeanor, between mysticalexperiences and offensive conduct causespitiful rejection at best and religious unrest atworst.Historical accounts of “religious insanity” arefound in a two-volume 1200-page textbook byGerman psychiatrist K.W. Ideler (1) who wasmedical director of the psychiatric department ofthe famous Berlin Charité. He attributes “religiousinsanity” to ancient mystics living in the desert, tothe flagellants of the eleventh century, possessionepidemics in medieval monasteries, as well asradical religious movements during Reformation,to name but a few examples. In 1879, Krafft-Ebing (2) described “paranoia chronica (acuta)halluzinatoria religiosa” (p. 293) and talked about“theomania.” Historical accounts of religiousdelusions go back to the very first issues of theAmerican Journal of Insanity , the precursor of theAmerican Journal of Psychiatry. (3, 4) However, intheir fascination with the often bizarre and grotesquereligious content of delusions, the authorsmostly failed to adequately express the respectfor healthy religion and to address the differencebetween functional and dysfunctional aspects ofreligion.Although William James did not directlyaddress the topic of religious delusions inhis seminal work on the varieties of religiousexperience, (5) he commented on religious mysticismto be only half of the great mystical stream,insanity being the other “diabolical” half.Over the last thirty years, an increasing bodyof literature has tried to approach the topic ofreligious delusions in more “objective,” scientificterms using psychopathology, anthropology, andcultural sociology on the one hand and neurobiologicaltechniques on the other hand to explorethe nature of this phenomenon.81

82 Sylvia Mohr and Samuel Pfeifer1.1. PrevalenceReligious delusions have been described in allmajor cultures across the continents. However,prevalence varies greatly with countries andsociocultural contexts. Several studies have beenconducted to compare the expression of symptomsin patients with schizophrenia in differentcultures. Here are some examples: In Malaysia,religious delusions were far more common forMalay patients (44 percent) than for Chinesepatients (5 percent).(6) The rate of religious delusionwas 6 percent in Pakistan versus 21 percentin Austria.(7) Another study showed rates of 21percent in Germany, 20 percent in Austria, and7 percent in Japan.(8) The rate of grandiose andreligious delusions was 19 percent for Africans;9 percent for Europeans; 8 percent for NorthAmericans, Australians, and New Zealanders; 6percent for Middle Easterners; and 8 percent forAsians.(9) Gender and social class affect the rateof religious delusions in Pakistani patients withschizophrenia. Religious delusions were foundmore often in men than women and in highersocial classes than lower ones.(10) A comparativestudy of the prevalence of religious delusionsin Eastern and Western Germany shows a distinctlyhigher prevalence in the Catholic regionof Regensburg, compared to very low prevalencerates in atheistic East Berlin.(11) The authorsconcluded that religious delusions are “above all,associated with cultural factors” and have to beviewed as a secondary phenomenon in schizophrenia,not inherent to the illness process.The prevalence of religious delusions varieswidely not only with geography, but also withtime. For example, in Egypt, the rate of religiousdelusions rose from 5 percent to 21 percent duringa twenty-two-year period when patterns ofreligious emphasis in Egyptian society changed.(12) In China, religion has been repressed by thecommunist government for decades. During thattime, religious delusions were low with a rate ofonly 8 percent in Shanghai, contrasting with the32 percent in Taiwan.(13)Obviously, the content of delusions is influencednot only by the religious background but alsoby cultural and political particularities. Politicalchange and technological progress have an impacton the content of delusions. For example, sincethe year 1997 when the Internet became availableto the general public, cases of “internet delusions”are increasingly reported in the literature. Internetdelusions are not considered as a new diagnosticentity but rather as a new type of delusional contentfor two well-known delusions: delusion of persecutionand delusion of control (14)1.2. Religious Delusions Not Restrictedto SchizophreniaDelusional phenomena are not limited to patientswith schizophrenia. They may be found in alldiagnostic categories that involve delusionalthought. Already in 1931, (15) a detailed statisticalanalysis of delusional content in manic- depressivedisorders was presented. Religious delusionswere found in 5 to 8 percent of manic-depressivepatients as compared with 12 to 15 percent ofschizophrenic patients.In a more recent study in the United States,among psychiatric patients hospitalized in anemergency ward, the rate of religious delusionswas higher for patients with schizophrenia(36 percent), but these symptoms were alsoobserved among patients with bipolar disorder(33 percent), other psychotic disorders (26 percent),alcohol or drug disorders (17 percent), anddepression (14 percent).(16)The content of delusions varies over diagnosticcategories, however. Delusional thought oftenseems to be more bizarre and linked to disorganizedactions in schizophrenic disorders.Case ExampleA 30-year-old man was arrested by thepolice when found lingering around anatomic power plant, being obviously disturbed.The man was not religious beforethe incident, but he reported that when visitinga church, he experienced an encounterwith God in the shape of a light thatshone through the stained-glass windows.He felt compelled to burn banknotes in the

Delusions and Hallucinations 83church. When he drove away, the oncomingcars and trucks gave him messages withtheir headlights. Finally, he left his car withthe ignition key on and continued his pilgrimageon foot, spending two nights inthe woods. He claimed to have received amission from God to protect the peoplearound the nuclear plant from harmfulradiations. He therefore approached thefence around the power plant, carefullypacing up and down. Finally, he urinatedinto a bottle, deposing his urine in dropsalong the fence to create a protective wall.In major depressive disorders with psychoticfeatures the content is “mood congruent,” underliningthe basic feelings of worthlessness, guilt,and rejection.Case ExampleSister Mary (not her real name), a memberof a Catholic women’s order, had a historyof bipolar illness. When she lapsedinto a depressive state, she was directed toa psychoanalyst and received antidepressantmedication. After two serious suicideattempts, she was admitted to a clinic. “Ideveloped feelings for my therapist whichwere not acceptable. It was infidelity againstJesus. I have fallen from grace. Bad thingshappen around me, and it is my fault. I havethe terrible feeling of the evil using me. I amlike a nuclear bomb, destroying and burningeverything around me. I have no moreright to live. It would be better to destroymy life than that of the community.”1.3. Religious Delusions Associatedwith a Poorer PrognosisReligious delusions may lead to violent behavior.Aggression and homicide have been perpetratedby religiously deluded people.(17–19)Some religiously deluded people have literallytaken statements from the Bible to justify pluckingout offending eyes or cutting off offendingbody parts. This may lead to autocastration.(17)Approximately half the cases of self-inflicted eyeinjury occur with psychotic preoccupations aboutsinfulness and higher deities.(18) Potentiallylethal self-injuries could be perpetrated underreligious delusion, as the following 30-year-oldman with paranoid schizophrenia reported.Case ExampleOne night, I was persecuted by voices.I drove a knife into my belly to kill thedemons.” Another example is a 23-yearoldman with paranoid schizophrenia, whoreported, “Once, during a crisis of anxiety, Iwas controlled by others, I believed myselfto be in a relationship with God, I had tokill myself to save the children (playing infront of his house). It was an obligation. Itook a leash to hang myself, the leash broke,I fell down, the children were still alive, andanxiety went away.Religious delusions have been associated withpoorer outcome more generally. In India for example,sexual, religious, and grandiose delusions andflat affect on admission predicted a poorer clinicaloutcome over a ten-year period.(19) In the UnitedKingdom, patients with religious delusions in onestudy appearred to be more severely ill.(20) In theUnited States, among hospitalized patients withschizophrenia, people with religious delusions werealso more severely ill; they had more hallucinationsfor a longer period of time.(16) In a German study,the intensity of religious faith was associated withpoorer outcome; however, religious delusions werenot differentiated from normal religious faith.(21)Thus, the association between religious delusionsand poorer outcome seems at least controversial.Is this relationship an artifact? Is it due to delusionor to religion? Or is religious delusion in itself amarker of the severity of the pathology?2. MODELS OF DELUSION2.1. What is Religious Delusion?To answer the question, we have to consider bothconcepts: the concept of religion and the concept

84 Sylvia Mohr and Samuel Pfeiferof delusion . The following case examples illustratesome of the questions involved.Case ExampleA 40-year-old man suffering from paranoidschizophrenia for fourteen yearsreported, “I am a Catholic. I believe in God,in paradise, in angels and also in the SunGod. Gods protect me. I listen to God, theseare no voices. God gave me the mission toconquer a sacred land, for soon comes theend of the world. The Sun God gives me thepower to do it. I have to prepare the war.”A 40-year-old man suffering from paranoidschizophrenia for ten years reported,“I have no problems in life. I am not sick.I have to put up with psychiatry becausethe good God does not forgive. Since I havedone some stupid things, God has frozenmy brain and made his puppet of me. Fromthat time forward God speaks with me andI speak with him. It’s great. I spend all of mytime speaking with the good God. I wouldlove to go to the movies, listen to musicor find a woman, but I can’t because Goddoesn’t allow me and he is never silent.”Many researchers understood the two termsof religion and delusion together in a rather pragmaticway, resulting in a variety of definitions ofthe construct, mainly influenced by the contentof the delusions. The heterogeneity of definitionsis one of the factors influencing the differentreported frequencies. Many studies have beenconducted with the Present State Examination(PSE), a widely used structured clinical interviewdeveloped in collaboration with the World HealthOrganization to assess psychiatric symptoms.(22) This instrument was constructed to providea reliable description of symptoms of mentalillnesses, irrespective of the language and theculture of doctor or patient. Religious delusion,one of the 140 symptoms listed, is defined as follows:“Both a religious identification on the partof a subject (he is a saint or has special spiritualpowers) and an explanation in religious terms ofother abnormal experiences (e.g., auditory hallucinations)should be included.” A symptom called“subculturally influenced delusions” includes“specific idiosyncratic beliefs held with convictionby small subgroups within the community,e.g., sects, tribes or secret societies, but not by thecommunity at large (such as Voodoo, witchcraftor special religious beliefs). If the subculturallyderived beliefs are held with exceptional fervorand conviction, or are further elaborated by thesubject, so that other members of the subgroupmight well recognize them as abnormal, then thesymptom is rated as severe.”Some of the studies cited above took thesymptom of religious delusion as defined by thePresent State Examination.(6, 9, 10 , 19) In otherstudies, grandeur delusion and belittlement delusionswith a religious theme were considered asreligious delusions.(8) In one study, (12) “religioussymptoms” were defined as any symptomwith a religious content, such as, special knowledgeor power from God, curse by black magic,control by an evil spirit, identification with a religiousfigure, relationship with a religious figure,being commissioned by God, possessed by anevil spirit, punished by God, a sinner, persecutionrelated to religion, or evil eye.In a final study, nine forms of delusions weredifferentiated (nihilistic, poverty, somatic, grandiose,persecutory, ideas of reference, guilt, beingcontrolled, jealousy) for twenty-one themes.Among those themes, “religious/ supernatural” wasseparated from “possession” and from “I am God/Jesus/Buddha/a heavenly being.” Persecution by“religious leaders” and “supernatural beings” wouldalso be identified as religious delusions.(13)2.2. Defining ReligionThere is no consensus in the literature as how todefine religion, in spite of the many concepts tobe found. In the present review, we favor a broaddefinition that includes both spirituality (whichis concerned with the transcendent, addressingthe ultimate questions about life’s meaning) andreligiousness (which refers to specific behavioral,social, doctrinal, and denominational

Delusions and Hallucinations 85characteristics). However, most studies have notused detailed inventories of personal religiositysuch as the construct of religious centrality.(23,24) Rather, emotional and behavioral aspectsof religious life have simply been described anddetailed. Interestingly, Siddle et al.(25) reportthat the dichotomous self-categorization of beingreligious or not used in their study was as validas more complex measures. The broad definitionof religion may include not only classical formsof religious life but also more exotic beliefs asdescribed in the following :Case ExampleA 50-year-old man with paranoid schizophrenia,who regularly attends the meetingsof a UFO association, reported, “I am a littlestrange. Since childhood, I have strangeexperiences. I regularly see UFOs. Once, Iwent too close to a saucer and was abductedby the aliens. This is why I have visions andI hear voices. These are not hallucinations.Since then I have a passion for UFOs, morethan that – it is a priesthood. I believe in God,but I prefer to call him ‘a highest benevolententity.’ Beside God, there are benevolentalien entities, i.e., Christ alien entities, andmalevolent alien entities, i.e., satanic entities.With those entities, one does not have anyliberty of choice, they influence us.”Indeed, the growing rate of people believingin UFOs and alien abductions has been analyzedin terms of the emergence of a new religiousmovement.(26)In this context, the cultural background isimportant, being likely to influence both worldviewand the contents of delusions. Thus, a cleardefinition of religious delusions is needed to allowthe clinician to be sensitive to cultural diversity.For such a definition, we need to go back to thedefinition of what a delusion is per se.2.3. What Is a Delusion?Defining delusion is not an easy task. The diagnosticapproach sets up qualitative differencesbetween delusions and other beliefs. Accordingto the Diagnostic and Statistical Manual ofMental Disorders, Fourth Edition, Text Revision( DSM-IV-TR ), (27) a delusion is a false beliefbased on incorrect inference about externalreality, which is firmly sustained despite whatalmost everyone else believes and despite whatconstitutes incontrovertible and obvious proofto the contrary. The belief is not one ordinarilyaccepted by other members of the person’sculture or subculture (for example, it is not anarticle of religious faith). When a false beliefinvolves a value judgment, it is regarded as adelusion only when the judgment is so extremeas to defy credibility.Delusional conviction occurs on a continuumand can sometimes be inferred from an individual’sbehavior. It is often difficult to distinguishbetween a delusion and an overvalued idea (inwhich case the individual has an unreasonablebelief or idea but does not hold it as firmly as inthe case of a delusion). Contents of the delusionmay include a variety of themes (for example,persecutory, referential, somatic, religious, orgrandiose).This definition of delusion has frequentlybeen criticized. The falsity criterion of delusionshas been dismissed for being not applicable,not resolved, or even resolved in the sensethat the content of the delusion was in fact true.(28) Especially, delusional religious beliefs lackany clear empirical content.(29) Indeed religiousbeliefs like delusions, lying outside the realm ofobjective falsifiability, subjective certainty, andincorrigibility.(30) The level of conviction maychange with time.(31) Individuals can group andform a community based on delusional beliefs.(32) Notwithstanding, the categorical nature ofthe diagnostic approach underlines a core psychopathologicalfeature indicative of substantialbreak with reality, which holds widespread clinicalacceptance and shows reliability.(33)Th e discontinuity between pathology andnormality has been challenged by epidemiologicalstudies with standardized diagnostic instrumentsthat demonstrate the presence of delusionsin persons without psychiatric disorders. It has

86 Sylvia Mohr and Samuel Pfeiferbeen shown that 10 to 28 percent of the generalpopulation have delusions (depending on thebroadness of criteria), whereas the prevalenceof psychosis varies around 1 percent.(34, 35, 36)This leads us to consider delusions not as discretediscontinuous entities, but as a complex andmultidimensional phenomenon. Assessing thepresence of a delusion may then best be accomplishedby considering a list of dimensions, noneof which is necessary nor sufficient, but which,when adding one to the other, result in greaterlikelihood of a delusion. For instance, the moreimplausible, unfounded, strongly held, not sharedby others, distressing, and preoccupying a beliefis, the more likely it is to be considered a delusion.(37) Although the number and the nature ofdimensions vary across studies, the most commondimensions are conviction, preoccupation,pervasiveness, negative emotionality, and actioninaction.(38)When comparing delusions in depression andschizophrenia, the criterion mood- congruent versusmood-incongruent delusional beliefs appearsas a specific dimension, “incongruence withaffective state.” The other dimensions are behavioraland emotional impact of delusional beliefs,cognitive disintegration, delusional certainty, andlack of volitional control. Delusions in depressiondisplay the same severity as delusions in schizophreniawith regard to delusional certainty andbehavioral and emotional impact.(39)Th e Peters Delusions Inventory (PDI) questionnairewas created to investigate delusionsin general and in psychiatric populations.(40)This scale scans for a set of beliefs, questioningif people hold them and how much they areconvinced, worried, and distressed by them.Those beliefs were mainly drawn from the symptomslist of the Present State Examination (22)and the Schneiderian’s first rank symptoms ofschizophrenia.(41) Several studies have beenconducted with this scale, comparing delusionalideations in healthy and psychiatric populations.For example, in a study of primary-care patientswithout lifetime history of psychiatric disorder,the range of delusional beliefs ranged from 5percent to 70 percent.(42) Of course, comparedto deluded psychiatric inpatients, healthy adultsappeared to endorse fewer of those beliefs and tobe less distressed, preoccupied, and convinced.Nevertheless, it is important to acknowledge thefact that, on average, healthy adults endorsedone-third of those delusional beliefs. Moreover,11 percent of healthy adults endorsed moredelusional beliefs than deluded psychiatricinpatients.(43) One study of particular interestis the comparison between deluded psychoticin-patients, new religious movements’ members(Hare Krishnas and Druids), and two controlgroups (nonreligious and Christian). The newreligious movements’ members endorsed asmuch delusional ideation as psychotic patients,with the same level of conviction , but with levelsof preoccupation and distress similar to the controlgroups.(40)Another way to tackle this is to differentiateinitial beliefs that are directly linked to observationand theoretical beliefs based on introspectionand judgments. By comparing delusionsamong inpatients with schizophrenia and thereligious belief (“God exists”) of highly religiousChristians acting as a control group, it appearedthat the religious beliefs and delusions did not differon levels of conviction, falsity, affect, nor influenceon behavior.(44) Those studies point out thatassessing the contents of beliefs is of little use todifferentiate religious beliefs from delusions.2.3.1. Formation and Conservationof DelusionsAnother approach to better understand delusionsis to focus on their formation and conservation.Three types of theoretical models tryto explain the formation of delusions based,respectively, on motivation, cognitive deficit,and perceptual anomalies. Theories based on themotivation view of delusions suggest that theyhave a defensive, palliative function, being anattempt to relieve pain, tension, and distress. Inthis view, delusions provide a kind of psychologicalrefuge and are understandable in terms of theemotional benefits they confer.Theories based on the deficit view of delusionsargue that they are the consequence of

Delusions and Hallucinations 87fundamental cognitive abnormalities. A set oftheories emphasize the cognitive biases and cognitivedeficits that have been found in deludedpeople, such as the jumping to conclusions, anexternal attribution style, an attention bias forthreatening stimuli, source monitoring deficits,and deficits in theory of mind. Thus, delusionsconstitute disorders of beliefs. For example, theformation of the delusion of persecution has beenexplained by a motivational factor (to preserveself-esteem) and a cognitive factor (attributingnegative events to external causes). The delusionof persecution is then upheld by a selective attentionfor threatening stimuli and a recall bias ofthreatening stimuli. (45)A third type of theoretical model is basedon the interpretation of abnormal perceptionsor experiences. Delusions are viewed as normaland rational explanations of such phenomena.(46) This model postulates that the mechanismsof formation of delusional beliefs are the same asthose of nondelusional beliefs.Like any other beliefs, delusional beliefs aimat giving meaning to events, they are personaltheories. Those personal theories are needed inthe face of unexpected events. The data not fittingwith the theory then will be either ignoredor reinterpreted. So, unusual beliefs are understandablein the personal and cultural context ofthe individual and his or her way to give meaningto his or her experiences.For Freeman et al., (47) the formation andthe maintenance of the delusion of persecutiongoes as follows. The delusion emerges after aprecipitating event that occurs often in a contextof anxiety and depression. For individualsprone to psychosis, stress induces confusionbetween internal and external events, whichleads to abnormal experiences (for example, hallucinationsand imposed thoughts and actions).The individual needs to explain those abnormalexperiences. In this search for meaning, previousbeliefs about self, others, and the world will beactivated. Those explanations are also influencedby the cognitive bias associated with psychosis.Th e conservation of the delusion is explainedby the reduction of the cognitive dissonance(selective bias for data confirming the delusionand avoidance of other data) and the disturbedaffect associated with delusion (anxiety anddepression). In summary, three componentshave been found in the formation and the conservationof delusion: cognitive deficits and bias,abnormal experiences, and emotions. However,there is no consensual model that explains therole of those dimensions in delusion, even if theyare all necessary. Indeed, some authors consideronly abnormal perceptual experiences as indispensablefor the formation of delusion.(48) Forother authors, although cognitive bias and deficitsare essential for the formation of delusions,this is not the case for abnormal perceptualexperiences.(45)The role of emotion in the formation of delusionis conceptualized either as a defense to preserveself-esteem (45) or as an emotional stateof anxiety and depression that contributes todelusion by a cognitive bias (for example, by theanticipation of the threat) and behavioral reinforcement(for example, by safety behaviors). (47)For Morrison, (49) delusions and hallucinationsresult from intrusions into consciousness ofthoughts, perceptions, and bodily sensationsthat are misattributed to an external source, dueto such thoughts being inconsistent with theperson’s beliefs about his or her own mental processes(metacognitive beliefs). This is the interpretationthat causes despair and dysfunction.The root of negative metacognitive beliefs aboutself and others often lies in childhood traumaticevents. Indeed, a robust association has beenfound between childhood negligence and abusesand the onset of psychosis.(50)2.4. Hallucinations and the Role ofAbnormal Perceptual Experience sTh e debate about the necessary or contingentcharacter of abnormal perceptual experience indelusion is still open. However, abnormal perceptualexperiences, like delusional beliefs, arenot restricted to psychiatric patients. For example,in an epidemiological study conducted inthe United States with 15,000 adults, 4.6 percent

88 Sylvia Mohr and Samuel Pfeiferreported having auditory hallucinations, with athird meeting the criteria for a psychiatric diagnosis.(51)Similar results were drawn from theUnited Kingdom: the annual prevalence of auditoryor visual hallucinations is 4 percent in thegeneral population, with only one out of eightpeople with hallucinations meeting criteria fora psychiatric diagnosis.(52) When taking intoaccount hallucinations in the domains of sight,sound, taste, touch, and smell, about 11 percentof the general population score above thatreported by psychotic inpatients.(53) Manydelusional patients report abnormal perceptualexperiences, yet not all of them.(54).2.4.1. What Is a Hallucination?According to DSM-IV-TR ,(27)“Hallucinationsare distortions of the perception. Hallucinationsmay occur in any sensory modality (e.g.,auditory, visual, olfactory, gustatory and tactile),but auditory hallucinations are by far the mostcommon. Auditory hallucinations are usuallyexperienced as voices, whether familiar or unfamiliar,which are perceived as distinct from theperson’s own thoughts. Certain types of auditoryhallucinations (i.e., two or more voices conversingwith one another or voices maintaining arunning commentary on the person’s thoughtsor behavior) have been considered to be particularlycharacteristic of schizophrenia. The hallucinationsmust occur in the context of a clearsensorium; those that occur while falling asleep(hypnagogic) or waking up (hypnopompic) areconsidered to be within the range of normalexperience. Isolated experiences of hearing one’sname called or experiences that lack the qualityof an external percept (e.g., a humming in one’shead) are also not considered to be hallucinationscharacteristic of schizophrenia. Hallucinationsmay also be a normal part of religious experiencein certain contexts.” So, the DSM-IV-TR(27) defines delusion as false beliefs and hallucinationsas false perceptions. How is it possible toexperience false perceptions?Th e origin of a false perception may be attributedto biological deficits in brain functioningthat produce psychotic experiences. Indeed,for Frith, (55) the basic mechanism lies in theincapacity to differentiate an internal from anexternal source of action (that is, confusion ofthe source of intended actions). Hence, peopledo not feel they control their own actions.Moreover, the incapacity to understand themental state of other people (theory of mind)leads to the incapacity to understand them,to confusion in relationships, and then wronginferences and suspicion.For Hemsley, (56) hallucination results froma confusion between memory and perception.The subject is unable to differentiate essentialelements from accessory elements in a situation.As thoughts are automatically retrieved throughmemory, when these are alien to his or herexpectancies, they are attributed to an externalsource. For Slade and Bentall, (57) five factors arerequired to produce a false perception: stressfulevents, cognitive deficits, external stimuli, reinforcementby the reduction of emotional tension,and expectancies (the subjects hallucinate whatthey know).Indeed, raised anxiety was found just priorto a hallucinatory report, as well as a decreaseof anxiety while hallucinating. Mood statereduction is then experienced as rewardingand increases the frequency of hallucinations.(58) Several hypotheses come from cognitivepsychology to explain the misattributionof an internal event to an external source. ForBentall, (59) the ability to distinguish betweeninterior and exterior, between reality and imagination,is a metacognitive ability. Some individualswould slide more easily from interiorto exterior, and then would interpret internalstimuli as external. Garety and Freeman (60)explained the phenomenon by a data-gatheringbias (no use of situational and cognitive clues)and by motivational factors (avoidance of negativeaffects and need to give meaning to incomprehensibleevents).For Morrison, (49) metacognitive beliefsconcerning both positive beliefs about worryand negative beliefs about uncontrollability anddanger associated with thoughts lead the subjectto attribute intrusive thought to the exterior; the

Delusions and Hallucinations 89hallucinatory experience is therefore favored bythe reduction of cognitive dissonance.Th e most common type of hallucinationis auditory. About 60 percent of patients withschizophrenia experienced auditory hallucinations.(57)However, most people experiencingminor auditory hallucinations have no psychiatricdisorder and are not in need of psychiatrictreatment.(51, 61, 62)So, what are the factors that differentiatevoice-hearers with psychiatric disorder fromvoice-hearers without psychiatric disorder? Tworelated factors are at stake: the characteristicsof auditory hallucinations and how the subjectreacts toward them. Romme and Escher developeda therapeutic approach for voice-hearersbased on the differential functioning of patientand nonpatient voice-hearers. As for the characteristicsof the hallucinations, both patients andnonpatients hear positive and negative voices.But the big difference between them is the effectof the voices. Nonpatients (i.e., those withoutpsychiatric disorder) feel their experiences asmainly positive, whereas patients are scared,upset, and disrupted in their daily life by thosevoices. For patients, they present a social-emotionalproblem that they are not able to solve.This leads to emotional distress, social isolation,and behavioral problems. Voice-hearers producemany different theories to explain their experience,which vary according to their own view onlife and religion and their cultural background.Psychiatry and psychology consider the voicesas within the person. But to the hearers, it betterdescribes their experience to say the voices layoutside of themselves. Some may view them asa symptom of disease, but for others, they comefrom other living people, from spiritual entities(God, ghosts, angels, evil spirits) or may indicatespecial spiritual powers (gift of mediumship or,telepathy). The attribution of the source of thevoices leads to specific coping strategies. Someof those theories are shared by various subcultures.(63)According to Chadwick and Birchwood, (64)auditory hallucinations are a trigger. The persongives a meaning to his or her hallucination,which then leads to emotional and behavioralreactions. What causes despair and maladjustedbehavior is a dysfunctional meaning attributedto the voices in terms of malevolence andomnipotence.2.5 Association of Delusionsand HallucinationsDelusions and hallucinations often go togetherboth in patients and in the general population.(65) This association may be partly dueto some delusions generated to give meaningto hallucinations. Another hypothesis for thisassociation lies in their common underlyingpsychological mechanisms: a basic cognitivedisturbance leads to an anomalous consciousexperience (for example, heightened perception,actions experienced as unintentional, racingthoughts, thoughts appearing to be broadcasted,thoughts experienced as voices, two unconnectedevents appearing to be causally linked).Such anomalous experiences are puzzling andassociated with anxiety and depression, andthey required explanations. Those explanationsare influenced by cognitive bias and metabeliefs.Hence, delusions are dysfunctional attempts tomake sense of anomalous perceptual experiences.(66) For Morrison, (49) metacognitive beliefsare an underlying factor for both delusions andhallucinations.All psychiatric and psychological theories ofhallucinations postulate the misattributionof an internal event to an external cause. Inthat, clinicians, like voice-hearers, developstrong convictions about the meaning of suchexperiences – meaning rooted in their culture.The DSM-IV-TR (27) points out the roleof culture in the definition of hallucination –“Hallucinations may also be a normal part ofreligious experience in certain contexts” – anddelusion – “The belief is not one ordinarilyaccepted by other members of the person’s cultureor subculture (e.g., it is not an article ofreligious faith).” We will now explore how tomake sense of these studies for application toclinical practice.

90 Sylvia Mohr and Samuel Pfeifer3. CLINICAL IMPLICATIONS: HOW TODEAL WITH RELIGIOUS DELUSIONS3.1. Disentangling Religion andPsychopathologyA number of studies have tried to establish theinfluence of premorbid religiosity on the formationof religious delusions. Thus, Getz et al.(67) examinedpatients from Catholic, Protestant, and nonreligiousbackgrounds regarding the frequency ofreligious delusions. They did not find any differencein the severity of religious delusions across the variousgroups. In conclusion, they wrote, “Religiousaffiliation may influence the frequency of religiousdelusions…, but religious affiliation appears to beindependent of religious delusion severity.” Siddleet al.(20) found 68 percent of their patients to havesome sort of religion, but only 23 percent showedsome form of religious delusion.From the studies on delusions and hallucinations,we have emphasized the continuity betweennormality and psychopathology, the multidimensionalcharacter of those symptoms, and their commonground due to the key role of beliefs for givingmeaning to strange experiences. Sometimes, thismeaning takes a religious flavor. Culture providesa framework of symbols that allows for meaningsto be created, and among them religious symbols.Religion has even been reduced by some to a systemof meanings.(68) The clinician is confrontedby a sensitive problem: how to distinguish a religiousbelief from a religious delusion.3.2. Delusion as a Dysfunctional BeliefSims (69) gave three criteria to distinguish areligious belief from a religious delusion:1 The experience reported by the patient givesthe impression of a delusion.2 Other psychiatric symptoms are present.3 The outcome of the experience seems morelike the evolution of a mental illness, ratherthan a life-enhancing experience.For studying religious delusions in patientswith schizophrenia, the acceptability of the beliefsby their religious community had to be added.However, this criterion is not sufficient in itself.Magico-religious beliefs are a major source ofconfusion for the clinician. Two examples fromdifferent cultural backgrounds may illustrate thisfact. About a third of Protestant Christians inAustralia endorse a demonic etiology of majordepression and schizophrenia.(70) Among religiousProtestant patients in Switzerland, 82 percentwith psychotic disorders believed that apossible cause for their problems was influenceof evil spirits. But 50 percent of patients withnonpsychotic disorders (mood disorders, anxietydisorders, personality disorders, and adjustmentdisorders) also attribute their disorders todemonic influences.(71)Similar figures have been found in a study inNorth India in a non-Christian context, wherethe ancient belief in magic is embedded in theprevailing religious context. In a study of magico-religiousbeliefs in schizophrenia conductedin India, (72) the authors found a high prevalenceof magico-religious beliefs (75 percent of patientswith schizophrenia). However, these were understoodprimarily as a guideline to treatment, ratherthan in terms of identification of pathology.Belief in supernatural influences was commonamong patients’ relatives (even from an urbanbackground and with adequate education), andtreatment based on such beliefs was sought to aconsiderable extent.Hence, the belief in demons or magical forcesas the cause of auditory hallucination is notsufficient to define a religious delusion. It hasto go along with other signs of mental illness,for example, disorganized behavior and otherbehavioral features that are not seen in thosewho may share some odd religious convictions.Moreover, demonic attributions to symptomsmay even have some beneficial effect, albeit in arather unusual way as the following case exampleillustrates:Case ExampleA 33-year-old man with paranoidschizophrenia who was a “born again”Christian, giving Christ a central position

Delusions and Hallucinations 91in his life, reported, “I am a schizophrenic.I have to take regularly my medication, otherwiseI speak with trees. I still hear voices,but I have the discernment. As I believe inGod, I believe in evil. I know that voices arefrom the enemy who wants to destroy mewith insults and belittlements. I don’t listento those voices, since the evil is a liar. Thereis nothing true in it. So I pray to Jesus whoheals my soul. Sometimes, I hear the voiceof God. He gives me strength, peace andcourage.”In this case, the patient’s religious frame ofreference provides him with effective religiouscoping strategies, such as selective attention topositive voices and reduction of the emotionalimpact of the negative voices. Voice-hearersoften give meaning to their voices, not as auditoryhallucinations, but as a form of communicationwith another plane, with a spiritualrealm, or access to different levels of consciousness.(63)Belief in demons as the cause ofmental health is not restricted to Christianity.Intensive religious practices are often associatedwith increased religious delusion rates (40, 67) ;however, they are not necessary for the onset ofreligious delusions.(20)The first step to disentangle religious beliefsfrom religious delusions lies in the functionalityof the belief. If the religious belief is a sourceof emotional distress or impaired behavior andsocial functioning, then it is a delusion. This perspectiveis documented by studies on content-freedimensions of delusions. This approach allowsthe clinician to distinguish a religious belief froma delusion, but does it mean that the delusion is“religious” (when it is)?3.3. Religious Delusion: A ConfusingCategory for CliniciansWe have already seen that the category of religiousdelusion includes or excludes the same contentsdepending on the classification criteria. Thelist of themes for delusions is infinite, with somedelusions specific to subcultures. New delusionsappear in relationship with socio-political eventsand new technologies.Th e general themes for delusions (such aspersecution, grandiosity, or belittlement) arefilled with a diverse set of cultural and idiosyncraticcontent. Religion is one of the manysources of “color.” In factor analysis, “delusionof persecution” is a factor by itself.(73) However,typical themes of religious delusions are persecution(often by the evil or demons), grandiosity(believing oneself to be God, Jesus, or an angel),belittlement (to have committed some unforgivablesin), and being controlled (possession).Then religious contents may be found in delusionsof influence (possession), self-significancedelusions (to be Jesus, to have committed theunforgivable sin), and persecution (by the evilor demons).So, to disentangle religious beliefs from religiousdelusions, one has to substitute the category“religious delusion” by a more valid typology ofdelusions (as, for example, delusions of influence,self-significance delusions, and delusion ofpersecution), and specify the presence (or not) ofreligious content. This approach reverses the wayto handle religious delusion by identifying firstthe presence of a delusion by its severity, thenthe type of delusion, and finally the presence orabsence of religious content.As an illustration of this strategy, we cite astudy focused on the content of persecutorydelusions that showed that in 19 percent of casesthe agent of persecution was a spiritual entity.(74) The content of grandiose delusion was ofreligious nature in 55 percent of the cases. (75)The agent of control in delusions of influencemay be another person, an anonymous group ofpersons, a nonhuman device such as a satelliteor computer, but it can also be a supernaturalentity.(76)3.4. Religious Delusion: A StigmatizingCategory for PatientsSuppressing the category of religious delusionwill not only lead to a better understanding of thepsychopathology of delusion, but also to a more

92 Sylvia Mohr and Samuel Pfeiferrespectful attitude toward the spirituality and religiosityof the persons involved. To label a delusionas “religious” often leads to an attributionof pathology to the spiritual and religious lifeof patients; this labeling is indeed stigmatizing.Like many people who turn toward religion tocope with stressful events in their life, psychiatricpatients often rely on religion to cope with theirsymptoms and the consequences of their illness.(24) However, the spiritual needs of psychiatricpatients are often neglected.(77) Just becausesomeone displays delusions with religious contentdoes not mean that all his or her spiritual and religiouslife is symptomatic of psychiatric illness.3.5. Functional Impact of DelusionsAccording to Pierre, (30) deciding whether religiousexperience is pathological should dependon its functional impact (if it causes distress anddysfunction). “Delusional” therefore refers not tothe content of a belief per se, but to how a beliefis held and its consequences (that is, with excessivepreoccupation, conviction, and emotionalvalence, and resulting in functional impairment).When looking for the content-free dimensions ofdelusions (conviction, pervasiveness, preoccupation,action, inaction, and negative affect) acrosstypes of delusions, delusions with religious contentseem to be accompanied by more intensesuffering than other forms of delusions.Do these approaches, focused on the dimensionsof delusions and the process of formationand conservation of delusion, imply that the contentmay be ignored? Definitely not. The greatvariation of delusional themes across cultures isevidence of their importance for the individual.Culture gives words and images for the expressionof suffering. The content of delusions is alsorelated to the person’s history.3.6. Psychodynamic ConsiderationsTherapy for delusions and hallucinations with religiouscontent requires a broad understanding ofthe underlying processes. It is not enough to givemedication to treat the pathological symptoms.Understanding the delusional person in the initialphase of the treatment is equally important.In a Swiss study, (78) four functions of delusionswith religious content were described:explanation, context, exculpation, and wishfulfillment/significance.Explanation refers to the interpretation orcognitive reframing of threatening hallucinations,psychotic experiences, and delusional perceptions.What is vaguely perceived as an evil,life-threatening, and overwhelming threat to aperson’s existence, obtains a new significance ifit is labeled “demonic.” “Why me?” is one of themost tormenting questions of the delusional person.Whereas normal life would give no explanationfor singling out an individual in such adestructive way, the events receive significance inthe light of religious writings, where the just isthreatened and attacked, even in the absence ofpersonal wrong-doing. But there are also positiveconnotations, such as identifying a comfortingvoice as the voice of Jesus or an angel in the midstof puzzling and threatening events.Context refers to the ultimate human desireto understand individual suffering in a largerframework of reference. Culture is a majorsource for such contextualization. For the religiousperson, accounts in the Bible, the Koran,or other holy books can serve as the over- archingscenario for his or her personal revelations, sensations,and fears. The end of the world, theapocalypse, is a common theme, but so is theadvent of a new era or of a savior. In grandiosereligious delusions, the person ascribes suchmeaning to herself, which is logical for her inthe delusional context but offensive to the religioussurroundings, resulting in rejection andsocial isolation. Delusional context can serve asa coping mechanism in persecutory delusions:The more powerful the subjects feel in the faceof their persecutors, the less depressed they areand the greater their self-esteem.(74)Exculpation or “ dis-egoification ” refers to thepsychodynamic mechanism of guilt reduction.Some patients report sexual desires and eroticsensations that they would never acknowledgein their healthy ego state. The delusion of Jesus

Delusions and Hallucinations 93coming to them in their sultry dreams exemptsthem from guilt. Others may commit self-mutilationsor aggressive acts against their family – ifit was ordered by an evil (delusional) power or a(delusional) logical necessity. It is not their fault.Thus, the religious delusion helps them to keepsome ego-stability, albeit fragile and deceptive, inthe midst of personal failure and a behavior thatwould not be compatible with their healthy religiousconvictions.Finally, wish-fulfillment and significance maycome out of delusional experiences. In a studyon the stressful events preceding the initial onsetof psychosis, grandiose delusions were often triggeredby loss.(79) Patients with schizophrenia oftenare socially isolated, poor, and rejected. Delusions,however, can give them significance beyond theirexternal misery. Thus, a single woman, living on afarm together with the family of her brother, developedthe delusion of pregnancy. She was convincedthat she had conceived the baby from the HolySpirit. Now she was a worthwhile woman, soonto have a baby like her sister-in-law, even morethan that – a chosen woman like the Virgin Mary.Unfortunately, the pleasant delusion was accompaniedby sleeplessness and disorganized behaviorthat finally required the patient to be hospitalized.3.7. Treatment ConsiderationsIn this context, clinicians need cultural sensitivity,to be respectful and to differentiate between functionaland dysfunctional beliefs. The question isnot if the belief is true or false, because this is notthe central question in delusions with religiouscontent. Rather, the clinician has to decide if thebehavior associated with the delusions and hallucinationsrequires care or not. In other words,is the belief a source of suffering; does it increasedistress and impair social and occupational functioning?If so, the treatment of the delusionalcondition has to be standard treatment for suchsymptoms, including medication, psychotherapy,and social support. Psychotherapy can draw onthe psychodynamics described above, helping tofind out what the belief means to the person inhis or her current life situation.Religious beliefs (as well as ecological convictionsand other prejudices) can be an obstacle forthe acceptance of medication and professionalhelp. Delusions with religious content have beenassociated with a poorer outcome, which couldbe associated with greater refusal of psychiatrictreatment.(20) Religious beliefs – delusionalor not – may be in contradiction with psychiatriccare.(80) Patients may prefer to seek helpin a religious context, for example, miraculoushealing or visiting the grave of a prophet or areligious shrine. Others are brought to magicalpractitioners or exorcists by their relatives – oftenwithout sufficient improvement.(71, 72) Wisdomis needed to convince patients and their familiesto accept medical treatment. This wisdom maycome from the religious community, as illustratedin the two following vignettes:Case ExampleA 24-year-old man with paranoidschizophrenia reported, “Two years ago, Ibegan to hear voices of demons; I believedI was Jesus Christ. I escaped from the psychiatricclinic to consult a priest for anexorcism. He told me that I could not beJesus Christ and he taught me the gospel.Since that time, I met with him every week.The voices told me not to take any medication.He told me not to listen to them,since demons are liars. He told me that themedication could help me. Since then, I’veagreed to take it.”A 20-year-old man with paranoid schizophreniareported, “I didn’t trust the psychiatrist;I believed I had no mental disorderbut rather had some supernatural power,being able to see and hear people otherscould not. Those hallucinations had meaning.So I went to consult a Buddhist monkto get his advice. The Buddhist monk toldme it was only my imagination and hetaught me how to meditate. He also toldme that he could not heal me and that I hadto go to a psychiatrist. It’s he who causedme to adhere to the Western biomedicine.”

94 Sylvia Mohr and Samuel PfeiferSocial support should also include relatives orpeers who must be informed about the nature ofdelusional disorder. Respect for religious beliefsand traditions could be combined with an explanationof neurobiological processes leading toa distortion of otherwise functional religiousbeliefs. Winning the trust of family and peers isa major way to ensure long-term compliance andrecovery.But more is needed with regard to the role ofspirituality and religiosity in patients’ lives. Inpatient-centered care, the clinician needs to proceedwith a spiritual assessment (see Chapter 16).Hence, the clinician will know if the patientbelongs to a religious community, if his/her religiousbeliefs are shared by other people, howsalient religion is in his or her life and for coping,if there are unmet religious needs, and if he orshe may benefit from religious support.REFERENCES1. Ideler KW. 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96 Sylvia Mohr and Samuel Pfeifer62. Posey T , Losch , ME . Auditory hallucinations ofhearing voices in 375 normal subjects . ImaginationCogn Personal . 1983 ; 2 : 99 –113.63. Romme M , Escher , S . Making Sense of Voices .London: Mind Publications ; 2000 .64. Chadwick PB , Birchwood M . The omnipotence ofvoices. A cognitive approach to auditory hallucinations. Br J Psychiatry . 1994 ; 164 : 190 –201.65. Laroi F , Van der Linden , M. Metacognitions inproneness towards hallucinations and delusions .Behav Res Ther . 2005 ; 43 : 1425 –1441.66. Garety PA , Kuipers L , Fowler D , Freeman D ,Bebbington PE . A cognitive model of the positivesymptoms of psychosis . Psychol Med .2001 ; 31 : 189 –195.67. Getz GE , Fleck DE , Strakowski SM . Frequencyand severity of religious delusions in Christianpatients with psychosis . Psychiatry Res . 2001 ; 103: 87 –91.68. Park CL . Religiousness/spirituality and health:A meaning systems perspective . J Behav Med .2007 ; 30 : 319 –328.69. Sims A . Symptoms in the Mind: An Introductionto Descriptive Psychopathology . London: WBSaunders ; 1995 .70. Hartog K , Gow KM. Religious attributions pertainingto the causes and cures of mental illness .Mental Health Relig Cult . 2005 ; 8 : 263 –276.71. Pfeifer S . Belief in demons and exorcism in psychiatricpatients in Switzerland . Br J Med Psychol .1994 ; 67 : 247 –258.72. Kulhara P , Avasthi A , Sharma A . Magico-religiousbeliefs in schizophrenia: a study from North India .Psychopathology . 2000 ; 33 : 62 –68.73. Kimhy D , Goetz R , Yale S , Corcoran C , MalaspinaD . Delusions in individuals with schizophrenia:factor structure, clinical correlates, and putativeneurobiology . Psychopathology . 2005 ; 38 : 338 –344.74. Green C , Garety PA , Freeman D , et al. Content andaffect in persecutory delusions . Br J Clin Psychol .2006 ; 45 : 561 –577.75. Smith N , Freeman D , Kuipers E. Grandiose delusions.An experimental investigation of the delusionas defense . J Nerv Ment Dis . 2005 ; 193 : 480 –487.76. Pacherie E , Green M , Bayne T . Phenomenologyand delusions: who put the “alien” in alien control?Conscious Cogn . 2006 ; 15 : 566 –577.77. Fitchett G , Burton LA , Sivan AB. The religiousneeds and resources of psychiatric inpatients . JNerv Ment Dis . 1997 ; 185 : 320 –326.78. Gasser R. Religiöser Wahn. Eine katamnestischeUntersuchung zu Verbindungen zwischen religiösemWahnerleben, belastenden Lebensereignissenund Überzeugungen religiöser Gemeinschaften[Religious Delusions. A catamnestic study on therelations between religious delusional experience,traumatic life events, and beliefs in religious communities].Lizentiatsarbeit an der Philoso-phischenFakultät: Psychologisches Institut II der UniversitätZürich; 2007 .79. Raune D , Bebbington P , Dunn G , Kuipers E . Eventattributes and the content of psychotic experiencesin first-episode psychosis . Psychol Med .2006 ; 36 : 221 –230.80. Borras L , Mohr S , Brandt PY , Gilliéron C , EytanA , Huguelet P . Religious beliefs in schizophrenia:their relevance for adherence to treatment .Schizophr Bull . 2007 ; 33 : 1238 –1246.

8 Religion/Spirituality and Mood DisordersARJAN W. BRAAMSUMMARYThe spectrum of mood disorders is extensive,ranging from melancholia and bipolar disorderat the clinical end to milder depression, adaptationreactions, and mourning at the other end. Inempirical studies, several aspects of religiousnessare often found to be associated with lower levelsof depressive symptoms. The findings generallypertain to community-based studies. Althoughthe studies rarely address clinical samples, thereis evidence that religiousness predicts a betterrecovery from depression. However, more andmore studies demonstrate that depressive symptomsare often accompanied by religious discontentmanifested as negative feelings toward Godor a sense of having been abandoned by God.There is hardly any evidence of how religiousnessis related to the presentation and course of bipolardisorder. It is hypothesized that religiousnessitself may become a subject of mood swings, butcould also evoke disillusionment in the patient,and suspicion in the clinician. Religiousness hasbeen reported to be associated with better outcomesamong those suffering from grief. Studiesof suicide statistics show that, to a limited extent,religiousness can protect people from suicide.One initial aim of a clinical approach involvingreligion is to include spirituality and religiousnessin the examination of psychiatric symptoms.Another aim is to establish a mutual understandingof how spirituality and religiousness arerelevant, which in the case of some patients canbe a meaningful investment in the therapeuticrelationship.Depression is common throughout the lifecourse. With a lifetime prevalence in the UnitedStates of 16.6 percent (1) and a twelve-monthprevalence of 6.7 percent, (2) it is one of the mentalhealth problems with the highest prevalencein the population, second to anxiety disorders –although there is a considerable overlap betweendepression and anxiety. Moreover, studies indicatethat people who recover from a depressive episodeare still at risk for recurrence. The World HealthOrganization (WHO) (3) notes that depression isone of the major causes of disability worldwide inall age groups and accounts for about 12 percentof all disability. Melancholia is the most typicaland classical presentation of depression with severalcompelling features such as impoverishmentof emotional life and delusions of nihilism orguilt. Milder depressions and subthreshold levelsof depression known to be persistent and to easilydevelop into depressive disorder are, however,much more frequent.Manic episodes that occur in bipolar disorderare among the most dramatic presentations inclinical psychiatry. Although the lifetime prevalence(3.9 percent) and twelve-month prevalence(2.6 percent) of bipolar disorder are much lowerthan of unipolar depression, (1, 2) the core featuresare well known, such as delusions of grandiosity,marked euphoric states, severe sleepdeprivation, and continuous agitation sometimesleading to humiliating and socially devastatingsituations. The subsequent depressive episodesare characterized by painful efforts to reverse thesocial effects of the manic episodes, the acceptanceof psychiatric vulnerability, a tendency todemoralize, and problems with side effects frommedication.97

98 Arjan W. BraamThis chapter offers an overview of how religionis related to depression and bipolar disorder.In addition to the results of empirical research,prototypical findings are presented on depression,bereavement, influence of life course ondepression, bipolar disorder, and suicide. Thebasic implications for clinical practice are thenaddressed, with special attention devoted toefforts to bridge the differences in style betweenmental health workers and patients regardingreligious and spiritual beliefs.1. RELIGION AND DEPRESSION: ACHESSBOARD IN BLACK AND WHITETh e relationship between religion and depressiongives rise to ample speculation. Is religionthe last spark of hope in times of darkness?Might religion provide sources of effective coping?Or could religion even prevent depressiveepisodes? If research findings about religioncapture the interest of the press, it can lead toheadlines like Religion Helps . But other questionsdeserve equal attention. Do certain typesof religious convictions induce a depression ifguilt feelings are disproportionately emphasized?If religious convictions are conceived asirrational cognitions, would the assumed potentialfor coping always be disappointing becauseillusions fail to offset the effects of adversity?These are some questions posed by skeptics, butskepticism should not be confused with clinicalobservations about the relationship betweenreligion and severe depression. In cases of melancholia,depression seems to turn the patientaway from religious life as well as from any otherpositive emotions or goal-directed behavior.Once even negative emotions are out of reach,the anesthesia of emotional life is complete,resulting in a state of hopelessness and emptinessthat is hard to imagine. Patients describeit as a state of profound darkness, a state sometimesresembling death or even hell, and at thispoint an existential aspect seems inevitable.Given these very different points of view, cliniciansneed to seek venues in this landscape ofreligion and depression. But what venues makesense? To gain greater understanding of therelationship between depression and religion,one common way to describe associations withdepression is summarized. Furthermore, somediscussion is focused on the many dimensionsby which religion may be conceptualized.Epidemiological insights into the emergenceof depression have been strongly influenced bythe theoretical and empirical work of Brown andHarris.(4) These sociologists demonstrate howvarious social factors influence the developmentof depression. They distinguish three factors intheir vulnerability-stress model : (1) provokingfactors, including the stressors directly precedingthe depression; (2) vulnerability factorsreflecting poor social resources such as alack of intimate relationships, poor personalresources such as a pessimistic attribution style,or personality traits such as a high level of neuroticism;and (3) symptom-formation factorsdetermining the severity and type of depressionsymptoms.The vulnerability-stress model can be complementedby two types of protective factors.(5) If afactor mitigates the effects of stress, it is referredto as a protective factor with a stress-bufferingeffect. This stress buffer is closely related to thenature and timing of a provoking agent. Stressbuffers can be viewed as ways of coping successfully.The second type of protective factor isdefined as acting independently of stress and isviewed as a protective factor with a main effect. Itexerts a background effect counterbalancing theeffects of long-standing vulnerability factors.None of the factors noted above sufficientlyexplain the possible types of effects that promoteor inhibit the recovery from depression.Therefore, depression-maintaining and recoverypromotingfactors should be incorporated in themodel as well.2. RELIGIOUSNESS AS AMULTIDIMENSIONAL CONSTRUCTFor decades there has been a consensus aboutthe multidimensionality of religiousness, (6)and many varieties can be distinguished within

Religion/Spirituality and Mood Disorders 99the behavioral, cognitive, affective, and motivationaldimensions. The behavioral dimensionpertains to organized religious behavior suchas church attendance as well as nonorganizedreligious behavior such as private prayer. Thecognitive dimension pertains to religiousbeliefs and convictions and traditions ofreligious beliefs representing the context ofsocialization. The motivational dimensionpertains to the relative importance or salienceof religion in personal life. Here, one conceptoften emerges in the literature: that is, intrinsicreligious motivation defined as the extent towhich people live from within their religion,with faith as a supreme value in its own right,permeating life with motivation and meaning.Another variation is extrinsic religious motivation,defined as the utilitarian type of religiousness,useful to the self in granting safetyand social standing.With respect to the relationship betweenreligiousness and depression (an affectivedisorder), one may assume that the affectivedimension of religiousness is of crucial importance.This affective dimension, however, didnot receive much attention in empirical studiesuntil recently. Glock (6) conceptualizedthe affective dimension as religious experience .Although unintended by Glock, the term experiencebears a connotation of relatively eccentricor, at any rate, very private emotions, as arelinked to conversion, mysticism, or exaltation.These sudden emotions may come up less indaily life and presumably do not apply to allreligious believers. Thus, the question remainsas to how basic religious feelings in commonlife should be interpreted.From a psychodynamic perspective, the affectivedomain of religiousness also includesobject-relational aspects of the God image asconceptualized by Ana-Maria Rizzuto.(7) Objectrelations are ongoing, internalizing representationsof relationships with significant others,especially with regard to the emotional functionsof the relationships. Rizzuto elaborated onpsychoanalytic ideas on the mental representationof the relationship with God. This specialtype of object relation bears some resemblanceto relationships with early attachment figures,but the God object relation also firmly relates tocultural traditions.(8) The God object relationor God image may nurture a sense of basic trust,but can also arouse a sense of awe, anxiety, discontent,or anger.Another domain of religiousness pertains toreligious coping. Initially, the conceptualizationof religious coping followed fairly random patterns.Pargament, (9) however, contributed to adeeper understanding. He distinguished betweenreligious destinations – objects of significancerelated to the sacred – and religious pathways –religious attitudes and behaviors. Pargamentargued that religious coping is determined byhow an individual either conserves or transformsreligious destinations and religious pathways.By no means does religiousness represent amonolithic concept. It involves a system withvarious dimensions, various aspects within eachdimension, and a range of positions and varietiesfor each aspect. Moreover, aspects of religiousnessnot only belong to various dimensions, theycan also change over time. Of course the aspectsof religiousness are interrelated, but here againa range of combinations can be discerned. Oneshould bear in mind that statements about associationsbetween religiousness and mental healthalways require specification about the dimensionsor specific aspects of religiousness.All the aspects of religiousness can be assumedto act as factors related to depression in variousways ranging from vulnerability factors to recovery-promotingfactors. The integral examination ofthe relationship between religiousness and depressioncan thus be depicted as a matrix, a chessboardwith numerous combinations (Table 8.1). In thecolumns, the types of factors related to depressioncan be distinguished, and in the rows, thedimensions of religiousness appear with theirmain aspects. For example, religious cognitionssuch as the conviction that every human carriesguilt throughout life may give rise to exaggeratedfeelings of guilt in times of depression, or even toreligious delusions about trespasses interpretedas having committed the unforgivable sin. This

100 Arjan W. BraamTable 8.1: Theoretical Matrix of Possible Relationships Between Religiousness and DepressionAccording to the Adapted Vulnerability-Stress Model of Depression.vulnerabilitymain effectprotectiveprovokingstress buffersymptomformationdepressionmaintainingrecoverypromotinghistoryonsetpresentationcourseBehavior- organized (community)- private (prayer)Cognitive- personal beliefs- belief traditionsMotivation- intrinsic- extrinsicAffective- God object relatione.g. supportivee.g. dominatinge.g. neglectwould imply a symptom-formation effect on therow for the cognitive dimension. As a secondexample, religious coping is not included as oneof the main dimensions of religiousness, becauseit represents an application within this framework:If in times of adversity people intensifytheir prayer and thus prevent depression, stressbufferingeffects can be located on the rows forprivate religious behavior and in the columnof stress-buffering effects. Not all the positionson this chessboard are relevant to understandingthe relationship between religiousness anddepression. Questions arise as to which positionsprove to be solid in the literature and whichrelevant clinical points can be derived from thisapproach.3. RELIGION AND DEPRESSION: MAINLINES AND PROTOTYPICAL FINDINGS3.1. Meta-analysesTwo recent meta-analyses identified the mainpatterns of findings in the available empiricalstudies, including a focus on the distinctionsbetween dimensions of religiousness. Hackneyand Sanders (10) distinguished three dimensions:institutional religion (for example, churchattendance), ideological religion (for example,belief salience or fundamentalism), and personaldevotion (for example, intrinsic religiousmotivation). They performed a meta-analysisand showed that institutional religiousness was

Religion/Spirituality and Mood Disorders 101associated with slightly higher levels of mentaldistress (46 studies) and persona l devotionwith lower levels of mental distress (35 studies).Following a different strategy with 147 studiesand focusing on depressive symptoms, Smith,McCullough, and Poll (11) report slightly moredetailed findings. Again, intrinsic religious motivationwas associated with lower levels of depressivesymptoms, but the association between themeasures of religious behavior and depressivesymptoms were not significant. Moreover, Smithand colleagues identified both a weak main effectand a slightly more pronounced stress-buffereffect for people facing problems in old age.Furthermore, post-hoc analyses revealed thataspects reflecting a critical attitude toward religion,extrinsic religious motivation, and negativereligious coping (for example, blaming God fordifficulties) were associated with higher levels ofdepressive symptoms. The results of the metaanalysessuggest a main protective as well as astress-buffer effect, but it should be emphasizedthat causal interpretations are not warranted.3.2. PrayerIn meta-analyses and reviews, prayer is often categorizedas religious behavior, but private prayershould not be confused with public religious participation.Prayer does not only involve the privateaspect of contemplation, but the frequencyof private prayer by far exceeds that of religiousbehavior in the context of attending services.Although prayer is viewed as an essential elementof religiousness, only a limited number of studieshave been conducted on prayer or other privatereligious behavior and depression, and the resultsare mixed. One possible reason for the conflictingresults may have to do with the process of copingitself. People intensify their praying in times ofadversity, which is when depressive symptomsand other signs of distress develop as well. Ifprayer is successful as a coping strategy, it canfacilitate the recovery from depressive symptomsover time. Ai and colleagues illustrated this principle(12) with their observation that, retrospectively,prayer related to higher levels of depressivesymptoms in the period immediately followingcoronary bypass surgery, but this association wasreversed after one year of follow-up.Another perspective on prayer has to do withits perceived importance among patients admittedto a mental hospital. In a small sample (N = 50)of psychiatric inpatients in the United States,Fitchett and colleagues (13) described that prayerremained important for 80 percent of the patients,almost two-thirds of whom suffered from mooddisorders. The percentage was similar in a comparisonsample of medical and surgical patients.It is uncertain whether prayer is a successful strategyfor coping religiously with depression, but thefact that people pray very often suggests that theystrongly adhere to it. In a U.S. sample studied inNorth Carolina, the frequency of prayer amongolder adults with major depression was 80 percentweekly or more (14) compared to 46 percent in anAustralian sample.(15) Despite these differences,the rates of prayer are substantial. Prayer did notrelate to depressive symptoms in these studies.3.3. Recovery from DepressionSeveral studies describe associations betweenaspects of religiousness and the outcome ofdepression. In three studies among (older)subjects with depression, intrinsic religiousmotivation, (16) salience of religion, (17) and positivereligious coping (14) were associated witha better depression outcome. Church attendancehad no significant association with the depressionoutcome in either of the above studies. However,in a large study among 1,000 hospitalized adultswith pulmonary or cardiovascular disease andconcurrent major depression, Koenig (18) didnot observe a significant association betweenintrinsic religiousness and remission of depression.Church attendance, however, predicted ashorter recovery time, after multivariate adjustmentfor health and social support. Higher levelsof religiousness can thus be assumed to predict abetter depression outcome among older patientsor subjects with a serious physical condition. Thequestion remains as to whether the severity ofthe depression was similar between people still

102 Arjan W. Braamable to express high levels of religiousness andthose unable to do so. It is not completely certainwhether a history of previous depressive episodesor other markers of vulnerability could be sufficientlyaccounted for in these studies.3.4. Type of Symptoms (and Syndromes)Moral issues play an important role in the Judeo-Christian belief tradition, with its adherence tomoral codes, emphasis on conscience, and keenawareness of guilt. People involved in religionmay therefore more often report feelings of guilt,even though this may reflect more about theirperceived moral standards and religious upbringingthan about pathological guilt. Indeed, in acommunity-based study among older adults witha major depression in the Netherlands, depressedRoman Catholics and depressed Protestants moreoften reported feelings of guilt than depressednonchurch members.(19) Stompe and colleagues(20) focused on the symptom of guilt in a crossnationalcomparison between depressive patientsfrom Austria (Vienna) and Pakistan (Lahore).The authors stated that feelings of guilt may beprominent in non-Christian societies as well,for example, in Islamic cultures. In their empiricalapproach, they draw a distinction betweenethical guilt representing more or less normalexpressions of guilt and delusionlike ideas representingmore exaggerated conceptions of guiltor false judgments about guilt. Ethical feelingswere observed in both countries to the sameextent, with Pakistanis generally only expressingmild self-reproach and Austrians tending toexpress feelings of guilt. Delusionlike ideas aboutguilt were less prevalent and only reported byAustrians.The issue of symptom formation can also beaddressed at a higher level, no longer regardingspecific symptoms within the depressive syndromebut ascending to groups of symptoms.A relevant distinction here is drawn betweeninternalizing and externalizing mental disorders.Internalizing disorders mainly correspondto depression and anxiety, whereas externalizingdisorders manifest themselves in altered behaviorsuch as substance abuse or antisocial conduct.This type of categorization has been applied byKendler and colleagues, (21) who assessed a widerange of aspects of religiousness in a populationbasedsample of twins in Virginia. They analyzedthe associations between these aspects and thelifetime history of nine psychiatric and substanceuse disorders, internalizing as well as externalizing.In their study, the social dimensions ofreligiousness, such as church attendance, wereassociated with lower rates of all types of disordersunder study. A positive God image ( InvolvedGod ) was only associated with a lower prevalenceof externalizing disorders. It might be useful tofollow the approach taken by Kendler and colleagues,using different samples with respect toage, region, culture, or religious affiliation. Withrespect to religious affiliation, the last aspect,Levav and colleagues (22) showed that the rateof major depression was significantly higheramong male Jews than among Roman Catholicsand Protestants, but the rate of alcoholism amongJews was lower.3.5. Pietistic Orthodox CalvinismA particular aspect of the relationship betweenreligiousness and depression can be found in onetradition, of a modest size, in the Netherlands.Strict adherence to Reformed, Calvinist doctrinesis thought to give rise to a mind-set characterizedby depressed mood, a tendency to refrain frompleasure, a sense of insufficiency, and guilt feelings.These aspects are in keeping with a more orthodoxapplication of the doctrines of John Calvin and theHeidelberg Catechism. This catechism formulatesthree articles, one on misery, one on salvation( How I may be delivered from all my sins and miseries),and one on gratitude as requirements forknowing whether one will be saved. The emphasison misery and powerlessness in Calvinist doctrinemight have certain implications for mentalwell-being. In their small and relatively closedcommunities, pietistic orthodox Calvinists characterizetheir attitude as heavy , with positive socialsanctions for behavior in line with the Catechism.There is ongoing interest in the Netherlands in this

Religion/Spirituality and Mood Disorders 103pietistic orthodox Calvinist tradition, and thereare empirical indications that the rates of depressionin these communities are twice as high comparedto other rural communities.(23)3.6. PentecostalsThe possible adverse effects of religious beliefsare not exclusive to pietistic orthodox Calvinistsand may also pertain to a certain extent toPentecostals. In a population-based study inNorth Carolina, Meador and colleagues (24)reported three times as high a risk for majordepression among members of Pentecostal congregationsas among members of other churches,after adjustment for several possible confounderssuch as life events and social support. One possibleexplanation the authors suggested was thatespecially depressed people may be particularlyapt to affiliate themselves with the Pentecostals.A similarity between orthodox Calvinists andPentecostals may be that their communities oftencombine a pietistic way of believing and strong,possibly over-regulating social networks.3.7. Religious DiscontentIn the literature on depression, a highly relevanttype of relationship is the one between religiousdiscontent , also referred to as religious struggle ornegative religious coping , and depression. Thereis a reported link between criticism of God or asense of being abandoned by God and higher levelsof depressive symptoms.(25, 26) This researchwas carried out among samples of somaticallyill hospitalized patients or older adults. The linkbetween religious discontent and depressivesymptoms is generally twice as strong as the onebetween intrinsic religious motivation or churchattendance and depressive symptoms. Most studiesnonetheless only included positive aspects ofreligiousness. Smith and colleagues (11) concludein their extensive meta-analysis that researchersshould devote more attention to negative formsof religiousness. Prospective research could forexample shed light on whether feelings of religiousdiscontent decrease or even disappear ifa depression ends, or if they represent, in fact, arisk factor for recurrent depression.4. LIFE COURSE PERSPECTIVESSo far there exists considerable scientific evidencefor a multifaceted relationship between religiousnessand depression. The findings should be understoodin their context, as is apparent from the verydifferent samples, ranging from the communitystudies, samples of older people, hospitalizedsomatically ill patients, or psychiatric inpatients. Ofcourse, knowledge of the religious tradition in thegeographical region where studies have been performedis crucial to understand the types of relationships.A related perspective pertains to the ageof the participants under study, the cohort in whichthey grew up, and their current stage of life. Is religionequally important throughout one’s course oflife? What can we learn from the few studies carriedout among children and adolescents?4.1. The Varieties of Religious DevelopmentIndividualization and secularization have permeatedthe Western world in the past century.Greater freedom has evolved to make choicesto which extent a religious way of life fits toone’s course of life, which will also relate toand depend on one’s social roles and familyties, personal inclinations, character traits, andspheres of interest. It would be good to havegreater insight into the choices people makewith respect to spirituality and religion. In theirstudy on The Varieties of Religious Developmentin Adulthood , (27) McCullough and colleaguessuggest that religiousness does not follow onegeneral trajectory throughout life, as seems to besuggested by higher levels of religiousness in laterage. They conducted an empirical analysis, focusingon the importance of religion, in a sample ofmore than a thousand young Californians understudy since 1940 with follow-up assessments forup to fifty years later. The results revealed threetrajectories of religiousness: (1) about 40 percentof the sample followed a pattern starting withintermediate levels of religiousness that increase

104 Arjan W. Braamaround age 54 and return to the initial level byage 80 ( parabolic class ), (2) about 40 percent ofthe sample exhibited a pattern with very lowreligiousness throughout their lifetime ( low/declining class ), and (3) less than 20 percent hadhigh levels of religiousness that even increasedthroughout their lifetime ( high/increasing class ).In this study, the distribution of 40 percent parabolic,40 percent low, and 20 percent high is fascinating,because similar distributions might welloccur in other populations. This research suggeststhat, for a minority (perhaps a large minority),religion is very relevant throughout life; forothers, there are stages when religion becomesrelevant; and for another, substantial number,religion seems to remain entirely irrelevant. Anexception to this last point is that people with anactive resistance against religion sometimes willnot be indifferent to religion at all and may havesuffered from a too-strict religious upbringing insome cases.In the course of a lifetime, some aspects of religiousnessmay become less important or less relevantto one’s mental well-being and be replaced byother aspects. In adolescence, church attendancemay affect moral directives, coping skills, and socialfunctioning.(28) In adult life, an intrinsic religiousmotivation emerges as an aspect relevant toself-realization and self- determination, which areimportant for goal-directed behavior in the contextof career development and family building.(27) Inlater life, both church attendance and intrinsic religiousnesscan play an important role as resourcesfor coping with adversity. It is uncertain whetheraffective aspects of religiousness such as a perceivedrelationship with God or spiritual aspects such asan openness to transcendental experiences developthroughout the life cycle. Moreover, the social context,especially the degree of secularization, plays adecisive role in the extent to which people have averbal repertoire to communicate about their religiousor spiritual inclinations.4.2. Children and AdolescentsOne study performed by Rew and colleagues (29)in a pre-adolescent sample (8–12 years) in Austin,Texas, focused on prayer. Prayer frequency wasassociated with social connectedness and senseof humor, but not with levels of perceived stress,possibly because the levels of stress in this populationwere generally low.A review by Wong and colleagues (30) includedtwenty studies on the association between religiosity,spirituality, or both and mental healthin adolescents in the 10 to 20 age range. Theydevoted specific attention to the various measuresof religiosity and spirituality. The most pervasivefinding produced by this strict and systematicapproach was that church attendance (and othermeasures of institutional religiosity) in particularexhibited positive associations with mentalhealth. This finding is quite different from theresults of meta-analyses on religion and depressionin samples of adults, (10, 11) where institutionalmeasures exhibit the weakest correlationswith mental health and devotional measures thestrongest. Wong and colleagues suggest that thesocial and behavioral impacts of religiosity mightbe more beneficial to adolescents than to olderadults because they provide adolescents with asense of order and belonging during a potentiallyturbulent period in their development.5. RELIGION AND BEREAVEMENTLosing a spouse or lifelong companion is somethingthat generally occurs in later life andconfronts the individual with a difficult task.Although there is no need to comprehend theresponse of mourning as a mental disorder,it does require a thorough adaptation processgenerally accompanied by transient or longerlasting depressive moods or other depressivesymptoms. In the stages of grief formulatedby Kübler Ross, (31) the bereaved are apt to gothrough the normal psychological stages ofdenial , anger , bargainin g, depression, and acceptance. Although there is insufficient empiricalevidence that all mourners go through all thesestages in this sequence, (32) the stages providea frame of reference for understanding some ofthe dynamic responses to bereavement and theirinterplay with religion.

Religion/Spirituality and Mood Disorders 105In its myths and beliefs, religion has a greatpotential for helping people cope with the endof life, bereavement, and dying. It is possible tospeculate on how religiousness relates to each ofthe five stages of grief. In the opinion of atheists,for example, the belief in an afterlife may be aform of denial. Anger might evoke problematicfeelings among religious people, such as guiltabout rebelling against the Creator or troubleexpressing anger at God. Bargaining can be donein an effort to influence one’s fate by altruisticbehavior or adherence to rituals, as is observedamong Roman Catholics. Calvinists might havecompelling questions about whether or notthey are predestined for salvation. Depressionmay follow any of the various religiousness anddepression patterns outlined above. As to acceptance,the role of religiousness may relate to theoutcomes of the previous stages. In any of thestages of grief, the religious community can oftenprovide a certain degree of consolation, moralsupport, human contact, and sharing in ceremoniesof mourning.An intriguing hypothesis about the psychologyof religion and bereavement derives from attachmenttheory. Kirkpatrick (33) stated that a personalrelationship with God resembles a secureattachment to a primary caregiver. Along theselines, the emotional compensation hypo thesisnotes that the relationship with God providescomfort if a loved one dies and helps compensatefor the lack of a love relationship.Becker and colleagues (34) evaluated thirtytwostudies on the relationship between religiousand spiritual beliefs and bereavement. Abouthalf the studies reported a positive association.Nevertheless, the approaches exhibited considerablevariation as regards the measures and outcomes.The vast majority of the studies examinedsamples consisting of white American Protestantfemales. One exception was a British study onthe fourteen-month outcome of bereavementamong 135 relatives of patients admitted to acenter for palliative care.(35) Spiritual beliefs, asassessed with the Royal Free interview on religiousand spiritual beliefs, (36) had a modest butrobust association with a better grief outcome,even after adjustment for baseline depressionscores. Because of the mixed and modest effects,Becker and colleagues concluded that the issue ofwhether religion is related to the grief outcomehas not been resolved.(34) They comment thatreligious and spiritual beliefs can be expectedto affect many other aspects besides depressivesymptoms, such as autonomy, personal growth,or engagement in social activities.6. RELIGION AND BIPOLAR DISORDERBy definition, the question of how religionrelates to bipolar disorder requires an approachthat addresses both poles. First, an approach tothe depressive pole would need to fit into thevulnerability-stress model described above.Other, complementary principles might have todo with the relationship between religiousnessand the manic phase. This simple suggestiondoes not consider the fact that the depressiveand manic phases occur in succession and oftendepend on each other. Furthermore, the vulnerability-stressmodel also applies to the manic pole,at least in the first episodes of bipolar disorder.(37) In view of the sensitization phenomenon,the provoking effect of environmental stressorsincreases over time with successive recurrentepisodes of mania. This means that, over time,minor stressors or even minimal stress may besufficient to provoke a new episode. A relatedfeature of bipolar disorder over time is the kindlingphenomenon , (37) where the frequency ofthe recurrent episodes gradually increases andsymptom-free intervals tend to shorten. Bipolardisorder medical treatment regimes not only aimto minimize the affective disturbances during theepisodes, but also to prevent recurrent episodesand at least prevent the bipolar cycle from accelerating.Besides prolonging the symptom-freeintervals, another task in the treatment of bipolardisorder is to help patients accept that they havea chronic mental disease, assist with social rehabilitation,and prevent demoralization.The relationship between religiousness and thetwo poles of bipolar disorder spectrum may thusfollow the vulnerability-stress model, with an

106 Arjan W. Braamemphasis on factors relating to the (cyclic) course.Moreover, becoming aware of one’s chronic vulnerabilitywill not be easy for most patients. Anacceptance of this unfortunate condition is conceptualizedas a loss situation, a loss of career possibilitiesand social roles, relational losses, and aloss of mental stability itself. Any loss evokes griefreactions and complicated losses, in turn, complicatethe grief process itself. The basic stages of griefaccording to Kübler Ross are outlined above.Regarding the relationship between facets ofreligiousness and bipolar disorder, four aspectsdeserve special mention.1 Symptom formation . Symptom formationfactors play a role in the stress-vulnerabilitymodel, but in the case of mania, religiousnesscannot be regarded as a peripheral factor.During mania, many patients experience statesof enlightenment and increased religiousmotivation, which easily shift to the level ofreligious delusions. Although religious delusionsare discussed in chapter 7, the questionremains as regards the extent to which aspectsof religiousness such as the religious traditioninfluence the emergence of increased religiousinsights and emotions during the manic state.2 Religious experiences during mania . Bipolarpatients sometimes tend to conceal the experiencesthey have during the mania frommental health professionals, but still ponderabout them or even cherish the memory oftheir enlightened state or spiritual insights,irrespective of the negative consequences ofthe manic episode. How should these religiousinsights be viewed? Would they underminethe grief process? Or would they serve tohelp to maintain self-esteem?3 Religious preoccupations as early signs . Whenbipolar patients intensify their religiousinvolvement, this may in turn lead to religiousand spiritual preoccupations. Mental healthprofessionals often recognize religious preoccupationsas early signs of a new manic episode.This provides an opportunity to preventa recurrent episode, but patients discover thattheir religious life leads to distrust from theirclinicians, who feel the urge and responsibilityto focus on the biological treatment regime. Sothe element of religiousness is not only a specialdomain in the contact between the patient andthe clinician, it is also laden with suspicion.4 Disillusionment with religion . There is a fourthaspect that may be relevant to the depressiveepisode as well as the symptom-free interval.After the mania, enlightened spiritual experiencesoften lose their charm once the euphoriahas faded away. In the depressive state and thesymptom-free interval, disillusionment withreligion and spirituality may be experienced.This may obstruct the grief about having tocope with a chronic mental disorder and representan additional loss in life, the loss oftrust in one’s religion. Religiousness and bipolardisorder may thus be deeply intertwinedin the dramatic euphoric manifestation aswell as in the component of loss. Religion maybecome the subject of cycling itself.So far, very few studies have been conductedon religiousness or spirituality and bipolar disorder.In 1969, Gallemore and colleagues describedthat conversion experiences were more than twiceas prevalent in patients with mood disorders.(38)However, patients with bipolar disorder did notdiffer from a control group with respect to otheraspects of religiousness. Similarly, the abovementionedstudy by Levav and colleagues did notreveal any differences in the prevalence of manicepisodes in people of various religious affiliations.(21) In a small sample of psychiatric inpatients,Kroll and Sheehan (39) noted that manic patientsreported higher personal religious experience rates(55 percent) than depressed patients (25 percent)or a national sample (35 percent). Two other studieson patients with psychosis (40, 41) showed thatthe prevalence of religious delusions was aboutequal among manic patients and patients withschizophrenic psychosis and about twice as highas among patients with a psychotic depression.Findings of this type show how religionemerges in the phenomenology of the mania. Ahypothesis can be formulated about symptomformationeffects in that people with a religious

Religion/Spirituality and Mood Disorders 107background may express manic symptoms in amore religious way than others.In a study on bipolar patients in Texas, African-Americans report higher levels of spiritual andreligious coping than Caucasians.(42) In a NewZealand study on eighty-one bipolar outpatientsin a stable phase, a majority of the patientsreported having found support in their religiousand spiritual beliefs, (43) but 40% said the bipolardisorder led to a decrease in their religious faith.Patients hospitalized in the past five years report ahigher frequency of church attendance. Regardingthe special relationship between religiousness andbipolar disorder, many other elements still needto be examined over time in empirical studieson patients in manic states, symptom-free intervals,and depressed states, and on the interactionbetween patients and clinicians.7. RELIGION AND SUICIDEEver since Durkheim’s Le Suicide was publishedin 1897, there has been considerable awarenessthat religion may affect and attenuate suiciderates. Durkheim hypothesized that suicide rateswould be higher in societies with lower levelsof social integration ( egoistic suicide) or withrapid changes and decreases in social regulation( anomic suicide).(44) Because predominantlyProtestant societies are more likely to havedeveloped modern economies with less socialintegration and regulation, there is a sociologicalexplanation for the higher suicide rates inProtestant countries. According to Durkheim,Roman Catholicism has adopted an antimoderniststance, which in turn might have led to lowersuicide rates. Roman Catholicism thus holds amore traditional position, but the levels of socialintegration and regulation are generally not asextreme as to produce other risks ( altruistic andfatalistic suicides). Although this brief summarydoes not do justice to the highly original andinfluential work by Durkheim, the role of religioustraditions has changed in the course of thepast century. Moreover, in applying Durkheim’stheory, the methodological caveat of researchat an aggregate level (for example, of regionsor countries) implies that no inferences can bemade about minorities within these aggregatedentities ( ecological fallacy ). Suicide, as an event, isrelatively rare, and extremely large samples witha longitudinal design are required to obtain thebest evidence pertaining to individual processes.Furthermore, the reliability of official suiciderecords might vary with the prevailing religiousand ethical views in, for example, RomanCatholic regions.The sociologists Pescosolido and Georgiannahave granted considerable insight into how religiousaffiliations related to suicide rates in asophisticated analysis of suicide data from 1970in the United States.(45) They showed that suiciderates were lower in regions with more RomanCatholics and higher in regions with more liberalProtestants. In regions with high church attendanceand low interfaith marriage rates, suicidewas strikingly rare. Pescosolido and Georgiannapostulated that the risk of suicide increases ifsocial networks generate poor integration (forexample, among atheists) or overly tight regulation(for example, with members subjected to astrong religious regulative authority, as in religioussects). They suggested a U-shaped curvilinearrelationship between suicide rates and thedegree of social integration and regulation, as isgenerated by the religious climate.A valuable cross-cultural insight is providedby Simpson and Conklin, who summarized theircross-national findings based on suicide statisticsfrom seventy-one countries: the percentage ofMuslims is inversely related to the suicide rate.(46)Controlling for economic, social, and demographiccharacteristics did not eliminate the effect of Islam,and Simpson and Conklin also tried to discountthe reliability level of the suicide statistics. Asa possible explanation, the authors referred toDurkheim’s theory on social integration and regulation,because Islam fosters a close religious communitythat orders the daily life of the adherents.Th ere are other explanations besides socialintegration for the lower suicide rates inregions with higher levels of religious affiliation.Neeleman and colleagues demonstratedin a cross-national analysis that religious beliefs

108 Arjan W. Braamwere strongly associated with limited toleranceof suicide, and that, in turn, limited toleranceof suicide was more relevant to the associationwith suicide rates than religious involvement assuch.(47) In an extensive sociological overview,Stack contended that only a few core religiousbeliefs (for example, in an afterlife) and prayerhelp prevent suicide.(48)In a recent overview of the literature, Colucciand Martin described the main patterns in theempirical findings about religion and suicide. (49)They conclude that religious factors are generallyassociated with lower suicide ideation, morenegative attitudes toward suicide, and lowersuicide attempt rates. They feel, however, thatmany of the studies need to be replicated inother samples and cultures. Far more researchhas been conducted about religion and suicidestatistics, and most of it indicates that variousaspects of religiousness offer some protectionagainst suicide.In short, religion does seem to provide someprotection against suicidal thoughts and behaviorvia better social integration (for example,embeddedness in a religious group), the contentsof religious beliefs, or adherence to social normssuch as the nonapproval of suicide. One of thefew studies with individual data on religion andsuicide should be cited here because of its revealingresults.(50) Sorri and colleagues presentedretrospective clinical data and interviews withthe relatives of 1,348 individuals who committedsuicide in Finland in 1988. They noted thata history of inpatient psychiatric treatment anda diagnosis of psychotic or depressive disorderwere more common among religious people(18 percent). Sorri and colleagues concluded thattheir findings tended to imply that a higher levelof mental suffering was necessary among the religiousbefore suicide occurred.8. A SUMMARY OF EMPIRICALFINDINGS PERTAINING TO MOODDISORDERSIn the following brief overview, eight statementsare made that relate to the empirical findings.1 [extensive evidence] Religiousness relates tosome degree to better mental health in thecommunity and represents a source of adaptivecoping in times of adversity.2 [some evidence] The recovery rate fromdepression is substantially better for patientswho attach intrinsic value to their religiousfaith and patients involved in a religiouscommunity.3 [good evidence] During depressive episodes,negative feelings such as discontent towardGod or feeling abandoned by God are highlyprevalent.4 [some evidence] Religious beliefs and practicesare equally common among psychiatricinpatients, including the depressed; the frequencyof prayer may be even higher, irrespectiveof whether it leads to recovery fromdepression.5 [some evidence] Depressed patients with aChristian background may be more likely topresent with feelings of guilt.6 [no evidence] During manic episodes, religiousbeliefs may transform, either viadelusional inflation or via possibly moremeaningful spiritual enlightenment, but tendto become the subject of cycling itself and to besurrounded by suspicion and disillusionment.7 [mixed evidence] Religiousness may helppeople cope with bereavement and may leadto a better grief outcome, although it is uncertainwhether this means less depression.8 [sociological evidence] Religion may havea small protective effect against suicidalthoughts and behaviors, but should not beoverestimated in the context of other riskfactors.9. APPLICATIONS TO CLINICALPRACTICE9.1. Why Raise the Subject of Religionand Spirituality in Clinical Contacts?It might seem only logical to some clinicians,nurses, or therapists that religion and spirituality

Religion/Spirituality and Mood Disorders 109should be included as a regular theme, althoughthis notion may meet with hesitation and evenreluctance in others. Because the subject hasmultifarious aspects such as strict moralityand adherence to literal beliefs and intolerancetoward people of other faiths, feelings of embarrassmentor annoyance are lurking or can provokethe conviction that the clinician does nothave sufficient knowledge about religion andspirituality. Although some awareness of one’slimitations often makes sense in mental healthcare, there can be advantages to discussing religiousnessin clinical contacts. It might be worthconsidering and may outweigh the uneasinessdescribed above.The first assumption here is that mental problemsin general and mood disorders in particularoften raise questions about the meaning of life.This can either pertain to loss of meaning, orthe revelation that one’s life can be experiencedat summits of meaning itself. Avoiding the matterof the meaning of life, whether accompaniedby presumptions of a transcendent reality or not,may hide a relevant domain of the patient’s life.Without going into the field of pastoral careand theology, there are two practical ways toinclude religion and spirituality in clinical contactswith patients with mood disorders. The firstis by examining in the diagnostic phase whetherreligious or spiritual ideas manifest themselvesas psychiatric symptoms or seem to color theexpression of symptoms. The second is by establishinga mutual understanding regarding howspirituality and religiousness represent a relevantdomain in life. This can be an investment in thetherapeutic relationship, and at some time in thetreatment phase, it can lead to a referral to a pastoralcounselor.9.2. Diagnostic Phase9.2.1. DepressionPatients with depressive disorders do notoften spontaneously share their religious andspiritual views, questions, or experiences withtheir clinician or therapist. Particularly in thecase of depressed patients, due to their tendencytoward inhibition or poverty of speech, manyelements in the diagnostic interview need to beraised actively by the interviewer. This requiresadditional efforts by the interviewer to get animpression of the patient’s inner conflicts andprivate concerns, including remnants of hope.An open inquiry should avoid rapid conclusionsabout which problems might bother the patientthe most. The investigation of mood, anxiety,substance use, psychotic experiences, physicalstate, and suicidal ideation all deserve equalattention. In the initial contact, the subject ofspirituality and religiousness may be only brieflycited to show the patient that the subject will notnecessarily be ignored in the future.Several signs of depression can be experiencedin a way relating to religion. With respectto depressive mood and anxiety, cognitions suchas attributions of the currently depressed state tomoral punishment may arise and connect to feelingsof guilt or worthlessness. Anhedonia, energyloss, concentration problems, and fatigue mayconnect to a lack of purpose in everyday life andbe related to a sense of abandonment by God orloss of an inner spiritual spark. As the evidenceof discontent with God in times of depressionproves to be fairly solid, one might inform thepatient that many depressed patients experiencethese feelings and ask whether the patientrecognizes this theme. A lack of perspective, lossof hope, and loss of self-esteem may turn intothoughts about death or activate latent cognitiveschemes about self-annihilation as a lastresort. A neutral inquiry about possible belief inan afterlife, heaven or hell, or reincarnation foradherents to Hinduism or some contemporaryspiritual movements can often be added in thediscussion about pondering death.9.2.2. ManiaWhen a patient is in a manic state, the clinicianfrequently has to try to regulate the contactand avoid conflicts that would ruin the chance ofa working alliance with the patient. Furthermore,manic patients tend to be talkative and force theinterviewer to listen to facts, achievements, and

110 Arjan W. Braamassociations about which the relevance is uncertain.It can thus frequently take some time forthe clinician to conclude to which extent thereis disorder in the structure of thought. Once thatclinical conclusion is arrived at, the contents ofthoughts seem to escape further consideration.It may nevertheless be fascinating to continueand to record what manic patients reveal abouttheir religious and spiritual insights. Patientsfrequently report feeling in contact with cosmicenergies and having religious experiences.Whether these experiences are classified asspiritual, religious, or delusional does not alwaysreceive sufficient attention. An important caveatis that, during the mania, mixed emotions maybe hidden: the religious perspective, once the clinicianasks about it, may reveal thoughts abouthumility toward God, shame about their currentstate of overconfidence, unfortunate expectationsabout the future, or even suicidal thoughts.9.2.3. GriefAlthough not a regular reason for consultingmental health services, encounters with individualswho have lost a spouse or someone they wereclose to are not exceptional and often require thebest skills of tactful and empathic communication.An early inquiry about whether religionmay in some way be a source of consolation orrelief may reflect the clinician’s personal reactionto manage a difficult and emotionally demandingsubject. Emotional reactions to unanticipated situationstend to come in waves. Empathic listeningand a focus on primary needs such as contactwith relatives or friends may be more relevant inthe first phase than inquiring about religion. Abrief allusion to the subject of religion or spiritualitycan let the patient know that the subject willbe open for discussion when the time comes. Themental health care professional can ask whetherthere are any religious rituals that can or shouldtake place.9.2.4. Suicidal ThoughtsProfessional guidelines in several Westerncountries recommend a systematic suicide riskassessment. A rigid systematic approach should,however, be more than counterbalanced by anempathic approach to facilitate an alliance withthe patient, which can serve as a life-saving bridgein moments of crisis. Two elements in the riskassessment may relate to religion or spirituality.First, the estimate of remaining hope: hopelessnessoccupies a central position in the developmentof suicidal thoughts. What sources of hoperemain? For those with religious or spiritualfaith, a perspective of hope may still be attainable.Second, to a certain extent religion itselfhas been shown to prevent suicide. However,this effect, examined in suicide statistics at aggregatedlevels, should not be estimated as morethan modest. As a rule, the risk of suicide in situationsof loss, severe depression, or psychosis andin people who experience hopelessness cannotcompletely be compensated by religiousness orspirituality.9.3. Connect: Abridging Personal StylesDiscussing the patient’s religious and spiritualhistory and experiences may provide anopportunity to examine the expression of psychopathologyin religious terms, as well as toaddress existential questions and the potentialof hope. Nevertheless, knowledge about whatwe can conclude from empirical research maynot be sufficient. Patients may inquire aboutthe religious preferences of the clinician, nurse,or therapist. Moreover, they may express theirbeliefs in a way that evokes uneasy feelings.Individual religious convictions will almostalways differ between two individuals (clinicianand patient) and tend to be very personal.Small differences might be noticed with evengreater sensitivity than huge differences thatare simply there because someone was raised ina different culture.Another reason for feelings of uneasinessmight be more relevant in that it is not the contentsof the religious or spiritual beliefs that differbut the cognitive, emotional, and moral style.James Fowler, as a scholar of the psychology ofreligion, provides some organizing principles inthis connection.(51) In his monograph Stages

Religion/Spirituality and Mood Disorders 111Table 8.2: Brief Summary of Fowler’s Stages of Faith. (51) Stages Printed in Bold Appear to bePrevalent in Adult Samples (Wulff, 1991, pp. 399–402). (52)StagePeriod1. Intuitive-projective faith Imagination and imitation Ages 3 – 72. Mythic-literal faith Story, drama and myth; concretereciprocitySchool age3. Synthetic-conventional faith Shaping of the personal myth; stayingclose to expectations by othersAdolescence4. Individuative-reflective faith Relativism, critical, demythologizing;own responsibility for one’s faithAdolescence5. Conjunctive faith Revaluation of early imagination,narratives and symbols; dialecticaland paradoxical6. Universalizing faith Inclusive of all being; unifying andtransforming; contagious; decentrationfrom selfMidlifeRareof Faith , Fowler theorizes about levels of faithdevelopment that run more or less parallel tocognitive, intellectual, and moral development.Table 8.2 summarizes the stages with keynotes asshort characterizations.The stages of faith can be helpful in estimatingone’s own preferred level of apprehending religionand spirituality and that of others. Recognizingthat others tend to communicate at a differentstage may neutralize feelings of uneasiness to somedegree, because it is apparent that others adhereto different themes and thematic expressions andhave different expectations concerning how tointeract about these themes. Many mental healthcare workers may recognize their own stage offaith as individuative-reflective , allowing for a criticaland sometimes skeptical attitude toward religionand spirituality. Pious church members mayfeel more comfortable with synthetic-conventionalfaith . Awareness of different ways to experiencebeliefs according to a categorization like Fowler’smay make it easier to communicate with thepatient. Using Fowler’s stages, however, entails therisk of a higher stage being equated with higherspiritual achievements or moral qualifications. Inprinciple, a neutral assumption might be that, ateach level, people can experience their spirituallife in optima forma.No research has been conducted yet onwhether patients with mood disorders experiencechanges in their stage of faith. One might imaginehow certain cognitions during depression couldtend to demythologize religious beliefs and leadto disillusionment. Manic patients, on the otherhand, may be convinced of their supreme insightsat the level of universalizing faith, although thismay be at odds with inflated self-esteem.10. CONCLUSIONAs a main principle in the application of religiousand spiritual themes in clinical practice, oneshould not divert from regular treatment strategies.Excessive enthusiasm on the part of mental healthworkers with respect to religion should be examinedas a sign of counter-transference. However,

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9 Spirituality and Substance Use DisordersALYSSA A. FORCEHIMES AND J. SCOTT TONIGANSUMMARYSpiritual values and meanings are importantdeterminants and regulators of behavior, and atreatment model that recognizes this componentoffers a more integrated view of how to best treataddiction. The authors of this chapter approachthe interface of spirituality and addiction fromthe premise that individuals possess a fundamentaldesire for meaning and purpose – componentscentral to spirituality – and that the difficulty infulfilling these needs sometimes results in destructivemethods of coping, including the problematicuse of substances. The authors propose a modelof how spirituality is involved in the developmentand recovery of addiction. We then reviewrelevant research literature and current methodologicalquestions that consider spirituality as anindependent, dependent, moderating, or mediatingvariable. Finally, clinical and practical implementationswill be discussed and augmented withcase studies.1. INTRODUCTIONConceptions of spirituality and addiction areintimately tied together in the United States.Twelve-step programs, founded on the doctrineand prescribed spiritual practices of AlcoholicsAnonymous (AA), are the dominant models forrecovery from addiction. Therefore, it is hard tospeak about addiction without speaking aboutspirituality.Spirituality is also addiction’s Tower of Babel.There is little consensus among both professionalsand laypersons as to what spirituality is, how itrelates to religion, how it should be measured, howit relates to recovery from substance use disorders,where it belongs in formal treatment, and howrelevant it is for recovery. Strong opinions havebeen voiced both for and against the inclusion ofspirituality in addiction treatment. Some arguethat it is one of the most important resources bywhich people achieve and maintain sobriety, whileothers argue that including spirituality within formaltreatment or mandating patients to twelvestepprograms is unconstitutional and challengesthe separation of church and state. Overall, then,spirituality has been a significant source of conflictwithin the treatment of substance use disorders,and consequently, clinicians fall along thespectrum in deciding to either emphasize or avoiddiscussing this subject with patients.Th is is an evidence-based chapter intended tohelp guide clinical practice. The authors beginwith a definition of spirituality. We then proposea model for understanding the role of spiritualityin the development and recovery from addictionas one way practitioners might understand thisinterface. We present the roots of the long-standinginterface between spirituality and addictionas stemming from the twelve-step model, rootedin spiritual practice and beliefs. Included in theoverview of the twelve-step model is a discussionof the frequency and magnitude of spiritualtransformations that are often experienced byindividuals during the process of recovery fromaddiction. We also present studies that haveattempted to move outside of the twelve-stepmodel and systematically incorporate spiritualdisciplines as an intervention for addiction. Wethen engage the reader in some of the currentdebates concerning the interface of spirituality114

Spirituality and Substance Use Disorders 115and religion, including a discussion of how spiritualitycan be classified as an independent, dependent,moderating, or mediating variable. Finally,the authors highlight clinical implementations ofwhy, who, how, and when clinicians should discussspirituality with patients in addiction treatment.The empirical and theoretical findings areaugmented with case studies.2. DEFINING SPIRITUALITYThe topic of spirituality is receiving increasedattention in addiction research, evidenced bya steady escalation in publications and fundedresearch since 1980.(1) Within the research literature,however, there is lack of clarity in thedefinition of spirituality. It is often confused withreligion even though spirituality and religion aredistinct constructs.(2)In a review of the literature on addiction andspirituality, Cook examined 265 publications toidentify the definition of spirituality by differentauthors.(1) Cook found that only 12 percent ofthe papers explicitly defined the term spirituality ,32 percent offered a description of the concept ofspirituality, 12 percent defined a related concept(such as “the spiritually healthy person”), and 44percent of the papers left the term spiritualityundefined. Breaking the conceptual content of thedefinitions into component parts, Cook classifiedthe content of the various definitions into thirteenconceptual components.(1) Cook found thatthe four components that were encountered mostfrequently and were most central to the definitionof spirituality were transcendence, relatedness,core/force/soul, and meaning/purpose.(1) Onthe basis of Cook’s descriptive analyses, a workinghypothesis definition was proposed. Cook’sdefinition (1) highlights the main components ofhow spirituality is understood within the addictionliterature:Spirituality is a distinctive, potentially creativeand universal dimension of humanexperience arising both within the innersubjective awareness of individuals andwithin communities, social groups, andtraditions. It may be experienced as relationshipwith that which is intimately“inner,” immanent and personal, withinthe self and others, and/or as relationshipwith that which is wholly “other,” transcendentand beyond the self. It is experiencedas being of fundamental or ultimate importanceand is thus concerned with mattersof meaning and purpose in life, truth andvalues (pp. 548–549).3. THEORETICAL RATIONALE FOR THERELATIONSHIP BETWEEN SPIRITUALITYAND ADDICTION3.1. The Role of Spirituality in theDevelopment of AddictionThere is, in human nature, a desire to connectwith that which is beyond the self; that whichgives life meaning. Despite this yearning, individualsare distracted from spiritual seeking asthey are pulled toward the material world andoffered alternative ways to silence this spirituallonging. Ram Dass (3) wrote:It’s not difficult to recognize how deep arethe ways our mind has been conditionedto deal with unpleasant situations by resistingthem. Throughout our whole lives wehave been encouraged to do anything wecan to escape from rather than to exploreand investigate unpleasantness. … It’s notjust physical pain we try to avoid, but allkinds of unpleasant conditions: boredom,restlessness, self-doubt, anger, loneliness,loss, feelings of unworthiness. In our culturewe do all we can to push these experiencesaside, or keep them at a distance. Wechoose to be entertained. (1985, p. 79)Enticed by the temporary comfort that isoffered through the use of a substance, an individualbegins to see substance use as the shortcutto wellbeing. Gerald May (4) wrote, “If Godindeed creates us in love, of love, and for love,

116 Alyssa A. Forcehimes and J. Scott Toniganthen we are meant for a life of joy and freedom,not endless suffering and pain. But if God alsocreates us with an inborn longing for God, thenhuman life is also meant to contain yearning,incompleteness, and lack of fulfillment” (p. 179).Absolving the state of yearning with a placatingsubstance is an enticing alternative to the questfor spiritual fulfillment.Th e writings of Alcoholics Anonymous echothis innate sense of awareness that a God conceptresides “deep down in every man” (p. 55). (5)One of the founding moments of AA was a letterBill Wilson, the co-founder of AA, received fromCarl Jung. Bill W. had written to Jung telling himabout the conversion experience and subsequentsobriety of Roland, a former patient of Jung’swho had been told he was a hopeless alcoholicwhose only possibility of recovery was througha spiritual experience. Jung’s letter stated thathe believed that Roland’s “craving for alcoholwas the equivalent, on a low level, of the spiritualthirst of our being for wholeness; expressedin the medieval language: the union with God”(p. 69).(6) Jung continued, “You see, ‘alcohol’ inLatin is spiritus, and you use the same word forthe highest religious experience as well as forthe most depraving poison. The helpful formulatherefore is: spiritus contra spiritum ” (p. 70). (6)Alcohol serves as a substitute for spirituality:without effort, the use of a substance offers asensation that brings one nearer to the divine.Gerald May (7) wrote, “Chemical abuse anddependency constitute for me the sacred illnessof our time. In few other conditions doesone come up so definitely against the fierce linebetween grace and personal willpower” (1992,pp. 160–161). Addiction characterizes an effortto control; it is an attempt to fill a spiritual voidwith chemical reality. As a consequence, ratherthan cultivating a stronger inner self and reinforcingone’s inner strength, addiction movesindividuals away from the core of their being. Inthe search for a simple solution, the use of a substanceoffers an instantaneous way to quiet restlessthoughts, suppress discomforting feelings,and soothe the inside with something from theoutside.Sanderson and Linehan (8) describe attachmentas “the mind’s habitual clinging to feelings,thoughts, and behaviors that are ineffective ornot reality based” (p. 205). Attachment to a substanceis a futile attempt to impose direction inone’s life; a direction that displaces one’s priorvalues, meaning structures, and goals. Instead,individuals become concerned with purposefulaction toward their next drink or their nexthigh. In Tillich’s (9) terminology, the substancebecomes the individual’s ultimate concern. Thetopic of attachment is apparent in the diagnosisof substance use disorders – part of the criteriafor substance use disorders is that a greatdeal of time is spent in activities necessary toobtain the substance (American PsychiatricAssociation, 1994). May (4) describes the spiritualnature of addiction as “a deep-seatedform of idolatry. The objects of our addictionsbecome our false gods. These are what we worship,what we attend to, where we give our timeand energy” (1991, p. 13).Addiction also involves a setting apart fromone’s self, others, and the world – a direct oppositionto spirituality’s emphasis of oneness with allof humanity. The use of substances offers a wayto “avoid being present to oneself ” (p. 44).(4)Isolation from one’s self is made possible throughthe distancing of self-awareness. Hull (10) proposedthat alcohol reduces the user’s level ofself-awareness, thereby decreasing sensitivity toinformation about present and past behavior. Ifbehavior “is, or has been, inappropriate and liableto self and other criticism, then a reduction inself-awareness may provide a source of psychologicalrelief ” (p. 138).(11) It is common for individualswith substance use problems to reportthat they feel disconnected from others, and asattachment to the substance increases there is atendency to isolate from important relationships.In AA, a common term is “terminal uniqueness,”describing the alcoholic’s perception of extremeuniqueness and alienation from his or her peers.In Buber’s (12) terms, isolation implies an I-Itrelationship, where others are viewed as a meansto an end, echoing this idea of detachment fromothers.

Spirituality and Substance Use Disorders 117From this perspective, substance use representsan attempt to fill a spiritual vacuum. Thespiritual components of transcendence, relatedness,meaning and purpose, and core/force/soul are, using Jung’s aphorism s piritus contraspiritum , displaced by the use of psychoactivesubstances. In an attempt to take the easier pathto spiritual enlightenment, substance use movesthe individual toward attachment and isolationand farther away from what they actually seek:purpose in life and connection to others. In thisconceptualization, a path out of addiction is toincrease one’s spirituality as a way to find meaningand purpose.3.2. The Role of Spirituality in Recoveryfrom AddictionThe choice then, to continue to rely on self or toturn to something higher, is a risk of faith and is asource of ambivalence for many seeking treatmentfor substance use disorders. Recovery requiresgiving up the demand to control one’s experience.Within Alcoholics Anonymous, the term powerlessnessembodies the paradox of surrender: gainingmore control by giving up control to somethinggreater. Cole and Pargament (13) describe thisprocess as one in which “the individual begins tosee the self in relationship to a higher purpose ortranscendent reality rather than the center of theworld” (p. 185). In other words, “Our deep desirefor this is not simply a spineless need to be withoutresponsibility; rather it is a heartfelt longing togive ourselves, in love and honesty, to someone orsomething truly worthy” (p. 302).(14)May (14) describes willingness as a “surrenderingof one’s self-separateness, an enteringinto,an immersion in the deepest processes oflife itself ” (p. 6). The spiritual practices of prayer,meditation, and fasting are practices that requireincreased self-control and foster increased selfawareness.These practices require an acceptanceof mystery, powerlessness, and an increasein self-awareness. Willingness implies humilityand represents “spirituality’s concern to preservethe sense of awe in the presence of mysteryand an awareness of the strengths tapped byan admission of powerlessness” (p. 40).(15) Thereliance on a higher power is an act of willingness.The individual must exercise the willingnessto accept acceptance, which, in Tillich’s (9)terms is an act of faith. The acceptance of one’sfinitude represents a significant gain in spiritualmaturity.Hope is found in the discovery of a powergreater than one’s self and an openness to thatwhich is beyond the realm of human understanding.In the spiritual sense, hope emerges after oneturns toward meaningful existence with humility.Hope implies an effort to search for, find, and clingto something significant in living, and the willingnessto accept the mystery of life. As Frankl (16)wrote, “Existence falters unless there is a strongideal to hold on to” (p. 50). One way that hope iselicited is through the process of identifying one’spersonal values in a way that offers inner structure.(17)This increase in value-behavior consistencystems from an ability to see beyond andaccept one’s circumstance rather than dull one’sfeelings through the use of a substance. A hopefulattitude allows an individual to relate to oneselfand others with a new outlook.Frankl (16) highlighted humans’ most fundamentalsimilarities when he wrote, “There is nohuman being who may say that he has not failed,that he does not suffer, and that he will not die”(p. 73). Spirituality increases by focusing onsimilarities rather than differences and by openingone’s self in a trusting relationship. As oneshares personal experiences, trust and closenessinevitably develop, which enrich both individuals’appreciation of their humanity. It is a realizationthat allows an individual to feel cohesionand structure, knowing there is a transcendentcore to which everything is connected. Here, theself and others are viewed as ends in themselves,reflecting Buber’s I-Thou (12) relationship thatinvolves an open, sharing, and complete relationshipwith another. In the culmination of spiritualgain, an individual reestablishes a connection tolife and others.From the perspective of a spiritual model ofrecovery from addiction, individuals engage inthe process of moving toward increased meaning

118 Alyssa A. Forcehimes and J. Scott Toniganwith a different perspective toward others and self.Reconnection is established to others and individualsare no longer in need of a substance to fillthe innate desire for spiritual longing.4. EMPIRICAL FINDINGS4.1. Categorizing Research on Spiritualityand AddictionGeppert, Bogenschutz, and Miller (18) developeda comprehensive annotated bibliography on spiritualityand addictions. A total of 1,353 papers metsearch criteria and were subsequently classifiedinto ten categories, including spiritual practicesand development and recovery, measurement ofspirituality and addiction, and religious and spiritualinterventions. Inverse relationships betweenreligiousness and spiritual practices and substanceuse were consistently observed. Of the empiricalstudies reporting results of spiritual interventionsfor substance users, transcendental meditationand other forms of meditation were foundto produce significantly reduced substance use.Finally, although there appears to be a consistentlypositive relationship between twelve-step attendanceand involvement and various measures ofspirituality or religiosity, a causal role of spiritualor religious change resulting from twelve-stepparticipation has received mixed support, at best.The authors note that a majority of the research inspirituality and addiction has been concentratedin a few areas and point to a need for longitudinaland prospective studies that begin to explore themechanisms of action of spirituality.4.2. Twelve-Step Programs: A SpiritualApproach to Recovery from AddictionIn the recovery from substance use, researchersare beginning to address spirituality and religionas important factors, a long overdue realizationthe recovery program of Alcoholics Anonymoushas promoted since 1935.(19) In the words ofBill W., the co-founder of Alcoholics Anonymous,those with substance abuse problems “have beennot only mentally and physically ill, [they] havebeen spiritually sick” (p. 64).(5) In twelve-stepprograms such as Alcoholics Anonymous, membersengage in specific prescribed behaviors tofacilitate spiritual growth.From the perspective of twelve-step programs,individuals must embrace the simplicity and submissionof spiritual surrender and give up the needfor heroic mastery of their own life.(5) Submissionis apparent in the first step, as the process of surrenderrequires individuals to give up independencefor proper dependence on God. Confession is alsoa part of the twelve-step tradition, when a memberadmits to himself or herself and others that he orshe is an alcoholic. This theme is echoed again in thefifth step, when an individual admits to God, himselfor herself, and another human being the exactnature of his or her wrongs.(5) Brenda Miller (20)argued that spiritual modeling, which she definedas “observing other persons who are exemplary inmodeling spiritual practices,” is a mechanism forthe transmission of spirituality in AA (p. 233).(5) InAA, learning through modeling occurs as membersshare their experiences of “strength and hope” andwork with a sponsor who has an understanding ofthe spiritual nature of the program.4.3. Spiritual Transformations in Recoveryfrom AddictionEvidence of the importance of spirituality withinan addiction population was supported in a studyconducted by Robinson, Brower, and Kurtz.(21)Results of this study included the significant findingthat 54.4 percent of patients entering treatmentfor alcohol problems had, at some time intheir lives, had a life-changing spiritual or religiousexperience, compared to 39.1 percent in a largenational survey. Alcoholics Anonymous holds thatspiritual transformations are the mechanism forchange and therefore transformational experiencesare an important component of the AA program.The twelfth step assures “having [had] a spiritualawakening as a result of these steps” (p. 60).(5)Within Alcoholics Anonymous, the spiritual transformationis understood as the means to movefrom destructive independence to proper dependenceon God and others.(22) The experience of

Spirituality and Substance Use Disorders 119a spiritual transformation in AA is defined by itsability to hold great personal significance, changeself-perception, and enhance one’s relationship toGod and the world (Alcoholics Anonymous, 2001).These experiences are discrete and often occur inthe absence of any significant external event andresult in profound lasting changes, including stablesobriety. AA argues, however, that gradual processes,such as the kind described by James (23)in The Varieties of Religious Experience , are equallyvalid to the instantaneous variety.In a study of Alcoholics Anonymous memberswho experienced transformational spiritualchange, (24) findings indicated that prior to thetransformational experience, most participantsreported low levels of happiness, desire to live,feeling of being in control, having close and lovingrelationships with others, satisfaction withtheir life, a sense of meaning in their life, or aclose relationship with God. After the transformationalexperience, participants reported anincrease in happiness, the desire to live, satisfactionwith their life, a sense of meaning in theirlife, and a closer relationship with God.4.4. Moving Beyond Twelve-Step Programs:Research on Spirituality as a ProtectiveFactorThe benefit of considering spirituality in the treatmentof addiction has been advocated outsidetwelve-step treatment modalities, although a systematicintegration has yet to be proposed.(22, 25)Spirituality and religiosity are well-known protectivefactors that consistently predict lowered riskof alcohol and drug abuse.(26, 27) According toStewart, (28) who studied college students’ spiritualand religious beliefs and their use of alcoholand drugs, spirituality was a protective factor inthe decision of whether to use substances. Theinverse relationship between spirituality and substanceuse is further supported by research on therole of spirituality in recovery. In a study of fortyindividuals in recovery from alcohol dependence,Jarusiewicz (29) reported that individuals maintainingsobriety indicated more evidence of spiritualitythan those who returned to problematic drinking.What remains unknown, however, is whether it isspirituality that protects or whether it is the communityor some other factor associated with spiritualitythat accounts for the lower substance use.4.5. Research on Spiritual Disciplines inthe Treatment of AddictionSpiritual disciplines offer a way for individuals toincrease their overall spiritual health through theuse of specific practices. Practices such as meditation,service, and celebration promote lifestylechanges that foster spiritual development. Researchevidence has supported the role of some of thesedisciplines as an intervention in the treatment ofaddiction. Inward disciplines, such as meditation,offer avenues of personal reflection and change.Outward disciplines, such as service, promote outwardactions and lifestyle changes. The corporatedisciplines, such as confession and celebration,bring us nearer to one another and to God.In a review of the literature, three spiritualpractices have received research attention. Thesepractices are rooted in religious traditions, clearlyindicating that religious resources have beenbrought to bear in addiction treatment.Meditation. The practice of silent centering. Theterm contemplation is also reserved here for practicesof silent centering, and thus is interchangeablewith meditation. Marlatt and Kristeller (30)described the clinical effectiveness of meditationas a treatment for substance use disorders, andWitkiewitz, Marlatt, and Walker (31) offered preliminarydata in support of mindfulness meditationas a treatment for addictive behavior.Prayer. Prayer differs from but overlaps with meditation,with its primary purpose being encounter,communication, and communion with the Divine.Johnsen (32) found that individuals who usedprayer and meditation following a twenty-eight-dayinpatient treatment showed better treatment outcomesat a six-month follow-up.Acceptance. There is a dialectic tension betweenaccepting what is and seeking to change it, that is

120 Alyssa A. Forcehimes and J. Scott Tonigancaptured in the famous “serenity prayer” that hasbeen adapted and widely used within AlcoholicsAnonymous: “God grant us grace to accept withserenity the things that cannot be changed,Courage to change the things which should bechanged, And the wisdom to distinguish theone from the other.” Also included in the disciplineof acceptance is the forgiveness of the selfand others and the act of submission, giving upindependence for a proper dependence on God.According to Lin and colleagues, (33) individualsrandomized to an adjunct forgiveness interventionreported lower depression, anxiety, and substanceuse at a four-month follow-up.Other than these studies that have examinedthe role of specific spiritual disciplines in thetreatment of addictions, many other specific spiritualpractices have not been studied empirically.Research is still in the early stages in determiningwhich spiritual disciplines may predict positiveoutcomes better than others.5. WHAT ROLE DOES SPIRITUALITYPLAY IN SUBSTANCE USE REDUCTION?Spirituality has been studied from distinct perspectives,and it is extremely important to distinguishthese perspectives when describing therole of spirituality in recovery. Spirituality has, forexample, been investigated as it directly affectssubstance use (independent variable). In contrast,spirituality has also been investigated as an outcomearising from prescribed practices intendedto reduce substance use (dependent variable).Third, spirituality has also been studied as a moderatingvariable in which people with some faithcharacteristic are more (or less) likely to acceptspiritual interventions. And, finally, spiritualityhas been investigated as a mediator or mechanismvariable that explains why particular behaviorsare predictive of substance use reductions.5.1. Spirituality as an IndependentVariableSpirituality has received mixed support as havinga direct effect on later substance use. In arecent book, Sober for Good (2001), Fletcher (34)discussed pathways to sobriety and noted,“Comments related to spirituality were amongthe five most frequent responses to open-endedquestions about key things … used to get soberand stay sober” (p. 239). Additionally, Flynn, Joe,Broome, Simpson, and Brown (35) reported that63 percent of their sample indicated that strengthfrom spirituality was reported as an importantfactor in the recovery from cocaine dependence,and Koski-Jannes and Turner (36) found thatspirituality was a factor associated with bettermaintenance of treatment gains.Evidence of the importance of spiritualitywithin an addiction population was alsosupported in a study conducted by Robinson,Brower, and Kurtz.(21) Results of this studyincluded the background finding that 54.4% ofpatients entering treatment for alcohol problemshad experienced, at some time in their lives, alife-changing spiritual or religious experience,compared to 39.1 percent in a large national survey.Participants in the Robinson et al.(21) studyalso rated their spirituality higher than their religiosity,and higher than did the national sample.Most important, after statistically controlling forself-reported frequency of AA attendance, positivegains in spiritual beliefs and practices significantlypredicted reduced substance use.It is important to note that, although patients’endorsement of the importance of spiritualitytends to be high in case studies and the empiricalliterature, there is a larger body of work to thecontrary. For example, the magnitude of the relationshipbetween spirituality/religiosity scoresmeasured at intake among an alcohol dependentsample (N = 1,726) and abstinence from alcohol(at a twelve-month follow-up) in an examinationof Project MATCH participants was smalland not clinically meaningful (37) albeit statisticallysignificant. Finally, Miller, Forcehimes, etal.(38) conducted the first two systematic evaluationsof the impact of a manual-driven interventiondesigned to explore and foster the practiceof spiritual disciplines on addiction treatmentoutcomes. The authors anticipated that spiritualguidance would enhance spiritual experience

Spirituality and Substance Use Disorders 121and increase personal spiritual practices duringfollow-up, which, in turn, would affect substanceuse outcomes. In both trials, however, contraryto prediction, spiritual guidance had no effect onspiritual practices or substance use outcomes atany follow-up point.5.2. Spirituality as a Dependent VariableRobinson, Cranford, Webb, and Brower (39)reported significant six-month changes in spiritualand religious practices, daily spiritual experiencesand forgiveness, positive religious coping,and purpose in life among their sample of substanceabusers attending AA. Likewise, in ProjectMATCH, for example, 27.6 percent (n = 108) ofthe outpatient clients who attended AA during thetwelve weeks of treatment (N = 391) also reportedhaving had a spiritual awakening as a result oftheir AA attendance. In the aftercare sample, 569clients reported attending some AA during treatmentof which 29.3 percent (n = 167) reporteda spiritual awakening in connection with AAattendance. (37) Strong evidence, across diversemeasures of religiousness and spirituality, documentsspiritual increases among AA members.5.3. Spirituality as a Moderator VariableA number of studies have investigated whetherindividual spiritual/religious beliefs and practicespredispose a person to use spiritual-basedinterventions and, if so, whether they receivedifferential and improved benefit by attendingsuch programs. Schermer and colleagues, (40)for example, reported that self-reported atheistswere significantly less likely to attend AA relativeto self-reported agnostics, spiritual, and religiouspersons. Interestingly, however, atheists who didattend AA reported equal benefit as religious andspiritual alcoholics. Likewise, Connors et al.(37)theorized that more spiritual/religious alcoholicswould fare better when they received twelve-stepfacilitation therapy relative to cognitive behavioralor motivational enhancement therapy.Here, they reasoned that enhanced comfort withthe therapeutic orientation of the spiritual-basedtwelve-step therapy would produce improvedoutcomes. Contrary to predictions, neither compliancewith therapy nor drinking outcomes differedfor matched and mismatched alcoholics.More recently, Kelly et al.(41) reported that spiritualand religious beliefs of a sample of 160 adolescentinpatient substance abusers was unrelatedto frequency of AA meeting attendance over aneight-year follow-up.5.4. Spirituality as a Mediator VariableIt is possible that spirituality influences thecausal pathway through a reduction of behavioralrisks brought about by the promotion of ahealthier lifestyle.(42) Spiritual disciplines, particularlythose offering complex beliefs abouthuman relationships, ethics, and life and death,are directly relevant to health, and spiritual feelingsand thoughts might enhance coping skills.For instance, Krause (43) found that spiritualbeliefs and practices were associated with higherself-esteem and feelings of self-worth, particularlyamong older adults. Ellison (44) reported asimilar finding, indicating that individuals witha strong faith report feeling happier and moresatisfied with their lives. Idler et al.(45) reported“spiritual interpretations of difficult circumstancesmay have the power to bring individualsto a state of peace of acceptance of a situation thatcannot be altered and give them the ability to livewith it” (p. 333).Research support has also been found forphysiological mechanisms that are alteredthrough spiritual practices. Benson (46) foundthat certain spiritual practices (that is, prayer andmeditation) elicited a “relaxation response,” anintegrated physiological reaction in oppositionto the “stress response.” This response resulted ina lowering of individuals’ blood pressure, heartrate, and changes in brain wave activity.Another possible mechanism is a social functionthat is altered through spiritual practices.Perhaps spirituality operates through an expansionof one’s social support network by providinga sense of friendship and emotional support, suchas that provided in a setting such as Alcoholics

122 Alyssa A. Forcehimes and J. Scott ToniganAnonymous. The context of a spiritual communitymay be the protective factor, or it may bethe community that is supportive of spiritualitythat accounts for the lower substance use. Forinstance, Kaskutas, Bond, and Humphreys (47)examined one-year outcomes in relation to AAparticipation and found that, although generalsupport from others was associated with improvementin functioning, only specific support fromAA members mediated abstinence. Additionally,having a greater number of sober individuals inone’s social network was predictive of abstinenceamong alcohol-dependent persons.(48, 49)6. SPIRITUALITY IN THE CLINICALCONTEXT6.1. Why Should Spirituality Be Discussedwith Patients with Substance UseDisorders?Within the larger framework of cultural sensitivity,spirituality is an issue that should not becompartmentalized as outside the psychotherapydomain. The separation between psychology andreligion/spirituality stems from a long-standingantagonism between these fields.(50) Parallelingthe recent increased attention spirituality isreceiving in substance use research, it is also fairlyrecent in the clinical context that spirituality hasbeen emphasized in the inclusive model of treatingall the aspects of a person’s experience. Thiscomplementary relationship is viewed as bothhelpful and respectful to the patients with whompractitioners work.The word religion (re-ligare) is Latin for “toconnect again,” and this broadened definitionexpands the boundaries of organized religion toencompass a broader definition of spiritualityand the emphasis on connection and meaning.Also, returning to the model described above,if addiction leads to disconnection (AmericanPsychiatric Association, 1994) (7) followingJung’s aphorism spiritus contra spiritum , spiritualityis the natural path toward reconnection andis a particularly important consideration in thetreatment of addictions.6.2. Who Should Discuss Spirituality?Although most clinicians regard their spiritualityas important and regard religion as beneficial topsychological well-being, mental health practitionersremain much less religious than the generalpopulation.(50) Although patients often will regardspiritual and religious issues as directly relevant totheir substance abuse problem, the therapist oftenwill not be an expert in the spiritual/religious traditionof the patient and hence may not be qualifiedto offer advice within that tradition.Many believe that leaders or experts in religionor spirituality are chosen or ordained to thesepositions after lengthy training and prayerful consideration.Research on the treatment of addictionsuggests that practitioners delivering treatmentdo not need to have personal experience of addiction;rather the practitioner can use empathy in anattempt to understand the patient’s situation.(51)Client-centered approaches, in particular, supportthe use of empathy as a way to create a collaborativerelationship between the patient and practitioner.Thus, the skillful use of client-centered methodsto draw out the patients’ own meanings andunderstanding is perhaps more critical regardingpatients’ spiritual or religious journey than manyother aspects of their psychological experience.One consideration in determining who isqualified to discuss spiritual and religious issueswith the patient concerns the difference betweenwithin-faith and between-faith interventions.Client-centered approaches are suitable forbetween-faith interventions, in which the therapistand patient’s spiritual and religious beliefsare not necessarily convergent. When, however,a patient is seeking within-faith advice, it is thenimportant for the therapist to recognize the needfor expertise in this area and discern whetherconsultation is necessary or whether it is appropriateto refer the patient to someone moreexperienced and knowledgeable in this area. Itis important to determine whether the patient’sissue concerns a theological question that wouldbe best addressed through a within-faith provideror a psychological issue that can be addressedusing client-centered methods appropriate for

Spirituality and Substance Use Disorders 123between-faith interventions. It is also importantfor providers to be aware of referral sources andknowledgeable of local religious or spiritual leadersfor consultation or referral purposes.Given the lack of empirical data on the effectivenessof addiction counselors delivering spiritualguidance, it is important to consider howmuch expertise and knowledge the patient isseeking and or expecting from the practitioner.Practitioners must consider the possibility that aspiritual intervention may require the practitionerto be in more of an expert role and that providersneed to have a sufficient level of expertisein the area of spirituality before addressing thisissue with patients.6.3. How to Raise the Issue of SpiritualityThe question of how to raise the issue of spiritualitywith patients is a primary difficulty for practitionersand patients in addiction treatment. Somepatients may not frame their dilemma as a spiritualone, others may have grown up without a spiritualvocabulary, and others may bear still-painful scarsof exposure to toxic religion. Whatever the reason,many patients who wish to discuss spiritual issuesmay not know where to begin. Similarly, manyproviders struggle with how to raise this issue duringassessment and treatment.Open questions are a good place to start, becausethese questions challenge patients to reflect and toexplore. Answering an open question requires notonly content, but also some processing and organizationof information. The provider thereforelearns not only facts, but also something of howthe person organizes meaning. These questionsare appropriate during the clinical interview partof an assessment or during an intake or followupsession as the provider begins to piece together thepatient’s narrative. Some examples of open questionsto begin exploration of this area are■■■What is your view of spirituality?To what/whom are you most committed inlife?How do you understand the relationshipbetween spirituality and addiction?■■How do you understand your purpose in life?What would you like to be different in yourspiritual life a year from now?6.4. When to Raise the Issueof SpiritualityAside from mutual-help recovery programs, formaltreatment programs rooted in a twelve-stepmodel and specific treatments linking patientswith twelve-step programs (for example, TwelveStep Facilitation), there is not an empiricallybased systematic approach for integrating spiritualityin treatment. Therefore, there is littleresearch regarding the timing of when a discussionof spirituality should be initiated or whenspiritual growth should be encouraged.Th e severity of the patient’s substance usedisorder may play a role in determining themost appropriate time to begin a discussion ofspiritual issues. Findings from two recent clinicaltrials of a spiritual intervention delivered inan inpatient addiction treatment setting (Miller,Forcehimes, et al., in press) suggest that introducingspiritual exploration too early in treatmentmay be counterproductive. According toMaslow’s (52) theory, people tend to fulfill needsin the hierarchical order of survival, safety, loveand belongingness, esteem, self-actualization,and finally spiritual or transcendence needs.Perhaps, for individuals who are early in therecovery process, other needs are prioritizedabove spiritual ones, and the timing was notappropriate to attempt to facilitate spiritualgrowth. Severely substance-dependent individualsseeking treatment are often unemployed,lacking adequate social networks, strugglingwith housing and financial stressors, experiencingsignificant relationship conflicts, and oftenhaving complicated concurrent medical issuessecondary to their substance use disorder.For these reasons, the authors suggested thatpatients’ basic needs of safety, love, and survivalwere of greater necessity than working towardspiritual growth and that the intervention mighthave been better suited to aftercare.

124 Alyssa A. Forcehimes and J. Scott ToniganTh is is not to suggest that it is definitelyharmful to explore spirituality early on in treatment.This was a population with severe drugdependence, and alternative explanations forwhy the treatment effect was null are also plausible.Perhaps a discussion of spirituality is helpfulearly on in treatment, but encouragementto begin practicing specific spiritual disciplineswas too burdensome during the early stages ofrecovery.6.5. Case StudiesAs we move into case studies of spirituality inaddiction treatment, we offer three examples ofhow spirituality may play a part in treatment. Thefirst is an example of how assessing a patient’sspirituality can actually be considered treatmentin and of itself. A second example is a vividdescription of a spiritual transformation, whichclinicians are likely to encounter and thus shouldbe aware of the nature and magnitude of sucha profound change.(21) Finally, the third casestudy describes a scenario in which it is appropriatefor the clinician to refer the patient out foradditional spiritual guidance.Assessment as Treatment. In a recent clinicaltrial (53) designed to increase patients’ practice ofspiritual disciplines, an unexpected finding wasthat those assigned to the control condition stillreported spiritual growth stemming only fromthe baseline assessment. The baseline assessmentincluded several instruments designed to assessthe patients’ spiritual and religious backgroundand beliefs. Unexpectedly, during the follow-upassessment, patients would often report thingssuch as the following:I really started thinking about things after Idid this first batch of paperwork. You know,since then, I realized how much I used topray and how I’d really gotten away fromthat and I’ve started doing that again, youknow, just praying to say thanks that I madeit through another day, and asking God towatch over my kids, and stuff like that.It seems then, that even though therapists maynot directly explore issues of spirituality with apatient, the act of completing an assessmentthat included questions about the frequencyof spiritual practices and religious attendanceand involvement can increase levels of spiritualpractice.Understanding Profound Spiritual Transformations.Up to 54 percent of treatment- seekingindividuals experience a profound spiritual experiencethat results in a magnitude of change.(21)Transformations are manifested dramatically,usually in a vivid, surprising manner without asalient external event. These events are highly significantfor the individual experiencing them, andthere is often a desire combined with a fear in discussingthem with a professional. Understandingthe nature of these experiences can assist in clinicalwork. Here is one such story:Jack had a troubled background, includingsexual and physical abuse, exposureto gang violence, heavy drug and alcoholuse, and financial struggles. He was a frequentdrunk driver, but had never beengiven a DUI (driving under the influenceof alcohol or an illicit substance).His transformational experience was adream, which to him was more real thanany dream he had ever experienced. Inhis mind’s eye, he saw himself driving onthe freeway after a long night of drinking.He hit the rail, the car spun, and hewas involved in a head-on collision withanother car. He could see himself gettingout of the car, uninjured, to examinethe damages. In the car, he saw thebloody wreckage of a family of four: themother, in the passenger seat, was theonly one breathing. The two small childrenhad been thrown from the car, theirsmall bodies distorted on the pavement,surrounded by pools of blood. The fatherhad not been wearing his seatbelt and hishead had gone through the windshield.Immediately sobered by the realization of

Spirituality and Substance Use Disorders 125what he had done, he watched in horroras the mother got out of the car to examinethe remains of her family. His dreamflashed forward, and he saw himself incourt, tortured by the agony of watchingthe mother sobbing. Then he saw himselfin prison, unable to handle the misery hehad imparted on this family. He awoke toreality just as he was losing consciousnessin his dream as a result of hanging fromthe ceiling of his jail cell.From the depths of despair, Jack woke upin a cold sweat and vowed to never drinkor use again. And ten years later, he continuesto keep that promise to himself.In this case study, the issue is not so much howto evoke change or spiritual growth, but ratherthat the clinician should be aware of the natureof such experiences and be prepared to help thepatients understand and integrate the experiencewithin their spiritual framework.Referring Out. Although we are encouragingthe inclusion of spirituality, it is also importantto note that there are times when referring thepatient to someone within a particular religioustradition is acceptable and even advisable.Consider the following example:Jon is a 52-year-old man seeking treatmentfor alcohol dependence. He wasdiagnosed with alcoholic cardiomyopathyand recently informed that the heartdamage and heart failure was irreversibleand that it is unlikely he will survive aheart transplant. During the intake session,Jon tells the therapist that he is adevout Catholic and that he has questionsabout whether or not he has lived a goodenough life to go to heaven and whetherGod will forgive him. The therapist realizesthat Jon is wanting specific answersrelated to a particular religious tradition,so arranges for Jon to meet with a priestonce a week.In this example, the therapist is aware thatthe patient is seeking theological rather thanpsychological questions regarding his religiousbackground and the nature of sin and salvation.For this within-faith intervention that the patientis seeking, the therapist is correct to refer thesequestions to a clergy member. It may be appropriatefor the practitioner to continue to see thepatient for substance abuse treatment in adjunctto seeing the priest for end-of-life questions, andthis should be discussed between patient andtherapist to determine the patient’s needs.7. CONCLUSIONTh e traditions of Alcoholics Anonymous emphasizethe vital importance of spiritual growthand transformation in recovery from substancedependence. Outside of the twelve-step modelof recovery, spirituality is receiving increasedattention, evidenced in both funded researchand etiological and treatment models of addiction.Clinicians and researchers continue to bechallenged by the complexity of defining whatspirituality is (and is not), the perspectives bywhich it is classified, and how to systematicallyintegrate it into addiction treatment. Theauthors have proposed one way of examining thedevelopment of addiction as related to spiritualdeficit and recovery from addiction as related tospiritual growth. Clinicians are encouraged toexplore, encourage, and support patients’ spiritualbackground and desire for spiritual growthand are offered suggestions for how to integratespirituality into the treatment of addictions.REFERENCES1. Cook CH. Addiction and spirituality . Addiction.2004 ; 99 : 539 –551.2. Mi l ler WR , Thoresen CE. Spirituality, health,and the discipline of psychology . Am Psychol .2004 ; 59 . 1 :54–55.3 . D a s s R , G or m a n P. How Can I Help: Storiesand Reflections on Service . New York : Alfred A.Knopf ; 1985.4. May G. Care of Mind/Care of Spirit . San Francisco :Harper Collins ; 1992 .5. AA World S er v ic es : Alcoholics Anonymous: TheStory of How Many Thousands of Men and Women

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10 Religion, Spirituality, and Anxiety DisordersHAROLD G. KOENIGSUMMARYAnxiety disorders are widely prevalent in theUnited States and around the world. Religiousbeliefs and activities are likewise prevalent andare often inversely correlated with anxiety symptoms.Furthermore, clinical trials show thatreligious therapies from a variety of religioustraditions appear to improve anxiety disordersymptoms to a degree that is equal to or greaterthan traditional secular therapies. Religiousinvolvement may also exacerbate anxiety in certainindividuals, and anxious individuals maysometimes distort or manipulate religion to serveneurotic ends. Anxiety can also be a powerfulmotivation for religious activity as persons turnto religion to cope with the distress that anxietycauses. In this chapter, I1 discuss whether religion is the cause or theconsequence of anxiety disorder.2 examine research on the relationship betweenreligion and anxiety in specific disorders(generalized anxiety disorder, panic disorder,post-traumatic stress disorder, obsessivecompulsivedisorder, and phobia).3 illustrate how religion may improve or exacerbateanxiety with specific case examples.4 examine implications for clinicians in theassessment and treatment of anxiety disorders(including specific ways that religion can beused in the management of anxiety disorder).5 discuss how to untangle the complex interactionbetween religion and anxiety by consultation,referral, or co-therapy with pastoralcounselors.Anxiety, worry, and nervousness are commonin today’s society where the average person hasnumerous roles to play and must encounterstressors from many different sources as part ofnormal daily life. There is a difference, however,between this “normal” anxiety and the anxietyexperienced by those with anxiety disorders.When worry and tension continue over time andsymptoms become so intense that they interferewith a person’s ability to function at work orin social relationships, then an anxiety disorderis said to be present. Anxiety disorders areamong the most prevalent of psychiatric conditionsdiagnosed in epidemiologic surveys of thegeneral population. According to the NationalComorbidity Survey Replication, the lifetimeprevalence of anxiety disorders in the UnitedStates is 28.8 percent (1) and the twelve-monthprevalence rate is 18.1 percent.(2) This meansthat almost one in every three Americans hashad an anxiety disorder at some time in the past,and one in five met criteria for an anxiety disorderwithin the past year. This makes anxietydisorder the most common psychiatric problemin the general U.S. population, more commonthan either depression or alcoholism. The lifetimeprevalence for anxiety disorders around theworld is about 17 percent, although methods ofmeasurement vary and may not be directly comparablewith U.S. figures cited above.(3)This chapter examines the role of religion/spirituality in the development, course, and treatmentof anxiety disorders. It is sometimes saidthat religion “comforts the afflicted and afflictsthe comforted.” However, religion may also afflictthe afflicted in some circumstances, particularlyindividuals already vulnerable to depression or128

Religion, Spirituality, and Anxiety Disorders 129anxiety. Conventional wisdom would argue thatreligious teachings about hellfire, punishment,and damnation could worsen psychiatric symptomsin the individual predisposed to anxiety.Freud described religion as the “obsessional neurosisof humanity” and believed that most peoplewould be better off without it.(4)These negative aspects of religion, however,may have been overemphasized by mental healthprofessionals in the past, and the benefits of religionunderemphasized. There is little doubt thatthroughout history, many of the anxieties andworries that humans faced as they encounteredthe immense and threatening universe aroundthem were dealt with through religious belief,which provided peace, security, and a sense ofcontrol.(5)The chapter will also focus on the role that religiousbeliefs and practices play in the assessmentand management of anxiety disorders. Anxietydisorders addressed in this chapter include generalizedanxiety disorder, panic disorder, posttraumaticstress disorder, obsessive-compulsivedisorder, and phobia. I examine the relationship ofthese disorders to religion, rather than spirituality,because religion can be more easily measured, andthere is more agreement on what religion actuallyis (versus spirituality).(6) Before proceeding inthat regard, however, I first examine how religionand anxiety may affect one another.1. RELIGION AS A CAUSESome studies show a positive cross-sectionalrelationship between religious involvement andanxiety.(7) In other words, the greater the religiousinvolvement, the greater the anxiety. Thisis particularly true when religion is measured aseither extrinsic religiousness, (8–10) (where religiousinvolvement is motivated by external concernsother than religion, such as economic orsocial goals) or negative religious coping (whereGod is seen as punishing, distant, abandoning, orpowerless).(11) In contrast to extrinsic religiosityis intrinsic religiosity, which describes religiousinvolvement motivated by religion itself, wherereligious concerns are the ultimate goal andend of the religious activity. Intrinsic religiosityis often inversely related to anxiety (that is, theintrinsically religious person is less anxious thanothers).(8 , 12–14)Furthermore, there is uncertainty about whatthe positive associations reported between religionand anxiety in cross-sectional studies reallymean. Do they exist because religion causes peopleto become more anxious or because anxietymotivates people to become more religious (likethe soldier who prays for safety or turns to Godwhile being shot at by the enemy)?As noted earlier, certain religious teachingsabout the afterlife and possible retributions therefor less-than-devout behavior could indeed fosteranxiety in vulnerable persons. Anxiety may appearin religious persons who are not living up to the highexpectations of their faith with regard to spiritualprogress. These individuals may worry about notbeing “good enough” to please God (for Christians,Jews, or Muslims) or to improve their karma forthe next rebirth (for Hindus or Buddhists). Suchconcerns could create psychological strains thatincrease anxiety. Although systematic longitudinalresearch documenting such phenomena is lacking,simple logic make such clinical scenarios quiteplausible (even if they are not widespread, as suggestedby the research below).2. RELIGION AS A COMFORTAlthough religion can potentially arouse anxiety,much data from cross-sectional and longitudinalstudies also suggest a protective effect for religion.Indeed, these epidemiological associations are buttressedby a handful of randomized clinical trialsshowing that religious interventions decrease anxietyand other symptoms of distress. For example,Hughes and colleagues (15) examined the crosssectionalrelationships between social support, religiosity,and anxiety in 282 hospitalized patients withheart disease. This patient population is of particularimportance given the negative effect that anxietyhas on cardiac outcomes. In the Hughes study,greater religiosity was related to lower state anxietyand also lower trait anxiety. Although those whowere more religious also had greater social support,

130 Harold G. Koenigwhich helped to explain the relationship betweenreligiosity and trait anxiety, this could not accountfor the relationship with state anxiety. In a secondcross-sectional study, Wollin and colleagues examinedchildren just prior undergoing general anesthesia.They found that children with the greatestanxiety were those whose mothers did not practicea religion. (16) At least two prospective studies havefound that anxiety symptoms decreased in personsfollowing religious conversion or rededication toreligion, (17, 18) and one recent study found thatpatients with panic disorder who reported religionas very important to them recovered more quicklyin response to traditional cognitive-behavioraltherapy.(19) Finally, two randomized clinical trialsin patients with generalized anxiety disorder(GAD) reported that religious interventions addedto secular treatments resulted in faster improvementof symptoms compared to secular interventionsalone.(20, 21)3. RELIGION AND SPECIFIC ANXIETYDISORDERSI now review these studies in greater detail sothat psychiatrists can have a better sense of whatexactly was examined and what was found.3.1. Generalized Anxiety DisorderPatients are diagnosed with a generalized anxietydisorder (GAD) when they have a long historyof worrying about many things, both minor andmajor, and these worries cause dysfunction intheir daily lives. Religious interventions appearto be effective in this type of anxiety disorderbased on the following three randomized controlledtrials.First, Azhar and colleagues randomized sixtytwoMuslim subjects to traditional treatment(supportive psychotherapy plus anti-anxietydrugs) or traditional treatment plus religiouspractices, such as prayer and reading verses fromthe Holy Koran.(20) Those who received therapysupplemented with religious practices improvedsignificantly faster than those receiving traditionaltherapy.Second, Razali and colleagues examined theeffects of Muslim-based cognitive-behavioraltherapy (CBT) on anxiety symptoms in a study inwhich they randomized eighty-five religious andeighty nonreligious Muslims with GAD to eitherstandard treatment (benzodiazepines, supportivepsychotherapy, and simple relaxation exercises)or standard treatment plus use of the Koran andHadith (sayings of Mohammed) to alter negativethoughts and behaviors and increase religiousness.(21)Religious subjects receiving thereligious CBT recovered significantly faster thanreligious subjects receiving standard treatmentalone; however, religious CBT had no impact innonreligious subjects.Finally, Zhang and colleagues examinedthe effects of Chinese Taoist cognitive therapy(CT) in 143 Chinese patients with GAD whowere randomized to Taoist CT, benzodiazepines(BDZ) only, or combined Taoist CT and BDZtreatment.(22) Subjects receiving BDZ treatmentalone experienced a rapid reduction in GADsymptoms by one month, but these benefits weregone by six months of follow-up. Those receivingTaoist CT alone had little improvement insymptoms at one-month follow-up, but showedsignificant symptom reduction by six months.Those in the group receiving both Taoist CT andBDZ experienced significant symptom reductionat both one- and six-month follow-ups. However,there was no way to determine whether there wasanything therapeutic about the religious aspects(Taoist) of CT or whether improvements weresimply due to the nonreligious aspects of CT.3.2. Panic DisorderPanic disorder (PD) involves brief but recurrentfeelings of extreme fear associated with physicalsymptoms such as rapid heart rate, difficultybreathing, and fear of dying. In some cases, panicdisorder may be associated with agoraphobiaor fear of the “market place” (open spaces orcrowds). Such patients may be literally imprisonedin their homes, fearful that if they go outinto the open where others congregate, they willexperience panic and not be able to escape. This

Religion, Spirituality, and Anxiety Disorders 131disorder is very disabling both because of thepsychological anguish that it causes during anattack and because people restrict their lives toavoid recurrence of symptoms.Religious involvement may help to relievepanic symptoms, particularly when accompaniedby traditional psychotherapy. For example,Bowen and colleagues in Saskatchewan, Canada,explored coping and motivation factors relatedto treatment response in fifty-six patients withPD participating in a psychotherapy clinicaltrial.(19) Subjects were treated with group CBT,and then were followed for up to twelve monthsafter the baseline evaluation. Self-rated importanceof religion was a significant predictor ofimprovement in panic symptoms and reducedperceived stress at the twelve-month follow-up.Investigators concluded that high importanceof religion reduced PD symptoms by decreasinglevels of perceived stress.3.3. Post-Traumatic Stress DisorderReligion is a source of coping for many personssuffering from severe trauma. Post-traumaticstress disorder (PTSD) results when people cannotpsychologically integrate a traumatic experience,allowing it to continue to overwhelm them.These persons’ worldviews have been so shakenby the traumatic event that the world no longerappears predictable or controllable. This resultsin a paralyzing type of anxiety whenever anythingreminds them of the traumatic event. When religiousworldview is affected and faith is weakenedor lost (that is, spiritual injury), PTSD symptomsmay be particularly persistent and unresponsiveto therapy. For example, consider a studyof 1,385 veterans from Vietnam (95 percent),World War II and/or Korea (5 percent) involvedin outpatient or inpatient PTSD programs.(23) In this study, conducted by the VeteransAdministration (VA) National Center for PTSDand Yale University School of Medicine, investigatorsfound that a weakened religious faith wasan independent predictor of use of VA mentalhealth services. This effect was independent of(and stronger than) severity of PTSD symptomsor level of social functioning. Investigators concludedthat the use of mental health services wasdriven more by a weakened religious faith thanby clinical symptoms or by social factors.3.4. Obsessive-Compulsive DisorderSteketee and colleagues examined the relationshipbetween religiosity and obsessive- compulsive disorder(OCD) symptoms in thirty-three patientswith OCD and twenty-four patients with otheranxiety disorders.(24) Although they reportedthat religiosity was significantly correlated withseverity of OCD symptoms, they found no relationshipbetween religiosity and general anxiety,social anxiety, or depressive symptoms, suggestingspecificity for the relationship betweenreligion and severity of OCD symptoms withinpatients with OCD. They did not, however, finda difference in degree of religiosity between thepatients with OCD and the patients with otheranxiety disorders. All associations were crosssectional, so it is not possible to say whetherreligiosity led to greater OCD symptoms inOCD patients or whether OCD symptoms ledto greater religiosity. Furthermore, again no relationshipwas found between OCD (as a disorder)and religiosity.More recent research has also failed to findevidence to link religiousness to OCD as a disorder.For example, investigators in Tel Aviv, Israel,compared religiosity between twenty-two OCDpatients, twenty-two panic disorder patients, andtwenty-two normal controls undergoing surgery,matching these groups by age and gender.(25)No difference in religiosity was found betweenthese groups on any of the five measures used toassess religiosity, except that patients with panicdisorder scored significantly lower on religiositythan did surgery controls. Other studies of OCDpatients from a variety of religious backgroundshave likewise found no relationship between religiousnessand OCD as a disorder.(26–28)In fact, there may be a bias that favorsthe detection of OCD symptoms in religiouspersons. (29) OCD symptoms scales appear to becontaminated with questions that traditionally

132 Harold G. Koenigreligious persons tend to answer in the affirmative,which could bias these scales toward detection ofOCD symptoms in religious persons. This couldhelp to explain why religiosity and severity of OCDsymptoms are associated in OCD patients, but thatthere is no difference in religiosity between subjectswith OCD and those with other psychiatric disordersor those without any psychiatric disorder.There may also be a difference between religiouspatients with OCD and patients with OCDwho have religious obsessions. When religiousobsessions and compulsions are present, thesepatients may have a worse prognosis. For example,a study of sixty outpatients with OCD inSpain that followed subjects for one to five yearsfound that those with sexual or religious obsessionshad poorer long-term outcomes despitetraditional treatment.(30) Another study of 153outpatients with OCD in London, England,enrolled in a randomized clinical trial of behavioraltherapy found that the presence of sexualand religious obsessions again predicted pooreroutcomes.(31) Although a form of faith-basedcognitive therapy has been developed to helptreat religious patients with OCD, it is not clearthat this treatment is as effective in OCD patientswith religious obsessions.(32)3.5. PhobiaPhobias are fears that relate to specific situations,such as fear of heights, fear of spiders, fear ofopen spaces, and so forth. When a phobic personis exposed to the feared stimulus, anxietyincreases to distressing levels. The person thenseeks to escape the stimulus – which, if successful,results in a reduction of anxiety – and avoidit in the future. Phobias are the most common ofall anxiety disorders in the general U.S. populationand can be quite disabling, depending on thetype of phobia.Although not much research has been doneon religious involvement and phobia, a few studiesare relevant. Morse and Wisocki surveyed156 persons aged 60 to 90 years whom theyrecruited from senior centers throughout westernMassachusetts.(33) Religious characteristicsmeasured were membership in church/temple,religious attendance, and religion as a source ofcomfort. Scores on these questions were thensummed to create a religiosity index, and subjectswere dichotomized into those with high and lowreligiosity. Subjects with high religiosity reportedsignificantly fewer phobia symptoms as measuredusing the Symptom Check List-90 (SCL-90).In another study, we examined the relationshipbetween religious involvement and phobias in arandom sample of 2,969 community-dwellingpersons of all ages living in the piedmont area ofNorth Carolina (Wave II of the National Institutesof Health Epidemiologic Catchment Areastudy). (34) Participants were divided into threegroups by age: 18 to 39 years (young), 40 to 59years (middle aged), and 60 to 97 years (elderly).Diagnoses of phobia and other anxiety disorderswere made using Diagnostic and Statistical Manualof Mental Disorders, Third Edition (DSM-III ) criteria;recent (past six months) and lifetime rateswere determined. Young subjects who attendedreligious services at least weekly experienced significantlylower six-month rates of agoraphobia(2 percent versus 5 percent). Middle-aged personsattending services at least weekly had significantlylower six-month rates of social phobia(0.2 percent versus 3 percent), and those claimingto be “born again” had both lower six-month andlower lifetime rates of social phobia. However, inthe young group, subjects for whom religion was“very important” had significantly higher sixmonthrates of simple phobia (10 percent versus5 percent). No significant associations were foundin the elderly group.In the most recent study, an Internet survey of1,402 adults, investigators examined the associationbetween psychiatric disorders and religiouscharacteristics.(35) A subscale of the SymptomAssessment-45 Questionnaire was used to identifypsychiatric disorders, including phobia. Religiouscharacteristics assessed were religious fundamentalism,religious attendance, frequency of prayer,and belief in an afterlife. Results indicated thatthere was no relationship between phobia andeither religious fundamentalism or religious attendance.However, frequency of prayer was related

Religion, Spirituality, and Anxiety Disorders 133to significantly higher phobia scores, while beliefin an afterlife was related to significantly lowerphobia scores. In fact, of the twelve characteristicsmeasured, age was the only characteristic that predictedfewer phobia symptoms more strongly thandid belief in an afterlife.Thus, the particular way that religion is measured,the age of the person, and the specific typeof phobia are all important in determining associationsbetween religion and phobia.4. CASE EXAMPLESThe research above suggests that religiousinvolvement is generally related to fewer anxietysymptoms and less anxiety disorder. However, itis useful to examine individual cases that illustratethe use of religion in either alleviating orexacerbating anxiety. The names below are fictitiousto protect patient confidentiality.4.1. The WorrierJane is a 40-year-old mother of three childrenranging in age from 4 to 10. She has a lifelonghistory of being a “worrier.” Just about everythingseems to make her anxious. As soon as oneproblem is solved, she quickly begins to worryand ruminate about other issues. When undera lot of stress, her worrying gets much worse –to the point that she is unable to function. Priorto seeking psychiatric help, she often had to askher eldest child to watch the younger childrenand even cook supper for the family. Jane simplydidn’t have the energy or the patience to do this.Her constant worrying also interfered with hermarital relationship. She felt an intense need tocontrol all decisions related to family matters andwould not listen to her husband or allow him arole in these decisions. This resulted in frequentand heated arguments.Frustrated with her anxieties and fearful thather husband would leave her, Jane saw a psychiatristwho diagnosed her with generalizedanxiety disorder. He gave her a prescription ofthe medication buipirone, which she was to takethree times per day. Although this medicine waspartially effective, it left her with considerableresidual anxiety. Always a religious person, Janeturned to this source for help with her anxiety. Inaddition to taking the buspirone, she now copeswith her many worries through prayer, readingthe Bible, and help from her faith community.Prayer enables her to give up some of her needfor control to God and consequently makes herfeel more peaceful. When she is in deep, seriousprayer, she finds herself relaxed both emotionallyand physically. Reading positive religiousscriptures also helps to counteract her negative,anxiety-provoking thoughts. Reading storiesabout Biblical figures overcoming their fearsgives her hope, and the promises in scripture ofGod’s continual presence makes her feel calmer.As she began to feel better, Jane also becamemore active in her religious community. Thisincreased her social contacts, which providedher with more emotional support outside herfamily and gave her ways to reach out to othersin need of help. This, in turn, reduced her worrying(or at least got her mind off of herself andher problems). Praying with other church membersand singing hymns during the church servicealso gave her a sense of peace and reducedher sense of isolation. Thus, the combination ofthe medicine prescribed by her psychiatrist andgreater involvement in religious activities hasimproved Jane’s quality of life and reduced herGAD symptoms.4.2. Panic at NightTom, a 28-year-old salesman, sees a psychiatristfor the treatment of panic disorder. Tom originallybegan having panic symptoms at night,when he would awake early in the morning withhis heart racing, short of breath, and feeling likehe was dying. His doctor initially treated him witha combination of paroxetine 40 mg per day andclonazepam 1.0 mg twice daily, with fairly goodresults. Nevertheless, he continued to occasionallyawake with panic-like symptoms. Althoughthey didn’t escalate into a full-blown panic attack,they disturbed him enough that he could oftennot go back to sleep. Switching the clonazepam

134 Harold G. Koenigto 2.0 mg at bedtime helped to control these episodes,but they did not go away. Whenever hewas stressed out over a big sales deal, the paniclikesymptoms at night would return, overridingeven the medication.Knowing that Tom was a religious man fromtaking a spiritual history, the psychiatrist suggestedthat he try meditation. The psychiatristdescribed several different kinds of meditation:Hindu-based transcendental meditation,Buddhist-based mindfulness meditation, andChristian-based centering prayer. Tom said hewould try the Christian-based centering prayer,but as a devout Catholic, he was not interested inEastern religious practices. His psychiatrist suggestedhe try centering prayer for twenty minutesbefore going to bed at night and then again fortwenty minutes on arising in the morning. If heawoke with panic-like feelings, he was instructedto go through his centering prayer routine fortwenty minutes. After about four weeks of thispractice, Tom noticed that the frequency of hispanic feelings at night began to decrease. Evenwhen they appeared, the centering prayer causedthem to quickly subside. Tom eventually combinedcentering prayer with repetition of theLord’s Prayer, which continues to work for himand is more consistent with his faith tradition.4.3. Lost FaithJohn, a 23-year-old soldier, was on his third tourof duty in Baghdad, Iraq, when his best friendJoe, riding next to him in a jeep, was killed by aroadside explosive device. The two men were veryclose. Joe had saved John’s life, once pulling himout of a burning building after he had lost consciousnessfrom smoke inhalation and anothertime dragging him to safety out of the line of fireafter he had been wounded. John couldn’t believethat his friend was now dead. “Why hadn’t thebomb killed me instead?” thought John. It justwasn’t fair. For nearly three years, he and hisfriend had been inseparable partners. Bothhad strong religious faith and prayed regularlytogether for protection over each other and theirfamilies. Why would a loving God have allowedthis? It didn’t make sense. If God allowed this,thought John, then he didn’t want anything to dowith God. He would simply make it on his own.Doing that, however, would prove to be more difficultthen he imagined.After he returned home from Iraq, he discoveredthat his wife had fallen in love with someoneelse and asked him for a divorce. On top of that,he couldn’t find work anywhere, particularly sincehe had only partial use of his left arm where hehad been wounded during his last tour of duty.He was able to drive an army jeep, but that wasabout all, and this skill now was hardly somethingthat someone would hire him for. Shortlyafter returning home, John began having nightmaresand flashbacks of his war experiences,found himself avoiding news programs reportingon war events and action-type TV shows, andnoticed that he startled easily whenever someonecame up behind him or surprised him. Life hadbecome painful and was losing meaning for him.What reason did he have to continue living? Overtime, the emotional burden that he was carryingbecame heavier and heavier. He sought help at theVeterans Administration (VA) hospital in the psychiatricoutpatient clinic. The psychiatrist he sawdiagnosed him with depression and PTSD fromhis war experiences and started him on medication.The psychiatrist also scheduled him to see asocial worker for counseling. John stabilized afterabout three to six months of this treatment, but hedid not return to his usual self. For the past severalyears, he has continued to seek help at the VAfor his emotional problems. Although the medicinehas been helpful and the counseling useful,no one has asked him how his wartime experiencesaffected his religious faith.4.4. Devout and PrayerfulRoberta is a 60-year-old accountant. Two yearsago her husband suffered a fatal injury at his workplace.She now lives alone and, other than drivingback and forth to work, lives a pretty quiet life.Members of her congregation, family, and friendshave long known Roberta for her religious devotion.She attended religious services before work

Religion, Spirituality, and Anxiety Disorders 135every morning at 7:00 a.m. at the local Catholicchurch and prayed the rosary at least five timesper day. She rose up early each morning becauseit took her several hours to get dressed and getready for work and church. When she attendedreligious services, she would always light a candlefor her two sons, which she believed would protectthem physically and help them to lead goodlives. Praying the rosary was also for her sons,but also for her ailing mother and for protectionagainst the dangers of living alone.Whenever circumstances prevented her fromeither attending daily Mass or saying the rosaryon time, Roberta became very upset and angryat whoever interfered with her routine; she alsobecame extremely anxious and had to call eachson and her mother to assure herself that theywere OK. When anything disturbed her religiousroutine, she would call her sons and motherexactly three times each. Although they tried tounderstand, this upset her sons who had busylives themselves. Although such behaviors werenot new for Roberta, they had increased in frequencyand intensity since her husband died.Roberta also had some other strangebehaviors that members of her church simplyexplained as, “that’s Roberta.” She would walkfrom her house to the church every morningat the exact same time and using the sameroute and could be seen walking from squareto square on the sidewalk, being careful not tostep on the lines. She also avoided opening thedoor of the church (and her home) without firsttaking out her handkerchief and cleaning off thedoorknob (or wrapping it with the handkerchiefas she turned the knob). If she touched any partof the doorknob with her hands, then she wouldimmediately go wash her hands.One day Roberta was hospitalized for a shortperiod following a small stroke. She was unableto attend Mass during this time. She became veryupset in the hospital and demanded that the nurseallow her to leave so that she could attend Mass. Asa result, a psychiatric consultation was obtained,and Roberta was diagnosed with obsessive-compulsivedisorder (after the psychiatrist obtaineda full history from her sons). She was placed onmedication, and arrangements were made forfollow-up after hospital discharge with a behavioraltherapist. Although medication reduced herintense need for attending Mass daily and prayingthe rosary, she refused to see the behavioraltherapist and continued to have active symptoms,especially when her routine was disrupted.4.5. Trouble Crossing StreetsPhil is 52 years old, divorced, and lives in a largecity where he moved about six months ago afterlosing his job in the small town where he hadlived and worked most of his life. Since moving tothe city, Phil obtained work as a nurse’s assistant(orderly) on the evening shift of a large hospital.Although he liked his job, Phil had one particularproblem that made his life difficult: crossingstreets. Because he lived fairly close to his workplace,Phil was able to make it almost all the wayto work without crossing any major streets. Thistook considerable effort and time. If he walkeddirectly to work from his apartment, he couldget there in about two minutes. The circuitousroute that he took to avoid crossing streets, however,took him about twenty minutes. Despite thisroute, however, he had to cross one large street toget to the hospital. This was not a new problemfor Phil. He had had trouble crossing large streetseven in the small town where he had lived. Priorto and during a street crossing, his heart wouldrace and he would experience extreme anxiety.That anxiety quickly abated whenever he was ableto either avoid crossing or after he had crossedover. His fear of crossing streets, however, hadgotten much worse since taking this new job inthe city, which had much larger and busier streets.Phil had actually missed a couple of shifts at workbecause he had become so anxious trying to crossthe street in front of the hospital that he had toreturn home and call in sick for the day.Phil was reluctant to seek help from a psychiatrist,because the cost of living in the city was high,and his medical insurance paid only half of thecost of mental health visits. However, if this continued,he might lose his job. So Phil obtained anappointment with a psychiatrist who prescribed

136 Harold G. Koeniga small dose of lorazepam, which he was to takeforty-five minutes before leaving home. The psychiatristalso gave him a referral to a therapist.Although the medication helped, it sedated himand made him feel sleepy at work, so he stoppedthe medication. Concerned about the cost of seeinga therapist, he instead sought help from therabbi at the synagogue he was attending.The rabbi listened carefully to Phil and thencame up with a suggestion. He encouragedhim to say quietly (but out loud) to himself theTwenty-third Psalm as he came closer and closerto the feared street. He was to recite the entirepsalm before reaching the street, and then, justbefore crossing, he was to start over and repeatthe entire psalm as he was crossing the street.After being sure that the light was green, the signalto cross was present, and no cars were coming(or had stopped), he was to step out into thecrosswalk and walk across while saying the psalmand thinking about the meaning of each verse.Th e first time he tried this, it didn’t workwell. His anxiety level continued to rise as he gotcloser and closer to the street, and by the timehe actually got there, he was so anxious that heforgot the words to the psalm. His mind racedwith fear, he got discouraged, and he went backhome, calling in sick for the day. Nevertheless,he tried it again the next day as his rabbi hadinstructed. The second time wasn’t quite as badas the first time, and at least he rememberedthe words of the psalm and got across the street(more, however, because he was afraid of losinghis job if he missed two days in a row). Over thenext week, he carried out this ritual every daygoing to and returning from work. Although hisanxiety level fluctuated from day to day, his feargradually began to decrease. After three weeksof this practice, he was able to cross the streetwith only minor anxiety and from then on didnot miss work again for that reason.5. APPLICATIONS TO CLINICALPRACTICEResearch findings and case reports such as thosedescribed above have many potential clinicalapplications that have to do with both the assessmentand treatment of patients with anxietydisorders.5.1. AssessmentThe most important application involves the psychiatristtaking a thorough and detailed spiritualhistory from the patient and perhaps from othersources as the patient gives permission (family,friends, and/or clergy). How detailed thatspiritual assessment is depends to some extenton whether the psychiatrist is only prescribingmedication, prescribing medication and doingtherapy, or doing therapy alone. Even if onlymedication is being prescribed, the spiritualassessment can provide information on whetherthe patient has religious beliefs that might conflictwith the taking of medication.Does the patient feel that taking medicationis consistent with his or her religious beliefs?How does the patient’s family and faith communityfeel in this regard? Is this acceptable, or istaking medication seen as counter to religiousbeliefs emphasizing a complete dependence onGod? Anything less than complete dependenceon God (such as taking medication or relying ontherapy from a mental health professional) maybe viewed by some as unfaithful. The religiouspatient’s compliance with the prescribed treatment,especially over the long term, will dependheavily on the answers to such questions. If thepsychiatrist brings up these concerns right fromthe start and allows the patient to discuss themin a supportive, accepting, and understandingatmosphere, then the patient will feel free to discussthese issues with the psychiatrist at a laterdate should they become relevant.If psychotherapy is contemplated, or even simplepsychological support, then a more detailedspiritual assessment will be needed to more fullyunderstand the role that religious beliefs play inthe patient’s coping and in the dynamics of hisor her psyche. This should initially be done in apositive and supportive manner. Does the patienthave any religious or spiritual beliefs? Are thesebeliefs important to the patient? If so, when did

Religion, Spirituality, and Anxiety Disorders 137they become important and why? Has the patienthad any key religious transformations or otherexperiences with religion that changed him orher in some significant way? What are the specificreligious beliefs and practices of the patient,and how does the patient see these as now affectinghis or her life? What benefits does the patientobtain from religious beliefs/practices? What aresome of the negative aspects of religious involvementas the patient perceives? Do religious/spiritualbeliefs provide comfort, or alternatively, havethey ever been a cause for stress and distress?Does the patient think there is a relationshipbetween religious or spiritual beliefs and his orher symptoms? How might such beliefs influencedecisions regarding medications or psychotherapy?How does the patient’s religious communityview psychiatric care, and are they likely to besupportive or discouraging in this regard?Some areas may need to be explored in greaterdepth. First, to what extent are religious beliefsbeing used in a healthy way to cope with emotionalproblems? Usually, there is a component of healthy,positive religious coping that is present. This componentis supportive, encouraging, and brings hopeand meaning to the patient’s life, despite painfulstruggles. Religious community involvement maybe a key component of the patient’s social supportsystem, even more important than family members.The religious patient’s primary friendshipsmay come from the religious community, andthose supportive relationships may influence thesuccess of his or her coping efforts.There may also be a negative component tothe religious coping, particularly among thosewho are less religious or no longer religious. Towhat extent is there a component of unhealthyreligious coping present that reflects anger atand disappointment with God, a clergy person,or faith community? The patient may phrase thisin terms of feeling punished by God, desertedby God, or seeing God as distant, uncaring, andimpotent. There may be anger at clergy or at othermembers of the faith community because theyhave not called or shown interest in the patient’sproblems. As noted, the original emotion drivingsuch negative religious coping responses isusually anger. While not always, sometimes thatanger is present because of an unhealthy, distortedunderstanding of God or the faith community.The patient’s relationship with God andexpectations from clergy may be influenced bypoor relationships with parental figures whowere experienced as uncaring, deserting, or abusive,which is then projected onto God or otherreligious figures.Second, to what extent is the patient usingreligious beliefs and activities to block constructivechanges that need to be made to live a freerand more fulfilling life? Religion can be either amotivating force for change and healing, or thepatient can use religion as a defense to avoidmaking necessary changes in ways of thinkingand relating to others. Usually, both are going onto some extent. The psychiatrist’s job in therapy isto determine to what extent each of these dynamicsis present. If a force for positive change, thenreligious involvement should be supported; if adefense against positive change, then the pathologicaluse of religion may need to be gentlyconfronted.6. TREATMENT6.1. InquireThe spiritual assessment itself is a powerful intervention.Simply asking questions about this areaof patients’ lives will cause them to think moreabout these issues and will help them to realizetheir potential for either good or harm. Given theimportant role that religion can play in holdingtogether the patient’s psyche, it is important toshow genuine respect for religious beliefs duringboth assessment and treatment and communicateappreciation of their value to the patient. Ofcourse, this applies to patients who are religiousand value religion, not to the person who has nointerest in religion. Care, however, must be takenbefore concluding that the patient has no interestin religion and that religion has no relevance,even for the most fervent agnostic or atheist(and possibly even more so for these patientsthan for others, because they have taken a stance

138 Harold G. Koenigagainst religion, which may conflict with culturalnorms).6.2. SupportDuring initial inquiry and throughout most ofthe treatment (certainly treatment with medicationsand in situations where therapy is purelysupportive), the psychiatrist should support thepatient’s religious beliefs. Such support dependson whether the patient’s religious beliefs are generallyhealthy, appear to be anxiety relieving, andespecially if there is a situational stressor that isdriving anxiety. Support should be shown in theway that the therapist makes inquiries about thereligious beliefs of the patient. Facial expression,tone of voice, body posture, head nodding, andverbal expressions of support should all be used.Being sincere is crucial, because the patient willquickly sense if sincerity is absent. The psychiatrist’srealization that much objective researchand logical sense dictates that religion can bea tremendous resource should help him or herconvey that sincerity to the patient.6.3. Using Beliefs in TherapyIf the patient is religious, if religious beliefs aregenerally healthy and nonobstructive to therapy,if the therapist is well informed about thepatient’s religious belief system, and if the therapisthas had training on how to address religiousor spiritual issues (that is, some kind of clinicalpastoral education), then he or she may considerusing the patient’s religious beliefs in the therapyitself. This is particularly true when doing supportive,cognitive-behavioral, or interpersonalpsychotherapy with patients who have anxietydisorders. This will be discussed below withina Judeo-Christian framework, about which thepresent author is familiar.6.4. SupportiveTh e purpose of supportive therapy is to provideemotional and social support to persons who aredealing with overwhelming real-life stressors.Anxiety symptoms themselves can be stressors(as the old saying goes, “There is nothing to fearbut fear itself ”). Although there is much withinJudeo-Christian beliefs that appears nonsupportive,such as teachings about hell, damnation,and devils, there are also many teachings that arepositive, uplifting, confidence building, and hopeconveying. Take for example the book of Psalms,which contains many scriptures that emphasizeGod’s love and nearness (Ps. 139), protection(Ps. 91), power to make a difference (Ps. 68), andreliability (Ps. 31). These may be used to help theanxious patient to feel reassured and more confident.Many scriptures emphasize the peace thatreligious beliefs provide (Isa. 59:19; John 14:27;Col. 3:15; Rom. 5:1; 2 Thess. 3:16), and describeways to achieve that peace (2 Cor. 13:11; 1 John4:18). If the patient has strong religious beliefs,then he or she may believe that the words ofscripture are words directly from God and may,therefore, receive those words as the ultimateauthority. The therapist may provide the patientwith a list of scriptures to meditate on or torepeat when facing situations that might arouseanxiety or fear.6.5. Cognitive-BehavioralMaladaptive cognitions that involve catastrophizingare common among persons with anxietydisorders. These negative thoughts, and the behaviorsassociated with them, create fear and anxiety.Cognitive-behavioral therapy (CBT) seeks tochallenge these exaggerated negative cognitionsand behaviors and replace them with more positiveways of thinking and behaving that are optimisticand realistic. For that reason, CBT is one ofthe most common treatments for anxiety disorders.A form of religious CBT has been developedthat relies on Biblical scriptures to challenge negativeself-talk, (36, 37) and this therapy has beenshown in at least one randomized clinical trial toachieve benefits equal to or superior to traditionalCBT in religious patients.(38) Positive supportivescriptures are used to counter negative thoughtsabout the self and the situations or surroundingsthat generate anxiety. For example, if the patient

Religion, Spirituality, and Anxiety Disorders 139routinely thinks that he or she is in danger, out ofcontrol, or dwells on disasters that might happen,then this patient would be instructed to modifyhis or her thinking so it will be more consistentwith what Biblical scriptures are saying.In fact, scriptures instruct people to dwell onthe positive, not the negative: “Finally, brethren,whatsoever things are true, whatsoever thingsare honorable, whatsoever things are just, whatsoeverthings are pure, whatsoever things arelovely, whatsoever things are of good report; ifthere be any virtue, and if there be any praise,think on these things [emphasis added]” (Phil.4:8). * For religious patients with anxiety disorders,then, the following scriptures may be usedto alter negative thinking. These represent promisesby God to his people:■■■■■■“Do not be anxious about anything, but ineverything, by prayer and petition, withthanksgiving, present your requests to God”(Phil. 4:6).“Do not be afraid; you will not suffer shame.Do not fear disgrace; you will not be humiliated.You will forget the shame of your youthand remember no more the reproach of yourwidowhood” (Isa. 54:4).“You will not fear the terror of night, nor thearrow that flies by day, nor the pestilence thatstalks in the darkness, nor the plague thatdestroys at midday. A thousand may fall atyour side, ten thousand at your right hand,but it will not come near you” (Ps. 91:6–7).“I will not fear the tens of thousands drawn upagainst me on every side” (Ps. 3:6).“God is our refuge and strength, an everpresenthelp in trouble. Therefore we will notfear, though the earth give way and the mountainsfall into the heart of the sea, thoughits waters roar and foam and the mountainsquake with their surging” (Ps. 46:1–3).“Do not fear, O Jacob my servant; do not bedismayed, O Israel. I will surely save you out* Scripture verses taken from the Holy Bible, NewInternational Version. Copyright © 1973, 1978, 1984,International Bible Society.■■of a distant place, your descendants from theland of their exile. Jacob will again have peaceand security, and no one will make him afraid”(Jer. 46:27).“So do not fear, for I am with you; do not bedismayed, for I am your God. I will strengthenyou and help you; I will uphold you with myrighteous right hand” (Isa. 41:10).“For I am the Lord, your God, who takes holdof your right hand and says to you, Do notfear; I will help you” (Isa. 41:13).Although the scriptures above are from theJudeo-Christian Bible, other world religionshave similar teachings that build confidence andmay calm the anxious person. Recall that bothMuslim and Buddhist (Tao) forms of CBT foranxiety disorders exist and have been studied inclinical trials.(21, 22) The type of religious CBTchosen, of course, should match the religion ofthe patient.Furthermore, the particular cultural environmentmay influence whether or not thepsychiatrist uses religious scriptures to combatdysfunctional cognitions. For example, whilereligious CBT may be perfectly acceptable in theUnited States, South America, the Middle East,Africa, and other religious areas of the world, inmore secular areas (such as found in some countriesof Europe), it may meet with resistance frompatients and peers. Regardless of cultural context,as mentioned earlier, a spiritual history is alwaysrequired to determine whether patients might bereceptive to such an approach.6.6. InterpersonalSome experts view the experience of interpersonalloss and disordered attachment as theunderlying causes for much of human psychopathology.Interpersonal psychotherapy (IPT)is a method of addressing these issues within atherapeutic framework.(39) Patients with anxietydisorders often have problems with attachmentrooted in their early developmental experiencesand relationships with parents. Religious IPTmay facilitate healing of these early relationships

140 Harold G. Koenigby focusing on the person’s image of God andsubstituting a relationship with God for missingor disordered parental attachments. Theophostictherapy is a Christian counseling method used tohelp patients recall suppressed or hurtful memories(often involving relationships with parentalfigures) so they can be healed in the present.(40)7. ENCOURAGING/PRESCRIBINGRELIGIONIn rare instances, the psychiatrist may gentlyencourage religious beliefs or activities thatpatients may not be currently engaged in, buthave been involved in previously. Such encouragementshould focus on the patient’s faith tradition.Considerable care needs to be taken, however,because encouragement or prescription is a muchmore aggressive approach. It is quite possible thatthe patient will see this as coercive (which is notacceptable). Most psychiatrists will not feel comfortableencouraging religion, and it is questionableas to whether this activity is even ethicallypermissible. However, if the anxious patient issocially isolated and in need of support, wasonce involved in religious practices, and there arepotentially removable barriers to resumption ofreligious involvement, then the psychiatrist maybring this up in therapy and consider encouragingthe patient to re-engage in such activity. Beforedoing so, the psychiatrist would be wise to checkwith an expert in pastoral care and counseling.Nevertheless the problems that can result frommental health professionals trying to evangelizepatients of no religion or a different religion fromtheir own are legion, given the personal nature ofreligious belief and the power differential in therelationship between patient and psychiatrist.(41)Furthermore, the focus of therapy should alwaysbe on the patient, not on the therapist or the therapist’sneed to share his or her faith.8. CHALLENGING UNHEALTHYRELIGIONAs noted above, religious beliefs may not alwaysbe helpful for patients with anxiety disorder, orthe patient may be using religion in a harmfulor unhealthy way. For example, the patient withgeneralized anxiety disorder may be focusing onreligious scriptures that warn about the dangersand agonies of hell. Anxious patients may fearthat their failure to live up to religious ideals hasdestined them for an eternity of pain and sufferingin the afterlife, and their anxious temperamentmay cause them to dwell on such fears.William is a 56-year-old teacher who hassuffered from generalized anxiety for mostof his life. He has found great comfortin his religious beliefs, in attending hisBaptist church and spending time with thefriends he has made there, and in readingthe Bible that gives him hope and courage.However, he sometimes worries aboutwhether he is really “saved,” and whetherhe has lived a good enough life to make itto heaven. He had a dream the other nightthat he was in hell, and he woke up in acold sweat. He could not get this off hismind all day. When he went in to see hispsychiatrist for his usual appointment, hetold the psychiatrist about the dream. Thepsychiatrist listened carefully and helpedthe patient explore his feelings about thedream.In other cases, the anxious patient may copewith anxious feelings by taking on an air of superiorityor self-righteousness, and then condemnothers whom he or she views as not living rightor believing correctly. Such attitudes may interferewith social relationships, lead to isolation, oreven result in paranoid thoughts about others.Stephanie is a 35-year-old wife and motherof three. She is the member of a fundamentalistreligious group, which sheencouraged her family to join. She is a perfectionistin her expectations of herself andothers. Stephanie believes that only thosein her religious group possess the truth,and others are wrong and going to hell,even those within her own congregation

Religion, Spirituality, and Anxiety Disorders 141who are not living up to her high religiousstandards. She is often critical of others,especially members of her family but alsoothers outside the family as well. This hasinterfered with her relationships, causingrifts within the family and also isolationfrom others in her community and congregation.By feeling better than others,Stephanie covers up a deep-seated insecurityand poor self-image. She is scrupulousand controlling, fearful that if she is notin control, then bad things will happen –as they have happened before. As a childshe was quite sensitive and needy, and shewas criticized mercilessly by a judgmentalmother with similar emotional problems.She wonders whether her husband is havingan affair, and at times can’t understandwhy he would love her.Patients may also misinterpret or misapplyreligious teachings, using them in a rigidand inflexible way that leads to excessive guiltand compulsive behaviors. Religious teachingsencourage persons to regularly perform religiousrituals, pray without ceasing, practice selfsacrifice,and focus on others’ needs. Each ofthese, while healthy if done in moderation, canalso be unhealthy if taken to an extreme.Bob is a married 32-year-old computerscience teacher with two young children.He is active in his church, where he is adeacon. He attends every social event atchurch and spends many hours cleaning upand putting things back in order at the endof church functions. Bob has to put everythingback in exactly the same place orhe feels anxious. He must check the lockson the church several times after lockingup, and sometimes has driven back to thechurch fearing he has left it unlocked. Hehas similar fears about locking up his ownhome at night. Bob’s wife has complainedto him on more than one occasion that hehardly ever spends time with his two children,and she would like to do other thingswith him besides going to church. Bob,however, explains that he is serving Godand is committed to the church, and that ifhe doesn’t do it then no one else will do itright. Because his wife has now threatenedto leave him, and he cannot seem to alterhis behavior, Bob has come to see a psychiatristfor help.As noted earlier, patients may also use religiondefensively to avoid addressing issues intherapy. Here, the patient uses religious justificationsfor ways of thinking or behaving thatreally have nothing to do with religion, buteverything to do with the patient’s desire toresist needed change.Sarah is a divorced 42-year-old sales clerk.Sarah has as history of being raped andbrutally beaten about twenty years agowhen someone broke into her home duringa robbery. She continues to suffer nightmaresof the attack, cannot watch violentmovies, and suffers from chronic depressionand anxiety. She is quite religious anduses much religious jargon in talking abouther past and present life. She has attendedmany religious revivals and healing servicesand reports having demons exorcisedfrom her on more than one occasion. Sinceher divorce, she has had many male boyfriendsin brief relationships but is unableto establish a lasting, intimate relationshipbecause of the fear that comes over herwhenever the relationship deepens. A psychiatristdiagnosed her with PTSD. In additionto treating her with medication, thepsychiatrist referred her for therapy to helpin her relationships with men. Wheneverthe therapist talks to her about the rapeevent, she immediately begins using religiousexplanations to minimize the event,claiming that the Lord healed her of all thatwhen she underwent exorcism. She thentries to change the subject. She has been intherapy for almost a year but is not makingmuch progress.

142 Harold G. KoenigIf religious beliefs are being used neuroticallyto obstruct needed changes or psychologicalinsights, then after a therapeutic relationshiphas been established the psychiatrist may need togently challenge those beliefs (as noted above).However, unless the therapist has pastoral counselingtraining and is quite familiar with the religioustradition of the patient, it may be best toseek consultation or referral to someone withpastoral counseling experience.9. PASTORAL REFERRAL ORCONSULTATIONWhenever complex religious issues or conflictsare present, the psychiatrist should always considerconsultation, referral, or co-therapy with apastoral counselor. Under certain circumstances,such referral should come sooner rather thanlater if religious issues are present and appear tobe related to the anxiety disorder. These circumstancesinclude those when the clinician is notvery knowledgeable about religious issues, whenthe particular religious background of the patientis different than the clinician’s, or when the patientrequests such referral. In religious patients withanxiety disorders, particularly if the disorder hasbeen present for many years, psychological andreligious issues are almost always deeply intertwined.This may even be true for nonreligiouspatients and is the reason why a spiritual historyis necessary for all patients.Effective pastoral consultation or referralrequires that the psychiatrist identify a pastoralcounselor whom the psychiatrist can work withand who has the skills to help patients in thesesituations. Pastoral counselors typically have fouryears of college, three years of postgraduate theologicaleducation, and either a master’s degree ordoctorate in counseling. If trained pastoral counselorsare not available, then clinicians should getto know the clergy in their area who do counselingand are open to consultation and referral(especially the clergy of patients that they maybe seeing, although that will depend on patients’preferences). It may be helpful to have a meetingor lunch with clergy before referring anyone tothem to get a sense of their experience, skills, andapproach to counseling. Community clergy varywidely in the type and extent of training, from notraining to modest exposure to counseling techniquesin seminary. Some clergy may seek additionaltraining, although that is not always true.Regardless of their level of training, clergy onaverage spend about 15 percent of their time inmarital, family, or individual counseling and areoften the first persons that religious persons go tofor help with their emotional problems.(42)Clergy should not be brought in, however, untilthe clinician has a thorough understanding of thepatient’s problems and a therapeutic relationshiphas been established. The clinician will also needto prepare the patient for pastoral involvement byemphasizing the importance of religious issuesand admitting his or her lack of expertise in thisarea, requiring consultation. Of course, beforeinvolving clergy or pastoral counselors (otherthan when obtaining informal consultation),explicit permission from the patient is needed.10. CONCLUSIONSReligious beliefs and practices are often inverselycorrelated with anxiety symptoms or disorders,but not always so. Religion helps many patientswith anxiety disorders to cope with their symptoms,and religious therapies are effective inreducing symptoms of anxiety. Religion mayalso exacerbate anxiety disorder; patients withanxiety disorder may manipulate or distort religion;and patients may use religion defensively toavoid healthy change. Clinicians with appropriatetraining can use the religious beliefs of patientsto help treat anxiety disorder by supporting,encouraging, or directly using those beliefs intherapy. Trained pastoral counselors and clergycan be helpful when religious beliefs need to bechallenged or when religious beliefs are deeplyinterwoven with psychopathology.REFERENCES1. Kessler RC , B erg lu nd P , D em ler O , Ji n R ,Merikangas KR , Walters EE. Lifetime prevalenceand age-of-onset distributions of DSM-IV

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11 Religion/Spirituality and Dissociative DisordersPIERRE-YVES BRANDT AND LAURENCE BORRASSUMMARYTh e connection between religion/spiritualityand dissociative disorders is complex. Possessionstates cannot always be interpreted as a kind ofdissociative disorder. The chapter begins withthe famous case of Achille being “exorcised” byPierre Janet and reminds us of how the healingtask of medical doctors is distinct from thatof priests. It then continues by discussing howthe Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition, (DSM-IV) approachescomplaints of possession (Code F 44.9). Duringthe twentieth century, the multiple personalitydiagnosis was renamed “dissociative identitydisorder” and constitutes only one subcategoryof dissociative disorder. The prevalence of dissociativedisorders is difficult to establish. Itdepends on cultural aspects (the Ross-Spanoscontroversy). Descriptions of cases show thevariety of relationships between religion and dissociativedisorders: identity disorder with religiouscontent but without possession (case 1),divine possession (case 2), and demonic possession(case 3). Anthropological criticism appliedto the assimilation of possession with dissociativedisorders brought about the introduction ofthe concept of “associative disorder.” The chapterconcludes with the discussion of the possiblecollaboration between psychiatrists and clergy,exorcists or shamans when a person is said to bepossessed. This chapter attempts to show underwhich conditions an ethno-psychiatric consultationmay be helpful.1. CHAPTER OVERVIEWAccording to epidemiologic studies, dissociativedisorders have a lifetime prevalence of about 10percent.(1) Dissociative symptoms may occur inacute stress disorder, posttraumatic stress disorder,somatization disorder, substance abuse,mood disorders, psychoses, dissociative identitydisorder, trance, and possession trance. Althoughdissociative trance disorders, especially possessiondisorder, are probably more common thanis usually thought, little systematic research intothis phenomenon has been done in psychiatry.Moreover, encounters with these disorders areincreasingly likely for mental health professionals,who may be unaware of the phenomenon.The experience of being “possessed” by anotherentity holds different meanings in different cultures.Possession states are often interpreted asbeing nonpathological: affected individuals caneven achieve higher status when they are viewedas having supernatural powers of healing andunderstanding. Alternatively, when individualsbecome so distressed and dysfunctional that theyseek assistance from healers and mental healthprofessionals, the interpretation of their sufferingas the consequence of a possession by entities likebad spirits depends on the cultural backgroundof the healer. In other words, such cases are challengingto diagnose and treat: viewing the diagnosisof possession as abnormal constitutes aculturally oriented decision.Th e first issue to discuss, then, is the questionof diagnosis. In the international classificationsof mental disorders, dissociative or possessiontrance is not considered to be a normal part of a145

146 Pierre-Yves Brandt and Laurence Borrasbroadly accepted, collective cultural or religiouspractice. A short historical perspective on possessionphenomena and exorcism will be followedby a brief reminder of what the DSM-IV and theInternational Statistical Classification of Diseasesand Related Health Problems 10th Revision( ICD-10 ) say about dissociative disorders. Theplace of possession in these classification systemswill open the discussion of cross-cultural variations.How do members of different cultures differand agree in their experience of and responseto the phenomenon of possession? What is thisphenomenon like in different cultural settings?The different approaches will be presented here.This discussion will then allow us to considerthe diagnosis and the treatment of dissociativedisorders from a differential diagnosis point ofview. Once again, cultural factors play an importantrole: Dissociative disorders are not diagnosedwith the same frequency in Europe andNorth America.Th e discussion will be illustrated by descriptionsof modern cases of psychiatric patientswho believed they were possessed and how theywere managed from both religious and medicalperspectives. An anthropological analysis willthen lead up to the conclusion, which is dedicatedto the question of how religious authorities,ethnopsychiatrists, and clinicians couldcollaborate.2. A HISTORICAL PERSPECTIVEHistorically, the diagnostic category of dissociativedisorders developed in several stages. Accordingto Spanos, (2) the history of dissociation beganin the nineteenth century with the diagnosis oftraumatic hysteria. Charcot believed that the“nervous shock” following a traumatic accidentcould produce a frightening idea, which was thenunconsciously transformed into hysterical symptoms.Janet (3) used the concept of dissociation todescribe the process of splitting and automatismof ideas. According to his theory, these dissociativeideas are organized into a state of consciousnessthat is different from normal consciousness.To illustrate this model he presented the case ofAchilles, a 33-year-old man who believed he waspossessed by the devil, which developed due to hisremorse at having been unfaithful to his wife ona business trip. (4) This thought, which tormentedhim unconsciously, was experienced by Achillesas a secondary demonic personality. Janet unhesitatinglyqualified the treatment, which consistedof modifying the traumatic memory throughhypnosis, as a modern exorcism. Later, this specificclinical case was reinterpreted according tothe theory of multiple personalities. Multiple personalitydisorder later became a diagnostic categoryof its own in the DSM-III .Janet’s explanation of the phenomenon ofpossession as a dissociative symptom withreligious content contrasts with the religiousinterpretation, which describes possession asthe expression of an invasion of the body byspiritual forces. The conflict between thesedifferent interpretations of the phenomenonof possession originally began several centuriesearlier. The conflict came to a head in1707, when King Louis XIV promulgated thelaw under which priests, monks, and nuns whopracticed medicine in France had to pay a fineof 200 French livres (p. 15).(5) This decisionwas a result of the concerted efforts of medicalprofessionals to legitimize the practice ofmedicine. It allowed them to obtain socialrecognition and even gave them the supremeauthority over health. With the establishmentof medical schools in different universities andsteadily increasing political support, physicians(doctors), who were considered as mereartisans in the Middle Ages, gained the statusof recognized scientists. This evolution wasaccompanied by a new definition of the lineseparating religious and medical treatments.From that point on, everything belonging tothe domain of the spirit was answerable tothe authority of the church or of philosophy,whereas the human body, considered as ananimal or a machine, fell under the authorityof medicine. Therefore, a priest, for example,who practiced the laying on of hands on a sickperson suffering from a fever and who prayedfor that person’s health, could be accused by

Religion/Spirituality and Dissociative Disorders 147doctors of practicing illegal medicine as anact of unlawful competition unless the priestcould prove that the origins of the fever wereexclusively spiritual.The distinction between illness and the phenomenonof possession appeared in the Roman ritualthat Pope Paul V promulgated in 1614. Througha differential approach, this ritual ascribed threesigns to the demon possessed: (1) pronouncing orunderstanding words in a language unknown bythe possessed person, (2) revealing hidden knowledge,and (3) the exhibition of a force that transcendsthe natural human condition.In practice, priests who performed exorcismswere more likely to express aversion toward religiousthings as the determining criterion. Forthis reason, Gassner (1727–1779), a priest whopracticed exorcism in the regions of Constanceand Ratisbonne, took the precaution of startingwith what he called a trial exorcism (p. 85). (6)To ensure that he did not cross over into thesphere of the medical doctor, he began the ritualby presenting a crucifix and asking the individualto kiss it. He also sprinkled holy water,and so on. If the individual remained quiet andpeacefully submitted to the veneration of holyobjects, then their suffering was caused by a naturalillness and they had to be seen by a medicaldoctor. But if the person began to blasphemeand/or have convulsions, then their sufferingwas caused by a supernatural illness requiringtreatment by an exorcist.This specific division of tasks is not exclusivelyreserved to Catholicism. The way of expressingour symptoms has been strongly influenced bythis division of tasks, which partly explains whypatients who consult a doctor whose practicecorresponds to the Western medical paradigmprefer not to formulate their suffering in religiouslanguage in front of the doctor. Instead, it is totheir religious authorities that they address theirmetaphysical fears or, if they feel the need, theirrequests for prayers or rituals. For this reason,individuals who believe that they are possessedand that they need the help of an exorcist rarelydiscuss this within the context of a psychiatricconsultation.3. DISSOCIATIVE DISORDERS ANDPOSSESSION IN DSM-IV AND ICD-10In the American Psychiatric Association’sDSM-IV, Text Revision ( DSM-IV-TR ), the multiplepersonality diagnosis has been renamedthe “dissociative identity disorder (DID).” It nowconstitutes only one of the five subcategories ofdissociative disorder, along with dissociativeamnesia (DA), dissociative fugue, depersonalizationdisorder, and dissociative disorder nototherwise specified (DDNOS). Complaints ofpossession are considered a kind of dissociativedisorder because the individual presents a state ofmind that appears to be under the control of twoor more entities that organize the individual’s psychiclife. But possession is no longer considereda form of multiple personality disorder as it wasin the DSM-III . The DSM-IV places pathologicalpossession in the category of possession trancesunder the diagnosis of dissociative disorder nototherwise specified (Code F 44.9). This showsthat a clear distinction has been made betweenthe phenomenon of possession and DID.The criteria for the differential diagnosis clarifythis distinction. While the DID is describedas a “mental state where separate and distinct differentpersonalities can cohabit (criterion A), andwhere one after another can take control of theperson’s behaviour (criterion B),” in mental statesof trance or possession (DDNOS), “subjects typicallysay that spirits or entities coming from theoutside have entered their body and have takencontrol of it.” The cultural dimension is importanthere. The DSM-III continued to associatepossession with a multiple personality disorder,whereas the DSM-IV specifies that dissociativestates of trance are disturbances “related to certainplaces or cultures” and are not necessarily ofa pathological nature. The ICD-10 also has a categoryfor trance and possession disorder.The ICD-10 provides a special category fordissociative disorder called trance disorder andpossession states. In this group of disorders,there is a temporary loss of identity and awareness,and the individual may appear to be takenover by another personality, a spirit, or a deity.

148 Pierre-Yves Brandt and Laurence BorrasThese disorders are limited to occurrences thatare involuntary, unwanted, and occur outsideof accepted religious or cultural experiences.Psychoses, multiple personality disorders, substance-induceddisorders, and temporal lobe epilepsyare excluded. This classification takes intoconsideration the sizable number of dissociativedisorder diagnoses that occur in nonindustrializednations and were previously diagnosed asatypical dissociative disorder or dissociative disordernot otherwise specified.(7)4. POSSESSION IN VARIOUS CULTURALCONTEXTSThe concept of possession exists in all parts of theworld. A review based on 488 societies showedthat 74 percent had one or more forms of possessionbelief (p. 249).(8) Possession beliefs mayor may not be linked to trance behavior. In somecultures, when someone becomes the new king,the soul of his predecessor enters him. Duringthe enthronement ritual, a brief possessiontrance can accompany the entrance of the soul.Afterwards, the new king will be considered aspermanently possessed by the soul of his predecessor.Similarly, when Christians say they areinspired by the Holy Spirit, this kind of “divinepossession” may be expressed by trance behavior.These two examples, the king possessed by thesoul of his predecessor and Christians possessedby the Holy Spirit, represent positive conceptualizationsof possession.Possession can also refer to negative experiences.Bourguignon considers trances as a kindof altered state of consciousness. She noticed thattrances were not necessarily associated with theconcept of possession, and when examining geographicdistribution, she observed that tranceswere highly correlated with America. She describedhunter-gatherer societies in which trances wereactively sought out, especially by men, and sometimeswith the help of drugs (South America). Incontrast to this type of trance with positive connotations,the possession trance is significantly correlatedwith agricultural societies in sub-SaharanAfrica and with the circum-Mediterranean region.This type of trance, which mostly affects women,has more negative connotations.Two main modes of traditional interventioncan be undertaken when a person complains ofbeing possessed by bad spirits or demons, whethera state of trance is observed or not: exorcism ormanipulation. Exorcism denotes rituals that aimto expel negative forces. Manipulation involvesrituals that seek to integrate negative forces. Inmany cultures, the coordination of such ritualsis entrusted to a person who has special knowledgeabout altered states of consciousness andpossesses special healing powers. This person isthought to have a kind of authority over negativeforces, either to chase them away or negotiate analliance with them. Exorcism can be understoodas religious coping, with God, gods, or good spiritsagainst demons, whereas manipulation can beunderstood as religious coping with demons.In a study focused on traditions in Morocco,Hell (9) shows that the treatment of possessionincludes a differential diagnosis. When the misfortuneis caused by a spirit ( djinn ) of lesser importance,the exorcism is performed by a learned andlettered man (a fiqh or taleb ) reciting verses fromthe Koran and carrying out purification rituals.But if the spirit ( djinn ) is more powerful, the onlysolution may be to seek the help of a traditionalbrotherhood that practices a possession ritual. Thebrotherhood of the Gnawa is the most renownedfor its practice of rituals of possession. By workingwith the spirits over extended periods during theserituals of possession, the possessed person learnshow to establish an alliance with the hostile forces.The idea that exorcists deal with different levels ofnegative forces is common in different cultures.5. THE DISTRIBUTION OFDISSOCIATIVE DISORDERSEpidemiologic studies find a prevalence of dissociativedisorders of around 10 percent in thegeneral population and of around 16 percent inpsychiatric inpatients, with a female predominance.(1)The higher rate of dissociative disorder diagnosesin the United States compared to other

Religion/Spirituality and Dissociative Disorders 149regions of the world, notably in Europe, has givenrise to different interpretations. Some believe thereason is a better capacity to diagnose a complicateddisorder. For others, the reason is a socialmovement that encourages physicians to diagnosevery sensitive patients with this disorder.It is a fact that only a limited number of psychiatristsare responsible for the vast majority ofdissociative disorder diagnoses. These differentpoints of view have prolonged the Ross-Spanoscontroversy about multiple personality disorder.Spanos believed this disorder was an artifact ofthe doctor-patient relationship, whereas Rossthought that it was simply a disorder that was verycomplex to diagnose.(10) The DSM-IV shows agreat deal of precaution by stating that this disordercould be specific to certain cultures. Couldthis be an indication that the cultural dimensionof personality should not be underestimated?Possession cannot always be interpreted asa kind of dissociative disorder. From a crossculturalperspective, we have seen that it is notnecessarily considered pathological. When theindividuals who complain of being possessedrequire medical treatment, their psychologicalorganization is not always of a dissociative nature(that is, exclusively falling within the dissociativedisorder category). In fact, as the expression of abelief, possession can be combined with differentforms of disorders. According to Janet, possessionwas considered a form of hysteria. However,it can also appear in association with schizophreniaor dissociative symptoms, as the followingcases will illustrate.6. DESCRIPTIONS OF CASESNone of the cases described below of patientssuffering from DID manifested an identity of areligious nature. Patients who believe that theyare God, Jesus, or a religious leader to whoma higher mission has been addressed are usuallyconsidered to be suffering from delusionsof grandeur. These delusions are classed withinthe category of positive symptoms of psychoticdisorders, which are more severe than dissociativedisorders. The first case presented belowhas similarities with this diagnosis. The descriptionof the second case provides an example ofdivine possession. The predominant trait of the“presence” inhabiting the sufferer contrasts withdemonic possession, of which an example will bedescribed in the third case.6.1. Case 1At the age of around 20, Mr. H. decompensatedafter a frightening experience when he wasattacked with a knife. He began to have regularauditory hallucinations. He heard voices, either ofJesus talking to him or maybe his future self. Lateron, he realized that he had heard voices when hewas about 13 or 14 years old. These voices sometimesseemed to belong to dissociated personalitieswho controlled his body. He said, “Becauseif I connect myself to my core personality, I feellike I am paralyzed” and “Someone else has controlledmy muscles for the past two years.” He thenexplained that it was either his future personality(self) or Jesus who controlled his body, and thatthey were very careful to closely imitate his corepersonality. He recounted that the dissociativesymptoms were at first associated with posttraumaticstress disorder, because they appeared afterhe was attacked. The diagnosis of schizophreniawith dissociative symptoms was only establishedlater. He himself believed that he was sufferingfrom a dissociative disorder (multiple personalitydisorder). If a psychiatrist had confirmed thediagnosis of multiple personality disorder, wouldhis suffering have more clearly taken on that form?At one point, he attempted to commit suicide. Hediscussed this event in these words: “At that time,another personality controlled my body …; it wasthe other personality who swallowed the pills; itwas not my current personality.” However, he didnot identify that personality. His religious beliefsdid not help him to cope with his suffering; on thecontrary, they seemed to intensify it. Voices toldhim that he would become the greatest saint inhuman history, but examples of the saints beforehim, such as Jesus, show that sanctification cannotbe attained without experiencing severe suffering.However, he thought that the voices were

150 Pierre-Yves Brandt and Laurence Borraskind because they encouraged him by promisinga better future. He prayed often, validating hisprayers with self-inflicted suffering even thoughhe realized that God wasn’t doing anything. Thisdidn’t prevent him from devotedly practicing hisreligion on an individual basis, nor did it keep himfrom calling himself a Catholic. His religiosityallowed him to have interesting discussions withhis brother who was a priest. Religion principallyprovided him with a framework to interpret themeaning of life and suffering. It also helped himto maintain a rational stance toward his ideas ofgrandeur and toward his unfulfilled expectationsthat he would be healed and his suffering wouldbe gone.6.2. Case 2One evening, at the age of 17, Elise had a strangeexperience on the beach.(11) Colors transformedinto a rainbow; she felt a strange sense of wellbeingand suddenly heard voices that told herto throw herself into the water: “Chase away thegood; chase away the evil; fly away into the duct.”She then threw herself fully dressed into the sea.Her parents found her much later on the beachhaving an imaginary conversation with a group ofpeople. According to Dumet and Ménéchal, whooriginally described the case, when she talkedabout the subject of her conversion, she was tryingto “convince them [her parents] of her divinepossession” (p. 159). Her family and friends haddoubts about the truth of her experience, and shestarted to doubt the reality of the experience herself.“She had firmly believed in it for years, andher life had been transformed afterwards. Thisinspired her to write, and it also made her feelthat she wasn’t alone in life anymore, that someonewas with her and in her who would alwaysfollow her. It was comforting and alarming at thesame time” (p. 159). In their description of thisclinical situation, Dumet and Ménéchal mentionthe dissociation of the being, the absence ofunity of the self and the feeling of being inhabitedby someone else. They do not hesitate tonote that the feeling of having someone insideyou is linked to the concept of possession, butthey hasten to add that the appearance of thispresence in Elise “is just an unconscious way ofocculting the void or rather the feeling of beingsucked into nonexistence that she had felt sincethe loss of the maternal object” (p. 165). Hersymptomology led them to believe that she had aschizophrenic pathology. However, Elise’s experienceon the beach in Normandy at the age of 17had permanently changed her perception of theexternal world and of herself. While she is now24 years old, the feeling of not being alone anymore,of being inhabited by someone else, doesnot alarm her. This unique experience, which shestill refers to, is also a source of creative energy.Since then, she has written a novel and poetry.Two years ago, she went to Paris to take theaterlessons. It is difficult for her to make sense ofher disturbing experience and to accomplish herartistic projects. Of course, she is also troubledby a feeling of persecution. But when a teenagerexperiences a feeling of possession, is the causealways to be found in a form of psychic dissociation?Wouldn’t it be more appropriate to talkabout the difficulties experienced in incorporatingconflicting psychic aspects in a case likeElise’s? Wouldn’t it make more sense to think ofthese difficulties as being the result of an incapacityto make the distinction between the insideand the outside, to define the limit between whatconstitutes “me” and what belongs to the “other”?Every culture furnishes landmarks for the constitutionof psychic containers (or “psychicenvelopes,” using an expression introduced byAnzieu).(12, 13) Perhaps these landmarks wereunclear in Elise’s case.6.3. Case 3In 1994, Father Schindelholz published the narrativeof the case of Barbara, a 19-year-old girl wholived in a city in Switzerland.(14) He recountsthat a Zurich psychiatrist diagnosed Barbarawith diabolic possession. The physician believedthat what the young girl was suffering from wasnot a matter of medical science. As a result, theCatholic family began to look for a priest whowould be able to help her. In the narrative, Father

Religion/Spirituality and Dissociative Disorders 151Schindelholz provides a description of Barbara’ssymptoms. At the end of August 1971, “Besidesvarious unexplainable afflictions, scratches suddenlyappeared all over her legs and red spotscovered her face. At that time, she had to quither job. Coughing, suffocating, rigid fingers, andback pain became more and more common. Shealso had the feeling that somebody was pushingneedles into her head, neck, lungs, and stomach.Whenever she entered a Catholic church (shebelonged to this faith), she was immediately ableto fold her rigid fingers and the coughing stoppedinstantaneously” (p. 10). Her health problemsforced her to quit her job in a children’s home.Barbara recounts that some time earlier, during alunch break, she had been reading about the lifeof a saint, and she had told herself that she’d liketo have a little of that saint’s sanctity. When shelaid the book down, she suddenly heard a lugubriousvoice. At the end of October 1971, shebegan to develop tremendous physical strength:During a crisis, four men were required to keepher lying on her bed. On October 29, she startedhearing voices and talking to them. The appearanceof her face changed. She grimaced full ofhatred, becoming unrecognizable during thattime – always between 11 p.m. and 1:30 or 2 a.m.There were seven different masculine voices whorefused to tell her their names, but who introducedthemselves with numbers. They talked agreat deal and answered questions. Number 1was a bit boorish and number 2 seemed to be thespokesperson for the others. Number 2 was theone who talked the most and was present at eachsession. Number 3 appeared only rarely and wasextremely violent. His voice was coarse and raucous.He violently threw Barbara against the wallsand threw objects across the room. SometimesBarbara had to put her head under the cold waterfaucet for fifteen minutes in the winter time. Herphysical health remained unaffected althoughshe was a frail girl weighing no more than fortykilograms at that time. Number 4 was haughtyand arrogant and appeared only rarely. Number5 was genteel, and the language he used was veryrefined. Number 6 was more serious and did notoften participate. Number 7 revealed his identityonly at the end of the ordeal, “saying that he wasa prince of hell” (p. 11). All of this went on for sixand a half years, occurring about 80 percent ofthe time. However, the voices did not disturb herat three different times of the year: Christmas,Easter, and during the summer holidays. FatherSchindelholz carried out many exorcism ritualsduring these years, always at the girl’s home (shestill lived with her parents). He only performedthese rituals between 11 p.m. and 2 a.m. whenthe voices manifested themselves, and someoneelse always attended these sessions. These witnesses,her family and close friends, met to helpsupport Barbara during her crises. After awhile,her parents were the only ones who continued toattend.Father Schindelholz describes his first meetingwith Barbara, when he arrived at 9:30 p.m. at thefamily home. “She came up to me immediatelywhen the door was opened. She greeted me witha smile and a cheerful ‘Good evening father.’ But Iperceived an expectation in her; she had the lookof someone who asks: ‘Is this one capable of morethan the others’” (p. 13). Afterwards, everybodysat down and chatted about everyday things.Barbara listened closely to the conversation andlaughed heartily when somebody told a joke.Nothing seemed to distinguish her from othergirls her age. Father Schindelholz noticed thatthere were no watches or clocks in the room andthat Barbara wasn’t wearing one either. Suddenlyshe stood up very straight and went quickly toher room. The priest looked at his watch; it was11 p.m. Everybody followed her. “The young girlhad thrown herself on the couch and was writhingin a strange way. I watched her attentively,but she didn’t seem to pay any attention to thepeople around her. She was short of breath, gasping,and her face was slightly redder than before.Her mother sat down beside her. The rest of uswere standing above her. I took the risk of askingthe ritual question: ‘Who are you?’ A suddenspurt of saliva in my direction was the answer. Istepped back and asked the same question, whichtriggered a litany of irate curses in response.I was able to catch a few words like: ‘pork of adog, dirty pig, head of a monkey, balls of a sheep,

152 Pierre-Yves Brandt and Laurence Borrasand so on. …’ Each insult was followed by snarling,grimaces of hate and bulging eyes filled withblood. It was already another, unrecognizable livingbeing which was lying there. This being wasthe opposite of the girl I had seen before whohad been so quiet, sweet, relaxed, gentle and gay”(p. 14). He then offered to perform an exorcism.After the parents agreed, he took out his prayerbook. He recounts that the demons tried to ripit away from him. The book flew into the air.“We immediately attached Barbara onto her bed,where she struggled violently, trying to breakaway. Four strong men had to hold her, while shespit at them and scratched them. I thought thatthe moment was right to start the exorcism, andI made the sign of the cross while throwing someholy water on the poor creature. The reactionwas immediate. She tried vainly to break free,crying and hurling curses at us. She belched outa series of extremely violent curse words, but Iwent on with the prayer. I wanted to observe duringthis first exorcism session whether the fourcharacteristic signs of possession would manifestthemselves” (p. 15). The priest then noted thatall of these signs were soon observed. A longmonitoring process then began. The priest wentto see Barbara regularly at her home to performexorcisms. Between his visits, her mother calledhim nearly every evening after 11 p.m. so thatthe numbered voices could speak to him on thephone, usually for fifteen to thirty minutes.No immediate improvement was visible. Onthe contrary, no progression was seen at all. Atthe beginning of November 1972, after performingseveral exorcisms, the priest wrote to thefamily that he was not sure that he could stilloversee the case. On November 16, the motherreplied that the night before she had cleaned thekitchen three times between 12:30 and 1:15 a.m.because “the numbers” had covered it with sugar.The priest advised her to go on a pilgrimage toLourdes or Lisieux, places that were known fortheir beneficial effects on visitors. A pilgrimagewas organized for Easter of 1973. During the massin the basilica of Lisieux, one of Barbara’s handsclosed and she could no longer open it. She hadto go home with her hand in this position.After the summer holidays, “the numbers”started to appear again. To help her begin workingagain, she was given typewriting tasks toperform at home. In the evening, “the numbers”destroyed the work done during the day. OnJuly 9, 1974, when the numbers left Barbara asthey did every year for the summer holidays, theyannounced that they would be back on August 5.A second pilgrimage to Lourdes was undertakenon July 25. Everything seemed normal. OnAugust 5, at 11 p.m., the numbers were back. Aturning point occurred at the end of October 1975when the numbers announced that they wouldleave Barbara one day when their “leader” toldthem to do so. But before that, they specified thatthey wanted a prey. In fact, it took several moreyears. On March 3, 1978, the numbers dictated animportant text, of which an excerpt reads: “Thebitch was left at our disposal. We could harass herbecause the one at the top allowed us to. We triedto use the strategy of illness, but we failed to bringher to our side. ‘Mister W.’ also helped us a lot inour work, but it has been a lost cause since thebeginning. Why did we really come? A very longtime ago, someone cursed Barbara’s grandfather,a curse related to a certain ‘book.’… Mr. W. calledus and asked us to help him through our work;that’s why so many of us came. Mr. W. belongs tous .… We are seven numbers. We cannot revealour names; it would be too dangerous, too dangerousfor us. The solution is called 1/2 + 1/2 = 1.That means that when the bitch gets married, wewill have to leave forever. Without conquering!We are damned, damned! cursed! damned!”Barbara’s grandfather had died in 1977.Mister W. was an acquaintance of the family.Barbara’s mother was convinced that this man hadbeen practicing black magic against them. In Aprilof 1978, Barbara was “released.” At that point,number 7 spoke for the first time and revealed hisname: “I am Astaroth.” The priest identified himwith a pagan divinity in the Bible and said thatthis divinity was the symbol of a powerful demon.(He said, this divinity is mentioned in the Bible;Astaroth is a plural. See Judg. 2.13, 1 Sam. 7.3 and12.10, and 1 Chron. 6.56). A few months beforeBarbara was “freed,” she had become involved in

Religion/Spirituality and Dissociative Disorders 153a romantic relationship with a friend. Her boyfriendnever found out what happened to herafter 11 p.m. They got married in the autumn of1978. In 1994, when the story was published, thecouple already had two children.From a psychodynamic point of view, itseems important to emphasize that Barbaradidn’t have a romantic relationship until afterher grandfather’s death and that when her anticipatedmarriage, which meant leaving her parent’shome, was announced in March of 1978, it wasfollowed by the end of her ordeal. What effect didthe curse that lay on her grandfather’s shouldershave on Barbara’s incapacity to start her own life?What was the nature of the relationship betweenBarbara and her grandfather? Was it necessaryfor him to die for a man to occupy a place inBarbara’s life? Was he the prey the numbers askedfor before their departure?A psychoanalytic approach would certainlylook for an unresolved intrapsychic conflict,perhaps stemming from incest, that caused theneurosis. In fact, several of Barbara’s symptomscorrespond to the classical description of hysteria.Father Schindelholz was convinced that Barbarawas not suffering from hysteria, schizophrenia,or a paranoid disorder. He believed that the factthat Barbara remembered what the numbers hadsaid after the episodes was proof that they werenot psychiatric phenomena. This allowed her towrite down most of what happened (p. 16). Infact, this criterion is insufficient.Ellenberger documented all the cases of multiplepersonalities while trying to classify all theclinical varieties of the phenomenon. There arecases of multiple personalities who are simultaneousor successive, mutually conscious of each otheror mutually unaware of each other, and even caseswhere only one of the personalities is aware of theother.(6) The remark that Barbara was aware ofwhat happened while she was possessed after theepisodes is Father Schindelholz’s attempt to finda criterion that would make it possible to clearlydistinguish possession from a psychiatric disorder.His attempt must be considered within thelarger context of the different interpretational conflictsthat have characterized the debates betweenmedical doctors and priests since the eighteenthcentury.Did Barbara suffer from hysteria or possession?Answering that question would lead us toreproduce the same distribution of tasks establishedbetween clerics and physicians in the eighteenthcentury. A different approach might bemore fertile. This approach admits the possibilitythat diverse interpretational levels coexist, withBarbara’s suffering in a central position. Froma psychopathological point of view, Barbara’spsychological manifestations would undoubtedlyhave been interpreted as a phenomenon ofhysteria. Diverse forms of somatization (coughing,suddenly paralyzed members, convulsions,and so forth) are considered to be distinctivefeatures of hysteria. The problems were solvedwhen Barbara became involved in a durable relationshipwith a man of her age, making us thinkthat an intrapsychic conflict was the source ofher suffering. Barbara’s case was not consideredfrom that point of view. The phenomenon wasinterpreted from the point of view of her family’ssystem of beliefs: a demonic possession. It isinteresting, however, to note the fact that, aftersix years of treatment, Barbara was freed fromher suffering without resorting to psychiatry.Should we compare the efficacy of the two differentsystems of treatment? In this specific case,limiting the phenomenon to a psychiatric diagnosisof hysteria without taking into considerationits spiritual meaning would probably havemade Barbara and her family feel misunderstood,which could have led them to refuse the treatment.By listening to Barbara and her family overan extended period and letting them guide hisinterventions, Father Schindelholz was able tooffer Barbara the therapeutic support that helpedher to get through a difficult chapter in her life andachieve independence. We should mention thatthe priest felt on several occasions that he couldnot understand the reality he was confrontedwith. When reading his narration, it seems thatthe positive outcome was brought about despitehis expectations. His merit consists in his endurance;he did not abandon Barbara when he couldhave considered the case hopeless. Too often,

154 Pierre-Yves Brandt and Laurence Borrasspiritual authorities are unaware of the relationshipthat is established between themselves andthe person in need of help when they begin anexorcism. A lack of professionalism in the managementof the therapeutic bond and the environmentthat is established through the practice ofexorcism can have very damaging effects. Insteadof considering that spiritual and psychic sufferingare mutually exclusive and necessitate two differentmodes of treatment, it seems wiser, in certaincases, to try to integrate both approaches.7. ANTHROPOLOGICAL CRITICISMThere is a principal criterion given in the DSM-IVto differentiate a possessed person from a personsuffering from a DID, meaning someone who hasseveral identities whether they are conscious ofeach other or not. In cases of possession, the identitythat takes the control of the person is felt to becoming from the outside. The difference is essentiallya question of how the person identifies withthe different entities: a possessed person would atleast sometimes identify himself or herself withthe spirit he or she feels possessed by. In otherwords, in a case of possession, when the spirit orthe entity speaks through a human being using “I,”the spirit or entity is not thought to have its originin the subject it talks through. In the list of examplesof dissociative trances that are not consideredas pathological, the DSM-IV tends to use the termpossession with cultural differences. However, thecase of Barbara, the presence of exorcist priests ineach diocese of the Roman Catholic Church allover the world, and the practice of exorcism inPentecostal evangelic churches in North Americaas well as in Europe show that the phenomenonof possession should not be exclusively associatedwith or limited to the non-Western world. Thisconcept is part of the modern Western world aswell. Certainly some would say that anthropologicalpre-modern conceptions are still presentin the Western world and that religious environmentssupport their conservation. But we believethat the opposition between what comes from the“inside” and what comes from the “outside” goesbeyond culture. This opposition makes it possibleto describe the multiplicity of the human psycheand identity and makes us question whether theterm dissociation is appropriate to describe thisphenomenon. When an individual describes himselfas being confronted with or having to face aspirit or an entity that comes from the outside andlives within him, why should we only talk about“dissociation” and not about “association” also?Systematically using the term dissociative revealsthat, although we recognize that subjects can feelthat external entities have penetrated their bodies,only one diagnosis is acceptable to us: theirpsychic cohesion is fragmented. This brings us toquestion an implicit assumption in this categorization;a fragmented identity or a multiple identitycan only be the result of dissociation. Thus,before such a fragmentation, the human psychewas necessarily a coherent whole, complete andunified. From this point of view, every kind ofpsychic evolution that leads toward a certain multiplicitycan only be the result of a loss of cohesion.The Western world is influenced by whatClifford Geertz calls “the occidental notion of theperson” (15) which1 tends to use the terms individual and personas if their meaning were equivalent; in otherwords, individual identity and personal identityare thought of as synonyms.2 qualifies identity, in particular individual identity,according to two criteria: unity and uniqueness.Accordingly, the person is seen in the Westernworld “as a cognitive universe that more or lessdetermines behaviour, like a dynamic centre ofconsciousness, emotion, judgement and organizedaction integrated into a distinctive whole, and that,at the same time, is opposed to other wholes andto the natural and social environment.” However,Geertz notes that in a broader global context ofdifferent cultures, this conception of a person isquite unusual. Several studies of intercultural psychology(16) or studies concerning the personalityin the ancient world (17–19) (p. 55) (note 17)and (pp. 72–73) (note 18) have shown that, inmost cultures, identity in the sense of uniquenessis assigned to a social group such as a family or a

Religion/Spirituality and Dissociative Disorders 155clan rather than to an individual. In other words,the individual identity is thought to be determinedby the social group of origin.The modern Western world conveys the projectto mold distinctive individual identities witha high level of self-awareness and a high levelof autonomy. We cannot contest the legitimacyof such a cultural project. Nevertheless, it doesseem valid to question the actual degree to whichthis project has been accomplished in Westernpopulations. What proportion of the populationhas actually achieved such maturity? The questioncan be considered from a sociological pointof view and also from the point of view of developmentalpsychology. At what point in developmentis this psychic maturity attained? We wouldlike to examine the following problem: Becausethe integration of psychic functions and the differentiationof identity are not innate, dissociationcan only jeopardize that which has alreadybeen integrated. When a unified, differentiatedidentity has not (yet) been constructed, whatparadigm can be used to examine the disturbancesstemming from multiplicity?Two hypotheses underlie our line of reasoning.First of all, the hypothesis of the incompleteasserts that a being is in a constant process ofgrowth (becoming). A being is never a whole,nor a finished entity. This statement is nothingoriginal; it is amply affirmed in psychotherapy:The confrontation with what lacks (failings,absence, project not yet achieved) is decisive forthe elaboration of desire. But this aspect has beensystematically forgotten in the exploration of thephenomenon of possession – the notion that asubject can be confronted with situations forwhich he is unprepared and which he is psychicallyunable to elaborate on a psychological levelseems to be inconceivable. The second hypothesisis that of the possibility of intrusions, of abreak-in. The trauma theory (20) examines psychiccontents that break into a psyche that is notready to assimilate them (for example, soldierswho witness traumatic scenes of violence duringthe war, persons present when a bomb explodesin a subway). Such contents can become obsessing:Although the scene took place a long timeago, every time it is evoked it seems to be as vividas it was the first time (for example, a soldier whowas suddenly attacked during the night; manyyears later, he is woken up with a start everynight by this scene). In that case, it means thatthese contents are not developed, not fantasized,not symbolized. If such contents trigger a dissociation,this would only be a secondary effect; itwould be a disorder resulting from a weakenedpsyche trying to integrate these contents (comparethe crypt concept introduced by Abrahamand Torok).(21)When the subject is not undergoing a psychicdisorganization of what has already been constructed,but suffers from the presence of psychiccontents that he is unable to deal with, wouldn’tit be wiser to designate this as an “associative disorder”rather than a “dissociative disorder”? Thismight help to show that the subject has taken elementsinside himself (for example, fantasies andfears) that do not belong to him (for example, proxytraumas). The same can be said of victims of torture.Some disorders result from the assimilation of thetorturers by persons tortured.(22) In other words,the disorder appears because the person was tryingto integrate a psychic content that he shouldn’t.8. COLLABORATION BETWEENPSYCHIATRISTS AND RELIGIOUSPROFESSIONALSWhen a person is said to be possessed, a questioncomes to the fore: What should the clergymanor religious authority (priest, pastor, exorcist,or shaman) be responsible for and what shouldthe psychiatrist be responsible for? Both parties,based on their systems of reference, are concernedabout the person’s autonomy. For the clergyman,the exorcist, or the shaman, the person who complainsof being possessed is thought to have losthis autonomy to think or act. The person is dominatedby forces that he cannot control. To be liberated,the possessed person counts on the authorityof the expert on spiritual matters. The spiritualauthority assumes that benevolent spiritual forces(gods, protecting ancestors, spirits, among others)will intervene and serve as allies to the exorcist or

156 Pierre-Yves Brandt and Laurence Borrasshaman. The efficacy of the intervention undertakenlargely depends on the extent to which thepossessed person, his family, and friends accept it.For the psychiatrist, the goal is the patient’spsychic autonomy. The complaint of possessionwill be interpreted as a paranoid delusion or as theexpression of the patient’s dependence on thoughtsof persecution. A therapeutic strategy could consistof reinforcing the “self” by helping the patientdevelop a rational stance toward the entities he feelspossessed by. The analysis could consist of demonstratingthat some of the patient’s ideas are incoherentor, in a more radical way, arguing against theexistence of the spiritual entities mentioned by thepatient and suggesting that he ignore these entitiesto show him that they only have the power that hegives them. This strategy can be effective, but it canalso be a complete failure because of the violentconfrontation involved between the demons or evilspirits and the authority of the psychiatrist. Evenworse, this strategy can lead to a conflict in thepatient’s loyalties that he cannot deal with, whenmedical compliance involves the humiliation of hisnative culture or religious faith.To avoid provoking a confrontation betweenantagonistic systems, the psychiatrist can chooseto occupy the position of someone who would liketo establish links between the two worlds of meanings.The aim is not for the psychiatrist to give uphis own system of reference. The challenge is toinclude the patient’s cultural perspective, the spiritualcounselor’s cultural perspective, and the clinician’spsychological viewpoint in the discussion. Atthe least, the patient must realize that the psychiatristis willing to take cognizance of the patient’s personalsystem of reference. Collaboration betweenthe psychiatrist and the patient’s religious system isnot always possible. For example, the patient mayseek the help of an exorcist who considers that hisintervention is incompatible with any psychiatricintervention. The aim would then be to help thepatient position himself so that he can accept thesupport of the medical system without necessarilybetraying his own system of reference. In any case,the psychiatrist should be aware that his domainof competence is based on a Western definitionof illness and suffering. Despite the difficulty hemay have in accepting that the patient attributes adifferent meaning to illness and suffering, the psychiatristwill benefit from taking a different pointof view into account. Understanding the role thepatient assigns him in his own system of referencecan only be helpful to the psychiatrist. To help thepatient view the therapeutic interventions of thehealers that belong to his system of reference froma critical angle, he must also develop an analyticalpoint of view toward the psychiatric interventionsrecommended within the context of the medicalsystem. Within the care setting, the aim is to providetherapeutic possibilities that help the patientmake choices leading to a higher level of psychicautonomy.9. ETHNOPSYCHIATRIC CONSULTATIONSAn “ethnopsychiatric consultation” (a term coinedby Georges Devereux who introduced the concept)can be helpful in this approach.(23) During such asession, a psychiatrist and co-therapists from differentcultural backgrounds meet with the patient todiscuss his symptoms and specific problems. Eachco-therapist can explain how these problems wouldbe interpreted by the system of reference that herepresents. In other words, the co- therapists playthe role of cultural mediator to facilitate the interpretationof one reference system through another.Possession can take on different meanings dependingon the patient’s system of reference. This specialsession can help him to more clearly formulatethe meaning of possession in his own system ofreference. As we saw in Barbara’s case, possessionis not always the result of cultural interpretationsoriginating outside the Western world. Thus, anethnopsychiatric consultation could also be usefulto patients coming from families with deep Westernroots. In this case, the participation of co-therapistswho can describe how the Catholic Church or differentprotestant and evangelical groups interpretpossession and exorcism would be important. Sucha session can help develop better communicationbetween the patient and the psychiatrist and facilitatethe construction of a common system of referenceincorporating the meanings of the patient’ssystem of reference as well as the meanings of the

Religion/Spirituality and Dissociative Disorders 157medical system. This can allow both participants,the psychiatrist as well as the patient, to continue thetreatment without each being locked into his ownsystem of reference. The ethnopsychiatric settinghelps construct a sphere that contains enough spacefor both of them, but that also forces them to change.This does not mean that the ethno psychiatric consultationbecomes a session for deliverance prayers,exorcism, or possession rituals. Because Devereuxhas constructed the concept of ethnopsychiatricconsultation as a possible component of a medicaltreatment, the consultation is supposed to be underthe responsibility of a doctor. So, even if one of theco-therapists had the status of a religious authorityin the patient’s system of reference, the ethnopsychiatricconsultation is conducted by a doctor andtakes place within the framework of the medicalsystem of care. As a unique psychiatric setting, thisconsultation enriches traditional medical treatmentand provides the opportunity for individuals fromdifferent cultures to construct a common frame ofreference. Although this frame is medical and notreligious and belongs to the Western system of care,this doesn’t prevent a debate about whether religiousrituals are appropriate. The topic can be discussed,but the final decision should be left to the patientand his family and friends. The purpose of the discussionshould be to help provide a meaning for thedecision to make use of religious rituals or not.ACKNOWLEDGMENTSWith our grateful acknowledgments to Dr. FrancelineJames, ethnopsychiatrist in Geneva, for her remarks.REFERENCES1. Ross CA , Duff y CMM , Ellason JW . Prevalence, reliabilityand validity of dissociative disorders in aninpatient setting . J Trauma Dissociation . 2002 ;3 :7 –17.2. Spanos NP . Multiple Identities and False Memories:A Sociocognitive Perspective . Washington : AmericanPsychological Association ; 1996 .3. Janet P . Major Symptoms of Hysteria . New York :Macmillan ; 1925 .4. Janet P . The Major Symptoms of Hysteria: FifteenLectures Given in the Medical School of HarvardUniversity . New York : Macmillan ; 1907 .5. R ausky F. Mesmer ou la révolution thérapeutique .Paris : Payot ; 1977 .6. E l lenb erger HF . The Discovery of the Unconscious .New-York : Basic Books Inc ., Publishers; secondprinting ; 1970.7. C o ons PM , B ow man ES , K lu ft RP , Mi lstei n V . Thecross-cultural occurrence of multiple personalitydisorder: additional cases from a recent survey .Dissociation . 1991; 4 (4): 124 –128.8. Bourguignon E . Psychological Anthropology:An Introduction to Human Nature and CulturalDifferences . New York : Holt, Rinehart and Winston ;1979 .9. Hel l B . Possession et chamanisme: Les maîtres dudésordre . Paris : Flammarion ; 1999 .10. Ross CA . Multiple Personality Disorder: Diagnosis,Clinical Features and Treatment . New York : JohnWiley ; 1989 .11. Dumet N , Ménéchal J . 15 cas cliniques en psychopathologiede l’adulte . Paris : Dunod ; 2005 .12. Anzieu D . Le Moi-peau . Paris : Dunod ; 1995 .13. Anzieu D , Briggs D. Psychic Envelopes . London :Karnac ; 1990 .14. Schindelholz G . Exorcisme, un prêtre parle .Porrentruy : Editions Le Pays ; 1994.15. Geertz C . “From the natives point of view”:on the nature of anthropological understanding.In: Basso KH , Selby HA , eds. Meaning inAnthropology . Albuquerque: University of NewMexico Press; 1976 :221–237.16. Triandis HC , Bontempo R , Villareal MJ , Asai M ,Lucca N. Individualism and collectivism: crossculturalperspectives on self-ingroup relationships. J Pers Soc Psychol . 1988; 54 (2): 323 –338.17. Malina BJ. The New Testament World . Atlanta :John Knox ; 1981 .18. Malina BJ , Neyrey JH. First-century personality:dyadic, not individual. In: Neyrey JH , ed.The Social World of Luke-Acts . Peabody, MA :Hendrickson ; 1991 :67–96.19. Brandt P-Y. L’identité de Jésus et l’identité de sondisciple: le récit de la transfiguration comme clef delecture de l’évangile de Marc (NTOA 50) . Fribourg :Editions Universitaires , Göttingen: Vandenhoeck& Ruprecht; 2002 .20. Lebigot , F. Traiter les traumatismes psychiques.Clinique et prise en charge . Paris : Dunod ; 2005 .21. Abraham N , Torok M. L’écorce et le noyau . Paris :Flammarion ; 1987 .22. Sironi F . Bourreaux et victimes: Psychopathologiede la torture . Paris : Odile Jacob ; 1999 .23. Devereux G . Essais d’ethnopsychiatrie générale .Paris : Gallimard ; 1970 .

12 Self-Identity and Religion/SpiritualityPIERRE-YVES BRANDT , CLAUDE-ALEXANDRE FOURNIER , AND SYLVIA MOHRSUMMARYSelf-identity results from construction. Selfconsciousnessis achieved in several steps. Basedon the attachment bond, the infant’s self is constructedwithin the framework of the first dyadicrelationships, particularly the relationship with themother. It successively enriches itself with new selfsenses (Stern). By language and by the access to thesymbolic function, infants get more directly in contactwith cultural constructs, reference points theycan identify with. Thus, religious figures replaceattachment figures and play the role of substituteof the parental figures. Based largely on a definitionof self-identity by Ricoeur, this chapter showshow the religious dimension of the self stems fromthe interaction between processes one can identifywith, present ever since infancy, and the culturalenvironment the individual comes into contactwith. Religious traditions carry reference pointsone can identify with especially via accounts, rites,and roles. Highlighting the aspects one must takeinto consideration when providing therapeutictreatment, we illustrate these processes of identificationby three case studies. Religion can helprestore identity but it can also weaken it. When thepatient and the therapist come from very differentcultural contexts, it is important for the therapistto try to integrate the patient’s reference system tosupport the therapeutic alliance.1. INTRODUCTIONSince the beginning of the twenty-first century,narcissistic issues have become quite meaningfulin the clinical picture. The increased fluidityof reference points has rendered identities moreunstable, more blurred. For a certain number ofour contemporaries, this context weakens the constructionof the relationship with the self. Whenthis situation is experienced in a painful manner,it results in a feeling of identity loss with a depressivecomponent, or even in identity disorders withpsychotic characteristics (identity confusion in themanic form of a grandiose self or schizoid organization,for instance). The need to relieve this sufferingmanifests as a quest for landmarks, in thehope of reassurance or even confirmation of one’strue self (for example, in the fields of sexual orientation,intergenerational relations, professional,or vocational choices). This expectation applies toall systems that provide a sense of purpose, amongwhich religions play a special role.2. THE ROLE OF RELIGION/SPIRITUALITY IN THE CONSTRUCTIONOF SELF-IDENTITYHow can a religious system or spiritual frameworkaddress this need? Let us note from the startthat individual identity is not an automatic given.It results from development during which psychologicalprocesses are at work. Based on initialfigures of attachment, the infant’s and then thechild’s self is constructed according to parentalmodels. Afterwards, by progressive socialization,the child gets in contact with an increasingly vastcircle of figures to identify with (potentially). Inadolescence, some of these figures (peers, adultrole models, or idealized historical or fictionalcharacters) will play a decisive part in finding thestrength to break away from the family environment.All these processes at work from birth until158

Self-Identity and Religion/Spirituality 159adolescence remain active throughout adult life.The interactions between religion/spiritualityand identification models are circular. Religiousbehavior and spiritual values are transmitted bymeans of an identity model of the child or adult.From an early age via the adults in their lives,individuals come into contact with religious orspiritual figures that help them shape their identities.The models lauded by religions and thereligious or spiritual figures taken as role modelsare created partly based on identity bearings discoveredduring development. The terms father,mother, brother, sister, friend, lover, companion,and so forth are often applied to religious models.The transmission of religious aspects of identity,however, is not limited to interpersonal relations.Socialization assumes the ability to find one’splace in a group. Children very rapidly becomefamiliar with customs and learn to assume roles,not only in contact with their parents, but also inlarger social groups.3. CHAPTER ORGANIZATIONAfter providing a definition of self-identity, thischapter will begin by presenting the developmentalaspects that condition the construction of theself. We will then discuss the construction of a coreself, the constitution of the first psychic envelope.Then we will approach the role of identificationprocesses in the construction of a differentiatedself-identity. These aspects will be articulated bymeans of attachment theory. After that, we will gointo detail on the interactions between religion/spirituality and identity construction. Towardthis aim, we will examine religious figures asfigures of attachment, the role of the parentalfigures, and then its extension to the relationshipbetween the individual and the group. This willallow an emphasis on various forms of collectivesymbols provided by the cultural environment:the identification figures presented in parables, theidentification models conveyed in rites, and thesocial roles. We will then present and analyze afew cases, some of which were followed up withpsychiatric treatment or psychotherapy. The conclusionwill provide a multicultural perspectiveon these issues. In summation, we will firstexamine how a religious or spiritual experiencecan threaten the cohesion of the self and thenexplore under what circumstances religion/spiritualitycan contribute to reestablishing identity.Second, we will discuss the provisions involvedin considering the patient’s reference system inthe treatment process. The goal is to determine,for each case, what in the patient’s religious andspiritual referents will permit the establishmentof a secure, defined self-relationship and lead toaccepted social roles.4. DEFINITION OF SELF-IDENTITYThe philosopher Paul Ricoeur distinguished betweenthe idem-identity and the ipse-identity .(1)The idem -identity designates what is not alteredby time. In relation to the individual, it tracesback to one’s genetic code as would be true for fingerprints,for example. On a psychological level, itdefines the character in the sense of the personalitytraits that individuals preserve throughouttheir lives. This is a static definition of identity. Onthe contrary, the ipse -identity designates the continuityof the relationship with the self throughthe inevitable alterations and discontinuitiesover a lifetime. This definition is a dynamic one;it takes into consideration the formation of theindividual. Of course, individual identity is supportedby one’s genetic foundation. Nevertheless,knowing only somebody’s genetic code is surelynot enough for assessing an individual’s identity.One’s psychological being is constantly developingthrough interaction with the environment. Thefeeling of identity, the feeling of “being oneself,”and the individual’s self-image are the result of anongoing process of construction that is a continualquest for balance. In this regard, the self is anentity situated at the interface of the intrapsychicand the social constructs of the personality.This entity must be distinguished fromother entities used to refer to the subject.The self is neither the ego nor the id . Theself designates self-representation; how

160 Pierre-Yves Brandt, Claude-Alexandre Fournier, and Sylvia Mohrindividuals think of themselves in the longterm. This representation is inevitably culturallydependent: it contains a certainconcept of self-identity that can vary infunction of age, sex, and social position. Itis “how the subject is advised to think ofhimself or herself.”So that this self does not remain an auxiliary,peripheral being (a false self?), it hasto be taken charge of by the ego (accordingto Freudian terminology here), whichadjusts the degree of centrality it grantsto the identifications offered by the (representationof the) self conveyed by culture.Furthermore, preferences in this fieldare more or less influenced by the familyenvironment.At each stage of their existence, individualsconstruct the self their ego is able to undertake,by means of identity representationsprovided by their environment. A transformationof the self can result from reorganizationcaused by endogenous factors (newcognitive abilities, new impulsive expressions),or by exogenous factors (access toa new social position, confronting situationsthat are not easily assimilated by thealready constructed self). Transformationof the self means: access to a new identity(pp. 56–57).(2)This definition of the self should not be mistakenwith the Self defined by Carl Gustav Jungas an archetype whose function is the union ofopposites and that is perceived by the ego astranscendent as it is able to integrate the ego andwhat the ego is not able to integrate, or shadow.For Jung, the relationship between the Self andthe ego is situated at the level of the intrapsychic.What we mean here by self is, on the contrary,located where the ego meets with its environment.It is an effect of symbolism that languageconstruction and self-representation are necessaryin communicational exchange.5. DEVELOPMENTAL ASPECTS OFIDENTITY CONSTRUCTIONIn his works on the interpersonal world of theinfant, (3) Daniel Stern pinpoints the emergenceof a sense of self to a very young age. Already attwo to six months, an infant begins to have thesense of a core self. The permanence of the contactwith his own body allows him to recognize himselfas a physical entity with its own cohesion andcontinuity. He experiences the permanent availabilityof the sensory and proprioceptive feedbackcoming from his own body, as opposed tothe exterior signals coming from outside his self.This description connects what Didier Anzieucalled the “Moi-peau,” (4) or “skin-ego”. The feelingsof identity and self-representation are basedon the construction of a psychic envelope, whichdevelops using the bodily envelope for support.The bodily envelope is a border between the bodyand the outside world and an internalization ofthis first experience of creating an inner vesselwithin oneself. This sense of a “core self as a separate,cohesive, delimited physical entity with itsown awareness of activity, affection, and temporalcontinuity” (p. 21), (5) will deepen at the ageof seven months with the sense of a subjective self ,when the baby is able to attribute to others thecapability of having a mental state similar to itsown. Then, during the second year of life, thissense is further enriched by the sense of a verbalself , which forms with the beginnings of verballanguage.The emergence of these different definitionsof the self is achieved in and by interpersonalrelationships, particularly with the mother (orwith any other person in charge of mothering).This relationship, integral to identity, is first ofall an affective one. Daniel Stern referred to itas “affective attunement.” The attunement canbe seen as the mother’s response to the child’sspontaneous activity and particularities. Thisresponse is both a validation of and a support totheir activity. There are of course different levelsof attunement, ranging from a pure and simplerebuff to modeling appropriate behavior ( thegood-enough mother , according to Winnicott).

Self-Identity and Religion/Spirituality 161The affective attunement is present from theemergence of the sense of a core self (in holding,handling, and presenting objects). Infants willinternalize “schemas-of-being-with,” which willserve as a model for future interactions. Thus,the “tickle the tummy” game is learned from themother, but it is recognized when played withother people. In other words, the identity is constructedin the relationship with the mother butis maintained in a prototype recalled by a cue.Identity is not part of the actual goal. By the rangeof affective attunements that she provides, themother will validate or repudiate certain experiences.Together with the creation of the sense of acore self , this initiates differentiation between thesocial self and the disavowed self. The social selfis created by the experiences of the self that areselected and attributed value because they satisfysomebody else’s needs and desires. The disavowedself consists of a conglomerate of disavowed selfexperiencesthat are not easily expressed usinglanguage. During development, the social self willbe perceived as a false self in personal experiencesfurther determined by the “internal conception,”to which being one’s true self will be attributed.This is because the social self satisfies the desiresof others before its own.With the emergence of the sense of a subjectiveself and of the infant’s newly acquired abilityto recognize in others a mental state similar toits own, the domains of privacy and intimacybecome possible. A third domain of the self isestablished, the private self , composed of experiencesone does not share, but that are not disavowed.The emergence of the sense of a verbalself creates a new way of being-with betweenmother and child by resorting to verbal symbolsin sharing meaning. In this sense, languageacquisition is not only regarded as an access toindividuation, but also as a powerful means ofmaintaining union. Indeed, learning languagestrengthens the psychological bond first withrelatives and then with other members of thelanguage’s culture. This developmental visionof early childhood (0–2 years old) conceives ofa forging of the identity within the crucible ofthe relationship. Infants establish themselves byinternalizing types of intersubjective relationships,that is, various forms of “being-with.”They are regarded from the start as differentiatedbeings. Another perspective on the constructionof identity emphasizes the object of the relationship;the person in the relationship rather thanthe manner of relating to him or her. This distinctionmatters from the moment we want tofollow Freud’s reasoning and associate partialidentification with only certain traits of a person,as opposed to a global identification withhim or her.6. THE PROCESS OF IDENTIFICATIONAccording to a Freudian interpretation, identificationis “the act by which an individual becomesidentical to another, or by which two humanbeings become identical” (p. 187).(6) Freud distinguishesthree identification modes: a primaryidentification, a secondary identification, and apartial identification.Primary identification is born in the first relationshipwith the mother. It is the original formof connection to another person, marked fromthe outset by affective ambivalence. Contrary toStern, Freud did not consider infants to be differentiatedfrom the very beginning. Rather, heassumes that as long as both sexual and generationallack of differentiation predominate in thefirst relationship with the mother, the ego and thealter-ego are not clearly differentiated and that,strictly speaking, an object relation cannot beestablished. The difference between Stern’s andFreud’s points of view results from a difference incriteria when talking about differentiation. Fromhis research on babies, Stern was able to highlightan infant’s sense of self that implies the ability todifferentiate between self and others long beforethe other is constructed as a love object differentfrom the self, according to Freud’s criteria.Characterized by primitive orality, the primaryidentification is thus an identification with therelative, the mother figure. It is experienced andsymbolized as a bodily operation: incorporation.Freud believes that, in the same way, duringmourning the lost object is incorporated

162 Pierre-Yves Brandt, Claude-Alexandre Fournier, and Sylvia Mohrand empowered at the same time with a loss ofinterest in the individual’s social life.Secondary identifications overlay this chronologicallypreceding primary identification. Thisprocess is no longer achieved by incorporation,but rather by introjection. This process conveyspeople and with them their inherent qualitiesfrom the inside to the outside in a fantasticalmode. Contrary to incorporation, it does notnecessarily imply reference to bodily limitations.Contrary to the first two identificationmodes, the third one, partial identification, canbe achieved without any relationship of love orhatred. On the basis of ability, or will, subjectscan identify themselves, or put themselves inthe same situation (community) as a person.Moreover, identification can concern a person’sunique trait.According to Freudian theory, identity can(from the view of the second stage) be tracedback to the construction of the self, of the ego.In the end, it stems from the product of the threeidentification modes. The construction of theindividual’s identity is thus initially marked bythe dyadic relationship (more or less undifferentiatedaccording to the authors’ required criteria)with the mother.As mentioned previously, primary identificationis the basis of the identifications that follow.Individual identity will develop based on this relationshipwith the mother. This dyadic relationshiptakes the lead, provides protection, and assuagesanguish. From the point of view of its object, therelationship can be projected at a higher levelonto a divine figure. It is therefore the maternalfunction (the qualities special to mothering) thatis projected on divinity (which is, in this sense,sexually undifferentiated) (Freud, 1927).The triangular relationship including a thirdparty succeeds this dyadic relation. The thirdrole is that of the father. Freud theorizes on theestablishment of this three-way relationship bymeans of the Oedipus complex. He estimatesit emerging at around 3 to 5 years of age, butit begins even sooner. This relational switch issimultaneous with the beginnings of sexual differentiation.Young children learn that they are aboy or a girl. The father interrupts the privilegedrelationship between mother and child. He necessitatesa sort of forsaking, a necessary separationfrom the mother. For the young boy, this breakleads to a relationship of rivalry and love with thefather. The young boy will thus identify himselfwith the father while simultaneously being hisrival (for access to the mother). Through thisexperience of duality, trying to keep two parentalimages together (the good and the bad father,according to Mélanie Klein), the child integratestwo structural taboos, just as much individual ascollective, which are the taboo on incest and thetaboo on murder. As much as in the introjectionof the parental images, what will survive in theformation of the personality is what has beeninternalized from the relationships among themembers of the triad. From a religious point ofview, the father’s arrival marks the arrival of law,of separation, and of judgment. In representationof the divinity, the paternal characteristicsprojected onto the divine figure do not erase thematernal traits, but rather join them. In adolescence,becoming a man or a woman (a sexuallydifferentiated adult) allows access to reproductionand therefore to identifications with paternalor maternal qualities and with the qualitiesof parents and adults in general. These partialidentifications go together with an attack on theparental imagos, a confrontation that is necessaryfor differentiation. Adolescents must be ableto assert themselves through rebellion to escapeidentification with a role model. Each integrationof differentiation (subject/object, pleasure-ego/reality-ego, differences in sex or generation) canbe traumatic if there are no anticipatory representations.“The cleavage of the Ego is a denial ofthese differences when they catch by surprise anunprepared by anticipatory representations Ego”(p. 98).(7) It is therefore a lack of sufficient representativeintroductions that make identity crisestraumatic for the child.As demonstrated by Freud, religious figurescan be empowered via the unresolved oedipalconflict to escape such a growth process and tolead to what he calls neurotic religion. However,religious figures can also serve as a support

Self-Identity and Religion/Spirituality 163in facing a growth crisis, either by offeringcounter-models allowing teenagers to assertthemselves before the parental figures, or elseby helping them surpass a deficiency or a lossby accepting the limits of the human condition.(8) Following the mode of partial identification,children will pursue the construction of theiridentity through the selection of attitudes, choiceof behaviors, and integration of value systems.This construction clearly stems from the constantinteraction with the educational environment.It can thus include an emphasis, markedby the educational environment, on a religiousor spiritual dimension.7. ATTACHMENT AND IDENTIFICATIONParental figures are the first identifying figures.However, before orienting the construction ofthe identity by encouraging certain attitudes ordependencies, the parental figures are responsiblefor establishing a bond for the infant that servesas a foundation for identification. This basicfunction has been more thoroughly describedby attachment theories. The attachment bondespecially has been researched in the context ofthe relationship between trauma and resilience.Studies on attachment are responsible for thegreatest and best contributions to understandingthe capacity for coping with trauma. Attachmenttheories have truly expanded through thework of John Bowlby.(9) According to Bowlby,“Psychological development exists in newborns’ability to establish a secure mode of connectionwith a close adult. It is this mode of connectionthat allows them to progressively distancethemselves from their mothers and to explorethe world while still being sure of their mothersproviding the security and affection they need.”Two important ideas emerge from these works.First of all, the importance of early care becomesevident. According to Donald Winnicott’s terminology,a “good enough mother” is the onewho gives the child basic psychological security,allowing him or her to deal with later trauma.Second, and what the attachment theorists arecurrently developing, children must be ableto benefit from at least one secure attachmentbond, from a stable landmark, to support themin the various difficult situations they must overcome.Boris Cyrulnik was primarily responsiblefor the promotion in France of the idea of “developmenttutors” or “resilience tutors.”(10) These“resilience tutors,” who are not medical careprofessionals, are suitable for ensuring a secureattachment, strengthening a person’s self-esteemin a delicate situation, and helping to make senseof life’s events. According to Serge Tisseron, “Theidea is to allow psychologically fragile peopleto create self-images, as well as images of others,that are able to think, feel, and distinguishbetween representations and emotions that areshared and those that are personal. In the end,these persons must arrive at a self-image that iscapable of creating and breaking bonds, both ina self-to-self dialogue – deep down inside – andin exchanges with others” (p.24).(11) In this way,they bear the history and thus the child’s identityduring periods of great fragility. “Resiliencetutors” are co-authors of the child’s history,allowing him or her to recreate self-images andimages of others.At this stage, it becomes possible to see howimpulse theory and attachment theories complementeach other. It is relationship, such as definedby Daniel Stern in affective attunement or by JohnBowlby in internal operating models, that contributesto the internalization of parental figures.These parental figures are stable and formativein a secure attachment that introduces the pleasureof a relationship; they are much less formativewhen the forms of attachment are insecureand are built on anxiety. Stable and structuringattachment figures favor introjection. They supportthe child or adult in the processes of symbolizationand liaison (according to the language ofmetapsychology). For Serge Tisseron, “the capacityfor introjection … is part of an intersubjectiveprocess between the child – or the adult – anda third person who fulfils maternal functions”(p.116).(11) Attachment figures that are not veryformative will favor what Nicolas Abraham andMaria Torok refer to as “inclusions,” a kind ofpocket containing psychological elements that

164 Pierre-Yves Brandt, Claude-Alexandre Fournier, and Sylvia Mohrcan produce strange manifestations in whichsubjects do not recognize themselves.(12)In summary, the attachment relationship is afoundation and a vector for the internalizationof the parental figures. It responds to a primaryneed. It is on the basis of this maternal function,later replaced by others, that the secondaryand the partial identifications develop, allowingaccess to the symbolization processes (communicationcodes, access to language). In this way, theinternalization of the relationship with stable andstructuring parental figures depends on attachmentand, therefore, on the subject’s capacities ofsymbolization such as employment, learning ofritual practices, and construction of social roles.8. RELIGIOUS FIGURES ANDATTACHMENTMary Ainsworth has shown how, on the pathto adulthood, the first attachment figures arereplaced by sexual partners, family members(grandparents, brothers, sisters, or other kin),and members of peer groups.(13) Therapists alsoare assigned the role of an attachment figure. Tofully benefit from psychotherapy, it is imperativethat the patient lean on a secure base.(9) Froma developmental point of view, religious figuresplay the role of attachment figures, because theyoffer a secure relational frame. Ainsworth notesthat priests or pastors are also potential attachmentfigures. In the religious field, divinitiesor saints can be used as reassuring figures. It isworth considering up to what point we can speakof attachment figures when perceptible contact isnot possible.In the psychology of religion, Granqvist andKirkpatrick have developed the idea that religiousfigures would fill a lack of attachment bonds andplay the role of “resilience tutors” by incarnatingthe parental function. In most Western religioustraditions and in attachment research, the religiousindividual’s close relationship with a personalGod is central.(14) In Bowlby’s normativeattachment conceptualization, the term attachmentrelationship does not refer to any type ofclose relationship but exclusively to those thatmeet four criteria: proximity maintenance, safehaven, secure base, and separation distress.(15)Granqvist’s and Kirkpatrick’s studies are based onthe assumption that these four criteria are reasonablymet as concerns the relationship of thebeliever with a spiritual object/figure. Hence, itis suggested that some aspects of attachment aresimilar for the believer in relation to his or herspiritual object/figure and for the child in relationto her parents, that is, they serve the function ofobtaining/maintaining a sense of perceived securitywhen in distress.(16) There are several meansavailable for the religious individual to establisha sense of proximity or closeness to a spiritualfigure/object, such as using symbols, engaging inrituals, and prayer.(14) Regarding the safe havenaspect of attachment, one of the best documentedfindings in psychology of religion is that believersturn to God in situations of distress. Such situationsare diverse and include loss through deathand divorce, (17) emotional crises, (18, 19) andrelationship problems, (20) all of which are likelyto activate the individual’s attachment system.Two different modes of psychological coherencerelated to spiritual/religious coping havebeen described. The correspondence hypothesissuggests that there is a correspondence betweenearly child-parent interactions on the one handand a person’s ability to cope in relation to a spiritualobject/figure on the other. According to thishypothesis, a secure attachment history wouldenable a person to use a spiritual/religious object/figure as an attachment figure, which proximitywould help regulate affects. The compensationhypothesis suggests that an insecure attachmenthistory would lead to a strong religiousness/spiritualityas a compensation of the lack of perceivedsecurity.(21)9. RELIGIOUS FIGURES PLAYING THEROLES OF PARENTAL FIGURESReferential religious figures can bridge the gapsbetween identification figures. In certain religioustraditions, people practicing a religious functionare called father or mother . These same denominationscan be applied to saints or to divine

Self-Identity and Religion/Spirituality 165figures. In other words, believers are invited tosituate themselves in a child-parent relationship.Antoine Vergote and Alvaro Tamayo have collectedstudies that have highlighted the way inwhich a divine figure, in the Christian contextbut also outside this context, combines paternaland maternal aspects.(22) Compared with thefather’s image or to the mother’s image, God’simage joins paternal traits such as maintainingorder and providing protection with maternaltraits such as unconditional love and kindness.These results, although based on a population ofBelgian children, could be generalized to othercultural environments.In the same vein, on a basis of case studies ona psychiatric population, Rizzuto (23, 24) showshow much God’s figure builds on the foundationof a given individual’s parental figures. This givesway to contemplation of two types of therapeuticintervention while dealing with patients towhom God or a divine figure plays an importantrole. In one scenario, the therapist can tryworking on the perception of divine figures toalter the bond to the paternal or to the maternalfigure. This involves inviting the patientsto explore their representation of God or otherdivine figure by asking whether it correspondsto their system of beliefs and whether this figureis influenced by the figures of their own parents.A second possibility is investigating whether thisdivine figure plays the role of an attachment figureor of an identification figure and whether itis possible for the patient to draw support fromthe figure to face her difficulties and build herown identity.10. THE INDIVIDUAL AND THE GROUPThe collective dimension is an essential elementfor the construction of the religious/spiritualidentity of the individual. The need for protectionand affective proximity can also be filled in a religiouscommunity, as a way station for the familyenvironment. Attachment theory is not exactly anadequate framework for describing this functionfulfilled by a group, because it applies in theoryto the relationship between two individuals. Thefunction of the receiving and protective groupwill be better described in terms of a substituteof the maternal envelope (Winnicott, 1968).(25)The source of religious or spiritual referencesmobilized by the subject to interpret the worldis not initially inherent to the individual, but israther found in cultural constructions. The subjectturns to her culture to find the words and theconceptual and behavior categories for interpretingher experiences. Thus, there are special ritesof passage that accompany the important transformationsof a major life event, such as birth,coming of age, marriage, or death. Nevertheless,in Western or Westernized societies, there is aclear tendency to individualize the rites. It is inthis context that David Le Breton (26) interpretsadolescents’ risky behaviors as attempts to fillthe void of the rite of passage from childhood toadult life in these societies. By putting their lifein danger, adolescents try to test their limits. Thisshould be understood as a sort of cry for help, anattempt to provide oneself with an understandingof the path to adult status. However, without clearsignals coming from the outside, young peopleare in danger of taking risks unaware. Extremesports without sufficient training, car racing,overdose, and excessive dieting are all attemptsto ensure that one is in control of one’s own lifeand of the world. Adults know that such controlcan only be relative and limited. Their task is toprotect the children, who are still incapable ofrecognizing their limits, and to help them getto know themselves so that they can becomeautonomous. In other words, the construction ofthe individual identity is achieved through recognitionfrom others. It is in the confrontationbetween the representation I have of myself andthe representation that others convey to me thatI learn who I am. Nonetheless, this confrontationis not only focused on the construction of thespecific identity. Surely, if everything goes well,individuals will learn to know themselves thanksto an image sent to them by their environment.However, a society’s educational system is also anexpression of expectation the society has of theindividual: that she adjust to fit the environment.The construction of the self is not only contained

166 Pierre-Yves Brandt, Claude-Alexandre Fournier, and Sylvia Mohrin the representation of what constitutes the individualon the basis of independent choices. Theself is also shaped by the environment that guidesthe choices. The self-image an individual projectsthus results from a compromise between whatthe individual emanates and what the societyexpects. The quality of an individual’s integrationin her life environment will depend on the extentof this compromise of combining individual andcollective expectations.11. COLLECTIVE SYMBOLIZATION OFTHE INDIVIDUAL IDENTITYAny given society proposes a culturally sharedconception of self-identity. The cultural representationsthat convey it vary. It can be expressedthrough artistic productions. Self-awareness,attitudes, and behaviors that can be lent toan individual are defined in novels, children’sstories, documentary films, and fiction movies.Advertisements, interviews, news stories,social roles dictated by professional activities,law, education, and health systems are all vectorsthat shape the conception of a given society’sself-identity. Religious institutions or thecircumstances responsible for the relationshipwith the unpredictable, transcendence, and theafterlife also contribute to the conception of theself. Hence, tales displaying mythological, divine,ancestral, or exceptional historical figures serveas a support to identification. Christian traditionheavily emphasizes the imitation of Christ . To citeonly a few examples, Moses is the classic examplefor a Jew, Buddha for a Buddhist, and a Sufi masterfor certain Islamic groups. Thus, in variousreligious traditions, exemplary figures contributeto the foundations of identity. Accounts of thesefigures’ lives are told, and episodes from theselives are taken as examples to follow. By readingor listening to these accounts, the reader or listenersets up the processes of identification necessaryto understand the story. The identity canthen be built by complete or partial appropriationof the figure brought out in the story, or, on thecontrary, by antagonistic reaction to this figure.In this case, the account can waken experiencesof the self to which the subject had not previouslyhad access. In other words, at certain moments oftheir lives, individuals can manage to make senseof the situation they are in by identifying similaritiesto a situation experienced by a central figureof the religious tradition they have chosen.It is then an already-experienced situation thatis retold through a story about a figure fromthe past. In all these cases, the cohesion of theidentity is found following the narration mode.The transformation of identity, threatening thecontinuity of the self, is supported by the narrativeplot: By telling the story of this transformation,individuals reestablish continuity beyondthe rupture. Herein lies the identity, in the senseof the ipse -identity, such as suggested by PaulRicoeur.(1) The staging of identity constructionin stories shows the narrative character of theindividual identity. The stories are the collectivesymbolization.Another form of symbolization of self-identityis its mise-en-scene during rites. Rites are culturaldevices built to shape the identity of those takingpart in them. Thus, there are rites of passageto mark coming of age, marriage, or death. Thewords, the concepts, or the behaviors establishedby these rites often contain an important religiousor spiritual dimension. Although each riteof passage is generally experienced only once byan individual, other rites, such as collective orindividual prayers, taking part in the Eucharist,confession, family or community celebrations,or pilgrimages, are reiterative. Whichever formthey take, these rites provide bearings that can beused for identification shared by those adheringto the tradition that conveys them. Their functionis one of facilitating integration into societyand social roles.As for rites of passage, they could be thoughtto only spur a transformation in the intendedindividuals. However, every person present at theevent reflects on his or her own path. Participationmeans putting oneself in a position of identification.For some of them, it means preparing forwhat they will one day be called on to experience;for others, reliving a past rite. In a narrativeor ritual manner, stories and rites symbolize

Self-Identity and Religion/Spirituality 167a process of construction of this identity. Theydirect the roles to be played.(27) In anticipation ofexperiences that patients could perceive as threateningthe cohesion of the self, rites and stories proposeinterpretation models of these experiencesas social roles one must assume. Psychotherapyoperates in the same way. In a therapeutic settingmarked by a certain rituality, it allows playing variousroles through interactive sequences integratingnarrative aspects.12. CASES WITH RELIGIOUS/SPIRITUALASPECTSThe case descriptions provided here have beenchosen to show how various aspects of what constitutesa religious tradition can be invoked by anindividual during the process of constructing hisor her identity. The first case refers to a personof Christian tradition, while the second and thethird cases concern individuals of Muslim tradition.What these case studies highlight is notrestricted to these particular traditions. The firstcase illustrates how a girl’s difficult time in distancingherself from her mother is accomplishedin late adolescence and then in young adulthoodwith the help of a community structure and ofattachment and identification figures of religiousnature. The second case highlights the nature ofidentification potentially contained in the practiceof a rite, but also the extent of the contactthat can be established with a secure foundationrelationship. The third case demonstrates howreligious traditions furnish social roles.12.1. Case 1Sister B. is a nun in a Benedictine monastery.She says she has been suffering from asthma eversince she was a child. She thus describes the relationshipbetween her and her mother as stifling.Her parents were bakers and she was allergic toflour. In adolescence, she managed to distanceherself by going abroad for her professionaltraining. She reports that her asthma attacksstopped after a prayer with a charismatic group,where she experienced the Spirit of Peace. Froma charismatic perspective, the Spirit of Peaceis considered to be a divine gift. The body collapses.If the person is standing, she falls withoutbeing hurt and remains like this for a while.Those who have experienced this describe it as adeep relaxation in which all internal tension disappears.A feeling of well-being takes its place,providing reassurance of being accompanied bya kindly presence. Sister B. was 23 when she hadthis experience. She attributes it as the result of ajourney of several years, made after several successivesteps. At the age of 33, she entered themonastery. A few months later, while still a novice,she was sent with a group of nuns to a fieldto collect stones and throw them into a tractor.They were supposed to clear the field of stonesbefore plowing. This was dusty work, which setoff an asthma attack. Reinterpreting what happenedat this specific moment, Sister B. believesthat the attack was triggered by fear. “It plungedme back into a situation in which I could onlysuffocate and I was in complete crisis.” Ten yearsbefore, she had been healed in a miraculous way,she recounts, and then wonders if she ought todoubt this healing. Her superior again sent her togather stones, thus confronting Sister B. with animpossible task, as she describes it. She recounts,“I prayed a lot and then asked the Virgin Mary toaccompany me, as I realized I had experienced alot and could do a lot of impossible things withoutsuffering an asthma attack. I thought thiswas a step I had to take.” During this new shiftof stone collecting, she didn’t have an asthmaattack. “I came back with a stone; I took the mostbeautiful one, I didn’t throw it in the tractor, butput it in my garden apron; I took it with me to themonastery and put it in a small sanctuary in thegarden, where there is a statue of Saint Mary, andsaid: here, this is the stone of victory.” She laughsand continues, “So, through an Impossible Task,as Saint Benedict describes it, I had really overcomesomething.” This account illustrates wellhow attachment coordinates with identification.First, charismatic prayer, with its lullaby-likesongs, built a maternal setting in which Sister B.experienced profound security. The account wasnot detailed enough to tell if a specific member

168 Pierre-Yves Brandt, Claude-Alexandre Fournier, and Sylvia Mohrof the charismatic group played an intermediaryrole as an attachment figure, or if the securebond was directly established with God withinthe protective framework of the praying group.At the monastery, however, the attachment relationshipwas established with the Virgin Marythrough prayer. This was how she developed asecure relationship through which she was ableto identify herself with Saint Benedict, founderof the Benedictine order she wanted to join. Theconstruction of her monastic identity was shoredexclusively upon exemplary figures from the past.There was also a human religious figure, presentat her side: the novices’ superior. She representedboth an identification figure for Sister B., becauseshe entered the convent before her, and a possibleattachment figure, because she was dedicated tohelping the novices as a guide. At the convent,Sister B. built her identity by depending not onlyon saints’ figures, but also on the nuns around her,especially the novices’ superior, called “MotherSuperior.” In this role, the superior served as amother, an intermediary for attachment, andsimultaneously, as a sister, an intermediary foridentification.12.2. Case 2Ms. T. is 27 years old. She is a university student.She has been diagnosed as suffering fromschizophrenia following a social breakdown andhospitalization. Her parents are both nonpracticingMuslims. Her mother comes from an Arabiccountry and her father is English. The patientreports that she prays many times a day, alone athome, but that she never goes to the mosque. Shealso says that her beliefs help her find comfort,although she says she is not sure of her creed.“They are MY beliefs; I find it difficult to answeryour questions.” One of the present difficultiesshe identifies is failing her university exams.When in an exam setting, panic and anxiety preventedher from performing satisfactorily. Aftera period of treatment, she returned to her studiesand succeeded in passing the exams two years ina row. She says that prayer helped her to overcomeher panic and anxiety. During a controlsession, questions were asked about the form andthe content of this prayer to identify the copingprocess employed. It was obvious that the patientwas talking about her own act of prayer, and notabout others praying for her. It was also obviousthat she was talking about the act of prayer thatshe reports practicing many times a day. It wasnevertheless impossible to determine conclusivelywhat kind of prayer she was practicing:the ritual Muslim one, five times a day, or a morepersonal one. This case allows us to highlight twoapproaches to coordinating religion/spiritualitywith the self and with individual identity.First possibility : She draws her strength fromritual practice of Muslim prayer. In this case, itis the identification with a reference group thatstrengthens her personal identity. In stressfulsituations, the feeling of being a good Muslimmakes her feel secure. While not sure of herselfwhen articulating her beliefs, she could havefound a means of leaning on a firm point of reference:all Muslims recite prayers five times a day.Because her parents are not practicing followers,she doesn’t have the opportunity of being taken tothe mosque. Social breakdown is one of the characteristicsymptoms of schizophrenia. Recitingthe five prayers at home could be a means ofestablishing a link with a reference group andtherefore reducing the feeling of isolation. Fromthis point of view, the coping process can bedescribed as a support found in the possibilityof being like everybody else. The indications fortreatment would therefore consist in extendingthis process onto other ways of “being like everybodyelse.” Knowing that psychological illnesshas a tendency of being experienced as a loss ofcommonality with the other humans (“Am I normal?”),and knowing as well that the paranoia incertain ideas attack the consistency of the subject’sidentity, knowing that one is “like everybodyelse” can be reassuring. Of course, in a Westerncountry, practicing the daily five prayers does notpermit identification with the entire society. Thesubjects will identify themselves with the groupthey feel they belong to. By reciting the dailyprayers, Ms. T. can feel she belongs to the Muslimcommunity. Regarding her recovery, it could be

Self-Identity and Religion/Spirituality 169useful to attempt to extend this process to otherareas such as hobbies or clothing, for example.It remains to be seen whether the goal of havingthe same hobbies as other young people her age(Muslims or not Muslims), or dressing like otheryoung girls her age would help the patient fightagainst social breakdown and find more confidencein public and in interpersonal relations.Second possibility : Praying helps Ms. T. tomaintain contact with a reassuring figure, thatis, God. In this case, the content of the prayerdoes not necessarily consist in recited formulasbut perhaps rather in a private conversationwith God, or even a silent certainty of being incontact with the divine presence. Praying couldbe a means of recalling the security of previousexperiences, or it could be a kind of psychologicalenvelope created to finally achieve a secureself. From this point of view, the coping processwould result from the activation of the attachmentbond where the divine figure replaces the previousattachment figures. Indications for treatmentwould consist in encouraging the patient to prayevery time she feels nervous and begins to panic,especially when she is confronted with a feelingof emptiness.Being able to distinguish between these twoforms of praying is very important because theycall for distinct coping strategies. Of course, thesestrategies can be combined. During ritual prayer,the Muslim believer can both strengthen herfeeling of belonging to a community of believersand her relationship with Allah. It is also possiblethat praying combines the recitation of the fivedaily prayers with other more personal instancesof praying. It is also possible, however, that theypractice only one kind of praying, which essentiallyentails only one of the processes described.Therefore, if Ms. T.’s praying consists exclusivelyof reciting the five daily prayers, and she doesnot rely on them to experience a secure relationshipwith God, but rather to experience the reassuranceof praying properly and being a goodMuslim, there are strong chances that the suggestionto pray whenever she starts to panic willnot help. As a matter of fact, reciting the dailyprayers means reciting them at precise hours.As for the feeling of panic, it can surface at anytime of day. If, on the contrary, her praying is notcentered around the five daily prayers but ratheraround establishing contact with God at variousmoments throughout the day, especially duringtimes of panic, a “be like everybody else” copingstrategy would not apply. The suggestion to try tostrengthen her feeling of belonging with youngpeople her age by trying to be like them risks nothaving any effect because it is not directly linkedto the coping mechanism she has created throughprayer to face the panic of exams. This is why itwould be more judicious to suggest that she findstrength in prayer every time that she feels helplessduring the day and not only when dealingwith exams. (Later, it was found that this optionwas the correct one.)12.3. Case 3Mr. Z. is an immigrant worker of Muslim originfrom a nonpracticing family environment.When he left his country, he started usingcocaine and LSD. He also lost contact with allreligious Muslim influences. He stopped takingdrugs four years ago when he married a womanwho came to join him from his country of origin.Since then, two children have been born.He claims to have returned to religious practiceat the same time and has become very devotedto it. He goes to the mosque every Friday andrecites his prayers five times a day. He declares,“Thanks to religion, I don’t do anything foolishand I don’t sin.” He complains of auditory hallucinations,mainly insults, and of recurrentheadaches. When he prays, he is attacked by astrong desire to insult God. He stopped workinga few months ago, but is supported by socialservices. He spends a lot of time in bed and saysthat his wife complains about him not takingcare of the children. Regarding his recovery,the issue at hand is to help him take action. Themost important area in which an improvementwould be desirable for both the patient and hisfamily environment is the patient’s involvementin raising his children. We examined therole religion plays among the different resources

170 Pierre-Yves Brandt, Claude-Alexandre Fournier, and Sylvia Mohrat the patient’s disposal. Indeed, when questionedon what helps him confront the illness,the patient himself confirms that his religioustradition helps him in this regard. On the otherhand, when it comes to his role as a father, he ishelpless and very detached from his children. Hedoes not have a role model from his own experienceas a child, because his father died when hewas 2 years old. During a session with his doctor,it clearly appears that his renewed involvementin Islam has allowed this man to recreate his culturalenvironment. He stays at home most of thetime with his wife and children. His wife goesout very rarely. This environment gave his essentialidentity the necessary support to help himovercome the crises of quitting drugs and beingunemployed. This coping strategy, however, risksenabling a breakdown, which could in time furtherdamage his ability to support himself. Thechallenge lies in how he will assume his parentalresponsibility. It was suggested to his doctor thatMr. Z. be brought back to the religious imperative“I want to be a good Muslim,” an approachthat has helped him confront his difficulties forfour years. This involves asking Mr. Z. how hischoice of being a practicing Muslim connects tobeing a good father. One must remember thatIslam is passed on through the father and thereforethe father’s role in maintaining and perpetuatingthe religious tradition is important. Inother words, this means that being a father andraising children is linked to religious membership.If, as Mr. Z. confirms, getting back in touchwith Islam helped him face his difficulties, it isplausible that his difficulty in fulfilling his roleas a father could also be remedied with the helpof the religious references he relied on for otherissues. It could even be suggested to him that tryingto be a good father is not an optional activity,but a necessary consequence of his choice topractice Islam. It could then be suggested thathe reflect on what his religious tradition has tosay on this subject. Through the constructionof the paternal role, Mr. Z. was confronted witha transformation of identity. Owing to his personalhistory, he struggled to find a role model towhom he could refer. During the therapy session,there was a discussion on whether the returnto Islam for guidance on the paternal role wastruly religious in nature, or whether it was moreabout seeking reference to the cultural environmentof the country of origin. This would be anappropriate time to highlight that religion doesnot only involve intimate beliefs such as “Godexists,” “God loves me,” “God punishes me,” andso forth. On the contrary, religion also encompassesthe symbolic systems that humans havedevised to explain the meaning of life in relationto events in human existence. Such systemsoffer guidelines for all aspects of life and bringtogether beliefs and practices that are regulatedwithin various religious institutions.13. RELIGION CAN ALSO WEAKENIDENTITYAs we have already seen, religion/spirituality canhelp restore identity when facing threateningconditions such as those experienced by patientswith severe mental symptoms (that is, patientswith long-term disorders like schizophrenia).However, religious experiences can also disturband destabilize. For example, reproaches heardin a sermon could be understood as persecution,a missionary appeal read in a sacred book couldnourish delusions of grandeur, or the experienceof a ritual or meeting where all members startto adopt the same behavior could lead to theanguishing feeling of losing contact with oneself.Experiences of losing awareness of the distinctionbetween the self and the nonself, regardedby some as mystic experiences, could for othersbe very distressing and disturbing.(28) Evenwhen the religious dimension does not disturban individual, it does not necessarily favor theindividual’s autonomy. Hence, an attachmentrelationship experienced with religious figurescan be reduced to a mere displacement of theprimary relationship. Such a relationship thushas the effect of reinforcing a regressive attitude.From a therapeutic point of view, keeping a criticaleye on the role played by the religious dimensionin identity construction is thus important.When the religious dimension is a part of the

Self-Identity and Religion/Spirituality 171patient’s reference system, one must make surethat it favors the integration of all aspects ofidentity.14. MULTICULTURAL PERSPECTIVEFrom a multicultural perspective, the patient’sreference system – especially the conception ofthe self unique to this system – does not necessarilycoordinate well with the therapist’s modelof medical care and psychological health. Is therea risk of a conflict between two conceptions ofindividual identity? Under which circumstanceswould it be possible to establish a therapeuticalliance between the therapist and the patient’sreligious/spiritual (cultural) reference system? Itis the therapist’s responsibility to build this therapeuticalliance. In terms of roles, the therapeuticrelationship, in its basic structure, assigns themother’s role to the therapist. The therapist has tooffer the patient a protective vessel for his or hersuffering. This vessel refers back to a third party:the medical model of interpretation of psychologicaldisorders. When this medical model seemsincompatible with the patient’s reference system,it is up to the therapist to adjust the therapeuticrelationship to the patient’s reference system. Thefirst effort will be one of translation: an attempt tointerpret the functions, categories of a particularelement in the patient’s belief system, in terms ofthe medical system. First of all, this involves establishingthe foundation for the subject’s identitycohesion. Contrary to what seems evident to themodern Westerner and thus to Western medicine,individual identity does not rely on the constructionof a psychological core-self in every culture.In many cultures, the cohesion of the individualidentity, what protects the individual againstintrusions or mental breakdown, is collectivelyguaranteed by belonging to a group. The treatmentthen requires the therapist to take into considerationthis way of perceiving one’s relationshipwith oneself and to adapt the treatment by integrating,according to the specific case, the familyand cross- generational dimensions – sometimesincluding even relationships with ancestors andgods. It is not that the success of the therapeuticintervention depends on the therapist’s adherenceto the patient’s system of meaning. However, it isin the caregiver’s best interest to understand howthe patient interprets his or her actions and, if necessary,to suggest other interpretations. Medicaltreatment in a multicultural context requires theconstruction of a therapeutic framework basedon a conception of the self that is valid for thepatient. A proposal of therapeutic interventionthat compels the patient to completely forsake hisculture has little chance of success. Hence, it ismore about building an intervention frameworkthat draws support from the conception of the selfadhered to by the patients and that translates thepotential therapeutic course of action into termsof the patient’s identity construction. Such anapproach requires a lot of creativity. In the end, ifsuccessfully achieved, it will have brought abouta reorganization of the patient’s identity, integratingelements belonging to the patient’s cultureof origin and those originating in the therapist’smedical system.REFERENCES1. Ricoeur P . Soi-même comme un autre . Paris:Seuil ; 1990 .2 . Br an dt P Y . S e t rouve r d’ai l l e u rs c om m e p arsurprise. In: Mancini S , ed. La fabrication depsychisme: Pratiques rituelles au carrefour des sciencshumaines et des sciences de la vie . Paris: LaDécouverte ; 2006 :55–78.3 . Ste r n D . The Interpersonal World of the Infant:A View from Psychoanalysis and DevelopmentalPsychology . New York: Basic Books ; 1985 .4. Anzieu D . Le Moi-peau . Paris: Dunod ; 1995 .5. Ster n D . Le monde interpersonnel du nourisson:une perspective psychanalytique et développementale. Paris : PUF ; 1989 :21.6 . L apl an ch e J , Pont a l i s J B . Vocabulaire de la psychanalyse. Paris; PUF : 2002 (original ed. 1967).7. Cosnier J . Les vicissitudes de l’identité . In:A l le on AM , Mor v an O , L eb ov ic i S , e ds . Devenir« adulte » ? . Paris : PUF ; 1990 : 95 –111.8. Grom B . Religionspsychologie . München/Göttingen :Kösel/Vandenhoeck & Ruprecht ; 1992 .9. Bowlby J . Attachment and Loss (3 vol.) . Harmondsworth/Ringswood : Penguin Books ; 1991.10. Cyrulnik B . Un merveilleux malheur . Paris: OdileJacob ; 1999 .11. Tisseron S . La résilience . Paris: PUF ; 2007 .12. Abraham N , Torok M . L’écorce et le noyau . Paris:Flammarion ; 1987 .

172 Pierre-Yves Brandt, Claude-Alexandre Fournier, and Sylvia Mohr13. Ainsworth MDS . Attachments beyond infancy .Am Psychol . 1989 ; 44 : 709 –716.14. Kirkpatrick LA . Attachment and religious representationsand behavior. In: Cassidy J , Shaver PR , eds.Handbook of Attachment: Theory, Research, and ClinicalApplications . New-York: Guilford ; 1999 :803–822.15. Hazan C , Zeifman D . Pair bonds as attachments:evaluating the evidence. In: Cassidy J , Shaver PR , eds.Handbook of Attachment: Theory, Research, and ClinicalApplications . New-York: Guilford ; 1999 :336–355.16. Sroufe LA , Waters E. Attachment as an organizationalconstruct . Child Dev . 1977 ; 48 : 1184 –1199.17. Granqvist P , Hagekull , B. Religiosity, adult attachment,and why “singles” are more religious . Int JPsychol Relig . 2000 ; 10 : 111 –123.18. James W . Varieties of Religious Experiences . New-York: Longman Green ; 1902.19. Starbuck ED . The Psychology of Religion . New-York: Charles Scribner’s Son ; 1899 .20. Ulman C . Cognitive and emotional antecedentsof religious conversion . J Pers Soc Psychol .1982 ; 43 : 183 –192.21. Granqvist P , Hagekull B . Religiousness and perceivedchildhood attachment: profiling socializedcorrespondence and emotional compensation . JSci Stud Relig . 1999 ; 38 : 254 –273.22. Vergote A , Tamayo A , eds. The Parental Figuresand the Representation of God . The Hague [etc.]:Mouton ; 1981 .23. Rizzuto AM . The Birth of the Living God: APsychoanalytic Study . Chicago: University ofChicago ; 1979 (Trotta, 1999 ).24. Rizzuto AM . Object relations and the formationof the image of God . Br J Med Psychol . 1974 ;47 :83–99.25. Winnicott DL . Holding and Interpretation: Fragmentof an Analysis . New York : Grove ; 1968(1987).26. Le Breton D . Conduites à risques: des jeux de mortau jeu de vivre . Paris: PUF ; 2002 .27. Sundén H . Die Religion und die Rollen: Eine psychologischeUntersuchung der Frömmigkeit . Berlin:Töpelmann ; 1966 .28. Hulin M . La mystique sauvage . Paris: PUF ; 1993 .

13 Personality, Spirituality, Religiousness, and the PersonalityDisorders: Predictive Relations and Treatment ImplicationsRALPH L. PIEDMONTSUMMARYThe purpose of this chapter is to demonstrate theconceptual and empirical value of religious andspiritual constructs for understanding and treatingindividuals with a personality disorder. Usingthe Five-Factor Model of Personality (FFM)as the organizing framework, it was shownthat spirituality and religiousness (collectivelyreferred to as numinous constructs) representqualities not redundant with the FFM domainsand are universal aspects of functioning. Thesenuminous constructs have a causal impact onpsychosocial functioning. The value of spiritualityand religiousness in treating those with apersonality disorder lies in the anti-narcissisticaspects of the numinous. Spirituality calls us tosee larger patterns and relationships that bringforth greater honesty and intimacy with others.The therapeutic value of spirituality is overviewedin the treatment of borderline, narcissistic, antisocial,and schizotypal disorders. Other potentialclinical values for spirituality in treating theremaining disorders are discussed.1. INTRODUCTIONAccording to the Diagnostic and Statistical Manualof Mental Health Disorders, Fourth Edition (DSM-IV ), (1) a personality disorder (PD) represents arigid and ongoing pattern of thoughts and behaviorsthat deviate markedly from the expectationsof the culture of the individual who exhibitsthem. These patterns are inflexible, nonadaptive,and consistent across many situations and representdisturbances in at least two of the following:cognitions, affect, interpersonal functioning, andimpulse control. Although these dysfunctionsrepresent deviations from expected norms, individualswith a PD do not see their eccentricities asproblem inducing, despite the fact that they mayexperience significant distress or impairment insocial, occupational, or intrapsychic functioning.Overall prevalence rates vary for the PDs in generaland for each specific PD depending on the nationexamined, the region of the country (that is, urbanvs. rural), and gender. Samuels et al. (2) noted in aU.S. community sample an overall prevalence of 9percent. Unmarried men with a high school educationor less were most vulnerable. Similar findingswere noted by Torgersen, Kringlen, and Cramer (3)using a representative sample of Norwegians. Theyfound a 13.4 percent prevalence rate, again withsingle, unmarried individuals being most at risk.Torgersen et al. also provided a review of ten otherstudies conducted in the United States and Europethat found rates for PDs ranging from 5.7 percentto 22.5 percent (median prevalence of 11.1 percent).Finally, Maier, Lichtermann, Klingler, and Heun (4)found with a German sample a 10 percent prevalencerate. Overall, it seems reasonable to concludethat approximately 10 percent of the general populationmay suffer from a PD.This is a rather large percentage of individuals,and such human volume carries with it significantcosts not only in terms of pain, suffering,and impaired functioning, but also economically,in dollars and cents. A number of studies haveexamined the actual social and economic costs ofthe treatment of individuals with PDs, and valuescan range into the tens of thousands of dollars inlost work productivity, health care, and treatmentcosts.(5, 6) Fortunately, however, psychotherapy173

174 Ralph L. Piedmontdoes offer an option to help individuals with PDsto cope better with their circumstances and toreintegrate back into society. Bartak, Soeteman,Verheul, and Busschback (7) found in their literaturereview that psychotherapy can be quite effectivein treating PDs, evidencing a large statisticaleffect in comparison to control groups. Gabbard,Lazar, Hornberger, and Spiegel (8) found thatpsychotherapy has a beneficial economic effectwhen used in the treatment of severe PDs byreducing long-term costs for inpatient care andwork impairment.Although help for characterological impairmentis available, improvements in psychotherapycan be made and efficacy rates can beincreased. To advance, treatment requires agreater understanding of the PDs, the factors thatcontribute to their development, and identificationof new personological resources that can beexploited in treatment. The purpose of this chapteris to provide a new perspective on PDs fromthe vantage point of the Five-Factor Model ofPersonality (FFM). The origins and developmentof this model will be presented, and its relationshipto the personality disorders will be outlined.Readers will then be introduced to the realm ofthe numinous. The term numinous refers to thegeneral dimension of psychological constructsassessing that which is considered hallowed,sacred, and awe-inspiring, such as spiritualityand religiousness. The relationship of these typesof variables to the FFM will be outlined, and theirvalue as empirically viable constructs reviewed,especially as they relate to PDs . The role of thesenuminous constructs for understanding the PDsand implications for treatment will be discussed.To understand personality dysfunction, oneneeds to understand those motivational qualitiesthat constitute the personality.2. DEVELOPMENT OF THEFIVE-FACTOR MODEL OF PERSONALITYLiterally thousands of personality trait variablesare available today in hundreds of differentinventories and scales. Such a cornucopiaof constructs can easily lead to confusion whendeciding which traits to use. Fortunately, recentresearch has discovered that the majority of thesetraits cluster themselves around five broaderdimensions known as the Five Factor Modelof Personality (FFM).(9) These “Big Five” factorsare: neuroticism , the tendency to experiencenegative affect; extraversion , which reflectsthe quantity and intensity of one’s interpersonalinteractions; openness to experience , the pro activeseeking and appreciation of new experiences;agreeableness , the quality of one’s interpersonalinteractions along a continuum from compassionto antagonism; and conscientiousness , the persistence,organization, and motivation exhibited ingoal-directed behaviors.(10) Research has shownthat these five dimensions do provide a usefullanguage for talking about trait variables and thatthese factors do predict a wide range of importantpsychosocial outcomes, including mentaland physical health, occupational, academic, andintrapersonal criteria.(11)These five dimensions have shown themselvesto represent a rather comprehensive taxonomy ofpersonality traits. A taxonomy is simply a frameworkfor classifying things on the basis of theirsimilarity. To accomplish this, one needs to identifyall the necessary qualities that distinguishthe entities that are to be classified, and thesedistinguishing characteristics must be mutuallyexclusive. In the FFM, each of the domainsis independent of the others, and research hasshown that these dimensions appear to representthe majority of variance found in most personalitymeasures. Table 13.1 provides a short overviewof this work.A number of studies have evaluated the degreeto which these five personality dimensions overlapwith psychological constructs from differenttheoretical models. Simply put, these studies askedthe question, “Are the qualities represented by thedimensions of the FFM the same as those foundin other scales, or do they represent somethingdifferent?” As can be seen in Table 13.1, whetherusing a measure of Murray’s needs, Gough’s folkconcepts, Jungian typologies, interpersonal behaviors,or vocational interests, the dimensions of theFFM are present among these theoretically diverse

Personality, Spirituality, Religiousness, and the Personality Disorders 175Table 13.1: Bibliography of Joint Analyses Using the Dimensions of the FFM.Instrument Construct Measured FindingsAdjective Check List Murray’s needs, Folk constructs All five factors foundBasic Personality Inventory Normal personality domains All five factors foundCalifornia Psychological Inventory Folk constructs, normal personality Agreeableness under-representedEdwards Personal Preference Schedule Murray’s needs All five factors foundEysenck Personality Profiler Biologically based personality constructs No openness foundGuilford-Zimmerman Temperament Survey Trait personality constructs All five factors foundMCMI I & II Axis II constructs All five factors foundMMPI Axis I constructs Openness not well representedMyers-Briggs Type Indicator Jungian personality constructs Neuroticism not foundPersonality Research Form Trait personality constructs All five factors foundSelf-Directed Search 3 Vocational interests Neuroticism not well represented16PF Trait personality constructs All five factors foundAdapted from Piedmont RL. The Revised NEO Personality Inventory: Clinical and Research Applications. New York: PlenumPress; 1998. With kind permission of Springer Science and Business Media.instruments. A large literature has developedshowing that the dimensions of the FFM are quitecomprehensive and represent the essence of whatis traditionally considered “personality.”Research has shown that the FFM dimensionsare linked to one’s genetic makeup, about onehalfthe variance observed in traits is inheritedfrom our parents. Traits also have been shown togeneralize cross culturally, so the same patternsin behaviors, attitudes, and actions we see inWestern culture are also found to occur in othercultural contexts, such as in Asia and Africa.Traits represent human universals for understandingbehavior.(12) Perhaps the most intriguingaspect of research on traits has been thediscovery that one’s trait profile does not changein adulthood. After age 30, all things being equal(for example, no psychotherapy or religious conversions),personality seems to be pretty muchset; our trait dispositions will remain stable overour adult lives. The value of this finding is thatonce someone’s trait standing is known, accuratepredictions about his or her behavior can bemade well into the future. However, until age 30,personality is still in flux and capable of modification.But after 30, an adaptive orientation to theworld emerges that leads us to pursue personalgoals that are the most satisfying to our needs(for example, the achievement-oriented personwill seek out competitive situations, the extravertwill seek out the company of others). Thus,the dimensions of the FFM represent genotypicaspects of the individual, biologically based entitiesthat govern the course of adult strivings.The value of the FFM is twofold. First, the FFMprovides an efficient framework for organizingpersonality-related issues around these fivedimensions. The personological qualities associatedwith these dimensions have been nicelyoutlined for both normal and clinical samples.(11, 13) For example, neuroticism has been linkedwith risk for a psychiatric disorder and burnout;extraversion and agreeableness define interpersonalstyles; openness to experience relates tocuriosity, empathy, and dogmatism; and conscientiousnessis related to achievement outcomesin school, work, and athletic environments. Thus,to obtain a comprehensive assessment of an individual,a clinician would want to make sure thatany measure contains information from all thesedomains.The second value of the FFM is that it providesstraightforward, clear language for describingand discussing personality-related information.The dimensions of the FFM provide a sort oflatitude and longitude for understanding personalityconstructs. By mapping scales from differentmeasures onto these five factors, one can understandsimilarities and differences among theconstructs. Correlations with the FFM dimensionscan be the personological fingerprint for ascale; an indication of those qualities reflected in

176 Ralph L. Piedmontits score. This parsing ability is perhaps the mostimportant feature of the FFM. It enables oneto avoid what Block (14) has referred to as the“jingle and jangle fallacies.” These terms refer to,respectively, the tendency to see scales as beingsimilar, or different, on the basis of their labelrather than on any empirical evidence. The formerterm sees convergence where none may exist,and the latter term allows useless redundancy todevelop. Perhaps the least useful place to lookfor a scale’s meaning is its name. Unfortunately,these “fallacies” too often characterize the field ofassessment.One case in point relates to research thatexamined the relationship between Type Apersonality styles and coronary heart disease(CAD). The Type A Behavior Pattern (TABP)was an identified aspect of personality that wasrelated to actual physical illness.(15) The timepressured,high-achieving, hyper-alert mentalcondition that characterized the TABP seemedto lead men to develop fatal heart problems.Although early research was supportive of thelink between TABP and CAD, later studies failedto find consistent relationships between the personalitystyle and health. What was identifiedas the “toxic component” to CAD was angerand hostility. Individuals having problems withexpressing anger in healthy ways seemed mostat-risk. But even here, the relationship was notalways observed; some measures of anger seemedto predict CAD, but others did not. It was notuntil various measures of anger were examinedwithin the context of the FFM that the puzzle wasfinally solved.It turned out that there are two types of anger.One type, characterized by emotional outburstsof screaming, yelling, and emotional upset isfrequently seen when someone gets frustrated oris provoked by another. The other type of angerdoes not show any type of negative emotionalarousal but rather reflects the malevolent attitude,“You hurt me and I will hurt you more.”One type of anger is affective in nature and theother more interpersonal and attitudinal. Whencorrelated with the FFM measures, the first typerelated strongly with neuroticism (reflecting thepresence of negative affect), while the secondtype correlated with low agreeableness (reflectinga very cynical, self-centered, mistrustful orientation).Surprisingly, it is the second type ofanger, related to low agreeableness that is relatedto CAD.(16) By mapping these measures of angeronto the dimensions of the FFM, we were ableto develop a more sophisticated and nuancedunderstanding of what is meant by anger .Although there are many scales that carry thelabel anger , they are not all measuring the sameconstructs. There are different types of anger,each with their own very different psychologicaland health-related implications. The FFM helpsus to clarify what our constructs measure andgives us a language for thinking more preciselyabout personality.3. THE FFM AND THE PERSONALITYDISORDERSBecause PDs represent enduring patterns thatcharacterize an individual’s long-term functioning,it seems reasonable to conclude that suchmaladaptive patterns would be related to one’sunderlying personality structure. Much has beenwritten concerning the linkages between the FFMand the PDs and the numerous conceptual issuesassociated with these comparisons (see Costa &Widiger (17) for an overview). Suffice it for ourpurposes to note that associations between theFFM and the PDs provide two points of interest.First, associations between these two sets of constructsdemonstrate that personality disordersrepresent more extreme variants of the normalpersonality dimensions. The FFM dimensionsrepresent a robust and economical set of personologicalqualities that are useful for understandingadaptive and nonadaptive aspects offunctioning. Second, the pattern of correlationsbetween the FFM domains and the PD dimensionscan, as noted above with anger, help toelaborate the kinds of temperaments underlyingthese disorders. Such information can facilitatedifferential diagnosis and enhance therapy byidentifying relevant etiological factors and anticipatingtreatment issues.

Personality, Spirituality, Religiousness, and the Personality Disorders 177Table 13.2: Partial Correlations Between SCID-IIP Screener Scales and FFM PersonalityDomains Controlling for Acquiescence.FFM Personality DomainSCID-IV PD ScaleN E O A CAvoidant .50*** –.52*** –.19*** –.08 –.17**Dependent .43*** –.12 –.17** –.03 –.32***Obsessive-Compulsive .32*** –.09 –.08 –.30*** .24***Passive-Aggressive .60*** –.23*** –.06 –.47*** –.33***Depressive .64*** –.41*** .04 –.36*** –.23***Paranoid .52*** –.31*** .00 –.55*** –.21***Schizotypal .29*** –.19*** .21*** –.31*** –.20***Schizoid .10 –.36*** –.11 –.22*** –.15**Histrionic .19*** .37*** .14 –.22*** –.17**Narcissistic .33*** .00 .06 –.56*** –.16**Borderline .66*** –.22*** .07 –.48*** –.38***Antisocial 1 (Adult Behavior) .32*** –.01 .10 –.51*** –.42***Antisocial 2 (Youth Behavior) .21*** –.05 .15** –.39*** –.23***N = 302Note: N = Neuroticism, E = Extraversion, O = Openness, A = Agreeableness, C = Conscientiousness.*** p < .001, ** p < .01, p < .05, two-tailedAdapted from Piedmont RL, Sherman MF, Sherman NC, Williams JEG. A first look at the DSM-IV structuredclinical interview for personality disorder screening questionnaire: more than just a screener? Meas Eval Couns Dev.2003;36:150–160.Table 13.2 provides the results of one studythat correlated scores from the Structured ClinicalInterview for DSM-IV Personality DisordersScreening Questionnaire (SCID-IIP) (18) and theFFM personality domains.(19) (Data are providedto show heuristic support for the arguments beingmade here. However, familiarity with interpretingpartial correlations is not essential for understandingthe points being made in the text. Readers soinclined can skip any review of the tabled data.)The SCID-IIP is a self-report questionnaire thatcontains the diagnostic items for each of the PDs.Individuals rate on a 1 to 5 scale the extent towhich each behavior is self- descriptive (for example,Do you often feel nervous when you are withother people?). These data were based on a studentsample of 302 individuals and are representativeof findings from other studies using otherinstruments. (Saulsman and Page (20) provide ameta-analysis of these relationships.) Two pointsof interest emerge from Table 13.2. First, all thePD scales correlate with at least one of the FFMdomains. Thus, characterological dysfunctioningcan be seen as a more extreme variant of the normaldimensions of personality. Particularly (high)neuroticism and (low) extraversion are moststrongly related to the PD scales, indicating thataffective dysphoria and social withdrawal are keycomponents to impairment regardless of how itis categorized. Agreeableness and conscientiousnessare also related, indicating a selfish, impulsiveorientation behind many of the PDs. Interestingly,openness has only a few points of overlap, indicatingthat qualities associated with permeability andrigidity are less strongly reflected in the current setof nosological definitions.A careful examination of each PD scale’srelation ship to the FFM domains also providesimportant insights into the personologicaldynamics of each disorder. For example,consider the FFM correlations for the avoidantPD scale. Notice, those who score high on thisscale also score high on neuroticism and low onextraversion. The low extraversion (that is, introversion)makes sense for this group. They tendto avoid contact with others and prefer a more

178 Ralph L. Piedmontsolitary orientation. The positive correlation withneuroticism indicates that these individuals arealso anxious and distressed; they avoid groupsbecause they may fear negative evaluations byothers or making social blunders. Those with anavoidant PD possess a clear social phobia thatmay underlie their withdrawal. Next, considerthe correlations found with the schizoid PDscale. Here is another disorder that is characterizedby social withdrawal and isolation. Like theavoidant PD, the schizoid PD also scores low onextraversion, reflecting the desire for privacy andseclusion. However, the schizoid scale does notcorrelate with neuroticism, indicating that thosewith a schizoid PD, unlike the avoidant PD, donot systematically experience social phobia as acause of their withdrawal. Those diagnosed as aschizoid are not necessarily threatened by groupsnor do they fear social contact in the ways thatthose with an avoidant PD do. Given that thesetwo types of disorders may present in similarways, knowing individuals’ scores on these FFMdomains can be quite helpful in making a differentialdiagnosis.The FFM provides a useful empirical andinterpretive framework for understanding awide range of psychological functioning and canbe useful in highlighting motivational qualitiesrelevant in diagnosis and treatment. Miller, (13)drawing on information from his own clients,provided useful clinical information into howindividuals high and low on each of the five personalitydomains would present themselves intherapy. He also outlined some of the key problemsthese clients were likely to experience alongwith potential treatment opportunities and pitfalls.For example, individuals high on neuroticismpre sent themselves with a variety of negativeaffects. Their presenting problems span the fullspectrum of neurotic pains. Such individualsmay always experience personal pain regardlessof how much therapy they receive, although suchemotional distress can certainly motivate patientcompliance with treatment. Miller also noted thatthose low on neuroticism and high on conscientiousnesshad better ratings of treatment outcome.In a study of outpatient substance abusers, I notedthat those high on neuroticism benefited fromclient-centered therapy and systematic desensitization,while problem-solving advice was notseen as effective with these types of clients. Thosehigh on agreeableness responded well to the AAand NA programs, while those low on agreeablenessresponded well to relaxation sessions, arttherapy, and journaling.(11) The FFM has muchto offer our understanding of Axis II functioning(i.e., PD clinical presentations).The question that we come to now concernshow spirituality and religiousness fit into thismodel. A number of important issues will beraised in the following sections that concern whatadded value these constructs bring to our understandingof Axis II functioning over the FFM.But first, these constructs need to be defined inways that are amenable to scientific analysis.4. DEFINING AND MEASURINGSPIRITUALITY AND RELIGIOUSNESSBecause spirituality and religiousness are seen bymany as being conceptually overlapping, in thatboth involve a search for the sacred, (21) someresearchers prefer to interpret these two dimensionsas being redundant.(22) Musick, Traphagan,Koenig, and Larson (23) have noted that insamples of adults, these two terms are highlyrelated to one another. They questioned whetherthere is a meaningful distinction between thesetwo constructs or if any disparities are simplyan artifact of the wishes of researchers hopingto find such differences (p. 80). Nonetheless,there are those who emphasize the distinctivenessbetween these two constructs.(24, 25) Here,spirituality is viewed as an attribute of an individual(much like a personality trait) while religiosityis understood as encompassing more ofthe beliefs, rituals, and practices associated withan institution.(26) Religiosity is concerned withhow one’s experience of a transcendent being isshaped by, and expressed through, a communityor social organization. Spirituality, on theother hand, is most concerned with one’s personalrelationships to larger, transcendent realities,such as God or the universe. In an effort to

Personality, Spirituality, Religiousness, and the Personality Disorders 179operationalize these two constructs in a mannerthat would solidly ground them in mainstreampsychological theory and measurement, I createdthe Assessment of Spirituality and ReligiousSentiments (ASPIRES) (27) scale. In this measure,there is a single broad dimension that capturesthe spirituality domain and two scales that assessthe religiousness domain. Each will be discussedin turn.In the ASPIRES, spirituality was defined asan intrinsic motivation of individuals to createa broad sense of personal meaning within aneschatological context. In other words, knowingthat we are going to die, spirituality representsour efforts to create meaning and purpose for ourlives. This need for meaning is seen as an intrinsic,universal human capacity.(25) The scale assessingspirituality is named the Spiritual TranscendenceScale (STS). The STS was developed to capturethose aspects of spirituality that cut across all religioustraditions (see Piedmont (27) for how thisscale was developed). This unidimensional scalecontains three correlated facets: Universality , abelief in the unity and purpose of life; PrayerFulfillment, an experienced feeling of joy and contentmentthat results from prayer and/or meditation;and Connectedness a sense of personalresponsibility and connection to others.In contrast to spirituality, religiousness is notconsidered to be an intrinsic, motivational construct.Rather, it is considered to represent a sentiment. Sentiment is an old term in psychology andreflects emotional tendencies that develop out ofsocial traditions and educational experiences.(28)Sentiments can exert a powerful influence overthoughts and behaviors, but they do not representinnate, genotypic qualities like spirituality. Thatis why the expression of sentiments (for example,religious practices) can and does vary over timeand across cultures. There are two measures ofreligious sentiments on the ASPIRES. The firstis the Religiosity Index (RI). The RI examines thefrequency of involvement in religious rituals andpractices (for example, how often does one pray,how often does one attend religious services). Italso queries the extent to which religious practicesand involvements are important. ReligiousCrisis (RC) is the second measure and examinesthe extent to which an individual feels alienated,punished, or abandoned by God (for example, Ifeel that God is punishing me). What is of interestabout these items is that they address the negativeside of religiousness, when faith and beliefbecome sources of personal and social distress.This scale enables an examination of the extent towhich disturbances in one’s relationship to Godcan affect one’s broader sense of psychologicalstability.The five ASPIRES scales (the three facet scalesof the STS plus the two religious sentimentsscales) provide a relatively comprehensive assessmentof the numinous dimension. Compared tomost measures in this field, the ASPIRES has arather large and comprehensive body of validityevidence. The increasing popularity of theASPIRES can be attributed to its ability to addresscritical empirical questions about the utilityof any measure of spirituality or religiousness.The next section will outline the four key validityissues and why the ASPIRES is an importantmeasure for understanding normal and clinicalaspects of psychological functioning.5. FOUR KEY VALIDITY ISSUESFOR THE ASPIRESPerhaps the single most important question tobe asked of any measure of spirituality and religiousnessis whether the construct representssomething unique about the individual. Criticsof spiritual research are concerned that numinousconstructs are only the “parasitization” ofalready existing personality variables.(29) To beof value, measures of the numinous need to demonstratethat they capture nonredundant aspectsof the individual and therefore provide insightsinto functioning that are missed by current psychologicalconstructs. A number of studies havejointly factor-analyzed the ASPIRES scales alongwith measures of the FFM and have consistentlyshown that the two sets of constructs are mutuallyindependent.(24, 30) Thus, spirituality canbe argued to represent the sixth major personalitydomain.(24)

180 Ralph L. PiedmontKnowing that spirituality and religiousnessrepresent unique personological qualities, thesecond key issue is to demonstrate that thesenuminous constructs are related to importantpsychosocial criteria over and above the predictivepower of established personality constructs. Inshort, to what extent do spiritual scales evidenceincremental validity over the FFM domains? Agrowing literature continues to document that theASPIRES scales do indeed predict a wide rangeof outcomes over and above the FFM personalitydomains in both normal (24, 27) and clinicalsamples.(31) The data further demonstrated thatwhile both the spiritual and religious sentimentsscales predict some outcomes in common (forexample, Satisfaction with Life, Self-Actualization,and Purpose in Life), these constructs also evidencedincremental validity over each other.In some instances, the STS was the sole predictorof outcomes (for example, Positive Affect,Individualism, and Social Support), while inother instances the religious sentiments scaleswere the only predictors (for example, Attitudestoward Sexuality, Negative Affect, and Pro-socialBehavior). Thus, although these two types of constructsare highly correlated, they do have sufficientunique predictive power to warrant theiruse as separate scales. These data suggest that differentpsychological systems mediate the expressionof spirituality and religiousness.The third major validity issue addresseswhether spirituality is indeed a universal aspectof human functioning. It has long been knownthat the majority of measures designed toassess spirituality are rooted in Christian-basedperspectives, (32) reflecting mostly a mainlineProtestant orientation.(33) Is the STS simply ameasure of this ideology or would non- Christianindividuals and those from other cultures findthese concepts relevant? Research using theASPIRES with non-Christian groups (for example,Jewish, Hindu, and Muslim) and across cultures(for example, India, Korea, Philippines, andMexico) continues to find the scales and theirrelated constructs to be reliable and valid withthese diverse groups.(25 , 34–36) The fact that thespiritual concepts in the ASPIRES can be readilytranslated into languages sharing no commonroot history with English strongly supports theuniversal salience of these ideas. Only genotypicqualities can evidence such cross-culturalgeneralizability.Th e final, and perhaps most essential, issueconcerns the ultimate nature of the relationshipbetween spirituality, religiousness, andpsychological functioning. As Emmons andPaloutzian (37) (pp. 392–393) noted, “We donot yet know whether personality influences thedevelopment of religiousness…, whether religiousnessinfluences personality…, or whetherpersonality and religiousness share commongenetic or environmental causes.” If one’s orientationto the numinous develops out of one’ssense of personhood, then it is the level of psychologicaladjustment that forms the experiencesof the numinous. Like any other behavior,relationships with some ultimate reality arereflections of more basic psychological dynamics.However, if spirituality and religiosity havea causal impact on our psychological system,then these variables become important conduitsthrough which growth and maturity canbe focused. In this scenario, the quality of one’srelationship to the transcendent has importantimplications for our own psychological senseof stability. Disturbances in our relationship tothe transcendent can have serious repercussionsfor the rest of our system. Demonstrating thatnuminous constructs serve as causal inputs intoour psychic systems would have far reachingimplications for how the social sciences conceptualizeindividuals and would open the possibilityfor a whole new class of potential therapeuticstrategies.(38)Employing structural equation modeling(SEM), a growing number of studies are examiningwhich of these two options is more likelycorrect.(39) Piedmont (40) showed in both U.S.and Filipino samples, and with self- and observerratings, that spirituality (as measured by the STS)was best described as a causal input into ourpsychological sense of emotional well-being.Our relationship with a perceived transcendentreality has important implications for our inner

Personality, Spirituality, Religiousness, and the Personality Disorders 181sense of emotional stability. It has also been demonstratedthat spirituality was a causal predictorof psychological growth and maturity.(39)Further, spirituality was shown to be a predictorof religious involvement. Certainly these findingshave far-reaching implications for how the socialsciences conceptualize individuals and openthe possibility for the development of a wholenew class of potential therapeutic strategies thatinvolve numinous-related motivations.Given the empirical robustness of the ASPIRESscales and their relatedness to emotional stability,it is a reasonable next step to examine how theseconstructs relate to Axis II functioning. Are theysignificant causal predictors of characterologicaldysfunctioning? Can disturbances in our relationshipwith the transcendent create intrapsychicconflicts? Or, does the development of mental illnessundermine spiritual and religious strivings?6. SPIRITUALITY, RELIGIOUSNESS,AND PSYCHOPATHOLOGYAs noted above, the majority of research withnuminous constructs has focused on generalfactors of well-being and life satisfaction. Whenresearch includes clinical dimensions, they aremostly affective in nature (for example, depression,anxiety, and hopelessness).(41) Findingshere show significant relationships betweennuminous constructs and affective dysphoria.An epidemiologic survey of Canadians showedthat religious involvement was related negativelyto depression.(42) MacDonald and Holland (43)examined the relationship between measures ofspirituality and religious involvement with theMinnesota Multiphasic Personality Inventory-2(MMPI-2) scales. In general, involvement inreligious activities and higher levels of spiritualitywere associated with lower levels ofpathology. Interestingly, both studies found thatreligious involvement was a better predictor thanspirituality.Very little research has been done examininghow explicit psychopathologic variables (forexample, symptom dimensions and diagnosticcriteria) are related to spiritual and religiousconstructs. One study examined the relationshipbetween symptom scores and spiritual well-beingin a sample of African-American patients with afirst-episode schizophrenic disorder. Consistentwith the literature for nonclinical samples, therewas a negative correlation between these twosets of constructs.(44) Carrico et al.(45) applieda path model to examine the role of spiritualityon depressive symptoms in HIV-positive persons.They found that a model specifying spiritualityas a causal input (albeit an indirect effect)into the experience of depressive symptoms fitthe data well. In contrast to the above research,both of the studies found spirituality negativelyrelated to symptom experiences. Lavin (46)employed a cross-lagged panel design to demonstratein a sample of adults that negative imagesof God (that is, high on neuroticism and lowon agreeableness) led to higher self-ratings ofsymptomological distress over time. Althoughthese studies provide support for the causal precedenceof numinous constructs, it remains yetto determine the power of religious involvementand spirituality relative to each other in predictingsymptom experience.Piedmont, Hassinger, Rhorer, Sherman,Sherman, and Williams (47) provided the onlyknown data linking measures of spirituality andreligiousness to Axis II constructs. The relationshipbetween the five ASPIRES scales and two measuresof Axis II functioning (the SCID-IIP PD Scalesdescribed above and the Schedule for Nonadaptiveand Adaptive Personality [SNAP (48) ]) were examinedwhile controlling for the predictive effectsof the FFM personality domains. SEM analyseswere also conducted comparing different modelsthat varied the causal relationship between thetwo sets of constructs. Because the findings weresimilar for both Axis II measures, only the resultswith the SCID-IIP PD scales will be discussedhere. The data for these findings are based on theresponses of 342 undergraduate volunteers froma midwestern state university.Table 13.3 presents the partial correlationsbetween each of the ASPIRES scales and theSCID-IIP PD scales, controlling for the predictiveeffects of personality. Thus, these coefficients

182 Ralph L. PiedmontTable 13.3: Partial Correlations Between the SCID-IIP Axis II PD Scales and the ASPIRESSpirituality and Religious Sentiments Scales Controlling for FFM Personality Domains.SCID-IV PD ScaleASPIRES ScalePF UN CN R RCParanoid –.05 –.07 .04 –.07 .16** .03*Schizoid –.01 –.03 –.13* .03 .15** .04**Schizotypal .16** .15** .04 .08 .15** .07***Antisocial-Adult –.15** –.11* –.02 –.25*** .21*** .08***Antisocial-Youth .10 .10 –.01 .15** –.03 .03*Borderline –.11 –.06 .02 –.17** .26*** .06***Histrionic .01 .07 .01 –.02 .13* .01Narcissistic –.07 –.01 –.04 –.09 .16** .06***Avoidant –.14* –.12* –.10 –.09 .16** .02*Dependent –.02 –.05 .00 –.02 .07 .01Obsessive-.18*** .11* .03 .24*** .00 .06***CompulsivePassive-Aggressive .01 –.01 .00 –.03 .22*** .05***Depressive –.10 –.14* –.09 –.12 .23*** .05***ΔR 2 .14*** .12*** .07* .17*** .11***ΔR 2N = 342. p < .05; ** p < .01; *** p < .001, two-tailed. PF = Prayer Fulfillment, UN = Universality, CN = Connectedness,R = Religiosity Index, RC = Religious Crisis.Note: Correlations in bold indicate a significant predictor in the regression analysis.Adapted from Piedmont RL, Hassinger CJ, Rhorer J, Sherman MF, Sherman NC, Williams JEG. The relations amongspirituality and religiosity and Axis II functioning in two college samples. Res Soc Sci Stud Relig. 2007;18:53–74.reflect the unique overlap between the numinousscales and Axis II functioning. There are fourpoints of interest here. First, with the exceptionof the dependent scale, all the PD scales correlatewith at least one of the ASPIRES scales. Thenuminous constructs relate to almost the entirespectrum of disorders. Second, the two religioussentiments scales appear to have more numerousassociations, and of higher magnitude, thanthe STS facet scales. Thus, learned religious sentimentsmay be more salient for understandingAxis II issues than spiritual motivations. Third,two series of regression analyses were performedto obtain the amount of overlapping variance.The last row of Table 13.3 indicates the amountof unique variance that each of the ASPIRESscales has in common with all of the SCID-IIPPD scales once the influence of personality isremoved. As can be seen, the PD scales explainfrom 7 percent to 17 percent of the variance ineach ASPIRES scale. These would be consideredvery large effect sizes.(49) Finally, the last columnin the table evaluates the amount of uniqueshared variance between each PD scale and thefive ASPIRES scales, controlling for the predictiveeffects of personality. In all but two instances(the Histrionic and Dependent PD scales), theASPIRES scales uniquely account for a significantamount of variance in each PD scale(from 2 percent to 8 percent). The magnitude ofthese effects would be considered moderate tostrong. The bolded correlations indicate thosescales that emerged significant in the regression.It is interesting to note that the religioussentiments scales were the consistent predictorswhile the STS facet scales tended to drop out ofthe analyses.(50)Th e second phase of this study was to applySEM to evaluate models that varied the causalrelations between the ASPIRES scales and thePD scales. Model 1 examined the causal impactof both personality and spirituality on Axis IIfunctioning. Model 2 examined the causalimpact of both personality and religious sentimentson Axis II functioning. Model 3 reversedthe causal sequence and evaluated the impact of

Personality, Spirituality, Religiousness, and the Personality Disorders 183personality and Axis II functioning on religioussentiments.The results indicated that the data had modestfit with Model 1. Interestingly, the pathway fromspirituality to Axis II functioning was nonsignificant.This indicated that Spiritual Transcendencedoes not have any substantive relationship withthis outcome. Thus the observed correlationspresented in Table 13.3 above can be attributedto method artifacts in the data (for example, thereliance on all self-report data and sample specificerror). The results for Model 2 indicated muchbetter fit of the data to the model. The pathwayfrom religious sentiments to Axis II functioningwas significant, indicating that one’s religiousinvolvements do have a significant, uniquecausal impact on characterological impairment.Model 3 had the worst fit of all, indicating thatreligious sentiments being a consequence of one’spersonality and temperamental dysfunctionalityis not very likely. That this pattern of findings wasalso replicated with the SNAP PD scales providesstrong support for the position that individualswho are not actively involved in the religiouspractices of their faith and also are experiencingdistress in their relationship with a transcendentbeing are likely to develop psychologicalinstability.(46) It is important to note that theserelationship problems with the transcendentare not a function of one’s innate interpersonalstyle (qualities of personality), nor a function ofinterpersonal impairment due to the personalitydisorder dynamics. The predictive power of theReligious Sentiments scales was not mediated bythese other related constructs. There appears tobe something unique about the relationship withthe transcendent that affects one’s affective andcognitive processes.The independence of spirituality from Axis IIfunctioning raises the possibility that spiritualitymay serve as an important personologicalresource for treatment of PDs. Spirituality’s lack ofinvolvement in the pathognomonic process suggeststhat these motivations may not be distortedor impaired among individuals with Axis IIissues. In other words, individuals experiencinga personality disorder do not necessarily havean impaired spirituality. Although its expressionmay appear odd or unusual in relation to moretraditional presentations, it nonetheless can providethe individual with an important adaptiveresource. Thus, working with spirituality aroundissues of transcendence may be able to providea more realistically based set of perceptions andbeliefs that can be therapeutically useful.7. THE ROLE OF SPIRITUALITYIN TREATING PERSONALITY DISORDERSThe emphasis of this section will be on how spirituallyrelated constructs can be deployed therapeuticallyto provide adaptive skills and potentialself-transformation. How this is accomplished varieswidely, from using more broadly defined meditativeand mindfulness techniques to promoteself-awareness, (51) to applying techniques andactivities that will directly access existential andspiritual questions (for example, past life regression,chanting, and bibliotherapy), (52) to incorporatingspecific scriptural passages that both guidethe therapy and provide relevant reflections thatspeak to core issues of spirituality.(38, 53) Findingways to spiritually intervene is a young area, andthere are a growing number of treatment-relatedtexts now appearing.(54) , (55) Applications ofspiritual and religious techniques to the PDs hasso far been limited to just handful of the disorders(for example, borderline, narcissistic, schizotypal,and antisocial). The utility of the numinous fortreating the others still needs to be researched. Theremaining part of this chapter will overview someof the clinical issues related to select PDs.7.1. Schizotypal PDPerhaps one of the central issues in managingpatients with apparent religious delusions orideas of reference is to accurately discern whetherthese “disturbances” reflect cognitive distortionsor real mystical/spiritual experiences. This isparticularly critical when dealing with individualsfrom non-Western cultures, where more animisticreligious beliefs and rituals that involve“spirits” and “demons” exist. To the untrained

184 Ralph L. Piedmonteye, valid mystical experiences may appear aspsychotic-like episodes, and to treat them as suchclinically would be inappropriate.Only one study to date has empirically examinedmystical experiences among psychotic inpatients,religious contemplatives, and normal adults.(56) Interestingly, it was found that psychotics andcontemplatives could not be discriminated on thebases of their scores on a mystical experiencescale. Both groups reported experiences that werephenotypically comparable. However, the twogroups were differentiated on the basis of theirscores on a narcissism scale; the psychotic groupscoring significantly higher. Selfishness, self-involvement,and grandiosity are clear characteristicsof a nonspiritual orientation. (50) However,positive signs of a real transcendent experienceinclude a sense of wholeness, perfection, joy, andacquired insight. Psychotic experiences will havethe effect of promoting psychological fragmentation,while true mystical experiences result in anenhanced sense of personal integration. Lukoff(57) provided a useful orientation for differentiatingbetween a true “spiritual emergency” and apsychotic episode.But spirituality can also be a useful therapeuticresource for those with a schizotypal PD, regardlessof whether their “mystical experiences” arevalid or not. Lukoff outlined a number of usefultechniques for managing such clients, such asmindfulness and promoting a connection to thetranscendent. Building a personal relationship toGod can be helpful in building an identity, creatinggreater self-responsibility, and promotinghope. Keks and D’Souza (58) also believed thatnuminous constructs can help individuals gain asense of self and develop a better sense of personalsupport for themselves. Involvement insupportive religious communities can help tomelt stigmas associated with having a psychiatriclabel and provide increased personal meaning.7.2. Borderline and Narcissistic PDsKhalsa (51) believed that psychospiritual interventionscan help clients with these PDs createfor themselves an inner mental state thatis dynamic, attractive, peaceful, and creative.Spiritual techniques help to promote moreinternally stable emotional states. This is accomplishedby using a blend of Dialectical-BehaviorTherapy (DBT) in conjunction with variousyoga and meditative practices. The goal is tohelp individuals identify their core personalityand to embrace it as a first step in making a personaltransformation. The meditative practiceshelp clients to sit with their thoughts and to seehow they initiate emotions.Lawrence (53) viewed the narcissistic PD asmuch of a spiritual issue as a psychological one.Using more Western religious techniques, sheargued that a developing relationship with Godcan serve as a useful intrapsychic object that canprovide personal security to the client enablinghim or her to counter the inner vulnerabilitiesthat compromise the narcissist from developingand maintaining healthy interpersonal relationships.Lawrence relies on an explicitly Christianframework for providing the basis to the interventionprocess. Spiritual growth is linked directlyto psychological growth and maturity, with theclient-God relationship being the core elementto the treatment process. Of course, the generalizabilityof this model is limited to those whoaccept established views of Christian theology.7.3. Antisocial PDMartens (52) argued that spiritually orientedpsychotherapy could be a powerful interventionfor antisocial and psychopathic personalities.Spirituality can be useful in promoting authenticity,moral and social capacity, and a greater faithin life. Martens’ approach uses more eclectic strategiesthan those outlined in the previous two sections.His “spiritual psychotherapy” is “intendedfor patients with spiritual interests and latentabilities to develop spiritual activities. Duringspiritual psychotherapy, spiritual themes like gettingwisdom … coping with loneliness … authenticity… development of personal ethics will bediscussed” (p. 207). The goal of this approach istwofold: (1) to help clients find a way out of theirpsychosocial problems and (2) to create a healthy

Personality, Spirituality, Religiousness, and the Personality Disorders 185attitude toward themselves and the world byexamining the spiritual dimensions of life.Piedmont (31) examined the predictive role ofspiritual transcendence as a predictor of outcomefrom an outpatient substance abuse treatmentprogram. Participants were long-term drug andalcohol users from an inner city, mostly homeless,population. The group’s overall personalityprofile showed low levels of both agreeablenessand conscientiousness, a pattern characteristic ofthe antisocial PD (see Table 13.2). The six-weekintensive program was fundamentally a spirituallyoriented intervention that included a numberof other modules (for example, vocational training,AA/NA groups, health awareness, and grouptherapy). Participants attended the programfive days week, for six hours a day. Individualscompleted a number of psychosocial measuresand the STS. Over the course of treatment,individuals experienced significant reductionsin emotional distress, improvements in copingabilities, and increased levels of spirituality.Interestingly, the STS facet scales of Universalityand Connectedness were the most robust predictorsof self and therapist ratings of outcome.Both of the facet scales stress one’s relationshipsto others. Universality reflects a recognition of lifeas being interconnected. Individuals are part of alarger social reality, a community of “oneness” thattranscends the many differences we experience inthis life. Connectedness stresses the importanceof the individual and his or her responsibility incaring for, responding to, and being involved withthe many social communities that a person is part(for example, family, neighborhood, and community).Enabling individuals to emotionally investin supporting communities may lead to generativebeliefs that provide a motivation for change.For those with an antisocial PD, creating anawareness of social responsibility works againstthe more manipulative, selfish orientation thatcharacterizes this disorder. As Piedmont (31)(p. 220) noted, “Spirituality’s therapeutic effectmay be in its ability to reintroduce [individualswho have been socially marginalized] asmeaningful players in the larger human polity.Spirituality stresses the value of people despitetheir brokenness; it emphasizes the importanceof each person’s life in maintaining the integrityof the fabric of human experience.”8. THE CURATIVE POWEROF SPIRITUALITYWhy does spirituality present as a useful therapeuticresource for treating personality disorders?There are certainly many answers to this questionranging from a belief in the healing powerof God’s grace to the perspective that spiritualityrepresents a “master motive” that organizes thepersonality and brings coherence to its strivings. Itis my opinion that the value of spirituality is that itserves as an antidote to narcissism. A materialistic,self-centered approach to life, where one is alwaysconcerned with obtaining gratification of personalneeds and wishes, leads to an impulsive style thatcan be easily frustrated by the demands of life.Here, life goals are usually oriented to the shortterm and relationships are usually manipulativeand emotionally superficial. Spirituality, on theother hand, represents a lifestyle that is transpersonalin nature, where one recognizes a transcendentreality that calls individuals to set personalgoals along an eternal continuum. A spiritual perspectiverecognizes that birth and death are onlydevelopmental signposts along a much longerontological process. Recognizing one’s connectionsto all life and embracing one’s responsibilitiesto care for others create relationships that are emotionallydeep, generative, and mutually satisfying.Being able to step outside of oneself and to putone’s life into a larger interpretive context can beemotionally healing and liberating. Committingto this larger vision allows individuals to find personalstability and coherence, even during timesof fluidity and disjuncture. For individuals lockedinto their own narrow worlds of emotional pain,personal ineptitude, and interpersonal inadequacy,this broader meaning may provide waysof coping with stressful events or creating buffersagainst negative feelings. It may also represent ahigher level of personality maturity.It is interesting to note that in reviewing theliterature on spirituality and the Axis II PDs, the

186 Ralph L. Piedmonttypes of disorders that are discussed all involve narcissismas a fundamental characteristic. The antisocial,narcissistic, schizotypal, and even borderlinerepresent disorders where selfishness and manipulativenessare salient. It now seems evident thatspirituality should be an important curative factorwith these types of disorders. However, the questionstill remains to be answered whether spiritualityand religiousness would be relevant for treatingother PDs that are less narcissistically oriented, likethe avoidant, obsessive-compulsive, schizoid, andhistrionic. Perhaps other aspects of spirituality maybe relevant, such as prayer fulfillment.Prayer fulfillment correlates significantlywith positive affect. Individuals who are ableto establish an emotional connection to a transcendentbeing are able to derive a sense ofjoy and contentment above and beyond whatcan be predicted by personality (that is, levelsof extraversion). Prayer fulfillment has beenshown to be a buffer to the experience of burnout,at least among clergy. Religious involvement(for example, frequency of prayer andattending religious services) has been shown tobe negatively related to neuroticism; those whoinvolve themselves in the rituals and practicesof their faith seem to experience less negativeaffect. So perhaps concerning those PDs thatare highly correlated with neuroticism (forexample, avoidant, dependent, depressive, andparanoid; see Table 13.2), the dimensions ofPrayer Fulfillment and Religiosity may be mostrelevant for treatment. It is up to future researchto examine these issues.9. THE DARK SIDE OF THE NUMINOUSA colleague of mine would always say, “Thebrighter the light, the darker the shadow” whenwe would witness talented people makingsurprising personal blunders. This clever sayingreminds us that all things in life carry with themassets and liabilities, and spirituality is no exception.Although the numinous mostly carries withit positive potentialities, one must also be awareof the potential adverse affects it may have. Oneaspect of this was noted earlier in describing theimpact of religious crisis and its very toxic impacton psychosocial functioning. Having a relationshipwith the transcendent can be uplifting andsupportive, unless one is feeling victimized and/or abused. In working with individuals who maybe religiously oriented or helping clients developa deeper spirituality, one needs to be careful thatthe spirituality that arises is not a source of pain,guilt, or exclusion.(58)Martens (52) cautions that some clients,especially those with an antisocial PD, may usespiritual information to manipulate others orto appear that they have grown to gain releasefrom psychiatric facilities. Employing spiritualmaterial in therapy with clients having a comorbidpsychotic or delusional disorder may fosterthe development of delusional ideation thatmay strengthen their resistance to treatment. Ofcourse in both scenarios, a trained clinical eyeis important. Being able to discern between realspiritual growth and superficial accommodatingis key. However, discernment between psychotic/delusional behavior of a religious nature andactual spiritual experiences requires a moredeveloped clinical palate.Working with religious-oriented clients orattempting to incorporate spiritual and religioustechniques into treatment requires that therapistsdevelop basic competencies in numinousrelatedissues. Understanding various religiousfaiths in terms of their practices and philosophiesis an important first step. Such knowledgehelps give insight into a client’s worldview andoutlines moral beliefs. However, as this chapterhas shown, spirituality is more than a demographicvariable. It is a significant psychologicalconstruct that also needs to be understood in itsown right. Making effective spiritual interventionscan be facilitated if the therapist has experiencewith the underlying numinous issues.With the inclusion in the DSM-IV of a newdiagnostic category named Religious or SpiritualProblem (V62.89), therapists need to be alert tothe influence of spiritual and religious dynamicsand their impact on a client’s larger clinicalsituation. Determining whether a spiritual crisisrepresents a real psychosocial decompensation

Personality, Spirituality, Religiousness, and the Personality Disorders 187or the precursor of enhanced transpersonalgrowth is critical to the accurate diagnosis andeffective treatment of the client.10. SUMMARYThese findings have considerable significance forclinicians who may be skeptical about numinousvariables, perhaps viewing them as “fuzzy” constructs.Taken together, the information presentedhere should lend confidence to professionalsregarding the empirical viability and conceptualsoundness of numinous scales: They can meetthe empirical criteria of scientific method andrigor. Spirituality and religiousness relate to howan individual creates a broad sense of personalmeaning for his or her life. Creating meaning canhave an important impact on the quality and stabilityof one’s psychic life. As was demonstratedhere, spirituality can have a buffering effect onlife’s stressors by creating a source of inner joyand contentment despite the distress. Further,disturbances in our relationship to a transcendentbeing can have a direct negative impact onour functioning. Feeling punished and shunnedby the God of one’s understanding can createmuch disruption in one’s sense of self and emotionalstability. In treating PDs, therapists needto include a consideration of the client’s spiritualorientation and bring this information into treatment.Helping the client to work through perceivedproblems in their spiritual world can helprestore a sense of calmness and stability. Workingto improve a more spiritual sense of meaning canenable a client to develop other psycho-socialconnections that can help facilitate the ongoingtreatment process. A wide variety of techniquesare already available for moving clients in a morespiritual direction, and therapists should acquaintthemselves with them.REFERENCES1. American Psychiatric Association. Diagnostic andStatistical Manual of Mental Disorder , 4th ed., texted. Washington, DC : Author; 2000 .2. S amuels J , E aton W W , Bienvenu OJ , Brow n C H ,C ost a PT , Nest adt G . Pre v a lenc e and c or rel ates ofpersonality disorders in a community sample . Br JPsychiatry . 2002; 180: 536–542.3. Torgers en S , Kr i ng len E , C r amer V. The prevalenceof personality disorders in a communitysample . Arch Gen Psychiatry . 2001 ; 58: 590 –596.4 . M a i e r W , L i c h t e r m a n n D , K l i n g e r T , He u nR. Prevalences of personality disorders(DSM-III-R) in the community . J Pers Disor.1992 ; 6: 187 –196.5. R endu A , Mor an P , Patel A , Knapp M , Mann A .Economic impact of personality disorders inUK primary care attenders . Br J Psychiatry .2002 ; 181: 62–66.6. Van Asselt ADI , Dirksen CD , Arntz A , Severens JL.The cost of borderline personality disorder: societalcost of illness in BPD-patients . Eur Psychiatry .2007; 22: 354 –361.7. B ar t a k A , S o eteman DI , Verhe u l R , Buss chb ach J J V.Strengthening the status of psychotherapy forpersonality disorders: an integrated perspectiveon effects and costs . Can J Psychiatry .2007 ; 52: 803 –810.8. G abb ard GO , L a z ar S G , Hor nb erger J , Spie gel D.The economic impact of psychotherapy: a review .Am J Psychiatry. 1997 ; 154: 147 –155.9. Digman JM. Personality structure: emergenceof the five-factor model . Annu Rev Psychol.1990; 41: 417–440.10. Costa PT , Jr , McCrae RR. Normal personalityassessment in clinical practice: the NEO PersonalityInventory . Psychol Assess. 1992 ; 4: 5 –13.11. Piedmont RL. The Revised NEO PersonalityInventory: Clinical and Research Applications . NewYork : Plenum Press; 1998 .12. McCrae RR , Allik J. The Five-Factor Model acrossCultures . Dodrecht, The Netherlands : KluwerAcademic Publishers; 2003 .13. Miller T. The psychotherapeutic utility of thefive-factor model of personality: a clinician’s experience. J Pers Assess. 1991 ; 57: 415 –433.14. Block J. A contrarian view of the five-factorapproach to personality description . Psychol Bull.1995 ; 117: 187 –215.15. Friedman M , Rosenman RH. Association of a specificovert behavior pattern with increases in bloodcholesterol, blood clotting time, incidence of arcussenilis and clinical coronary artery disease . J AmMed Assoc. 1959 ; 2208: 828 –836.16. Barefoot JC , Dodge KA , Peterson BL ,D a h lst rom WG , Wi l l i ams R B, Jr. The Cook-Medley hostility scale: item content and ability topredict survival . Psychosom Med. 1989; 51: 4 6–57.17. Costa PT , Jr , Widiger TA. Personality Disordersand the Five-Factor Model of Personality , 2nded. Washington, DC : American PsychologicalAssociation; 2002 .18. First MB , Gibbon M , Spitzer RL , Williams JBW ,Benjamin LS. User’s Guide for the StructuredClinical Interview for DSM-IV Axis II Personality

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14 Religion, Spirituality, and Consultation-Liaison PsychiatryHAROLD G. KOENIGSUMMARYReligious beliefs and practices play an importantrole in enabling medical patients to cope withdisability, dependency, fear, loss of control, andunpleasant medical symptoms. Besides influencingthe development and course of emotionaldisorders such as depression and anxiety, religioncan play a role in a host of other psychiatricconditions that mental health professionals arelikely to encounter in medical settings, includingsomatization, agitation, behavioral problems, andsubstance abuse. In each of these conditions, religioncan serve as either a resource or a liability.Religious beliefs may facilitate psychiatric care,or alternatively, conflict and interfere with it. Forthese reasons, and to provide culturally sensitivecare, psychiatrists and other mental health professionalsneed to understand how religion caninfluence the onset, course, and treatment of conditionsfor which medical physicians are likely toconsult them. In this chapter, I describe researchon and case examples of how religion can influencepatients’ mental health. I also provide recommendationson how to take a religious/spiritual history,what to do with this information, and whenpastoral care collaboration or referral is necessary.Given the wide prevalence of religious beliefs andbehaviors in medical patients, and their potentialimpact on both mental health and medical prognosis,it is essential that clinicians consulting onthese patients be informed.Consultation-liaison psychiatry is growing rapidlyand will continue to do so as our populationsage, chronic illness increases, and persons withacute medical problems are hospitalized or treatedin outpatient settings. The need for a distinct psychiatricapproach to patients with acute, chronic, orterminal medical illnesses is now fully recognized.This chapter focuses on the emotional challengesand psychiatric illnesses that medical patientsexperience. In particular, it explores the rolesthat religion/spirituality play in the presentationand management of these conditions. Research isreviewed, cases are presented, and clinical applications(spiritual interventions) are discussed from amulticultural perspective that includes collaborationwith chaplains, pastoral counselors, and communityclergy.1. REASONS FOR PSYCHIATRICCONSULTATIONThe most common reasons why medical physiciansare likely to consult psychiatrists in acutemedical or surgical settings are the following:anxiety, depression, psychosis, somatoform disorders,pain, posttraumatic stress disorder (PTSD),substance abuse, delirium, agitation, psychosis,and dementia.(1) In one early study conducted ina general hospital setting, reasons for psychiatricconsultation were 35 percent depression, 29 percentuncooperative/management problem, 23percent bizarre behavior or affect, 22 percent delirium,19 percent previous psychiatric history, 16percent maladjustment to illness, and 14 percentsuicidal behavior.(2) Depression, suicidal behavior,and maladjustment to illness, then, make upthe vast majority of consultations. Similarly, psychiatricconsultation for nursing home patients isheavily weighted toward depression or behavioral190

Consultation-Liaison Psychiatry 191disturbances related to depression, anxiety,dementia, pain, and mal adjustment to illness.(3)Many of these same conditions are related to oraffected by religious beliefs and practices, as istheir management.2. COPING WITH MEDICAL ILLNESSPsychiatrists need to understand psychologicaland social factors that underlie common emotionaland other psychiatric problems found inmedical patients. Unlike psychiatric patients,who often have prior personal and family historiesof psychiatric illness, childhood trauma,and/or personality issues, medical patients haveusually been psychologically stable until theydeveloped medical illness. The onset of healthproblems, then, often underlies depression, anxiety,and other psychiatric disturbances.Chronic medical conditions, and especiallyacute exacerbations of those illnesses, pose enormouschallenges to the patient’s ability to cope. Ifthere is also a history of prior psychiatric illness,then coping with medical problems may be evenmore difficult. Challenges include adjustment toloss of health and vigor, loss of energy and sleep,acute or chronic pain, increases in disability,changes in roles played in family and society, difficultymaintaining social relationships, troublemaking new friends, loss of ability to work, loss ofability to meet life goals, loss of the ability to makea positive difference in others’ lives, and most difficultof all, loss of a sense of purpose and meaningin life. The result of these losses and changes:anxiety, humiliation, despair, and loss of hope.commodity that cannot be bought, and when diseasetakes it away, there may be nothing that onecan do to get it back.2.2. Loss of Energy and SleepHealth problems often drain the patient’s vitality,as the body tries to fight off the illness. This mayleave little energy for physical or emotional activitiesthat bring pleasure and enjoyment. If themedical condition also interferes with sleep (asdo illnesses such as congestive heart failure, restlessleg syndrome, painful neurological conditions,and arthritis), then the fatigue of insomniaadds to and magnifies the physical and emotionalexhaustion. Feeling tired all the time can itselflead to depression or other psychiatric problems,because this interferes with meaningful activitiesand relationships.2.3. Acute or Chronic PainThere is a heavy overlap between pain and depression,which reinforce one another. Pain forces one’sattention to the body part affected, making it difficultto think about anything else except a desireto relieve or escape the pain. Pain, especially whenchronic, can completely dominate the patient’s life,affecting sleep, hobbies, work, and relationshipswith family and friends. The treatments for pain, infact, may also have negative consequences becausethey interfere with level of alertness, ability to communicate,drive, and function effectively. This canresult in anxiety and depression, which furthermagnify or worsen the physical pain experienced.2.1. Loss of Health and VigorHealth and physical vigor are usually taken forgranted until they are lost, but once lost their valuesuddenly becomes apparent. To be free of physicalsymptoms and able to work and play withoutrestriction are perhaps the most precious abilitiesthat humans possess. No matter how much financialresources, power, or influence one has, withoutphysical health, independence, and energy, itis difficult to enjoy life. Physical health is that one2.4. Increase in DisabilityAs chronic illness affects physical function andability to care for the self, there is an increasingneed to depend on others. There are few thingsthat people value more than independence andability to control the direction of their lives. Noone wants to be a burden on others, especially inindependent societies such as the United Statesand Europe. Dependency can be particularly disturbingin situations where caregivers become

192 Harold G. Koenigresentful over their extra burdens, and then communicatethis resentment directly or indirectly tothe dependent person. Is there any wonder whylevel of disability is one of the strongest predictorsof depression in medical patients?2.5. Change of Roles in Familyand SocietyWhen patients are no longer able to work, generatean income, or contribute to family responsibilities,their importance and leadership positionsin family and community are affected. The sick ordependent person often loses value and respectin the eyes of family members and society. Thisloss of “position” can be very distressing, especiallyfor those who derived a great deal of satisfactionin being independent and able to providefor themselves and others.2.6. Loss of Social RelationshipsPatients with chronic and/or serious medical illnesshave a difficult time both maintaining socialrelationships and making new ones. Hearing difficultiesmay interfere with communication, andchronic disability may impair mobility necessary toattend social events. Medical symptoms, especiallyloss of energy, can keep patients in their homes orrooms and may reduce motivation to get out forsocial interactions. Social isolation, then, becomesa huge problem for those with chronic illness andmay lead to depression, which may increase socialwithdrawal and increase loneliness. A vicious cyclequickly develops with increasing social isolation andincreasing depression, which feed on each other.2.7. Loss of Ability to WorkWork not only structures how people spend theirtime during the day, but also is a major sourceof identity and self-esteem for many. Not beingable to work or contribute meaningfully becauseof medical illness or disability can be devastating.Loss of work can also mean loss of ability togenerate income and provide support for self andothers. If depression is to be successfully treatedover time, then issues related to loss of work mustbe addressed.2.8. Loss of Opportunities to MeetLife GoalsMedical illness may portend permanent changesin physical functioning or may limit cognitiveabilities, which can result in the realization thatlifetime goals in work, career, or family maynever be achieved. These patients need to identifynew goals that are within their remainingabilities given their physical limitations. Patientsmay need counseling to develop their abilitiesso that worthwhile life goals can be successfullypursued despite limitations. Keeping motivation,hope, and vision alive become crucial.2.9. Loss of the Ability to Makea DifferenceUntil becoming sick, many patients may have takenpride in making a positive difference in people’slives. Providing for family, raising children, contributingto church or community, helping a neighbor,contributing to goals in the workplace, and soforth may have been important and meaningful.Illness can interfere with all that, particularly whenillness is chronic. Inability to make a positive difference,or its opposite, seeing oneself as making anegative difference in family or friends’ lives, canbe devastating to self-esteem and self-image.2.10. Loss of Purpose and Meaningin LifeAny one or a combination of the above lossescan leave patients feeling as if their lives have lostmeaning and purpose, and that they no longerhave a reason for living. Such feelings lead tohopelessness, discouragement, loss of motivationfor self-care, and can ultimately lead to the convictionthat life is not worth living and that deathis the only way out. Although antidepressants,anti-anxiety drugs, and other biological treatmentscan be extremely helpful in relieving painfulsymptoms, they do not address the core issues

Consultation-Liaison Psychiatry 193driving depression. Incomplete or only partialtreatment response, which is so common in medicalpatients, may be due to lingering existentialconcerns that were not adequately addressed aspart of the overall treatment plan.Given the massive losses and life change thatphysical illness causes, it is not surprising thatdepressive disorders are so common in hospitalsettings. Eventually, patients’ efforts to meet thesemultiple challenges become exhausted. Our studiesshow that rates of major or minor depressionin older patients acutely hospitalized with medicalillness approximate 50 percent, (4) and, ratesare even higher among younger hospitalizedpatients where medical illness and disability arenot “on time” as they are in older adults.(5) Themajority of these depressive disorders are undiagnosedand untreated.(6) Even if depression isidentified as a problem, primary care physiciansoften lack the training to manage such disordersappropriately.(7) Despite their lack of expertisein treating depression, medical physicians referonly about 10 percent of these patients to psychiatrists,even when the patient has a major depressivedisorder.(7) Some physicians may rationalizethat patients with chronic illness and multiplelosses have a good reason to be depressed, andso there is no need for treatment of this “normal”reaction to illness. Such therapeutic nihilism canonly be addressed by education and by the experienceof positive results when these patients aretreated or referred for psychiatric care.Because emotional disorders in medicalpatients are often a direct result of inability tocope with massive life change and loss, mentalhealth specialists should seek out resources thatcan help patients adjust successfully to illness.Identifying and supporting such coping resourcescan complement existing biological, psychological,and social therapies.3. ROLE OF RELIGION/SPIRITUALITYConsultation-liaison (CL) psychiatrists and othermental health professionals should be aware ofthe roles, both positive and negative, that religiousbeliefs and practices can play in the adjustment ofpatients to medical illness. On the one hand, religiousbeliefs may be a symptom or cause of psychiatricdisorder. On the other hand, religion maybe a powerful coping resource for some patients,prevent the development of emotional disorder, orreduce the time it takes for these disorders to remit.Let us consider each of these possibilities below.3.1. Religious Belief as a SymptomReligious beliefs may be a symptom of depressionor other emotional illness. For example, the medicalpatient may attribute the extreme guilt andsadness from their depressive disorder to havingcommitted the “unpardonable” sin that doomshim or her to eternal damnation and suffering.The patient may feel great remorse and sense offailure and explain these feelings as punishmentfor trespasses of some sort, either real or imagined.Religion may also be used to normalizeweight loss or improper attention to nutrition.The religious patient may try to cover up anorexiaor weight loss by claiming that he or she is fastingfor religious reasons. In all these instances, thereligious belief is used to justify symptoms whoseunderlying cause is depression, not religion. Inthis case, then, the depressive symptom doesnot result from religion, but from the underlyingdepressive disorder and is simply explainedby the patient in religious terms because of his orher religious worldview.3.2. Religious Belief as a CauseIn some instances, religious beliefs may actuallylead to the development or worsening ofemotional disorder in vulnerable individuals.Religious beliefs and teachings may promote feelingsof excessive guilt or remorse. Here, religiousbelief is contributing to the worsening of symptoms.High religious standards and values may bedifficult to live up to. Honesty, generosity, selflessness,kindness, and gratefulness are difficult tolive out even by the most saintly among us. Howoften such guilt or shame occurs – and proof thatit is the religion that is the origin of the negativeemotional symptoms – is uncertain, given the

194 Harold G. Koeniglack of research in this area. Conventional wisdomand clinical experience, however, suggestthat this does happen. Prospective studies areneeded to help to sort out cause versus effect (thatis, whether religion causes depressive symptoms,or whether depressed patients are more likely togravitate toward religion because it offers comfortor healing).3.3. Religious Belief as a Coping BehaviorRather than being a cause for depression or asymptom of it, religious beliefs and practicesmay be used by patients to cope with the painand suffering that depression causes. This may beparticularly common in medical patients (versuspsychiatric patients) where emotional disorder ismore often the result of difficult circumstances(situational depression). Religious beliefs mayhelp medical patients to reframe their losses in amore positive light, give a sense of purpose andmeaning, and provide hope that something goodcan result from the situation.4. RELIGION AND DEPRESSIONBecause depression is so common and resistantto treatment in patients with medical illness anddisability, CL psychiatrists will be frequently calledon to manage these patients. Although antidepressantmedication and psychotherapy have animportant place in the treatment of medically illpatients with depression, they are often not sufficient.Treatment-resistant depression or partiallytreated depression is extremely common, evenafter all traditional psychiatric therapies have beentried. Thus, helping patients identify resources thatcan help them adapt to the disturbing symptomsof medical illness or to the psychological distressof chronic disability or dependency is an importanttask.A number of cross-sectional and prospectivestudies in medical inpatients suggest that religiouscoping is common in such settings and isassociated with more rapid adaptation to medicalillness and disability. This is especially true forpatients with the most severe illness and greatestdisability and those whose physical conditionsare not responding to medical treatments.In the early 1990s, we studied a consecutivesample of men admitted to the medical and neurologicalservices of the Veterans AdministrationMedical Center in Durham, North Carolina.(8)Eight hundred and fifty men aged 65 or olderwere examined for depressive symptoms usingthe self-rated thirty-item Geriatric DepressionScale (GDS) and Brief Carroll Depression Scale(BCDS); patients over age 70 years were alsoassessed with the observer-rated seventeen-itemHamilton Depression Rating Scale (HDRS).Religious coping was measured using the threeitemReligious Coping Index (RCI) whose scoresrange from 0 to 30. In that study, 21 percent ofpatients indicated that religion was the “mostimportant factor” that enabled them to cope, and56 percent indicated that they depended at least alarge extent on religion to cope.In the cross-sectional analysis that used a multivariatemodel to control for nine other patientcharacteristics relevant to depression, RCI scoreswere significantly and inversely related to bothself-rated (GDS) and observer-rated (HDRS)scales. Particularly important, this associationwas strongest for men with the most severe disability.In the longitudinal phase of the study, allsubjects readmitted within the sixteen-monthstudy period and subsequent five months (averagefollow-up six months) (n = 202) were reassessedfor depressive symptoms (combination ofGDS and BCDS). The baseline RCI score was theonly characteristic that predicted fewer depressivesymptoms on follow-up, after controlling forbaseline depression and other covariates.Although religious beliefs and practices appearto protect against the development of depression,religious people do get depressed. Even when thathappens, however, depressive disorder appears toremit more quickly in these patients (that is, adaptationoccurs more quickly). At least two studiesin medical inpatients are relevant in this regard.In the first study, eighty-seven hospitalized medicallyill patients on general medicine, cardiology,and neurology services of Duke Hospital werediagnosed with depressive disorder using the

Consultation-Liaison Psychiatry 195Diagnostic Interview Survey (which makes diagnosesusing the Diagnostic and Statistical Manualof Mental Disorders, Third Edition, DSM-III , criteria).(9)Intrinsic religiosity (IR) at baseline wasmeasured using an established ten-item intrinsicreligiosity scale. Patients were followed for an averageof forty-seven weeks, and baseline predictors ofspeed of depression remission were analyzed usingCox proportional hazards regression. After controllingfor baseline physical, psychological, andsocial characteristics, for every ten-point increaseon the IR scale (that ranged from ten to fifty), therewas a 70 percent increase in the speed of remission(Hazard Ratio = 1.70, 95% Confidence Interval =1.05–2.75). As in the earlier study, among a subgroupof patients whose physical illness was eithernot improving or was getting worse (n = 48), effectswere particularly strong. For those patients, everyten-point increase on the IR scale predicted over a100 percent increase in speed of depression remission(HR 2.06, 95% CI 1.02–4.15).In a second much larger study, researchers systematicallyidentified 1,000 medical inpatientswith depressive disorder. All subjcet were overage 50 and had congestive heart failure and/orchronic pulmonary disease.(10) Depressive disorderwas diagnosed using the Structured ClinicalInterview for Depression (SCID). Detailed informationwas obtained on depression, psychiatricand social characteristics, physical health, andreligious involvement. Patients were followed afterdischarge (over twelve weeks for those with minordepression; over twenty-four weeks for those withmajor depression). Again, Cox proportional hazardsregression was used to examine the independenteffects of religious involvement on timeto depression remission, controlling for baselinecharacteristics. Of the 1,000 depressed patientsidentified at baseline, follow-up data on depressioncourse was obtained on 87 percent.Results indicated that patients who attendedreligious services and participated in othergroup-related religious activities remitted fromtheir depressions significantly faster than did lessreligiously involved patients. This effect persistedafter controlling for other baseline characteristicsand could not be explained by social support.More important, patients with a combination offrequent religious attendance, prayer, scripturereading, and high intrinsic religiosity (14 percentof the sample) went into remission 53 percentfaster than other patients (HR = 1.53, 95% CI1.20–1.94, p = 0.0005, n = 839) after controllingfor multiple baseline demographic, psychological,social, and medical predictors. Social supportexplained only 15 percent of this effect. Basedon these results, investigators concluded thatdepressed medical inpatients who were highlyreligious (as determined by multiple indicatorsof religious involvement), particularly thoseinvolved in religious community activities, remittedfaster from depression than other patients.5. SUICIDAL THOUGHTSAND BEHAVIORChronic medical illness is associated with highrates of successful suicide, even though contactwith medical providers may be frequent.These patients are often reluctant to share suicidalthoughts with their physicians because ofthe stigma that depression carries with it. Otherpatients may try to recruit their medical providersto assist them in committing suicide, whichcan prompt referral to a psychiatrist for evaluationand management.In some cases, suicidal (or homicidal) thoughtsmay be prompted by religious delusions. For example,a mother developed the religious delusion thather two young children would be forever damnedto hell if she did not kill them. She drowned bothchildren in the bathtub. Another example is thatof a young man who felt extreme religious guilt fornot living up to his religious ideals. He reasonedthat if he killed himself, then this would be sufficientpunishment to prevent his eternal damnationfor the sins he had committed. He hung himselfin his garage. Certain radical fundamentalists (forexample, extremist Muslim groups) may favorsuicide and homicide as an act of service to God.Most religious doctrines and teachings in almostevery major religion around the world, however,discourage suicide. This is particularly true for suicideas a solution to personal suffering.

196 Harold G. KoenigIn some Eastern cultures (Japan and some areasof China), suicide may be viewed as an honorableact in certain rare circumstances (after shamefuldeeds or in service to country), but it is not condonedto avoid or escape from pain and suffering.Within Judeo-Christian faith traditions, tokill oneself is equivalent to murder, for one of theTen Commandments is “Thou shalt not kill,” andthere is no distinction made between killing one’sself or killing others. Such prohibitions are powerfuldeterrents to the sequence of psychologicalevents that eventually lead to successful suicide.Religious and spiritual beliefs often help peopleto cope with the pain and suffering that leadto suicidal thinking, and thereby convey hopeand meaning that can prevent suicide. Religiousinvolvement can also surround the suicidal personwith a community of people who can supportthe person and help him or her bear theemotional burden. “Am I my brother’s keeper?”asked Cain in Genesis. God’s answer, “You betyou are.” At the heart of some faith communities(although not all) is the care that membersdemonstrate toward one another. This is the idealthat the Christian scriptures (and the scripturesof other world religions) emphasize. “Whoeverdoes not love does not know God, because Godis love” (1 John 4:8, NIV).Plenty of research supports the claim that religiousinvolvement can prevent suicide in thosewith or without medical illness. People withstrong religious beliefs, particularly if involvedin a supportive religious community, have fewerthoughts about suicide, have more negativeattitudes toward suicide, and commit suicideless often than those who are not religious. In areview of sixty-eight studies that examined therelationship between suicide and religion, fiftyseven(84 percent) found that religious personswere more negative about suicide, had fewerthoughts about it, attempted it less, and were lesslikely to complete suicide. In these studies religiousnesswas measured in many different ways:from frequency of religious activities to degreeof personal religiousness to regional rates of religiousbook publication. Countries of the worldthat publish fewer books on religion have highersuicide rates than countries that publish morereligious books.(11)Critics say that areas of the world that are morereligious often have stronger cultural taboos aboutcommitting suicide, which then affect whetheror not cases of suicide are reported. Muslims,for example, strongly condemn suicide, whereasmembers of Eastern religious traditions such asBuddhists, Hindus, Chinese, and Japanese religionsare more tolerant (with Christians and Jewsfalling in between, depending on how conservativetheir beliefs are).(12, 13)More recent studies on religion and suicideinclude subjects of different ages across the lifespan and from various ethnic groups. Because suiciderates are greatest at the age extremes (adolescents/teenagersand older adults), studies in thesepopulations are particularly relevant. Greeningand Stoppelbein examined religiousness and suicidalattitudes in 1,098 Caucasian and African-American adolescents, asking them to rate thelikelihood that they would ever commit suicide.(14) Investigators controlled analyses for depressionseverity, hopelessness, social support, and styleof causal attribution. Of all these characteristics,religious orthodoxy (commitment to core beliefs)was the single strongest predictor of negative attitudestoward suicide. Furthermore, while severityof depression predicted a greater self-reportedfuture likelihood of committing suicide, greaterreligious orthodoxy reduced the likelihood ofdepressed adolescents saying that they would everdie by suicide (that is, religious orthodoxy moderatedthe effect of depression on suicide).The same pattern appears to be true in olderadults, where the suicide rate is higher than anyother population group. In a study of 835 urbanlow-income African-Americans, with an averageage of 73 years, Cook and colleagues examined predictorsof active and passive suicidal ideation.(15)Passive suicidal ideation is a desire to die or wishto be dead, but no active plans or intentions to endlife. Active suicidal ideation involves more seriousplans on how to commit suicide and active desire toharm self. Of the multiple characteristics measured(anxiety, social dysfunction, somatic symptoms,low social support, absence of a confidante, older

Consultation-Liaison Psychiatry 197age, lower education, more depressive symptoms,and poorer cognitive functioning), only two characteristicsindependently predicted passive suicidalideation: depressive symptoms and low religiouscoping. Low life satisfaction and low religious copingwere also the only characteristics that independentlypredicted active suicidal ideation.The inverse relationship between religiousnessand suicidal ideation is also present in patientswith severe medical illness, which brings thistopic into the realm of CL psychiatry. For example,McClain and colleagues examined the relationshipbetween spiritual well-being, depression,and desire for death in 160 terminally ill cancerpatients with less than three months to live.(16)Scales measuring depressive symptoms, hopelessness,attitudes toward a hastened death, andthe FACIT-Spiritual well-being (SWB) scale wereadministered to patients. A single item measuredrecurrent thoughts of death or suicide on a scalefrom absent to “high risk requiring suicide precautions.”SWB was significantly and inverselyrelated to a desire for hastened death, hopelessness,and suicidal thoughts, and of all variables,was the strongest predictor of these three outcomes– even stronger than severity of depression.In fact, while depression was strongly correlatedwith desire for a hastened death in those with lowSWB, no correlation was found between depressionand suicidal yearnings in those with highSWB. This study, published in The Lancet , concludedthat SWB provided substantial protectionagainst end-of-life despair.Examining attitudes toward euthanasia andassisted suicide in an Australian outpatient cancerpopulation, (17) Carter and colleagues studied theimpact of mental health and other characteristicsin predicting attitude toward these suicide-relatedpractices. The sample consisted of 228 patientsattending an oncology clinic in Newcastle, Australia.Possible predictors of suicidal attitude includeddemographic characteristics, disease status, mentalhealth (depression, anxiety, and prior suicideattempts), and quality of life. Results indicated thatthe majority of respondents supported euthanasia(79 percent) and physician-assisted suicide (69percent). Only 2 percent, however, had ever askedtheir physician for either euthanasia or physicianassistedsuicide. Active religious belief was the mostimportant predictor of attitudes toward all threesuicide-related behaviors (euthanasia, assistedsuicide,and personal support for euthanasia orassisted-suicide). Patients with an active religiousbelief were 79 percent less likely to have positiveattitudes toward euthanasia, 65 percent less likely tohave positive attitudes toward assisted suicide, and74 percent less likely to personally support euthanasiaor assisted-suicide (all highly statistically significant).Interestingly, depression, anxiety, recentsuicidal ideation, and history of suicide attemptwere unrelated to any of these three outcomes onceactive religious belief was take into account.5.1. Timely Psychiatric CareReligious beliefs and activities may also affectsuicide rates in other ways besides simply prohibitingsuicide. In particular, religious involvementmay increase the likelihood that personswith suicidal thoughts will obtain timely psychiatriccare. Members of the religious communityoften consider it an obligation to check on thosewho may be depressed or otherwise at risk forsuicidal thoughts. This may be particularly truefor those with medical illness or in other difficultlife situations obvious to members of theirfaith community. First, as noted earlier, the supportfrom members of the congregation may helpto reduce the negative emotions responsible forthe desire to commit suicide. Second, churchmembers may encourage people to seek professionalassistance for their problems before thoseproblems get to a point that suicidal thoughtsdevelop. Third, if suicidal thoughts are alreadypresent, then members of the religious communityare likely to encourage the suicidal personto seek professional help to relieve their distressor discover alternative ways of dealing with theproblem besides suicide.I Want to DieRichard is a 70-year-old retired businessmanwho lost his wife of forty-fiveyears, Ethyl, to cancer two years ago. He

198 Harold G. Koenighas chronic lung disease from years ofsmoking cigarettes, and drinks about threeshot-glasses of vodka every night to relaxand help him get to sleep. Richard and hiswife had few social activities during theiradult years, focusing most of their time ontheir children and work, although they didattend religious services regularly together.For many years, he served as an usher inhis Methodist congregation, although hehad to stop this activity about a year agobecause of health problems. Nevertheless,he continued to attend religious services,albeit on an irregular basis in recent days.Richard had not been doing well since hiswife passed away. He missed her terribly,especially when he would retire to bed atnight. She had slept there next to him forover four decades and now her side of thebed was empty. He also had a lot of shortnessof breath due to his worsening lungdisease and spent most of the day inside hishome watching TV and sleeping on-andoff.Becoming more and more depressed,Richard started having suicidal thoughts.He had a shotgun in the garage and beganthinking about using it to take his life.Around this time, a member of his church,Sam, called Richard on the telephone tofind out how he was doing. Sam hadn’t seenhim in church for the last two Sundays,and so had become concerned. Richardbroke down on the phone. He confessedto Sam that things had been really difficultfor him, and told him, “I just want to dieand be with Ethyl again.” Sensing Richard’sdistress, Sam told him that he was comingright over. When Sam arrived, he foundRichard sitting on the couch with a blankexpression on his face. When Richard sawSam, he broke into tears. After listening toRichard for a while, Sam insisted that hetake Richard to see his family physician.Richard reluctantly agreed. After talkingwith Richard and learning about histhoughts of dying, the family physiciancalled a psychiatrist colleague and made anappointment for Richard that afternoon.Sam assured the physician that he wouldtake Richard to the appointment.Religious involvement, however, does notalways increase the likelihood that persons at riskfor suicide will seek timely psychiatric care. Infact, religious beliefs may delay necessary psychiatriccare by encouraging treatments within thefaith community, thereby allowing depression orother psychiatric illness to worsen and suicidalbehavior to emerge. Lack of timely referral, ornegative attitudes within a religious congregationtoward psychiatric care, can be at fault for unnecessarysuicides.Depending on GodSherry is a 37-year-old unmarriedwoman who was recently diagnosed withrheumatoid arthritis. Due to the pain anddisability that this illness caused, she soughthelp from her pastor to cope. Her pastorencouraged her with scriptures from theBible, prayed with her, and suggested shebecome involved in a women’s group atchurch. After three months of counseling,however, Sherry felt no better. Her pain wasworse and the depression had become moresevere. In fact, she was so depressed that shedidn’t have the energy or the concentrationto pray, read the Bible, or get involved in thewomen’s group, which made her feel guiltyand like a failure. In fact, the depression gotso bad that she barely had enough desire toget up in the morning and drive to her jobas a department store clerk, which she wasdepending on to pay her bills. She had beenlate to work several times now, and wasfearful of losing her job.When she asked her pastor if perhaps sheshould seek professional psychiatric care,he encouraged her to “depend entirely onGod” for healing and suggested that herdesire to seek psychiatric care was a sign ofher weak faith. Soon, feeling trapped in a

Consultation-Liaison Psychiatry 199situation that seemed to be without escape,she developed suicidal thoughts and tookan overdose of pain medications. Luckily,she was found in time by a neighbor andrushed to the hospital, where she was successfullytreated for the overdose. ThereSherry was referred to a psychiatrist whobegan her on antidepressant medication.In four weeks, she was back to work andfeeling more like herself again. She foundanother church and became an activemember there.6. ANXIETY IN MEDICAL SETTINGSAlthough this topic is covered more fully inChapter 10, I address anxiety disorders here inthe context of medical illness, where CL psychiatristsare likely to be called on for assistance.Patients may have a variety of worries and fearswhen they are hospitalized with medical illness.Loss of control and feelings of helplessness driveanxiety in this setting. Patients are fearful of whattheir medical illness may mean for their ownfuture and the future of their families. They maybe worried about the results of lab tests or procedures.Some patients may become anxious afterbeing told about a disabling or terminal diagnosis.In some cases, the anxiety may become paralyzing,especially if patients have a history ofanxiety problems in the past.Religious beliefs may influence the type andthe severity of anxiety that patients experience.On the one hand, religious worries may centeron concerns about salvation, fear of hell, or guiltover becoming sick. Such patients may becomepreoccupied with religious worries or becomeinvolved in a frenzy of religious behaviors suchas compulsive prayer activity or repeated confessions.These behaviors may extend beyond “normal”kinds of religious involvement and becomepathological in nature.On the other hand, religious beliefs mayhelp medical patients cope with the anxietydue to medical illness, or if an anxiety disorderis present, help patients cope with the painand suffering that the anxiety causes. Religiousbeliefs and practices can give patients a sense ofcontrol over what is happening to them. Prayergives patients something they can do, which mayhelp to make a real difference in their situations.Patients may believe that prayer will physicallyheal their illness or give them the strength tocope with illness. The effectiveness of prayer inrelieving anxiety depends on the strength of thepatient’s religious belief, the specific kinds of religiousbeliefs as they relate to healing, and the useof prayer in the past as a coping behavior.Meditation may also help to relieve anxiety,although through a different mechanism thanthe kind of personal prayer described above.Personal prayer depends on the patient’s relationshipwith God and is heavily dependent oncognitive processes (for example, belief, commitment,and trust). Meditation in the Easternreligious traditions of Hinduism (transcendentalmeditation) or Buddhism (mindfulness meditation),however, involves more of a behavioralmechanism. The clearing of the mind and a repetitionof a sound, word, or phrase while sittingin a certain position, causes reflex relaxation –almost like biofeedback or progressive musclerelaxation – and if done consistently, can reduceanxiety or tension. This kind of meditation doesnot depend on a strong belief in, personal relationshipwith, or communication with God,but rather on a practice that involves a specificspiritual behavior that through physical proceduresresults in a deep, relaxed state. HerbertBenson has called this bio-behavioral reflex theRelaxation Response.(18)A number of randomized clinical trials haveshown that religious-based psychotherapy or psychotherapysupplemented by religious practices,may increase the speed of remission of anxiety,especially generalized anxiety disorder (GAD),which is common in medical settings. For example,Azhar and colleagues (19) randomizedsixty-two Muslim patients with GAD to eithertraditional treatment (supportive psychotherapyand anti-anxiety drugs) or traditional treatmentplus religious psychotherapy. Religious psychotherapyinvolved use of prayer and reading

200 Harold G. Koenigverses of the Holy Koran specific to the person’ssituation. Patients receiving the religious psychotherapyimproved significantly faster than thosereceiving traditional therapy.Likewise, Razali and colleagues (20) testedthe effects of a Muslim-based religious cognitivepsychotherapy (RCP) as a treatment forGAD in eighty-five religious and eighty nonreligiousMuslims. Religious and nonreligious subjectswere randomized to either the interventiongroup or to a control group. All subjects receivedstandard treatment for GAD including benzodiazepines(BZD), supportive psychotherapy, and/or simple relaxation exercises. Patients in theintervention group received cognitive therapythat included use of the Koran and Hadith (sayingsof Mohammed) to alter negative thoughtsand behaviors and to increase religiousness. Eachof the four groups (religious subjects receivingRCP, religious controls, nonreligious subjectsreceiving RCP, and nonreligious controls) wasassessed at four, twelve, and twenty-six weeksafter the start of the intervention. Results indicatedthat religious subjects who received RCPimproved significantly faster than religious controls.However, no difference was found betweennonreligious patients receiving RCP and nonreligiouscontrols. This study suggests that religioustherapies work best in religious patients.Finally, Zhang and colleagues examined theeffects of Chinese Taoist-based cognitive psychotherapy(CTCP) in 143 Chinese patientswith GAD.(21) Subjects were randomized toCTCP only (n = 46), benzodiazepines only (BDZ)(n = 48), or combined CTCP and BDZ treatment(n = 49). CTCP combined cognitive therapy andTaoist philosophy (using the thirty-two characterTaoist formula). Those in the CTCP and combinedgroups received one hour of CTCP weeklyfor four weeks and then twice monthly one–hoursessions for the remaining five months. Subjectsreceiving BDZ remained on the same dose ofmedication for the final five months of the study.Results indicated that patients receiving BDZtreatment alone experienced the most rapidreduction in GAD symptoms, but that these beneficialeffects were gone by six months. CTCPalone had little effect on symptoms in the shortterm(at one month) when compared to BDZtherapy, but showed significant symptom reductionby six months. Combined treatment withboth CTCP and medication showed symptomreduction at both one and six months. The majorproblem with this study was that the design madeit impossible to determine whether the religiousaspect of the cognitive therapy had anything todo with the benefits observed (because a secularcognitive therapy group was not included in thestudy to compare with the CTCP group).Finally, there is some evidence that cognitivetherapy in patients with panic disorderworks better if the patient is more religious (seeChapter 10). Patients with strong religious beliefsdepend on religious scriptures for comfort, particularlythose scriptures promising that they areloved and never alone, and that there is nothingto fear, even death itself. These are powerful cognitionsthat can counteract anxious thoughts thatmay contribute to panic or other severe anxietysymptoms.I’m AfraidJanet is a 27-year-old unm arried schoolteacherwho lives with her parents. She hasrecently been diagnosed with a rare formof breast cancer and is undergoing chemotherapy.Janet was in the hospital gettingher weekly chemotherapy when she wokeup suddenly in a panic. Her sister Sally, whowas sitting across the room reading, immediatelycame to her bedside and asked whatwas wrong. Janet frantically told her, “I’mafraid I’m going to die. I can’t get my breathand my heart is jumping out of my chest.Am I dying? Please help me!” The patient’ssister rang the patient’s call bell to alert thenurse on duty and then reached over andgently took Janet’s hand. Sally said, “Janet,let’s pray.” When Janet nodded consent,Sally said a short comforting prayer askingGod to calm her sister’s nerves, giveher a deep sense of peace, and let her knowthat God loved her, was with her now, andwould never leave her. Gradually, Janet

Consultation-Liaison Psychiatry 201began to calm down. Her breathing slowed,and she became less frantic. After about 10minutes, the nurse on duty came into theroom, apologizing profusely for her tardiness(there had been another emergencyon the ward and the nurse was preoccupiedwith that situation). By the time she arrived,however, Janet was feeling better and incontrol. The prayer had helped.7. SOMATOFORM DISORDERSSomatoform disorders are physical complaintsor signs for which no physical etiology can beidentified and are therefore thought to be due topsychological causes (that is, are somatic manifestationsof psychological pathology). Amongthe most common and well-known somatoformdisorders are conversion disorder, somatizationdisorder, and hypochondriasis.There is little systematic research on whethersomatoform disorders are more or less frequentamong religious persons compared with the nonreligious.Only four studies have examined therelationship between religion and somatization(two studies coming out of our research group).In the first of these, Chaturvedi and Bhandarireported religious differences in beliefs about theunderlying cause of psychosomatic complaints.(22) In a small sample of thirty-one psychiatricoutpatients (twenty-four Hindu, seven Muslims)in Bangalore, India, they found that Muslimswere more likely than Hindus to report that theirillnesses were the result of physical causes despitethe fact that they were told they were of psychologicalorigin.Second, a study by Koenig and colleaguesreported results from the North Carolina site ofthe National Institutes of Mental Health EpidemiologicCatchment Area survey (n = 2,969).(23) No difference was found in rates of somatizationdisorder based on any religious characteristic,including religious attendance, prayer/Biblestudy, religious TV/radio, importance of religion,religious affiliation, or “born again” status (the latterinvolves making a conscious commitment toturn one’s life over to God and live life in a waythat reflects the life of Jesus Christ). This is theonly study that examined a random sample ofcommunity-dwelling residents diagnosed withsomatization disorder using a structured psychiatricinterview (Diagnostic Interview Schedule) andusing DSM-III criteria.Third, in a study of 300 primary care patientsin Greece, Androutsopoulou and colleaguesfound that Muslims scored significantly higherthan Christians on the somatic complaints subscaleof the General Health Questionnaire, a differencethat persisted after controlling for othercovariates including gender.(24) It is not clear,however, what this finding means because complaintof somatic symptoms by primary carepatients does not necessarily indicate a somatizationdisorder.In the most recent study, Flannelly and colleaguesconducted an Internet survey of 1,403readers of Spirituality & Health magazine usingthe Symptom Assessment-45 Questionnaire,with a subscale that measures somatization.(25)They found no relationship between somatizationand frequency of religious attendance orreligious fundamentalism. Although a weak positiveassociation was found between frequency ofprayer and somatization, there was also a weaknegative association between belief in an afterlifeand somatization. Overall, then, there is littleevidence for a relationship between somatizationdisorder and religious involvement.Although not associated in general, a connectionbetween somatization disorder and religionmay sometimes occur, even if not very frequently.Such cases received an unusual amount of attentionduring the late nineteenth century because ofhistorical trends at the time they were reported.During this period, the French Revolution hadsucceeded in throwing off the last vestige of religiousinfluence. This is when the famous Frenchneurologist Jean-Martin Charcot claimed thatthere was a connection between religion, hysteria(a form of conversion disorder), and otherneurological illnesses.(26) Charcot emphasizedthe physical positioning and posture of Catholicsaints as depicted in famous religious paintings

202 Harold G. Koenigfrom the early Middle Ages through the seventeenthcentury. Using more than five dozen illustrations,he argued that the Catholic mystics inthese paintings were actually examples of hysteria(St. Catherine of Sienna being the prototype).(27) Paintings of saints in positions of prayer andeven those of the crucifixion were said to illustratehysteria. In some cases, Charcot actually claimedthat these saints were suffering from opisthotonus(a severe hyperextension of the head in which thehead, neck, and spinal column enter into a bridgingor arching position). Charcot believed thatthe ecstatic states of the religious in these greatworks of art were manifestations of psychopathology.A more detailed and fascinating discussionof this topic is provided elsewhere.(28) Charcot’swritings and teachings are particularly relevantbecause Freud would later train under Charcot,and the development of Freud’s negative viewstoward religion could have been due to Charcot’sinfluence.Might religious beliefs contribute to thedevelopment of some kinds of somatoform disordersas Charcot argued and Freud would lateremphasize? Examples of physical manifestationsof psychological conflicts related to religioninclude the phenomenon of stigmata, where aphysical wound (or bleeding) appears spontaneouslyon the body of a religious person in thesame location as the wounds suffered by Jesus.(29, 30) The Italian priest, Padre Pio, is reportedto have had stigmata on his hands, feet, side, andchest.(31) Other more contemporary examplesof physical manifestations of spiritual-psychologicalforces might include the “faint” thatoccurs when someone is “slain in the spirit” ata Pentecostal healing service (where the ministerplaces his hand on the forehead of a memberof the congregation, who then faints and falls tothe ground) or perhaps even the manifestationof “speaking in tongues.” While not examplesof somatoform disorders, they do illustrate howphysical manifestations may occur as a result ofreligious beliefs acting through psychologicalphysiologicalprocesses.There have also been reports of more seriousreligion-related conversion disorders thatinterfere with functioning and cause great distressand suffering. According to DSM-IV , conditionsthat occur in a specific religious or culturalcontext are diagnosed as “culture-bound syndromes,”and are often characterized by dissociationand seizure like manifestations.Please Don’t Kill MeSarah is a 24-year-old married, unemployedPuerto Rican woman, with twochildren ages two and four. She presentedto a neurologist with the complaint of “seizures”that were completely incapacitatingher. Sarah was diagnosed with tonic-clonicgeneralized seizures and treated with carbamazepine.Despite this treatment, shecontinued to have seizures two or threetimes per week. She would typically have aheadache, and then soon afterward wouldbecome unconscious and begin tonic-clonicmovements, which would last for aboutten minutes. After arousing, she wouldnot recognize family members and wantedto leave the home. After the seizures, shewould sometimes hallucinate a threateningfemale figure and was observed by familymembers to be begging, “Please don’t killor harm me.” Further history revealed thattwo years before the seizures began, at theage of 17 years old, Sarah witnessed thesuicide of her grandmother, who burned todeath when she set fire to her home. Sarahfelt guilty over this because she thoughtthat if she had alerted people sooner, theycould have saved the grandmother’s life.When asked to explain her behaviors,Sarah said that she and her family believedin espiritismo (Spiritist religion) and participatedin séances. They believed that disturbedspirits could take possession of theliving, especially spirits of persons who haddied a violent death. Such spirits could lingerindefinitely in space and attack peopleto extract revenge. After twenty-two treatmentsessions in psychotherapy over severalmonths and nearly a year of follow-upwith less frequent sessions, her psychogenic

Consultation-Liaison Psychiatry 203seizures nearly completely subsided. Thispatient’s story is based on a case reportedin the literature.(32)The resolution of this case depended on thetherapist addressing the patient’s symptomsfrom her religious viewpoint. The therapist onlygradually introduced the notion that there wereother possible explanations for her symptoms,including unresolved guilt over the death of hergrandmother. The therapist also used rituals inline with espiritismo beliefs to help the patientassist the grandmother out of her trapped placein the spirit world and on to a more peaceful andrestful existence.8. PAINThe topic of religion often comes up when talkingabout pain and suffering. In fact, many ofthe world’s great religions may have arisen inresponse to the difficulties that self-conscioushumans faced when struggling with difficult lifeand death situations. These religions all addresssuffering as a central part of their rituals andtheological traditions. Religious beliefs may be acause for, a response to, or a way of coping withpainful medical conditions, and consultationliaisonpsychiatrists need to be familiar with howreligion and pain interact and are connected.First, religious beliefs, particularly if rigid andinflexible, may worsen pain. Religious patientsmay feel guilty for having a painful condition andseek to understand why God is allowing them tosuffer so. They may feel that God is punishingthem for past sins, or doesn’t care, or isn’t ableto make a difference in their pain. Such religiouscognitions may worsen the patient’s psychologicalstate, which can exacerbate the pain, addingspiritual suffering to physical suffering. Althoughsuch “negative religious coping” in response topain is not particularly common in medical settings,(33) it does occur, and patients need to beasked about it. Pastoral care referral is often necessaryto help patients deal with such religiousstruggles.Second, and much more common in medicalpatients, is that religion is turned to in anattempt to cope with the pain. Patients may pray,read religious scriptures, or engage in religiousrituals to help them deal with pain, especially theemotional consequences of the pain, that is theanxiety, sense of helplessness, and hopelessnessthat chronic pain frequently causes. The followingclinical case, which illustrates the positiverole that religion can play in coping with pain,appeared a few years ago in the Journal of theAmerican Medical Association . This is a real case,although the name has been changed to ensureconfidentiality.I PrayMargaret is an 83-year-old widowedwoman who sees a physician in Boston,Massachusetts. Her doctor is an attendingphysician at Beth Israel Deaconess Hospitaland is a professor of medicine at HarvardMedical School. Margaret has multiplechronic medical problems, includingadvanced diabetes mellitus and hypertension.The diabetes is probably the cause fora diffuse polymotor and sensory neuropathythat has resulted in chronic, progressivepain. Margaret has had chronic pain foralmost fifteen years now, and the pain hasproven resistant to most traditional treatments,including gabapentin, topiramate,mexiletine, tramadol, rofecoxib, celecoxib,acetaminophen, codeine, oxycodone, and afentanyl patch. The pain appears to be neuropathicin nature and is narcotic-resistant.Her neurologist has signed off the case, sayingthere is nothing more he can do for her.When she goes to see her internist, the doctordoesn’t have much to offer her. Most ofthe time, Margaret and her doctor just sitand talk about her pain and the challengesshe faces with functioning, because littleelse can be done. Despite her long-standingchronic pain, Margaret is doing well from apsychological standpoint. She is optimistic,hopeful, and positive in her outlook. Whenher doctor asks her how she maintains such

204 Harold G. Koeniga positive attitude, she says that religionhelps. Here are her words:I don’t dwell on the pain, you know. Somepeople are sick and have pain, and it gets thebest of them. Not me. Praying eases the pain,takes it away. Sometimes I pray when I am indeep, serious pain; I pray, and all at once thepain gets easy. Praying helps me a lot. I feelthat has helped me more than the medication.A doctor is a doctor. Not everybody isbound to believe in God. It’s your own mind,your thought, and your belief. The doctorgives you medicine. God works through thedoctor. He is a great physician and He heals,but you have to believe. I believe in God.He’s my guide and my protector. Wheneveryou pray, you will get healing from God. Youwill. But you must have that belief. Becauseif you don’t believe in God and turn your lifeover to Him, it’s nothing doing. You can’t justpray, “God, I’m suffering, and I ask You toheal my body.” It don’t work like that. Youhave to really be a child of God.(34)The role of religion in coping with pain isdescribed above from a Judeo-Christian religiousperspective. Religious coping, however, isnot restricted only to this faith tradition. All theother major world religions – Islam, Buddhism,Hinduism, and the Chinese religions – addressthe problem of pain and suffering in their uniqueways. Patients from Eastern religions may seekto detach themselves from the pain (or from theneed to be free of the pain). In these traditions,pain may be given meaning and purpose by associatingit with “karma.” By suffering willingly andbravely, this will ensure a better, happier life intheir next rebirth. Eastern meditative practices,such as “mindfulness” meditation in the Buddhisttradition or “transcendental” meditation in theHindu tradition, may further help to relieve painby focusing the mind elsewhere, thereby blockingpain pathways in the brain.For example, Kabat-Zinn and colleagues (35)described the effects of mindfulness meditation aspart of a Stress-Reduction and Relaxation Program(SRRP) in ninety highly screened chronic painpatients. The intervention was carried out overten weeks (there was no control group, so thiswas an observational study only). Comparison ofmeasurements before and after the SRRP interventionshowed a statistically significant reductionin pain, mood disturbance, and psychologicalsymptoms. Furthermore, pain-related drug usedecreased and self-esteem increased. Effects wereindependent of sex, source of referral, and type ofpain. Although there was no true control group,the course of symptoms in patients receiving theSRRP intervention was compared to a parallelgroup of patients being seen in another pain clinic(n = 21). The comparison patients did not showsimilar improvement after treatment with traditionalprotocols. Improvements in pain in SRRPpatients were maintained for fifteen months forall but one measure of pain.Religious involvement may also help to reducethe secondary complications seen in chronic painpatients, including substance abuse (alcohol andillicit drug use) and pain medication addiction.By providing an alternative coping behavior thatis under the patient’s control, there is less of a needfor these more self-destructive behaviors. Many,many studies show an inverse relationship betweenreligious involvement and substance abuse. In ourreview of this literature, eighty-six studies examinedthe relationship between religious involvementand alcohol; seventy-six of those studiesfound significantly lower alcohol use, abuse, andaddiction in those who were more religious.(36)The findings are even more striking for illicit drugaddiction. Of the fifty-two studies that examinedreligiousness and drug use, forty-eight found thatthose who were more religious were less likely touse drugs. Although I’m not aware of any studiesof religion and substance abuse in chronic painpatients, the general relationship is likely to holdtrue for these patients as well.Religious beliefs and practices may eitherspeed the resolution of pain or reduce the perceptionof pain. The Kabat-Zinn study abovefound that pain symptoms were improvedafter ten weeks of mindfulness meditation andrelaxation. Eastern meditation, however, is not

Consultation-Liaison Psychiatry 205the only religious practice associated with painreduction. For example, Christian prayer wasexamined as an intervention in the treatmentof pain in patients with advanced rheumatoidarthritis. Matthews and colleagues conducteda randomized clinical trial designed to examinethe effects of in-person intercessory prayerministry (IPM) as an adjunct to standard medicalcare for patients with rheumatoid arthritis.(37) Forty patients (82 percent female, all-white,mean age 62) who had active rheumatoid arthritiswere given a three-day IPM intervention thatincluded six hours of instruction and six hoursof direct-contact prayer (“laying-on-of-hands”).Subjects were assessed at three and twelve monthspost intervention. Before and after comparisonsrevealed significant overall improvement(p < 0.0001), with sustained reductions in tenderjoints (seventeen versus six), swollen joints(ten versus three) (p < 0.001), self-reported pain(p < 0.004), fatigue (p = 0.007), and functionalimpairment (p = 0.007). Number of tender jointswas less in the prayed for group compared tosubjects randomly assigned to a waitlist controlgroup at six months (p = 0.02).9. DEMENTIA, AGITATION, BEHAVIORALDISTURBANCEPsychiatrists are often called to acute care hospitalsor long-term care facilities to see patientswith delirium, agitation, and/or psychosis. Theseconditions can be due to dementia, side effects ofmedication, or an underlying undiagnosed medicalor psychiatric illness. Assuming that medical ormedication side effects are not the cause, what canbe done? Usually, the psychiatrist will prescribe anantipsychotic or a sedative (benzodiazepine) tocalm the patient down. Unfortunately, these medicationsall have major adverse side effects thatinterfere with quality of life and may cause directinjury to the patient because they reduce alertnessand impair balance, and antipsychotics can havenegative neurological, cardiovascular, and metabolicconsequences. Is there anything else that canbe done besides tranquilizing these patients withdrugs? Might religion help out in this regard?Although there has been no systematicresearch on this topic, there are a plethora of casereports from nurses and other clinicians in longtermcare settings who report that religious interventionsmay be useful in such circumstances,particularly if the patient is religious. Theseinterventions include holding religious services,singing religious hymns, praying with, or readingreligious scriptures to patients (the Psalms,for example).I’m ScaredHilda is an 86-year-old patient in anursing home. She was diagnosed withAlzheimer’s disease about five years ago.After a couple years, she became unableto care for herself, forcing her family toput her in a nursing home. Hilda is oftenagitated, especially when the nurses try togive her a bath in the morning. She is alsoparanoid and believes that the nurses arestealing from her and may even be poisoningher food. When she gets agitated, shesometimes strikes out at the nursing staffand may even assault other residents ona rare occasion (slapping them). Duringagitation spells, she refuses all of her medication,including the low dose antipsychoticthat the psychiatrist prescribed forher agitation and paranoia. When askedwhy she would not cooperate with thenursing staff, Hilda’s only response was,“I’m scared.”One day when Hilda was having one of herfits during the morning bath, the nurse’saide caring for her began to quietly sing areligious song (“Amazing Grace”). To hersurprise, Hilda began to sing along withher. As she sang, she calmed down andbecame much more cooperative. Furtherhistory from the family revealed that Hildahad been a devout church member whenshe was younger and served as a member ofthe church choir for many years. Once thenursing staff learned about the aide’s experience,whenever they wanted Hilda to calm

206 Harold G. Koenigdown or cooperate with care, they wouldquietly sing “Amazing Grace” with her.When patients with dementia have a religiousbackground that includes a heavy emphasis on rituals(if Catholic, for example, saying the rosary orreceiving communion), then engaging the patientin such rituals or prayers may help to reduce agitationand increase cooperation. Repeating theTwenty-Third Psalm or the Lord’s Prayer with thepatient may have the same effect. Again, however,a thorough religious history is necessary from thepatient (or from the family, if the patient cannotremember or communicate). Several types of religiousinterventions may need to be tried, althoughfinding out which religious behaviors, rituals,prayers or hymns, were particularly meaningful tothe patient will probably be most successful. If thepatient has never been particularly religious, however,such interventions are unlikely to help.Religion can also assist patients cope with thestress involved in the development of dementia,especially the early stages when patients still haveinsight into what is happening to them. This isa time when emotional distress (depression oranxiety) is common. If religion has been of valueto patients in the past, then it may be used to helpcalm them as they recognize that they are losingcontrol. Praying with patients, reading religiousscriptures to them, or singing favorite religioushymns may all serve to calm their emotions,just as described above for patients with moreadvanced dementia with agitation.There is even some evidence suggesting thatreligious involvement may forestall the developmentof cognitive impairment in older adults(38) or may slow its progression in Alzheimer’sdisease.(39) Because depression and high stressmay increase levels of serum cortisol, andbecause cortisol has adverse effects on the brain(particularly on the large pyramidal cells in thetemporal lobes), (40) a mechanism does exist bywhich religious involvement could help to preservememory functions. By reducing depressionor speeding its remission, and/or decreasingstress levels, religion could prevent the increasein serum cortisol that adversely affects braincells. Lower cortisol or healthier cortisol rhythmsamong those who are more religious have alreadybeen demonstrated in several studies.(41–43)Whether or not religious involvement helpsto prevent cognitive decline in normal aging ordementia, we know that such involvement can behelpful to those caring for patients with dementia.It is often the caregiver who brings the patientwith dementia to see the psychiatrist, and level ofcaregiver burden is a strong predictor of whetherpatients with dementia can be cared for at home(versus placement in a nursing home). Caregiverstress also affects both the mental and physicalhealth of the caregiver. A number of studies havedemonstrated that religious beliefs and practicesare associated with lower caregiver stress.(44–46)Religious belief often gives the caregiver a senseof meaning and purpose in their caregiver dutiesand provides a community of support that canhelp counteract the isolation and loneliness ofthe caregiver role.10. SUBSTANCE ABUSEPsychiatrists are often called in when medicalpatients are withdrawing from alcohol or illicitdrug use. Co-morbid substance abuse is widespreadamong patients with chronic physical healthproblems, as self-medication with these substancespromises at least temporary relief of their suffering.What is the role of religion in substance abuse disorders,and how might religious factors influencethe management of these patients?First, as noted earlier, there is a large research literatureshowing that religious persons are less likelyto abuse alcohol and drugs. The result is that theseconditions are less likely to be a problem in patientswho are more religiously involved. Religious involvementfrom an early age helps to prevent the onsetof alcohol/drug abuse and addiction. Furthermore,it provides an alternative coping behavior (prayer,scripture reading, rituals, and community support)that can counter the stress that may drive people touse these substances. In addition, religious experiencesand spiritual interventions have been shownto be effective in helping persons recover from substanceabuse and addiction. In a study published in

Consultation-Liaison Psychiatry 207the American Journal of Psychiatry in 1953, Lamerereported, “In the generations covered by this survey,religion was often a powerful force in promotingabstinence [from alcohol] and 13, or 24% of these53 who quit [outside of a terminal illness], did soin response to spiritual conversion.” (47) In his classicstudy of the life history of alcoholics, Harvardpsychiatrist George Vaillant likewise notes, “In thetreatment of addiction, Karl Marx’s aphorism ‘religionis the opiate of the masses’ masks an enormouslyimportant therapeutic principal. Religionmay actually provide a relief that drug [and alcohol]abuse only promises.” (48)Spiritual principles of recovery have beenoperationalized in AA and NA. These programs,run by recovered substance abusers, have beenenormously successful worldwide. The key tothat success have been the following factors:1 Admission of powerlessness (that the addictedperson does not have within them the powerto overcome their problem alone; that is,“I have sinned and cannot beat this problemon my own”)2 Surrender to a Higher Power (for many, thisis God, and such surrender involves religiousconversion; however, this is not always thecase)3 Commitment to help other brothers or sisterswith alcohol addiction by supporting themand helping them to remain sober (that is,“love thy neighbor”)Thus, from a religious view, the process is confession,surrender, and loving others – often consideredthe key and most essential doctrines ofthe religious faith (at least in the Judeo-Christiantradition).Thus, in managing patients with substanceabuse problems, the psychiatrist may considerreferring these patients to an AA or NA group.If those groups are not readily available, thensimilar resources should be identified and theaddicted person connected to them. The faithcommunity often provides supportive relationshipsnot centered on drinking alcohol or use ofdrugs as the addicted person’s prior communityof support was. Getting away from relationshipswith other active substance abusers may be key tomaintaining sobriety.11. RELIGION AS A DETERRENTTO PSYCHIATRIC CAREAlthough religious beliefs and practices may helpmedically ill patients and their families to copewith the stress of medical illness, they can sometimeslead to the avoidance of mental health care.Although I have already discussed this above inthe example concerning suicidal risk, I will elaboratefurther here because the potential for conflictis so serious. Given the long and generally antagonisticrelationship between religion and mentalhealth professionals, beginning with Freud in theearly 1900s, devoutly religious patients may avoidpsychiatric treatments with medication or psychotherapy.They may argue that praying, trustingin God, reading the Bible or other religiousscriptures, and going to religious services is allthat is necessary to cope with the stress of medicalillness, and the need to seek professional mentalhealth care may be viewed as having insufficientfaith or religious commitment. Although todaythis is becoming less common and occurs primarilyin small fundamentalist religious groups,such negative views of psychiatry and mentalhealth care may be subtle and prevent or delaypsychiatric care. For example, clergy may providecounseling to persons with chronic medicalillness without recognizing the development ofsevere depression or suicidal thoughts, resultingin a delay in referral for antidepressant treatment.Although no systematic research exists on howfrequently this occurs, anecdotal cases and newsreports illustrate the disastrous consequences thatcan result.Just Pray MoreCatherine is a 36-year-old housewifeand mother. She has three children, allunder the age of 5 years. Catherine firstnoticed that she was becoming depressedafter the birth of their third child when shebegan experiencing extreme fatigue, lack

208 Harold G. Koenigof motivation, and a voracious appetite. Itgot to the point that when the baby cried atnight, she was unable to get up to changethe baby’s diapers and feed him. Instead,she begged her husband to do so. She alsostopped making meals for the family andspent most of the day either in bed or sittingin front of the television set. Catherine andher husband are members of a fundamentalistChristian community in Houston,Texas. Her husband, getting more and moreupset over Catherine’s condition, took herto see their pastor. The pastor began counselingwith Catherine, encouraging her tojust pray more, read the Bible regularly,and attend religious services every week.He also asked her about any sin in her lifeand emphasized her need to confess the sinbefore she would feel better. Despite thevisits with her pastor, she became more andmore depressed. Catherine’s husband askedthe pastor if he should take her to see psychiatrist,given that she was doing worse.The pastor discouraged him, saying that allCatherine needed to do was put her entirefaith in God, confess her sin, and pray andthat seeing a psychiatrist was equivalent toputting her faith in man instead of in God.12. RELIGION AS A FACILITATOROF PSYCHIATRIC CAREOn the other hand, involvement in most mainstreamreligious groups can also increase thelikelihood of early detection of mental illnessand facilitate psychiatric referral. Increased levelsof support and contact with other membersof a faith community can result in early detectionand encouragement to seek care. Religious people,because they have relationships with otherswithin their community, are less able to avoidseeking help because others are more likely to bechecking on them, calling them, visiting them, orseeing them during religious activities.Religious involvement may also encouragecompliance because religious people are taught torespect authority and to be responsible. Biblicalscriptures encourage the faithful to do as those inauthority tell them:Obey your leaders and submit to theirauthority. They keep watch over you asmen who must give an account. Obey themso that their work will be a joy, not a burden,for that would be of no advantage toyou. (Heb. 13:17) 1Everyone must submit himself to the governingauthorities, for there is no authorityexcept that which God has established. Theauthorities that exist have been establishedby God. (Rom. 13:1)Psychiatrists and other mental health professionalsmay be seen as authority figureswhose instructions must be followed, increasingpatients’ likelihood of compliance with medicationand psychotherapy. Furthermore, if psychiatricillness is viewed as a biological illness thatrequires treatment, then scriptures that advocaterespect for the body (which the brain is obviouslypart of) may enhance compliance with medicaltreatments:Don’t you know that you yourselves areGod’s temple and that God’s Spirit lives inyou? If anyone destroys God’s temple, Godwill destroy him; for God’s temple is sacred,and you are that temple. (1 Cor. 3:16–17)Finally, religious values promote a responsiblelifestyle. Religious persons may see themselvesas having been given the gift of life and specialtalents that they must use to serve God and theirfellow humans, rather than bury those talents.(See Matthew 25:15–28.) Because good mentalhealth is necessary to fully use one’s talents, religiouspersons may be more willing to seek andcomply with treatment when their mental healthis compromised.1All citations from the Holy Bible are from the NewInternational Version (NIV).

Consultation-Liaison Psychiatry 209I Need HelpGeorge is a 46 year-old electrician whoattends a local Baptist church with his wife.George is a deacon in the church and makesregular mission trips to Guatemala to helpbuild houses for poor families. One day atwork when fixing a transformer on an electricalpole, he tripped on a loose wire andfell about thirty feet to the ground, landingon his side. George was hospitalized withfive broken ribs, a crushed pelvis, a fracturedfemur (upper leg) and radius (wrist).After surgical stabilization of his fractures,he was transferred to the rehabilitation sectionof the hospital. Recovery was slow, andafter about six weeks of little improvement,George got discouraged and start to giveup hope that he was ever going to recoverenough to go home and resume his workand ministry. Actually, his physical recoverywas right on schedule, and now it washis emotional state that was holding himback. One day, he told his physical therapist,“I need help. I’m so discouraged that Idon’t want to try any more. But I know thatGod has a plan for my life, and I won’t beable to live out that plan unless I started tofeel better.” The therapist asked George ifhe would mind if the therapist spoke withhis physician and ask him to obtain psychiatricconsultation. George replied, “If apsychiatrist can do something to make mefeel like praying again, reading the Bible,and getting back on the mission field, thenI want to see him.”Systematic research has examined the relationshipbetween religious activity and use of mentalhealth services. For example, investigators analyzeddata from the 2001–2003 National Surveyon Drug Use and Health to examine the relationshipbetween religion and use of mental healthservices.(49) Two large subgroups were identified:those with moderate (n = 49,902) and withserious mental illness/emotional distress (n =14,548). Sophisticated probit models were usedto examine past twelve-month use of outpatientmental health care and prescription medications.Religious measures were frequency of religiousattendance, strength of religious beliefs, andinfluence of religious beliefs on decisions. Othervariables controlled in the analyses were DSM-IVdisorders, symptoms, substance use and relateddisorders, self-rated health status, and sociodemographiccharacteristics.Researchers found that in those with moderatemental illness/emotional distress, there wasa positive relationship between religious attendanceand increased outpatient mental healthcare use; however, importance of religious beliefswas inversely related to outpatient use. In thegroup with serious mental illness/emotional distress,religious attendance and importance ofreligious beliefs were both positively related tooutpatient mental health service use and medicationuse; however, influence of religious beliefson decisions was inversely related to outpatientmental health services. The authors concludedthat these findings argued against the widespreadnotion that religious involvement discourageduse of mental health services, especially amongthose with serious mental illness.Other research that has examined the relationshipbetween religion and use of mental healthservices is the NIMH Epidemiologic CatchmentArea Survey (the first large community studyto determine rates of psychiatric illness in thecommunity based on criteria established in theDSM ).(50) This study reported that Pentecostals(fundamentalist Christians) in North Carolinawere less likely to use psychiatric services thanmainline Protestants. However, when analyseswere stratified by frequency of religious attendance,the low rate of mental health services usewas almost completely confined to Pentecostalswho attended religious services infrequently. Infact, despite a 30 percent prevalence of mentalillness in this subgroup of Pentecostals, not asingle person had seen a mental health professionalin the previous six months. In contrast,Pentecostals who attended religious services atleast weekly used mental health services at twoto six times the rate of other Protestants. In fact,Pentecostals who attended church frequently

210 Harold G. Koenigused these services more appropriately (that is,those with diagnosed mental illness sought mentalhealth services, while those without mentalillness were unlikely to seek such services). Thus,even among fundamentalist religious groups,those who are active in their faith community usemental health services as much or even more frequentlythan those from more mainline or liberalreligious traditions (and use those services moreappropriately).The psychiatrist may also wish to expand thespiritual history to obtain a deeper understandingof the role of the patient’s religious/spiritualbeliefs in health or pathology. (See Spirituality inPatient Care for a more in-depth spiritual historyfor the mental health patient.(51) ) If any issuescome up that the psychiatrist is not familiar withor competent to address, then referral to a chaplain(in the hospital) or a trained pastoral counselor(in the community) is indicated.13. WHAT SHOULDPSYCHIATRISTS DO?What should the CL psychiatrist do with thisinformation? How might it change his or herassessment and management of the patient? Inmy discussion above, I inferred numerous waysthat psychiatrists could take advantage of theinformation presented in this chapter. However, Isuccinctly summarize here some common assessmentand management strategies.13.1. Take a Spiritual HistoryThe initial assessment of the medical patientshould always include a spiritual history as partof the social assessment. The following questionsshould be asked:■■■■■■What is the patient’s religious or spiritualbackground (denomination, faith tradition)?Is religion/spirituality used to cope withstress?Is religion/spirituality a source of support or acause of stress and conflict?Are there religious/spirituality beliefs thatmight influence psychiatric care or conflictwith psychiatric treatments (psychotherapyor medication)?Is the patient a member of a religious/spiritualcommunity, and is that community supportiveor nonsupportive (and how)?Are there any spiritual needs that someonewith expertise in pastoral care could helpaddress?13.2. Take a Spiritual Historyfrom Other SourcesIf the patient is unable to give a spiritual historybecause of altered mental status or dementia, thentake the spiritual history from family, friends, orthe patient’s minister. Note, however, if obtainingthe history from anyone but a competentpatient, it is necessary to obtain approval fromthe patient’s power of attorney (POA) for healthcaredecisions or guardian. If this person knowsthe patient well (such as a family member), thePOA/guardian would be the recommended personto obtain the spiritual history from. Becausethis is a delicate and personal area, special careneeds to be taken when exploring spiritual issueswith anyone but the patient.13.3. Anticipate Religious ResistancesSome patients will use religious beliefs as a defenseagainst making needed life changes for health andgrowth or as a defense against taking medicationwith unpleasant side effects. For example, bipolaror schizophrenic patients may refuse mood stabilizersor antipsychotics on religious grounds, whenin reality they simply don’t like the side effects ofthese medications. This also applies to treatmentsfor medical disorders. The hypertensive patientmay refuse blood pressure medications for similarreasons, claiming that God will heal him orher (or that God’s will be done). Religious teachingsmay also be used to avoid changing behaviorsthat are adversely affecting mental or socialhealth. For example, the patient with an obsessiveor compulsive personality is involved in so much

Consultation-Liaison Psychiatry 211religious activity in church that he or she neglectsdependent family members, causing social strife.Another example might be the refusal of psychotherapybecause of a desire to rely entirely on religioustherapies.13.4. Acquire Psychodynamic InsightsTaking a detailed and thorough spiritual historycan provide psychodynamic insights that maybe useful in psychotherapy. Although less of anissue for the medical patient than for the psychiatricpatient, in medical patients with a historyof psychiatric problems, this will be relevant. Thestress of medical illness may trigger deep-seatedpsychological conflicts, especially those regardingdependency, which could cause agitation andirritability sufficient to interfere with medicalcare (or may even precipitate suicide).Religious issues related to image of God, derivedfrom unhealthy parental relationships, may needto be addressed. Religious guilt over past lapses injudgment may surface at this time, as patients fearretribution in the next life. Childhood abuse maygive rise to shame and feelings that patients arenot “good enough” to receive God’s love, mercy,and blessings. Some religious patients may bedistressed over thoughts that God is punishingthem, has deserted them, or is powerless to makea difference in their situation. Research shows thatreligious conflicts of this nature may affect themedical condition of the patient and even lead topremature mortality.(52)13.5. Respect Religious BeliefsThe psychiatrist should always and at all timesshow respect for patients’ religious beliefs. This iseven true for patients whose religious beliefs areconflicting with medical or psychiatric care. Bearin mind that these beliefs are usually intensely heldand serve a variety of psychological functions, somehealthy and some unhealthy. Even if unhealthy,however, the psychiatrist must establish a therapeuticalliance with the patient before attemptingto change or alter those beliefs. Showing respect forpatients’ religious beliefs will facilitate the developmentof that alliance and allow the psychiatrist tolater challenge unhealthy beliefs if necessary.13.6. Support Religious BeliefsIf the patient’s religious beliefs are generallyhealthy (and the vast majority of nonpsychiatricmedical patients’ religious beliefs will be healthyand adaptive), then the psychiatrist should considersupporting those beliefs. Bear in mind thatthe psychiatrist is being asked here to support thepatient’s religious beliefs, not introduce new beliefsor proselytize his or her own beliefs. Support forpatients’ religious beliefs can be conveyed in manyways, both verbally and nonverbally. Efforts toensure that patients’ spiritual needs are being metand that religious resources are made available areimportant ways of demonstrating support.13.7. Use Religious Beliefsin CounselingSome psychiatrists with pastoral training maydecide to use the patient’s religious beliefs as partof therapy. This is particularly true with medicalpatients who are dealing with overwhelming situationalstressors related to illness, disability, pain,and other medical symptoms (and the patient’spsyche is relatively healthy). Integrating religiousbeliefs into psychotherapy should only be donewith religious patients and would not be usefulfor nonreligious patients in most circumstances.Research shows that such integration (as in religiouscognitive-behavioral therapy) is most effective forreligious patients, (53) and may not be effectivein the nonreligious.(20) The religious patient willlikely be quite responsive and appreciative to suchintegration, whereas the nonreligious patient maybe offended. On the other hand, integrating religioninto psychotherapy can be done whether thetherapist is religious or not. In fact, some researchshows that religious cognitive therapy is moreeffective if delivered by nonreligious therapists thanby religious therapists.(53) The reasons for this arenot entirely clear. Perhap nonreligious therapistsin this study were more objective, more acceptingand less judgmental, or more rigorously applied the

212 Harold G. Koenigreligious therapy according to protocol because itwas less familiar to them.13.8. Prescribe Religious Beliefs/ActivitiesPrescribing religious beliefs or practices for nonreligiouspatients is not recommended. This canbe viewed as coercive and should be avoided.If the patient is religious and is using religiousbeliefs to cope, then pointing out the benefits ofreligious practice as demonstrated repeatedly inthe research literature as described here, wouldbe supportive and encouraging to the patient.Doing so with nonreligious patients, however,would not be supportive in most cases and confusingand upsetting, particularly in patientsstruggling with medical stressors.13.9. Collaboration with Chaplains,Pastoral Counselors, and CommunityClergyThere will be many instances when the psychiatristwill wish to seek assistance or counsel froma chaplain or pastoral counselor in the managementof religious patients. This would be particularlytrue when religious conflicts are present orwhen religion is important to the patient and thepsychiatrist is unfamiliar with the patient’s religionor uncomfortable dealing with it. In hospitalsettings, chaplains are readily available to assistin this way and are trained to address religious/spiritual issues from a multifaith perspective.Of course, the psychiatrist must obtainapproval from the patient before bringing in areligious professional. Many patients, however,may not understand what chaplains or pastoralcounselors do or the type of training thatthey receive to address emotional and spiritualissues. Thus, the psychiatrist should explain thisto the patient, and if the psychiatrist doesn’tknow the competencies of a chaplain/pastoralcounselor, then further information should besought (see Spirituality in Patient Care ).(51) Insome instances, the mental health professionalwill want to include the patient’s clergy, especiallyif (1) chaplains or pastoral counselors areunavailable, (2) the patient prefers, and/or (3)the religious tradition of the patient is not wellknown.14. CONCLUSIONSPsychiatrists will often be called on to see medicalpatients with psychiatric disturbances, especiallyas our population ages and the number of personswith chronic, disabling medical conditionsexpands. Medical physicians without specialtraining and expertise in these matters will callon psychiatrists to assist them in the managementof patients with emotional disorders suchas depression and anxiety related to difficultiescoping with medical illness. Psychiatrists will alsobe consulted on issues related to somatoform disorders,chronic pain syndromes, agitation, behavioraldisturbances, and substance abuse. Religiousbeliefs and practices play a key role in enablingmany medical patients to cope with overwhelmingcircumstances. They may also play a role inother psychiatric disorders as well, either as aresource or as a liability. Religious beliefs mayfacilitate psychiatric care and compliance withtreatment, or they may conflict with and impedepsychiatric care. CL psychiatrists and other mentalhealth professionals working in medical settingsneed to learn about the religious/spiritualbeliefs of patients by conducting a thorough anddetailed spiritual history, findout what to do withthis information, and recognizing when pastoralcare collaboration or referral is necessary.REFERENCES1. Leigh H , Streltzer J . Handbook of Consultation-Liaison Psychiatr y . New York, NY : Springer ;2007 .2. Karasu TB , Plutchi k R , Stei nmu l ler R I , C onteH , Sie gel B . Patter ns of psychi at r ic c onsu lt at ion i na general hospital . Hosp Community Psychiatry .1977 ; 28 : 291 –294.3. Callegari CM , Menchetti M , Croci G , Beraldo S ,Costantini C , Baranzini F . Two years of psychogeriatricconsultations in a nursing home: reasonsfor referral compared to psychiatrists’ assessment .BMC Health Serv Res . 2006 ; 6 : 73.4. Ko enig HG , G e orge L K , Pe ters on BL , Pie p er C F .Depression in medically ill hospitalized older

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214 Harold G. Koenigof spirituality, religiosity, and QOL . Neurology .2007 ; 68 : 1509 –1514.40. Lee BK , Glass TA , McAtee MJ , et al. Associationsof salivary cortisol with cognitive function in theBaltimore memory study . Arch Gen Psychiatry .2007 ; 64 : 810 –818.41. Carrico AW , Ironson G , Antoni MH , et al. A pathmodel of the effects of spirituality on depressive symptomsand 24-h urinary-free cortisol in HIV-positivepersons . J Psychosom Res . 2006 ;61 (1):51 –58.42. Dedert EA , Studts JL , Weissbecker I , Salmon PG ,B anis PL , S ephton SE . Pr ivate relig ious prac t ice:Protection of cortisol rhythms among women withfibromyalgia . Int J Psychiatry Med . 2004 ;34 :61 –77.43. Ironson G , Solomon GF , Balbin EG , et al.Spirituality and religiousness are associated withlong survival, health behaviors, less distress, andlower cortisol in people living with HIV/AIDS:the IWORSHIP scale, its validity and reliability .Ann Behav Med . 2002 ;24 :34 –48.44. Hebert RS , Dang Q , Schulz R . Religious beliefs andpractices are associated with better mental healthin family caregivers of patients with dementia:findings from the REACH study . Am J GeriatrPsychiatry . 2007 ; 15 : 292 –300.45. Rabins PV , Fitting MD , Eastham J , Fetting J . Theemotional impact of caring for the chronically ill .Psychosomatics . 1990 ;31 :331 –336.46. Rabins PV , Fitting MD , Eastham J , Zabora J .Emotional adaptation over time in care-giversfor chronically ill elderly people . Age Ageing .1990 ; 19 : 185 –190.47. Lemere F. What happens to alcoholics ? Am JPsychiatry . 1953 ; 109 : 674 –676 (quote from p 674).48. Vailland GE. The Natural History of Alcholism:Causes, Patterns, and Paths to Recovery .Cambridge, MA : Harvard University Press ; 1983(quote from p 193).49. Harris KM , Edlund MJ , Larson SL . Religiousinvolvement and the use of mental health care .Health Ser Res . 2006 ; 41 (2): 395 –410.50. Koenig HG , George LK , Meador KG , Blazer DG ,D y ke P . R elig ious affi liation and psychiatric disorderin Protestant baby boomers . Hosp CommunityPsychiatry . 1994 ; 45 : 586 –596.51. Koenig HG. Spirituality in Patient Care , 2nd ed.Philadelphia, PA : Templeton Foundation Press ;2007 : 161 –174 (Spirituality in Mental HealthCare).52. Pargament KI , Koenig HG , Tarakeshwar N ,Hahn J . Religious struggle as a predictor ofmortality among medically ill elderly patients:a two-year longitudinal study . Arch Int Med .2001 ; 161 : 1881 –1885.53. Propst LR , Ostrom R , Watkins P , Dean T ,Ma s hbu r n , D . C omp ar at ive e ffi cacy of religiousand nonreligious cognitive-behaviortherapy for the treatment of clinical depressionin religious individuals . J Cons Clin Psychol .1992 ; 60 : 94 –103.

15 Community Psychiatry and ReligionMARCUS M. MCKINNEYSUMMARYMore people in the spiritual community aroundthe world offer counseling and support to thosesuffering from mental illness than we can presentlymeasure effectively. Yet these individualscollectively care for the soul in ways that our communityrelies on every day. When we think aboutwhere people go to access care when they are sufferingfrom mental illness, we cannot overlookthis group. Clinicians depend on sophisticatedcredentialing and training to provide their services.Although many in the spiritual communityare also equipped to minister to their members,they often do not receive specialized training incounseling and even fewer have supervision availableto them.Th e inclusion of spiritual providers of carein training, collaboration, and referral withmental health providers provides challengesand opportunities for many communities. Bothwill be addressed in this chapter. Sustainedrecovery-oriented models of care can buildon the unique resource of spiritual providersembedded in the community. In this section,we explore why people sometimes go to spiritualleaders for help, identify who the providersare, and discuss how to honor this point ofaccess while adding quality to care. We will alsooffer ideas about developing locally relevanttraining and present ways to collaborate andestablish a network of referral. Finally, we willoffer resources to guide the process of ensuringquality for all providers sensitive to communitypsychiatry and religion.Anyone who wants to know the humanpsyche will learn next to nothing fromexperimental psychology. He would be betteradvised to put away his scholar’s gown,bid farewell to his study, and wander withthe human heart through the world. There,in the horrors of prisons, lunatic asylumsand hospitals, in drab suburban pubs, inbrothels and gambling halls, in the salons ofthe elegant, the Stock Exchanges, Socialistmeetings, churches, revivalist gatheringsand ecstatic sects, through love and hate,through the experience of passion in everyform in his own body, he would reap richerstores of knowledge than text-books a footthick could give him, and he will know howto doctor the sick with real knowledge ofthe human soul.(1)– Carl Gustav JungOn any given day in any given town, odds aremany people in distress will reach out to theirlocal, trusted faith leader for help. In fact, aboutone-quarter of people with a psychiatric diagnosiswill have first sought help from clergy.(2)Faith leaders (“Faith Leader” is a general termpurposely used along with “spiritual leader”and clergy to signify the multiple importantroles of religious/spiritual persons often soughtby average people when in distress) do notoften have advanced training to provide mentalhealth services, yet they remain a primaryaccess point of care for many. These faith leaders“care for the soul,” (3) an ancient notion thatappreciates the root idea behind the “psyche.”They are well acquainted with “real knowledge215

216 Marcus M. McKinneyof the human soul” that Jung alludes to in thequote above.We will consider how psychiatric care todaychallenges practitioners to learn how spiritualresources in communities provide collaborativeopportunities and sustained support for individualswith mental illness. Although there is notadequate research on those local resources yet,with a little creativity and some training, thoseresources can be brought alongside clinical practiceto aid and support patients.Th is chapter requires us to be honest and takesome risk. We need to be honest about wherepeople go for help and to whom they go andwhy. We need to acknowledge the need to begintraining spiritual caregivers who are seeking toattend to mental health needs in our communities.Let’s help them do what they do better. Thiscan be done while also inviting collaborationwith other professional mental health providers.In so doing, we may develop a more clinicallysound, spiritually relevant model of care for ourcommunities.Th is chapter also moves us one step closer tothe streets, closer to our neighborhoods. Herewe find that physical, emotional, and spiritualneeds may not be differentiated. They come inthe door at the same time. On these streets, youwill find motivated spiritual leaders, often nottrained, seeking to care for people as they are.We will look at existing and potential trainingopportunities of faith leaders in those neighborhoodsas well as needed training for clinicians.This training will help us identify possiblecollaborators, but also help us become moreunderstanding of the value in bridging thedivide between the clinical and spiritual aspectsof care.When the idea of “provider of care” is broadenedto include the natural, chosen network ofpatients and families in their community, severalprimary issues surface. Do the providers knowhow to maintain confidentiality? Are they knowledgeableabout the patient’s condition? Will theybe accountable to the authorized medical teamresponsible for the patient’s clinical care? Willthey support the “treatment plan”? Will there besensitivity to the precept primum non nocere , dono harm?With increasing economic and time pressures,the mental health practitioner might fairlyask, “In what way will collaboration truly helpmy clinical role?” We should honestly confrontbarriers to collaboration like having little time, aswell as innovative benefits being considered nowin recovery-oriented systems of care in behavioralhealth approaches. If a clinical practicedepends on collaboration with colleagues in themedical community, how might the same kindof collaboration with spiritual “providers” ofcare assist the psychiatric plan? What concernsmight arise?Ideally, a clinical practice will include training,collaboration, and referrals responsive to thespiritual and mental health needs of the community.Regardless of the location of a practice,the community will have religious/spiritual waysof understanding and responding to psychiatricneeds. This chapter recommends seven steps tobuild a local, spiritually relevant strategy of care.Along the way, we will hear from examples ofspiritual leaders who reflect on the intersectionof psychiatry and religion in their community.1. STEP ONE: REALIZE PEOPLEACCESS CARE THROUGH MANYPATHWAYSLet’s start by admitting that many people accesscare for psychological issues through local spiritualleaders. In many urban and rural settings,spiritual leaders are often the most accessible“providers” of care, even if they are not alwaystrained. For a host of reasons, accessing mentalhealth care may be challenging to averagepeople. Economics, stigma (fear of discrimination),and the amount of time it takes to get anappointment with a “credentialed professional”all seem to push for creative options in mentalhealth. If it takes weeks to get an appointmentand I am limited to five visits, for thirty-minutesessions, I may find myself exploring whoelse I can talk to while waiting. Trends in communitypsychiatry are taking into account

Community Psychiatry and Religion 217numerous modalities that broaden the notionof “providership.” In addition, “wrap-aroundservices” show interesting outcomes for peoplein recovery. Wrap-around services includeservices like supportive counseling, often providedby faith leaders (although they have lessoften been considered a “provider of care” in acollaborative sense). With a little work, a cliniciancan stimulate added supports for clients,understand the community better, and establishan ongoing training program that informs aclinical team and local spiritual leaders on waysto work together. In some regions, asset-basedcommunity development serves this purpose.This strategy involves incorporating natural,local resources and supports that are positivein nature, often identified by the client (and/orfamily) supplementing the expertise of mentalhealth practitioners. In many instances family,faith leaders, elders, and physicians are thepredominant first line of care for people sufferingfrom mental health issues. Faith leadersand trusted spiritual elders who are commonlyrecognized as people who offer wisdom in theeveryday problems of life can become part ofthe team whose center is patients themselves.Nazeh Natur, a psychologist in training, servingin Israel notes,” People in our communitiesapproach the ‘old man’ or ‘old woman’ inthe village … they would try to treat the illnessby reading from the Qura’n.” (Nazeh Natur is aPh.D. Candidate in Psychology. This quote isfrom our conversations at a federal conferenceon Arab/Islamic Behavioral Health issues. Usedby permission.)Th e local pathways a community choosesevery day may not always be connected to otherlevels of mental health care.In Connecticut, we have welcomed peoplefrom every imaginable religious tradition intopastoral counseling training. Aside from formalreligious groups, many people see theirrole in a broader spiritual way. The increasingdemand for these individuals to assess andcare for people’s emotional lives seems constant,and the importance of bridging thesecaregivers with professional mental healthproviders will not diminish. This chapter willintroduce the field of pastoral counseling asa growing discipline addressing the need forcommunity-based psychologically trainedspiritual providers.Every pathway of healing can potentiallyinclude specialized options in mental healthcare. Once we accept this, there is the potential tocollaborate and refer for optimal care.1.1. Reflection from India: Father ThomasPuthiyadom, Catholic Priest“Average people in my country will try and hidemental illness until they find it impossible tomanage by themselves. They might mention itto the local faith-leader and ask advice. Usuallythe priest sees them and refers them to the localpsychiatric facility that can maintain confidentiality.The main barrier to getting treatmentis the social stigma. Usually village people allknow each other, so when people do seek treatment,they try to go where the care is hiddenfrom the public. In my village, the family andthe community provide a great deal of emotionalsupport.”1.2. Reflection from Nigeria: Father EliasN. Menuba, Catholic Priest“In my country it would be very uncommon forsomeone to go in search of a ‘clinic’ or hospitalfor mental problems. It is very hard to admit onehas such problems. People are considered outcastsif they do. But people do go to their religiousleader to seek help, for all kinds of problems. We( religious leaders) then often see them for a whileand, as we need to, get them more help. I comefrom the Anambra State of Nigeria. In this regioncertain types of ‘madness’ are also treated by somenative doctors (dibias) with native herbs. Manydiseases, in fact, are treated at home. We do nothave training opportunities in pastoral counseling,but I have tried to take such classes in theUnited States. In our tradition, both happinessand sorrow of individual members are shared bythe entire family or community to which he/she

218 Marcus M. McKinneybelongs. Counseling needs to include more thanan individual and it must avoid blaming.“I believe if faith leaders could receive pastoralcounseling the whole country would profit.Pastors are unable to help because they have notbeen taught. And while they do help many people,unless they get proper training they “burnout” and experience depression in their work.“In general, faith leaders do not collaboratewith physicians. The culture sees the two areasseparate. Some faith leaders use their practices totry and bring healing instead of advising a personto seek medical attention. It would seem strangeto imagine the two (doctors and clergy) workingtogether. It would be great to have pastoralcounseling offered to those suffering from mentalillness in my country.”1.3. Reflection from Arab/MuslimCountries: Sameera Ahmed, The FamilyYouth Institute“In most traditional Muslim countries the family(nuclear and extended) is the main supportsystem that people go to when experiencingemotional difficulties. They often turn to theirphysician since many of the emotional illnessesare presented as somatic complaints. Dependingon the religiosity of the family and their connectionto the mosque, individuals may go toa Muslim scholar while others turn to peoplewho claim to be able to do exorcism or homeopathymedicine, etc. In Western countries,Arab/Muslim individuals tend to rely on theirlocal religious leader or Imam as well as theirfriends within the community. Depending onthe level of acculturation of the individual orthe desperation of trying to find a solution toone’s difficulties, Muslims may seek the use ofmental health services. Where Muslim mentalhealth workers [are] present, sharing of religiousand/or cultural similarity appears to helpbuild trust with the individual. In addition,mental health workers that are engaged withthe Muslim community aid in normalizationand acceptance of mental health issues withinthe Muslim community.”2. STEP 2: GET TO KNOWSPIRITUAL CARE PROVIDERSWhen the State of Connecticut embarked on aFaith-Based Initiative in Behavioral Health, somethingremarkable was revealed. Few behavioralhealth providers identified spiritual professionalsthey had existing relationships with for referral.Likewise, few religious leaders could identifybehavioral health professionals whom they knewand collaborated with regularly. Breaking downthe barriers to establish a meaningful referralnetwork began with numerous conferences andtraining forums that included both audiences(faith leaders and mental health professionals). Itbegan with a desire to meet others who serve theemotional needs of the community.Consider for a few moments colleagues youhave known who are mental health practitionersbut, as you have come to know them, you discoveredthey were also active or knowledgeablein local religious practices. A person trained inmental health and participating in a religiousgroup can have unique insight into clients. Wecall these practitioners “boundary spanners.”In research and practice these individuals canoften help bridge cultures (medical/psychiatricand religious) and the languages unique to bothworlds. Identifying boundary spanners is animportant first step to creative training in religiousand psychological settings.My experience has been very positive in thisarea. My career began with basic ministry training,then advanced training in hospital chaplaincy,and then specialized training in psychology.Each area brought its own “credentialing” process.I had an interest in teaching and foundwonderful insight in bringing approaches fromone field of study to another. On a deeper level,I found myself helping translate ways of caring .Psychiatry, for example, depends on “diagnosis.”Ministry might make an assessment. Clinicianshave “patients” or “clients,’” while faith leadershave members of a congregation or fellowship. Iftranslation of culture is not attended to, one sidemay feel the other is labeling a person or judgingthem. Now, as a licensed therapist who is also a

Community Psychiatry and Religion 219minister, I work to value both cultures (knowingneither is perfect). It is helpful to identify andacknowledge other people who serve as boundaryspanners in the community: people who arecredentialed mental health providers but mightalso be ministers or religious leaders.Some health professionals have advancedtraining in mental health and spiritual practice.Chaplains, pastoral counselors, and faith leaderswho also serve in professional behavioral healthagencies are potential “boundary-spanners” whoare trusted and recognized in the community,while able to “translate” languages (clinical andreligious). The term pastoral counselor refers toan individual who blends insight from theology,spirituality, and behavioral health in ministry. Insome areas, you will find pastoral counselors credentialedthrough professional organizations likethe American Association of Pastoral Counselors(described at the end of our chapter). Otherregions might have individuals who describetheir ministry as pastoral counseling and mightnot even know of a professional category outsidetheir own congregation or religion. In a similarway, chaplains are usually individuals who servein (sometimes hired by) institutions to serve thespiritual needs of people within the institution,including families and staff members. Manychaplains have professional training and seetheir lifelong work in this specialized ministry.Yet many see their role in chaplaincy amendingtheir other religious duties in the community. Itis best to become acquainted with chaplains andpastoral counselors locally to better understandhow they might work to serve patient/client spiritualand mental health needs. In many ways, theopportunity to provide holistic care lies in the artof translating those two powerful cultures.Boundary spanners will likely know aboutthe delicate issue of using their background andunderstanding in ways that assist care rather thandrive a religious agenda. We encourage forumsthat invite leaders in the spiritual, psychiatric, andmedical communities together to consider modelsof referral and collaboration. Maybe periodictalks can be arranged on aspects of each community’sapproach to healing that would be helpfulto everyone. An individual practice (not as a partof a group or institution) might consider offeringto lecture on some evening to a local placeof worship on a common issue in mental health.Even a brief talk followed by lively discussion canincrease mutual understanding of what peoplebelieve helps and potentially reduce stigma.Like the mental health and addiction fields,those in the spiritual field have increasingly“ specialized” into a more stratified system overthe years. For example, institutional spiritual professionalsare held to different bodies of accountabilitythan those in worship or congregationalsettings. Others are accountable to their own religiousbody only and may not have any counselingoversight. Yet their role remains critical becausethey are commonly chosen by congregants whenseeking help. We are cautious not to call all of this“counseling.” But let’s be honest: Whatever wecall it, people are attending to emotional needs.Consider the variety of “providers of care” in thespiritual community and the implications for thecare of patients.One way to increase awareness of a patient’ssupport system is to offer a more in-depth spiritualassessment that would include a questionlike “who provides you with personal spiritualsupport?” This will likely elicit a more meaningfulresponse than the typical spiritual assessmentquestions that are important but incomplete fromthe “every day” experience of a client. Sometimespeople will offer a neighbor’s name, a laypersonin their religious congregation, or possibly a clergyperson.Their answer will reveal their chosenspiritual provider of care. The closer we get to the“personal” support the client is using, the morewe will understand and support their healing.We found in our pastoral counseling trainingprograms that many people asking for trainingwere coming at the permission of their religiousauthority (pastor, priest, imam, denomination)but who, long beforehand, had discovered theywere the “kind of people everyone sought out forhelp.” A more formal role for these individualsnaturally followed. I am mindful that “titles” maynot convey sufficiently the role spiritual leadersserve. But if we are collaborating, it is helpful

220 Marcus M. McKinneyto know how to identify spiritual leaders. Hereare some of the titles you might look for in yourcommunity:Abbot or Abbess : A title given to the head of amonastery in various religious traditionsaround the world.Priest : A person having authority within areligion, usually in terms of liturgy and sacraments.In some traditions, a priestess is asimilar designation. It is helpful to rememberthat most ministry roles invite personal supportand counsel. When a person is sick ina parish, it is likely the priest will be soughtand will attend to the person in need, even ifthere also are many others offering care in theparish.Imam : An Islamic leader, usually a leader in amosque or in the community.Minister : A broad term used in many traditionsfor a person with responsibilities that mightrelate to worship or teaching as well as interpersonalsupport.Healer : A broad term that would be defined bylocal religious groups. This term may alsoreference a growing category of practitionerswhose self-identified caring role aims towardthe healing of mind, body, soul/spirit.Monk : A person usually devoted to celibate, contemplativeliving within a religious tradition.Living alone (from the word monos ) or in amonastery is associated with this religiousrole. People in these roles are often felt to behelpful in the struggle people feel in religiousand psychological life.Bible teacher : A person with responsibilities toinstruct scripture, often in class settings. Theseteachers often focus on age-specific studentsand are a primary support for everyday issuesin a congregation.Pastor : A leading role in congregations thatincludes the idea of shepherd. It usually isidentified with clergy. The primary role is tolead the congregation. In some congregations,the pastor is involved in everyday emotionalconcerns of the congregants, while in othersthe role might be more administrative.Deacon : A person (sometimes ordained) whoassists a priest or pastor. The role might beto “serve” members of a congregation. Oftenthis person is to be accessible to members foremotional concerns.Elder : May refer formally or informally to a personwith seniority in a religious setting. Thistitle is also loosely applicable to those identifiedin a community who are valued as goodcounselors or guides.Bishop : A senior member of a Christian Church,usually with oversight responsibilities of otherpastors/priests/ministers.Spiritual guide/advisor : Terms used in manytraditions (for example, in India, Tibet, andWestern Spiritualist traditions). Sometimesthe term refers to a person trained in spiritualapproaches of a variety of traditions.Temple/tribal leader : Religious groups sometimeswill have an informal designation ofa person who might bear this title in theirtemple or tribe. Much like other less-formalpositions, this role might only be known anddefined locally, but can be an important liaisonbetween the religious community andmental health provider.Lay leader : The exact role of lay leaders can bealmost any ministry. This title is often used toclarify that the person is not ordained as anofficial clergyperson, but has specific ministerialduties.Evangelist : A person whose role is to evangelize,preach, and/or reach out to people. In somechurches, this person may minister one-tooneto those in need.Preacher : A title that signifies more of a pulpit orpreaching role – one who gives sermons. Butagain, this title may be misleading, becausemany preachers also are associated with specificministries within a congregation.Chaplain : More often this is an institutional titlefor a person designated to meet the spiritualneeds of patients (for example, in hospitals,prisons, homes, and assisted living settings)and link to local religious resources. Manyinstitutions use professionally designatedpersons while others use volunteers from the

Community Psychiatry and Religion 221community who may also have local religiousresponsibilities. Many congregations designatethat chaplains or pastoral ministers goto local institutions to minister to their ownmembers.Pastoral counselor : As mentioned earlier, thiscategory has unique implications for meetingthe mental health and spiritual needs of people.From dealing with the everyday worriesof life to complicated psychiatric situationsrequiring support in the community, this personcan be a lifeline to recovery for someonesuffering from psychiatric illness.Heath-care institutions in a community mayhave designated spiritual care providers who havetraining in mental health. Typically they will becalled chaplains and can be found in pastoral caredepartments. In times of economic challenge orin poor areas, there may be no one on the hospitalstaff with the role of pastoral caregiver. If thereis a chaplain, he or she can be helpful in exploringcommunity resources addressing spiritualityand mental health. Generally speaking, however,a chaplain will not often have a community practicefor referral. The work to access communityresources will likely take a few more steps.3. STEP 3: STRENGTHEN QUALITYAND EXPAND ACCESS3.1. Reflection from the Republicof Trinidad: Reverend Elton Adams,Protestant Minister“In Trinidad and Tobago the only place ofresource for the mentally ill person is in the mainhospital. A person with psychiatric illness mightgo first to a general hospital and, if needed, go tothe long-term mental health facility. All costs forthis care is born by the government.“In our country it is often believed that a personwith mental illness is ‘filled with a demonor evil spirit.’ This brings the experience ofbeing shunned by family as well as the community.Medication is used a great deal. Seldomare patients seen by a pastoral counselor. We donot usually have chaplains in this role. Pastors,Pundits, and Imams visit their people.“The main barriers to getting help seem to bestigma issues and shame, even felt by the wholefamily at times. Private counseling would be verycostly. Often there is a sense of failure. A widelyheld belief is that illegal drugs are the main reasonfor much of the mental illness in my country.”People seeking psychiatric care usually valueboth clinical and empathic skills. Ideally they areall wrapped up in one provider. More realistically,we may find them in a mix of “providers” includingprofessionals, faith leaders, and others. Not allcaregivers, even if carefully chosen by a client, arenecessarily “trained” to provide the empathic andclinical services needed. We must acknowledgethe important value of sophisticated psychiatrictraining while appreciating that “real knowledgeof the human soul” may be sometimes found inthe caregiver who has less clinical training. And,of course, there are many who work to acquireskills both in psychology and spirituality.It is also worthwhile to consider developing acommunity training program designed to buildrelationships and increase knowledge (spiritualand behavioral health) in ways that are not tootime consuming or complex. It can be as simpleas a single event for spiritual leaders, a forumto talk briefly on how to assess common mentalhealth problems (depression, anxiety, dealingwith stress), that invites spiritual insight intostrategies for healing.Usually faith leaders with responsibility forcongregational leadership (like a youth pastoror priest) are trained in theological insight andministry application. “Pastoral care” might bestdescribe the intervention often required of theirwork with members. Typically the membersthemselves set the agenda. As leaders are trainedfor more “counseling” skills, the shift will moveto hold the leader in more accountable roles.“Pastoral counseling” signifies a more psychologicallyrigorous training, sometimes performed byprofessionals whose single ministry is counselingin a religious, private, or institutional setting.Whether trained in listening skills for supportor clinical assessment skills for treatment, faith

222 Marcus M. McKinneyleaders who have partnered with clinicians oncare for their members refine their identity andeffectiveness as an important “provider of care”in the community. It is no surprise that such collaborationsallow clinicians to expand their referralbase and expand their knowledge of spiritualresources. They may also increase their comfortin addressing spiritual issues in therapy to theextent such a partnership is established.If we admit that stigma related to acknowledgingone has an emotional struggle is a very commonexperience, then we might look in a more sophisticatedway at what role people play in recovery andcare. For example, part of our modern experienceis to hold high the level of hard-earned training inany given field. So medicine and counseling (andgovernmental authorizing bodies) may have verystrict guidelines giving license to levels of practice.Professional credentials, organizations, andextensive designations seek, appropriately, to raisethe quality of care for people. However, we mayhave to consider ways to strengthen quality whilebroadening access at the same time.Let’s consider some of the barriers that mightinhibit a person seeking help from seeing a fullycredentialed psychiatric professional. First, economics.In addition to the stigma sometimesexperienced by a person “admitting” they areill or struggling with emotional issues, manypeople go to faith leaders in the communitybecause they cannot afford the inevitable cost ofseeing a “credentialed” mental health provider.The credentialing movement brings assumedquality and cost.Second, people may ask for help, but resisttreatment. With this in mind, a movement to trainand support people who are in the spiritual communityseeking clinical skills to offer pastoral counselingis worth considering. The Substance Abuseand Mental Health Services Administration in theUnited States has increasingly found good outcomesfrom “psychological first aid.” (4) Some professionalorganizations have begun to incorporatea category of membership that embraces this levelof intervention that comes closer to the networkof trust and access that people seem to appreciate.For example, the American Association forPastoral Counseling (5) now offers an entry membershiplevel designated ‘Pastoral Care Specialist’.Some faith leaders find this movement validatingtheir front line role as providers of care embeddedin the community.We also need to keep in mind that many peopleseek mental health services through their primarycare provider, that is, people go to a physician oftenfor emotional and psychiatric reasons, be it to seekmedicine or ask for guidance. Most psychotropicmedication in the United States is dispensedthrough a primary care physician. If we are seriousabout early detection, prevention, or even effectivereferral, the larger community of care must be reimagined.Informal links between physicians, mentalhealth providers, and spiritual leaders representa strong fabric of recovery for assessment, support,and care in our communities.In the United States there is significant interestin how primary care physicians addressmental health needs. For our purposes here,let me illustrate great potential in an integrativeapproach that can strengthen quality andexpand access.For decades, I have worked alongsidephysicians at a large acute care hospital in anurban setting (Hartford, Connecticut). First asa chaplain, then as a pastoral counselor takingreferrals, I worked primarily in the hospital setting.I would hear from my physician friends how thecounseling needs of patients had grown and theresources to get them help had decreased. Theactual problem seemed to be that they could nolonger refer a patient to their own preferred localmental health provider in their community. Theyhad to keep a list of common insurance companies… a “panel” of providers. Provider lists wouldchange, sometimes every six months. The referralprocess would frustrate patients. Eventually manyphysicians simply gave up and suggested theirpatients call their own insurance company. Ofcourse, that nonpersonal referral does not usuallyget followed up. And many patients came back totheir physician with their symptoms worse.We piloted a process to embed a pastoralcounselor in some of the medical practices sothe counseling referral process could be more

Community Psychiatry and Religion 223personal and the site of care more familiar topatients. We included a sliding scale fee for mostanyone, based on his or her ability to pay. Theactivity was significant. And the ability to referto mental health providers was easier because thepastoral counselor understood the psychiatric process.Such an integrative approach does not haveto be huge. But it probably needs to be personal.A final word on quality: It is important toremind ourselves an individual who is credentialed(licensed, certified, or otherwise designatedas authorized to provide mental health services)may not necessarily produce good outcomes for aperson. In the same way, spiritual intention doesnot guarantee a desired outcome for people seekingmental health support. The best assurance ofquality is accountability through having a caringsupervisor. Supervision would be a place to safelyaddress how to improve the counseling work. Webelieve this is a lifelong need for clinical and spiritualcaregivers. And this enhances the likelihoodthat mutual referral will take place.4. STEP 4: IDENTIFY REASONSTO REFERWhat motivation(s) should we identify amongclinicians and spiritual providers of care thatmight make referrals beneficial? “Referral” and“collaboration” take a common protocol in hospitalsand among medical professionals. It is lesscommon with religious leaders. That is not to saythey would not jump at the opportunity. Bothdisciplines would have reservations, however. Itprobably only makes sense if you feel the patientcould benefit and your work would be amendedin ways that could sustain healing outcomes.In a hospital setting, medical professionalsrefer frequently to other subspecialties. Peopleknow each other and their expertise pretty well.(Economic factors in Western Medicine maychange this notion: The growing categories ofPhysician Assistant and Hospitalist may createmore distance in the collaborative experienceamong even health practitioners.) Progress notes,often the residue of exhaustive assessment, areshared between peers. The language is commonand complex. There are lots of abbreviations. Amulti-disciplinary team in a hospital shifts a littlecloser to “collaboration,” although the team islikely also schooled in medical language.From a patient’s perspective, they may feelreferral honors their desire to talk about spiritualissues safely. It can “normalize” their care to takeinto account their whole person.When practitioners feel their care of clientsand families will be enhanced by having spiritualissues addressed, many reasons to refer or collaboratewith spiritual providers can be found thatboth facilitate care and honor the larger healingfabric that patients access frequently in everydaylife. These reasons may have clinical and diagnosticimplications and enhance client-centeredapproaches.By using patient-approved collaboration,a practitioner will better “translate” spiritualthemes. For example, if “guilt” is an issue frequentlyraised in therapy, a spiritual providermay shed light on how guilt is framed within thepatient’s belief system. Pathology can be differentiatedmore effectively. A faith leader may greatlyappreciate simple, clinical clarification. Religionhas a remarkable way of inviting pathologicalprojections unless there is careful insight.When clinicians are caring for more impairedclients who might benefit from socially meaningfulactivity, religious resources can build on anysocialization tasks prescribed.Spiritual themes permit the possibility of ashift away from the stigma associated with mentalillness. Where the faith leader or religiousenvironment is empathic, a “client” can find languagethat is dynamic for healing, helping themto feel that, as James Hillman notes, all humanshave problems. To be human is a problem. Weare all on that common ground.But let’s not be naïve. It must be acknowledgedthat some religious perspectives might add tostigma by (like some medical models) labelingthe illness in such a narrow and negative way thatthe person is defined by the illness. This can putblame on the person. It is less likely, of course,that such a community would warm up to collaboration.But in any community, there will be

224 Marcus M. McKinneychallenges like this. Initiating a nonjudgmentalrelationship with spiritual leaders will serve toclarify common ground.Referring to faith leaders can lighten thepressure clinicians and/or faith leaders may feelin caring for people. In our pastoral counselingtraining program (6) we have seen medical, psychiatric,and faith leaders benefit from the supportthey receive by a more collaborative style. Theysleep better at night. They feel less responsiblefor “ curing” the person and experience more of acaring role that has healing outcomes.The life of a client seen from the perspective ofa spiritual leader can fill in critical diagnostic andcompliance information. A common reason forpatients decompensating may be noncompliancewith a treatment plan. Typically a person mightstop taking a medication or going to therapy.Spiritual leaders may know well what is causingresistance with a patient. Sometimes a personmay use their religion as a reason to justify noncompliancewith a care plan.Clinicians can learn key spiritual resources thatmake a difference to client outcomes. Spiritualleaders might know some common practiceswithin their own traditions that help, for example,depression. Clinicians might be more limited toacademic studies on spiritual resources. Groupsthat can assist people with talking about their illness,or about navigating employment, or findinghousing can be initiated in the community.It is good practice to have readily available localcontact information outlining such resources forpatients. I suspect nothing is more valuable thanlocal understanding of what helps a communitywith their mental health.Aside from our propensity to think of “mentalhealth” as individual in nature, it is advisableto assess the community mental health. By that Imean that culture and regional norms influenceour individual mental health. Where do we learnabout this? Collaboration with faith leaders whothink in those terms can inform us better as weassess and treat mental illness. For example, acommunity might be very introverted. Not rightor wrong, just is. The person with socializationneeds might inappropriately seek to “cure” his orher introversion. A clinician might value weighingfrom different perspectives (spiritual, cultural,individual) insight that can shape assessment andcare. In short, clinicians can learn from spiritualproviders also.Clients coming for psychiatric care mightnot know of an option to see a pastoral counselor.(Pastoral Counselor – This term refers toa minister who practices pastoral counselingat an advanced level which integrates religiousresources with insights from the behavioral sciences.Pastoral Counseling – This term refers toa process in which a pastoral counselor utilizesinsights and principles derived from the disciplinesof theology and the behavioral sciencesin working with individuals, couples, families,groups and social systems toward the achievementof wholeness and health.) Their contactwith spiritual professionals may be limited to“official” clergy from their denomination or localplace of worship. Many people desire a personwho can preserve their spiritual life while notneeding to defend any particular dogma, religion,or clergyperson.A referral would also be recommended whena clinician feels very passionate about his or herown spiritual orientation (or, conversely, has beeninjured by a spiritual/religious experience) and aclient presents in a way that tests the transferencearound their own issues.Sometimes a client may simply ask about theclinician’s religious faith. One way to hear thisquestion is the desire of the client to feel safe orhave common ground with his or her belief system.In many cases, the issue is addressed andno longer needs attention. However, this can betricky, even if both clinician and the client are ofthe same religious tradition. If the client’s carecan be facilitated by having a faith-based counselorserve as his or her primary support person,this might be considered. If transference is anissue and it is not addressed, the alternative cansometimes be having this issue float around theroom behind the scenes, popping out unexpectedlyas topics are touched.A final reason to refer is a bit controversial.Psychiatry and religion both can have a tendency

Community Psychiatry and Religion 225to be practiced in “fundamentalist” ways. Whenone modality of care is the “only way to treat,”or when “religious rules” become narrow andoppressive, we are appealing to the desire of averagepeople for a simple solution. In fact, healingmore often occurs (spiritually and medically) ina slow fashion. Of course there are exceptions.But the culture of “quick fix” feeds the way weview healing. Quick prayer would be nice. Oneunqualified pill (with no adjustments next month,please!) would be preferred. Mutually respectfulcollaboration over time between clinicians andfaith leaders can assist in keeping perspective onthis cultural tendency.5. STEP 5: INTENTIONALCOLLABORATION, TRAINING,AND SUPERVISIONCollaboration doesn’t just happen because wehave chosen to work together. Collaboration isan art more than a strategy. If “parity” or mutualrespect is not experienced by both providers ofcare, it may confuse rather than assist the client.In my practice over the years, I have noticedsome pastoral counselors and clergy abandontheir empathic skills when ministering to peoplesuffering with emotional illness in favor ofa more distant approach they feel is appropriateand more acceptable in the medical world. Here itis worth emphasizing that effective treatment andcare does not limit itself to clinical approachesor spiritual approaches. There are many paths tohealing. Good spiritual responses will providehealing outcomes but will likely look a bit differentthan clinical strategies.The best collaboration probably needs twoindividuals who appreciate supervision. I havenoticed how students I teach (spiritual leadersand clinicians) do not often get the kind of supervisionthat might have been available a few yearsago. I mean the kind of supervision that is supportiveand feels safe enough for me to hear whatin me is getting in the way of a good assessment.The idea of getting supervision in this way is foreignto some spiritual leaders, yet it can releasethe great burden they feel as “leaders expected tohave all the answers.” And can we admit that, insome clinical settings, supervision looks more likeadministrative oversight than honest, supportivereflection on our own issues? Supervision, in thissense, is probably much less common than any ofus would admit.It is interesting that the history of some regionsreveals why there is great distance between faithleaders and mental health practitioners. Storiesmay live in a particular region of “turf wars”between those who hold the “authority” to treat,or who can explain human behavior, or who arequalified to offer remedy. Sometimes historicalevents support religion as primary, while otherregions might support medicine or science. Fartoo often the result is not a shared model of caring,but a polarized tension expressed by a criticaleye that someone is not qualified. Lack oftraining or reckless lack of sensitivity can scarthe possibilities of collaboration. However, creativemodels of training that incorporate spiritualand psychological insight matched with buildingrelationships between the helping professionscan go a long way toward forming a collaborativeoption for caregivers.A couple of training models are worth mentioninghere. Both nurture the kind of collaborationthat helps to avoid polarization.If mental health practices/agencies reviewtheir “continuing education” events (conferences,case presentations) as an outreach to local faithleaders who see their work as a pastoral counselingministry, the chances increase for mutualunderstanding and insight. This is especially true,of course, if their insight is sought to understandinga case. This might be the first move towardcollaboration. The required continuing educationupdate in a clinical topic might need someattention to language (allowing for clinical andeveryday language) for such an event. The avoidanceof condescending attitudes will encouragehonest discussion and ideas.A program specifically designed to blendspiritual and psychological insight in trainingand case discussion is a second model thattakes a bit more planning. The pastoral counselingprogram (6) in Connecticut falls into this

226 Marcus M. McKinneycategory. A “middle ground” has been found indepth psychology. Carl Jung, the Swiss psychiatrist,wrote with a global respect for religionand medicine. A pastoral counseling program,from our experience, can welcome a wide varietyof religious backgrounds, including veryconservative religious groups that historicallyfound the psychiatric world hostile to theirviews. And more and more health practitioners(integrative and complimentary practitioners)are seeking a middle ground as well and havefound their way to the program. During thethirty-hour class, we include speakers frompsychiatry, medicine, and religion. The classmix encourages networking that often ends inreferral possibilities locally.Given the paucity of mental health providersin many areas, an increasing “counseling” burdenis now felt by average faith leaders (as wellas professional pastoral counselors). Offeringa training experience for these individuals toassist them in their roles, whatever they are, hasproved to be energizing for clinicians and faithleaders alike. The goal in such training is modestbut critically important: to provide a spirituallyrelevant and clinically sound forum for anyonewho would benefit from pastoral counselinginsight. Mental health practitioners, faith leaders,nurses, and lay leaders have all exhibitedinterest in these programs.Mental health providers, complimentarypractitioners, and spiritual leaders have participatedin pastoral counseling training becausethey feel the nature of their work requires regeneration.All of these disciplines are in the helpingprofessions. How do we care for ourselves? Formany, the insights of ancient spiritual wisdomsustain the modern calling of caring for the soul.A spiritually informed training can add insightinto ourselves and the culture we live in.One of my clients who arrived late on his firstappointment indicated he was “sent by his psychiatrist”because he had an obsessive- compulsivedisorder (OCD). For an hour he spoke of hisstruggle with this malady. After a few sessions, hereflected on how our sessions forced him to slowdown. He noted how he drove really fast on thehighway to get to work. He felt guilty for slowingdown, because it seemed he needed to keeppace with his world. The TV, the Internet, traffic,and even his cell phone seemed to be suffering,he said, from OCD.Putting our culture in contact with the wisdomof the ages is not a bad idea. In a culture thatsuggests more information, especially the latestresearch, is best, where is the voice to slow down?Is more always better?A male middle-aged patient in our cardiacrehabilitation class who built his career as anengineer gave our class some insight on this matter.He said he always minimized dreams. He feltthey were simply caused by worry or bad digestion.When he discovered he had to go for cardiovascularsurgery he got on the Internet to findout what it was like. After an hour or so he wasfull of information. Not all accurate of course. Butthe result was a feeling of panic. That night, justbefore surgery, he had a dream. Essentially it wascalm and – in his mind – boring. But it stayedwith him the next morning. Going into surgery,he felt one of the images of the “boring” dreamcalmed his nerves and gave him a sense all wouldbe okay. In our class, he said it ran against all hebelieved that a dream could help him, especiallyas an engineer. But he could only say it made thedifference. Spiritual leaders around the worldmight not be surprised at his story.6. STEP 6: BUILDING A REFERRALNETWORKA faith leader who has participated in a trainingprogram that is integrated as noted above mayreturn to his or her community setting talkingin a different way. Before such an experience, heor she might have said to someone, “Go to SaintFrancis Hospital, someone there can help youin the clinic,” or “please check your insuranceplan to find someone,” or “have you looked intothe yellow pages?” Now they are inclined to say,“Talk to Dr. Smith. Here is her number. I knowher well and she can help.”Sometimes referral networks begin with a singlecontact within an institution. For clinicians

Community Psychiatry and Religion 227attached to hospitals, a concerted effort to connectwith a chaplain or pastoral counselor withadvanced training can begin bridge buildingwith other sources in the community. Knowingtime is a precious commodity, a small initiativecarefully planned can make a big difference.Public health agencies (local, state, and national)are frequently assigning a liaison to networkwith the spiritual community. Having a forumthat honestly discusses the common resourcesand challenges of the helping professions in themental health and faith communities can bein line with most public health missions and isworth recommending.It’s funny how large bureaucracies (like public/stateagencies) sometimes become great barriersto networking. Middle managers can tryand read the “political winds of the day” and feelanything religious is too sensitive to address. Ihave heard at times interesting explanations, forexample, as to why a conference bringing spiritualand mental health leaders together is dangerous,even though patient-centered care oftenemphasizes the need of patients to have spiritualityincorporated into care. A senior administratorcan advocate for honoring the spiritualdimension of care, but mid-level anxiety dampensthe actual implementation of any conferenceor assessment tool. Religion is too hot a topicfor some. It can get you in trouble. Someonemight be offended. All these worries might beaddressed with carefully planned open forumsin institutional settings. It is good to invite communityproviders to such forums.7. STEP 7: IDENTIFY COMMON ISSUESIN SPIRITUALITY AND PSYCHIATRYTh e chances are good that a person seeking a clinician’shelp has been to many others before. Acommon issue in counseling can be described as“bad experiences people have with providers ofcare.” Those wounds are painful and seem to staywith us for a long time. In time, a person mayseek help again out of necessity to deal with hisor her pain. If the wound came from an experiencewith a religious leader, a person mightaddress this to a clinician. Or if the wound wasexperienced while in therapy with a clinician, aperson might seek help from a spiritual or religiousleaderAn example might be a client who shares ahorrible experience he or she had while going tochurch, or seeing a spiritual leader, or counselingwith their minister. That person cannot get overhow damaging it was, and he or she wonders howpeople in places of responsibility like that can dosuch terrible things.Or maybe a member of a church confides tohis or her pastor how a psychiatrist completelymisunderstood the expression “being in relationshipwith God.” That person now feels unable toreturn to that psychiatrist.Both people may get an empathic hearing. Buta person (faith leader or clinician) who has a collaborativestyle might find a unique opportunityto offer some options for the client/member thatdoesn’t lose the spiritual or psychiatric reason aperson originally sought care.Many of my clients have justified their intentto stop medication because of psychiatricunprofessionalism. Many clients have abandonedGod because a faith leader was hurtful.Either result, of course, can have devastatingconsequences, even if we all understand whythey responded a certain way. Developing astyle that is informed by spiritual aspects ofcare, even if only by studying a text like thisone, will support a more balanced assessmentfor patients.Aside from inviting faith leaders into a setting,or participating in training programs, Isuggest an old-fashioned approach: invite a faithleader to lunch. I recommend the same thingto faith leaders: invite a psychiatrist to lunch.Sound silly? One of the few ways to really askthe kind of questions needed to understand howyou might collaborate is by exploring who theperson is over lunch. Ask what they believe,what has been their experience? What does thefaith leader feel about medication? What doesthe psychiatrist feel about prayer? And, reflectingon what patients might ask, take note of theapproach the person takes.

228 Marcus M. McKinneyUnderstanding that we are, as providers, onlypart of the healing equation will help us referand collaborate more. If a clinician thinks theyare THE answer (any discipline can take too narrowof an approach … a medicine, a theory, aspiritual practice … all can be viewed with suchorthodoxy as to blind providers of care from themany streams of healing insight), or even the primaryanswer, they may miss the opportunity toparticipate in the mystery of healing. The symptomcan be wrestled down. We can participate inthe science but miss the art. Likewise a “formula”approach to religion can focus too narrowly on“right and wrong” or “how to behave” (admittedlyimportant dimensions of life) but miss a healingassessment of what is going on deep inside.One of my students in pastoral counselingwas a 50-year-old Pentecostal minister. In histradition, he was taught to be very skepticalof psychology. As he sat in our class, he woulduse his remarkable knowledge of scripture inaddressing the counseling needs of his members.After awhile, he wanted to assess what was happeningat a deeper level causing mental healthsuffering for his members. While in supervision,he recounted the story of a woman who came tohim after many prayer requests for healing. Shehad spoken to him for months about her anxiety.He said, “Mrs. Jones (not her name), youwould benefit from pastoral counseling. Let’smeet this Tuesday at church at 7.” Believing hewould pray or read scripture she came and sat.When she began asking for Bible verses, he said,“Mrs. Jones, we both believe in God and willcontinue to pray, but for the next hour I want toknow what is going on with you – tell me whatis really going on.” Only he could shift from onemode of religious care (prayer, scripture) toanother (insight into her life). A mental healthpractitioner might not have been permitted tomake that transition for some people.A psychiatrist once reflected to me that thereasons he would not want to assess the spirituallife of patients is that he “felt so unqualified”and the subject was “so personal” and he admittedhaving some bias of what he called “skepticism”when people spoke of their “spiritualexperiences.” When a clinician feels this way, areferral should be considered. Again, an evolvinglist of known referral resources and a willingnessto collaborate would help facilitate this process.I recall being asked to lecture on psychologyand spirituality to the staff of a large mentalhealth agency. When I arrived, I was directed to alarge empty room. As I set up my computer andprojector, my anxiety increased. What controversialquestions would they ask? Were they forcedto attend?To my surprise, a staff member began escortinginto the room forty pleasant-looking folkswho, I was told, were “consumers,” people fromthe community who receive psychiatric servicesat the agency. “Okay,” I thought, “let’s go toplan ‘B.’ ” I shut down my computer. I facilitateda remarkable discussion on how they get spiritualneeds met. They were amazingly talkativeand expressed how they felt therapists at theagency were not comfortable talking about spiritualthings. They spoke of how important such adiscussion was to them. And they talked abouthow they worked to find people in the communityto have this addressed. The last person tospeak suggested the staff be required to attendthe next session.We have a long way to go in understandingcommunity resources, designing spirituallyappropriate training, and responding to the spiritualneeds of our patients. Agencies and individualclinicians can begin by listening to thosethey serve.Research needs to be done regarding psychologicallysound, spiritually relevant models ofcare and training around the world. Best practices,as they are developed, need to be broadenough to embrace a sophisticated notion ofspirituality that is expressed in many forms: conservativereligious orientations, liberal traditions,as well as forms of spiritual practice that are contemporaryand local with no obvious connectionwith recognized faith groups.The modern medical model, from which psychologicaltheory and practice grows, needs tobe examined for its strengths and weaknesses.We should revisit ancient spiritual lessons that

Community Psychiatry and Religion 229assist our wounds and help in healing. The primarywork of Thomas Moore, Ph.D., writer andtherapist, is critically important for this reason.As a starting point, we invite readers to reviewthe resources and curriculum of our pastoralcounseling training web site.(6)All helping professions that invite spiritualand psychological insight for healing are growingin our day. The people we seek to help are insearch of a meaningful life. If we can walk “withthe human heart through the world” takinglessons on “real knowledge of the human soul,”we will surely help those who come to us for care.Take some time to engage the community thatseeks to teach us these lessons.I would like to suggest one final resource.We can build on the strong tradition of pastoralcounseling. Next you will find importantresources regarding standards and ethics thatwill be useful in providing care and cultivatingrelationships with spiritual leaders in yourcommunity. We invite clinicians to share theseideas, add to them, and join in conversationwith others who are equally committed to careof the soul.8. STANDARDS OF PASTORALCOUNSELINGStandards of pastoral counseling worldwide arealways evolving. For the purposes of helpingreaders become acquainted with a primary organizationin this field, I recommend becomingaware of the American Association of PastoralCounselors (AAPC). The standards below (fromthe AAPC directory and Web site) delineatemembership, ethical considerations, and issuesof confidentiality.The American Association of PastoralCounselorsThe American Association of PastoralCounselors (AAPC) represents and sets professionalstandards for over 3,000 PastoralCounselors and 100 pastoral coun selingcenters in North America and around theworld.(7) AAPC was founded in 1963■■■as an organization that certifies PastoralCounselors, accredits pastoral counselingcenters, and approves training programs. Itis non-sectarian and respects the spiritualcommitments and religious traditions ofthose who seek assistance without imposingcounselor beliefs onto the client.AAPC Code of EthicsAs members of the AmericanAssociation of Pastoral Counselors, we arecommitted to the various theologies, traditions,and values of our faith communitiesand to the dignity and worth of each individual.We are dedicated to advancing thewelfare of those who seek our assistanceand to the maintenance of high standardsof professional conduct and competence.We are accountable for our ministrywhatever its setting. This accountability isexpressed in relationships to clients, colleagues,students, our faith communities,and through the acceptance and practiceof the principles and procedures of thisCode of Ethics.In order to uphold our standards, as membersof AAPC we covenant to accept thefollowing foundational premises:To maintain responsible association with thefaith group in which we have ecclesiasticalstanding.To avoid discriminating against or refusingemployment, educational opportunityor professional assistance to anyone on thebasis of race, gender, sexual orientation,religion, or national origin; provided thatnothing herein shall limit a member or centerfrom utilizing religious requirements orexercising a religious preference in employmentdecisions.To remain abreast of new developments inthe field through both educational activitiesand clinical experience. We agree at all levelsof membership to continue post-graduateeducation and professional growth including

230 Marcus M. McKinney■■■■supervision, consultation, and active participationin the meetings and affairs of theAssociation.To seek out and engage in collegial relationships,recognizing that isolation can lead to aloss of perspective and judgment.To manage our personal lives in a healthfulfashion and to seek appropriate assistance forour own personal problems or conflicts.To diagnose or provide treatment only forthose problems or issues that are within thereasonable boundaries of our competence.To establish and maintain appropriate professionalrelationship boundaries.Confidentiality Statement of AAPCAs members of AAPC we respect theintegrity and protect the welfare of all personswith whom we are working and havean obligation to safeguard informationabout them that has been obtained in thecourse of the counseling process.All records kept on a client are stored ordisposed of in a manner that assures securityand confidentiality. We treat all communicationsfrom clients with professionalconfidentiality.Except in those situations where the identityof the client is necessary to the understandingof the case, we use only the firstnames of our clients when engaged insupervision or consultation. It is ourresponsibility to convey the importance ofconfidentiality to the supervisor/consultant;this is particularly important whenthe supervision is shared by other professionals,as in a supervisory group.We do not disclose client confidences toanyone, except: as mandated by law; toprevent a clear and immediate danger tosomeone; in the course of a civil, criminalor disciplinary action arising from thecounseling where the pastoral counseloris a defendant; for purposes of supervisionor consultation; or by previously obtainedwritten permission. In cases involving morethan one person (as client) written permissionmust be obtained from all legallyaccountable persons who have been presentduring the counseling before any disclosurecan be made.We obtain informed written consent of clientsbefore audio and/or video tape recordingor permitting third party observationof their sessions.We do not use these standards of confidentialityto avoid intervention when it isnecessary, e.g., when there is evidence ofabuse of minors, the elderly, the disabled,the physically or mentally incompetent.When current or former clients are referredto in a publication, while teaching or in apublic presentation, their identity is thoroughlydisguised.We as members of AAPC agree that as anexpress condition of our membership inthe Association, Association ethics communications,files, investigative reports,and related records are strictly confidentialand waive their right to use samein a court of law to advance any claimagainst another member. Any memberseeking such records for such purposeshall be subject to disciplinary action forattempting to violate the confidentialityrequirements of the organization. Thispolicy is intended to promote pastoral andconfessional communications withoutlegal consequences and to protect potentialprivacy and confidentiality interests ofthird parties.

Community Psychiatry and Religion 231REFERENCES1. Jung C G . Two Essays on Analytic Psychology. CW 7Appendix 1: “New Paths in Psychology.” PrincetonUniversity Press; 1912:246–247.2. Wang PS , B erg lu nd PA , Kessler RC . Patter nsand correlates of contacting clergy for mentaldisorders in the United States . Health Serv Res .2003 ; 38 (2): 647 –673.3. Mo ore , T. Care of the Soul – A Guide for CultivatingDepth and Sacredness in Everyday Life . New York:Harper Paperbacks ; 1994 .4. Psychological First-Aid For First Responders.http://download.ncadi.samhsa.gov/ken/pdf/katrina/Psychological.pdf . Accessed December 1,2008.5. The American Association of Pastoral Counselors.http://aapc.org . Accessed December 1, 2008.6 . Th e Pastoral Counseling Training Programat Saint Francis Hospital and Medical Centerwww.pastoralcounselingtraining.com . AccessedDecember 1, 2008.7. The American Association of Pastoral Counselors.www.aapc.org . Accessed December 1, 2008.

16 Religious and Spiritual Assessment in Clinical PracticeSYLVIA MOHR AND PHILIPPE HUGUELETSUMMARYSpirituality/religion are rarely assessed in psychiatry.However, for many reasons, such an assessmentis useful. The primary reasons are the manydomains of interdependence between mentaldisorders and culture, including religion.What should be evaluated in a spiritual/religious(S/R) assessment? Although several instrumentshave been developed for this purpose, the clinicalinterview, which allows clinicians to adapt theirlanguage to the beliefs of each individual, appearsto be the most appropriate evaluation method.Specific aspects elements of this assessment aredetailed in this chapter, such as religious/spiritualbackground and preferences, the illness’s effect onspirituality and/or religiousness over time, currentspiritual/religious beliefs, religious practices inprivate and in the community, amount of supportfrom the community, and the subjective importanceof religion in the patient’s life. Dependingon how important religion is to the patient, furtherquestions should be asked about the spiritualmeaning of the illness, the way patients copewith symptoms, the degree to which their spiritualbeliefs comfort them, and the relationship (that is,synergy versus antagonism) between spirituality/religiousness and psychiatric care.Examples of individual situations warrantingspecific approaches are provided at the end of thechapter.Evidence exists that spirituality and religionare rarely assessed by clinicians caringfor psychiatric patients. A Swiss study aimingto assess clinicians’ knowledge of the spiritualityand religiosity of their patients sufferingfrom chronic psychosis found that only onethirdof them reported discussing spiritual andreligious issues with their patients. Moreover,none of the clinicians initiated discussionsof the topic themselves. (1) The replication ofthe study in Québec, Canada, elicited similarresults. (2) In another Canadian study, only onethirdof psychiatric patients reported that theirpsychiatrist had inquired about spirituality/religiousness. (3) Psychiatrists reported severalreasons for not discussing religion/spiritualitywith their patients: insufficient time, concernabout offending patients, insufficient knowledge/training,general discomfort, concern thatcolleagues would disapprove, and lack of interestfrom the patient.( 3 , 4 )Several factors may account for the neglect ofspiritual and religious issues in psychiatric practice.First, religiously inclined professionals areunderrepresented in psychiatry, as compared tothe general population. This has been reportedfor United States, (5) Canadian, (3) British, (6)and Swiss psychiatrists. (1) Second, mental healthprofessionals often lack the necessary educationin religion/spirituality.(7 , 8 ) Third, mental healthprofessionals tend to pathologize the religiousdimension of life (Lukoff, 1995).(8 , 9 ) Fourth, theneglect of religious issues in psychiatry may alsobe linked to the rivalry between medical and religiousprofessions that stems from the fact that bothaddress the dilemma of human suffering.(10 , 11 )Clinical and existential concerns overlap acrossissues of identity, hope, meaning and purpose,232

Religious and Spiritual Assessment 233morality, and autonomy versus authority. (12)However, in recent years, the historic divisionbetween psychiatry and religion has narrowed. Inthe United States, all psychiatric residencies mustinclude didactic sessions on religion/spirituality,(13) and recent findings tend to indicate thatpsychiatrists may be more comfortable and havemore experience in addressing religious/spiritualissues, as compared to other physicians. (4)In the present chapter, we adopt a broad definitionof religion, including spirituality (concernedwith the transcendent, addressing the ultimatequestions about life’s meaning) and / or religiousness(specific behavioral, social, doctrinal, anddenominational characteristics). (14)1. WHY SHOULD SPIRITUALITY/RELIGION BE SYSTEMATICALLYASSESSED?S/R assessment is recommended as part ofpsychiatric evaluation in several evidence-basedguidelines for good clinical practices. According tothe American practice guidelines for the psychiatricevaluation of adults, the developmental, psychosocial,and sociocultural history domain mustbe systematically evaluated. Religious and spiritualassessment is included in that domain with aquestion to consider: “What are the patient’s cultural,religious, and spiritual beliefs, and how havethese developed or changed over time?” Religionand spirituality are emphasized because they maygive meaning and purpose to the patient’s life andprovide support. Moreover, cultural factors andexplanatory models of the illness can affect attitudestoward, expectations of, and preferences fortreatments. Therefore, the spirituality/ religiousnessassessment may play a crucial role in developing atherapeutic alliance, negotiating a treatment plan,and enhancing treatment adherence. (15) Theseissues are discussed in more detail below.1.1. Religion/Spirituality as a Componentof Cultural SensitivityIncluding spirituality/religion in the more generalcategory of culture could suggest that it’s ofgeneral interest but not worth spending valuabletime on during the clinical encounter. Culturalpsychiatry makes the opposite argument. Indeed,culture can “1) define and create specific sourcesof stress and distress; 2) shape the form and qualityof the illness experience; 3) influence the symptomatologyof generalized distress and of specificsyndromes; 4) determine the interpretation ofsymptoms and hence their subsequent cognitiveand social impact; 5) provide specific modes ofcoping with distress; 6) guide help- seeking andthe response to treatment; and 7) govern socialresponses to distress and disability.” (16) Religionand spirituality are considered cultural factorsinfluencing the process of diagnosis and treatment.So, S/R assessment is a component of aclinical practice that is sensitive to culture.1.2. Religion and Mental HealthAre Interdependent PhenomenaNumerous studies have emphasized the relationshipsbetween religion and mental health. (17)These reviews have indicated that religion generallyhas a positive effect on mental health, well-being,drug and alcohol use, suicide, and familial issues.Religion may play a central role in the psychologicalrecovery process in mental illness (18) andsubstance abuse. (19) So, the therapeutic approachshould take into account the spiritual resourcesand needs of individuals in the recovery process.However, not all spiritual/religious practicesare healthy. Many patients cope with their illnessthrough spirituality and religiosity, but this maytake place in either positive or negative ways. (14)Therefore, the clinician needs to differentiatebetween religion as a resource and religion as aburden. Sometimes, patients do not benefit fromneeded psychiatric treatment due to religiousbeliefs (see Chapter 18), or spiritual crises may leadto emotional, behavioral, or social disturbances.1.3. Motive for Psychiatric ConsultationIn 1994, the American Psychiatric Associationincluded the category “religious and spiritualproblems” in the Diagnostic and Statistical

234 Sylvia Mohr and Philippe HugueletManual of Mental Disorders, Fourth Edition( DSM-IV ) to describe problems that may leadto psychiatric consultation and that are not tobe avoided or considered as psychopathological.“Examples include distressing experiences thatinvolve a loss or questioning of faith, problemsassociated with conversion to a new faith, or aquestioning of spiritual values that may not necessarilybe related to an organized church or religiousinstitution” (20) (p. 685).Spiritual life has been conceptualized as aprocess with stages of development. Problemsmay arise during transitions from one stage toanother, which are often experiences involving acrisis of faith. (21) A loss or questioning of faithcould be compared to the grief process with itsassociated clinical problems: anger, resentment,emptiness, despair, sadness, and isolation. Forsome individuals, a loss of faith involves questioningtheir whole way of life, purpose for living,and source of meaning. This problem canoccur when an individual is ostracized by hisor her religious community. (8) Struggling withreligious beliefs during an illness diminishes thechances of recovery. (22) Changes in membership,practices, and beliefs often disrupt people’s livesand may be misdiagnosed as mental disorder,especially when conversion to a new faith occurs.New religious movements may be dangerous andgenuinely destructive. But these are not the rule.Membership in cults isn’t necessarily oppressiveand detrimental to mental health. Some cults arehelpful to their adherents. Moreover, belongingto a new religious movement is typically a transientexperience, because 90 percent of adherentsleave within two years. (23)Case ExampleAs an example of religious and spiritualtransformation, a 45-year-old manwithparanoid schizophrenia reported atbaseline that he had greatly suffered whenhis religious community had rejected him.“What happened to me was very hard. Thespirit group cannot put up with the factthat I go on to smoke cannabis. I tried toquit several times, but I failed. I have lost allmy friends. I have lost the meaning of mylife. I do not believe in spiritism any more.”Three years later, he reported that he hadspent a few months at the hospital after asuicide attempt. During his stay, he met thechaplain regularly and he joined a Christiancommunity in his neighborhood. He said,“Now, when I feel very deep sorrow, I readthe Bible and I find consolation in JesusChrist. This is what helps me, what restoresmy hope.”Sometimes, spiritual experiences involve distressand may be misdiagnosed as psychopathological.The most common spiritual problemsinvolving distress are related to mystical experiences,near-death experiences, spiritual awakening,meditation, and medical illness. (8) An S/Rassessment is necessary to make a differentialdiagnosis, which is often not an easy task.1.4. Satisfaction with Psychiatric CarePsychiatric care is not only oriented toward psychopharmacologyand psychosocial treatments,but also toward promoting psychological recoveryfor people with severe mental disorders. Despitepersistent symptoms and disabilities, people maylive fulfilling lives and develop a positive sense ofself founded on hope and self-determination. (24)In a patient-centered approach, examining theindividual’s spiritual and religious history is atherapeutic tool in itself. Indeed, patients whovalue spirituality and religion will appreciatethe doctor’s sensitivity and feel understood andrespected. As a result, the patient’s satisfactionincreases and the quality of therapeutic relationshipis improved. (25) A qualitative study using aphenomenological approach showed that patientswish to have their spiritual needs addressed inmental health care. (26)2. WHAT SHOULD BE ASSESSED?Numerous scales and questionnaires have beendeveloped to assess religion, which is a multidimensionalconstruct. (27) Numerous studies have

Religious and Spiritual Assessment 235highlighted the relationships between religionand mental health. (17) These studies encouragethe search for the specific dimensions of religionthat may have an effect on mental health. Theworking group of the Fetzer Institute has identifiedsome of the specific physiological, behavioral,psychological, and social mechanisms ofspirituality and religiousness and provides a multidimensionalquestionnaire for use in clinicalresearch ( however, this should be distinguishedfrom spiritual assessment tools used in clinicalpractice).At the physiological level, religious practicesprompt a relaxation response that reduces stressreactions. At the behavioral level, spirituality andreligiousness may indirectly protect against diseaseby encouraging healthy lifestyles. In particular,a robust inverse relationship has beenestablished between religiosity and substancemisuse. (28) At the social level, religious and spiritualgroups may provide supportive, integrativecommunities for their members. At the psychologicallevel, spirituality and religiousness providebeliefs about life and death that can directlyhelp patients to cope with illness. (29)Any instrument devoted to S/R assessmentmust be adapted, because no questionnaire canfit every kind of religious belief and practice. (30)In clinical practice, the most appropriate evaluationmethod is the clinical interview, whichallows clinicians to understand their patients’views on the world. Nevertheless, the researchabove has provided categories of spirituality andreligiousness that are useful guidelines for clinicalpractice.Psychiatric assessment is a time-consumingtask. To minimize the time devoted to spiritualassessment, some authors suggest a short listof screening questions. For example, Koenigand Pritchett (31) refer to four systematic questions(FICA) developed by Dale Matthews andChristina Puchalski:Faith: “Is religious faith an important part of yourlife?”Influence: “How has faith influenced your life(past and present)?”Community: “Are you currently a part of a religiousor spiritual community?”(A) Needs: “Are there any spiritual needs that youwould like me to address?”As a mnemonic reminder, Anandarajah proposedthe HOPE questions, which systematicallyaddress four domains, that is, the sourcesof hope, strength, comfort, meaning, peace, love,and connection (H); the role of organized religionfor the patient (O); private spirituality and practices(P); and the effects on medical care (E). (32)These instruments emphasize the dimensions ofspirituality and religiousness that are relevantfor patient care. In clinical practice, S/R assessmentaims to understand this dimension in thepatient’s life. As spirituality and religiousnesstake on so many different individual meaningsand evolve over the course of a lifetime, particularlywith illness, a concrete framework helps theclinician to elicit relevant data.3. HOW TO CONDUCT A SPIRITUALASSESSMENT IN CLINICAL PRACTICEDuring the screening phase of the S/R assessment,we suggest establishing an outline of the patient’sspiritual and religious history. Spirituality andreligiousness are loose concepts, not only for clinicians,but also for patients. Creating a temporalorganization of significant events and significantothers in his/her spiritual/religious life helps thepatient to clarify cultural influences, significantchanges, current involvement and interactionwith the illness. Domains and questions to considercan be found in Table 16.1.3.1. Religious/Spiritual HistoryAt the beginning of an S/R assessment, establishthe patient’s cultural background by askinga few open-ended questions about religiouspractices of the family of origin and significantothers and about religious education. Spiritualityis known to evolve over the course of a lifetime.What is of importance for the clinician isthat these experiences may affect mental health

236 Sylvia Mohr and Philippe HugueletTable 16.1: Religious and Spiritual Assessment.Religious/Spiritual historyFamily backgroundWhat were your father’s religious or spiritual beliefs and practices?What were your mother’s religious or spiritual beliefs and practices?ChildoodIn which religious tradition were you raised?When you were a child, what kind of religious practices were you involved in? How often?AdolescenceWhen you were a teenager, did you experience changes in your religious beliefs or religious practices?Which ones?AdulthoodIn your adult life, have you experienced changes in your religious beliefs or practices? Which ones?Effect of the illness upon spritiuality/religiousnessSince you have been ill, have you experienced changes in your religious beliefs or practices? Which ones?Current spiritual/religious beliefs and practicesReligious preferenceAt the present time, what is your religious preference?BeliefsWhat are your spiritual or religious beliefs today?Private religious practicesDo you have private religious or spiritual practices? Which ones? How often?Religious practices in communityDo you engage in religious or spiritual practices with other people? Which ones? How often?Support from religious communityTo what extent, do people in your religious community help you cope with your illness?In which ways?Subjective importance of religion in lifeSalienceIn general, how important are your religious or spiritual beliefs in your day-to-day life?In which ways?Meaning of lifeTo what extent do your religious or spiritual beliefs give meaning to your life?In which ways?Subjective importance of religion to cope with the illnessMeaning of the illnessTo what extent do your religious or spiritual beliefs give meaning to your illness?In which ways?Coping with symptomsTo what extent do your religious or spiritual beliefs help you to cope with your illness?In which ways?Coping styleTo what extent do your religious or spiritual beliefs help you gain control over your illness?In which way?Source of strengthTo what extent are your religious or spiritual beliefs a source of strength and comfort for you?In which ways?Synergy of religion with psychiatric careMedicationTo what extent are your religious or spiritual beliefs in conflict with your medication?In which ways?TherapyTo what extent are your religious or spiritual beliefs in conflict with seeing a psychiatrist?In which ways?Comfort levelHow does it make you feel talking about your religious or spiritual beliefs with me?

Religious and Spiritual Assessment 237status. Inquiries about life-changing spiritualexperiences or religious practices are especiallyimportant to understand the impact of religionon mental health status. This initial investigationmay uncover that drastic changes have occurredin the patient’s spiritual and religious biography,such as significant growth or loss of faith, conversion,or apostasy.3.2. How the Illness Affects Spiritualityand/or ReligiousnessThe experience of the illness may also affect spiritualityand religious practices. This is why thepsychiatric interview inquires about relationshipsbetween the illness and changes in spirituality/religiousness. When confronted with mental illness,as with other stressful events, some peoplelean on their religious background to cope.Religious coping is not always effective; it canalso lead to negative outcomes. (14) Some peoplemay endow their delusions or hallucinations withspiritual meaning (see Chapter 7). Some peoplemay seek spiritual healing in various religiouscommunities (see Chapter 18). Some people mayquestion or lose their faith when confronted withadversity.of the appropriate spiritual language to use, makingit possible to adapt subsequent questionsaccordingly.3.4. Private Religious PracticesPrivate religious practices are individual religiousbehaviors occurring outside the context oforganized religion, and not always at a set time orplace. Praying, reading holy scriptures, listeningto religious radio programs, watching religioustelevision programs, or meditation are commonprivate religious practices.3.5. Religious PreferenceAsking about religious preference elicits whichreligious community or tradition the patient identifieswith. This preference doesn’t imply currentreligious practices but rather a social or culturalidentity. This cultural identity is of clinical interestbecause it may affect the patient’s attitudes andbehaviors toward substance use, sexuality, family,suicide, and other issues. It also indicates whichreligious community may support the patient ifneeded.3.3.Current Spiritual/Religious Beliefsand PracticesExploring the spiritual and religious historyleads to inquiries about current religious andspiritual status. Beliefs belong to the cognitivedimension of spirituality. By definition, beliefsdiffer from religion to religion. However, beliefsabout the meaning of suffering and death are insome way central to all religions and thereforemay be related to mental health status becausethey provide a framework of interpretation andexpectation. Beliefs not only vary across religioustraditions, but also among believers sharing thesame tradition. For patients who believe in Godor in a deity, it can be informative to ask abouttheir image of God and their relationship withhim. Asking the patient about his or her spiritualbeliefs gives the clinician an understanding3.6. Community Religious PracticesUsually, community religious practices includeorganizational religiousness that encompassesbehaviors such as membership in a congregation,frequency of attendance at religious services,involvement in other activities in the religiouscommunity (for example, choir practice, volunteeractivities, participation in a special interestgroup). It is also important to find out if thepatient meets individually with one or severalreligious leaders of the community and the frequencyof nonorganizational social contacts withother members of the congregation. This leads tothe question about the patient’s relationships withmembers of the religious community. Becausesocial isolation is so often associated with mentalillness, this item focuses on religious practicesthat the patient shares with others.

238 Sylvia Mohr and Philippe Huguelet3.7. Support from the ReligiousCommunitySupport from the religious community is foundedon two dimensions: first, the social support thatmembers of the religious congregation mayoffer, just like any other social network, and second,specifically religious support. The religiouscommunity may assist the patient at severallevels (material, emotional, and informational).Moreover, many religions emphasize the importanceof helping others, which may encouragethe patient in a role of assisting others. Thisattitude is especially relevant to self-esteem andrecovery. However, patients may also feel thattheir religious communities reject or judge them.They may be disappointed or angry with theirreligious communities. This potential negativeaspect must also be elicited and elaborated, likeother conflicts in relationships.3.8. Subjective Importance of ReligionAt this point in the interview, the clinician hasalready learned about the patient’s spiritual beliefs.To gain a better understanding of the salience ofspirituality and religiousness in the patient’s life,the clinician must accommodate the patient’s spiritualand religious language. For example, if thepatient believes in God, the clinician will replace“your religious or spiritual beliefs” by “your beliefin God” and ask, “In general, how important isyour belief in God in your day-to-day life?” Giventhe variety and looseness of the concepts of spiritualityand religiousness, appropriate language isessential. To help the patient express the salienceof his or her spiritual beliefs, the clinician maysuggest anchored points of importance, such as“not at all,” “a little,” “some,” “very,” or “essential.”By providing support, spiritual or religious beliefsmay bring hope, acceptance, joy, and meaning tolife. But religious beliefs may also be a source ofsuffering and despair.At this point in the interview, the clinicianshould be aware of the patient’s religious preference,his or her spiritual beliefs and practices,major changes in his or her spiritual history, andthe salience of spirituality and religiousness inhis or her life. But to what extent is this relevantto clinical outcome and care?For the assessment of spirituality and religiosity,Huber (33) has pointed out the keyconcept of centrality. Centrality describes thehierarchical status of religion in personality.The more central the religion is, the more it caninfluence the person’s experience and behavior.When religion is central, it has a powerfulinfluence on every domain of life (health and illness,family, career, sexuality, politics, and otherbeliefs and behaviors). When religion is subordinateor peripheral, it influences fewer areas. Atthis point, the clinician can readily identify thepatients for whom religion is marginal in theirlife, that is, for whom religion has never beenimportant and who currently have no or fewreligious practices.Case ExampleAs an example of low centrality, a45- year-old man with paranoid schizophreniareported, “I am a Catholic. I haven’t goneto church since I was a teenager because Iam not interested. I believe in God; this givesme hope for an afterlife. I don’t think aboutit in my daily life or use it to help me.”For patients with low centrality, the spiritualassessment should end at this point for tworeasons. First, assessment of these areas is notneeded because there is no apparent relationshipbetween religion and their psychiatric condition.Second, the clinician must respect every kind ofspiritual stance, including a professed absence ofbelief. Addressing religious coping with patientswith low religiosity could send the ill-fated messagethat they are missing something, and thus beharmful. Excessively concentrating on religionin this case may be the counterpart of the dismissivemessage about spirituality that is so frequentlysent when the issue is not addressed withpatients for whom it is central. The prevalence oflow centrality varies according to area, cohort,and population studied. In Germany, one studyfound that religion was marginal for 26 percent

Religious and Spiritual Assessment 239of nontheological students and for none of thetheological students. (33) For outpatients withschizophrenia or schizoaffective disorders, religionwas marginal for 15 percent in Switzerlandand 7% percent in Québec, Canada. (2)3.9. Importance of Religion in Copingwith IllnessFor all patients with high centrality, the screeningof spirituality and religiousness will be deepenedby the assessment of spiritual or religiouscoping. This will give the clinician an indicationof whether religion is an asset or a burden, and ifsome kind of intervention is needed.3.9.1. The Spiritual Meaning of the Illness.When confronted with illness, people lookfor meaning: “Why did this happen to me?”Biomedicine has no answer to this question.Some people turn to religion to find meaning.Some authors have even reduced religion to ameaning-making system. (34) Pargament (14)identifies four typical spiritual meanings of illness:a benevolent religious reappraisal (that is,redefining the illness through religion as benevolentand potentially beneficial); a punishingGod reappraisal (redefining the illness as a punishmentfrom God for the individual’s sins); ademonic reappraisal (redefining the illness asthe act of the devil); and a reappraisal of God’spowers (redefining God’s power to influencethe illness). These different spiritual meaningshave been associated with positive and negativeoutcomes in some studies. For example, a studyamong patients coping with psychosis foundthat benevolent religious reappraisals of the illnesswere predictive of stress-related growth andpsychological well-being. Conversely, punishingGod reappraisals and reappraisals of God’spower were predictive of self-reported distressand personal loss. (35) The same trends wereobtained with medically ill elderly patients. (22)However, it is not the religious content per se thatautomatically influences the outcome. For example,in the Pentecostal tradition, it is common toattribute illness to demons, but if the patient is aborn-again Christian, he or she has power overdemons and, therefore, is in control. Hence, inthis situation, the demonic reappraisal of the illnessis linked with empowerment, a componentknown to be a key of psychological recovery. (24)This short digression aims to emphasize the needto understand the psychological meaning of spiritualbeliefs for the patient. Moreover, the openendedquestion about the spiritual meaning ofthe illness makes it possible for spiritual meaningslying outside the Judeo-Christian traditionto emerge. For example, a Buddhist woman withschizoaffective disorder answered this questionwith the concept of karma; she believed her illnesswas due to her wrongdoings in a previouslife. This spiritual belief brought her hope for abetter karma in her next life in reward for hercurrent pro-social behaviors.3.9.2. Coping with SymptomsSpirituality and religiousness are not onlyeffective in giving meaning to the illness, butalso in alleviating psychiatric symptoms. Whendealing with depression, people may find hopeand comfort in spirituality/religion. When dealingwith anxiety, people may find peace. Arobust relationship has been established betweenreduced depression and anxiety and religion. (17)Emotional and behavioral disturbances associatedwith delusions and hallucinations may alsobe reduced by religion. (36) However, spiritualbeliefs may also aggravate psychiatric symptoms.Worries about sin, hell, and demons may nourishanxiety, depression, and delusions. This itemhelps the clinician to determine whether spiritualor religious coping alleviates or aggravatessymptoms.3.9.3. Coping StylePargament (14) identifies three major spiritualor religious methods of coping to gain controlover symptoms. The patient may rely onhimself alone without God’s help (self-directingreligious coping style), he may rely passively onGod or plead for direct intercession (deferralstyle), or he may do his best to collaborate with

240 Sylvia Mohr and Philippe HugueletGod (collaborative style). These styles are notpositive or negative per se, but depend on thescope of the individual’s power to influence thecourse of the illness in the context of a specificsituation.3.9.4. ComfortTh is item examines the emotional influenceof spiritual beliefs. Inquiring about this aspectis especially necessary when the patient hasrecounted only the cognitive dimension of hisor her spiritual beliefs. The strength and comfortprovided by spiritual beliefs are associatedwith lower levels of depression. (29) Often, spiritualbeliefs bring hope and comfort; however,they may be a source of suffering too. The illnessmay call attention to the fact that spiritualstruggles are a necessary stage of any spiritualjourney.3.10. Synergy of Religion withPsychiatric CareTh e literature examining the pathways to psychiatriccare points out that spiritual and religiousbeliefs about mental illness may influencehelp-seeking behavior and adherence to psychiatrictreatment. (37) Different kinds of relationshipsexist between spirituality/religiousnessand psychiatric care. For some patients, the twoareas have nothing in common; psychiatry andreligion are two separate areas in their lives.However, when religion is central in people’slives, it encompasses almost all areas, includingpsychiatric care. This spiritual meaning may fosteror hinder adherence to psychiatric treatment.Some patients believe that God gives knowledgeto the clinician to care for them; thus, they trustin psychiatric care. Other patients first put theirtrust in religious professionals who advocatedpsychiatric care, thus allowing the patients totrust psychiatry. But other patients experienceconflicts between their spiritual beliefs and psychiatriccare. These conflicts may lead to noncomplianceand distress, so this issue must beaddressed.4. S/R ASSESSMENT: OTHER ELEMENTSThe semistructured interview guide providedhere (see Table 16.1) outlines a first spiritual/religiouscase formulation in a single assessment lastingabout half an hour. Based on a global clinicalimpression, the first element to examine is thecentrality of spirituality/religion. If it is low, theS/R assessment is of no importance for currentclinical care. However, because spirituality andreligiousness tend to change over time, especiallyin association with mental illness, drastic changesmay occur over the course of a lifetime. We recommendregular checks of this dimension, likeother areas assessed in long-term follow-up casemanagement.Th e second element to examine is thepatient’s relationships with his or her religiouscommunity. Does the patient currently belongto a religious community? Is he or she supportedby this community or does he or she feelrejected or in conflict? Does the patient ask forsupport from the religious community for hisor her mental illness or does he or she feel tooashamed or guilty? Do his or her symptoms hinderhim or her from participating in religiousactivities? Do religious professionals from thereligious community collaborate with the psychiatriccare network or are they in conflict?Could they be integrated into psychiatric care?To summarize, is the religious community anasset or a burden?Patients’ relationships with their religiouscommunities deserve special attention becausethey provide a natural social network that maybe a powerful resource for social integration andpsychological recovery. Like family, the clergymay need psycho-education and support fromclinicians to deal with people suffering fromsevere mental illness. (37)The third element to examine is the positive ornegative role of spirituality and religiousness forthe patient. Is spirituality/religiousness a sourceof hope, comfort, meaning in life, and joy or asource of suffering? Is the individual upheld inhis or her identity by spirituality/religiousness orundermined?

Religious and Spiritual Assessment 241If a patient’s spirituality/religiousness is anuplifting force, it should be sustained throughoutfollow-up care. Spirituality and religiousnessbecome key elements of psychological recoverywhen they are central in a patient’s life andintegrated into–not in conflict with–other fundamentaldimensions of life. In this case, spiritualityand religiousness give meaning to theperson’s life, foster acceptance of the illness andpsychiatric care, and provide coping methods tocope with symptoms, social support, and guidelinesfor a healthy lifestyle.Case ExampleA 34-year-old man with paranoidschizophrenia reported, “As a child, I wassexually abused. God gave me the strengthto forgive and restored my dignity to me.I hope God will heal me. God gives methe security I need. I pray to be relievedof sadness, the desire to die and anxiety. Istill hear voices, but I don’t mind any more.They are evil spirits who want to bring medown. I focus on God and I don’t listen tothem. Now, I see schizophrenia as a blessing.If I didn’t have this illness that brokeme down, I would live like everyone else:work, marriage and children. I would notlong for God and to meet Jesus. God putpsychiatrists and psychologists on my pathto help me and to open my mind.”In such situations, the salience of spiritualityand religiousness is associated with reducedpsychopathology and enhanced social functioning.(36) However, spirituality and religiousnessmay be positive for the self without being integratedinto the process of coping with the mentalillness. In such cases, although religion plays acentral role in the patient’s life, it is not associatedwith coping with the mental illness.Case ExampleA 47-year-old woman with schizoaffectivedisorder reported, “When I wasa teenager, I wanted to become a nun. Ilived in a closed convent for two years.But community life with other women wastoo hard for me so I left and worked in aCatholic organization for years. Finally, Ialso left this church because I can’t standfeeling that I am part of a community, I wasafraid of being imprisoned. Spirituality is theessence of my life, a personal experience; itbelongs to me and nobody else. I pray everyday; this is what holds me up. For severalyears, I had the vision a woman who tellsme to end my life by killing myself. I don’tknow if she is right or not. I have tried tokill myself several times. Spirituality doesn’thelp me to cope with the voice, because Iexpect nothing from it. Medication reducesmy anxiety so it hinders me from whollyexperiencing my spiritual life.”Case ExampleSimilarly, a 30-year-old man with paranoidschizophrenia reported, “I have beenunable to work for three years now; theonly thing I do is go to the synagogue everyday. Believing in God comforts me. Therabbi and the other students at the synagoguedon’t support me as I have never toldthem about my psychiatric condition.”Because spirituality and religiousness encompassseveral dimensions, they can have a positiveimpact at the level of the self and a negative impactat other levels. A spiritual belief in a life after deathmay facilitate suicidal behavior to end current,unbearable suffering. (38) Spirituality often playsa central role in recovery from substance addictions,but substance misuse may also be used tocope with spiritual suffering. (39) Patients may betormented by conflicts between spirituality andpsychiatric care. (40) An assessment of the variousdimensions of spirituality and religiousnessbreaks the myth that all kinds of spirituality andreligiousness are healthy. Some aspects may needto be targeted by clinical intervention. In othercases, spirituality and religiousness are negativefor the self. When confronted with mental illness,individuals may feel abandoned by God orangry with God, or they may lose their faith. They

242 Sylvia Mohr and Philippe Hugueletreport distressing spiritual struggles and conflictssimilar to those that anyone may endure in timesof hardship. In these cases, the S/R assessmenthelps the clinician to identify which religious professionalscan best provide spiritual counseling tothe patient. Spirituality and religiousness may benegative for the self when they intermingle withpsychopathology. Indeed, current spirituality andreligiousness may be by-products of the patient’sdisorder. This aspect is discussed in several chaptersof this book. In manic states, patients sometimespresent delusions of grandeur with religiouscontent; for example, they believe they are Christor Buddha. In persecutory delusions, the agentsof persecution may be spiritual entities, especiallydemons (see Chapter 7). People with depressionmay lose all interest and motivation, includingspiritual and religious involvement. In anxietydisorders, people may be excessively tormentedby worry about sins and hell. In obsessive-compulsivedisorder, religious rituals may becomepathological, with an intense focus on avoidingsin or error (see Chapter 10). In personality disorders,spirituality and religiousness may be usedin unhealthy ways to cheat others, serve personalneeds, or dismiss the individual from personalresponsibility (see Chapter 13). However, it isimportant to keep in mind that even if a patient’sspiritual life may be distorted by the mental illnessat times, this doesn’t mean that the spiritual lifeof those patients is only – and always – psychopathological.Spiritual and religious assessmentcan provide some indication of how to orienttreatment in those cases. In addition to the usualclinical care, the clinician can decide whether toaddress spirituality or not, in collaboration withclergy if needed.5. SYNTHESISS/R assessment is an important part of thepsychiatric evaluation. It should be performedat the beginning of treatment and at regularintervals in cases of mid- or long-term care. Theprincipal elements of this assessment have beendescribed in this chapter. Other elements specificto different diagnoses or clinical situations aredescribed in other chapters of this book. Whatall these situations have in common is that (1)psychiatrists are confronted with patients’ cultural/religiousbackgrounds even more thanother clinicians, so this dimension must be takeninto account; (2) particularly when involved inpsychotherapy, the question of meaning shouldbe addressed, including its religious/spiritualdimension; (3) the phenomenology of psychiatricsymptoms may be characterized by religiouselements; (4) when treating patients withpersistent mental disorders, recovery-orientedcare should involve a religious dimension whenneeded; and (5) all spiritual orientations must berespected when addressing spirituality/religionwith patients, including a professed absence ofbelief.REFERENCES1. Huguelet P , Mohr S , B or r as L , Gi l l ieron C , Br andtPY . Spirituality and religious practices amongoutpatients with schizophrenia and their clinicians. Psychiatr Serv . 2006; 57 (3): 366 –372.2. Borras LMS , Brandt P-Y , Gillieron C , Czellar J ,Huguelet P . Religious coping among patients withschizophrenia in Quebec vs. Geneva, Switzerland.Submitted. 2009.3. B aet z M , Gr i ffi n R , B owen R , Marc ou x G .Spirituality and psychiatry in Canada: psychiatricpractice compared with patient expectations . CanJ Psychiatry . 2004; 49 (4): 265 –271.4. Curlin FA , Lawrence RE , Odell S , et al. Religion,spirituality, and medicine: psychiatrists’ and otherphysicians’ differing observations, interpretations,and clinical approaches . Am J Psychiatry .2007 ; 164 (12): 1825 –1831.5. Curlin FA , Lantos JD , Roach CJ , SellergrenSA , Chin MH . Religious characteristics of U.S.physicians: a national survey . J Gen Intern Med .2005; 20 (7): 629 –634.6. Ne eleman J , Ki ng M B . Psychi at r ist s’ rel i g iousattitudes in relation to their clinical practice: asurvey of 231 psychiatrists . Acta Psychiatr Scand .1993 ; 88 (6): 420 –424.7. Shaf ranske EP . Religion and the Clinical Practiceof Psychology . Washington, DC : AmericanPsychological Association ; 1996 .8. Lu koff D , Lu FG , Turner R . Cultural considerationsin the assessment and treatment of religiousand spiritual problems . Psychiatr Clin North Am .1995; 18 (3): 467 –485.9. Crossle y D . R el i g ious ex p er ienc e w it hi n ment a lillness. Opening the door on research . Br JPsychiatry . 1995; 166 (3): 284 –286.

Religious and Spiritual Assessment 24310. Roberts D . Transcending barriers between religionand psychiatry . Br J Psychiatry . 1997; 171: 188 .11. Sims A . The cure of souls: psychiatric dilemmas .Int Rev Psychiatry . 1999 ; 11 : 97 –102.12. Peteet J . Therapeutic implications of worldview.In: Josephson AM PJ , ed. Handbook of Spiritualityand Worldview in Clinical Practice . Washington,DC : American Psychiatric Publishing, Inc. ;2004: 47 –59.13. American Medical Association. Programrequirements for residency education in psychiatry.Graduate Medical Education Directory2002–2003. Chicago: AMA; 2002 :218–225.14. Pargament KI . The Psychology of Religion andCoping: Theory, Research, Practice . New York : TheGuilford Press ; 1997 .15. Vergare MJ , Binder RL , Cook IA , Galanter M , LuFG . American Psychiatric Association practiceguidelines . Am J Psychiatry . 2006 ; 163 (3): 1 –36.16. Alarcon RD , Alegria M , Bell CC , et al. Beyondthe funhouse mirrors: research agenda on cultureand psychiatric diagnosis. In: Kupfer DJ ,First MB , R e g ier DA , e ds . A res e arch agend a forDSM-V. Washington, DC : American PsychiatricAssociation ; 2005: 219 –282.17. Koenig HG . Handbook of Religion and MentalHealth . San Diego : Academic Press ; 1998.18. Fallot RD . Spirituality and religion in recovery:some current issues . Psychiatr Rehabil J .2007 ; 30 (4): 261 –270.19. Galanter M , Dermatis H , Bunt G , Williams C ,Trujillo M , Steinke P . Assessment of spiritualityand its relevance to addiction treatment . J SubstAbuse Treat . 2007; 33 (3): 257 –264.20. American Psychiatric Association . DSM-IV:Diagnostic and Statistical Manual of MentalDisorders . Washington : APA ; 1994 .21. Fowler J . Stages of Faith . San Francisco : Harperand Row ; 1971 .22. Pargament KI , Koenig HG , Tarakeshwar N ,Hahn J . Religious struggle as a predictor ofmortality among medically ill elderly patients:a 2-year longitudinal study . Arch Intern Med .2001 ; 161 (15): 1881 –1885.23. Mayer J-F . Confessions d’un chasseur de secte . Paris :Cerf ; 1990 .24. Andresen ROL , Caputi P . The experience of recoveryfrom schizophrenia: towards an empiricallyvalidated stage model . Aust N Z J Psychiatry .2003 ; 37 (5): 586 –594.25. D’Souza R . The importance of spirituality in medicineand its application to clinical practice . Med JAust . 2007 ; 186 (10): 57 –59.26. Koslander T , Arvidsson B. Patients’ conceptionsof how the spiritual dimension is addressed inmental health care: a qualitative study . J Adv Nurs .2007 ; 57 (6): 597 –604.27. Hill P , Hood, R . Measures of Religiosity . BirminghamAL : Religious Education Press ; 1999 .28. Kendler KS , Gardner CO , Prescott CA . Religion,psychopathology, and substance use and abuse; amultimeasure, genetic-epidemiologic study . Am JPsychiatry . 1997; 154 (3): 322 –329.29. Institute F . Multidimensional measurement of religiousness/spiritualityfor use in health research.US Department of Health and Human Services;1999 .30. Wulff DM . Psychology of Religion: Classic andContemporary . New York : John Wiley ; 1997 .31. Koenig HG , Pritchett, J . Religion and psychotherapy.In: Koenig HG , ed. Handbook of Religion andMental Health . San Diego : Academic Press ; 1998:323–336.32. Anandarajah G , Hight E . Spirituality and medicalpractice: using the HOPE questions as a practicaltool for spiritual assessment. Am Fam Physician .2001 ; 63 (1): 81 –89.33. Huber S . Are religious beliefs relevant in dailylife? In: Streib H , ed. Religion Inside and OutsideTraditional Institutions . Leiden, Netherlands : BrillAcademic Publishers ; 2007:211–230.34. Park CL . Religiousness/spirituality and health:a meaning systems perspective . J Behav Med .2007 ; 30 (4): 319 –328.35. Phillips RE , III, Stein CH. God’s will, God’spunishment, or God’s limitations? Religiouscoping strategies reported by young adults livingwith serious mental illness . J Clin Psychol .2007 ; 63 (6): 529 –540.36. Mohr S , Brandt PY , Borras L , Gillieron C ,Huguelet P . Toward an integration of spiritualityand religiousness into the psychosocialdimension of schizophrenia . Am J Psychiatry .2006 ; 163 (11): 1952 –1959.37. Leavey G , Loewenthal K , King M . Challengesto sanctuary: the clergy as a resource for mentalhealth care in the community . Soc Sci Med .2007 ; 65 (3): 548 –559.38. Huguelet P , Mohr S , Jung V , Gillieron C , BrandtPY , B or ras L . E ffect of religion on suicide attemptsin outpatients with schizophrenia or schizoaffectivedisorders compared with inpatientswith non-psychotic disorders . Eur Psychiatry .2007 ; 22 (3): 188 –194.39. Huguelet P , Borras L , Gillieron C , Brandt P-Y ,Mohr S . Influence of spirituality and religiousnesson substance misuse in patients with schizophreniaor schizo-affective disorder . Subst use Misuse .in press.40. Borras L , Mohr S , Brandt PY , Gillieron C , EytanA , Huguelet P . Religious beliefs in schizophrenia:their relevance for adherence to treatment .Schizophr Bull . 2007 ; 33 (5): 1238 –1246.

17 Integrating Spiritual Issues into TherapyRENÉ HEFTISUMMARYThe task of this chapter is to give recommendationson how to integrate religious and spiritualaspects into the treatment of persons sufferingfrom mental illness, based on the evidencefrom past and recent research and from clinicalexperience.Religious coping is highly prevalent amongpatients with psychiatric disorders. Surveys indicatethat 70 to 80 percent use religious or spiritualbeliefs and activities to cope with daily difficultiesand frustrations. Religion helps patients tomaintain hope, purpose, and meaning. Patientsemphasize that serving a purpose beyond one’sself can make it possible to live with what mightotherwise be unbearable.Religious coping is also prevalent among familycaregivers and enhances emotional adjustment,lowers levels of depression, and fostersself-care. A substantial proportion of familymembers of persons with serious mental illnessmobilize religious and spiritual resources to copewith their situation as caregivers.Programs that successfully incorporate spiritualityinto clinical practice are described anddiscussed in detail. Studies indicate that theoutcome of therapy in religious patients canbe enhanced by integrating religious elementsinto the therapy protocol and that this can besuccessfully done by religious and nonreligioustherapists alike.1. SPIRITUAL PERSPECTIVESON MENTAL ILLNESS1.1. General ConsiderationsPrevious chapters of this book have demonstratedthe importance of religious and spiritual aspectsin psychiatric disorders providing evidence ofthe therapeutic potential for integrating spiritualityinto mental health treatment. Neverthelessspiritual approaches in mental health care arestill in their infancy, certainly in Europe butalso in the United States. Due to concerns aboutharmful effects, a controversy is ongoing regardingwhether or not to integrate spiritual elementsinto the treatment of persons suffering from mentalillness. At the same time, a growing body ofevidence shows beneficial outcomes of religiousand spiritual approaches to psychiatric disorderswith regard to the following aspects: seeing spiritualityas a unique human dimension, ( 1) makinglife sacred and meaningful, ( 2) being an essentialpart of the physician-patient-relationship, ( 3)and the recovery process.(4 , 5 )1.2. Spirituality and the RecoveryPerspectivePersons suffering from mental illness have beenexploring spiritually based approaches to mentalhealth for decades. Most importantly, they emphasizethat psychiatric diagnosis does not affect thedeepest human drives, that is, to live with purposeand to flourish as a human being. Understanding244

Integrating Spiritual Issues into Therapy 245one’s problems in religious or spiritual terms canbe a powerful alternative to a biological or psychologicalframework. Although reframing the issuein this manner may not change the reality of thesituation, but having a higher purpose may makea big difference in an individual’s willingness tobear pain, work hard, and make sacrifices. Giventhe fact that people with serious mental illnessesalready struggle against widespread prejudice anddiscrimination, it would seem important to maintainor strengthen people’s existing religious affiliationsand support systems as part of their treatmentor rehabilitation plan. (2)Furthermore, mental health practitioners willincreasingly be seeing clients who choose to viewtheir mental health problems through a traditional,non-Western lens. Although a significantmajority of Americans define themselves asChristians (76.5 percent), the percentage of theU.S. population that identifies itself with otherreligious and spiritual traditions is increasing. (6)Substantial increases are seen in the percentageof people identifying themselves as New Age(240 percent), Hindu (237 percent), Buddhist(170 percent), and Muslim (109 percent). TheChristian population showed only a smallincrease (5 percent), and the Jewish populationeven declined slightly (-10 percent). As a consequenceof this shift, many culturally based“alternative” treatments are widely accepted asbeneficial, including prayer and faith healing.1.3. The Voice of Persons Sufferingfrom Mental IllnessMany individuals with psychiatric disabilitiesview spiritual activities as an integral part of theirrecovery process. They have consistently indicatedthat religion and spirituality can serve asa major resource in recovery. (5, 7–14) Lindgrenand Coursey (15) interviewed participants in apsychosocial rehabilitation program: 80 percentsaid that religion and spirituality had been helpfulto them. Trepper et al. (11) found that participantsexperiencing greater symptom severityand lower overall functioning are more likely touse religious activities as part of their coping.Symptom-related stress leads to greater use ofreligious coping, a phenomenon that has beenshown in other studies too.( 16 , 17 ) Baetz et al.(18) demonstrated among psychiatric inpatientsthat both public religion (for example, worshipattendance) and private spirituality were associatedwith less severe depressive symptoms.Religious patients also had shorter lengths ofstay in the hospital and higher life satisfaction.Koenig, George, and Peterson (19) followedmedically ill older persons who were diagnosedwith a depressive disorder and found that intrinsicreligiosity (following religion as an “end initself,” rather than as a means to other end) waspredictive of shorter time to remission of depressivedisorder, after controlling for multiple otherpredictors of remission. Pargament ( 20 , 21 ) hasstudied extensively the role of religious copingmethods in dealing with stress. He found consistentconnections between positive styles of religiouscoping and better mental health outcomes.Religious coping styles such as perceived collaborationwith God, seeking spiritual support fromGod or religious communities, and benevolentreligious appraisal of negative situations havebeen related to less depression,( 19) less anxiety,( 22) and more positive affect. (23)1.4. Religious and Nonreligious TherapistsCan nonreligious therapists deliver religious therapyfor religious patients, and if yes, how effectiveare they? Is religious therapy per se more effectivefor religious patients than nonreligious therapy?To answer these questions, Rebecca Probstfrom the Department of Counseling Psychology,Portland, Oregon, conducted a comparative studyof the efficacy of religious and non-religiouscognitive-behavioral therapy with religious andnonreligious therapists on religious patients withclinical depression. (24) She hypothesized that religiouscognitive-behavioral therapy (RCT) mightbe more effective for religious patients than standardcognitive-behavioral therapy (CBT) becauseof higher consistency of values and frameworks.

246 René Hefti2520BDI1510501 2RCT-NTRCT-RTCBT-NTCBT-RTP-CareWLCFigure 17.1. Reduction of BDI-scores during treatment period (1 = pre-treatment, 2 = post-treatment).In that study, religious cognitive- behavioral therapygave religious rationales for the procedures,used religious arguments to counter irrationalthoughts, and used religious imagery proceduresaccording to a manual published by Probst in1988. (25) Furthermore, the study was designed todetermine whether nonreligious therapists couldsuccessfully implement RCT.Focusing on pre- and posttreatment results(see Figure 17.1 ) Probst et al. found that religiousindividuals receiving RCT reported more reductionin depression (BDI) and greater improvementin social adjustment (SAS) and generalsymptomatology (GSI, SCL-90-R) than patientsin the standard CBT. Individuals in the pastoralcounseling treatment group (PCT), which wasincluded to control for the nonspecific effects ofthe treatment delivery system, also showed significantimprovement at posttreatment and evenoutperformed standard CBT. This finding is analogousto the results obtained with a nonclinicalpopulation in a previous study. (26)The most surprising finding in the recent studywas a strong therapist-treatment interaction. Thegroup showing the best performance on all measureswas the RCT condition with the nonreligioustherapists (RCT-NT), whereas the groupwith the worst pattern of performance was thestandard CBT with the nonreligious therapists(CBT-NT). Less difference in performance wasnoted between the cognitive-behavioral therapyconditions for the religious therapists (RCT/CBT-RT). This pattern of therapist-treatmentinteraction suggests the following:1 E ffectiveness of CBT for religious patientsdelivered by nonreligious therapists can beenhanced significantly by using a religiousframework.2 Impact of similarity of value orientation oftherapists/therapy and patients on outcome oftherapy seems to suggest that neither extremevalue similarity nor extreme value dissimilarityfacilitates outcome.Value similarity must be defined as a combinationof the personal values of the therapistand the value orientation of the treatment. Doneso, the RCT conditions with religious therapistsand standard CBT with nonreligious therapistsshow the most value similarity. Neither of them,however, showed high performance.The Probst study clearly indicates that theoutcome of therapy in religious patients can be

Integrating Spiritual Issues into Therapy 247EXTENDED BIO PSYCHO SOCIAL MODELReligion SpiritualityPsychology of ReligionSociology of ReligionPsycho-SocialBio-“Biology of Religion”Figure 17.2. Extended bio-psycho-social model integrating religion/spirituality as a fourthdimension (published by Hefti R, 2003).enhanced by integrating religious elements intothe therapy protocol and that this can be successfullydone by religious and nonreligious therapistsalike.2. A HOLISTIC AND INTERDISCIPLINARYMODEL FOR THERAPY2.1. The Extended Bio-Psycho-SocialModelIn psychiatry and psychosomatic medicine, thebio-psycho-social model, introduced by George L.Engel (27) is the predominant concept in clinicalpractice and research. It shows that biological,psychological, and social factors interact in a complexway in health and disease. Our book illustratesthat there is a fourth dimension involved.Religion and spirituality constitute an additional,distinct, and independent dimension, interactingwith biological, psychological, and social factors.I have called this model the extended bio-psychosocialmodel (Figure 17.2 ).(28)Th e extended bio-psycho-social model is auseful framework to understand the religiousand spiritual dimension in clinical practiceas well as in religion, spirituality, and healthresearch. It shows that religion and spiritualitycan be causing, mediating, or moderating factorson mental health and disease in the sameway as biological, psychological, and social factors,constituting biology of religion, psychologyof religion, and sociology of religion. Themodel illustrates that pharmacotherapeutic,psychotherapeutic, sociotherapeutic, and spiritualelements must be integrated in a holisticperspective, thus establishing a whole-personapproach to mental health.2.2. Religion and Spirituality as a MainResourceIn general, people who are more religiously orspiritually devout report better physical health,psychological adjustment, and lower rates ofproblematic social behavior. (29–32) Spiritualitystrengthens a sense of self and self-esteem,( 5 , 10 , 33) of feeling more like a “whole person,”and of being valued by the divine (as part of creation,as a “child of God”), countering stigma andshame by positive self-attributions and, throughall of this, reinforcing “personhood.”( 34)Spirituality is associated with decreased levelsof depression,( 35) especially among people with

248 René Heftiintrinsic spirituality or faith based on internalizedbeliefs. (36) Spirituality correlates with lower levelsof general anxiety ( 31 , 36 , 37) and with positiveoutcomes in coping with anxiety. (38) Higher levelsof spirituality among individuals recovering fromsubstance abuse are related to resiliency to stressand optimism,( 39) and spiritual coping methodsare found to have positive effects for persons diagnosedwith schizophrenia. (40) Participation inspiritual and religious activities helps to integrateindividuals into their families. (41)Religion and spirituality also deliver socialand community resources ( 10 , 33 ) beingenhanced by the “transcendent nature” of thesupport. Belonging to and finding acceptance ina religious community may have special importancefor people who are often rejected, isolated,or stigmatized. (42) Spiritual experiences facilitatethe development of a fundamental sense ofconnectedness. Religion and spirituality foster asense of hope and purpose, a reason for being,as well as opportunities for growth and positivechange.( 5 , 33 , 43) These are ways in whichthe patients have expressed the experience ofenhanced personhood or empowerment.2.3. Religion and Spirituality as a BurdenIt is important to be aware of the “negative” (or atleast challenging) effects that religion and spiritualitycan have on mental health outcomes andrecovery.Negative religious coping involves beliefs andactivities such as expressing anger at God, questioningGod’s power, attributing negative eventsto God’s punishment, and discontent with religiouscommunities and their leadership. Negativereligious coping in community samples has beenlinked to greater affective distress, includinggreater anxiety and depression and lower selfesteem(44) and more PTSD symptoms. (45)Religious struggles involving interpersonalstrain rather than social support, conflictswith God rather than perceived collaborationand support, struggles with belief rather thanclear meaning and coherence, and difficultiesrelated to imperfect striving after virtue havebeen linked to higher levels of depression andsuicidality. (46) Negative experiences with religiousgroups can aggravate feelings of rejectionand marginalization. (47)Religious convictions can intensify excessesof self-blame and perceptions of unredeemablesinfulness. If they are woven into obsessive ordepressive symptom patterns, they can be evenmore distressing. Furthermore, they can be reinforcedby religious communities that see mentaldisorders as signs of moral or spiritual weaknessor failure. Prayer or other religious rituals canbecome compulsive and interfere with overall dailyfunctioning. (11) Finally, beliefs involving themes ofdivine abandonment or condemnation, unrelentingrejection, or powerful retribution may makerecovery seem unattainable or unimportant. (48)2.4. An Interdisciplinary ApproachApplying a holistic or whole person approach tomental illness demands an interdisciplinary concept.Different competencies have to be representedin the therapeutic team ( inpatient setting,Figure 17.3 ). (28) The pastoral/spiritual counselorshould be a full member of the interdisciplinaryteam with rights and responsibilities equal tothe other therapists. This guarantees working oncommon therapeutic goals and prevents playingoff pastoral counseling against the other disciplines,what we consider an important aspect inthe psychiatric and psychotherapeutic context.3. RELIGIOUS AND SPIRITUAL COPINGIN MENTAL DISEASE3.1. The Key Role of Religious Copingfor PatientsSeveral surveys showed a high prevalence ofreligious coping among patients with severeand persistent mental illness. Tepper et al. (11)investigated 406 patients at one of thirteen LosAngeles County mental health facilities. Morethan 80 percent of the participants used religious

Integrating Spiritual Issues into Therapy 249Physicians,psychiatristaPsychiatricnursesPastoralcounselorsPsychologists,PsychotherapistsMentally illPatientSocial workersArt and musictherapistsPhysiotherapistsFigure 17.3. Model of an interdisciplinary team (inpatient setting).beliefs or activities to cope with daily difficultiesor frustrations. A majority of participantsdevoted as much as half of their total coping timeto religious practices, with prayer being the mostfrequent activity. Specific religious coping strategies,such as prayer or reading the Bible, wereassociated with higher SCL-90 scores (indicatingmore severe symptoms), more reported frustration,and a lower GAF score (indicating greaterimpairment). The amount of time that participantsdevoted to religious coping was negativelyrelated to reported levels of frustration and scoreson the SCL-90 symptom subscales. The resultsof the study suggest that religious activities andbeliefs may be particularly important for personswho are experiencing more severe symptoms,and increased religious activity may be associatedwith reduced symptoms over time.This is not only true in the United Statesbut also in Europe. The findings of Tepperet al. have been replicated by Mohr et al. inGeneva, Switzerland. (49) Semistructured interviewsfocused on religious coping were conductedwith a sample of 115 outpatients with psychoticillness at one of Geneva’s four psychiatric outpatientfacilities. For a majority of patients, religioninstilled hope, purpose, and meaning in their lives(71 percent), whereas for some, it induced spiritualdespair (14 percent). Patients also reportedthat religion lessened (54 percent) or increased(10 percent) psychotic and general symptoms.Religion was also found to increase social integration(28 percent) or social isolation (3 percent). Itreduced (33 percent) or increased (10 percent) therisk of suicide attempts, reduced (14 percent) orincreased (3 percent) substance use, and fosteredadherence to (16 percent) or was in oppositionto (15 percent) psychiatric treatment. The resultshighlight the clinical significance of religion andreligious coping in the care of patients with schizophrenia.Thus, spirituality should be integratedinto the psychosocial dimension of care.Huguelet et al. from the same public psychiatricoutpatient department in Geneva investigatedspirituality and religious practices of outpatients(N = 100) with schizophrenia and comparedthem with their clinician’s knowledge of patients’religious involvement. (50) Audiotaped interviewswere conducted about spirituality and religiouscoping. The patients’ clinicians (N = 34) wereasked about their own beliefs and religious activitiesas well as their patients’ religious and clinical

250 René Hefticharacteristics. A majority of the patients reportedthat religion was an important aspect of their lives,but only 36 percent of them had raised this issuewith their clinicians. Fewer clinicians were religiouslyinvolved, and, in half the cases, their perceptionsof patients’ religious involvement wereinaccurate. Some patients considered treatment tobe incompatible with their religious practice, butclinicians were seldom aware of such conflicts.These findings about religious coping reflect theexperiences we are having at the SGM-Clinic forpsychosomatics, psychiatry, and psychotherapyin Langenthal, Switzerland ( inpatient and outpatientdepartment). For a majority of our patients,religious or spiritual coping is an essential partof their coping behavior. Religion providespatients with a framework to cope with diseaserelatedstruggles. Existential needs such as beingsecure, being valued, and having meaning andpurpose are addressed by clinicians and pastoralcounselors, despite and beyond psychiatricconditions. (51) To illustrate this, I quote somepassages from open, unstructured interviews thatwere performed with depressed patients as part ofa qualitative study conducted in our clinic. (52)32 year old male patient: The patient ismarried and has a 1-year-old son. He hasbeen working in the same company formany years and is a member of a Protestantchurch. He was hospitalized because of asevere depressive episode. How did heuse religious coping to overcome hisdepression?■■By reading scriptures/psalms: “Readingpsalms helped me a lot to feel closer toGod in difficult times. I realized thatothers (the writers of the psalms) hadto cry also and felt desperate in theirsituation. They argued with God andpleaded to him.”By getting spiritual support: “In the verydark moments, when I felt totally lost andabandoned by God, I couldn’t cope withmy situation any more. I couldn’t fightnegative thoughts about the future andmyself. I needed somebody from outsideto tell me that these are lies, that I am notabandoned either by God or by my family,that I am not worthless but loved.”65 year old female patient: The patient grewup in a small village in the countryside. Shehad five brothers and sisters. Her fatherwas an alcoholic. The patient left home atan early age. Her first marriage collapsedbecause of her husband’s alcoholism.They had two children. After the divorce,the patient experienced her first depression.Later she married again and becamea member of a Methodist church (after areligious conversion). Depressive episodesbecame less frequent and less severe. Whatdid the patient do to help her cope withdepression?■■Controlling depression by faith/prayer:“When I feel sad and my thoughtsbecome gloomy, when I wake up earlyin the morning and can’t sleep anymorethen I go outside into nature and speakwith God, thanking him for being incontrol and for not letting me go down.”Not asking why: “In past times I alwaysbegan to ask why, why did I marry thisman, why did God let this happen?But this made things worse. I began toturn in circles. Today I stop this kind ofthinking and focus on God.”Our task as a physician, psychotherapist,or mental health worker is to support the copingcapacities of patients by understanding andempowering them.3.2. The Key Role of Religious Copingfor Family CaregiversResearch that has examined the outcomes of religiouscoping has generally found that religiosityamong caregivers is linked to enhanced adjustment.For example, in a longitudinal study ofsixty-two caregivers of persons with Alzheimer’s

Integrating Spiritual Issues into Therapy 251disease or cancer, Rabins and colleagues (53)found that strength of religious belief at baselinewas associated with better emotional adjustmentamong caregivers at two-year follow-up, evenwhen personality variables, family functioning,and levels of anger and guilt were controlledfor. In another study of 127 caregivers of elderlypersons with disabilities, Chang and colleagues(54) found that caregivers who used religious orspiritual beliefs to cope with caregiving stress hada better relationship with care recipients, lowerlevels of depression, and better self-care; forexample, they experienced less “submersion” inthe caregiving role.Only a few published studies have quantitativelyassessed and examined the correlates of religiosityamong family caregivers of persons with seriousmental illness. (55) For example, sixty Hindufamily members of patients with schizophreniawere recruited through a public hospital in India.These individuals completed measures of caregivingburden, coping activities, religious beliefs andpractices, and adjustment. The results of the studyhighlight the prevalence of religious coping; 90percent of participants reported praying to God,and 50 percent viewed religion as a source of solace,strength, and guidance in coping with caregivingdemands. In multiple regression analyses,the authors found that strength of religious beliefwas linked to greater well-being among caregivers,with other types of coping and demographic characteristicscontrolled for. Although generalizationof these results is limited by cultural context, thesefindings highlight the prevalence and potentialbenefits of religiosity among caregivers of personswith serious mental illness.Johnson (56) interviewed a sample of 180family members about their understanding oftheir relative’s illness, sources of support, andways of coping and found that family membersoften turn to religion to cope with the stressof caring for an ill family member. Bland andDarlington (57) echoed these results in theirstudy of hope among family members of personswith serious mental illness. Five of the sixteenparticipants spontaneously identified religiousbeliefs and participation as a significant sourceof hope. Thus, research points to the importantrole of religiosity among family caregivers ofpersons with serious mental illness. Moreover,these preliminary studies, along with work inother caregiving populations, suggest that religiositymay have salutary effects on caregiveradjustment.A recent study aimed to characterize thenature of religiosity and sources of spiritualsupport in a sample of family caregivers of personswith serious mental illness in the NationalAlliance on Mental Illness (NAMI) Family toFamily Education program. (58) Forty-fourpercent reported having a relative with schizophrenia,50 percent had a relative with a majoraffective disorder, and the remaining 6 percenthad a relative with another diagnosis. The meanrating of importance of religion and spirituality,on a scale of 1 to 4, was 3.43 ± .83±, which ishalfway between “fairly important” and “veryimportant.” The mean rating of whether participantsconsidered God to be a source of comfortand strength was 3.26 ± 1.03, falling between“quite a bit” and “a great deal.” Overall, this was amoderately religious and spiritual sample, comparableto the general population.Thirty-one participants (37 percent) reportedthat they had received religious or spiritual supportin coping with their relative’s illness in thepast three months. The most frequent types ofspiritual support were praying or meditating,reading the Bible or other religious literature,and watching or listening to religious programson television or the radio. Notably, nineteen participants(23 percent) reported that they contactedclergy or a religious leader to talk aboutproblems or concerns related to their relative’sillness. Twenty-three participants (28 percent)reported relying on members of their congregationfor support in coping with their relatives’ illnessduring the previous three months. Personalreligiosity was positively associated with level ofmastery (r = .26, p = .017) and self-care (r = .33,p = .003) and negatively associated with level ofdepression (r = –.25; p = .025).Th e major findings of this study are twofold.First, a substantial proportion of family members

252 René Heftiof persons with serious mental illness mobilizereligious and spiritual resources to cope withtheir situation as caregivers. Second, higher religiositywas associated with greater self-esteemand self-care and less depression among familycaregivers. This pattern suggests that religiositymay bolster the internal coping resources offamily members who are caring for people withserious mental illness. The strongest relationshipobserved was the link between religiosity andself-care, suggesting a pathway whereby religiositymay contribute to enhanced well-beingamong caregivers by expanding the capacity ormotivation for self-care.3.3. The Key Role of ReligiousCommunities (Faith-Based Organizations)A recent survey of faith-based organizationsin the Los Angeles area highlighted a highdemand for mental health services in religiousand spiritual communities but also identifiedsignificant barriers to the implementationof such services; for example, limited expertiseand resources. In reporting these results,Dosset and colleagues (59) emphasized thatpartnerships between mental health providersand faith-based communities may be a particularlyeffective strategy for meeting the mentalhealth service needs of populations that areunderserved by the mental health system, suchas persons with low incomes, ethnically diversecommunities, and recent immigrants. In oneattempt to include caregiver services within areligious congregation, Pickett-Schenk ( 60)conducted a church-based support programfor African-American families coping with themental illness of a family member. In a study oftwenty-three caregivers, participants reportedthat they were highly satisfied with the groupand perceived gains in knowledge and morale.In another vein, NAMI provides support tofaith-based communities that are attempting toaddress the needs of persons with serious mentalillness through projects such as the FaithCommunities Education Project and Faith Net(www.nami.org/faithnet).It is critical for mental health professionalsto appreciate the role of religion and spiritualityamong persons with mental illness and theircaregivers. Clinical interventions should includeroutine assessment of this area, and interventionsshould be appropriately tailored to buildon relevant religious and spiritual resources,while respecting the diversity of backgroundand beliefs. It is important for mental healthprofessionals to effectively collaborate withclergy and other religious professionals in providingservices to persons with serious mentalillness and their caregivers. Collaborative partnershipsbetween mental health professionalsand religious and spiritual communities ( 61)represent a powerful and culturally sensitiveresource for meeting the needs of family caregiversof persons with mental illness.4. MENTAL HEALTH CARE PROGRAMSINTEGRATING RELIGION/SPIRITUALITY4.1. An Overview of Past and RecentProgramsTh e first therapy group on spiritual issueswas started by Nancy Kehoe in 1981 in theDepartment of Psychiatry at Cambridge HealthAlliance and Harvard Medical School, Belmont,Massachusetts. (62) She felt the need to provideseriously mentally ill persons with an opportunityto explore religious and spiritual issues inrelation to their mental illness. At first, the ideaof having such a group generated anxiety, fear,and doubt among staff members. It brought outthe ambivalence that many mental health professionalshave about religious issues, an ambivalencereflected in Gallup poll findings. (63)In addition, Bergin and Jensen’s work (64) hashighlighted the marked difference between thereligious beliefs and practices of the generalpopulation and those of the mental health professionals.Staff training and instruction alleviatedsome staff concerns about Kehoe’s group.However, the long-term success of the grouphas been the strongest factor in staff acceptance.Group rules contributing to its success are

Integrating Spiritual Issues into Therapy 253tolerance of diversity, respect of others’ beliefs,and a ban on proselytizing. Another factor is thatmembership is open to all, regardless of religiousbackground or diagnosis.At least three other programs integratingspiritual issues into mental health care originatefrom the United States. The main informationon these four spirituality groups is presentedin Table 17.1 . The programs will be describedin detail in the following paragraphs. In addition,the integrative concept of the SGM-Clinicas a European model will be discussed andillustrated.4.2. “Spirituality Group” at the HollywoodMental Health Center, Los AngelesThe study of Ana Wong-McDonald et al. (65)examines the results of a spirituality group thatwas offered at a psychosocial rehabilitation programat an inner-city community mental healthcenter in Los Angeles. It was anticipated that,along with proper medication and psychiatricrehabilitation, the inclusion of spirituality asa therapeutic component would enhance therecovery of persons who wish to incorporate it asa part of their treatment services.Of the forty-eight individuals included inthe study, twenty attended the spirituality group(SG). All of the participants in the SG indicatedthat spiritual issues are important in their livesand that they wish to discuss them in the group.Eighteen participants professed adherence tosome form of Judeo-Christian faith. The groupmembers indicated that the following issues werepertinent in their recovery: finding hope again;dealing with depression, fear and anxiety, negativethoughts, self-doubt, and self-worth; emotionalhealing; and forgiveness.The standard psychosocial rehabilitation programwas conducted two days per week, fivehours on each of the days, emphasizing skillstraining, psycho-education, community integration,and cognitive behavioral treatment. (66)In April 2003, however, a spirituality group wasoffered as a sixty-minute optional weekly sessionin the same time slot as the regular standardgroup. The spirituality group was open-ended.Each session focused on a topic of interest (forexample, forgiveness). Spiritual interventionsincluded discussing spiritual concepts (forexample, raising awareness of God’s promises ofpeace, love, and faith and helping participantsto see their self-worth based in God’s promises),encouraging forgiveness, referring to spiritualwritings (for example, encouraging participantsto read the story of the prodigal son to understandGod’s love and forgiveness), listening tospiritual music, and encouraging spiritual andemotional support among the SG members (forexample, praying for one another and telephoningeach other for support).The general purposes of the interventions wereto help participants understand their problemsfrom an eternal, spiritual perspective, to gain agreater sense of hope, to emotionally forgive andheal past pain, to accept responsibility for theirown actions, and to experience and affirm theirsense of identity and self-worth. Participantswere also encouraged to connect with their faithcommunities for social and spiritual support.At time of entry into the psych rehab groupand at six-month intervals thereafter, participantsset treatment goals for symptom management,community integration, and improvementin their overall quality of life. Examples of goalsincluded health-related wellness (such as loweringthe frequency of panic attacks, losing weight,decreasing cigarette smoking, and lowering thenumber of hospitalizations), socialization goals(such as making at least one new friend, goingout on a date, or saving money to go on vacationswith friends), and vocational and educationalgoals (such as obtaining a driver’s license, maintaininga car, earning a high school diploma, andobtaining a volunteer job).All twenty participants (100 percent) in thespirituality group (SG) achieved their treatmentgoals, compared to sixteen out of twenty-eightpeople (57 percent) in the nonspirituality group(non-SG). The difference in goal attainmentbetween the two groups was highly significant(p = .0001). Individual examples of how spiritualitymay enhance recovery give an idea of its

254 René HeftiTable 17.1: Overview of Four Programs Integrating Religious and Spiritual Issues.Therapy Group onSpiritual IssuesSpirituality Group (SG) Spirituality MattersGroup (SMG)Spiritual IssuesPsychoeducational GroupAuthor(s) Kehoe NC Wong-McDonald A Revheim N,Greenberg WMCenter Day treatment center Hollywood Mental Nathan Kline Institute,Health Center Clinical ResearchEvaluation FacilitySettingFormat of the SGPurposeSpiritual key elements,interventionsEvaluationResultPersonal statements ofgroup membersConclusionOutpatient setting,chronically illpsychiatric patients,22 to 60 years old45 minutes weekly,ongoing, typically 10to 12 clients, attendingfor 2 to 3 yearsFoster tolerance,self-awareness, andnonpathogenictherapeuticexploration of valuesystemsExploring waysin which beliefsand practices helpor hinder copingwith mental illness.Consideringquestions, problems,and feelings aboutreligious belief. Strictgroup rules: toleranceand respectFeedback of the groupand co-workersTranscripts ofgroup meetings:exemplification ofgroup interactions“Group interactionsreveal that individualsare more than theirmental illness”A group focusingon religious issuescan provide anopportunity to exploretopics usually ignoredby mental healthpracticeCommunity-basedpsychosocial rehabprogram, psychiatricoutpatients, 2 days aweek1 hour per week, 20participants, openended,focusing ontopics of interestEnhance recovery,support treatmentgoals, helpparticipants gain aspiritual perspectiveDiscussing spiritualconcepts, encouragingforgiveness,referring to spiritualwritings, listeningto spiritual music,encouraging spiritualand emotionalsupport amonggroup membersand with their faithcommunitiesDegree of goalattainment100% goal attainmentin the SG vs. 57% inthe non-SG“By remembering thatJesus suffered morethan I ever did keptme from self-pity”Spirituality asa therapeuticcomponent canenhance recovery ofpersons with severemental illness24-bed state-hospitalinpatient unitfor persons withpersistent psychiatricdisabilitiesContinuousenrollment, typically12 to 40 sessions,multi- disciplinaryconceptPromote spiritualand social supportand improve copingresources, emotionfocusedcopingStructured grouptreatment approachaddressing spirituality,promote usingspiritual beliefs forcoping, shiftingperspective fromvictimization toresilience. Readingpsalms and spiritualstories, recitingprayersEvaluation period inthe second yearMore qualitative,e.g., new insights:medication as a giftof GodAs an outcome of agroup discussion: “OhLord, your medicationhas brought me asense of peace”Reviewing activityplans and group notesidentified themesconsistent with an“emotion-focusedcoping” modelPhillips RE, Laking R,Pargament KILocal communitymental health centerOutpatient setting,people with seriousmental illness (SMI),referred by mentalhealth workersSeven weeks, 1.5hrs/week, psychoeducationalprogram,10 participantsProvide newinformation aboutspirituality and allowparticipants to shareexperiencesPresenting aninclusive set ofspiritual topics:spiritual resources,spiritual strivings,spiritual struggles,forgiveness of others,and spiritual strategiesto promote hopeSurvey for feedback ofthe groupAppreciation of thegroup, the uniqueopportunity to discussspiritual issues“I liked hearing fromother spiritual beliefsand interests”The interventionappeared to reach itsoriginal objectivesand provided asafe environmentto discuss spiritualconcerns

Integrating Spiritual Issues into Therapy 255role in psychiatric rehabilitation. One participantwith a thirty-year history of agoraphobiaand daily panic attacks shared that she was ableto “push away” the symptoms by using a combinationof prayer and relaxation techniques.Another group member with bipolar disorderand a history of risky sexual behaviors sharedthat by returning to God, he had stopped hisbehaviors for over a year. A third participantsaid that her hope in Christ empowered her tojourney through her depression. Finally, a fourthgroup member said, “By remembering that Jesussuffered more than I ever did kept me fromself-pity and on the course to getting better.”Participants as a group stated that sensing God’spresence helps lessen feelings of sadness, calmsfears and anxieties, and helps in dealing withforgiveness and resolving daily problems.The findings from the Wong study encourageinclusion of spirituality in psychiatric rehabilitationas a promising approach. Participants’ selfreportand goal-attainment outcomes point tothe positive effects that spirituality has for peoplein recovery.4.3. “Spirituality Matters Group”at the Nathan Kline Institute, New YorkThe Spirituality Matters Group (SMG) was developedin 2001 at the Clinical Research EvaluationFacility (CREF) of the Nathan Kline Institute forhospitalized persons with persistent psychiatricdisabilities,( 67) following the rationale thatspiritual support fosters the recovery process.SMG is distinct from comparable groups ( 68)in its multidisciplinary leadership that focuseson integrating spiritual/religious, psychological,and rehabilitative perspectives over an extendedtreatment period. Staff concerns about potentialdeleterious effects (for example, increased psychopathology)were discussed in the context ofstaff resistance encountered by proponents ofthis treatment format. (62) SMG’s purpose wasdescribed as strength-based, offering individualspersonal choice, respect, and peer support, correspondingto accepted core principles for mentalhealth recovery (www.samhsa.gov). The SMG ismade up of self-referred persons who join threegroup co-leaders (representing psychology, pastoralcare, and rehabilitation) in exploring nondenominationalreligious and spiritual themesdesigned to facilitate comfort and hope, whileaddressing prominent therapeutic concerns.Patients are told this group “focuses on the use ofspiritual beliefs for coping with one’s illness andhospitalization.”The one-hour weekly SMG has had continuousenrollment over the last five years. Attendanceranges from six to eight members, withparticipants making a commitment to the groupfor the duration of their hospitalization at CREF,typically twelve to forty sessions. Group membershipdemographics during an evaluation periodin SMG’s second year included ( n = 20): averageage 35 years, education 11 years, first hospitalizationage 21, and current inpatient stay 255 days.Seventy-nine percent were male; 33 percent black,42 percent white, 12 percent Hispanic; 72 percentdiagnosed with schizophrenia, 28 percent schizoaffectivedisorder; 80 percent had past substanceabuse and 5 percent a history of pathologicalreligious ideation. Participants identified themselvesas Protestant, 25 percent; Catholic, 35percent; Jewish, 2.5 percent; Muslim, 2.5 percent;other, 10 percent; multiple, 5 percent; and none,20 percent. The highly-structured group formataccommodates cognitive deficits and limitedsocial skills, prevalent in persons with persistentpsychiatric disabilities.During each session’s initial phase , membersare introduced, the group’s purpose reviewed,and seasoned group members orient newcomerson how the group can be used (for example,using spiritual beliefs to cope with daily stressorsand for support with behavioral change). Themultireligious and nondenominational natureof the group is affirmed. Spirituality is defined as“personal beliefs and values related to the meaningand purpose of life, which may include faithin a higher purpose or power.”In the middle phase , a topic with a relatedgroup activity or exercise is introduced, withwarm-up questions for personal sharing andreflection, followed by distribution of handouts,

256 René Heftireadings, or other materials that are read aloud.Topics are selected by leaders on a rotating basisand carefully prepared so that both negative andpositive emotions are addressed. For example,individual members’ guilt, anxiety, and intoleranceor cognitive distortions resulting fromprevious religious/spiritual experiences areexplored. Group members are encouraged toshare how the topic has relevance to the perceptionof their illness, previous behavior patterns,treatment failures (for example, medicationnonadherence, rehospitalization), and futuregoals (for example, appropriate discharge planning,commitment to treatment recommendations).At least one group leader is familiar withthe individual treatment plans and offers suchinput into the group process when appropriateto ensure integration with other clinical programmingfor goal attainment.In the ending phase , group members summarizethe session’s emergent themes and new learningthat influences goals and future choices, followedby a formal closing with a prayer composed bygroup members : “Give me light and insight so thatI may trust. Let me learn the way of peace so thatI may grow…. May those who find themselves offtrack, be guided. May those who are afraid, findcomfort. And may we all find patience on ourpath.” Topics for subsequent groups emerge fromeach week’s discussion, which fosters continuity,repetition, and self-disclosure.Group activities and exercises highlight usingspirituality as a coping mechanism during recovery.The principal group activities are readingPsalms (consistent with most participants havingJudeo-Christian identification), reading prayers,writing prayers, and telling stories from a varietyof faith perspectives.■■■faith that maintain strength and perseveranceduring these difficulties.Reciting prayers together that are familiar andcommon (“St. Francis Prayer”) or those specificfor personal needs (for example “prayersto start the day”) reinforce individuals’ existingreligious/spiritual practices. Using congregateprayers with individuals with limited socialskills can enhance social support throughfocusing on a shared goal.Writing original prayers helps improve selfawarenessof one’s needs and allows articulationof one’s experiences in a setting thatbrings comfort and a sense of closure. The useof templates or prayer formats (praise, thanksgiving,and intercession) assists individuals inthis creative and empowering experience.Reading spiritual stories, fables, allegories andpersonal narratives of others allows groupmembers to identify personal needs and values,and through identification, offers opportunitiesto express difficult emotions.Reviewing activity plans and group notes identifiedthemes consistent with an “emotion-focusedcoping” model.( 70) Emotion-focused copingincludes cognitive reframing, social comparisons,minimization (“looking on the bright sideof things”), and behavioral efforts to feel better(exercise, relaxation, meditation, support, religion,humor, and talking). Emotion-focusedcoping is useful when a situation cannot bechanged, and only the emotional response canbe changed, which can be self-affirming andempowering. This coping style is congruent withboth recovery and SMG goals and can coexistwith problem-focused approaches.■Readings from the Book of Psalms (69) evokethe full range of human emotions from thanksgivingand praise to anger, fear, desperation,despair, abandonment, hope, and protection.Reading selected Psalms as a group, followedby personal sharing, emphasizes the universalnature of experiencing conflicts and strugglesin daily life, while focusing on elements of4.4. “Spiritual Issues PsychoeducationalGroup” at a Community CenterThis study describes an innovative program forpeople with serious mental illness (SMI) whoare dealing with spiritual/religious issues. (68)The program was a seven-week semistructured,psycho-educational intervention in which participantsdiscussed religious resources, spiritual

Integrating Spiritual Issues into Therapy 257struggles, forgiveness, and hope. The interventionwas designed to provide new informationabout spirituality to participants and to allowthem to share experiences and knowledge thatthey felt might be of value to others. An additionalgoal was to present a more inclusive set ofspiritual topics to clients with SMI than has previouslybeen described.Group members were recruited throughreferrals from mental health workers at a localcommunity mental health center. Potentialmembers participated in individual interviewsto determine whether their needs, expectations,and level of functioning were appropriate for thegroup. The interview examined their religious/spiritual background, the role that religion/spirituality has played in their experience withmental illness, and their expectations for thegroup.There were ten participants, all Caucasian, and70 percent were female. One-third of the groupmembers reported a diagnosis of schizophrenia,one-third indicated a diagnosis of depression,and one-third reported personality disorders astheir primary diagnosis. In terms of religiousaffiliation, 30 percent identified themselves asRoman Catholic while all others were affiliatedwith Protestant denominations. Two doctoralstudents in clinical psychology served as ongoingfacilitators for each group session. Furthermore,each week (with the exception of the first and lastweeks) an additional graduate student joined thegroup to introduce discussion on a specific topic.Therefore, on most weeks, three facilitators werepresent. The group took place once a week for 1.5hours over the course of seven weeks.Week One: Introduction. The facilitators gavegroup members an overview of the group formatand what topics would be discussed. In addition,the group rules were reviewed and group membersshared their “personal spiritual journey.”( 62)Questions revolved around the theme of theirpast and present spirituality, how their spiritualitywas affected by their mental illness, and viceversa.Week Two: Spiritual Resources. This sessionwas intended to elicit members’ ideas ofpersonal and community spiritual resources. (20)The session began by providing the group withdefinitions and examples of spiritual resources.Multiple resources were generated by participants,including prayer, reading religious literature,prayer groups, going to religious services,journaling, listening to spiritual music, burningcandles, doing artwork, and just socializingwith friends. In addition, potential barriers tousing these resources were also explored, such asavoiding church when experiencing high levelsof symptoms.Week Three: Spiritual Strivings. The primaryobjective was to have group members exploreways to create and achieve meaningful, realisticgoals related to their spiritual journey. Emmons(71) has discussed the importance and positiveimplications of spiritual strivings. The facilitatorfirst discussed the importance of having strivings.To facilitate the discussion, group membersgenerated personal lists of their strivings. Theselists were based on what participants foundmeaningful.Week Four: Spiritual Struggles. The overallgoals were to emphasize the importance ofexpressing thoughts and feelings about spiritualstruggles, validate and normalize anger withGod or the church, and reframe struggles as atime of potential personal growth and change.Group members were given a list of commonstruggles with God (for example, feeling abandoned,spiritual emptiness, feeling sinful, andfeeling frustrated) and church (for example, notfeeling welcomed, feeling abandoned, stigma,and paranoia) and asked to circle ones that theyhave experienced. They then shared with othergroup members ways in which they have dealtwith these struggles.Week Five: Forgiveness of Others. The primarygoal was to examine how forgiveness related tothe members’ lives. First, group members discussedthe definition of forgiveness. They thenexplored what forgiveness is not; that is, forgivenessis not forgetting, reconciliation, acceptanceor tolerance of injustice, letting go of anger, condoning,excusing, or legal pardon. Next, groupmembers generated ideas about the costs and

258 René Heftibenefits of forgiveness. Then members reflectedon incidents in their lives when they were hurt byanother person or institution. Finally, the stepstoward forgiveness were briefly outlined. (72)Week Six: Hope. The primary goal was toexplore spiritual strategies that could be usedto hold on to hope. Facilitating questions weretaken from readings on integrating hope andspirituality into treatment. (73) Group membersfirst talked about the meaning of hope and reasonsto retain hope. They then divided into pairsand discussed their personal hopes. The majorpathways to keeping hope alive were throughspiritual rituals (for example, hymns, reading theBible), trusting that God has a greater purpose,and through supporting each other.Week Seven: Wrap-up. In the final session,the two permanent facilitators reviewed thetopics covered by the group, solicited feedbackfrom group members, and shared their personalreactions. Emphasis was placed on maintainingconfidentiality even after the group ended. Asurvey was also distributed to gather feedback.Participants were asked what they learned fromthe group, what they found most helpful andleast helpful, and what suggestions they had forfuture groups. Most members spontaneouslyexpressed that they wanted the group to continue.Although most members felt they did notnecessarily learn new information, they enjoyedand appreciated the unique forum in which theycould explore an area that is often neglected inthe mental health services setting. Participantsfurther reported that they liked hearing others’spiritual beliefs and interests.In conclusion, this intervention appeared toreach many of its original objectives. It provideda safe environment for those with SMI to discussspiritual concerns. This unique topic of interventionappeared to be highly valued by participants.Community mental health professionals mayfeel that it is not their place to employ a spiritualissues group in a publicly funded agency. YetRichards and Bergin (74) (p. 159) note that there“are no professional ethical guidelines that prohibittherapists in civic settings from discussingreligious issues or using spiritual interventionswith clients.” In fact, they assert, it is unethical toderogate or overlook this dimension.Overall, this intervention holds promise asa useful addition to current community mentalhealth practice. Such groups have been run bylicensed nurse practitioners,( 62) social workers,(75) and clinical/community psychologists. (15)With some training in the area of serious mentalillness and spiritual concerns, professionalsfrom diverse areas of training (for example, psychiatristsand hospital chaplains) could also leadgroups or supervise the intervention.4.5. The Integrative Concept of theSGM-Clinic Langenthal (Switzerland)Th e scientific framework for our integrativeconcept is the extended bio-psycho-socialmodel (28) as described earlier in the chapter.We believe that in mental as well as in physicalillness there is always an existential and thereforea spiritual dimension that will influencetherapy in an explicit or more implicit way. Forthis reason, we take a spiritual history fromevery patient. We want to know whether andhow religiousness or spirituality determines thepatient’s understanding of his illness. Does thepatient have spiritual resources in coping withhis mental condition, or are his religious beliefsa burden and an obstacle in the therapeuticprocess?If a patient doesn’t consider himself religiousor spiritual, he will get a state-of-the-art-treatmentfor his mental illness focusing on his or herpersonal treatment goals. If a patient is religiousor spiritual, we try to understand how he wantsto integrate these aspects into his treatment program.Spiritual treatment goals can be:■■■■■Regaining hope and meaningStrengthen the relationship with God to bettercope with mental illnessPersevere in difficult circumstancesResolving anger, frustration, or disappointmenttoward GodUnderstanding why God allows bad things tohappen in patients’ lives

Integrating Spiritual Issues into Therapy 259Table 17.2: Overview of Spiritual Activities/Offerings for Patients in Addition to Their StandardTreatment Program. Bars Illustrate Patient’s Appreciation of the Activity/Offering (from Leftto Right: “It Helped M e a Lot,” “It Helped Me Quite a Bit,” “It Helped Me Some,” “It Didn’tHelp Me.”)Activity/offering Description/focus Duration/ frequency EvaluationPsycho-educational groupmeetingsSpiritual singing and musicgroupSpiritual issues discussiongroupSpiritual art therapyIntegrating therapeutic andspiritual issues, focus on copingwith life and mental illnessSinging spiritual songs, listeningto spiritual music, recitingprayersDiscussing upcoming spiritualissues in an open group setting,led by a pastoral counselor,including religious ritualsExpressing spiritual topics in arttherapy, e.g., creation, self-imageand God image, psalms1 hour, 4x/week1 hour, 1x/week no evaluation1 hour, 1x/week new activity/offering1–2 hours weeklySpiritual counseling andpsychotherapyIntegrating spiritualelements into counseling andpsychotherapy, e.g., forgivingmyself/others, individual prayersindividualPastoral careIndividual pastoral counseling,delivering rituals andsacraments, anointing of the sick,Lord’s supperindividualPatient LibraryContaining a broad range ofreligious and spiritual books1–2x/weekno evaluation■■Working toward forgiveness in difficultrelationshipsBeing more aware of God’s presence and guidancein daily lifeSpiritual needs and treatment goals are discussedin the therapeutic team, of which thepastoral counselor is a ordinary member. Wethen evaluate the best way to meet these needsand to help the patient attain his treatmentgoals. We also verify whether the spiritual goalsare in line (don’t conflict) with the other treatmentgoals. Spirituality can be a way of escapingfrom reality, which we would not support in thetherapeutic context.For many years we have been offering psycho-educationalgroup meetings focusing on theintegration of therapeutic and spiritual aspectsand emphasizing the benefit and importance ofreligious and spiritual coping (see Table 17.2 ).( 11 , 20 , 49 , 70 )Typical topics of these interactive group meetingsare:■■■Developing life perspectives despite illnessand limitationsCoping with fear and depression; listening tothe Book of PsalmsAttaining personhood, spiritual identity (“Icalled you by your name”)

260 René Hefti■Understanding healthy and unhealthy religiosityand spiritualityWe also have a spiritual singing and music group.Patients can get actively involved by proposingsongs, playing their own instruments, performinga dance, focusing on the presence of thedivine, or just listening to the music. Singinghelps patients to overcome negative feelings orthoughts.Furthermore, we offer a spiritual issues discussiongroup led by our pastoral counselor(similar to groups discussed elsewhere).( 62 , 65 )Participants can introduce spiritual topics, questions,or problems related to their illness or personalsituation. They are discussed in the group,and the pastoral counselor shares insights fromhis spiritual background. Participants learnhow to use their own spiritual resources, howto cope with spiritual questions and strugglesrelated to their illness, and how to support othersspiritually.Another approach to spirituality is arttherapy. Figure 17.4 shows a patient sufferingfrom chronic pain and depression. Her chronicpain had two components, represented bythe two human figures: a “red” one (middle)representing a burning type of pain difficult tosustain and a “black” one (right) expressing adull type of pain making the patient depressive.Figure 17.5 demonstrates the patient’s fight tomaintain her relationship with God despite painand depression. She mobilizes all her energyto grip God’s outstretched hands while slowlysliding out of them – a picture of existentialfight and despair. Figure 17.6 visualizes the furtherspiritual and therapeutic process. God letsher go and fall into a seemingly endless depth.But at the bottom of the hole, God is absorbingher smoothly, carrying her through the painfuland dark valley. Deep relaxation and painrelief results. (76–78) Furthermore, the patient’srelationship to God changes in character anddepth.The integration of spiritual issues in counselingand psychotherapy (24) represents anotherform of spiritual support. For example, a patientin a submanic/psychotic state felt energizedby God’s overwhelming presence in his mindand body. The therapist discussed this “spiritualperception” in the psychotherapeutic sessionswith the patient. Other topics are feelingsof guilt, shame, being rejected or abandoned bythe divine, and working toward forgiveness. If apatient has unhealthy beliefs, it is important tochallenge them from a spiritual as well as a psychotherapeuticpoint of view.We also provide pastoral care to meet thespecific religious and spiritual needs of ourpatients. This includes rituals and sacraments,for example, anointing with oil or taking theLord’s Supper. The pastoral counselor is a memberof the interdisciplinary team with equalrights and obligations. He reports back at theteam meetings.Finally, there is a patient library with a widevariety of religious and spiritual books patientscan borrow, for example, “Canvas of Love –Reflections on a Rembrandt” by Henri J. M.Nouwen,(79) reflecting the story of the two sonsand the father, known as the prodigal son parable(Luke 15, 11–32).5. RECOMMENDATIONSAND GUIDELINES5.1. Recommendations Based on Patients’PerspectivesPatients’ hopes and concerns lead to specificrecommendations about the place of spiritualityand religion in mental health service contexts(80) :■Mental health programs should adopt aholistic approach to both assessment andintervention, addressing patients’ own understandingof religion and spirituality and theimportance in their lives. They should askwhether or how patients would like to havespiritual concerns or goals included in theirtherapy and should develop structured waysto discuss spirituality in group or individualmeetings.

Integrating Spiritual Issues into Therapy 261Figure 17.4. A patient suffering from chronic pain and depression. The drawingshows the patient’s perception of her pain differentiating two main components: aburning and dull type of pain (burning = figure at the bottom in the middle; dull= figure on the right side).■■It is important for service providers and programsto have an open and inclusive understandingof religion and spirituality, sensitiveto the many differences of experience andconviction among patients.Most patients want service providers toaddress spiritual and religious issues (81); butthey do not want them to “push” either religionin general or a particular expression ofspirituality or religion.■For some patients, the experience of spiritualityis profoundly personal, private, and meaningful.Many are cautious in discussing it withservice providers. (15) Some fear that clinicianswill “reduce” or trivialize their beliefs orthat they will see them as a sign of pathology.This requires clinicians to take a respectful andindividualized approach to spiritual and religiousrealities.

262 René HeftiFigure 17.5. A patient suffering from chronic pain and depression. The drawingreflects the patient’s fight to maintain her relationship with God.5.2. Recommendations Basedon Professional PerspectivesThe most obvious recommendation is the needfor more extensive training and education forhuman service providers (including psychiatrists,psychologists, social workers, and psychiatricnurses) on how to integrate religion and spiritualityinto patient care, training that is pertinent tothe particular service setting in which staff andpatients work together. (80)Such training needs to address the followingtopics:■■Taking a spiritual history, understanding theways in which religion and spirituality relateto patients’ overall well-being, and evaluatingwhether patients’ particular expressionof spirituality is helpful or harmful for therecovery processDeveloping the ability to talk with patientsabout spirituality in a manner that is neither

Integrating Spiritual Issues into Therapy 263Figure 17.6. A patient suffering from chronic pain and depression. The drawingillustrates the further spiritual and therapeutic process. Finally, the patient findsherself in God’s hand experiencing security, relaxation, and pain relief.■intrusive nor reductive but that communicatesrespectful openness to a patient’sunique spiritual experiences, both positiveand negativeSupporting religious and spiritual coping,for example, prayer and meditation, readingpsalms or other religious/spiritual literature,and attending religious services■■■R eflecting countertransference reactions thatcan be influenced by the therapist’s religiousor spiritual experiences (p.165) (82)Encouraging family members/caregivers touse their spiritual resources (56–58)Delivering social and community resourcesand providing opportunities to expand theconnections between religious or spiritual

264 René Hefti■activities in the community and in the mentalhealth program itself (59–61)Learning when and how to make referrals toreligious professionals, to faith-based programs(www.nami.org/faithnet), or to centersof spiritual activity, based on an adequateunderstanding of the patient’s needs andpreferencesPrograms integrating spiritual issues range fromshort-term psycho-educational groups designedto explore ways in which spirituality mayenhance self-esteem and social support (15) toopen-ended discussions of “religious issues” andthe way they relate to mental health concerns.( 62 , 65 ) For additional information on how toincorporate religious and spiritual interventionsin clinical practice, see the following list ofbooks, addresses, and Web sites.5.3. Recommended Books, Addresses,and Web SitesBooks■■■■■■Koenig HG. Spirituality in Patient Care: Why,How, When and What , 2nd ed. Philadelphia:Templeton Foundation Press; 2007.Miller WR, ed. Integrating Spirituality intoTreatment: Resources for Practitioners.Washington, DC: American PsychologicalAssociation; 1999.Richards PS, Bergin AE, eds. Toward religiousand spiritual competency for mental healthprofessionals. In: Handbook of Psychotherapyand Religious Diversity. Washington, DC:American Psychological Association; 2000:3–26.Shafranske EP. Religion and the ClinicalPractice of Psychology . Washington, DC:American Psychological Association; 1996.Sperry L, Shafranske EP. Spiritually OrientedPsychotherapy . Washington, DC: AmericanPsychological Association; 2005.Peteet J. Selected annotated bibliography onspirituality and mental health. South Med J .2007;100(6):654–659.■■■■■■Heft i R, Fischer F, Teschner M, et al. Glaubeund seelische Gesundheit . Langenthal: RSH-Publikationen; 2007.Addresses and Web SitesNAMI (National Alliance for the Mentally Ill).Faithnet: Resources, Web pages, and Internetlinks for faith communities caring for thementally ill. Address: Colonial Place Three,2107 Wilson Blvd., Suite 300, Arlington,VA 22201, phone: 703–524–7600, fax: 703–524–9094, Web site: www.nami.org/faithnetArchdiocesan Commission on Mental Illness.Address: Deacon Tom Lambert, Our Lady ofMt Carmel Parish, 708 W Belmont, Chicago,IL 60657, phone: 773–525–0543, ext. 21,e-mail: olmcinfo2@aol.com, Web site: www.miministry.orgPathways to Promise, Faith community outreach.Address: 5400 Arsenal Street, St. Louis,MO 63139, phone: 314–644–8834, Web site:http://pathways2promise.orgCenter for Spirituality, Theology and Health(CSTH). Address: Duke University MedicalCenter, Box 3825, Busse Building, Suite 0507,Durham, NC 27710, phone: 919–660–7556,Web site: www.dukespiritualityandhealth.orgResearch Institute for Spirituality andHealth (RISH), Switzerland/Europe. Address:Weissensteinstrasse 30, 4900 Langenthal, phone:0041–62–9192211, fax: 0041–62–9192200,e-mail: info@rish.ch, Web site: www.rish.chREFERENCES1. Fran k l V. Men’s Search for Meaning . New York :Washington Square Press; 1984 .2. Blanch A. Integrating religion and spiritualityin mental health: the promise and the challenge .Psychiatr Rehab J. 2007 ; 30 : 251 –260.3. Matt hie ws DA . The Faith Factor: Proof of theHealing Power of Prayer . New York : PenguinBooks; 1998 .4. Russinova Z , Blanch A. Supported spirituality: anew frontier in the recovery-oriented mental healthsystem . Psychiatr Rehab J. 2007 ; 30 : 247 –249.5. Fallot RD. Spirituality and religion in recoveryfrom mental illness . New Dir Ment Health Ser .1998 ; 80 : 25 –33.

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18 Explanatory Models of Mental Illness and Its TreatmentLAURENCE BORRAS AND PHILIPPE HUGUELETSUMMARYDespite overwhelming evidence that psychopharmacologyis effective in the acute treatmentand maintenance therapy of psychiatric disorders,40 to 60 percent of patients do not taketheir medication and thus are at increased riskfor relapse. Episodes due to nonadherence havenegative consequences for both the patient (bylowering quality of life and treatment outcome)and society (by increasing costs). “How to finda cure?” is a question that these suffering peopleask themselves, especially when medicinedoes not heal, or when one is facing a chronicdisease. Many psychiatric therapies and mutualaid groups have their foundations in differentreligions and still use values, concepts, andtherapeutic methods that have their origins inreligious beliefs and practices. However, thereare many people who resort to alternativetherapies, over-the-counter products, and traditionalapproaches to healing. In this chapter,we will describe the treatment of mental disordersacross history and according to variouscultural settings. Then we will describe howreligion may influence patients’ perceptions ofillness and its treatment. The positive and negativeimpacts of spirituality on the outcome ofillness and adherence to treatment will be discussed.This will lead to considerations as tohow clinicians should address these issues.Many people with chronic mental disorderare in search of healing, living a deep identitycrisis caused by their increasing marginalization.Understanding the individual’s point of view bytaking into account the biological, psychological,and social dimensions is essential, becauseit enables a better understanding of our patientsand their pathologies. When referring to “socialdimension,” we mean culture in its broadest senseas well as the religion and spirituality that usuallycome along with it.“Where to find a cure?” This is the questionthat most suffering people ask themselves,especially when medicine fails to heal or whensome chronic disease takes hold of the individual.Many psychiatric therapies and supportgroups inspired by various religions promotevalues, concepts, and therapeutic methods thathave their origins in religious beliefs and practices.In spite of this, many people continue toprefer alternative therapies. Do patients’ spiritualand religious beliefs influence the understandingthey have of their disorder? To what extentdo religious beliefs about illness influence theirunderstanding of the treatment and the relationshipwith the medical staff? Would it be possibleto improve the patient-doctor relationship bytaking into account the patient’s religious beliefs?And if so, how?In this chapter, we will attempt to describethe different understandings of mental disordersthroughout history and according to various culturalsettings. Then we will describe how theseperspectives may influence patients’ understandingof their disorders and treatments. This willlead to considerations of how clinicians shouldapproach this issue.268

Models of Mental Illness and Its Treatment 2691. MENTAL DISORDERS THROUGHOUTTHE CENTURIESA brief look into history will allow us to betterunderstand the great number of theoreticalperspectives on mental disorders that have preoccupiedhumanity since the beginning of time.Indeed, in every culture and at all times, theunderstanding of mental disorders, their treatment,and healing had their foundation in religion.In prehistory, illness, suffering, and deathwere probably already being interpreted in supernaturaland magical terms. Therapy and healingwere left to shamans and healers who, thanksto their privileged relationship with their gods,were thought to be able to cure madness and helppeople escape evil forces by using religious andmagical rites (incantation, herbs, and physicaltherapy). (1)During antiquity, while Pythagoras, Hippocrates,and Plato were laying the foundations for diseasebasedpsychiatry, ordinary people would continueto associate medicine with magical practicesand religion. Mental disorders were perceivedas impurity, so healing and salvation were left topriests. (2)During the Middle Ages, religious and themedical approaches to mental disorders coexisted.From a religious viewpoint, some patientssuffering from mental disorders were consideredto be possessed by demons. People sufferingfrom psychosis often thought they were“possessed by the devil,” to the point that theywould proclaim it themselves. Therefore, ratherthan going to the doctor, would entrust their illnessto the saints, who were thought to have thedivine power to chase away the demons. Thus,people suffering from psychosis often foundshelter in monasteries. (3)In terms of health services provided topatients with mental disorders, the Renaissancewas a mere prolongation of the Middle Ages, butit also marked the epoch of the first great humanistdoctors. One of them, Jean Wier (1515–1588),of Belgian origin, defended the medical thesisof mental disorders and strongly rejected thesatanic theory, protesting against “the practice ofburning mad people at the stake.”( 4)During the seventeenth and eighteenth centuries,the religious perspective on diseases continuedto prevail. People believed that diseaseswere sent by God as a warning or a punishmentand that they were meant to guide the spirit toits salvation. So a good Christian was expectedto endure disease with patience and even withjoy. Doctors and priests jointly took care of thepatient; in addition, the doctor even had the dutyto make sure that the patient confessed his sins.In 1712, according to a royal declaration, doctorscould not visit severely ill patients morethan three times, unless the patient provided hisconfession certificate. The priest himself had atherapeutic role. Beside its spiritual effects, theadministration of the unction sacrament wasthought to help restore the body’s health. (5)Along with the nineteenth century came theemergence of psychiatry and the classification ofmental disorders. General psychopathology, psychoanalysis,phenomenology, biologic psychiatry,and sociocultural approaches also developed.However, the major schools of thought as well asthe understandings of the disease and its treatmentremained influenced by various religiousand sociocultural factors. (4)2. THE SOCIAL UNDERSTANDINGSOF DISEASEMental disorders are explained and studiedvia a medical discourse based on classification.However, mental disorders are definitely morethan a mere medical inventory based on scientificresearch.They actually point to a complex reality: Forsociety and for social actors, disease is synonymouswith sorrow or with an event threateningto disrupt one’s personal life, social status, andmeaning of life in general. (6) Suffering peopletend to build their understanding of the diseaseaccording to social constructions collectivelyelaborated, which cannot be reduced to mere

270 Laurence Borras and Philippe Hugueletinstitutional or medical definitions. These understandingsinclude religious, collective, existential,emotional, and sentimental dimensions. Hence,diseases can be described better by including theindividual dimension in terms of severity, prognosis,and treatment options. (7)Medical anthropology distinguishes amongthree realities under different words, defininghealth problems as biological abnormalities(disease), subjective experience of alteredphysical state (illness), and the process ofsocialization of pathological episodes (sickness).(8) Even though they belong to the sameculture in its broad sense, doctors and patientshave different visions of medicine and the waydiseases affect individuals. Thus, when thedoctor and the patient meet, there are actuallytwo cultural and spiritual perspectives toreconcile through communication, confrontation,and sometimes even negotiation: the doctor’s(disease) and the sick person’s (illness).Unfortunately, medicine often has a selectiveapproach to the patient’s experience. The “key”symptoms enumerated by the Diagnostic andStatistical Manual of Mental Disorders, FourthEdition ( DSM-IV ) (9) are considered to bemore “real,” more significant, and more interestingthan the way in which patients perceivewhat they are going through. Doctors tend tocreate an objective reality of the disease basedon causes, symptoms, and evolution, and theyoften try to impose it on patients via diagnosis.They very rarely ask patients questions abouttheir own understanding of the disease.On the other hand, patients develop a personaland therefore subjective experience (illness),mixing symptoms, emotional reactions,and impulsive interpretations of the disorders.Patients also try to find an explanation for theirsituation. They ask themselves questions such as,“Why do I deserve this?” In some cultures theyask, “Who wants to harm me?” The pattern servingas an interpretation grid for the disease isoften included in a larger model, which attemptsto explain feelings of unhappiness, misfortune,and adversity. (10) These three competing perspectivestoward the disease are not always clearlydistinguishable, and illness, sickness, and diseaseactually have more than one point in common.For instance, the subjective perception of thedisorder (illness) is built mainly on social understandings(one of the sickness aspects), but alsoon biomedical understandings as conveyed bythe media (bridge between illness and disease).These are not always clearly distinct from thepopular understandings of the disorder (bridgebetween disease and illness). (8)Herzlich (1969), a French sociologist, identifiedthree types of understandings of illness,resulting from the integration of medical andprofane knowledge. Illness is “destructive” whenit entails the breaking of social bonds, as wellas the loss of one’s social role and ability to performactivities, which lead the patient to socialexclusion. In this case, illness is interpreted in afatalistic manner. Illness can be “cathartic” whenit offers the individual the possibility to escapea social role perceived as suffocating, unbearable.Illness is therefore seen as an opportunityto give a new meaning to one’s life. When reallysevere, illness can be experienced as a “profession”:The professional activity of the individualis being replaced by a daily combat against thedisease, which becomes the central focus of one’sexistence. (11) It is only natural to assume that thetype of understanding patients have of their illnesswill deeply influence its evolution and thepatients’ views of the recommended treatment.Very often, doctor and patient have completelydifferent interpretations of the disease. This canexplain why sometimes patients leave the hospitalfor apparently no reason, and they turnto alternative medicine or healers or becomenoncompliant with treatment. In this respect,the ethno psychiatrist Jean Benoist (1996) said,“Once set in, the disease, starts growing its owndouble which is to be imagined as a subtle representationof itself, yet as persistent as the paincaused by the sick organ.”( 12)A study led in Germany in 1992 by GerndMutz and Irène Künhlein indicated the differentways in which patients could combine theknowledge imparted by the doctor and their ownknowledge to reshape their understanding of the

Models of Mental Illness and Its Treatment 271disease. Patients tend to be quite selective in whatthey learn from their doctor. This information isused to fill in gaps in their previous knowledgeand to normalize at a higher level the understandingthey have of their disease. As for therest, they would simply stick to their daily andtraditional interpretations of the disease. (13)Also, the patients’ understanding is multifacetedand dynamic. Indeed, patients change theirunderstandings quite rapidly, and sometimesthey can use several explanatory models at thesame time, under the influence of the events takingplace in their lives and of the changing societythey live in. (14) Williams compared severalexplanatory models of depression among threecategories of population: the general community,people in the process of being diagnosedwith depression, and people who already had anestablished diagnosis of depression. These threepopulations had different understandings of thedisorder and of its treatment. These perspectivesmay evolve differently as illness is taking holdof the patient. Indeed, community surveys inWestern societies tend to point to an explanatorymodel of mental health problems that is primarilysocial rather than biological. (15–17) On theother hand, most people today diagnosed withdepression tend to consider it biological. (18)Perceptions of cause are also reflected in beliefsabout the appropriateness of particular treatments.Out of a healthy community, less than25 percent of the patients ( 16 , 17 ) might benefitfrom an antidepressant treatment and morethan half of them from talking therapies (16)whereas for more than two-thirds of the peoplediagnosed with depression, antidepressant treatmentis necessary. (19) The data suggest thereforethat a reformulation of beliefs and a transition intherapeutic perspectives may take place amongpeople who develop mental disorders. Someresearchers suggest that in the early stages of themental disorder, there is a moment when changeis most likely to take place. Indeed, Leventhaland Nerenz (1985) have suggested that whenan individual faces a problematic psychologicalor physiological experience (or simply changesstates), he will construct an understanding ofthe problem based on five dimensions. Theseare identity (label), perceived cause, time line(how long it will last), consequences (physical,psychological, and social), and curability/controllability.(20) Such understandings may drawon explanatory models of diseases specific tothe various cultures and societies. Those peoplefacing a mental health problem for the first timein their life actively attempt to make sense of it.In doing so, individuals may explore and choosebetween a complex set of beliefs. However, suchbeliefs should not be regarded as taking the formof a coherent explanatory model but rather as amap of possibilities, providing a framework forthe ongoing process of making sense and seekingmeaning.3. MENTAL DISORDERS IN DEVELOPINGCOUNTRIESClinicians meet patients with mental disorderswho are embedded into various cultural/religiousbackgrounds. In many developing countries,there is a different approach to the understandingof the disease, as compared to that found indeveloped areas. In larger cities, we are increasinglydealing with patients belonging to migrantpopulations. In this context, it is important for theclinician to understand the perception patientshave of their own disorder and to be aware ofelements of their culture such as the understandingsof disease, the body, and indigenous healingsystems. Compared with Western societies, peoplein developing countries seem to attach moreimportance to the symbolic and spiritual side ofthe illness. (21) Empirical knowledge of the diseaseis influenced by a quasicompulsive searchof the reason for the disease (the meaning of thedisease). Generally speaking, the mental diseaseis not the result of a situation involving individualsin their personal organization. The environment,which historically helps determine thesick person’s personality, is not concerned withthe origin of the disease. Disease comes fromsomewhere else. Irrespective of ethnic groupsor religious systems, mental disorders are consideredto be the result of an aggression against

272 Laurence Borras and Philippe Hugueletthe sick person or against the group to whichthis person belongs. Social changes brought bymodernism or by imported religions (Islam andChristianity) have not always affected this primarymodel. Even if, according to their socialorigin, people may sometimes refer to a “vague”notion of “illness caused by a natural cause,” theunderstandings of this attack are always verydynamic and are shared by the sick person, his orher entourage, and the healers. These modalitiesof understanding can be schematically reducedto two possibilities: the individual is beingattacked by another individual or he is attackedby a spirit that is understood as a real creatureand that is most often produced by the religioussystem. (22) In Africa, for instance, the attackby an individual is essentially set up accordingto two systems: anthropophagic-witchcraft andmaraboutage. The attack by “spirits” is referredto in indigenous religions, as well as in importedreligions. These explanations of mental disordersare found in most African societies.Designations may differ, indeed, but what isimportant and constant in the understandingsof diseases is the association of their causes withsome attackers recognized by everybody. Thesemodels of understanding of mental diseasesattempt to explain the phenomenon and to situateit in a familiar framework of categories, butit still opposes the biological explanation of thedisease. (23) It follows that the sick person carriesa message (the disease), which needs to bedecoded and integrated into the symbolic languageof the culture, a language shared by theindividuals of the same social group. (24)4. CONTAINING THE FLOODOF UNDERSTANDINGSTh e different representations of the disease asthey are developed by patients may influencesimultaneously or in turn the treatment choices.The logic of these choices can result from acombination of several signification areas, correspondingto the various ways of expressingpain. In developing countries, indigenous healers,religious therapists (priests and healingprophets), doctors, or nurses are the “significationcarriers.”( 25) Traditional therapists are theprotagonists of traditional medicine. For them,“madness” may be seen as a sign that the familyhas deviated from cultural norms or as a formof harm instigated by some jealous third party,but it may also be understood as a form of socialjustice or a mere physical problem.( 26 , 27 ) Theyprovide health care by using methods based onboth religious and sociocultural foundationsas well as on knowledge, behavior, and beliefsrelated to physical and mental well-being and tothe etiology of disease and disabilities prevailingin the community. (28) In Africa, for instance,more than half of the population appeals totraditional therapists for health problems. (25)Their etiotherapeutic understanding of the diseaseis essentially of a magical-religious nature,and they share the same beliefs with their religioustherapists as a basis for the healing process.Religious therapists are those who claimto be able to heal via the word of God and inhis name. They attribute “madness” to the evilinfluence of Satan or of Jinnh. (26) There are twotypes of religious therapists: priests and healingprophets. For the first, healing is not immediatebecause it is considered in terms of hope;for the latter, healing is an end in itself. Beingconfronted with populations for whom healingis a process combining both supernaturalelements of faith and medical elements, societyentrusted priests with a therapeutic role. Thisrepositioning of priests was accompanied bythe birth of new practices with therapeutic purpose,with new names such as the “independentchurches” and the “charismatic prayer groups.”Interventions include prayers for deliveranceand counseling. (29)Doctors and nurses are trained in medicalinstitutions and act according to a biomedicalconception of the disease. They areofficial health professionals, unlike the indigenousand religious therapists, who are consideredto be nonofficial practitioners.( 30 , 31 )Anthropologists such as Helman or Good considerthem to be the representatives of a distinctmedical culture, which is the biomedical

Models of Mental Illness and Its Treatment 273culture, taking into account not only the biologicalaspects, but also the scientific rationality.(32 , 33 ) A study carried out by Wamba inCameroon in 2005 (25) explored the impact ofthe coexistence of different interpretive modelson the behavior of patients seeking health careas well as on the practitioners’ conduct. On theone hand, some patients prefer religious therapists,who combine in their healing methodboth indigenous and religious means of healing.On the other hand, some patients would rathersee indigenous healers, who work according toancestral beliefs using medicinal plants. Otherpatients prefer to go to missionary hospitalsbecause of the biomedical and religious therapythey provide (missionary priests practicingas nurses and doctors). In this list, secularallopathic hospitals are the last option, onlywhen biological assessments and treatmentsare needed. Patients switch from one understandingof their illness to another, accordingto their personal history and to the evolutionof the disease. Therapists are introduced to newsystems of meaning made of elements selectedfrom several levels of signification, which havea major impact on their daily practice. Indeed,some traditional therapists are now aware ofthe limits of their knowledge and feel they needadditional medical training. Doctors want tocontinue practicing medicine by adapting theirmethods to the social mutations in terms ofmedical and sociocultural crossbreeding. Theywant to improve their knowledge of elementarymedicine in their attempt to slow down themigration of patients from countryside to cities.Priests too are trying to enhance their medicalknowledge and to adjust Christian healing practicesto established religions. Bilu and Witztum(34) report their experience in Jerusalemwith ultra-orthodox Jewish patients who wereseverely ill and spoke about the epistemologicalgap between the medical reality of mentalhealth practitioners and the sacred reality ofthe patients. These patients turn to the mentalhealth clinic as the very last resort, that is,after having attempted – and failed – to employreligious healing. Patients try to incorporatereligiously congruent elements composed ofmetaphoric images, narratives, and actions intothe secular treatment modalities that they seek.The authors found that medications such asantipsychotics, initially ineffective, turned outto be quite potent when accompanied by a religiouslyinformed intervention.Khan and Pillay (35) reported that SouthAsian patients with schizophrenia living in theUnited Kingdom preferred home care becausethey wanted to continue practicing their faithand to have the possibility to add faith healingto their psychiatric treatment. The authorsexplain these motivations in terms of will tomaintain their cultural identity (an importantcomponent of recovery), but also as a way to geta more holistic treatment. In Uganda, Africa,Teuton et al. (26) investigated qualitatively theconceptualization of “madness” across indigenous,religious, and “allopathic” healers andexamined the relationships between service providersinvolved in the treatment of people with“psychosis.” For indigenous healers, madness isa sign of a deviation, a form of harm instigatedby some jealous party. Religious healers attributeit to the evil influence of Satan. Allopathic healers(that is, psychiatrists and specialized nurses)have fewer resources and provide services limitedto psychotropic medication. The indigenousand religious healers had a rather tolerant attitudetoward allopathic medicine, although religioushealers often attributed its success to theChristian or Islamic influence. Unlike them,allopathic healers made little reference to religioushealers and were ambivalent toward indigenoushealers. Finally, the relationship betweenthe religious and indigenous healers emerged asone characterized by conflict. Religious healersrejected the beliefs and methods of indigenoushealers, whereas the latter regarded indigenousspirituality and evangelical Christianity asincompatible with their system. All the studiesmentioned above underlined the necessity toimprove dialogue between indigenous and religioushealers and allopathic doctors to developan integrative model of health care intended forindividuals with mental disorders.

274 Laurence Borras and Philippe Huguelet5. ALTERNATIVE THERAPY USE BYPATIENTS WITH MENTAL DISORDERSIn Western societies, patients feeling that theirunderstanding of the disease and their personalperception of being ill are not properly understoodhave many different reactions, and we, asdoctors, have to deal with them. Classical medicinedefines diseases as a general or local failurewithin a complicated system of a physical andchemical nature. The spiritual factors related tohealth conditions are generally left out of thisinterpretation. Given this context, it is only naturalfor the patient to turn toward alternative andcomplementary medicine. A survey published in2002 in the United States stated that 36 percent ofthe population resorts to “alternative and complementarymedicine.”( 36) Chinese and ayurvedicmedicine, acupuncture, meditation, hypnosis, taichi, qi gong, chiropractics, praying, and spiritualhealing are among the many practices that generateseveral billion dollars per year, which patientsspend without hesitation and without any financialsupport. This is true for most Western countriesbecause, according to surveys, the numberof consumers seeking alternative health servicesvaries between 20 percent and 50 percent, oreven 65 percent in Japan.( 37 , 38 ) Chronic mentaldisorders represent a major reason why patientsturn toward alternative therapies. (39) This is inresponse to their lack of satisfaction with conventionaltherapies, their desire to seek controlover their health-care decisions, and their desireto include their philosophical values and religiousbeliefs in these therapies.( 40 , 41 ) Severalstudies revealed that health professionals tend tounderestimate the extent to which patients turnto such therapies, which, in some cases, mayworsen medical compliance and interaction. (42)On the other hand, as shown earlier, more andmore general practitioners have been willing toentertain the idea of spiritual healing and includeit in their daily practice or referral network. Theyhave understood that recognizing patients’ beliefsin the face of suffering is an important factorin health-care practice. The counseling methodsincorporated in these medical approachesemphasize the person’s concept of God, his orher sources of strength and hope, and the significanceof religious practices and rituals for thatperson. (43) Twenty-five percent of the medicalpractitioners in the United Kingdom, 50 percentin Canada, and 80 percent in Victoria, Australia,regularly refer their patients to complementarymedicine practitioners. In Victoria, 20 percentresorted to meditation, 5 percent to prayer, and50 percent expressed their intention to attendtraining programs. A significant number ofhealth professionals in the United States actuallypray with their patients, because praying is recognizedas an efficient coping strategy. (42) Thetreatment of alcoholism has historically includedspiritual considerations. (44) Such treatments foralcohol abuse were often a composite of physicalmethods of relaxation, psychological methods ofsuggestion and autosuggestion, social methods ofgroup support and service to the community, andspiritual techniques of prayer. Such proceduresare still in use today and have been extendedinto the realm of chemical dependency and drugabuse. (45) Spiritual healing groups increase innumber every day. In some regions of the world,they have organized themselves into confederationsto practice in hospitals and take referralsfrom physicians. Their code of conduct coverslegal obligations and emphasizes full cooperationwith medical authorities. (46) Spiritual healing ispracticed throughout Western Europe and theUnited States and occurs in two different ways.The first involves hands-on contact or near contactbetween the healer and the patient, similar tothe church ritual of the laying on of hands. Thesecond is distant healing, where a healer or groupof healers pray or meditate for the absent patient.There are various explanations for how spiritualhealing works, including metaphysical, magnetic,psychological, and social. Most spiritualhealers maintain there are divine energies thatare transferred from the spiritual level by thehealer and that produce a beneficial effect on theenergy field of the patient. The notion of theenergy field is a source of disagreement betweenorthodox researchers and spiritual healers. (46)Researchers argue that, if such a field exists,

Models of Mental Illness and Its Treatment 275then it should be possible to measure it by physicalmeans. However, the explanation of theenergy field is as yet unsubstantiated by scientificresearch. Although spiritual healing is often dismissedas a placebo response, some studies claimthere is a direct influence.(47 , 48 )For the patient, it is vital to make sense of theexperience when confronted with illness. There isa need to search for meaning in the face of chaos,loss, hopelessness, and suffering. New efforts forlay involvement in medicine and in the churchand a call for spiritual (or holistic) understandingof illness are the expressions of individual callsfor such meaning according to patient beliefs.Alternative therapies such as spiritual healingappear to be of particular benefit when requestedby the patient. Recognizing a patient’s beliefs andfacilitating the practice of health that takes intoaccount those beliefs appears to be an importantinitiative in the management of suffering andloss. (46)6. EXPERIENCES OF PATIENTSIN RELATION TO THE SPIRITUALASPECTS OF BEING ILLThe experience that patients have of being illstrongly depends on one’s personal understandingof the illness. Spiritual aspects are of vitalimportance to patients when they are dealingwith their illness and their relationships, whenthey are making decisions and facing their lossdue to illness, and when they are complying withtheir treatment. Spirituality may, in some cases,have a negative effect on the normal functioningof a person.( 49 , 50 )6.1. Religious Beliefs and Views on LifeBased on research by our group, we have foundthat themes according to religious beliefs andviews on life can be both positive and negativeand can influence or be influenced by theconceptualization of the illness and its prognosis.Positive influences are manifested in thesense that some of the patients during illnessand treatment were trusting in God, believedin miracles, and found strength in themselves,their faith, and nature. (50) A patient said,“What I read in the bible gave me lot of faith andrest. Yes, I could leave it in Gods hands easily. Ithas deepened my faith; my illness has enrichedmy life.” Another patient said, “You have to prayand give it to God. He will take care of it.” To thecontrary, some patients talked about faith andtheir view of life in a negative way by saying thatthey were angry at God or could no longer drawany strength from their faith. A patient said, “Iam not religious any more. I stepped out. I amangry with God because he sent me illness andpain.”( 50)6.2. Goal in Life and Life BalanceConfrontation with their own vulnerability influencesthe patients’ balance of life. Some of thepatients experienced the illness as an experienceof loss, because they could not go on living asthey did before the illness. They were confrontedwith their own limitations. A patient said, “Thisdisease makes me lose my abilities to resist and itis God who sent it to me perhaps in order to punishme for something I did.”( 50) Some patientsexperienced their situation as a fate, in whichthey could find rest or in which they could givetheir illness a place in their life. “Everybody getshis turn. Everyone has his own cross to bear.Everyone gets it in his own way on his own time.Let’s make something of it.”( 49)6.3 HumilityBy confronting a severe disease, the patientbecomes more aware of his personal history. Apatient said, “Before, I was very full of myself. Ifelt I was the most beautiful and I would alwaysoutdo the others. This illness has turned me intoa more humble person and has made me meditateupon what is really important in life and forme.”( 50) Patients said they were looking back ontheir life more and made up a kind of balance.Some of them took hope and strength out of earlierdifficult life experiences that helped them tofight against this setback now. (49)

276 Laurence Borras and Philippe Huguelet6.4. Courage, Hope, and Growth“Acceptance” and “letting go” were importantthemes. It entails the belief that patients can givemeaning to their disease, surrender themselvesto the new situation, and seek new perspectivesin life. The way in which patients handle this newsituation differs for every person. Some patientscould accept their situation easily, while othershad more difficulty with it or could not acceptit at all (at the moment). A patient said, “I haveaccepted my illness. I think God sent it to me inorder to make me able to encourage the otherpersons suffering from the same disease.”( 50)6.5. GuiltWhen people are affected by a disease for a significantamount of time, they usually developa subjective explanation for its causes. Duringour clinical practice, we have often been struckby the importance of guilt in some severely illpatients. In others, we noticed the will to understand.“Why is this happening to me? Have Idone something wrong or bad? Am I a victimof someone or of something? Who is responsiblefor it?” The answers to these questions, takinginto account the subjective explanation, arevery important in the process of dealing with thedisease. Patients’ lack of understanding or guiltadds to the suffering just as much as their feelingthat they are a victim of a more or less identifiedenemy. In response to this understanding,many dioceses in Europe have to set up exorcisingteams to expel the enemy. This phenomenonclearly shows that, in Western cultures, the notionthat disease is caused by an enemy is increasinglygaining ground. Mental health therapistsare being asked for meaning and sometimeseven for salvation. Spiritual leaders or prayinggroups are being asked for therapeutic services,while patients are dominated by guilt. In mostcases, this is due to our religious education. It isalso worth noting that certain pathologies, suchas the obsessive-compulsive disorder or melancholia,have a higher incidence in religious countries,especially in Muslim and ultra-orthodoxJewish cultures of the Middle East countries,where cultural identity and religious identityare inseparable. (51) Given these facts, the medicalpractitioner may find it useful to have someinformation about the understanding of illnessthat major religions of the world have.6.6. Spiritual Understandings of DiseaseAs shown, the patient’s understanding of illnesscan be influenced by religious beliefs. (52)Pargament describes four religious methods ofcoping to find meaning in negative events suchas an illness. First, patients can define illnessthrough religion as benevolent and potentiallybeneficial. The disease will then be consideredas an ordeal sent by God or as a divine plandesigned to turn the patient into a stronger personor to convey a message. It may also aim atactivating the patient’s spirituality or at makingsuffering acceptable. Second, patients can definethe illness as a punishment from God for one’ssins. Third, the illness can be defined as an actof the devil. Fourth, the patient redefines God’spower to influence the stressful situation that canbe a mental illness. A patient said, “I realized thatGod cannot answer all my prayers.” At the beginning,patients may have a negative representationof their illness but in time, they may also starta dynamic process of coping with it positivelyby integrating it constructively. A 48-year-oldpatient suffering from schizophrenia said, “Myillness was sent by the Devil; but I’m strugglingto overcome it, to make Good win against Eviland I know that God is on my side in this struggle.”(50) In some rare cases, the patient will reintegratethe illness in a negative manner by feelingguilty and being pessimistic about the prognosis.A patient said, “My illness is a punishment formy sins, I deserve it and I must endure it.”( 50)Yet it is quite rare that patients take a punishingGod into account in their understanding of theirillness. Most patients have a positive religiousinterpretation of their condition and feel guiltyfor what they go through without blaming Godor others. (53) Patients’ understanding of illnessalso has an impact on their acceptance of the

Models of Mental Illness and Its Treatment 277recommended therapy and on the prognosis ofthe disease in addition to influencing their copingwith its symptoms. Several studies have shownthat there is a negative correlation between a negativerepresentation of illness and the acceptanceof the recommended therapy. (52, 54, 55)6.7. Religious DeliriumIn our research study, six to 10 percent of thepatients with psychosis presented manifestationssuch as delusions or religious hallucinations,which obviously can influence the patients’understanding of their psychological processesand their understanding of illness and treatment.Some of these manifestations may be aggressiveand lead to feelings of guilt, thus being a discouragingfactor that can negatively influence theprognosis of the disease. A 30-year-old patientsuffering from paranoid schizophrenia said, “Iam transparent; everybody knows my thoughts,my feelings and my dreams. God wants to killme; He wants to kill my soul. Everybody knowsthat God is planning to assassinate me. They’retalking about it on the TV and on the radio too.I have tried to kill myself twice, but now I havegiven up, God will do it for me anyway.”( 52)Other manifestations of this kind may have apositive impact on the patients’ coping with theirillness. A 40-year-old patient suffering from paranoidschizophrenia said, “My illness opened mymind to spirituality. I do not talk about it to psychiatristssince they do not believe me. Before Ireceived medication, I heard voices. Once I tookrefuge in a church, I prayed to the Virgin Maryand the voices felt silent. Since that day, she hadprotected me. Sometimes she appears to me; it isnot a hallucination.”(52)6.8. Spiritual Understanding of TreatmentThe understanding of medical treatment mayalso be influenced by religious beliefs. As shownearlier in this chapter, certain patients may considermedical treatment and psychotherapy asa divine gift intended to cure the disease. Godis thus enlightening humans, whereas doctorsare perceived as God’s instrument. Thus, therecommended treatment will be more easilyaccepted. For others, treatment related to religiousbeliefs may be seen as destructive, beingoften perceived as a foreign body or as poisonor even as a straitjacket. What they are tryingto highlight is that the recommended treatmentand their religious beliefs are not compatible.A patient said, “Only God can control people’sthoughts. Doctors and drugs cannot do that.”Another patient said, “People are the way theyare because God wanted them to be this way, sowe shouldn’t try to change this through medication.Another said, “God thinks that this is notnecessary.” Some patients seek spiritual healingonly, as often dictated by their religious leader.Other patients emphasize the incompatibilitybetween what is being transmitted to them duringpsychotherapy sessions and their religiouseducation. Taking care of oneself and learning tosay no and to aspire toward self-accomplishmentmay enter into conflict with certain religiousteachings. These teachings often encourage serviceto others and the community and the subordinationof one’s personal needs. Suffering andbenevolence may be perceived as salutary. (54)7. RELIGION AND MEDICAL TREATMENT:INTERFERENCE OR MUTUAL BENEFIT?Over the last forty years, several articleshighlighted the relationship between spiritualityand understandings of illness. They also emphasizedthe need to take spirituality into account inthe development of health-care services, especiallyaiming at improving the acceptance of therecommended therapy by the patient and themedical relationship with the patient. This issuewas closely looked at in research studies concerningpatients suffering from severe chronicsomatic diseases (56–60) and patients with unipolaror bipolar mood disorders, (55) schizophrenia,(54) or substance addiction. (61) In mostcases, a positive impact of religious beliefs onadherence to the treatment was reported, whichfacilitated the current integration of a spiritualapproach into many health-care services. This

278 Laurence Borras and Philippe Hugueletpositive impact also contributed to patients’improvement of their quality of life as well as toa more active social support and a more positiveunderstanding of the disease in religious patients.Nevertheless, religious beliefs may interfere negativelywith certain aspects of the treatment inseveral ways, for example, when the patient seeksspiritual healing only, when patients associatefeelings of guilt with their religious understandingof the illness or of the treatment, or whenthere is incompatibility between religious educationand psychotherapy. A study by Borras etal. (54) highlighted the fact that 57 percent ofpatients suffering from schizophrenia have anunderstanding of illness and treatment influencedby their religious convictions: positively in31 percent (“test sent by God to put them on theright path,” “a gift from God or God’s plan”) andnegatively in 26 percent (“punishment of God, ademon, the devil, or possession”). The other 43percent largely adhered to a medical understandingof disease and spoke about their condition interms of genetic fragility or vulnerability. It is thepatients rejecting the recommended treatmentwho generally develop a spiritual representationof their illness, whereas patients who accepttreatment tend to favor a biological understandingof their suffering. Moreover, a third of nonadherentpatients underlined an incompatibilitybetween their religious convictions and medicationand supportive therapy. Some patientsreported to the evaluator that medical treatmentor recommended behavior encouraged by thepsychiatrist may enter into conflict with certainreligious teachings of various religious groups.Certain religious groups promote spiritual healingexclusively. It is also worth noting that, inthis study, the understanding of illness and thepossible incompatibility between religious convictionsand treatments were addressed in lessthan 20 percent of the cases, most of the medicalpractitioners having a tendency to overlook orunderestimate the importance of their patients’spiritual dimension. The drug-addicted patientsincluded in a methadone maintenance treatmentprogram mention spirituality as a predictor foradherence to the treatment, spirituality beingthus a source of strength and self protection aswell as a source of altruism and protection of theothers. They highlighted the importance of takinginto account this dimension in the recommendedtherapy, which represents an incentive toavoid risky sexual behavior while observing moreclosely the medical recommendations and growinghope for recovery.( 61 , 62 ) A study conductedon patients with bipolar disorders highlightedthe importance of exploring the patients’ understandingof their illness and of the treatment toobserve, because they may be influenced by theirreligious convictions, with a direct impact ontheir observance of the treatment. Thirty percentof the patients with bipolar disorders actuallyconnect illness to spirituality and 32 percentof them reported difficulties in reconciling theirreligious faith with the treatment recommendedby the doctors. In such cases, interference of aspiritual leader against medical treatment maybe suspected, along with an underlying desire toseek spiritual healing only. This may become ananxiety-producing dilemma for the patient. (55)Concerning somatic and neuropsychiatry diseases,a review of literature analyzed twenty-sevenstudies addressing spiritual beliefs that couldinfluence the treatment preferences of AfricanAmericans throughout the course of illness.The most frequently cited theme was the importanceof spiritual beliefs and practices, particularlyprayer, in coping with illness, a strategy of“turning it over to the Lord.” Another frequentlycited theme was the power of spiritual beliefsto promote healing: Many studies highlight theidea that prayer is the most helpful intervention,including medication. It was also mentionedas the most important help in their medicationdecisions. A third theme was the belief that Godis ultimately responsible for physical and spiritualhealth: God’s will appears to be the most importantfactor in recovery. The belief in miracles andfaith healing as well as the preference to attendfaith healing services rather than psychiatrictherapy are obvious consequences of this. A finaltheme was the belief that the physician is God’s“instrument” in promoting healing and that Godacts through doctors to cure the disease. All these

Models of Mental Illness and Its Treatment 279themes describing spiritual beliefs that may influencetreatment throughout the course of illnessseem to be more present in African Americanthan Caucasian patients. (63) Pfeifer (64) pointedout that in Switzerland, 38 percent of the patientsassociate their psychological disorder with thefact of being possessed by an evil force, whereas80 percent sought deliverance through prayersand exorcism. In most cases, these practices ofspiritual healing are perceived as a positive experiencethat allowed these people to overcometheir anguish and accept psychiatric treatment,as encouraged by their spiritual leaders. In somerare cases, these practices excluded other formsof treatment completely and induced feelings ofdistress, guilt, fear, isolation, and even psychoticdecompensation, which needed hospitalization.Wilson (65) describes similar experiences of spiritualhealing contributing to allaying anguish andviolent behavior, but he also mentions a few casesof aggravation of the symptoms. In the same line,some authors (66) have described “possession”cases with dramatic outcome, due to the patient’srejection of neuroleptic medication. Thus, it isnot the belief in a demonic origin of the diseasethat causes trouble, but rather the distress andthe rejection of psychiatric treatment induced, insome patients, by their religious practices, as it isthe case for certain sects.( 67 , 68 )A study of McCabe and Priebe (69) exploringexplanatory models of disease in four differentcultural frameworks highlighted the finding thatwhite people are more likely to have a biologicalexplanatory model, as compared to African-Caribbean, West Africans, and Bangladeshis, whoare more likely to have a social or supernaturalexplanatory model. Having a biological explanatorymodel, especially compared with a socialexplanatory model, is linked with greater treatmentsatisfaction and better therapeutic relationships.People who cited supernatural causes fortheir disease were less open (that is, less likelyto accept that they had a mental disorder) andtherefore less compliant with treatment. A studyby Saravanan et al. (70) assessing the explanatorymodels of psychosis in South India showed thatpatients’ views of schizophrenia do not concurwith prevailing professional ideas, and this maybe a source of conflict. Seventy percent of patientsattributed schizophrenia to spiritual and mysticalfactors, whereas social and biological causesaccounted for less than 20 percent of the overallattributed causes. The most individual folk causesreported are “black magic” and “evil spirits.”Spiritual/mystical and social causal models wereboth associated with visits to indigenous healers.Thirty-five percent of patients held more than onetreatment model for their psychosis, for example,“People may not improve with medications, sowe go to the temple to pray for them.” All thesearticles highlighted the importance of communicationwith patients regarding their representationof disease and treatment. On the one hand, thiswould help increase therapeutic trust as well as thepatients’ resources; on the other hand, it could helpovercome the obstacles in the healing process.8. CONCLUSION: THE ROLE OFTHE MEDICAL PRACTITIONERGiven the vulnerability and the anguish thatmay be generated by mental disorders, therapistsshould feel concerned about the meaning of thedisease to the patient, because it dramaticallyinfluences the therapeutic relationship as well asthe healing process. The aim is to understand thereligious (or nonreligious) and cultural understandingsof the patient’s disease. Unfortunately,in psychiatry, when patients talk about strangeperspectives or understandings unknown by thedoctor, the latter tends to overlook the meaninggiven by the patient to what he is experiencing.Even worse, the patient’s account of the situationmay be perceived as irrational or inconsistentbecause it refers to things that disturb thedoctor. The doctor also may ignore the patient’saccount because it is dissimilar to his own beliefpattern. A study by Hilton et al. (71) based on theobservations of the physicians in an acute mentalhealth unit for older people, showed that religiousbeliefs were only discussed with patientswho had psychotic symptoms that had a religiouscontent. Yet it is essential that the clinicianis responsive to the patient’s understandings of

280 Laurence Borras and Philippe Hugueletillness. Empirical evidence suggests that patientsare more satisfied when their psychiatrist sharestheir model of understanding distress and treatment.(72) It has also been shown that patientsare not less observant toward a clinician of adifferent culture.(73 , 74 ) The success of strategiesaimed at controlling the disease does notdepend as much on the efficiency of the medicalprescriptions (for example, medicines and traditionalremedies) as much as it depends on theway the prescriptions are being prescribed andon the meaning attributed by the patient to thetherapeutic process. (75) The clinician acts as amirror, being simultaneously the recipient of thelaments and the source of medical recommendations,of psychotherapeutic treatment and evenof rituals. The clinician is also a mirror to himselfbecause he has to ponder his own role as a specialistprescribing conduct and meaning, whilerealizing that his own sociocultural and religiousheritage affects the therapy he recommends. Theclinician must also take into account the therapeuticevolution of the patient, whose representationsof the disease and its treatment maychange, and along with them the patient’s choicesin terms of therapeutic solutions. Instead of callingthese oscillations a therapeutic mistake, theclinician should remain open to the patients andjoin them in trying to understand the new interpretationsdetermined by a set of complementarycircumstances and explanations. When the cliniciandeals with a patient of a different originor religion, it is interesting to have access to theelements specific to the patient’s culture such asthe representation of the disease, the body, andthe healing system of his or her tradition to beable to adopt the most appropriate strategy andthe best way to attend to the patient. It would beactually a good initiative to provide clinicianswith an introduction to the general aspects of theculture of the immigrants. Nevertheless, as usefulas this approach may seem in improving theunderstanding of differences, it cannot be generallyapplicable. In each country, there are culturaland religious variables between cities, regions,villages, regions, and ethnic groups. It is thereforehighly insufficient to take into account only theoriginal culture of the migrant, while denyinghis or her own individuality and historical background.If therapists are informed of some essentialaspects of their patients’ culture and religion,they will be able to identify better the thin linebetween the healthy and the psychopathologicalexpression of religious convictions to improvetheir approach to patients. However, the majorrecommendation for approaching patients in thebest way is to have available someone who willlisten. It is also true that, for our Western societies,listening is time-consuming and thereforeeconomically problematic. Things are completelydifferent in traditional allopathic medicine,which tends to promote a more deliberate andthorough approach to patients. In some cases,traditional allopathic medicine often takes intoaccount, along with clinical symptoms, aspectssuch as personality, character, or the physical andthe psychological environment, the living conditions,and the patients’ relationships, as well astheir moral issues and beliefs.Kleinman and Becker (14) recommended thata patient’s explanatory models of illness shouldbe elicited using an ethnographic approach thatexplored their concerns: “Why me?” “Why now?”“What is wrong?” “How long will it last?” “Howserious is it?” “Who can intervene or treat the condition?”Thus, the clinician would gather a betterunderstanding of the subjective experience of illnessand so promote collaboration and improveclinical outcomes and patient satisfaction.REFERENCES1 . d e B e au n e S A . C h am an i s m e e t pré h i s toi re.Un feuilleton à épisodes , L’Homme . 1998 ;38 : 203 –219.2. Sournia J-C. Histoire de la médecine et desmédecins . Paris : Ed. Larousse ; 1991 .3. Nic oud M. Éthique et pratiques médicales auxderniers siècles du Moyen Âge . Médiévales, n° 46,Paris, PUV; 2004 : 5 –10.4. Pichot P . Un siècle de Psychiatrie . Paris : Editionsles Empêcheurs de penser en rond ; 1983 .5. Mar ion M . Dictionnaire des institutions de laFrance au XVIIème et XVIIIème siècle . Paris : AyerPublishing; 1968 .

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19 Psychiatric Treatments Involving Religion: Psychotherapyfrom a Christian PerspectiveWILLIAM P. WILSONSUMMARYIn this essay, we observe that most religious therapieshave as their goal the cognitive restructuringof the minds of those who seek therapy. Thus,cognitive-behavioral therapy is done by mostpractitioners. It is also true that the holy writingsof each faith are used to teach their versionof the “truth” to the person being treated. Islambelieves that the patient should reconnect withtheir Muslim faith before therapy is undertaken.Christianity believes that a personal relationshipwith the living God is necessary for Christiantherapy to be used. The goal of therapy in allfaiths is to transform the mind of the believerso that they may have meaning and purpose intheir relationship with a higher power. In somefaiths, another goal is for them to encounter theirhigher power.Christian psychotherapy differs in one majoraspect. It seeks to enable patients to have a relationshipwith the living God who comes and dwellswith them and in them. This is possible becausethe mind of man is supernatural and because thesupernatural God can install himself in the mind.This means that God then can, with the believer’spermission, guide and direct their thinking andactivity in a positive way. Christian practices andinterventions can then bring about the transformationof the mind we so earnestly seek.process. Nevertheless, what information doesexist helps us to understand that most cognitiverestructuring is done in the context of the religion.An Islamic author (1) believes that therapymust be done after the patient has becomedevoutly Muslim. The restructuring is thendone using the teachings found in the Koran. InHinduism and Buddhism, it is assumed that thebeliever seeking therapy accepts the teachingsof that particular faith. Hindu and Buddhistpsychotherapy uses meditation focusing on ahigher power and on right thoughts. Cognitiverestructuring in all is done using the principlesespoused in their holy writings. There also isan effort to contact a higher power throughmeditation, by good works, or through asceticpractices. Christian psychotherapy is a disciplinethat uses the teachings found in the Biblewith an integration of current secular concepts.Therapy is facilitated by the power of the HolySpirit to transform lives. The goal is transformationof the person so that he or she has a lifewith less conflict and symptoms as well as morehappiness. In the light of the fact that there aresimilarities of practices in the psychotherapeuticapproach of all faiths, we will take a detailedlook at a psychotherapeutic approach intowhich Christian concepts have been includedto achieve this transformation.1. ANALYZING PSYCHOTHERAPIESReviewing the literature concerning psychotherapyin the major religions of the world,one finds that there is very little informationthat describes in detail the psychotherapeuticIn an overview of current secular methods ofpsychotherapy, Karasu (2) noted that at least140 claim to be distinctive. Certain factors,however, are said to be common to all methods.Among these are (1) an emotionally charged,283

284 William P. Wilsonconfiding relationship; (2) a therapeutic rationalethat is accepted by the patient and the therapist;(3) provision of new information, whichmay be transmitted by precept, example, and/orself discovery; (4) strengthening of the patient’sexpectation of help; (5) provision of successexperiences; and (6) facilitation of emotionalarousal. (3)After discussing the differences claimed foreach method, Karasu reduced the 140 varietiesof psychotherapy into three groups: thedynamic, the behavioral, and the experiential.He then summarized the following themes ofthese three groups as follows: (1) prime concern,(2) concept of pathology, (3) concept of health,(4) mode of change, (5) time approach and focus,(6) type of treatment, (7) the therapist’s task,(8) primary tools and techniques, (9) treatmentmodel, (10) nature of therapeutic relationship,and (11) the therapist’s role and stance. In noneof these areas did he consider spiritual aspects,although he later recognized that they shouldhave been considered. (4)Because the proponents of each technique ofpsychotherapy tend to focus on certain aspectsof their therapeutic approach, it is difficult todetermine whether their claims have merit andwhether significant differences really do exist.Karasu’s scholarly analysis produced some orderout of the chaos that appears to exist in the fieldof psychotherapy and provides us with a frameworkwithin which we can evaluate each therapeutictechnique with standardized dimensions.It is within this framework that I shall attempt toevaluate Christian psychotherapy.The title of this chapter presupposes that thereis such a thing as Christian psychotherapy andthat it differs significantly from secular formsof therapy. A casual reader of the literature onpastoral counseling, or Christian psychology,would probably not be convinced that there isa distinctively Christian form of psychotherapy,for he would find that many Christian therapistsuse Freudian dynamic therapy, Rogerianclient-centered therapy, Adlerian individualpsychological therapy, Jungian analysis, andother secular methods. Only a few writers suchas Tweedie, (5) Collins, (6) Adams, (7) Minirth, (8)and Crabbe (9) begin with a distinctive base, theBible, and describe a counseling technique basedon biblical teachings. From their books, articles,and the Bible, as well as my own observations,I have attempted to determine the fundamentaltheses of Christian psychotherapy.2. FUNDAMENTAL THESESFirst, we have to have a cosmology. The Christian’scosmology includes a transcendent God. It alsoincludes a worldview. A worldview is a comprehensiveconception or apprehension of theworld especially from a specific standpoint. TheChristian’s standpoint is contrasted with that ofthe agnostic or atheist. It is, therefore, importantfor us to understand our worldview becauseit affects our view of the planet, our society, thenature of man, and our place in the world. Themost important of these is the nature of man.There is no question that our view of man’s natureaffects our approach to psychotherapy. Whatthen should our worldview be?Leo Apostel,( 10) a Belgian philosopher,hypothesized that there are five fundamentalcomponents to a worldview. The first is a modelof the world that allows us to understand how theworld functions. This includes (1) the universe,(2) the earth, (3) life, (4) the mind, (5) society,and (6) culture. Second, there should be anexplanation for it all. We should know why it isthe way it is, where it all comes from, and wherewe come from. Third, we need a futurology. Thisis an extrapolation of the past into the future tohelp us answer the question as to where we aregoing. Fourth, we need values. Values are things,especially beliefs, that make a favorable differencein our lives. (11) We need to know what isgood and what is evil. When we know this, wecan have a code of ethics or morals. Fifth, weneed knowledge. Our actions can be based onlyon what we know and the information availableto us. We can then formulate plans based on theoriesand models describing the phenomena thatwe encounter. Knowledge acquisition allows usto distinguish between better and worse theories.Values will help us distinguish between what istrue and what is false.

Psychotherapy from a Christian Perspective 285Karasu commented that the starting point orfoundation of all psychotherapies is a concept ofthe nature of man. Christians believe that man’shuman nature has three functional units: body,soul, and spirit (1 Thess. 5:23). The body is morethan the various organ systems and flesh. Theyuse the term flesh here to describe the muscles,bones, and skin. It is also made up of the biologicaldrives such as psychomotor activity, sex,sleep, and appetite that are hardwired into thebrain. These give rise to certain behaviors thatwill satiate the appetites. The soul is made upof (1) the emotional reflexes; (2) the intellect,which includes knowledge, memories of events,and the emotions elicited by them; (3) the valueswe have learned; and (4) our ability to process,compare, evaluate, and respond to incomingstimuli. The spirit is, in the biblical sense, ananimating force that resides in man and operatesthrough the flesh and soul. In the past ithas been called the life force or elan vitale. Oncareful inspection, it may be concluded that thespirit does have undifferentiated feeling tones,those of pleasantness and unpleasantness. (12)Unfortunately, secular therapists have a morelimited view of man’s nature and of the factorsdetermining behavior. The best secular effortmade to formulate a concept of man’s nature todate has been that of Freud, who divided it intothree parts: the id, the ego, and the super-ego.His concept ignores the spiritual aspect of man’snature and includes only incomplete ideas ofthe flesh and the soul.The behaviorists focus on the soul. BothSkinner (13) and Glasser (14) pay only minimalattention to the spirit or the body in theirwritings. The experientialists , on the other hand,focus on the transcendental or spiritual aspect ofman and minimize the importance of the bodyand the soul.Tournier,( 15) who is considered the dean ofChristian psychotherapists, has based his counselingapproach on a holistic view of man. He haschosen to view man biblically and has postulatedthat his nature has three parts: body, psyche, andmind. The body includes the instincts, appetite,and physiological functions. It grows old,gets sick, and dies. The psyche is the part of manthat experiences emotion and is able to imaginethings. The mind is the part that thinks, reasons,wills, and deals with abstract ideas. Tournier’sideas differ in many details from those of otherChristian writers, but the major defect in hisview of man is his failure to include the conceptof man’s spirit as a specific entity, even though heis aware of the transcendental and emphasizesits role. Nevertheless, Tournier’s theories andtechniques have had a profound influence on thefield of Christian psychotherapy largely becausehe reconciles secular and biblical concepts in away that reveals the essential truths of both. Hebelieves that man does have a mind that containsthe spirit and it is in his mind that God communicateswith him.Among secular psychotherapists, only theexperientialists take into account the possibleexistence of a prime mover,( 16) which they conceiveof as a vague universal consciousness. Incontrast, Christian psychotherapy is based onthe certain knowledge that a prime mover doesexist and that he (God) is more than simply consciousness.He is the great I AM (Rom. 1:19, 20),a person, who manifested himself in the form ofa man, Jesus Christ (Col. 1:15). This Jesus died,was resurrected, and after returning to the Fathersent his Spirit (the Holy Spirit) to live in believersto reveal the truth, to give power (Acts 1:8),and to fill them with love for their fellow man.Man experiences God transcendentally throughhis Spirit (1 Cor. 2:12) and his Word (2 Tim.3:16). In the biblical record of his dealings withthe Israelites and in Jesus, God has revealed hisown personality attributes, provided guidelinesfor right living and emotional control, and hasgiven a set of rules for right living that will makea favorable difference in human life (2 Tim.3:15–17). One of the most important ideas inthe Christian belief system, however, is that Godgives his followers the power to live these values(Rom. 8:5–8).Having outlined the major differences in themetaphysical anthropology of psychotherapists,let us now compare the thematic dimensions ofChristian psychotherapy with those of the threeother streams of therapy. In Table 19.1, I havesummarized these thematic dimensions.

286 William P. WilsonTable 19.1: Summary of Thematic Dimensions of Four Kinds of Psychotherapy.Theme Dynamic (D) Behavioral (B) Experiential (E) Christian (C)Prime concern Sexual repression Anxiety Alienation Alienationfrom God –incompleteness (sin)Concept of pathologyConcept of healthMode of changeTime approach andfocusType of treatmentTherapist’s taskPrimary tools andtechniquesInstinctual conflicts;early libidinaldrives and wishesthat remain outof awareness, i.e.,unconsciousResolution ofunderlying conflicts;victory of ego overid, i.e., ego strengthDepth insight;understandingof the early past,i.e., intellectualemotionalknowledgeHistorical; subjectivepastLong-term andintenseTo comprehendunconscious mentalcontent and itshistorical and hiddenmeaningInterpretation; freeassociation, analysisof transference,resistance, slips, anddreamsLearned habits;excess or deficitbehaviors thathave beenenvironmentallyreinforcedSymptom removal;Absence of specificsymptom and/orreduction of anxietyDirect learning;behaving in thecurrent present,i.e., action orperformanceNonhistorical;objective presentShort-term and notintenseTo program, reward,inhibit, or shapespecific behavioralresponses to anxietyproducingstimuliConditioning;systematicdesensitization,positive and negativereinforcements,shapingExistential despair;human loss ofpossibilities,fragmentationof self, lack ofcongruence withone’s experiencesActualization ofpotential; selfgrowth,authenticity,and spontaneityImmediateexperiencing; sensingor feeling in theimmediate moment,i.e., spontaneousexpression ofexperienceAhistorical;phenomenologicalmomentShort-term andintenseTo interact in amutually acceptingatmosphere forarousal of selfexpression(fromsomatic to spiritual)Encounter;shared dialogue,experiments orgames, dramatizationor playing out offeelingsA combinationof D, B, and E,along with sin andits consequences(death); inability tocontrol behavior;painful emotionalstateA combination of D,B, and E; wholeness-(holiness) with peaceand love and fruitsof love; ability tocontrol behaviorA combinationof D, B, and E;reconciliation withGod; receipt of HolySpirit; creation ofpleasant emotionalstate; increasedselflessness andcontrol of behavior;adoption of newvalue systemA combination of D,B, and E; historical,nonhistorical,ahistorical,subjective past,objective present,phenomenologicalmomentAny time and anyintensityDetermination ofrelationship withGod; spiritualgrowth, to relate toperson in love, touncover conflicts, toassist in resolution;to program, reward,shape responsesConversion; prayer,determination ofhistorical originsof conflicts,analysis of dreams,free association,interpretation,conditioning,education(continued)

Psychotherapy from a Christian Perspective 287Table 19.1 (continued)Theme Dynamic (D) Behavioral (B) Experiential (E) Christian (C)Treatment modelNature ofrelationship to cureTherapist’s role andstanceMedical; doctorpatientorparent-infant(authoritarian), i.e.,therapeutic allianceTransferential andprimary for cure;unreal relationshipInterpreterreflector;indirect,dispassionate, orfrustratingEducational; teacherstudentor parentchild(authoritarian),i.e., learning allianceReal but secondaryfor cure; norelationshipShaper-adviser;direct, problemsolving,or practicalExistential; humanpeer-human peeror adult-adult(egalitarian), i.e.,human allianceReal and primary forcure; real relationshipInteractor-acceptor;mutually permissiveor gratifyingTeacher; friend,fellow struggler,essentially egalitarianbut at timesauthoritarian but asan agent of GodTransferential butreal and primaryfor cure; realrelationshipInterpreter, shaper,adviser, interactor,acceptor, realityorientor, teacher,limit setterMo d ified after Karasu. (2) Reprinted with permission from the American Journal of Psychiatry (copyright 1977). AmericanPsychiatric Association.3. THEMATIC DIMENSIONS3.1. Prime Concern and Conceptof PathologyKarasu observed that the prime concern of thedynamic psychotherapist is with sexual repression.The behavioral psychotherapist is primarilyconcerned with anxiety. The experientialtherapist is concerned with alienation. I wouldpropose that the Christian therapist is primarilyconcerned with man’s alienation from God,which leads to alienation from man and societyas well. His alienation from God is an outgrowthof sin. This sin is either original sin or acts ofrebellion against God’s authority, or both.Becoming a Christian is purported by someto produce wholeness without other interventions.They argue that Christians should notneed psychotherapy if they are truly “saved.” Butin spite of their admonitions, many authentic(17) Christians do consult psychiatrists or otherprofessionals for psychotherapy. Why then doChristians need psychotherapy? Our response tothe question is to say that if an ideal Christiancommunity existed and was populated only byperfect Christians, psychotherapy might not beneeded. But there are no perfect Christian communitiesand there are no perfect Christians, sothe need exists. The reason it exists is that, in thepast, most Christians believed in a kind of inheritedsin. Many still do today. This inherited sinoutweighs the good (Rom. 3:23). These samepeople also believe that there is a personal supernaturalforce for sin in the world (Satan) thatseeks to destroy (1 Pet. 5:8). Such a belief is incontrast to the ideas held by the dynamicists andbehaviorists, who see man at birth as a blank personality(tabula rasa). He learns to be bad eitherby the actions and teachings of parents, society,culture, or circumstance. The experientialists donot consider sin in their discussion of man’s predicament.(18) They do mention man’s revolt as away of responding to his alienation. This revoltmanifests itself in a rejection of God and society’svalues.Most Christian psychotherapists admit theexistence of a tendency to revolt. They call itoriginal sin. Jay Adams (a theologian), LawrenceCrabbe, Jr., and Frank Minirth, mentioned earlier,all consider sin as a primary cause of man’s neurosesand spiritual problems. But what is sin? Mostpersons would define sin as a set of specific behaviorssuch as drinking, smoking, cursing, sexualindiscretions, and other such misbehaviors. Theseare, to be sure, manifestations of sin, but sin ismore than specific behaviors. It is conscious rebellionagainst the authority of God . Because of thisrebellion, man indulges his biological drives andrelates to others in ways that are contrary to the

288 William P. Wilsonrules God has given him. These rules commandthat he relate to God and other men in love. Beingalienated from God by his rebellion, man is notwhole. His life is empty and meaningless.Sin has consequences that result in pathology.The Bible used the term death to describe thispathology. The biblical concept of death has severalinterpretations. The most important aspect isalienation from God. A second is failure to receivethe abundant and eternal life that the Bible promises.A third is the emotional pain, which resultsfrom man’s inability to control his behavior andhis failure to respond to the love of God. McKay(19) has called this lack of control moral paralysis.C. S. Lewis (20) has pointed out, “Until theevil man finds evil unmistakably present in hisexistence in the form of pain, he is enclosed inan illusion. Once pain has roused him, he knowshe is in some way or another up against the realuniverse: he either rebels … or else makes someattempt at adjustment which, if pursued, will leadhim to religion.” The painful emotions of sorrow,fear, anger, emptiness, confusion, shame, jealousy,or disgust are manifestations of pathology.More recently, Moshe Spero (21) has pointed outthat the pain arising from sin manifests itself asneurosis. In contrast, because neurosis results ina preoccupation with self, it is sin.Finally, the Bible makes it plain that the finalconsequence of sin that is not dealt with is eternalseparation from God and punishment (Matt.25:46).3.2. Concept of HealthTh e concept of health usually considered characteristicof Christian psychotherapy is holiness.Tournier is the leading proponent of holinessin today’s psychotherapeutic world, a world inwhich the word holiness often suggests emotionalinstability and religious fanaticism. Butthis is not what holiness originally meant. JohnWesley,( 22) who was an outspoken proponent ofholiness, believed that holiness, or sanctification,begins with a transcendental experience (salvation),but is at the outset incomplete. Wesleybelieved that confession, reproof, instruction,and the performance of good works in love areall part of the process through which behavioris modified and men are made whole. In aworld where medical care was almost nonexistent,Wesley went to the trouble to write a bookon home medical care. He did not omit thebody from his concern for the spirit and soul.Tournier’s therapy of the whole man is in thesame tradition.The three secular systems list resolution ofunderlying conflicts, symptom removal, andactualization of potential as the primary goalsof therapy. All these are goals of the Christiantherapist. He knows that to attain wholeness theymust be achieved. But there is more. The patientmust also be reconciled to God and continue tobe transformed as he matures in his faith.3.3. Mode of ChangeThe mode of change in Christian psychotherapyinvolves a synthesis of the various mechanismsused by the proponents of the three kinds ofpsychotherapy. Not only is depth of insight necessary,but also direct learning and behaving aswell as immediate experiencing are also necessary.In addition, the Christian therapist’s goal isreconciliation with God, if this has not alreadytaken place. A transcendental experience withGod is one of the primary effectors of change(2 Cor. 5:17, John 3:3). The joining of God’s Spiritto man’s mind is essential if therapy is to becometruly Christian. It is unfortunate that other writershave not emphasized this point. Reconciliation toGod provides power to change (Rom. 8:7, 8).3.4. Time Approach and FocusEven in Christian therapy, however, we have torealize that the “present is viewed through thepast in anticipation of the future.” Therefore, anunderstanding of the past is necessary to determinewhat changes must take place before newpatterns of thinking and behaving, determined bythe patient’s Christian value system, can be established.(23) Christian psychotherapy should use avariety of methods to bring about the necessary

Psychotherapy from a Christian Perspective 289changes. It is conceptual narrowness of the worstkind to assume that all patients can be treatedwith the same approach.At this point, we must emphasize the understandingthat we derive from the Bible abouttime. In the dimension of the supernatural, thereare no dimensions of time and space as we knowthem. Therefore, God is the Lord of time. Thismeans that he can take us back in time, in away that is impossible without his involvement.God’s intervention allows us to heal events in thepast as we relive them. This ability to supernaturallywarp time back on itself is the basis forwhat is called inner healing. Because change isto be effected in different ways, we should alsoknow that the time approach and focus would bevariable. Christians cannot ignore the past, forin it are buried the experiences that determineresponses in the present and their anticipationof the future. Christian therapists must, therefore,examine the objective reality of the patient’spresent situation to determine the significance ofthe subjectively remembered past. The intellectualand emotional knowledge thus gained canbe used to help the patient understand his currentdysfunctional thinking and behavior. Afterthe therapist and patient together have examinedtheir findings in the light of the biblical ideal, it isthen possible to undertake the necessary modificationsin thinking and behavior.3.6. The Therapist’s TaskThe task of the Christian psychotherapist is moreformidable than that of the dynamic, behavioral,or experiential therapist. He must not only beable to determine the meaning of unconsciousmental conflict, but he also must program,reward, inhibit, or shape behavioral responses toanxiety-producing stimuli. In addition, he mustinteract in a mutually accepting atmosphereto help arouse of self-expression. He begins byestablishing an atmosphere of mutual acceptanceto encourage the patient’s self-expression. Tobe effective in this task, the therapist must be amature Christian who is able to interact with thepatient in a nonjudgmental, caring way. He hasto accept the patient as he is and care for him inspite of his problems.Such caring demands nothing and has as itsconcern the best interests and welfare of the otherperson. It is nonsexual, not exploitive, and eternal(Ps. 136:1). The bond established will be greaterif both the therapist and patient are Christians.At the beginning, the therapist must determinethe nature of the patient’s relationship with Godand/or his level of maturity in the Christian faith.This demands a thorough knowledge of spiritualdevelopment. Because of the relationship, thetherapist is able to shape behavioral responseswhen necessary.3.5. Type of TreatmentLittle has been written about the type and durationof treatment that Christian psychotherapistsshould employ. Secular therapists use longtermintense, long-term not intense, short-termintense, or short-term not intense. As we haveexamined the activities of Christian therapists, itappears that they use different types determinedby the patient’s need. In many instances, a singleencounter may be sufficient. In others, it maybe necessary to see the patient up to sixty timesto bring about healing. Patients with addictions,eating disorders, deviant sexuality, and borderlinepersonalities are most likely to require longtermtherapy.3.7. Primary Tools and MethodsOnce the appropriate atmosphere has beenestablished and the therapist has determinedthe level at which he and the patient can relate,he must explore the areas of conflict and determinetheir genesis. In many cases, it will benecessary to strip away defenses by which thepatient maintains repression of the experiencesthat have given rise to his or her symptoms.Christians are particularly prone to deny conflict,simply because it is not compatible withtheir idea of Christian perfection. Having beentaught that Christians should not get angry orhate, think lustful thoughts, should always love,and should not fornicate or commit adultery,

290 William P. Wilsonthe patient who considers himself a Christianmay deny or repress thoughts, feelings, orbehaviors that are not Christian because ofshame and guilt. The therapist must be familiarwith these defense mechanisms and know howto get around them. He can then comprehend(like secular therapists) the patient’s consciousand subconscious mental conflict and its historicaland hidden meanings. Next, the therapisthas the task of helping the patient understandhow this subconscious conflict is influencinghis or her current behavior. By respondingto the patient in ways that do not rewardthe behaviors that produce pain and anxiety,the therapist helps to bring about extinctionor inhibition of such behaviors. He then mustteach (or program) new behavioral patternsthat will provide the patient with positive reinforcements.Because the Christian therapist willuse biblical guidelines in his selections of newbehaviors, familiarity with the Bible is essential.The use of journaling, psychodrama, visualizationtechniques, role playing, and gestalttechniques helps the patient “get in touch” withhis long repressed feelings, so that he can takesome definitive action to deal with them. Ofparticular importance is the management ofshame and anger. In many cases, the patient’ssymptoms or behavioral aberrations are derivedfrom profound shame and guilt, hate, or resentment.These emotions are derived from whatthe Bible calls a record of wrongs against oneselfor others (1 Cor. 13:5 Good News Bible(TEV)). The only way to deal with these recordsof wrongs is to use God’s forgiveness. Dynamictherapists believe that understanding results inforgiveness. Behaviorists believe that people aresomewhat helpless in dealing with their pastconditioning. Even so, they are responsible.Experientialists regard man as inherently goodand, therefore, do not consider the need for forgiveness.For the Christian, it is impossible todeny moral responsibility. When a person hasbroken God’s laws, he is guilty of transgressionand must deal with the guilt. Tournier, Hyder,Crabbe, Adams, and Minirth all emphasize therole of forgiveness in Christian psychotherapy.Biblically, God is the source of all forgiveness(Luke 5:21), for forgiveness can come only outof the infinite love he has for mankind. (24) Itis the task of the therapist to use this forgivenessfor dealing with the anger he has towardothers and the shame he feels about his owntransgressions (John 20:23). Once the patienthas accepted God’s forgiveness for himself, hecan develop a realistic self-concept. When hehas forgiven those persons who he feels havewronged him, he can relate to them in love.Th e primary tools and techniques of Christianpsychotherapists are those used by dynamic,behavioral, and experiential psychotherapists,with several additions. The most vital additionis conversion. Biblically based Christiantherapy takes seriously the statement of Jesusthat “you must be born again” to enter the kingdomof God (John 3:3). Regeneration, or conversion,is the sine qua non of truly Christiantherapy. If the therapist and the patient havenot been born again, Christian therapy cannottake place. Wholeness in the patient cannot beattained without it. Even nonbelievers attest tothe importance and the usefulness of conversionin some healings .Another unique tool available to the Christiantherapist is a reward system that produces a highlymotivated patient. The promises of love, joy, andpeace (Gal. 5:22, 23), to say nothing of abundantand eternal life (John 10:10, Mark 10:30), arepowerful incentives for working toward healing.In a like manner, Jesus’ promise to heal creates anexpectation in the patient that he will be healed.The patient and his therapist believe that healingis more than a promise (something called disparagingly“pie in the sky by and by”), it can happennow.Finally, the Christian therapist can use prayer,Bible study, worship, and the Eucharist (themeans of grace) to help him in his teaching andconditioning tasks. One of the advantages ofprayer is illustrated in Norman Grubb’s statementthat prayer is not intended to convince God, butto convince the person offering the prayer. (25)

Psychotherapy from a Christian Perspective 2913.8. Treatment ModelThe treatment model used by dynamic andbehavioral therapists tends to be authoritarian.The model used by experiential therapists is egalitarian.The Christian may use an authoritarianmodel, but he prefers an authoritative egalitarianmodel. Because the Christian therapist is a fellowstruggler in the quest for holiness, he does not seehimself as always having answers, neither does hehave power to effect change. He is fully aware ofthe wisdom and power of God to work throughhim to bring about healing in the person underhis care. He assumes many roles in his relationshipwith the patient, but he is always a teacher and afriend. He is working to bring about a completechange of the patient’s mind (Rom. 12:2). This isdone by restructuring the patient’s thoughts, butalso by decathecting (detaching) damaging emotionsaccumulated in the past. This will liberatethe patient from the influence of these emotionsover his thinking and behavior. If the damagingemotions are decathected, the patient’s anticipationof the future will be changed. In short,patients will be released from their bondage tothoughts and behavior determined by their pastexperiences and will have hope for the future.3.9. Nature of RelationshipFor the Christian therapist, the nature of relationshipfor cure is the same as for any secular formof therapy. It must be real and primarily directedtoward cure. The relationship is, however, one oflove, otherwise it is not Christian.If Christian psychotherapy is to be effective,there must be something unique about the therapist-patientrelationship. Paul’s statement thatChristians are not to consider themselves betterthan others clearly commands us to have an egalitarianrelationship (Phil. 2:3). This is in keepingwith Jesus’ commandment to love one anotheras he has loved us (John 13:34). In an egalitarianrelationship, we will love our patients andauthoritatively use the knowledge we possess tohelp bring about their healing. It is interestingthat Meltzoff and Kornreich,( 26) in their summaryof research in psychotherapy, observed that“caring” was the single most important factor inachieving good treatment results. The relationshipof therapist to patient should be, therefore,one of loving acceptance. The therapist shouldnot see himself as superior or as having specialpowers, but should be humble. Humility is beingable to see yourself as God sees you with all yourvices and virtues, your perfections and imperfectionsas well as your assets and liabilities. Inhumility, he will accept the fact that he is just ashuman as the patient, but will understand thathe has been given gifts of knowledge and healingto use to heal fellow strugglers in a broken andharsh world.3.10. The Therapist’s Role and StanceBecause most physicians and mental health professionalshave a tendency to adopt an authoritarianrole, they have a proclivity to adopt apriestly or prophetic role, but avoid a pastoralone. Psychiatrists, psychologists, ministers,and other therapists who adopt the priestly rolemay forget that they themselves are human. Thehumanity of some, however, is all too obviousto those who carefully inspect their lives. Theyhave more suicides and some of them have justas many divorces and problems with alcoholism,drug addiction, and sex as society at large. It isa fact that they too frequently have “messed up”children. If they adopt a priestly role, it is likelythat their human desire to appear strong willkeep them from relating in an honest, real, andopen way with their patients. This will hindertheir therapeutic efforts.Assuming that the pastoral or egalitarian roleis the most desirable, what other roles shouldthe therapist assume while treating his patients?Carl Rogers (27) promoted the idea that the therapistis to be nondirective and patient centered.He is to be genuine and open in dealing with thepatient. He should have an unconditional positiveregard for the patient as well as an accurate,empathic understanding of the patient’s feelings,

292 William P. Wilsonsentiments, and attitudes. This allows the patientto express his thoughts and feelings and increasinglybe able to listen to his own communications.As he progressively accepts the therapist’sfeelings toward him, he can be more open andgrow toward self-actualization. Although thisapproach to treatment has been accepted andpracticed widely, it is only partly biblical. Jesusdid relate this way with all the hurting people hecame in contact with, but he assumed many otherroles while he unconditionally accepted them.Carlson (28) has described the many rolesJesus took while relating. He was critic, preacher,teacher, interpreter, mediator, confronter, admonisher,advocate, sustainer, supporter, lecturer,adviser, burden-bearer, listener, reprover, warner,helper, consoler, and pardoner. If we comparethis list with the roles listed by Karasu, we findthat the roles adopted by therapists using secularsystems are quite limited. The roles adopted byJesus included those used by secular therapists,but went far beyond. Because we are to treat personsusing biblical insights, we should model ourtherapeutic role after the greatest healer of all.The stance of the Christian therapist shouldbe as variable as his role. There are times whenhe will have to be loving, comforting, accepting,permissive, confronting, gratifying, direct, problem-solving,and practical. At other times he willneed to be indirect, dispassionate, or frustrating.4. SPIRITUAL DISEASETo a physician, the concept of spiritual disease isnot difficult to accept if he or she believes thatman has a spirit. However, theologians may havea problem with such a concept. Even so, it wasrecognized in Jeremiah 8:22 when it was said thatthe people of Israel needed healing for their idolatryand rebellion. The concept is also found inChristian hymnody in the use of the term “sinsick souls” to describe people who need Christ.If we analyze the scriptures, we are able toidentify four spiritual diseases. The first of theseis a congenital one that all are born with, andthat is to be unregenerate (i.e., not regeneratedand therefore requiring to be born again into thespiritual life). This came about because Adamand Eve sinned in the Garden of Eden when theywanted to “be like God.” We are rebellious fromthe beginning. All one has to do to confirm thisis to watch a child in the first two years of life.One of the first words he learns is “no.” His rebellionwill continue throughout his life. Before thefall, man lived in union with God; afterwards, hewas alienated. This alienation is only relieved bya conversion experience.A second spiritual disease is sin. Jay Adamsmade sin the center of his pastoral counselingapproach. He was, however, a spiritual reductionistand did not consider man’s other spiritual diseases.We have already defined sin as consciousrebellion against God. It occurs in both unregenerateand regenerate persons. W. M. McKay sawsin as a disease as did Moshe Spero. McKay saidthe thing that most characterized sin as a symptomwas that it gave rise to moral paralysis. It alsogave rise to deceit because the sinner did not wantothers to know of his moral dereliction. It alsogives rise to negative emotions. Most commonlythese are shame, fear (anxiety), and sorrow. Thelatter is due to the existential despair of moralitythat develops secondary to the moral paralysis.Sin pollutes the environment. McKay recognizedthis and said that moral pollution makesthe environment infectious. I need only refer tothe drug-ridden environments of our schoolstoday, which are as infectious as they can be forchildren who spend their time there. This is whywe have an epidemic of drug use by teenagers.A third spiritual disease is demonization.Satan’s existence has been controversial for manyyears. (29) The Bible makes the existence of Satanexplicit as it describes his person and works. Jesuswas said to have come to destroy the works of thedevil (1 John 3:8).Satan’s intimate interaction with mankindis called demonization. Satan uses his minions(demonic spirits) to accomplish this. Demonizationhas three forms. There is possession, oppression,and obsession. In possession there are diagnosticfeatures. These have been summarized byNevius. (30) The primary manifestation of this stateis the regular appearance of another personality,

Psychotherapy from a Christian Perspective 293who has a name, behaves in a manner compatiblewith his name, and has supernatural knowledgeand power.Oppression causes the afflicted to be in a statethat is similar to depression. There is a grayness(gloom) that surrounds the person. One patientadmitted because she was suicidal that she hadbeen a witch, but kept her witch’s paraphernaliaafter she had renounced witchcraft and becamea Christian. The oppression occurred while inher apartment. Every time she entered, a graynesswould descend on her. It lifted when sheexited. When she disposed of the satanic bible,her cauldron, her cookbook for brews, and theingredients for brews, she no longer experiencedthe gloom surrounding her. Another patientwho had been oppressed for years had thegloom disappear when he was delivered fromthe oppression.Mature Christians have spiritual immunityfrom all forms of demonization, but especiallypossession. They must, however, maintain anadequate level of piety. In doing so, they maintainspiritual immunity. Spiritual immunity ismaintained by practicing regular prayer, Biblereading, and worship.Obsession is to be abnormally preoccupiedwith some thing. It is almost universally one ofideology. There were many communist leaderswho were obsessed. We see it among Christians,Muslims, and Hindus and, in our day, amongthe extreme animal rights people and environmentalists.Finally, there is fanaticism. It can be anextreme form of demonic obsession, although itis usually a psychological state. We see it amongChristians, Muslims, and Hindus and, duringWorld War II, among the Japanese. Fanaticismalso occurs in mental illness. This is especiallytrue of some forms of schizophrenia and occasionallyin mania where it occurs as one of thesymptoms.In completing this section, I must say thatall spiritual disease is psychospiritual. It has todo with beliefs that we call cognitions, but haveemotions connected to them. The behaviors thatarise out of these beliefs are then good or evil,correct or erroneous, constructive or deleterious,and pleasant or painful. They will then determinethe degree of happiness a person will experiencein his life.Spiritual disease can be both primary andsecondary. There is no question that to be unregenerateis a primary disease. It gives rise to asecondary disease of sin. But sin may occur as aprimary disease in the regenerate. Demonizationis usually a primary disease occurring mostlyin the unregenerate, but under certain circumstancesit also occurs in the regenerate. Fanaticismcan occur in the regenerate or the unregenerate.Psychospiritual problems almost alwaysoccur in psychiatric diseases described in theDiagnostic and Statistical Manual of MentalDisorders, Fourth Edition ( DSM-IV ). The writersof the Bible saw man as a unity, and one must usea systems approach to recognize that if one partof the system is not functioning correctly thenit will affect all other parts of the system. VonBertanlanffy,( 31) who was the great proponentof General Systems Theory, said that psychiatryand psychology needed to consider it in its diagnosisand treatment of mental problems. In thelight of his ideas, we can say that all illness has apsychospiritual component. We must recognizethat to treat one aspect of illness and neglect theother two is an omission.5. CHRISTIAN INTERVENTIONS5.1. EvangelismJust as the Muslim therapist feels the patientmust be correct in his Islamic faith before therapycan be carried out, the Christian therapistmust ascertain the spiritual state of the patientand determine whether the patient would benefitfrom Christian psychotherapy. Schizophrenicsand some bipolar disorders (manic phase) shouldbe treated without reference to Christianity.If a patient is unregenerate and is not opposedto Christian therapy, they should be offered thechoice of what form of therapy they desire. Thetherapist must always remember that the humanwill does not tolerate the imposition of another

294 William P. Wilsonwill above its own, so one must make an appeal totheir will. It is not possible to forcibly evangelizesomeone! There is the criticism that Christiantherapists who do evangelism are taking advantageof vulnerable people. In most instances havenot found this to be true. Most patients realizethat their therapist has their best interests atheart and readily agree to be evangelized. Evenif a person submits unwillingly, they will notbenefit from the experience, and one still cannotuse Christian interventions and have them beeffective.The most effective form of evangelism ispersonal witness. One-third of all persons whobecome Christians come as a result of the personalwitness of another believer. Personal witnessof healing is especially desirable in thetreatment of alcoholics and drug addicts. If oneis dealing with a person who has a borderline disorderit is sine qua non. If the patient is willingto accept Christ as his Savior, then the therapistmust know the plan of salvation that should berevealed to the patient. The plan is that the personis a sinner, that Christ died to take his punishment,and that he can receive pardon if he askshim into his life. The patient and therapist praya prayer of surrender together. To illustrate thispoint, I cite the response of twenty-one Malagasyalcoholics. The lecturer was asked to preach tothem. He chose as the basis for his lecture thescripture 2 Corinthians 5:17. It says that if anyoneis in Christ he is a new person. These menwere in a Christian healing community, so it wasappropriate for him to deliver his message usingscripture. After he had explained the scripture,he asked how many of the men had become newpersons. No hands went up. He then asked howmany of them would like to become new persons.All hands went up. He next asked if they knew theplan of salvation. None of them did, even thoughtwo of the men were Roman Catholic priests. Hethen explained the plan of salvation to them andasked them to pray the prayer of salvation withhim if they desired to become a new person. Theyall did pray as he recited it. After the service wasover, the two priests came and asked the lecturerif they could use this plan with their catechists.He told them that they would be remiss if theydidn’t.Sometimes if the patients have been regeneratedbut have grieved the Spirit with their sin,they may need to rededicate their lives to theLord to regain their ability to be healed.On occasions God will act sovereignly in aperson’s life and will reveal himself to the person,who then has the opportunity to accept or refusethe offer. Lord Kenneth Clark,( 32) the producerof the BBC series Civilization, had suchan experience. He was standing in the church atSan Lorenzo in Italy when “ for a few minutes mywhole being was irradiated with a kind of heavenlyjoy, far more intense than anything I hadknown before. This state of mind lasted severalminutes, and wonderful though it was, it posedan awkward problem in terms of action. My lifewas far from blameless: I would have to reform.My family would think I was going mad, and perhapsafter all it was a delusion for I was in everyway unworthy of receiving such a flood of grace.Gradually the effect wore off and I made no effortto retain it. I think I was right; I was too deeplyembedded in the world to change course.” Mostaccept such an offer.5.2. DiscipleshipLike any newborn baby, the newborn Christianneeds to be taught how to live a Christian life.Just as a child needs to learn how to communicatewith his parents, the newborn Christianneeds to learn how to communicate with Godand to understand who God is and how herelates and communicates with him. The processof teaching the skills necessary to do this is calleddiscipleship.It has been shown that only 5 percent ofmembers of mainline denominational churcheshave any training at all. It is clear that if thetherapist is to be effective in transforming liveswith Christian psychotherapy, he must disciplehis patients or make sure they are discipled.What do they need to learn? This is described indetail in my book entitled The Nuts and Bolts ofDiscipleship. (33)

Psychotherapy from a Christian Perspective 2955.3. PrayerMost effective persons in the Christian worldare people of prayer. In an unpublished studyof people who were effective Christian leaders,I found that all prayed at least two hours a day.Jesus prayed more than that. Christian therapistsalso need to be men and women of prayer.To cooperate in therapy, a believer has to knowhow to pray. Prayer is described as a conversationbetween two people who love one anther–Godand man. It is the single most effective interventionin the Christian therapist’s armamentarium.It has to be carried out to initiate the spiritual lifeof a patient, but it also has to be used in the transformationof the person’s mind.Other faiths also practice prayer as a meansof communicating with the divine but in most ofthem they use prayers composed by their leadersor pray their particular holy writings. They alsohave certain behavioral rituals that they performas part of their prayers. Islam is notable for itsritualistic prayer. Orthodox Jews also write outtheir prayers and lay them before God by puttingthem into crevices at the Wailing Wall whilebowing. Buddhists inscribe them on wheels thatthey twirl. Hindus repeat a mantra. However, it isnot clear what the content of the mantra is exceptit is usually taken from their holy writings andis quite varied. The frequent repetition of theirprayers has a transforming effect on their minds.All prayer has as a goal putting the person prayingin contact with his higher power.Christian prayer is designed especially to putthe person praying in contact with the triune God(Father, Son, and Holy Spirit). It has two aspects.The most commonly practiced is spoken prayer.The mature Christian does, however, more thantalk, he also listens. There is one prayer thatJesus taught us to pray that is formal. It is calledthe Lord’s Prayer. Most of his recorded prayers,however, were conversational. Christian prayershould be conversational.God speaks to us in two ways. He puts illuminatedthoughts into our minds, and he illuminateshis message in the Bible. This illuminationresults in eureka or ah-ha experiences. He mayalso speak to us through his current prophets.The main reason why most prayer is a one-wayconversation is that people do not intently listen.An example of God’s communication wasobserved in a young Christian woman who wasmiserable in her bondage to her mother. She hadnever separated and individuated and was tryingto free herself, but could not find a way. Her therapisttold her to listen to God and find out whathe would say. She was reminded in the ensuingsilence of a scripture story that had a stubbornperson in it who became obedient and washealed. She realized that she had to be obedienttoo. When she took steps to free herself, she wasfreed and healed.Prayer does many things that facilitate transformationof a person’s mind. It may reveal truthsnot perceived before. This is especially true ifscripture is prayed. Prayer also reveals the errorsin misbeliefs (or lies) that the person has learnedin his early life so they can be corrected with thetruth. This is not to say that the therapist as anauthority can do the same, but prayers of thanksgivingfor the truth will facilitate the change inthinking.Prayer also facilitates the release of damagingemotions. This occurs when prayer visualizationor prayers for the healing of memories are carriedout.5.4. Healing of MemoriesThis form of prayer is uniquely Christian. (34) Itis a prayer in which the therapist uses the patient’sability to remember and visualize to bring intoconsciousness the traumatic event and have theHoly Spirit release the damaging emotion(s) bydivine intervention and heal the memory.Memories of traumas suffered in the past or,as the case above illustrates, of sins we have committedcan be healed using an intervention calledinner healing or healing of memories. It can alsobe used to bring about a release of bondage tothe living or dead. In the post-abortion syndrome,one has the patient try to discern the sexand name of the fetus. To illustrate the use of thiskind of prayer, I will relate the following case.

296 William P. WilsonA wife of a physician in her late forties camebecause of depression of three years duration. Ithad not responded to several different antidepressantsprescribed by a psychiatrist in her city.Her illness began when she was involved in awreck while taking her son to reading therapy forhis dyslexia. She had all the classical symptomsand signs of major depression. She was tried on anew antidepressant, but she did not respond to iteither. Continuing cognitive behavioral therapywas of no avail, so it was decided to review herhistory to see if something of dynamic significancehas been missed.She said in this session that she was drivinga small Volkswagen with her son when she lostcontrol of her car and rolled it several times. Withfurther questioning, she remembered that as thecar rolled she thought, “I will have killed both mysons.” The therapist said, “But you only have oneson.” “Oh!” She said, “I did not tell you. I had anabortion.” She then guiltily explained her reasonsfor having one.When she was asked how she knew it was aboy, she said that she “just knew.” “I was going toname him Christopher.” After she had finishedher story she was told that she needed to commitChristopher to the Lord. She agreed and ina ceremony called “requiem healing” she committedChristopher to God. (35) A modified standardEucharistic service in the Book of CommonPrayer was used. The liturgy contains a request forforgiveness. She then committed Christopher tothe Lord for his eternal destiny. As she did, shevisualized standing at the threshold of the kingdomof God with the light of God’s presence in thebackground. An angel then came out of the lightand took Christopher off into the light of God’spresence. At this point she wept for a few minutes.They then celebrated the rest of the Eucharisticservice for closure. She was instantly healed ofthe depression and taken off medication. She hasremained well for the last twenty-five years.5.5. Use of the BibleThe Bible is for the Christian the authoritativeword of God and the source of all truth. Becauseit is considered sufficient to lead a person to salvationand as a guide to right living, it is usefulin helping the therapist transform the mind ofthe patient he is counseling. Almost all personshave a distorted image of God and themselves.One job of the Christian therapist is to help themsee who God really is and who they really are.Most persons view God as they view their father.Most of them appraise themselves as they havebeen appraised. Some have low self-esteem andfeel unworthy, whereas some are prideful withdistorted views of their actual worth. All personsneed to see God rightly. It is easy to correct theirdistorted view because God revealed himselfwhen he sent Jesus to live among us (John 14:9).Throughout the Bible, there are statementsof who a person is in Christ and how God seeshim. Neil Anderson, in his book Living Free inChrist ,( 36) has listed these so that they can seethemselves as God sees them. If they have a distortedimage of who they are, then praying thesescriptures will facilitate a change in their view ofwho they are and their security in God’s love.There are many other things the Bible doeswhen we read it. They include:1 It provides a correct image of God. He isrevealed to the believer.2 It makes him wise for salvation. Each stepof the plan of salvation has a scripturalreference.3 It speaks to the person’s security.4 It provides knowledge about meaning andpurpose for life.5 It speaks on how to deal with sin bya Urg ing c onfession.b Calling to repentance.c Providing the offer of forgiveness.d Instructing how to meet and mastertemptation.6 It c o n d e m n s s e l f i s h n e s s a n d t e a c h e sselflessness.7 It teaches how to maintain rightrelationships.8 It provides rules for a successful marriage.9 It speaks negatively about divorce.10 It provides directions for family life.

Psychotherapy from a Christian Perspective 29711 It teaches how to nurture children.12 It enunciates rules of sexual behavior.13 It enhances our self-esteem.14 It teaches how to avoid diseases.15 It teaches how to control greed.16 It teaches good dietary habits.17 It provides the basis for emotional healing.18 It provides real values.19 It defines real humility.In these and many other ways, the Bible teaches ahealthy way of living.5.6. WorshipThe purpose of worship is to bring us into anencounter with the living God. Having queriedmany who have left a church, I find that mostleave because they do not encounter God there.An alive church will foster such encounters. Peoplewill encounter God in the music, in prayer andscripture reading, occasionally in the proclamationof God’s Word, and especially in the witnessof other believers. All should encounter him in theEucharist.Encountering God will result in access to anew experience of the Holy Spirit. All need thisfrom time to time. God’s Spirit guides and revealsChrist to the person. With these encounters, theperson is spiritually renewed. The need for refillingby God is best stated by Dwight Moody. Hewas asked if he was filled with the Holy Spirit.His response was, “Of course I am, but I leak.”I doubt that anyone understands why thisoccurs, but it may be the same thing that istrue of all relationships. The need to be constantlyrenewed with regular encounters is trueof almost all intimate relationships, and thisis probably the reason for the need for repeatencounters with God.People encounter God in music. Music elicitsemotions. In worship, music will elicit theemotions of love and awe. The music that mostcommonly brings about an encounter is music inthe idiom of that culture. Karen Boring, an ethnomusicologistwith Wycliffe Bible Translators,said in one of their newsletters, “Music, althougha universal phenomenon is not a universal language.It carries cultural meaning.” I have seenAfrican natives respond to music expressed intheir heart language with behavioral evidence thatthey are encountering God. I agree with CharlesWesley that the devil should not have all the goodmusic.Prayer, whether solitary or corporate, canbring about an encounter with God. It is importantthat the prayer be of praise and not petition.When petitionary prayer is self-centered, itmay not have the intimacy that brings about anencounter. Because music is a form of prayer, itis easy to understand why nonmusical prayers ofpraise will also be stimulating.J. B. Phillips has commented that the purposeof the Eucharist is to provide a refilling with theHoly Spirit. Even so, it rarely elicits an encounter.The problem is not with the sacrament, but has todo with the celebrants. They do not understandits real meaning and the necessity of preparingfor the sacrament. Therefore, they come to thetable unworthily (1 Cor. 11:27, 28).5.7. Confession, Repentance,and ForgivenessThese three spiritual interventions usually gotogether, so they will be described in the order Ihave listed them. Most patients come to a therapistwith the expectation of confessing theirwrongdoing. They may not consider it as such,but they will still confess it. In the course of thehistory taking, they will reveal their most innerthoughts and describe past behavior and its consequencesin detail. In a like manner, they mayfeel that they deserve punishment to atone fortheir wrongdoing. This gives rise to the despairof morality. To alleviate their suffering, theymust repent, that is, they must realize that theyhave sinned against God (Ps. 51:4) and intend toamend their ways. They do, however, need to beforgiven. Forgiveness can only come from God(Luke 5:21). Fortunately, Jesus deputized his followersto pass on God’s forgiveness to repentantsinners (John 20:23). Thus, the therapist caneffectively forgive in the name of Jesus. Human

298 William P. Wilsonforgiveness does not have the effect of spiritualforgiveness. The following is a case that illustratesthe healing power of forgiveness.This patient was a Vietnam veteran who hadbeen regenerated early in life, but in time becauseof cultural influences became an alcoholic andaddicted to marijuana. He also, while stationed inKorea for a short time, got a woman pregnant butthen deserted her when sent to Vietnam. He hada wife and two children back in the United States.He was sent to Vietnam in a noncombat role. Intime he was issued a new rifle that he took witha friend to the rifle range to learn how to shootit. He was drinking a pint of whiskey a day andsmoking two to four joints of marijuana at thetime. On their way back, they stopped by theroadside to shoot at random targets. They sawan old man and woman approaching them. Hisfriend said, “Hey look, there’s a couple of targets.”With that, he fired two shots and killed themboth. The next day, he was a psychiatric casualty.Eventually, he was evacuated to Okinawa,Honolulu, San Francisco, and finally dischargedto a Veterans Administration (VA)hospital wherehe spent six months. Finally he was dischargedfrom the VA, essentially unchanged, and returnedhome, but soon he chose to move and work inour community. For eleven years he lived withhis guilt and shame. A month of treatment tenyears later did not help, and one year later duringa vacation he finally came back to our local VAhospital to find out if anything else could be donefor him. The resident felt he did not know whatto do. His supervisor then suggested he presenthim to me because I had done research on posttraumaticstress disorder (PTSD).When I interviewed the patient he admittedto his sins. I asked if he felt he could be forgiven.He said no. He said he had prayed that someonewould kill him to punish him for his sins.When reminded that he could commit suicidehe said, “No I deserve to be punished for whatI did.” I chose not to debate the issue with him,but instead dismissed him. I then discussed theexistential despair of morality and death that hesuffered from with the residents and medical studentswho were in attendance.After my teaching session, I told the residentthat I had unfinished business with the patient,and wanted to see him again. In the company ofthe resident and a medical student, I took himin an office and asked why he said he could notbe forgiven. He said that he had committed anunpardonable sin. I told him that it was onlyunpardonable if he attributed his murder of thetwo people to God. He responded, “No, I didit.” I then told him that if Jesus could forgive hismurderers as they were crucifying him, surely hecould be forgiven. Then I said, “In Jesus’ nameand by his power you are forgiven.” Big tears teeteredon his lower lids for a moment and thentrickled down his cheeks. With this he beganto sob and weep profusely. He spontaneouslyembraced me and laid his head on my chest saying,“Are you sure?” “Yes,” I replied. “The Biblesays that if we confess our sins he is faithful andjust to forgive us of our sins and cleanse us of allunrighteousness”(1 John 1:9). After he wept forat least ten minutes and thoroughly soaked myshirt with his tears, he asked me if there was anythingelse he needed to do. I told him he neededto rededicate his life to the Lord. He did and wastotally healed.5.8. ExhortationExhortation was commonly practiced in the earlychurch and is still considered a gift of the Spirit.Exhortation as a gift is the ability to help others toreach their full potential by means of encouraging,challenging, comforting, and guiding. Christiantherapists should remember that they are not tobe neutral when transforming minds. To achievethe change they have to positively exhort a patientbecause it is difficult to refute many misbeliefs.Exhortation (strong encouragement) was usefulin a woman with three children who consultedme because her husband was divorcing her. Heleft her to marry a much younger woman. Thisman was obsessed with building an estate, so hewanted to divorce her and not have to pay anyalimony or child support. The woman was verydepressed and hopeless so she wanted to agree tothe settlement that he proposed. This would have

Psychotherapy from a Christian Perspective 299cheated her out of everything she had helped toaccumulate. At the time, our state did not havea law requiring an equitable division of assets indivorces. There was a bill pending in the legislature,but it had not been passed. Feeling that whathe proposed was unjust, I exhorted her to refuseto agree until he relented. She did so, but it tookconstant exhortation because he did not relent. Intime, the equitable division bill passed in the legislature.Her lawyer then forced an equitable divisionand justice was done.5.9. DeliveranceAuthentic Christians have no difficulty in believingthat personified supernatural evil exists.Satan uses his demons to harass man. I havealready described his means, but it is well topoint out that unregenerate and even regeneratepersons can be demonized. Authentic Christiansdo, however, have to strongly believe that Satancan exploit to demonize them. The only way hisforces can be dealt with is deliverance. It is truethat Jesus deputized all of his disciples to cast outdemons. We have the same power today if we aremature Christians.A mature Christian can deliver a possessedindividual with a simple command to thedemon(s) to depart and be taken to Jesus fordisposition. If the person (the one commandingthe demon to leave) is not a mature Christian, heor she may be attacked as the sons of Sceva werein the Bible (Acts 19:14) when they tried to castout demons.In our culture, demon possession is rarelyseen, but in the third world demonization is muchmore common.5.10. The Holy Spirit and ChristianPsychotherapyTo a nonbeliever, the above discussion of theHoly Spirit and demons will probably seem quitebizarre. But we have to realize that when themind-brain problem is discussed, there are twoopposing views. There are those that believe thatthe mind exists above the brain, or that the mindand brain are one. The former is called dualistinteractionism, the latter monism. In his discussionof the supernatural, C. S. Lewis (37) said thatthe mind is supernatural. Wilder Penfield,(38)the neurosurgeon, Sir John Eccles,( 39) the neurophysiologist,and Karl Popper,( 40) the philosopher,subscribe to dualist interactionism. Thus,the work of the Holy Spirit and Satan is relevantto Christian psychotherapy because Christiansbelieve that there is a supernatural dimension toexistence and that it is inhabited by supernaturalbeings.It is unfortunate that the church has not givenmore importance to the transforming power ofthe Holy Spirit in the lives of believers. Instead,most churches have done everything they couldto quench the Holy Spirit and eradicate anyattention to its presence. This began in the thirdcentury when Montanus and Tertullian emphasizedthe work of the Holy Spirit. Admittedlysome of their beliefs were heretical, but the beliefin the presence of the Holy Spirit had truth andpersisted in their followers for centuries. Thecharismatic movement was present from timeto time in other isolated parts of the church, butrecurred with the Huguenots who were put to thesword by the French king because their beliefswere thought to be heretical. At approximatelythe same time, people were filled with the HolySpirit in the Wesleyan revivals, but they were notpersecuted.Jesus was emphatic about the role of the HolySprit in the life of the believer. On two occasionshe said that we would first be clothed (Luke24:49) and then filled (Acts 1:8) with power whenthe Holy Spirit came upon us. This happens withsalvation. We may not get a full measure of theHoly Spirit, but we get enough to bring aboutthe changes described by William James. Thereis more of course, and we can ask for a new measureof the Holy Spirit anytime we wish. Godoften responds.The fullness of the Holy Spirit is given whena person absolutely surrenders. Jesus demandedthat we be absolutely surrendered to him if wewere to be his followers (Luke 14:33). This did

300 William P. Wilsonnot mean that we were to give up just a fewthings. He said all! Then he told Peter that havinggiven up everything he would get it all back(Mark 10:29, 30). It is with absolute surrenderthat one gets filled with the Holy Spirit. Thisact adds to the power and increases fruits of theSpirit (Gal. 5:22,23). The fullness of the supernaturalpresence of the Holy Spirit installed in ourlives is the source of power and gifts that makesthe Christian therapist so effe c t ive.REFERENCES1. Islamic Psychology. http://islamic-world.net/psychology/psy.php?ArtID+174.Accessed November23, 2008.2. Karasu TB. Psychot her apies : an over v ie w . Am JPsychiatry . 1977; 134 :851–863.3. Fran k J. Persuasion and Healing: A ComparativeStudy of Psychotherapies . Baltimore : Johns HopkinsUniversity Press; 1971 .4. Karasu TB. Spiritual psychotherapy . Am JPsychotherapy . 1999; 53 :143–162.5. Twe e die DF. The Christian and the Couch: AnIntroduction to Christian Logotherapy . GrandRapids, MI : Baker; 1963 .6. C ol lins GR . Psychology and Theology: Prospects forIntegration . Nashville, TN : Abingdon; 1981 .7. Ad ams J. Competent to Counsel . Nutley, NJ :Presbyterian and Reformed ; 1971 .8. Minir t h FB. Christian Psychiatry . Old Tappan, NJ :F. H. Revell Co .; 1977 .9. Crabb e L. Basic Principles of Biblical Counseling .Grand Rapids, MI : Zondervan ; 1975 .10. Aerts DL , Apostel B , DeMoor , et al. Worldviewsfrom Fragmentation to Integration . Brussels : VUBPress; 1994 .11. Baier K. The concept of value. In: Lazlo E , WilburJ , eds. Value Theory in Art and Science. New York :Gordon and Breach; 1973 .12. Wilson WP. Man’s human nature. Unpublishedlecture, 1973.13. Skinner BF. About Behaviorism . New York : VintageBooks; 1976 .14. Harris TA. I’m OK You’re OK: A Practical Guideto Transactional Analysis . New York : Harper andRow; 1969 .15. Collins GR. The Christian Psychology of PaulTournier . Grand Rapids, MI : Baker Books; 1973 .16. Frankl V. What is meant by meaning? JExistentialism . 1966; 7 :21–28.17. Ryle JC. Practical Religion. Auburn, MA :Evangelical Press; 2001 .18. Kobasa SC , Maldi SR. Existential personalitytheory. In: Corsoini R , ed. Current PersonalityTheories . Ithaca, IL: Peracock; 1987 :243–276.19. McKay WM. The Disease and Remedy of Sin .London : Hodder and Stoughton; 1918 .20. Lewis CS. The Problem of Pain . New York : TheMacmillan Co .; 1948 .21. Spero M. Sin as neurosis and neurosis as sin, furtherimplications of a halachic metapsychology . JRelig Health . 1978; 17 :274–287.22. Wesley J. Primitive Physic . London : R. Hawes;1774 .23. Marias J. Metaphysical Anthropology . Lopes-Murillo M, trans. University Park, PA : PennsylvaniaState University Press; 1971 .24. Wilson WP. The Psychological Significance ofForgiveness, Unpublished Manuscript.25. Grubb N. Once Caught, No Escape. My life Story .London : Lutterworth Publishing; 1969 .26. Meltzof J, Kornriech M. Research in Psychotherapy .New York : Atherton Press; 1970 .27. Rogers C. Perceptual reorganization in clientcentered therapy. In: Blake R , Ramsey G , eds.Perception: An Approach to Personality . New York:Ronald Press; 1951 .28. Carlson DE. Jesus style of relating: the searchfor a biblical style of counseling . J Psychol Theol .1976; 4 :181–191.29. Barnhouse D. The Invisible War . Grand Rapids,MI : Zondervan ; 1965 :156.30. Nevius JL. Demon Possession . Grand Rapids, MI :Kregel Publications; 1968 .31. Beranlanffy V. General Systems Theory:Foundations, Development, Applications . NewYork : Braziller ; 1968 .32. Clark KM. The Other Half : A Self Portrait . London :J. Murray ; 1977 .33. Wilson WP. The Nuts and Bolts of Discipleship .Lima, OH : Fairway Press ; 2007 .34. Seamands D. Healing of Memories . Wheaton, IL :Victor Books; 1985.35. Mitton M , Parker R. Requiem Healing . London :Daybreak ; 1991 .36. Anderson N. Living Free in Christ . Ventura, CA :Regal Books ; 1991 .37. Lewis CS. Miracles . New York : The MacMillanCo .; 1947 : 10–16.38. Penfield W. The Mystery of the Mind . Princeton,NJ : Princeton University Press; 1975 .39. Eccles JC. The Human Psyche . New York : SpringerInternational; 1980 .40. Popper K. Knowledge and the Mind Body Problem .New York : Routledge; 1994 .

20 Psychiatric Treatments Involving Religion: Psychotherapyfrom an Islamic PerspectiveSASAN VASEGHSUMMARYReligious thoughts and behaviors can play animportant role in the relief or exacerbation ofpsychopathologic symptoms in Muslim patients;therefore, every successful psychotherapist needsto be familiar with Muslim culture in his or hercountry. Furthermore, some clinical trials showthat adding religious psychotherapy to the usualsecular therapy can accelerate clinical improvementin religious Muslim patients. In this chapter,I will (a) provide a short description of thebasic tenets of Islam, (b) describe importantpoints in initial assessment of Muslim clients,addressing transference and countertransferenceissues, and (c) discuss several Islamic conceptsuseful in treatment of depression, anxiety,and interpersonal problems in Muslim clients.Clinical examples are also provided to show howthese concepts can be used in psychotherapeuticsettings.Defining psychotherapy is difficult(pp. 6–7). (1) Although there are many kinds ofpsychotherapy (2) and many differences betweenthem, it seems that all of them have at least onecommon goal: decreasing clients’ overall suffering.Each client coming to a psychotherapeuticsession has some problems, that is, some issuesthat cause (usually serious) negative feelingssuch as depression, anxiety, or anger. The morea psychotherapist succeeds in helping the patientovercome these negative feelings and preventtheir recurrence, the more successful is his or herpsychotherapy.There are about 1.2 billion Muslims in theworld and Islam is the second largest religionin Europe and anticipated soon to be the secondlargest religion in the United States. (3)Whether psychotherapists are Muslim or not,if they are to help their clients, they need to befamiliar with Muslim clients. If not, they maytry to apply unmodified Western theories of psychologyand psychotherapy and apply their ownstereotypes of Muslims to Muslim clients, whichcan cause therapeutic failure and frustration (p.ix). (4) Moreover, unfamiliarity with Muslimculture can cause serious diagnostic errors. Forexample, some Muslim patients may fear invisiblecreatures called Jinns, and this fear couldbe falsely diagnosed as psychosis by inexperiencedclinicians. (5) Also, the collectivist natureof Muslim culture may be interpreted as “dependentpersonality disorder” (p. 73) (4) and Muslimwomen’s hair coverings as a sign of their oppression.(6) Attempts to free Muslim clients fromthis perceived dependency or oppression maycause them to feel misunderstood and may causethem to drop out of therapy.Muslims come to psychotherapy for variousproblems, including anxiety and depressive disordersor family and cultural problems. In addition,after the September 11 terrorist attacks,many Muslims in Western countries sufferedincreased social pressures such as physical orverbal attacks and discrimination (7) and experiencedadjustment problems.There is no single, best type of psychotherapyfor all Muslim patients, and many of themneed an eclectic approach. Although theoreticallyall kinds of psychotherapy can be used withMuslims, cognitive and behavioral interventions301

302 Sasan Vaseghseem to be more suitable for most Muslim patients(p. 100). (4) Psychoanalysis or insight-orientedpsychotherapies have sometimes been regardedas counterproductive in Muslim clients, leading topremature dropouts or worsening of the patient’scondition. (6) Indeed, cognitive- behavioraltherapy is also the psychotherapy with the mostempirical evidence. (8)Is Islamic psychotherapy really effective?Unfortunately, there are only a few studies inthis regard. These show that Islamic-orientedcognitive-behavioral psychotherapy, when addedto the usual secular therapy, leads to significantlyfaster recovery in anxious or depressed Muslimpatients. (9–11) But to use Islamic concepts in thetreatment of Muslim patients, the therapist needssome expertise in Islam, and most clinicians arenot experts in Islam. The way to partially overcomethis problem is to be aware of this lack ofknowledge and seek more information regardingthe patient’s religious and ethnic backgroundfrom trusted sources. There are case reportsthat show this approach can be very helpful. Forexample, Ali et al. (12) report an interesting casein which a non-Muslim male counselor couldeffectively help a young Muslim female clientonly after using this approach (see below).The goal of this chapter is to suggest importantclinical points and psychotherapeutic techniqueshelpful in therapy with Muslim clients.Both Islamic teachings and psychotherapy areso extensive that it is impossible to fully describethem in this chapter; therefore, I will begin with ashort introduction to Islam basics and then I willbriefly describe several Islamic techniques usefulin problems common to Muslim patients.1. ISLAM BASICSIslam literally means submission , that is, submissionto the word of God. Muslims believethat all previous prophets, such as Jesus, Moses,Noah, Abraham, and others, were Muslims, forthey really obeyed God (who Muslims referto as Allah). According to the Koran (Islam’sholy book), the Prophet Muhammad is the lastprophet, and the only religion acceptable to Godis Islam.The pillars of Islam are five fundamental beliefsor behaviors that are shared by almost all Muslimgroups. These are Shahadat (the profession thatthere is no God but Allah, and Muhammad ishis Prophet), Siyam or Sawm (fasting in the holymonth of Ramadan), Salat (Islamic five-timedaily prayers), Zakat (a tax providing financialhelp to the poor), and Haj (a pilgrimage toMecca) (p. 16). (4) The first pillar is the mostimportant and is enough for one to be regardedas a Muslim, that is, one need only acknowledgethat he or she believes there is no god butAllah, and that Muhammad is Allah’s messenger.Because Islam’s official language is Arabic, thesetwo acknowledgments usually are said in Arabicand are referred to as “shahadatain ,” that means,“the two acknowledgments.”Just as some Christians apply their knowledgeof Jesus’s life and try to model their behaviorafter his, (13) religious Muslims try to followthe Prophet Muhammad. So the ProphetMuhammad’s Sunnah (meaning his sayings anddeeds) is one of the main sources of Islamic laws.The other source is the Koran, the holy book ofthe Muslims. The Koran is believed to be God’swords revealed to the Prophet Muhammad bythe angel Gabriel. Only ten years after the foundationof Islam in 610 AD, it became acceptedby most people in the Arabian Peninsula in spiteof strong opposition. The Koran was one of themost important factors in the fast spread of Islambecause it sounded so beautiful that many Arabsaccepted Islam after hearing only a few versesfrom it. Indeed, Koranic verses were so effectivethat when some of the early Muslims immigratedto Abyssinia (present-day Ethiopia) and recitedverses from the Koran about the Blessed VirginMary in front of the Abyssinian king and hisChristian clerics, the latter were highly impressedand began to weep (p. 181). (14) In addition, Islamannounced equality and brotherhood for all peopleand prohibited violent acts such as buryingtheir daughters alive and torturing slaves, thusmaking it more attractive.

Psychotherapy from an Islamic Perspective 303Islamic rules are very extensive and coverall aspects of a Muslim’s life: marriage, education,private and group worship, politics, eating,drinking, clothing, and so on. Some rules aremandatory, and others are recommended. Forexample, it is mandatory for a Muslim to pray thefive Islamic daily prayers and to avoid consumingalcohol, but it is recommended that a Muslimmarry, pray night prayers, and not sleep or eattoo much. People usually depend on Islamic clericsto learn about their religious duties.Islamic laws are remarkably flexible. Forexample, although consuming alcohol is strictlyforbidden, if a trusted physician prescribes it asnecessary to treat an important disease, it can betemporarily consumed. Or if a Muslim cannot doIslamic daily prayers in the usual standing position,she or he can do them while sitting or evenlying down in bed. This flexibility is inferred fromthe two sources of Islamic laws: the Koran andthe Sunnah. During his life, Prophet Muhammadhad many situations in which his deeds and sayingsindicated his flexibility. Some sayings of theProphet Muhammad and verses of the Koranmay seem inconsistent on a particular subject,for example, women’s rights and the rights ofparents and children. These Koranic verses anddeeds of the Prophet may be interpreted differentlyby Islamic clerics. Usually, Islamic clericswithin each Islamic division infer similar rulesand orders regarding basic Islamic elements; soIslamic divisions have many similarities (in basicelements). They also, however, have differences(usually in details). For example, all religiousMuslims believe in the five Islamic prayers, butsome parts of the prayers differ between Islamicdivisions. Usually the more they deviate from thebasic rules, the more controversial they will be,even in a particular division. For example, theremay be different attitudes toward details of parenting,women working , acceptable relationshipswith God, and forgiveness in a given Islamicdivision. This flexibility plays an important rolein psychotherapy with Muslim patients, becausemost seemingly rigid issues causing psychologicaldistress are really in fact flexible.Th ere are two main Islamic branches: Shia(about 15 percent) and Sunni (about 85 percent).(3) Shias predominate in Iran and Iraq.Although describing the similarities and differencesbetween Shias and Sunnis is beyondthe scope of this chapter, some points deservebrief description. The most important differencebetween Shias and Sunnis is that most Shiasbelieve in twelve Imams (religious leaders) afterthe Prophet Muhammad and believe that theirdeeds and sayings (Sunnah) are the continuityof the Prophet’s Sunnah and must be used as aroot for Islamic inference. This belief is similarto what Christians believe about Jesus’s Apostles.These Imams begin with Imam Ali (cousin of theProphet Muhammad) and end with Imam Mahdi(born 869 AD), who is believed to be still aliveand will come someday in the future to save theworld from oppression. Interestingly, they believethat Jesus Christ will return and will be one ofhis special aides. So in addition to the ProphetMuhammad’s Sunnah, Shias have many yearsof Shia Imams’ Sunnah and volumes of booksof their sayings and prayers that can be used inpsychotherapy.Many nonfunctional thoughts and behaviorsof Muslim patients are rooted in their culture andnot in their religion. However, they may thinkthat these thoughts and actions are religiouslyjustified (15) and may use them to resist change.Furthermore, despite many adaptive thoughtsand behaviors in Islamic sources, a Muslim clientmay not be aware of or pay enough attentionto them. If a psychotherapist can use his or herknowledge of Islam to show this to the Muslimclient, adaptive changes may be more easilybrought about.But what can non-Muslim therapists who arenot experienced with Islam do? As some casesshow, (12) if non-Muslim therapists becomeaware of their lack of knowledge, respect thepatient’s culture and religion, and seek informationfrom trusted sources, they may effectivelyhelp these clients. Indeed, some Muslim clientswith religious conflicts may prefer non-Muslimtherapists. (12)

304 Sasan VaseghIn the following sections, I will describe someIslamic concepts useful in psychotherapy forcommon problems in Muslim patients. It shouldbe noted that effectively using the Islamic conceptsin psychotherapy also depends very muchon the psychotherapist’s own characteristicsand experience with psychotherapy. Like othercognitive and behavioral approaches, specificreligious concepts are better used indirectlythrough Socratic questioning and guided discovery(pp. 43–86) (16) to help the clients changemore effectively toward more functional cognitionsand behaviors.2. COMMON FACTORS AND INITIALASSESSMENTSurprisingly, despite wide theoretical differencesbetween various psychotherapeuticapproaches, some meta-analyses have shownall of them are more or less effective. (8) Thisresearch emphasizes the importance of the socalled“common factors,” that is, factors suchas warm and positive involvement with thepatient, instillation of hope, and offering newperspectives to the patient’s problems. Someof these factors and other first session issuesrelevant to Muslim patients are described hereunder broad concepts of “countertransference”and “transference.”2.1. Countertransference and Therapist’sMisunderstandingsBecause Muslims are minorities in most Westerncountries, they are usually stereotyped.( 7 , 12 ) Afterthe terrorist attacks of September 11 and negativemedia attention, misunderstandings have becomemore common and may unconsciously affect thetherapist’s feelings toward Muslim patients.Th ere are many differences between Islamicculture and individualistic Western culture.Muslims often live in extended families andbelieve they must respect and obey their parentsunless their orders oppose God’s orders(Holy Koran 31:15). Muslim people usually areinvolved with and are ready to provide helpto other family members. Islam has differentlaws regarding some rights and duties of menand women. For example, according to Islam,a Muslim man must provide for almost all ofhis wife’s needs, but a Muslim woman does nothave to work at home or outside to compensate.Although Muslim women must cover theirbodies or hair in front of strange men, recommendationsfor Muslim men’s clothes are muchmore lax. These rules have been interpreted byIslamic clerics as measures to strengthen familylove and ties and to prevent sexual immoralityof both men and women. (17) The non-Muslimtherapist facing these differences may automaticallyassume that the Western culture is alwaysmore adaptive to the patient, an assumptionthat is not supported by empirical evidence(pp. 26–28). (4) Many Muslim women are successfulat work and in their family and do notwant to change their culture. Assuming thatMuslim women should be saved from their“oppressor” culture, religion, or husband ignorestheir interest in their family and religious/cultural background and may cause them tofeel misunderstood and to leave the therapy.On the contrary, some Middle Eastern womenbelieve that Euro-American women workingboth inside and outside the home are greatlyoppressed and that Euro-American men are notaccountable enough for their families. (18)Even if a Muslim client accepts the therapist’spoint of view, this may result in severe interpersonalconflicts and may end in a more disturbedand distressed patient. Therefore, although forsome patients it may be better to modify someof their cultural or religious attitudes, if theyshow resistance to such modification, therapistscan cautiously offer the pros and cons ofthese changes and then let patients decide forthemselves. (12)2.1.1. Female Muslim ClientWhen a Muslim woman consults a non-Muslimmale therapist, some areas may cause misunderstandingbecause Islam affects all aspects ofa Muslim woman’s daily life. (19) For instance,Islam discourages men and women from

Psychotherapy from an Islamic Perspective 305looking at the bodies of persons of the oppositesex (except one’s spouse), supposedly toprevent sexual immorality and marital damage.Looking at the face is a lesser matter, althougheven this may be discouraged in many Islamicreligious societies. Islam encourages sexualrelationships between wife and husband,but prohibits any sexual relationships outsidethis boundary. In addition, in many religiousMuslim families, women and men have more orless separate social groups. For example, whenthey attend a family party, most conversationsoccur within each sex group, and many partiesmay be exclusively for men or for women.Also, many Muslim women do not work outsidethe home and have little contact withstrange men. All of these factors may cause theMuslim female patient to have less than usualeye contact with her male therapist, which cancause negative attitudes in the therapist or maybe interpreted by him as a sign of depression,avoidant personality, or lying.Islam also prohibits any bodily contact betweennon-relative opposite sexes. For example, aMuslim man is allowed to shake hands with hiswife or sister but not with his female cousin orteacher. In a case described by Ali et al., (12) themale counselor visiting Mona (a Muslim Arabgirl) for the first time wanted to greet her byshaking hands with her, but this approach causeddistrust in Mona and turned out to be his firstmistake. Nevertheless, he was eventually able tohelp Mona after he showed more interest in herMuslim culture and after Mona felt that he wasnot going to rescue her from “her religion that isoppressive to women.”When a Muslim family immigrates to aWestern country, the man often comes first and,after a period of stressful anticipation and preparation,other family members follow. Even if theyimmigrate together, men usually work outsideand women at home. Therefore many immigrantMuslim women are not fluent in English andmay bring a relative or child as a translator.This may also be interpreted as excessivedependency and create negative feelings in thetherapist.2.2. TransferencePhysicians are highly valued in Islamic culture.In addition, consultation with a physician ortherapist is generally favored and recommendedto Muslims and even to the Prophet Muhammadin the Koran (Holy Koran 3:159 and 42:38).These recommendations can be used to facilitatethe development of a working alliance withMuslim patients. However, Muslim clients mayhave negative stereotypes about Western cultureand Western therapists resulting from their feelingof oppression by Western politicians and mayuse terms such as you (Westerns or Americans)and we (Muslims or Arabs) (p. 23). (4) Therapistsshould not take these statements personally butrather should help the clients think less categorically.For example, the therapist may say to thepatient, “I understand you! I know some Westernpolicies may have hurt you. But … may you havenegative feelings toward me because I am alsoa Westerner? Because this negative feeling mayadversely affect the success of our sessions, can Ido anything to make you feel easier with me?”Muslim clients in Western countries are underpressure of the dominant Western culture, so theymay also feel shame and inferiority and fear punishmentfrom the Western therapist. By adoptinga sensitive and warm attitude, the therapist mayhelp decrease these negative feelings.2.2.1. Warm GreetingsWhen meeting a Muslim for the first time,warm greetings usually help to establish a morepositive transference. In many Muslim cultures,standing up from a sitting position when someonearrives implies respect for him or her andis encouraged. Shaking hands with the samegenderclient is also helpful.2.2.2. Admiring Strong PointsAt the end of the first session, we should havedetermined and negotiated the therapeutic goalswith the client, and the client should have gainedenough hope and developed a good enough transferenceto continue therapy. This good impressionalso usually needs to be impressed upon the client’s

306 Sasan Vaseghfamily because the client may be dependent onthem to come to psychotherapy. One importanttool to instill hope and a good transference in theclient or her family is to admire and encouragethem and reinforce their positive characteristicsand strong points. For example, the therapist cansay to the client’s husband, “Supporting your wifeto come to psychotherapy shows that you feelresponsible and love your family, because it maynot be easy nowadays to come to a psychiatrist orpsychotherapist.” Dwairy (pp. 116–117) (4) hasdescribed that this approach helped his clientsremain in therapy and receive effective help. Ifthe client feels positive toward his or her religionor culture, admiring and showing respect forthe religion/culture is another important way tocreate a positive transference.2.2.3. Admitting to One’s Lack of KnowledgeAdmitting to one’s lack of knowledge aboutthe patient’s culture or religion is another wayto establish a positive therapeutic alliance. Thiscan decrease the client’s inferiority feelings andencourage more open communication. The followingstatements indicate a non-Muslim psychotherapist’ssincerity and respect toward aMuslim client: “Because I am not a Muslim, myknowledge about Muslims’ practices and beliefsis limited and there may be some misunderstandings.I would be glad if you would let me knowshould I make a mistake regarding your cultureor religion.”2.2.4. Paying Attention to Negativeor Positive CuesEven when we try our best to help our clients,there may be some misunderstandings(pp. 31–41) (15) ; therefore, it is important to besensitive to the clients’ verbal and nonverbalcues. If a negative cue appears, help the patientto clarify it. Say, “You seem somewhat troubled.Was there anything in what I said or behavedthat caused a negative feeling in you? Could youplease explain your thoughts?” In addition, at theend of each session, it may be appropriate to askabout the client’s feelings and thoughts about thesession.2.2.5. Predicting and Anticipating ReactionsSome Arabs or Eastern Muslims may have difficultyspeaking about intimate or sexual subjectsto therapists of the opposite sex. They may alsoexpect the therapist to offer them direct advice andmay expect the number of therapeutic sessions tobe quite limited. If given homework or tests, theymay think that this is childish. Anticipating suchthoughts, feelings, or behaviors in the course ofthe therapy is another effective way of increasingclients’ compliance and preventing them fromdropping out. For example, the therapist may say,“Some clients may feel that doing homework ischildish. The exercises may sometimes seem useless.How do you think we should handle thesethoughts should they occur?” Or the therapistcould say, “You said you had marital problems forabout five years. How would you feel if I told youthat it may take up to six months to control theseproblems? Does this seem too long to you?” Suchquestions can help clients anticipate their ownreactions and manage them better.2.2.6. Similarities and DifferencesAll Muslims are not the same. Although thereare many similarities, these shouldn’t blind usto the differences. One difference is related toMuslims’ countries of origin. Usually the longer aMuslim has lived in a specific country or region,the more similar are his or her attitudes to theculture of that country. For example, ChristianArabs are culturally very similar to MuslimArabs (p. 5), (4) but when they immigrate toWestern countries, both gradually move towardthe Western culture. Yet Arabs account for only20 percent of all Muslims (3) and other Muslimsmay differ culturally from Arabs.Another important dimension is their religiosity.Muslims differ in their acceptance of variousIslamic beliefs and practices and in the degree ofthis acceptance. So before using religion-relatedtechniques in therapy, we should first take areligious history. (20) If the patient agrees, thetherapist should also obtain information fromother significant family members because thismay yield a very different picture of the patient’sproblem.

Psychotherapy from an Islamic Perspective 3072.3. Two Important Questions BeforeUsing Religious TechniquesTwo important questions must first be answeredbefore using religious techniques in therapy. First,“Are religious conflicts important as part of theclient’s problems?” For example, if religious guiltplays an important part in the client’s depressionor anxiety, the therapist should take time to helpthe client resolve her or his religious guilt; but ifthe problem is a specific phobia, religious techniquesmay be less helpful to the patient.The second and more important question is,“How much is a religious technique really meaningfulto the client?” For example, if a Muslimclient has negative attitudes toward religiousscriptures or Islamic daily prayers, trying to usethem in therapy may cause negative feelings andresistance, while the same client may have privateprayers and nonritualistic relationships withGod that may be more effectively used in therapy.Therefore, in addition to taking a religious historyat the first session, it may be necessary tocollect more information about the client’s attitudestoward specific religious techniques beforeusing them.Depression, anxiety, and various interpersonalconflicts are among the most common problemsseen in Muslim clients, so I will briefly explainIslamic concepts useful in each of these problems.Reyshahri (1992) (21) has summarized andclassified thousands of sayings of the ProphetMuhammad and Shia Imams using many Sunniand Shia books as references in his ten-volumeArabic book میزان الحکمة (balance of wisdom).My Hadiths quotations will be from this book.Related verses from the Holy Koran will alsobe provided, along with clinical examples oftechniques.3. ISLAMIC CONCEPTS USEFUL INPSYCHOTHERAPY OF DEPRESSION3.1. Believing in an AfterlifeAccording to cognitive theory, thoughts concerningan important loss cause sadness. (22)Examples of these thoughts are: “I wish mywife was still alive!” or “It is terrible that I havediabetes!” Every time clients attribute muchimportance to an unattainable object, they feelsad. Many Muslim patients cope with these unattainablewishes or inevitable losses by believingin an afterlife where life will be much better.Believing in an afterlife, along with believing inone omnipotent God and the prophetic missionof Prophet Muhammad, is one of the fundamentalbeliefs of Islam. Afterlife issues are recurrentlyrepeated in the Holy Koran, and almostall Muslims believe in some kind of reward andpunishment after death, although the interpretationsmay vary. Some accept the Koranic versesabout afterlife reward or punishment literally,while others may believe that these verses havemore symbolic meanings.According to the Koran and Sunnah, afterliferewards are not only considered for Muslims’good deeds, but also for their good intentionsor wishes and even for sufferings from problemssuch as poverty or death of loved ones,provided that these sufferings are not causedvoluntarily or unduly by Muslims themselves.So there are many circumstances in which thesereligious beliefs can be used to lessen clients’sufferings.3.1.1. PovertyOne example of a situation where believingin an afterlife and stating the Prophet’s sunnahcan be used to decrease the patient’s suffering ispoverty or monetary need. Although poverty isnot regarded as good by itself in Islam (7:495), (19)showing patience when in this state and trying toovercome poverty by honest work are seriouslyencouraged. In addition, great afterlife rewardshave been promised to poor believers who cannotafford things that they wish. One examplefrom Prophet Muhammad Sunnah is: “Somepoor Muslims said to Prophet Muhammad thatsometimes they saw fruits in the bazaar and likedto buy them but hadn’t any money, and askedhim if this would result in afterlife reward forthem. The Prophet said: ‘Isn’t the reward exactlyfor these things?’ ” (7:521). (19) The Holy Koran

308 Sasan Vaseghrecommends the Prophet Muhammad to supportthe religious poor Muslims and to not rejectthem and turn toward the wealthy (Holy Koran18:28). The Prophet himself loved the poor, andmany famous Muslims were poor at some timeduring their lives. These statements show thatGod and his Prophet love poor Muslims whopatiently endure, so the psychotherapist may usethem to increase patients’ self esteem.3.1.2. Death of a BelovedAnother important example of loss is the deathof one’s beloved. For instance, great rewards arepromised to parents suffering loss of children,and it is stated that the lost children will protecttheir parents against hellfire. (7) Interestingly,positive concepts are also found in Christianityregarding the death of a child. (13)3.1.3. Diseases and DisabilitiesShowing patience when suffering diseasesand disabilities is also rewarded in the afterlifeaccording to Islamic teachings. Because havingpatience is not an all-or-nothing phenomenon,all patients have some patience and thereforedeserve afterlife rewards, and this reappraisalcan lessen their suffering. In addition, sufferingfrom disease is believed to atone for sins(9:122–126). (19)3.1.4. Reward for Daily Usual ActivitiesEven many daily and usual activities are inIslam regarded as good and deserving of greatafterlife rewards. Examples are greeting eachother, helping parents, helping one’s spouse, havinggood intentions (even when not able to practicethem), having sexual relationships with one’slegal partner, and so on. According to the HolyKoran, reward of each good deed is ten times thepunishment of a bad deed. “Whoever does a righteouswork receives the reward for ten, and theone who commits a sin is punished for only oneand no one suffers injustice” (Holy Koran 6:160).When patients’ attention is drawn to these rules,many of them feel better and can better toleratetheir losses.3.2. Prayer and Asking GodAsking from God is usually a central part ofprayers, although prayers have other purposestoo. (23) Many religious people turn toward Godwhen disturbed, and ask him to relieve theirdistress. Theoretically, asking God and sayingprayers can have different consequences. If theprayer is perceived as granted, it can increase theperson’s faith and optimism. If the prayer is perceivedas rejected (for example, when the problemcontinues or worsens), it can lead to negativethoughts that in turn lead to feelings of guilt andhopelessness.Asking from God is seriously encouraged inIslam. The Holy Koran says, “And your Lord says,Pray unto ME; I will answer your prayer” (HolyKoran 40:60) and “Say: My Lord would not carefor you were it not for your prayer” (Holy Koran25: 77).There are many points and recommendationsin Islamic scriptures regarding various aspects ofthe prayers, (3:243–281), (19) but two interestingpoints especially are useful in psychotherapy:1) All prayers have effect.Among other similar Hadiths, it isquoted from the Prophet Muhammadthat, “No Muslim does pray to the eminentAllah, provided that he does not prayagainst his family or for a sin, unless theeminent Allah will give him one of thesethree things: expedites what he prays for,or reserves it in the afterlife for him, or willremove an equivalent trouble from him”(3:279). (19)2) We may pray against ourselves!It is stated in the Holy Koran, “But youmay dislike something which is good foryou, and you may like something which isbad for you. God knows while you do notknow” (Holy Koran 2:216).Although sins are considered as obstaclesfor prayers to be complied with, the forementionedpoints provide useful alternative

Psychotherapy from an Islamic Perspective 309interpretations that, if used appropriately intherapy, can prevent excessive guilt feelingand hopelessness in the troubled client.3.3. Guilt FeelingGuilt, like other negative feelings, is naturaland sometimes helpful. For example, peoplewith antisocial personality disorder have minimalguilt, insufficient to prevent their violenceagainst their victims. Excessive guilt feeling, onthe other hand, is one of the most importantcognitive components of depression. Accordingto Beck’s theory, depressed people have prominentnegative interpretations regarding themselves,their environment, and their future. (20)Guilt is part of negative self-esteem in depressedpatients and may lead to hopelessness, self-destructivebehavior, anxiety, and fear of punishmentin this world and the afterlife. Depressedreligious clients may selectively focus on God’spunishments and thereby enhance their guiltfeelings. Thus, drawing attention toward the followinghopeful scriptures showing God’s mercycan help them.3.3.1. There Is No One Who Does Not Sin“There is no one who does not sin” is a commonpositive concept between Christianity (Kings8:46) and Islam against the negative thoughtin religious depressed patients, which may beexpressed in words something like, “I have sinnedso much, so I am bad.” Shia and Sunni Muslimsboth believe that all people are needful of God’sforgiveness and mercy (Holy Koran 35:15), andall people (except the twelve Imams, the ProphetMuhammad, and his daughter Fatimah in Shiabelief) may sin. So sinning does not mean thatone is totally bad.3.3.2. Mercy and Benefi cence of GodDrawing clients’ attention to many versesfrom the Koran that help them realize the greatmercy and beneficence of God is another wayto decrease guilt feeling. For example, of the114 sections (Suras) of the Koran, 113 startwith “In the name of Allah, the beneficent, themerciful.” Other examples of God’s mercy fromthe Koran are, “O my servants who have actedextravagantly against their own souls! Do notdespair of the mercy of Allah; surely Allah forgivesthe sins altogether; surely He is the Forgiving theMerciful” (Holy Koran 39: 53); and, “Surely Allahdoes not forgive that anything be worshiped withHim, but forgives what is besides that to whomsoeverHe pleases” (Holy Koran 4:48, 116).3.3.3. Number of Good and Bad DeedsAnother way to decrease guilt is to countnumber of good and bad deeds that one has doneduring his or her life. As mentioned above, manyordinary activities are regarded as good in Islam,so the client’s good doings usually greatly outnumberthe sins, leading to decreased guilt.3.3.4. Thoughts Are Not PunishedSometimes guilt is related to blasphemous orshameful thoughts. Usually, the more patients tryto control these thoughts, the more they becomeintrusive and obsessive. According to ProphetMuhammad sayings, people are not punishedbecause of their thoughts, provided that they notput them into action. Sometimes religious obsessionalthoughts are regarded as a sign of strongfaith (10:448–450). (19)3.3.5. Feelings Are Not SinsSome religious clients have guilt related totheir inability to control their negative thoughtsand associated feelings. For example, they mayfeel guilt because they cannot accept their fate ortheir loss of dear ones, and therefore feel sad. (7)Mehraby has used the Prophet MuhammadSunnah successfully with these patients. (7) Shesaid to these patients that the Prophet Muhammadcried publicly on several occasions for the lossof his dear ones, without feeling guilt. He criedover the death of his mother, his son, and hiswife Khadijah. Khadijah was very helpful to theProphet and the Prophet loved her so much thateven several years after her death, he cried everytime he remembered her. Also it is quoted fromhim while burying his little son Ibrahim, “The

310 Sasan Vasegheye weeps and the heart is sad, but I do not sayanything that angers God” (p. 360). (13)3.3.6. Physicians’ Credit in IslamSometimes guilt is the result of a sin that theclients cannot quit. Such excessive guilt can causehopelessness and decreased self-esteem, resultingin even more repeating of that sin. One way todecrease this guilt is to use the physicians’ creditin Islam. One Islamic rule is that if a trusted physicianrecommends a basically prohibited actionto treat an important disease, doing that action isnot regarded a sin anymore and even may becomemandatory. For instance, breaking one’s fasting atRamadan holy month is not regarded a sin if itis prescribed by a trusted physician as necessaryfor a patient’s health. Similarly, some Muslimpatients feel excessive guilt and are severely anxiousor depressed because of doing masturbation.If a trusted physician considers this to be animportant element in a patient’s severe anxiety ordepression and recommends that he or she occasionallyperform masturbation to decrease his orher tension, this act is not regarded a sin anymoreand can sometimes be done.3.4. Hopelessness and SuicideSuicide is regarded as an unforgivable great sinby almost all Muslims. (24) It is unforgivablebecause one has no time to repent from and compensatefor it, for repentance is only allowed untildeath. In an aggregate study involving seventynations (1989), it was found that after controllingfor a large number of socioeconomic variables,the percentage of Muslims in the populationwas negatively correlated with suicide rates. (22)Considering suicide a great sin may be the onlyfactor preventing some Muslim patients fromcommitting suicide, so it should be encouragedin these patients.Losing one’s hope in God’s mercy too isregarded as one of the worst sins in Islam (HolyKoran 12:87). Some patients think of suicidebecause they feel hopeless, and consideringhopelessness a great sin may aggravate their guiltand hopelessness. The following example showshow to use Socratic questioning to decrease thisguilt feeling.Patient (crying): I am completely hopeless. Noone can help me. I know hopelessness is a greatsin so I have lost both my life and afterlife.Therapist (sympathetically): Certainly this feelinghurts you so much. It is a very unpleasantfeeling. How many sessions have you come totherapy by now?Patient: About eight sessions.Therapist: Are you going to continue yoursessions?Patient: I think yes.Therapist: You have patiently come to eight sessions,and you want to continue. Do you thinkthis could be a sign that you hope that thesesessions may be helpful?Patient (stops crying): Yes. Actually if I thoughtthese sessions were useless, I never wouldhave attended them.Therapist: That is definitely true. So, can we saythat you have not lost your hope, but you havebeen bravely fighting hopelessness by continuingyour sessions?Patient (after a pause): I don’t know. I neverthought of it that way before.Therapist: If someone like you fights against agreat sin, doesn’t she deserve God’s rewardand great mercy in spite of punishment, aspromised in Koran?Patient: Maybe that is true. Yes, I have not lost allof my hope.3.5. Saints as ExamplesProphet Muhammad himself, all Shia Imams,and other significant Muslims suffered a greatdeal in their lives. They tolerated many kinds ofeconomic and social pressures and physical tortures.(25) Some of them were martyred and othersremained, both fates being regarded as victories inIslamic culture. This can be used in psychotherapy,because when religious Muslims compare theirdifficulties with those of the Prophet Muhammadand significant Muslims, they usually feel somewhatrelieved. One Iranian woman who had lost

Psychotherapy from an Islamic Perspective 311her children in the Bam earthquake (2003) saidon Iranian television, “My sufferings never reachZaynab’s sufferings, so I’ll try to be patient.” Zaynabwas Imam Hussein’s (the third Shia Imam) sister.Her brothers, her sons, and many of her familymembers were martyred in front of her eyes duringtheir unequal battle against thousands of theenemy, and she was taken captive, but she bravelytolerated it and even fearlessly lectured against theenemy sovereign.3.6. God’s Wisdom and LoveWhen a problem occurs, several kinds ofthoughts may come into a religious person’smind, for example, “This is a punishment fromGod because of my sins” or “It is a trial for me tobe revealed whether I will be patient or not” or“It can be a prevention from more serious problemsin the future” or “God loves me and wantsme to have a better afterlife and to forgive mysins.” None of the above sentences can be provenlogically, but those who see preferentially God’swisdom and love through a problem (the lasttwo thoughts) may better tolerate it. The secondsentence can increase self-esteem should the clientsee herself as tolerant, but if she feels that shecould not pass the trial, it can lessen self-esteemand worsen her guilt feeling.Many verses of the Koran imply God’s love forseveral kinds of people, for example, “the beneficentpeople” (Holy Koran 2:195), “those whorepent and want to purify themselves” (HolyKoran 2:222), “the pious” (Holy Koran 3:76), “theequitable” (Holy Koran 5:42), and others. Becausethese characteristics are not all or none, almostall clients can be helped by showing that they aresignificantly “good” and deserve God’s love.3.7. LonelinessFeeling alone often worsens sadness. According toKoran, God is always with us. For example, Godsays to Moses and Aaron, “Fear not, surely I amwith you both, hearing and seeing” (Holy Koran20:46). Another verse promises, “He is with youeverywhere you may be, and Allah is seer of whatyou do” (Holy Koran 57:4). Therefore, repeatingthese phrases and strengthening this beliefthrough praying and talking with God can helpreligious people.3.8. “Thanks to God!”According to the Holy Koran, “If you wouldcount the graces of Allah, never could you beable to count them. Truly! Allah is Oft-Forgiving,Most Merciful” (Holy Koran 16:18). Some religiouspeople use this belief to emotionally copewith the problems (losses). For example, if theyhave a car accident, they may think, “Thanksto God, we are still healthy and can recoverfrom it.” Even when they are injured, they say,“Thank God, it could be worse, someone couldbe killed”; and if someone has been killed, “Itcould be worse. Thank God that most of us arestill alive!”Even when there is a disaster, cautiously pointingto many important things that one still hasthrough Socratic questioning can instill hopein and love for one’s God and decrease religiousconflicts. Sometimes, however, increasingthe clients’ awareness of God’s blessingsinvokes guilt feelings because the patients feelthey have not been thankful enough. This guiltfeeling can be dealt with through paying attentionto the fact that God’s blessings and gifts areso numerous that no one can completely thankGod, because thanking God in itself is anothergift from God!4. ISLAMIC CONCEPTS USEFULIN PSYCHOTHERAPY OF ANXIETYAnxiety and depression are usually found together.Many thoughts causing depression can also causeanxiety and vice versa. It depends on one’s pointof view. A loss considered as certain is usuallyassociated with sadness; the same loss consideredas probable is more associated with anxiety. Forexample, the thought “surely I will be in the hell.God will never forgive me” may cause more sadness,but the thought “maybe God doesn’t forgivemy sins. What should I do now?” causes more

312 Sasan Vaseghanxiety. So most Islamic concepts described inpsychotherapy of depression are also useful intreating anxiety. Here some other Islamic conceptsuseful in psychotherapy of anxiety in religiousclients are described.4.1. Afterlife: Causing or PreventingAnxiety4.1.1. Probable LossesBecause anxiety is provoked by perceivinga significant probability of an important loss,thoughts or concepts decreasing the subjectiveimportance or probability of the losses candecrease anxiety.According to Islam, all losses in this world canlead to afterlife rewards for a faithful Muslim, providednot caused intentionally and if the Muslimshows patience. The Holy Koran says, “And weshall certainly try you with something of fearand hunger and loss of property and lives andfruits. And give good news to the patient!” (HolyKoran 2:155). Because patience is really a relativeconcept, almost all clients can be shown tohave some significant patience. This reappraisalcan lessen the significance of probable losses andreligiously decrease anxiety.4.1.2. Probable PunishmentAlternatively, afterlife thoughts can themselvescause anxiety or fear if the client’s mindturns toward the negative side of the coin, thatis, punishment for the sins. Although this anxietycan have positive consequences, such astrying more to avoid sins, it can decrease theclient’s functionality if excessive and should becontrolled. So all previously mentioned Islamicconcepts for decreasing guilt feeling are of usehere. For example, paying attention to the Islamicrule “Whoever brings a good deed, he shall haveten like it, and whoever brings an evil deed, heshall be recompensed only with the like of it,and they shall not be dealt with unjustly” (HolyKoran 6:160) and to the great mercifulness ofGod can lower the subjective probability of afterlifepunishment and decrease anxiety.4.1.3. The Grave AnxietySome religious Muslim patients have anxietyregarding the grave. Some may have excessivethoughts that they will be alive again soon afterdeath, and must answer harsh questions fromthe angels regarding their faith in Allah andthe Prophet Muhammad, and will be punishedif not able to answer correctly. Although thereare sayings of the Prophet Muhammad andShia Imams pointing to in-grave interrogation(not pointing to becoming alive, but pointingto souls being asked questions), there are othersayings that say not all Muslims undergo sucha trial, and that the grave will turn into a wideand beautiful place for the good and faithfulMuslim’s soul (8:11). (19) Again, having faithand being good are relative subjects, and evidencefor goodness and faithfulness of the clientcan usually be found.4.2. Reliance on GodAnxiety-provoking thoughts usually consideronly one side of the event: the worst one. SomeMuslims try to think more positive probabilitiesby repeating religious phrases such asالله (Arabic: “God is great” or “I rely on God”These conceptually mean, “I’ll ‏.(توکلت علیtry my best to prevent the harm but I also tryto accept whatever happens because it is God’swill and God is great enough to protect me orto strengthen me enough to tolerate it.” Suchclients’ adaptive religious behaviors should beencouraged and appreciated in the psychotherapeuticsession.4.3. Fear of JinnsAccording to Koran, there are invisible creationsnamed jinns that resemble human beings inthat they have faithful or infidel groups or maysometimes have unusual powers. (26) SomeMuslim religious people (mostly uneducated)fear that they may see jinns or jinns may hurtthem. No routine religious ritual is widely practicedin Islam regarding protection against jinnsor relationships with them. This fact can be used

Psychotherapy from an Islamic Perspective 313in these patients, saying to them, “If relationshipwith jinns or protection against them was reallyimportant in Islam, shouldn’t there be somewidely accepted rituals in this regard?” or “Couldyou state some Islamic evidence that emphasizethe importance of doing some actions to protectagainst jinns? Is there any evidence that jinnscan usually be seen? If not, can we say this is notreally an important thing in real life?”5. ISLAMIC CONCEPTS USEFULFOR INTERPERSONAL PROBLEMSIslam is, in fact, a social religion because thereare many Islamic laws and recommendationsregarding interpersonal relationships, most ofthem emphasizing unity and love. The followingexamples from the Koran and Hadiths demonstratethis issue:And of His signs is that He created for youhelpmeets from yourselves that you mightfind rest in them, and He ordained loveand mercy between you. Surely there aresigns in this for a people who reflect. (HolyKoran 30:21)(O Muhammad!) It was mercy from GODthat you became compassionate towardsthem. Had you been harsh and meanhearted,they would have broken away fromabout you. (Holy Koran 3:159)Those who have daughters and don’t annoyand intimidate them and don’t prefer sonsto them, God will enter them heavenfor this (from the Prophet Muhammad)(10:705) (19)As a thank for (God’s) favor to you, do favorto the one who did evil to you (from ImamAli, the first Shia Imam) (2:445) (19)God never permits carelessness in threecircumstances: returning the deposit toits owner whether righteous or wicked,faithfulness to one’s promise whether tothe righteous or to the wicked, and doingfavor to one’s parents whether righteousor wicked (from Imam Baagher, the fifthShia Imam) (10:710) (19)Although religion is an important part ofMuslims’ culture, many interpersonal behaviorsare determined by local Muslim culture and donot really have their roots in religion. So whenMuslims are informed from a trusted source aboutIslamic concepts opposing their nonfunctionalcultural view, they usually are surprised and canbetter accept more adaptive thoughts or behaviors.Some psychotherapists report successful interventionsusing this approach in marital conflicts. (6 , 17)Here some common interpersonal problemsin Muslim clients that can be addressed usingthis approach are briefly discussed.5.1. Sensitivity to the Opinions of OthersSome patients are unusually sensitive to other’ssuggestions. This sensitivity can cause anxiety indisorders such as social phobia or avoidant personalitydisorder, or frustration and rejection sensitivityin other personality disorders. In Islam, itis important to be righteous, regardless of whatothers may think, as the Holy Koran says. “Allahwill bring a people whom He loves and wholove Him … striving hard in Allah’s way and notfearing the blame of any blamer” (Holy Koran5:54). Also, it is believed in Islam that if anyonesays something against another Muslim, forinstance, publicizing a wrongdoing of anotherMuslim, then the accuser’s afterlife rewards willbe transmitted to the accused, and the accusedMuslim’s sins are transmitted to the accuser’safterlife dossier (7:337). (19) These concepts mayhelp the client to reappraise others’ negative viewsof them and thus better tolerate the situation andmaintain his or her self-esteem.5.2. Oppression and ForgivenessSome clients feel oppressed and are angry towardthe perceived oppressor(s). Although this angermay strengthen the client in efforts to receive

314 Sasan Vaseghhis or her rights, often it can be destructive inclose relationships and lead to more provocativebehaviors and even greater oppression. Forexample, a woman’s anger toward her mentallyand physically abusive husband may cause herto behave in such a way that irritates her husbandmore and results in her being even moreabused. In Islam, oppression and being passivelyoppressed are both condemned, but theoppressed are encouraged not to abandon righteousnessin the requital. It is also recommendedthat the oppressed try to forgive the offender,despite having the right to retaliate. The HolyKoran says, “And [believers are] those who,when suffering a great injustice, seek to defendthemselves. ۞ Th e just requital for an injusticeis an equivalent retribution, but those who pardonand maintain righteousness are rewardedby God. He does not love the unjust. ۞ Th ereis no way [to put blame] on those who defendthemselves after they have been wronged. ۞The way (of blame) is only against those whooppress mankind, and wrongfully rebel in theearth. For such there is a painful doom. ۞ Andwhoever is patient and forgiving, these mostsurely are actions due to courage ۞ ” (HolyKoran 42:39–43).To avoid unwanted consequences, therapistsshould not impose their own view of oppressionor life on the clients. For example, a Muslimwoman may not view seeking her independenceand obtaining a divorce as a suitable solution toher marital conflict. Similarly, she may or may notsee her husband’s insistence on her Islamic headcover as oppression. A therapist’s one-sided insistenceon these issues may result in the client droppingout of therapy and so should be avoided.5.3. Doing Good in Response to EvilSometimes, quarrels and bitter arguments resultin pathogenic cycles in the family, so that memoriesof the arguments will cause more argumentsand so forth. Breaking these cycles needs oneor both of the partners to stop responding negativelyto the other’s negative stimuli. This maynot be easy, especially when negative argumentshave continued for a long time. One way forreligious Muslim clients to accept this logic andtry to alter their negative relationships is to drawtheir attention toward the Islamic concept of“doing favor in response to the evil.” One examplefrom the Holey Koran is, “And not alike are thegood and the evil. Repel (evil) with what is best,so he between whom and you was enmity wouldbe as if he were a warm friend. ۞ And none isgranted it but those who are patient, and noneis granted it but the owner of a mighty goodfortune ۞ ” (Holy Koran 41:34, 35).5.4. Duties in a Muslim MarriageIslam offers a hierarchical system in which everyMuslim has duties and rights according to his orher position. For example, according to Islamiclaw, men have a duty to cover all monetary needsof their wives including their food, clothes, andhealth expenses, even if the women are themselveswealthy (p. 261). (16) Alternatively, a Muslimwoman should go nowhere without her husband’sconsent unless absolutely necessary or otherwiseagreed on in the marital contract. In Islam, it is notmandatory for women to do housework, and theyhave the right to request salary even for breastfeedingtheir own infants (Holy Koran 65:6). Inpractice, usually both husband and wife need torenounce some of their rights. For example, mosthusbands need their wives to work inside (andsometimes outside) the home, and therefore needto give up most of their controlling rights.These Islamic laws are usually modified byculture, so that Muslim men or women may actculturally but think of their behavior as religious.For example, some Muslim men expect theirwives to work both outside and inside the homeas their duty. Although similar to Christianity(Col. 3:18–19), women are exhorted in Islam toobey their husbands; husbands, too, are encouragedto respect their wives and not oppress them(Holy Koran 4:19). Likewise, men cannot forcetheir wives to do housework. It has been shownthat cautiously drawing the attention of husbandsto these Islamic rules and Sunnah of the ProphetMuhammad related to the treatment of women

Psychotherapy from an Islamic Perspective 315can help them modify their expectations andresult in decreased marital conflict. (17)5.5. Muslim Women and Extended FamilyMost Muslim psychotherapy clients are women(p. 120), (4) and among the most common problemsthey face are those related to interpersonalrelationships with their husbands and the familiesof their husbands. Parents have a high positionin Islam so that Muslims are encouraged notto say even the slightest harsh words to parents,especially their mothers and especially when theyhave become old (Holy Koran 17:23 and 31:14).Furthermore, Muslim women in many familieshave to take care of their own parents as well astheir husband’s parents. Fighting this situationand trying to help the client toward more independencemay result in negative feelings both inthe client and her husband and lead to the terminationof therapy. The therapist instead can firsttry to learn about the family dynamics and thenuse those dynamics to help the client withoutunnecessarily confronting them. For example,Daneshpour (2008) reports a case in which shehelped the client use her mother-in-law as an allyto alter her husband’s behavior. (17)5.6. PolygamyHaving more than one wife is allowed in Islam,but because the polygamous men usually havedifficulty complying with their duties to theirwives, it is restricted in many Islamic countriesand is therefore rare. For example, in Iran andseveral other Muslim countries it is allowed onlyby means of court order that either requires thefirst wife’s consent or her right to divorce. (27)Although this law may be interpreted asoppression against women, Islamic clerics arguethat not allowing legal polygamy may be moreoppressive against women. They say that youngwomen usually outnumber men, because moremen work outside the home (especially in Islamiccountries) and more men die due to accidentsor wars. Thus, allowing polygamy gives widowsand single women more chance to marry legallyand be eligible for support. Second, abandoninglegal polygamy does not prevent men fromhaving multiple sexual partners becausethere are easier but more unsafe ways for this(pp. 363–454). (16)Again, therapists should be aware of their ownpossible negative feelings and not allow thesefeelings to interfere with their effort to professionallyhelp their clients.6. CONCLUSIONGiven the complexity of psychotherapy itself,psychotherapy of a client from another religion orculture will be more difficult and more complex.Naturally, psychotherapeutic skill and experienceplay an important role in success. However,of the many other variables, obtaining sufficientknowledge about the client’s culture and religionseems vital. Although this chapter can helptherapists to better understand and help religiousMuslim clients, it is to be regarded only as a shortintroduction that by no means is complete. Thus,searching for more information from other valuablesources is always recommended.REFERENCES1. Sommers-Flanagan J , Sommers-Flanagan R , eds.Counseling and Psychotherapy Theories in Contextand Practice. New Jersey : John Wiley & Sons;2004 .2. Hers en M , Sle d ge W , e ds . Encyclopedia of Psychotherapy. New York : Academic Press ; 2002 .3. R ig gs T, e d. Worldmark Encyclopedia of ReligiousPractices , Vol 1. New York : Thomson Gale;2006 :349, 350.4. D wair y M. Counseling and Psychotherapy withArabs and Muslims: A Culturally Sensitive Approach .New York : Teachers College Press; 2006 .5. Husain SR. Religion and mental health from themuslim perspective. In: Koenig HG, ed. Handbookof Religion and Mental Health . San Diego:Academic Press; 1998 :289.6. Badri M. Can the psychotherapy of Muslimpatients be of real help to them without beingIslamimized? In: Fadel HE, ed. FIMA yearbook2004 . Jordan : Jordan Society for IslamicMedical Studies; 2005 :61–87. Also available athttp://www.islamic-world.net/psychology/psy.php?ArtID=204 .7. Mehraby N. Psychotherapy with Islamic clientsfacing loss and grief . Psychother Australia .2003 ; 9 (2): 30 –34.

316 Sasan Vasegh8. Aveline M , St r auss B , St i les W B. Psychot her apyres e arch. In: Gabbard GO, Beck JS, Holmes J,eds. Oxford Textbook of Psychotherapy. New York :Oxford University Press; 2005 :449–462.9. Azhar MZ , Varma SL. Religious psychotherapyin depressive patients . Psychother Psychosom.1995 ; 63: 165 –173.10. Azhar MZ , Varma SL , Dharap AS. Religious psychotherapyin anxiety disorder patients . ActaPsychiatr Scand . 1994 ; 90 : 1 –3.11. Razali SM , Hasanah CI , Aminah K ,Subramaniam M . Religious – sociocultural psychotherapyin patients with anxiety and depression. Aust N Z J Psychiatry . 1998 ; 32 : 867 –872.12. Ali SR , Liu WM , Humedian M . Islam 101: understandingthe religion and therapy implications .Prof Psychol Res Pr. 2004 ; 35 (6): 635 –642.13. Carone DA , Barone DF. A social cognitive perspectiveon religious beliefs: their functions andimpact on coping and psychotherapy . Clin PsycholRev. 2001; 21 (7): 989 –1003.محمد ‏(ص)‏ Persian) 14. Rasuli Mahallati SH , ed. (In(Biography of Prophet Muhammad زندانی حضرتدفتر نشر فرهنگ اسلامی Tehran: [PBUH]), 11th ed.(Office of Islamic culture publications); 1998 .15. Daneshpour M. Lives together, worlds apart? Thelives of multicultural muslim couples . J CoupleRelat Ther. 2003; 2 (2/3):57–71.16. Sudak DM , ed. Cognitive Behavioral Therapy forClinicians: Psychotherapy in Clinical Practice .Philadelphia : Lippincott Williams and Wilkins;2006 .حقوق زن در اسلام Persian) 17. Motahari M. , ed. (In( Organization of Women Rights in Islam ), 14th نظامed. Tehran: Sadra Publication; 1991 . Available athttp://www.motahari.org/asaar/books.htm.18. Daneshpour M. Couple therapy with Muslims:challenges and opportunities. In: Rastogi M,Volker T, eds. Couple Therapy with EthnicMinorities . Sage Press. (in press).19. Carter DJ . and Rashidi A. (2004). East meetswest: integrating psychotherapy approaches forMuslim women. Holistic nursing practice , Volume,152–159.20. Koenig HG , Prichette J. Religion and psychotherapy.In: Koenig HG, ed. Handbook of Religionand Mental Health. San Diego : Academic Press;1998 ;324–335.21. Reyshahri M , ed. (In Arabic) میزان الحکمه (bal-الاعلام الاسلامی Qom: ance of wisdom), 4th ed..1992; مکتب22. Beck AT , Rush AJ. Cognitive therapy. In:Sadock BJ, Sadock VA, eds. Kaplan andSadock’s Comprehensive Textbook of Psychiatry.Philadelphia : Lippincott Willi ams and Wilkins;2000 :1267–1277.23. Koenig HG , Mccullough ME , Larson DB, eds.Handbook of Religion and Health. New York :Oxford University Press, 2001:21 .24. Anees MA. Salvation and suicide: what doesIslamic theology say? Dialog J Theol . 2006; 45 (3):275 –279.25. Basit A. An Islamic perspective on copingwith catastrophe . South Med J . 2007; 100 (9):950 –951.برگزیده تفسیر نمونه Persian) 26. Babaii A. (In(Chosen parts of The Example Interpretation [of: 1998 ‏;دارالکتب الاسلامیة Tehran: Koran]), Vol 5.308–310.27. Mir-Hosseini Z. Polygamy. In: Martin RC , ed.Encyclopedia of Islam and Muslim World . NewYork : Macmillan Reference; 2004 :552–553.

21 Psychiatric Treatments Involving Religion: Psychiatric CareUsing Buddhist PrinciplesCHARLES KNAPPSUMMARYThe Windhorse Therapy approach was developedin 1981 by Chogyam Trungpa and Dr. EdwardPodvol. It is based on the Buddhist understandingof fundamental health and sanity and the inseparabilityof one’s entire life from one’s environment,while integrating applicable Western psychology.The primary activity involves creating individuallytailored, therapeutic living environments for peoplewith a variety of mental health issues. Withinthese comprehensively coordinated arrangements,clients are able to significantly reduce the chaosand confusion of mental disturbances and improvelife functioning. Briefly outlining this approach, wewill discuss foundational training, roles, and sometherapeutic elements of a recovery environment. Acase example is provided that illustrates the theoreticalunderpinnings and what a representativerecovery process can look like. A version of thispaper was published in 2008 in the book BrilliantSanity .1. WINDHORSE THERAPYThe Windhorse Therapy process is a unique multilayeredand comprehensive treatment approachfor people with a wide variety of mental healthrecovery needs. In this approach, for every client,we create an individually tailored therapy environment,addressing his or her needs in a wholeperson manner. This whole person approach alsoincludes, whenever possible, the voice and needsof the client’s family.Windhorse Therapy is based on ancient understandingsof the fundamental nature of humanhealth and the energy it takes to recover frommental and life disturbances. With this as itsfoundation, Windhorse incorporates a combinationof ordinary common sense, twenty-sevenyears of clinical experience with the treatmentprocess, and the application of fitting psychologicaltherapy or therapies. A key element of potencyin this approach, both in its view and our experience,is that no matter how severely confused amind has become, recovery is possible.The term windhorse refers to an energy thatis naturally positive, confident, uplifted, and,according to the Buddhist tradition, fundamentalto human beings as a “life force” energy. Ourindividual connection to this energy can waxand wane depending on what’s happening in ourenvironment and inside ourselves. And windhorseenergy can be deliberately roused and cultivated.When our connection to this energy isstrong, we feel confident that our life is workable.Windhorse was chosen as the name of this type oftherapy because it is the energy that is essentialfor people to discover and rouse to recover frommental illness and difficult life problems. (1)A simple snapshot of a Windhorse Therapylooks like the following: A client lives in a houseor apartment with a housemate who is part of atreatment team. Their relationship resembles anormal roommate relationship. There are a numberof clinicians on the team who spend timewith the client on a regularly scheduled basis,sometimes one “shift” per day or more, doing awide variety of activities, from keeping the housein order to helping him or her to get out and connectwith interests in the world. These activitiesare elements of an individually tailored environmentto help the person live in an ordinary and317

318 Charles Knapphealthy way, with good relationships and meaningfulpursuits. The client may work, see friendsand family, and be part of the normal communityin which she or he lives. The schedule usuallyincludes meeting with a psychotherapist andwith a psychiatrist if medications are used. Thereis a system of meetings that all members of theteam, including the client and his or her family,participate in to keep the activity of the therapy,household, and treatment team coordinated andup-to-date. Most treatments last six months totwo years.2. HISTORICAL ROOTSThe Windhorse Project, as it was originally called,arose out of the powerful environment of theearly 1980s at Naropa University and the atmosphereand teachings of its Buddhist founder,Chogyam Trungpa. At that time, many outstandingand accomplished people had been drawn tohim, and his influence invariably had the effectof helping experts to see their respective disciplinesin a new light and larger context. Scholars,poets, dancers, musicians, and many involvedwith psychology found these experiences notjust enlivening, but revolutionary in the way theynow saw their activities. The late Dr. EdwardPodvoll, who had had a distinguished career asdirector of psychiatry at the inpatient psychiatrichospital Chestnut Lodge, was one of these people.Through years of inpatient psychiatric work,Podvoll knew about the benefits and deficits ofthe inpatient environment. That knowledge,coupled with his developing contemplative perspective,showed him that there were other waysone could work with people in extreme mentalstates. In 1981, with the help of Trungpa and agroup of committed students, Podvoll foundedthe Windhorse Project. (2)Windhorse Therapy was originally designedonly for individuals with acute mental disturbances,and many treatments are still conductedfor people with extreme and chronic major mentalhealth issues: schizophrenia, schizoaffectivedisorder, bipolar disorder, and major depression.Over time, we have also found WindhorseTherapy effective in treating milder forms ofmood disorders, substance abuse and addictions,eating disorders, autism, head injuries, and issuesof old age.Given the range of the types of treatmentswe conduct, there is a wide variation in size, andrelated to the size is cost. At the extremely structuredend of our care continuum, expenses canapproach those of inpatient services. At thelightly structured end, expenses resemble outpatientpsychotherapy. It is common that costs maybe high at the beginning of treatment, due to theneed for more contact and support at that transition.And, as recovery progresses, our teamsadjust the level of contact so that costs can fluidlyreduce.3. THERAPEUTIC FOUNDATIONSWindhorse Therapy is based on three healingprinciples. The first is that all human beings arefundamentally sane and healthy. As Trungpastates, “Mental confusion exists and functionsin a secondary position to one’s basic health.”( 3)This first principle is not about just adoptingan optimistic attitude toward human beings.Confidence in basic sanity is a direct experiencethat results from the clinicians’ exposure to contemplativediscipline, which we will discuss later.The second principle of the Windhorse Therapyprocess is, because human beings are inseparablefrom their environments,( 4) if a healthy environmentis created for the treatment, then clients willhave a greater probability of recovery. As statedby Trungpa, “The basic point is to evoke somegentleness, some kindness, some basic goodness,some contact. When we set-up an environmentfor people to be treated, it should be a wholesomeenvironmental situation. A very disturbedor withdrawn patient might not respond rightaway – it might take a long time. But if a generalsense of loving kindness is communicated, theneventually there can be a cracking of the cast-ironquality of neurosis: it can be worked with.”( 5) Aswe will see, creating tailored healing environmentsis the core therapeutic methodology of theWindhorse Therapy process.

Psychiatric Care Using Buddhist Principles 319The third principle of Windhorse Therapy isthat recovery is discovering and synchronizingwith one’s own fundamental health and sanity. (3)As our clinical results show, the client gainshealth, skills for his or her particular life needs,confidence, and independence as this discoveryand synchronization take place and stabilize. ForWindhorse Therapy clinicians, recovery is characterizedby a significant, stable, and hearteningincrease in the client’s “windhorse” energy.A thoroughly trained Windhorse Therapyclinician has a confident and practical understandingof all three of these core principles, plustherapeutic expertise for treating specific psychologicaldisorders.4. CONTEMPLATIVE ROOTSWindhorse Therapy is a treatment process whoseinnovations are founded in the practice of a contemplativetradition. Whatever its form, contemplativediscipline invites a progressively more intimaterelationship with one’s own mind and life in a fresh,moment-to-moment way. (3) For our purposes, it’simportant to note that a typical individual’s contemplativepath follows the basic pattern of a typicalprocess of mental health recovery. (4) This parallelhas great implications for the design of our tailoredrecovery environments and for how a client’s recoveryprocess is understood, nurtured, and achieved.One’s contemplative path often begins withthe distinct sense that something is not right withthe way one’s life is going. For some individuals,a safe, simple, and attractive method to interruptthis repetitive confusion is to adopt a contemplativepractice such as meditation, tai chi, oryoga. Most Windhorse Therapy clinicians haveexperience with the contemplative practice ofBuddhist/Shambhala meditation. This is a simplediscipline of attending to or watching one’s stateof mind without judgment. This can be done formallyin periods of “sitting meditation” and alsoinformally in the midst of ordinary activity as cliniciansgo about their day. (6)To begin, one simply learns to tolerate how itfeels to be aware in the present moment, and howit feels to be with whatever is going on in one’slife without self-conscious judgment. Over time,one develops the ability not to be overly carriedaway by strong positive or negative thoughts andfeelings. As one’s mind becomes more settled,clarity and awareness develop. With this comesvivid insight, or islands of clarity, as this experienceis referred to in Windhorse Therapy. (7) Theability to tolerate and appreciate insight is a basiclife skill and is essential to any process of recovery.As a typical contemplative path continues,healthy self-love begins. This is called “maitri”in the Buddhist tradition. (8) Maitri is the experiencethat one has basic intelligence, warmth,compassion, good intentions, and the brilliantcapacity to love and forgive oneself for not livingup to unrealistic judgments. This healthy self-loveis also a basic life energy, and the discovery andexperience of maitri is frequently a turning pointin the path of recovery.In the contemplative process, one also discoversa naturally confident energy, windhorse ,that can be used in the service of counteringhopelessness, depression, and the mindless repetitionof habitual patterns. In contemplation, asin recovery, the more we see our lives and ourselvesclearly, the more we have a sense of whichactions and thoughts lead to harmonious livingand which lead to suffering and unnecessaryconfusion. Making skillful choices, and rousingthe confidence to implement them, becomes anemerging discipline. (9) In Windhorse Therapywe refer to this emerging discipline as having anallegiance to sanity . (2) With the recognition anddiscipline of one’s allegiance to sanity, it’s naturalto feel that recovery from a confused state is notonly possible, but likely.A thoroughly trained Windhorse Therapyclinician has direct experience of the processdescribed above. One result of this contemplativefoundation is the clinician’s personal convictionthat synchronization with one’s basic sanity andhealth is possible for all human beings. It is alsoclear that the more one knows one’s own mind,the more one has insight into and compassionfor how others’ minds are working. This is notacademic knowledge for the clinician, but livedexperience.

320 Charles KnappAs one’s contemplative path progresses, itbecomes apparent how much we affect and areaffected by our friends, family, household, andthe world around us. We see clearly that as individualswe are inseparable from the powerfuleffect of our environment. This insight influencesthe methodology of Windhorse Therapytreatment environments, because our clinicalwork with a person’s specific mental healthrecovery issues, such as schizophrenia or bipolardisorder, is inseparable from how we “treat”the person’s environment to make it a healthierplace to be.From contemplative practice, we also knowdirectly that there is no end point after which wehave an absence of problems or suffering. Instead,we have tools to work with whatever comes up inour life. Attempting to synchronize with our fundamentalsanity and health becomes a way of lifein relationship to ourselves, our friends and family,and our environment as a whole. Fundamentally,we haven’t become something different. We havebecome a more synchronized version of who webasically are. This is how recovery is defined in theWindhorse Therapy process: A person achieves away of life, unique to himself or herself, that is synchronizedwith his or her fundamental health andsanity.5. RECOVERY ENVIRONMENTWindhorse Therapy is often conducted by a smallnumber of clinicians, using the same fundamentalprinciples as large teams. However, for thepurposes of this paper, the following discussionwill relate to fully developed teams.To clarify the therapeutic methodology of“treating” the client’s environment, WindhorseTherapy defines environment as having threeaspects: body, speech, and mind. (10) Very simply,body has to do with a person’s body, how theydress, and any aspect of their immediate physicalworld. This includes their home, how they eat,how they exercise, their use of drugs and alcohol,and their use of money. Speech is about literalcommunication with the world, emotions, creativity,and relationships. Mind has to do with howone thinks, attitudes toward oneself and others,spirituality, and schedule.When we are called to meet with someonewho has been struggling with mental health andlife issues, it is very common to see the followingkind of situation. On the body level, the person’shome may have become a very disorganized place.It’s difficult to maintain a good place to live whenyou don’t feel well, or are somehow absorbedinto states of mind where you don’t notice what’saround you. There may not be regular cleaninggoing on so the home feels dirty and uninviting.Clothing is not being washed enough. Shoppingand preparing food aren’t regularly done, andwhat is eaten may not be nutritionally sound.Any form of exercise, even going for walks andgetting enough fresh air, can be neglected. It’svery common for money to be a problem as well.Even if one has enough, without a sense of budgetor adequate tracking of what one has and what isspent, the chaos of running out of money, bouncingchecks, and not feeling clear about what onehas is a very unsettling stressor. Drugs and alcoholare often a contributing factor to one’s life circumstancesbeing in disarray.On the speech level, communication is oftenvery strained between this person and his or herparents. It’s not that they don’t love each other,but there are so many problems that need workingwith, it’s become almost impossible to havea normal conversation due to everyone’s anxietyand fear. On the part of the son or daughter,he or she may be angry and frustrated becauseof wanting to be independent from the parents,but still needing help in many ways. And the parentsmay be the only really reliable people in hisor her life. It’s very common for this person tobe socially isolated, and what friends she or hehas may have a variety of problems themselves,which can create negative consequences whenthey get together.On the mind level, this person may have hada creative and meaningful intellectual life. Nowshe or he is cut off from these disciplines and allthe feelings of success and confidence that comefrom engaging in these aspects of intelligence.There may not be enough meaningful activity

Psychiatric Care Using Buddhist Principles 321to engage in, like a job or school, and his or herschedule is highly irregular. All this combines tomake one feel very disconnected with the worldand terrible toward oneself. If she or he is a sensitiveperson, and so many who are strugglinglike this are profoundly sensitive, the intricacyof how interconnected and self-sustaining theproblems of environment are creates a hopelessstate of mind. At this point, the person’s windhorseenergy is deflated and there is little lovingkindness toward oneself. When one feels thisbad, you really believe that you are bad. This personand family feel at a loss as to where to beginthe recovery process. We know that if we wantto help a person and his or her family to breakout of the variety of cycles and compoundingfeedback loops built into this life predicament, itwill be far more effective to work with all aspectsof personal needs and the environment concurrently.By creating individually tailored recoveryenvironments, the unique strengths and difficultiesof each client and family can be simultaneouslyengaged. (11)When we create a recovery environment, we areactually forming a very specific arrangement of elementsand relationships, with a beginning, middle,and end. We attempt to create an environment thatholds all aspects of the client’s life, within optimalboundaries that are permeable yet containing,between him or her and the outer world. This environmentis a comprehensively coordinated organizationof body, speech, and mind, comprised ofthe household, the people and relationships, therapeuticmethodologies, schedules, intentions, andawareness. Influenced by the Buddhist concept of“mandala,” defined as a total environment, association,“orderly chaos,” or “gestalt,” (12) a recoveryenvironment functions as a compensatory, external,organizing entity.In many ways, families naturally work thisway. If a family member has a life situation – forinstance, a woman has a baby – it is very hard forthe first few weeks for the mother to be able toshop, cook, clean house, and take care of all thebaby’s needs. There is a good chance the mother’ssleep is disrupted, and there is simply not enoughenergy to do the tasks of life in the way that hasbeen normal. It is very common under these circumstancesfor partners to take time off fromwork to make sure that everything in the life ofthe mother and child can be accomplished asnecessary. Other family members may also helpout. In this case, the mother and the baby are thefocus, but anyone who is helping out will do theirbest to help in a balanced way, so they themselvesdon’t lose their health in the process. Likea Windhorse Therapy recovery environment, thisfamily system is compensating for a change thathas occurred, and there is a sense that this is atransitional phase.6. THERAPEUTIC ELEMENTS AND ROLESTo create a recovery environment, a team is createdmade up of the clinicians, the client, andwhenever possible, the family. These people workin a complementary system of roles, each carryingout a range of functions and therapeutic activitiesthat develop, maintain, evolve, and “are” a largepart of the environment. The cohesion and communicationof this “whole person system” is carriedout within the household, the meetings, andthe relationships of the team. To understand thecontext for much of the relationship activity ofthe team, we will now look at basic attendance.6.1. Basic AttendanceA highly flexible and innovative clinical practice,“basic attendance” is the most active, apparent,and principal therapeutic activity in a WindhorseTherapy recovery environment. Influenced bythe Buddhist practice of being attentive or simplywatching the mind without judgment inthe midst of everyday activity, basic attendanceis being actively and with helpful intention inrelationship with someone in the broad spectrumof his or her life activities, to promote thesynchronization of body, speech, and mind, andconnection to his or her fundamental health. (2)Its possibilities range from being with a client inthe ordinary domestic activity of a household,doing artwork, signing up for classes, looking foremployment, or simply having time to relax and

322 Charles Knappplay. The work of “basic attendance” may lookvery simple to the untrained eye, but a seeminglysimple task for the client, such as cooking a meal,can stimulate a powerful profusion of conflictingthoughts, emotions, and growth frontiers. Itcan take a great deal of skill and sensitivity on thepart of the clinician in a “basic attender” role tocreate a safe and successful experience.6.2. Clinician RolesMost of the direct clinical contact in WindhorseTherapy is performed by a basic attender , asdescribed above. He or she will usually have twoshifts per week, generally two to three hours inlength.Th e team leader, also doing basic attendance,is the primary coordinator and a major participantin the direct clinical contact. He or sheoversees the day-to-day flow of activity for theteam as well as being a sturdy, dependable, andknowledgeable reference point in the life of theclient.The housemate’s job has two primary functions.The first is simply to live, with good boundaries, inthe therapeutic household and support the functioningof a normal and uplifted domestic setting.The second is to be in relationship with theclient in that ordinary and earthy way that tendsto occur when people share a home. As with allroles, but particularly for the housemates, we arevery careful to establish appropriate therapeuticboundaries, prohibiting sexual contact betweenthe staff and clients.The psychiatrist is often a part of a recoveryenvironment, because frequently our clientsare using medications. Some psychiatrists mayonly be doing medication management, so theirinvolvement with the team could be minimal.Others, particularly those whom we have workedwith over many years, can be a critical part of thetreatment management. As it is often the casewhen a client is in one of our teams, she or heis able to be on less medication, and his or herneeds change over time. We find that the psychiatristwill have a more subtle knowledge ofwho the client is and what his or her needs are ifthe psychiatrist is an integrated part of the teamstructure.Usually meeting once or twice per week withthe client, the psychotherapist is looking for theintelligence and patterns that reside below andwithin the often-confused behaviors of the client.He or she learns this through the work donein sessions with the client as well as throughexperience in meetings where the housemate,basic attenders, team leader, and psychiatristdescribe their client contact. Likewise, theinsights about the client that the psychotherapistprovides in the meetings help inform theentire clinical team.The team supervisor watches the dynamicsand patterns of the team as the treatment progresses,often working with the family membersas they make their own recovery journey. Theteam supervisor also has a key role in creatinga “visualization” for the team and the entireWindhorse Therapy plan, while holding the overallactivity of the recovery environment in his orher awareness.6.3. The Therapist-Friend RelationshipIn most psychotherapeutic disciplines, therapyoccurs in an office. For some roles in a WindhorseTherapy recovery environment, the formality andboundaries that are a normal part of how mostpsychotherapy operates would seem altogetherunnatural and stiff. In fact, the basic attendersintentionally acknowledge and cultivate clientrelationships that are part friendship and parttherapist. With this in mind, basic attenders arecarefully chosen to match a client’s interests, deficits,and diagnosis, with an eye toward whetherthey might actually like one another. (2)Th e therapist–friend relationship brings anumber of benefits to the recovery environment.First, it can make basic attendance morerelaxing and fun, much more like normal lifethan therapy. Second, many of our clients havehad a very difficult time forming treatmentalliances. For these people, having clinicianswho share at least a slight mutual attraction asfriends may make it possible to join and stay in

Psychiatric Care Using Buddhist Principles 323treatment. And as with ordinary friendships,as the therapist-friend relationship develops, itis common for shared interests to “jump-start”dormant passions and interests in each other’slife. Third, it opens up the possibility of beingable to bring a client into a team member’shousehold. Whenever appropriate and in wellconsideredmeasure, a Windhorse Therapy clinicianwill often invite a client into the world oftheir family and home. This can provide a powerfulexperience of acceptance and role modelingfor the client as he or she enters the homeand relationships of the “therapist-friend.”6.4. Mutual RecoveryA therapeutic element related to the therapistfriendrelationship is called “mutual recovery.”( 2)This originates with the contemplative trainingof a Windhorse Therapy clinician, and his or herown process of recovery and eventual lifestyle ofsynchronization. As Trungpa stated in CreatingEnvironments of Sanity , “You don’t just regardpsychology as a J.O.B.”( 12) This means that theWindhorse Therapy clinician aspires to conducthis or her professional work in fundamentally thesame way that he or she lives life. This trainingpromotes a sense of inclusion of everything inone’s personal discipline, a “sacred world” orientation,to borrow a Buddhist concept, where“sacred” doesn’t mean precious or rare, but whatreminds one of basic sanity and goodness. (13)Because everything is included in one’s view ofhow to live and work with life, the relationshipwith the client and his or her recovery environmentis naturally part of this. Instead of “I’m well,you are sick, and I’m going to fix you,” there is asense that we are in this together, and we all areworking on our humanity.6.5. MeetingsIn a recovery environment, meetings play acompletely critical role. There are a variety ofmeetings, and all are designed with complementaryfunctions to enhance the communication,cohesion, synchronization, and awareness of theteam, the client, and the family. The dynamics ofmind in meetings are remarkably energetic, complex,often subtle, at times not, and can generate awide range of feeling experiences. For those whoare paying attention, a wealth of informationabout how the client is doing and what is goingon altogether in the recovery environment isavailable. (14) Of the types of meetings generallyconducted in the course of Windhorse Therapy,these four – the house meeting, the supervisionmeeting, the team meeting, and the familymeeting – have the most central roles. (15)Attended by the team leader, client, andhousemate, and held in the home once a week,the house meeting supports the operation of thetherapeutic household. Helping the client andthe housemate work with relationship and communicationissues is a large part of the work ofthis meeting.The supervision meeting is held at an office,usually every other week in alternation with theteam meeting. The entire team, except the clientand family, attends. These meetings typicallyhave a relaxed but precise focus, often with goodhumor. Aside from issues of recovery environmentcoordination, this meeting is a place wherethe team can freely discuss the experience of hisor her work and develop further understandingof the treatment issues. While checking in, weencourage clinicians to take risks by saying whateverhe or she is thinking and feeling, because itis so often the odd and even embarrassing experiencesthat are most informative about how theclient is doing. This meeting also covers the nextsteps the therapy may need to take and how tobest care for the health of the entire team.The clinicians and the client attend the teammeeting . When possible, it is held in the client’shome. Because of this, the team is very careful totailor the meeting to the client’s needs and sensitivity.Some clients can comfortably participate,with all of us being relatively direct and forthcomingin our communication. Others needmore emotional insulation and a less stressfulmeeting environment. And some can’t, or won’t,participate for some time. A team meeting is aholding environment that allows the client and

324 Charles Knappclinicians to be comfortable, but also sustainsenough tension to produce therapeutic work.The family meeting includes whatever combinationof client and family is most relevant to therecovery process, plus the clinician or clinicianswho specifically work with them. Because familycircumstances and their readiness for therapyhave so much variation, these meetings are carefullytailored in their form and frequency. (16)6.6. The Phenomenon of Group WindhorseThe team often shows up for meetings havingdone a lot of individual work since the last gathering.Some may be feeling isolated and roadweary. The basic attenders, team leader, psychotherapist,housemates, team supervisor, and psychiatristhave all had their experience of clientand family, and of each other. Clients and familymembers likewise have had to deal with the team,themselves, and each other. Feelings have developed,questions have come up, perhaps a troublingobservation needs to be discussed with thegroup. Intense emotional energy may have arisenfor some. In these varieties of meetings, the teamhas a chance to hear and feel what is going on witheach other and to explore personal experience inthe work. A significant task for the group is tohelp everyone say what’s going on for him or her.Once again, no matter how negative, painful, orhopeless it might sound, the team members needto feel heard and to be connected to the whole.From there, the team tries to make sense of feelingsand experiences as they relate to the commondeveloping understanding of the recoveryenvironment, the client, and this unique sharedpath of recovery. Once team members feel heardand connected to the whole, feelings aren’t experiencedas being quite so solid, and people tendto relax. (17) With relaxation and clarity oftencomes the experience of heightened compassionand windhorse energy being aroused in thegroup. This phenomenon of “group windhorse” isan experience of certain qualities of mind beingheightened – upliftedness, confidence, compassion,not being fixed on a thought. WindhorseTherapy clinicians recognize this experience, andit is directed back to the client and family in ourindividual contacts after the staff-only meetings.In the meetings involving the client and family,everyone is participating in this heightenedpositive atmosphere of mind, which promotes anarousal of windhorse energy. Through meetingpractice, confident life energy is strengthened inthe team, and the entire recovery environment isaffected positively. Meetings maintain the pulseand breath of a recovery environment.7. CASE STUDYGiven the complexity of Windhorse Therapy, itis hoped that this case study will provide a usefulsense of how treatment actually looks andworks.Julie was a 27-year-old woman whom WindhorseTherapy worked with for about two years.Five years prior to our first meeting, she hadexperienced her first manic episode. By the timewe met, she had been hospitalized seven times,while maintaining that she did not need psychologicaltreatment. What was different abouther current hospitalization was that for the firsttime she said she was tired of being “thrown inthe hospital” and wanted some help. The hospitalthought Windhorse Community Servicescould be a good resource, and her mother, Beth,called us.Beth was in a guardedly hopeful state of mind,but also heartbroken, bewildered, and exhausted.Because she had never heard Julie say she neededtreatment, this was stunning. While being carefulnot to create false hope, I described theWindhorse Therapy approach, which made greatsense to Beth. We agreed that I should go to thehospital to meet Julie.Even in hospital pajamas, Julie looked like anathlete. She was 5’8” tall, weighed around 145pounds, and looked physically strong. She had apleasant face, and the ruddy, fair complexion ofsomeone who had spent a lot of time outdoors.Our initial meeting in the hospital didn’t last longbecause she immediately told me that her motherhad described what Windhorse Therapy does andthat sounded fine to her, “just to get everyone off

Psychiatric Care Using Buddhist Principles 325my back.” She said she really didn’t need treatmentbut agreed to work with us for six months.It felt like she was commanding me to listen, notinterrupt, and not to make eye contact or sayanything that would put her on the spot. I compliedwith her “commands,” asked her if it wouldbe OK if I started introducing her to potentialteam members while she was in the hospital,and she said a bit dismissively, “of course.” Shereported no preference for men or women on theteam and “anything else you need to know mymom can tell you. Are we done?” Though she wasoutwardly a bit hostile, I found her quite likable.I could see it was unspeakably difficult being inher situation and thought she did a good job ofgetting to the point and taking care of herself. Ileft with the impression that Julie was terrified,feeling completely vulnerable, and making a tremendouslycourageous effort to try somethingdifferent in her life.From all we could gather in our ensuingassessment, including, importantly, her historyof sanity and success, (2) Julie had grownup quite normally as an energetic, intelligent,athletic, and creative person. She had begun toexperience mood instability late in high school,at times needing to withdraw a bit from her usuallively flow of activity, seeming depressed withlower energy. Once in college, Julie continuedto do well in all areas, but her mood irregularitybecame more pronounced. Sleeping was oftendifficult, and it was harder for her to keep anenergetic schedule. Her art at times became morebrilliant and subtly expressive, but she also didless of it. She tried medications for a brief period,but rapid weight gain and unimpressive resultsconvinced her that they weren’t worth the troubleand she stopped. In the meantime, Beth andJulie’s father were in the midst of a fairly amicabledivorce, which resulted in her father moving outof state and essentially out of her life.After a heroic struggle to stay in school, andwith her life badly deteriorated from how shehad been at the beginning, she finally graduatedfrom college. Shortly after that, Beth visitedher and immediately knew that something wasterribly wrong. Julie was talking in a rapid andpressured way, was very irritable, and was speakingin an urgent manner about what soundedlike Christian mysticism. Her apartment lookedlike someone had ransacked it, and it appearedthat Julie might not have been sleeping for awhilebecause her bed was now under many layers ofoddly arranged artistic creations that appearedto constitute a shrine. When Beth urged her tosee her old psychiatrist again, Julie stormed outof the apartment and recklessly drove off. Shewas picked up later that day by the police andwas taken to the psychiatric hospital on a mentalhealth hold. Thus began the cycle that wouldbecome her life for the next five years: briefperiods of stability interrupted by involuntaryhospitalizations, medications, weight gain, and“stupidity,” sometimes a job that was hard to copewith, no friends, no meaning, “mom worriedabout me all the time,” “wanting my life and freedomback,” and almost dying on two occasionsafter intentionally stepping into traffic.The consensus of the assessment was that Julieneeded a fully developed team and two shifts perday to begin with. This is a lot of contact, whichcould be overwhelming, but we also sensed thatwe needed a very solid structure for her to actuallystabilize and be safe. The shifts would berelatively brief, an hour and a half in the morning,to help her get breakfast and organize theday, and another shift at around 6 to 8 p.m., toget dinner and to make the transition from theday to evening. With the day book-ended in thismanner, it was also designed to get Julie’s sleepcycle stabilized with her being awake during thedaytime. We had worked on this plan as best wecould with her, but she was not interested in thedetails of what we would all do. She just said, “I’lldo whatever for six months.”As with so many of our clients, Julie washighly ambivalent toward psychiatric medications.Windhorse Therapy does not have a policythat dictates or prohibits the use of medications.Rather, we attempt to approach each client’s needsand desires, without pre-judgment, from a place of“taking a fresh look.” From what we heard in Julie’scase, it was reasonably clear that medications hadhelped to settle her moods for brief periods in

326 Charles Knappthe past, and she was currently on mood stabilizersthat seemed to be having a positive effect. Shehad not tried these before, and significantly, sheseemed to be getting benefit without feeling “likemy head is full of concrete.” We were very carefulnot to push the idea of medications toward her,but rather to help explore whether or not now wasthe time to try an experiment with them, withina more structured environment. Consistent withher resolve to break out of the familiar, destructivecycle, Julie opted to try medications, “for sixmonths.”The immediate work at hand was creating therecovery environment. For the psychotherapist,a man named John was chosen and for the teamleader a woman named Sandy. Both were veryexperienced Windhorse Therapy clinicians withstrong expertise in bipolar disorders. BecauseJulie was quite intelligent and had a severe anddeadly mood disorder with psychosis, we knewthe team likewise needed skilled basic attenderswith experience in bipolar disorder. We wantedthem to be in their late twenties or early thirties,and the team needed a gender balance.Fortunately, just such candidates were available,and after the first interviews, Julie accepted themall. The team had three women basic attendersand two men. There was also a woman housemateavailable immediately whom Julie reallyliked. Rounding out the team was a psychiatristwith extensive Windhorse Therapy experience,and myself in the role of team supervisor. Withthe team selected, it was now time to gather forthe first supervision meeting to assemble theschedule and create a vision for the beginningphase of the journey we were about to take.As the treatment began, Julie ‘s terse guardednesswith me was in stark contrast to howshe spoke in one-on-one situations with John,the therapist, and with Sandy, the team leader.She related to them as if they were her students,and she was a spiritual teacher. She was a littleformal, tolerant, and “patient” with how distractedthey were by mundane life activity. Atany given opportunity, she would teach about thespiritual aspects of life, relationship, the universe,and anything at hand that had inspired her. Shewould let John and Sandy do their work, andshe would cooperate and teach them when shecould. She related to the basic attenders in a similarmanner.Our shift contact began when Julie was stillin the hospital, and shortly after she was discharged,the schedule began in full. A good dealof the early shift activity, especially for the teamleader and Donna, the housemate, was spentfinding an apartment and shopping for furnishings.Of anyone on the team, Donna seemed tohave the most relaxed relationship with Julie. Itwas the least professionally oriented relationship,and they often were just in the house together ina quiet way. They both enjoyed working togetherto make a comfortable home, and she did verylittle teaching with Donna.Julie settled into the basic attendance schedulein what appeared to be a surprisingly unconflictedmanner. She was on time for shifts, didn’tseem to get particularly close to people, still dida lot of teaching, and tended to be pretty organizedabout how the time was spent. She wouldtypically use shift time to do errands, get coffee,take a walk, or organize her art studio. Her psychotherapysessions, which were once per week,were rapidly evolving in a less comfortable way.She and John would meet in his office, and shebegan to be either completely silent or wouldshow the same kind of guardedness she had withme in the beginning. When she did talk it wasmostly to teach.Julie declined to be part of the family meetingto begin with, although she spoke with hermother several times per week.Although things were going well for a beginningphase, in the supervision meetings somebasic attenders expressed feeling useless and irritated.The shifts felt like a waste of time. My experiencewas almost always one of vigilance. Despitehow easy almost everything about the treatmentwas, I felt like we were constantly on the verge ofsomething dangerous happening, some disaster.We were also easily able to see what a lovely personJulie was, and her good-heartedness showedin many ways. Even her teaching felt like a generousoffering to us. It had a touch of a psychotic

Psychiatric Care Using Buddhist Principles 327flavor, but you could see that she really caredabout what she was saying. We all liked her andsensed she had been, and continued to be, in aterrible life predicament.The team meetings were held at her house.These were generally not very comfortable, a difficultvariation on a basic attendance shift, withJulie needing to keep the relationships at a safedistance. The house meetings, also held at thehome, were more comfortable and productive asthey focused on details of running the home withDonna.Julie continued showing up for every shift,but as time passed, she was beginning to let it beknown that we were all nice enough people butquite useless as therapists. Especially John. Therewere many sessions where they would just sitwith a lot of silence. A little teaching would happen,and then Julie would tell John what a wasteof time therapy was. She didn’t need therapy, andJohn was a lousy therapist anyway.One morning Julie didn’t want to get outof bed. Her polite demeanor had been slowlychanging over the last month, and she stoppedteaching. This morning she looked withdrawnand terrified, like she was really suffering, asif it were difficult for her to breathe. She spentthe morning in bed but seemed to appreciatethe quiet company of the basic attender,who brought her tea and food and read a bookwhile Julie lay in bed, not wanting to talk. Laterin the day she had a therapy session with John,and strangely, she seemed interested in seeinghim. At the beginning of the therapy session shewas quiet, but it had a completely different feelingabout it. Instead of angry and guarded, sheappeared completely vulnerable and fearful, veryuneasy. Finally in a quiet tone she said, “I can’tbelieve this is who I am.” Then in a steady andmeasured flow of words, she described how horribleit had been over the last five years to see lifeas she thought it would be, completely washeddown the drain. She couldn’t count on herself,and nobody else could count on her, except todo something crazy, destructive, and stupid. Shehad wanted to ignore it, but the mania kept comingback. She wanted to leave everything, but thepolice kept bringing her back. Now she was hereand having more awareness than she wanted andJohn, after having survived so much of her anger,felt like the safest person to be with. At least forright now. Caught between the depression, whichmade her feel like a hopeless and utterly bad,worthless person, and the insight of what she hadlost, and without having any sense of a way outof this horror, she saw no realistic option but tokill herself. She had no immediate plan, but shepromised that if she tried again, it would be successful.It was clear that she meant it.John quietly listened to her. When sheappeared to be done, he said that he was glad shecame in that day. The simplicity of him just beingthere listening to all this horror and then genuinelycommunicating that he was glad to be withher, spoke straight to the level of her experiencewhere she felt utterly lonely and unlovable, cutoff from everyone, unspeakably afraid and outof control in a world without allies. She cried formost of the rest of the session until John took herhome. Once there, Sandy, the team leader, joinedJulie and John to talk about what was going on.After believably agreeing not to hurt herself, theyall felt it would be best to increase her shift supportfor at least the next week. Because we hadexpected her to get depressed at some point andthought this was likely to be a positive development,no medication changes were indicated.Waking up to who you are and how your lifehas been is a critical part of the recovery process.This dramatic shift in Julie’s awareness was verysudden, which is a dangerous place for a lot ofpeople to be. It can be extremely difficult to toleratehow it feels to be suddenly that aware. Often,a person needs to diminish awareness throughcultivating psychosis again, finding other waysof being defended, or killing oneself. But Juliewas able to tolerate this experience and use it asa reference point throughout the rest of her timewith the team. It was very striking to her that theteam did not shy away from the painful intensityof her emotional state, but actually seemedto appreciate her all the more in her vulnerabilityand for being genuine. Julie’s awakening wasa dramatic example of an island of clarity , an

328 Charles Knappinsight or experience that interrupts confusionand helps one to become oriented to the reality,potential sanity, and promise of the here andnow. Stated succinctly by Trungpa in Creating anEnvironment of Sanity , “Earth is good.”( 18)Julie’s first shifts with each clinician after thisbreakthrough were a little awkward. She wasembarrassed that people had seen her act theway she had and was very touched that everyonestood by her. It seemed to her that we hadmore confidence in her than she had in herself. Itappeared that she genuinely no longer wanted todie, but instead was connecting with energy andpassion to be physically active and to resume herartwork.This middle phase felt like an unleashing of herpent-up desire to have a normal life again. If thatwere simply a matter of her taking medicationsand having some therapy to help recover fromfive years of life trauma, we could have ended theteam. But having had a radically unstable moodfor such a long time, it took Julie about a yearand a half to get her moods, and the persecutoryvoices that came along with them, to settle. Ashard as it was for her to be patient with this continuedmood cycling, it was encouraging whenshe noticed that, as she became more stable andcloser to her normal mood baseline, the quieterand at times nonexistent the voices became.As her mind became less chaotic, Julie continuedto become clearer about what she valued inher life and to pursue reengaging activities thatreflected these. Volleyball and tennis, first withthe team members, later with the city’s Parks andRecreation leagues, became great opportunitiesto get her weight back down to where she feltmore comfortable, had more energy from beingin shape, and felt more like her competent self.These activities also helped her to meet new peopleoutside the team.At this point, a major part of the work of theteam was helping her learn that how she engagedwith her physical world, including medications,how she related to people, how she workedwith meaningful activities, and how she workedwith her thinking had a profound effect onwhether her moods were more or less stable. Shelearned that sleep was connected to appetite, thather relationship world affected how she ate andslept, and that her thinking was related to everything.As this understanding grew, she was beginningto have more of a sense of maitri towardherself. She was developing unconditional confidencethat she was not a bad and hopeless failureof a person. She was feeling better, more alive,and more positive and she liked herself again.She was gaining windhorse energy.Julie was also becoming a peer on the team toall of us, and she did not hesitate to confront uson our blind spots. For instance, she felt that forall our nice attitudes about the therapist-friendrelationship, she often found us to be arrogant,as psychotherapists can be, about the fact thatshe was the “client” and we were the “matureprofessionals” who have their lives together and,therefore, could help her with how to live hers.As uncomfortable as this was at times, we alsoappreciated the piercing accuracy of her observationsand her confidence to speak directly tous. Our team meetings were now almost alwayslively, sometimes intense, as we were all not holdingback as much. That shift in honesty with all ofus was the outer reflection of a shift in her interestand capacity to be more honest with herself.She was gaining strength in unflinchingly identifyingwhich of her actions and thoughts ledto more confusion and suffering, and which tomore health and harmony in her life. It was clearthat her allegiance to sanity was becoming a reliablereference point.Julie never felt compelled to be an ongoing partof the family meeting as the tension between herand her mother, Beth, seemed to resolve throughtheir informal contacts. Between the infrequentface-to-face meetings we had with Julie and Beth,and Beth’s more frequent phone conversationsand visits, they did manage to establish a muchmore natural relationship tone and distance for amother and her adult daughter. This was largelypossible because Julie was being “held” by therecovery environment. She was healthier, andBeth was not induced into so much vigilance andprotection. Beth could behave more like a motherand not as a caretaker. Also, in a parallel process

Psychiatric Care Using Buddhist Principles 329with Julie, Beth’s confidence in Julie’s recoverywas strengthening. She was very appreciativeof how the team was being helpful to Julie andcould see the lessening of her dependence on thecompensatory nature of the team as her healthbecame more resilient.By the end of eighteen months, Julie had developeda reasonably energetic schedule of ordinarycommunity activities outside the team structure.This allowed the schedule to be reduced to fourbasic attendance shifts per week and one psychotherapysession per week. With fewer shifts, wewere able to reduce the number of basic attendersneeded.There was one more significant life developmentthat occurred in this phase that shouldn’thave been a surprise. Once Julie was more confidentin her ability to be in complex socialenvironments outside the team, she found a progressiveChristian church to attend that practicedmeditation and centering prayer. Besides participatingin many social activities and making somenice friendships, she began a daily meditationpractice.The end phase of Julie’s Windhorse Therapytreatment was brief, and it began with an argument.Her sister Lisa was coming to town for avisit, and this seemed like an opportunity to haveher join a family meeting. Julie really liked thatidea. Her life was in a much better place. She wasphysically healthier, was more mood stable, andthe voices had almost entirely disappeared. Shewas now doing most of the organizing of her lifethat the team had done. She continued to workon relationships both in and out of the team in awonderfully direct and honest way, and she hadlearned for the first time how to live with someoneher age in relative harmony and be close withthem at the same time. Once we settled into thefamily meeting, Lisa said in a heartfelt way howamazed she was to see her having such a goodlife. Julie exploded. “You think this is my life! I’min treatment and have paid friends! Don’t try tomake me feel good because I’ve learned to tie myshoes and you’ve got your life so together.” Lisawas stunned. She was glad that Julie was doingthis well and tried to express it. Julie acceptedher apology and over the next hour and a halfthey were able to resolve the immediate tensionbetween them. Something that was particularlymeaningful to Julie was an insight that both Bethand Lisa had when Julie had become angry andessentially declared that having half a life was notgoing to be settled for: “This feels like we’ve gotour Julie back.”Very significantly, we all noticed that Julie didnot experience any mood instability from thisvery intense emotional event, as she previouslymight have. She too was surprised by this andlater said, “This showed me that I was ready toleave treatment.”In the next week’s team meeting, Julieannounced that she was leaving the team in onemonth. She had been researching colleges whereshe could get a master’s degree in physical educationand had found one that she liked in a smallcity out of state, about an hour from where herfather lived. School would be starting in ninemonths and she wanted to move there, get her lifeestablished, and apply to school. Once there shewould also look for a psychiatrist and a psychotherapistto continue the work she had done withus. She expressed appreciation for all we had donetogether, “I think you actually saved my life,” butsaid she was tired of having training wheels andpaid friends, and needed to get on with her life. “Ithink I’ve learned the care and feeding and thinkingof Julie, and have a good toolbox for whenthings come up that I need to deal with.” Once shefinished talking, she seemed to glow with a quietresolve, confidence, and a bit of defiance.To say we were stunned was an understatement.Also, we knew this was absolutely the rightthing for her to do. But we were not ready forher to leave. We had a more graduated plan forthe eventual team reduction and how we couldcontinue to see her for years to come. We reallyliked her. We wanted to feel appreciated and valued.As is usually the case in the life of a family,artificial or not, emancipation isn’t how the parentsplanned it. And as is usually the case witha successful treatment, recovery is almost alwaysmore intelligent than the clinician imagines andcertainly not in the clinician’s control. John was

330 Charles Knappthe first to speak, and much like once before, hesaid something simple, that “this sounded reallyright.” Others expressed support. Someone elsesaid, “What took you so long to figure this out?”from which we all got a good laugh.The last month went quickly while we saidour good-byes and packed up the house. Juliewas busy making her plans and saying good-byeto friends. Without a lot of sentimentality, sheended with us as individuals, as part of the group,and as the host of a lovely going away party. Thenshe was gone.In summary, this case shows the compensatoryrecovery environment in action. Julieentered treatment in a highly disturbed state, inwhich she was not able to care for herself andhad no sense of how to get back to a meaningfuland recognizable life. In a very real way, Julie’srecovery began as she became part of a recoveryenvironment that allowed her to have a life thatfunctioned, because the recovery environmentfunctioned in a comprehensive and synchronizedmanner with her and her mother fully integratedinto it. Simultaneously, the recovery environmentprovided specific and integrated psychologicaltreatment that identified and disorganizedconfusion-producing life patterns and behaviors,helped establish new ones based on health, andover time stabilized those new behaviors.In the beginning we saw Julie explore whethershe could trust the team, knowing that she neededto do something different or die, either literallyor die to herself as she knew herself. She thenlearned to tolerate difficult, life-changing insight,becoming fearless and attentive to the islands ofclarity that she had previously avoided. She wasalso continuing to live as an integral part of asane environment. This was a world with goodbody and domestic practices, strong and healthyrelationships, good rhythms that tended to supportthe harmony of the total environment, andadaptable intelligence and awareness. The mindexperience of the environment was strong witha sense of allegiance to sanity, maitri, and windhorse.By herself and in the varieties of dyadicand group relationships, the practice of wakingup to her sanity and developing confidence in herpath of recovery became a compelling and livedexperience, not unlike the contemplative and lifeexperience of the Windhorse Therapy clinicians.As Julie grew healthier and more independent,we collaboratively reduced the structure ofthe environment. This reduced the compensatoryeffect, and she progressively lived a less protectedand more normally engaged life, at a more comfortablerelationship distance with her mother.With solid skills around working with her moodstability and with confidence in her health andthat she was on a resilient recovery path, Julieleft treatment. By then, she had internalized atreasure of healthy experience gained from beingpart of the recovery environment.In Julie’s case, recovery included an abatementof her primary destabilizing symptoms anda return to normal life at a higher level of functioning.To herself and her family, after treatmentJulie looked like a mature and wiser version ofthat bright and good-hearted child they knewgrowing up.8. CONCLUSIONAfter twenty-seven years and hundreds of treatments,much has been learned about WindhorseTherapy. We know it is a highly adaptable formof psychological treatment that can work witha wide variety of complex mental health andlife problems. We create compensatory recoveryenvironments that range in size from beingquite small to being like small towns. Not everyoneneeds or wants this type of treatment, butfor many who do, it can really work. It works forthe client, it works for the family, and it worksfor the team itself. Those of us who have beenfortunate to participate in this process find eachteam, in its own way, to be a health-promotingand clarifying experience for our own growthas human beings and as clinicians. A significantreason for this is the ability to cultivate individualand collective windhorse energy, which promotesstaying committed, continually learning,and being unconditionally confident in eachperson’s possibility of recovery and growth,including our own.

Psychiatric Care Using Buddhist Principles 331We also know, based on our personal contemplativeexperience as well as from conductingtreatments, that Windhorse Therapy is basedon a powerful integration of elements centralto the well-being of human beings. Succinctlyput, Windhorse Therapy connects the fundamentalhealth of a human being, which is naturallyinclined toward recovery, with finely tunedtreatments for the psychological disorders thatare present, within a highly adaptable recoveryenvironment. This makes Windhorse Therapyparticularly effective for complex and difficultto-treatconditions.Looking forward, we believe WindhorseTherapy has tremendous potential to evolve overtime and be ever more relevant to individual andsocial well-being. We believe this can occur asthe complementary therapies included withinthe recovery environments continue to advance,as new applications for whole person recoveryenvironments become apparent, and as we continueto deepen our understanding of this promisingtherapeutic process.REFERENCES1. Tr ungp a C . Great Eastern Sun . Boston: ShambhalaPublications ; 1999.2. Po dvol l E. Recovering Sanity . Boston: ShambhalaPublications; 2003 .3. Tr ungp a C. The Sanity We’re Born With . Boston:Shambhala Publications; 2005 .4. Epstein M. Going to Pieces without Falling Apart .New York : Broadway Books; 1999 .5. Trungpa C. The Collected Works of ChögyamTrungpa: 2:254 . Boston: Shambhala Publications;2003 .6. Mipham J. Turning the Mind into an Ally . NewYork : River Head Books; 2003 .7. DiGi ac amo A M , Her r ick M . Beyond Psychiatry:The Windhorse Project . Berlin : Peer LehmanPublishing; 2007 .8. C hö drön P . When Things Fall Apart . Boston :Shambhala Publications; 1997 .9. Kne en C. Awake Mind, Open Heart . New York:Avalon Publishing Group; 2002.10. Rabin B , Walker R. A contemporary approachto clinical supervision . J Contemplat Psychother.1987 ;9:135–146.11. Almaas AH. Facets of Unity . Boston : ShambhalaPublications; 1998 .12. Trungpa C. The Collected Works of ChögyamTrungpa, vols. 2 and 6 . Boston : ShambhalaPublications; 2003 .13. Kneen C . Shambhala Warrior Training . Boulder:Sounds; True 1996 .14. Knapp C. Windhorse therapy: creating environmentsthat arouse the energy of health and sanity.In: Kaklauskas FJ , Nimanheminda S , Hoffman L ,Jack M , eds. Brilliant Sanity: Buddhist Approachesto Psychotherapy . Colorado Springs : University ofthe Rockies Press; 2008 :275–297 .15. Fortuna J. The windhorse project: recoveringfrom psychosis at home . J Contempl Psychother.1994 ; 9 :73–96.16. Miklowitz DJ , Goldstein MJ. Bipolar Disorder: AFamily Focused Treatment Approach . New York:Guilford Press; 1997 .17. Weisman A . Gaviotas: A Village to Reinvent theWorld . New York: Chelsea Green Publishing; 1998 .18. Trungpa C . The Collected Works of ChögyamTrungpa: 2:255 . Boston: Shambhala Publications;2003 .

22 Teaching Religious and Spiritual IssuesELIZABETH S. BOWMANSUMMARYUnited Kingdom, American, and World PsychiatricAssociation guidelines for education of psychiatryresidents recommend teaching religion-spirituality.Elsewhere, educational guidelines implicitlysubsume religion-spirituality under cultural competencerecommendations. American ethical guidelinesrequire knowledge of religion-spirituality forpsychiatrists and psychologists. In the United Statesand Canada, approximately 25 percent of psychiatryresidencies teach religion-spirituality. Trainingof North American psychologists lags but has risento about 15 percent of programs. Virtually no informationis available about religion- spirituality educationof African, Australian, or Middle Easternpsychiatrists or psychologists. I review psychiatryand psychology education availability in eightAfrican and eleven Middle Eastern countries.Interest in religion-spirituality in Australia is risingbut lags behind that of North America. Religionspiritualityis taught to medical students in 101American and Canadian medical schools, butinformation is unavailable on medical student educationin religion-spirituality elsewhere. I discusseducation grants, an English religion-spiritualitycurriculum for psychiatry and psychology residents,other teaching resources, teaching methods,faculty qualifications, and recommended contentprioritized into essential, important, and helpfulcategories. This chapter also addresses resistanceto curricular integration of religion-spirituality.Religion-spirituality education of psychiatrists andpsychologists is low, but rising, and would be morecommon if educational and ethical guidelines werefollowed.This is a book for clinicians. This chapteris about teaching religious-spiritual a issuesto psychiatric and psychological trainees.Did it take the wrong exit on the editorialfreeway and end up in this book instead ofan educational one? Clinician colleague,before you decide to skip this chapter, considerthis: Why did you decide to read thisbook? Was it because your clinical trainingdidn’t teach you enough about religionspirituality?If teaching about religion-spiritualityin clinical mental health care wasinadequate in your training, do you wantthe future generations of your colleaguesand their patients to suffer the same fate?1. RATIONALE FOR TEACHINGRELIGION-SPIRITUALITY1.1. Scope of Issue and Rationale forTeachingReligion and spirituality are nearly ubiquitous inhuman life, and mental illness afflicts approximately500 million people worldwide. (1) Nocountry lacks religion or mental illness. Thus, theeducation of mental health professionals mustaddress treatment of illnesses in people of allreligions. But why teach it to psychiatric, psychological,and other trainees? I propose three reasons:for our field, for our patients, and for ourcolleagues in training.aFor ease of expression, this chapter refers to religion andspirituality with one hyphenated term. This implies inclusionof both, but not equivalence. This chapter conceptualizes religionas institutional or organized and spirituality as a connectionto the transcendent or sacred.332

Teaching Religious and Spiritual Issues 3331.1.1. For the Mental Health FieldI will state this bluntly: Someday we are allgoing to die. If we do not teach our knowledgeto a new generation, it will die with us. The nextgeneration will lack the skills and knowledge wehave acquired. If we mental health professionalscannot provide care for religious-spiritual issues,our patients will go (and already are going) elsewhere.(2–4) Either we provide treatment relevantto our patients’ needs, or we die as a field.Training in this field, like training in other topics,will improve the competence of mental healthclinicians and will strengthen the healing powerof our professions. In fifteen years of teachingreligion-spirituality to psychiatry residentsand psychology interns,( 5) I have observed thattrainees exposed to religion-spirituality teachingare usually more well-rounded clinicians thanunexposed ones.1.1.2. For our PatientsPeople who seek mental health care are asreligiously oriented as the general populations inwhich they live. (6) Mental illness causes intensesuffering. People cope with suffering by seekingmeaning in their suffering, very often through religion,which provides a system of meaning. (7–9)Morally and professionally, we owe our patientsand clients the best possible care. That includescare for religious-spiritual issues, which patientsview as essential to their overall health. (8) If you,the reader, are a person for whom faith is essential,wouldn’t you want a therapist for yourselfor your family who was skillful in dealing withreligion-spirituality?1.1.3. For our Colleagues in TrainingThe World Psychiatric Association’s recommendedcurriculum for psychiatry residents worldwide(discussed below) explicitly recommendsteaching religion and spirituality (p. 10). (9) Thetraining requirements of psychiatrists in theUnited States and Canada require teaching of culturalissues such as religion.( 10 , 11 ) Standardsfor training of United Kingdom psychiatrists andAmerican psychologists refer to teaching culturalcompetence, which includes religion.( 12 , 13 ) Theethical guidelines for American psychologists andpsychiatrists (14–17) require competent treatmentof religious and spiritual issues in treatment. TheAmerican Psychological Association’s ethical code18 ( section 2.01b) explicitly states that “psychologistshave or obtain the training, experience, consultation,or supervision necessary to ensure thecompetence of their services” and expects them tobe competent in “factors associated with … religion… essential for effective implementation oftheir services.” Ethical requirements dictate thatwe educate our younger colleagues to meet competencyrequirements in religion-spirituality.We can ensure good care for the next generationof patients by providing skilled clinicians to helpthem with their religious-spiritual issues. Thoseclinicians are not going to absorb this knowledgeby osmosis. They have to be taught religion-spirituality,just as each of us had to be taught assessmentand psychotherapy techniques. If we don’teducate them about a topic as universal as religionspirituality,we have failed in our duty to give themthe best possible education. We wouldn’t dream ofneglecting to teach trainees about common andimportant conditions such as depression, anxiety,or psychosis. The same is true of religion-spirituality:It is a core human issue and is more prevalentin the population than all mental illnesses combined.We can’t be silent about it and pretend to beeducating fully competent colleagues.1.2. Why Focus on Students and Trainees?Given the reality that few practicing psychiatristsand psychologists were given adequate trainingin religion-spirituality, why focus on educationof students and clinical trainees? Surely we haveenough education to do with clinicians already inpractice. That’s true, but it’s short-sighted. First,it is far easier to initially teach someone a skillcorrectly than to struggle to reshape inadequateskills practiced for decades. Old dogs can learnnew tricks, but it’s much easier to teach the puppy.If we teach residents, interns, and students aboutreligion-spirituality, we can form their lifelongattitudes and practice skills toward competenttreatment of religion-spirituality.

334 Elizabeth S. BowmanSecond, if we teach this topic to trainees,some of them can become the next generationof researchers on religion-spirituality in mentalheath. All vibrant fields need to mentor their nextgeneration of researchers while they are young.My interest in this topic blossomed in my firstyear of residency after I attended a conference onpsychiatry and religion-spirituality where I wasexposed to academicians working in this field.My interest grew into an academic career, yearsof educating residents, and mentoring at leastone to an academic career in religion-psychiatry.Third, this chapter focuses on teaching psychiatricand psychological trainees because thatis already occurring in increasing numbers ofprograms with success. Grant funding,( 18) a curriculum,(19) and ample research data ( 20 , 21 ) areavailable to support evidence-based education inreligion-spirituality. Religion-spirituality is nowa viable academic option for psychiatric and psychologicalfaculty.most curricula, it emphasizes teaching attitudes,skills, and knowledge. This curriculum includesreligion-spirituality relevant objectives of integrating“humanistic, scientific and technologicalaspects of knowledge of psychiatry,” teaching “thecontext of an integrated biological, psychologicaland social approach,” and teaching the “skill toevaluate the role of personal and social factors inthe patient’s behaviour.”( 1)The medical student curriculum also expectsmedical students to communicate with “nonmedicalagencies involved in the care of patients,”learn “teamwork skills necessary for the doctorto … work in conjunction with non-medicalstaff,” and learn the “principles of psychiatric carein non-psychiatric settings and in the community.”(1) In many countries, these agencies wouldinclude religious groups or clergy. These requirementsimplicitly include teaching of the religiousspiritualaspects of psychological sciences tomedical students.2. EDUCATIONAL STANDARDS FORTEACHING RELIGION-SPIRITUALITY2.1. International Standards forPsychiatric Education of Medical StudentsThe World Psychiatric Association’s (WPA) (22)psychiatry curriculum for medical students (1)grew out of the 1988 Edinburgh World Conferenceon Medical Education. (23) This curriculumdescribes the minimum requirements in psychiatryfor medical students who will enter furthertraining in either primary care or any medicalspecialty. It emphasizes that medical educationthat concentrates on curative medicine is nolonger enough; disease prevention and healthpromotion must also be taught. (1 , 24–25) Thiscurriculum is directed primarily at medicalschool teaching of psychiatry.The WPA-World Federation for Medical Education(WMFE) medical student curriculumdoes not explicitly mention teaching aboutreligion-spirituality, but renders it necessaryvia numerous expectations regarding educationon the social setting of mental illness. Like2.2. Standards for Educationof PsychiatristsTh e WPA also has produced a Core Curriculumfor Postgraduate Training in Psychiatry. (26)Unlike the medical student curriculum, the residencytraining curriculum explicitly includes arecommendation to teach “religion and spirituality”as one of seventeen areas of “special aspects”of curricular knowledge (p. 10). (26) Anotherrecommended special aspect is “ cross-culturalpsychiatry.” This curriculum is general enough tobe applied to training in the WPA’s 104 membercountries, so further details are not offered. Whatis important is this: The world’s foremost psychiatricauthority has recommended all psychiatryresidents be taught religion and spirituality.2.2.1. Guidelines for American PsychiatristsAmerican guidelines mandate or encourageteaching of religion and spirituality in thetraining of psychiatrists. The most influentialAmerican guideline encouraging teaching of religionand spirituality in psychiatry residencies isthe 1994 training requirements for accreditation

Teaching Religious and Spiritual Issues 335of U.S. psychiatry residency training programs,published by the American Medical Association’sAccreditation Council for Graduate MedicalEducation (ACGME). (10) This document requireseducation of residents about religious and spiritualfactors in psychiatric care and prescribes inclusionin the didactic curriculum of “religious/spiritual”factors influencing development. The ACGMEguidelines also include religion/spiritualityamong issues to be taught as part of competencein cultural understanding. Thus, teaching religion-spiritualityhas been mandated for accreditationof American psychiatric residencies forfourteen years.In 1990, the American Psychiatric Association(APA-psychiatry) approved ethical guidelinesfor possible conflict between psychiatrists’ religiouscommitments and psychiatric practice. (15)These guidelines specify that psychiatrists respectfullyaddress their patients’ religious andspiritual beliefs. In 1994, the fourth edition ofthe Diagnostic and Statistical Manual of MentalDisorders (DSM-IV ) (27) included a category“Religious or Spiritual Problem” among nonpsychopathologicalConditions that May be a Focusof Clinical Attention. Neither the ethical guidelinesnor the inclusion of “Religious or SpiritualProblem” in the DSM-IV mandate training in religionand spirituality, but each provides a rationalefor training.2.2.2. Guidelines for Canadian PsychiatristsPsychiatric training in Canada occurs underthe auspices of the Special Committee in Psychiatryof the Royal College of Physicians and Surgeonsof Canada (RCPSC). The RCPSC’s psychiatrytraining requirements (11) do not specificallymention spirituality or religion. The RCPSC’sstandards for accreditation of psychiatry residencyprograms (28) do not mention religion or spiritualitybut make room for it: They require facilitationof “the acquisition of knowledge, skills, andattitudes relating to aspects of … culture and ethnicity”(28) (part B.4, p. 2) and mandate “opportunitiesfor consultations to … community agencies”(28) (part B.4.3c, p. 4). Religion is an aspect of cultureand ethnicity. Consultations with pastoralcaregivers and religious congregations would fallunder community agencies. These references arequite spiritually and religiously nonspecific, butthese requirements are Canadian applications ofa more religiously and spiritually specific set ofcurricular requirements from the Royal College ofPhysicians (RCP) of the United Kingdom. (12)2.2.3. Guidelines for United Kingdom (UK)PsychiatristsThe Royal College of Psychiatrists (RCP) is thepsychiatric organization of the Royal College ofPhysicians in the UK, which is the parent organizationof Royal Colleges of Physicians of BritishCommonwealth nations. The Competency-BasedCurriculum for Specialist Training in Psychiatryof the RCP (12) is the standard for psychiatry residencytraining in England and Northern Irelandand is used in Canada and other current or formerCommonwealth nations. In two places in the competencystandards of these guidelines, residentsare expected to “take into account …spiritual …factors in service development and delivery” (12)(section G.a.11) and to “take account of the complex… religious … issues that play a role in thedevelopment and delivery of services” (12) (sectionG.d.11). In addition to these two specificreferences to religion and spirituality, this curriculumfrequently mentions delivery of servicein “culturally diverse” or “multicultural” settings,terms that include religion and spirituality. Thepsychiatry residency curriculum of the UnitedKingdom is clear that residents should learn competencyin spiritual factors and religious issues inclinical care, but it is not explicit that residencyprograms teach it.2.3. Standards for the Educationof Psychologists2.3.1. American PsychologistsThe American Psychological Association(APA- psychology) standards for accreditation ofgraduate school programs in psychology includereligion by requiring focus on “cultural and individualdiversity … with regard to personal and

336 Elizabeth S. Bowmandemographic characteristics. These include butare not limited to age, color … religion, sexualorientation” (13) (p. 5, italics added). APA trainingstandards require programs to inform thestudent of relevant knowledge and experiencesin the area of diversity. This means religionspiritualityshould be taught to all American psychologistsin training.3. WHAT TRAINEES ARE ACTUALLYBEING TAUGHT3.1. Limitations of Available DataOur field is still in the stage of convincing the largerscientific community of its clinical importance.Accordingly, the scientific literature on education ofmental health clinicians about religion- spiritualityis still quite limited. Most research on religionspiritualityin health care is clinical, not educational,in focus. Research on religious-spiritualtraining in psychiatry and psychology consistsmostly of surveys of the prevalence and extent ofsuch education. Few teaching outcome data areavailable. Most research on mental health religionspiritualityeducation has come out of psychiatryand psychology in North America and formerBritish Commonwealth nations. Accordingly, thischapter focuses primarily on those professions, butincludes some information on religion- spiritualitytraining for medical students. Unfortunately,addressing the fields of social work, marriage andfamily therapy, and pastoral counseling is beyondthe scope of this chapter.3.2. Religion-Spirituality Training:Psychiatry and PsychologyInformation on actual training in religion- spiritualityin psychiatry and psychology across the world islimited. This chapter reviews available informationon training efforts arranged by continents.3.2.1. North American Psychiatry Training:CanadaThe RCPSC is the Canadian society of theRoyal College of Psychiatrists of the UK. Canadianpsychiatric training uses the 2006 standards ofthe Royal College of Psychiatrists,( 12) discussedabove. The RCP psychiatry standards encourageteaching of religion and spirituality. Is this actuallyhappening?A majority (78 percent) of Canadians endorsebelief in God. (29) Among Canadian psychiatricinpatients, 59 percent believe in a personal God and27 percent attend worship services frequently. (30)Canada has sixteen accredited general psychiatryresidency training programs. (31) In a 2003 survey,fourteen of these programs reported on spiritualityand religion training available to residents. (32)Four programs (25 percent of all Canadian programs,28 percent of responding programs)offered no formal or informal training in this area.Four programs (25 percent of all, 28 percent ofrespondents) reported mandatory didactic teaching,but the maximum hours offered was four inone program and one hour in two programs. Nineprograms (56 percent of all, 64 percent of respondents)offered case-based supervision to interestedresidents (three of them in programs withdidactic teaching). Two programs (12.5 percentof all, 14 percent of respondents) offered clinicalelectives related to religion and spirituality.Residents in three programs (19 percent of all, 21percent of respondents) were involved in relatedresearch endeavors under the supervision of facultyexperts. Thus, a maximum of one-fourth ofpsychiatry residents in Canada receive mandatorytraining in religion and spirituality, and the timeallotted to training is quite brief. In response toreports from Canadian psychiatry residents thatthey support introduction of formal lectures onreligion and spirituality, Grabovac and Ganesan(32) offered a ten-session proposed psychiatryresidency curriculum on religion and spiritualityspecific to Canadian cultures.Religion and spirituality are taught to abouthalf of Canadian psychiatric residents, but the doseof religious-spiritual education that Canadian psychiatryresidents receive appears small, perhapsbecause few Canadian residencies have appliedfor the Templeton Foundation psychiatry curricularawards discussed later in this chapter. TwoCanadian psychiatry residencies have received

Teaching Religious and Spiritual Issues 337these awards, which encourage religion-spiritualityeducation in all years of residency. Ampleopportunities exist for the expansion of trainingin religion and spirituality for Canadian psychiatryresidents.3.2.2. North American Psychiatry: UnitedStatesA 1988 survey of American psychiatry residencytraining directors found that very fewresidency programs had either frequently oralways offered didactic course work (12 percent)or provided clinical supervision (33 percent)that usually addressed religious issues. (33) Twothirdsof directors reported rarely or never offeringcourses on religion-spirituality. Few residentsreceived training in the dynamics of religiousbeliefs, or were supervised regarding the dynamicsof their own or their patients’ religious beliefs,regardless of the program’s association with religiouslyaffiliated institutions.In 1992 and 1993, Waldfogel et al. (34) surveyedthe religious lives and didactic and supervisionexperiences in religion-spirituality of 121American psychiatry residents in five programsnot affiliated with religious institutions. Theyfound 86 percent of residents had a religious affiliation,higher than the 76 percent found in 1990by Bergin and Jensen. (35) This level of religiousaffiliation may have been elevated by AfricanAmerican psychiatry residents who reportedconsiderably more religious participation andpersonal religious belief than white residents.Waldfogel and colleagues found that 49 percentof residents prayed at least weekly, although only22 percent attended religious services weekly,compared with 32 percent of a national sample ofpersons of similar age. (36) Twenty-seven percentof residents and 29 percent of third-year throughfifth-year residents reported that religion wasdiscussed or presented in their didactic program.A significant relationship was found betweenhaving either didactic (p < 0.005) or supervisionexposure (p < 0.001) and residents statingthat religion is important in the clinical setting.A high percentage of residents reported feeling“somewhat (72 percent) to very (12 percent)competent” in their ability to recognize andattend to a patient’s religious and spiritual issues.Feelings of clinical competence in recognizingand dealing with patients’ religious-spiritualissues were significantly correlated with didacticor supervisory education in religion-spirituality(p < 0.05). Waldfogel’s sample,( 34) although moderatein size, shows that religious-spiritual educationof psychiatry residents can affect clinicalattitudes. It is not known if residents’ clinical skillsincreased along with their confidence.These studies indicate that American psychiatrists,like Canadian ones, remain less religiousthan their patients, but are more religiously affiliatedthan reported in the past. Even in intenselyreligious America, in the early 1990s, at most30 percent of residencies were teaching aboutreligion-spirituality. However, that began tochange as funding of religious-spiritual educationbecame available.This author believes two major factors –guidelines (discussed above) and educationgrants – and two less influential factors have generatedincreased interest in teaching religion andspirituality in American psychiatry residencyprograms. Before the 1994 accreditation requirements,the majority (67–75 percent) of psychiatryresidents in the United States were exposedto little or no training about this topic. Is this stillthe case? Not since grants for religion-spiritualityeducation have been available.More U.S. psychiatry residencies began toteach religion-spirituality after 1997 when theJohn Templeton Foundation (37) inauguratedan award program for religion and spiritualitycurricula in psychiatric residency trainingfor accredited American and Canadian adultand child psychiatry residencies. This programwas administered by the National Institute forHealthcare Research (NIHR) until it ceased operationsaround 2002. Since then, this program hasbeen administered by the George WashingtonInstitute for Spirituality and Health (GWISH)(18) of Georgetown University in Washington,DC, which funds three to five psychiatry residencyprogram awards yearly. Since 1997, atleast forty-nine American and two Canadian

338 Elizabeth S. Bowmanpsychiatry residencies have received awards. Farmore residencies have created curricula to applyfor these grants, but the number of unsuccessfulapplicants who teach their curricula withoutmonetary support is unknown. Standards forreceiving awards are high: Awardees must teachreligion and spirituality to nearly all years ofresidents, use a diverse array of teaching methods,and have visibility in the community. Theinfusion of monetary support into educationon religion-spirituality in psychiatry has greatlyaccelerated interest in teaching it to residents.But what proportion of American psychiatry residenciesdoes this represent?The Accreditation Council on GraduateMedical Education (ACGME) lists 181 accreditedpsychiatry residencies in the United Statesand Puerto Rico. (38) The fifty-one programs(forty-nine American; at least two Canadian)that have received Templeton awards account for27 percent of accredited American residencies. Ifeven half of the approximately fifty unsuccessfulapplicants for Templeton awards are teaching thecurricula they developed, seventy-six (42 percent)of accredited American psychiatry residencies areinvolved in teaching religion-spirituality to theirresidents. This is not a majority of American psychiatryresidencies, and we have no actual datathat more than 27 percent of residencies teachreligion-spirituality. The proportion of psychiatryprograms teaching religion- spirituality isquite similar in Canada and the United States,probably because of cultural similarities.A third factor that may have encouraged teachingof religion-spirituality in U.S. psychiatry residenciesis the availability of a 1997 curriculumspecifically for psychiatry residents. Funded bythe Templeton Foundation, the 105-page ModelCurriculum for Psychiatric Residency TrainingPrograms: Religion and Spirituality in Clinical Care.A Course Outline (19) (hereafter referred to as theModel Curriculum ) was developed as a guide forresidencies applying for the Templeton psychiatrycurricular awards. This ready-to-use curriculumis applicable to psychology or social worktraining programs in any English-speaking country,and for use in continuing medical education(CME) presentations. It contains three core modules(overview, assessment, and human development),eight accessory modules, discussion oflearning formats, and a sample evaluation form. Itis unknown how many residencies are using thiscurriculum.A fourth factor, the intense religiousness ofAmerican culture, may also contribute to thewillingness of American psychiatry residenciesto offer courses in religion-spirituality. Surveysof Americans consistently show high endorsementof religious belief and practice: 95 percentof Americans endorse belief in God (39) , 90 percentpray, and 50 percent pray daily.(40) Almostthree-quarters of Americans say their religiousfaith is the most important influence in their life.( 35 , 36 ) The religiousness of American society isnot necessarily shared by American psychiatrists,who are much more likely (21 percent) than thegeneral U.S. population (6 percent) to considerthemselves atheist or agnostic (36) and less likely(40–70 percent) than their patients to believe inGod. (14) However, Bergin and Jensen (35) foundpsychiatrists (40 percent) no less likely than thegeneral American public (42 percent) to regularlyattend religious services.(36 , 41 )3.2.3. Psychology Training: United Statesand CanadaPsychology is a mental health disciplinethat prides itself on its objective scientific base.Thus, we might expect psychology training to bedevoid of education on religion-spirituality andfew psychologists to be personally religious. Dodata support these predictions?The picture of religion-spirituality educationin North American psychology has not beenpretty. A quarter century ago, Bergin (42) notedthat “training in the clinical professions is almostbereft of content that would engender an appreciationof religious variables in psychological functioning.”In 1990, Shafranske and Maloney (43)reported that as few as 5 percent of American clinicalpsychologists reported having had religiousor spiritual issues addressed in their professionaltraining. The next year, Lannert (44) reportedthat no psychology internships offered education

Teaching Religious and Spiritual Issues 339on religious or spiritual issues. Brawer et al. (45)noted psychology’s “general negative stance” onreligion and spirituality. Despite this, they notedthat psychology is following the U.S. trend towardaddressing religion- spirituality in medical training,but not to the degree seen in medical schoolsand psychiatry residencies. Brawer and colleaguesnote more journals and more research devotedto psychology and religion-spirituality and thecreation of Division 36 of the APA (psychology)devoted to religion-spirituality in psychology.The latter development indicates a considerablenumber of psychologists with a primary interestin religion-spirituality. But does this translate intoattention to this topic in training?Brawer and colleagues (45) investigated thisquestion with a survey of education in religionspiritualityin the APA-accredited clinical psychologyprograms in the United States andCanada. They considered course work, research,and clinical supervision in a survey of directorsof training of the 197 programs accredited as of1998. Among ninety-eight respondents, theyfound that 13 percent of programs offered a specificcourse on religion-spirituality in psychology.Twenty-four more programs were consideringadding such a course. In the 77 percent of programsthat addressed religion-spirituality in clinicalsupervision, coverage was often inconsistentlyincorporated into the usual supervisory process.In 61 percent of programs, religion-spiritualitywas covered as part of another course not devotedspecifically to religion or spirituality: in culturaldiversity courses (57 percent), ethics courses(41 percent), psychotherapy courses (32 percent),psychopathology courses (19 percent), andcourses on psychology history, family, and assessment.Brawer and colleagues concluded that psychologytraining programs tended to incorporatereligion-spirituality into multiple course offerings.More than 30 percent of the training programshad a faculty member who had published scholarlywork on religion-spirituality, and 22 percenthad a faculty member who identified this fieldas a major area of interest. Forty-three percentof programs had a student whose major area ofinterest was religion- spirituality. This study didnot specify if programs were masters or doctoratelevel. Data collection methods for Brawer et al.’sstudy and for research on psychiatry residenciesare too different for meaningful comparison ofreligious-spiritual education of psychiatrists andpsychologists in North America.Th e data of Brawer and colleagues’ studyneed replication, but indicate that religionspiritualitytraining, while infrequent, is becomingmore available to Canadian and Americanpsychologists. Systematic training in this fieldstill occurs only in a minority of psychologicalprograms ( systematic in 17 percent),( 45) butinterest appears to be rising, and a corps of facultymembers is forming to mentor research inreligion-spirituality for future generations ofpsychologists. Still, the majority of programs donot offer much education in this area. Furtherevidence that North American psychology ismore interested in religion-spirituality comesfrom the APA’s (psychology) recent publicationof several books dealing with religion in therapy:Shafranske’s Religion and the Clinical Practiceof Psychology (46) and Richards and Bergin’sHandbook of Psychotherapy and ReligiousDiversity . (47) Like our polar ice caps, thefrostiness of psychology to religion-spiritualityappears to be melting somewhat.3.2.4. European Psychiatry Training:United KingdomLittle information is available on whetherreligion-spirituality courses are actually taughtin U.K. psychiatry residencies. As in the UnitedStates, U.K. psychiatrists are considerably less personallyreligious than the general population: 27percent of 231 London teaching hospital psychiatristsand psychiatric residents reported areligious affiliation (versus two-thirds of the residents’parents) and 23 percent (versus 70 percentof the U.K. population) endorsed a belief inGod.(48 , 49 ) Among respondent psychiatrists,87 percent attended religious services once a yearor not at all. Psychiatrists who trained outsideEurope tended to report a belief in God morethan those who trained in Europe (35 percentversus 20 percent, p = NS). In practice, about half

340 Elizabeth S. Bowman(48 percent) of these London psychiatrists andresidents usually or always inquired about theirpatients’ religious beliefs, but only 42 percent hadever initiated a referral to clergy. Psychiatristswho regularly attended religious services weresignificantly more likely (p < 0.005) to havemade a referral to clergy. The attitudes of theseLondon psychiatrists toward religion and mentalillness were diverse, with a minority holdingpositive views of the effect of religious belief onmental health. Neeleman and King’s (48) dataare not a direct survey of training on religionspiritualityin the United Kingdom, but suggestit is unlikely this group of academic psychiatristsand residents had received effective training inreligion-spirituality.3.2.5. Australian Psychiatry TrainingAs a group, Australians are less religious thanAmericans: 61 percent of Australians believein God, 67 percent pray at least sometimes,and 25 percent attend religious services at leastmonthly. (50) Interest in spirituality and generalhealth may be rising in Australia, as evidencedby conferences on this topic in July 2005 andAugust 2007 and publication of the proceedingsof the 2005 conference as a supplement tothe Medical Journal of Australia in 2007. (51)This author was not able to find information onteaching religion-spirituality to Australian psychiatryresidents.3.2.6. Australian Psychology TrainingAustralian psychologist Passmore (52) holdsthat Australian psychologists have been lessactive than their American colleagues in stimulatingdebate, conducting research, and makingclinical application in religious issues in psychotherapy.She called for training Australian psychologiststo sensitively deal with religious issuesin therapy.3.2.7. African Psychiatry and PsychologyTraining: UgandaUganda has few psychiatrists. Kenyanpsychiatrist Njenga (53) describes the ranks ofUgandan psychiatry being decimated “in the darkdays of consecutive dictatorial regimes” via migrationelsewhere. The Department of Psychiatry ofUganda’s Makerere University Faculty of Medicinein Kampala offers Uganda’s only postgraduateprogram in psychiatry. Makerere Universitytrains psychiatrists for clinical work and trainsthem to train other mental health professionalsand primary health-care providers. MakerereUniversity’s psychiatry training program is centeredin Butabika Hospital, a national referralgovernment hospital in Kampala that providesinpatient and outpatient psychiatric and generalmedical care. (54) This author found no informationavailable about religion-spirituality educationin Butabika’s or Makerere University’s psychiatryprograms or any information on psychologytraining in Uganda.3.2.8. African Psychiatry and PsychologyTraining: TanzaniaNjenga (53) reports mental illness was traditionallylinked to demon possession and spiritualfactors in indigenous Tanzanian society.Modern psychiatry also is present in Tanzania.The Muhimbili National Hospital in Dar EsSalaam is the main teaching and referral hospitaland the only psychiatry training facility inTanzania. (53) The Department of Psychiatry ofthe School of Medicine of Muhimbili Universityof Health and Allied Sciences (MUHAS) (55)offers a master of medicine in psychiatry degree(equivalent to a Western psychiatry residency).MUHAS distinguishes itself by having anInstitute of Traditional Medicine for the studyof indigenous healing practices, which are oftenlinked to religion or spirituality, but this institutedoes not appear to provide education on mentalhealth. The Tanzanian Ministry of Health has asection of traditional medicine, but its focus isnot on education. Njenga (53) reported that in2001, Tanzania had ten psychiatrists total workingin the public sector. Mental health is taughtin all five years of medical school training atMUHAS, but details of the curriculum are notavailable.The people of Tanzania have a single trainingprogram in psychiatry, but no information

Teaching Religious and Spiritual Issues 341is available about whether trainees are educatedabout religion-spirituality. However, the existenceof the Institute of Traditional Medicineindicates Tanzanian academic medicine is likelyaware of traditional healing practices that maybe linked to spiritual beliefs. This author was notable to find information about psychology trainingin Tanzania.3.2.9. African Psychiatry and PsychologyTraining: KenyaThe medical director of Mathari Hospital inNairobi, Dr. Frank Njenga, reported in 2002 (53)that all psychiatrists in Kenya were Europeansat the time of the country’s independence in the1960s. In 1971, the Department of Psychiatryof Nairobi University School of Medicine(NUSOM) was founded in Nairobi. (56) In 1982,this department began to train adult and childpsychiatrists at Kenyatta and Mathari NationalHospitals for certification in the United Kingdomand established a three-year master of medicinein psychiatry degree. At Mathari Hospital, mostof the patients are Christian; treatment is Westernand biological.( 53 , 57 , 58 )The first indigenous Kenyan qualified in psychiatryin 1970 from the United Kingdom. In1975, NUSOM arranged with the University ofLondon to place four Kenyans each year for psychiatricstudies in the United Kingdom, trainingunder U.K. psychiatry standards. (53) In 2008,the NUSOM Department of Psychiatry was alsotraining medical students and nursing studentsand was offering degrees in other mental healthspecialties, including a master of science in clinicalpsychology, a master of medicine in psychiatry(psychiatry residency), and postgraduatediplomas in psychiatry, substance abuse, andsocial work. This author was not able to findinformation on whether religion-spirituality areaddressed in these degree programs, but found arequired course in social and transcultural psychiatryin the master of medicine in psychiatrycurriculum.Kenyan psychiatrists use Western approachesin large hospitals where the most severely illpatients are treated. However, in much of Kenya,traditional healers are used more than psychiatrists.In regional health centers across Kenya,psychiatrists work collaboratively rather thancompetitively with traditional healers such asherbalists and spiritualists, and even offer themtraining. (58) Publications by Kenyan psychiatristsoften refer to indigenous beliefs and practicesthat are effective in treating many mentalillnesses. It is unknown if Kenyan psychiatryresidents are taught about religion-spiritualityissues, but their faculty appear well aware ofthese issues. A second Kenyan medical school,Moi University, established in 1990 does not offerpsychiatric training. (59)3.2.10. Psychiatry Training: South AfricaEmsley (60) reports “qualification for registrationas a psychiatrist” [in South Africa] canbe accomplished either by completing a university-basedmaster’s degree in psychiatry –MMed(Psych), or completing the fellowship ofthe College of Psychiatrists of the Colleges ofMedicine of South Africa– FCPsych. Both theMmed(Psych) and FCPsych degrees require a4-year full-time training period in an approvedregistrar post. Admission requirements includean MBChB degree, a year of internship, andan additional year as a medical practitioner.Psychiatry is a popular specialty among SouthAfrican physicians. (60) Training programshave waiting lists. Psychiatric treatment takesa biological approach, but South Africa alsohas a Jungian Psychoanalytic Institute.In 2001, South Africa had eight medicalschools, with approximately 130 registrar(resident) posts. Since the national regulatorybody, the Health Professions Council ofSouth Africa, recognized psychiatry as thefifth major clinical specialty, a clinical rotationin psychiatry is required in the sixth yearof MBChB training. Most medical schools, inspite of staff shortages, provide undergraduateteaching courses in psychiatry. South Africanacademic psychiatrists spend an average of 7.5hours weekly teaching while managing largeclinical loads. (61)

342 Elizabeth S. Bowman3.2.11. African Psychiatric Training: MalawiBritish psychiatrist Herzig (62) visited Malawias a missionary in the 1990s to find himself theonly psychiatrist in the country and the only psychiatrichospital staffed primarily by nurses andorderlies. He opined that specialist psychiatriceducation was a luxury beyond the means of thepoorest countries where clinical services are tooinadequate to provide experience for trainees.Malawi’s situation rendered Western psychiatriccurricula unusable. Most mental and behavioralproblems are treated by traditional healers, withthe most disturbed patients being brought to thehospital or left untreated. Herzig recommendedMalawi’s College of Medicine approach offocusing on teaching medical students to treatcommon mental illnesses in outpatient primaryhealth-care clinics and on supervising and trainingpsychiatric nurses to provide mental healthcare in hospitals and in rural clinics. Herzig’s(62) only reference to religion-spirituality intraining was to recommend medical students betaught to consider “local cultural explanationsfor abnormal behavior such as bewitchmentand spirit possession.” No information on psychologicaltraining in impoverished Malawi isavailable.3.2.12. African Mental Health Training:MoroccoMohit (63) reports Morocco’s World HealthOrganization (WHO) Collaborating Centre inCasablanca conducts psychiatric research and wasactive in collaborating with WPA-WFME in thedevelopment of the medical student core curriculumfor psychiatry. (1) Morocco contains morethan 2000 psychiatric beds and offers psychiatrictraining in Casablanca and Rabat. Psychiatricnursing courses are also available. No informationis available about religion- spirituality educationin training in Morocco.3.2.13. Psychiatric and Psychological Trainingin the Middle EastThe vast Middle East, stretching from northernIndia to northern Africa, contains a richarray of religions. Its ancient cultures spawnedZoroastrianism, Judaism, Christianity, and Islam.After the rise of Islam in the sixth century CE,medicine and mental health treatment flourished.Currently, psychiatric education in many middleeast countries occurs in conjunction with theWHO and WFME. Numerous Muslim-associatedmental health groups exist in the Middle East.The Muslim Mental Health Association (64)publishes the Journal of Muslim Mental Health .The MMHA web site ( http://www.muslimmentalhealth.com/index.php?option=com_weblinks&Itemid=14 ) features links to nineteenrelated Muslim mental health groups worldwide,including the International Associationof Muslim Psychologists and the World IslamicAssociation for Mental Health. (65) The ArabBoard of Psychiatry offers certification of psychiatristsin a number of Middle Eastern countries.Very little, if any, information is availableon education in religion-spirituality in most ofthese predominantly Muslim countries, so thischapter discusses mental health training.3.2.14. EgyptEgypt has approximately 9000 psychiatric bedsand 500 to 1000 psychiatrists. (66) Psychiatrictraining is offered in major medical schools andcertification is given through national examinationand the Arab Board of Psychiatry. TheInstitute of Psychiatry at Ain Shams University,a WHO Collaborating Centre, offers trainingin child psychiatry. Egyptian training is availablein psychiatric nursing and clinical psychology.No information is available on teachingreligion- spirituality to Egyptian psychiatrists orpsychologists.3.2.15. IranThe Islamic Republic of Iran has 9200 psychiatricbeds, about 1000 psychiatrists, 350 mastersand doctoral level psychologists, and morethan 50 psychiatric nurses. (63) Currently, tenuniversities offer specialty training in psychiatry,and several centers offer subspecializationin child psychiatry. Psychiatric certification isgranted through the Iranian Board of Psychiatry.Iran also offers doctoral and masters degrees in

Teaching Religious and Spiritual Issues 343psychology, a doctoral degree in child psychology,and masters degrees in social work, psychiatricnursing, and occupational therapy. Details oftraining requirements were not available to thisauthor. Doubtless, the overwhelmingly Islamicmilieu of Iran affects training.3.2.16. IraqIraq has psychiatric facilities in at least threelocations, one of which, the main Shamaeeahhospital, is from the mid-twentieth century.Mohit (63) reports the conditions of psychiatrictreatment deteriorated after the 1991 internationalembargo. With Iraq now in the sixth year of war, itis likely that mental health training, about whichlittle information is available, may be severelydisrupted. No information was available to thisauthor about mental health training in Iraq.3.2.17. LebanonPsychiatric training for physicians has beenavailable in Lebanon since the mid-nineteenthcentury from American University in Beirut andthe Lebanon Hospital for Mental and NervousDisorders. The Lebanon Hospital has providedBritish-oriented training to numerous internationalpsychiatrists. In the twentieth century,Deir El-Saleeb (Hôpital de Croix), affiliated withthe French Faculty of Medicine, has trained psychiatricnurses and other auxiliary psychiatricworkers. (63) A one-year, postgraduate mentalhealthnursing course is available. Lebanon alsohas a twentieth century Muslim psychiatrichospital. This author could find no informationabout religion-spirituality in mental health trainingin Lebanon. The mixed Christian and Muslimpopulation likely leads to salient religious issuesin treatment.3.2.18. JordanThe country of Jordan has about 330 publicand private psychiatric beds and 50 psychiatrists.(63) Mental health services are oftenprovided in general outpatient health clinics.Mental health training is available to generalphysicians. This author found no information onpsychiatric or psychological training in Jordan,whose population includes primarily Muslims(over 90 percent) and Christians.3.2.19. PakistanAt present, eighteen medical colleges havedepartments of psychiatry, psychiatric hospitals,and specialty training programs. (63) Psychiatricresearch is conducted in Rawalpindi by theInstitute of Psychiatry. Master degree trainingin mental health nursing is available in Pakistan.The Pakistan Board of Psychiatry offers certificationof mental health specialists. Pakistan hasmaster’s degree training for mental health nursing.Pakistan’s mental health system offers integratedcare. Naeem and Ayub (67) include “lossof religious values” and “prejudices based on …sect” among factors contributing to high rates ofmental health problems in Pakistan, a countrythat is 97 percent Muslim.In 2004, Pakistan had about 870 teachinghospital psychiatric beds, four mental hospitalsand about forty psychiatric units attached tomedical colleges, most of whom have psychiatrydepartments. (67) Psychiatry is recognized by thePakistan Medical and Dental Council (PMDC)as part of the medical school curriculum. ThePMDC lacks a prescribed curriculum for teachingbehavioral sciences, so medical school psychiatriccurricula vary widely. No information is availableregarding inclusion of religion- spirituality inthe medical school curricula.Postgraduate medical training in Pakistanis regulated by the College of Physicians andSurgeons of Pakistan (CPSP), which accreditstraining institutes and sets curricula for specialties.Few general practitioners receive postgraduatetraining in psychiatry. (67) The CPSP offersfellowship (FCPS) exams in psychiatry that allowphysicians to practice psychiatry. Candidatesmay sit for the first part of the FCPS exam afterobtaining a MBBS or equivalent degree and completinga one year “house job” (internship) inany clinical area. Candidates must complete fouryears of psychiatry training in a recognized institutebefore they qualify to take part two of theFCPS psychiatry examination. Psychiatry trainingconsists of registering with a tutor approved

344 Elizabeth S. Bowmanby a college with an accredited department ofpsychiatry. Information is not available on thecontent of the curricula of psychiatric postgraduatetraining in Pakistan.3.2.20. Saudi ArabiaSaudi Arabia has inpatient psychiatric treatmentavailable at Shahar Hospital in Taif, and inJeddah, Riadh, and other large cities. (63) As inmuch of the Midle East and Africa, Saudi mentalhealth treatment is integrated into primaryhealth care. Specialty training in psychiatry isavailable, as are national certification and certificationthrough the Arab Board of Psychiatry.Information on psychological training or inclusionof religion-spirituality in psychiatric trainingwas not available to this author.3.2.21. SyriaThe Syrian Arab Republic has two twentiethcenturypsychiatric hospitals in Damascus andAleppo. Psychiatric training is conducted bymedical schools. (63) No curricular informationis available.3.2.22. United Arab Emirates (UAE)The UAE boasts a newly built psychiatric hospitalin Abu Dhabi. Psychiatric training is offeredby the United Arab Emirates University Collegeof Medicine and Health Sciences Departmentof Psychiatry and Behavioral Sciences, whichoversees an eight-week junior medical studentpsychiatry clerkship, a child psychiatry rotation,psychiatric CME, psychiatric training of primaryhealth care trainees, and a four-year postgraduatepsychiatry training in hospitals accredited by theArab Board of Psychiatry. (68) Psychiatry traineescomplete two years of adult and child psychiatryin Al-Ain before rotating for training in subspecialtypsychiatry in the Psychiatric Hospital inAbu-Dhabi. Neither the four-year didactic curriculumin psychiatry nor references to religionspiritualitywere available to this author.3.2.23. Palestinian TerritoriesIn 2001, Mohit (63) reported the PalestinianAuthority was operating a Ministry of Health,with a community mental health center andsmall inpatient unit in Gaza and a 320-bedinpatient unit in the West Bank. At thattime, Palestine had psychiatrists, psychologists,social workers, and trained psychiatricnurses. The dire current conditions imposedon Palestine by Israel in their political conflictrender it impossible to state whetherthese facilities are still operating or if psychiatricor medical education is available in thePalestinian territory.3.2.24. IsraelFounded mostly by European Jewish refugees,Israel is aligned with Western medicine. It is onesixthMuslim and contains a population of orthodoxJewish patients, for whom religious factorsmay require treatment modifications. (69) Mentalhealth training in Israel might be expected toinclude religion-spirituality.Israel has a system of mental hospitals, outpatientclinics, and community mental healthcenters operated by the government and privateorganizations. (70) With one psychiatricbed for every 1,000 people in the population,its services appear advanced compared to itsMiddle Eastern neighbors. Enosh (71) (Israel’sMental Health Association) provides a widearray of community-based support and advocacyservices.Psychiatry residency training is available froma number of universities. Child psychiatry is theonly psychiatry subspecialty recognized by theIsrael Medical Association, but other subspecialtytraining is available. Tel Aviv University operatesa two-year postgraduate program in forensic psychiatry,(72) programs in infant psychiatry, child/adolescent psychiatry, and basic and advancedlevel three-year programs in psychotherapy forpsychiatry residents, psychiatrists, psychologists,and social workers. (73) The Departmentof Psychiatry of Hadassah Hebrew University inJerusalem offers psychiatric training from its twomassive Hadassah University Medical Centerhospitals. (74)Little information is available about religionspiritualityteaching in Israeli mental health

Teaching Religious and Spiritual Issues 345training. Blass (75) described a frameworkfor teaching psychiatry residents to assess andtreat religious patients, but did not describeefforts that had actually been carried out in thatdirection. Lev-Ran and Fennig (76) mentioned“the increasing popularity of different spiritualmovements” in a list of issues not adequatelyaddressed in contemporary psychiatric residencyprograms in Israel. Israel appears well-situatedin providing mental health care and training,but efforts at including religion-spirituality maybe spotty, despite this nation’s Jewish-Muslim-Christian mix.3.3. Training of Medical StudentsThe WPA curriculum for psychiatry for medicalstudents does not specifically mentionreligion-spirituality, but strongly emphasizesthe worldwide trend toward integration of psychosocialand community issues in medical care.Are medical students being taught the religiousand spiritual aspects of psychosocially integratedcare?3.3.1. United States and CanadaTempleton grant support for teaching religion-spiritualityin medical schools has spurredcurricular development in the United States andCanada. (18) More than 100 U.S. and Canadianmedical schools (up from only five schools inthe early 1990s) (77) have developed courses(70 percent required) to teach students to dospiritual assessments with patients, to integratespiritual concerns into therapeutic plans, and toprovide guidance on when to refer patients tochaplains. (78)3.3.2. AustraliaIn 2003, Peach (50) called for more researchto improve the “current superficial knowledgeof Australian spirituality” and concluded, “Theproportion of physicians who currently enquireinto their patients’ spirituality is unknown, butis probably small. Spirituality has a place inAustralia’s medical courses, but perhaps not inpractice until more data are available.” It appearsdoubtful that many Australian medical studentsare trained in religion-spirituality. This authorfound no data on this topic in Australia.3.4. Training of Primary Care Physiciansin Religion-SpiritualityPrimary care physicians (family physicians, generalpractitioners, pediatricians, and internalmedicine specialists) deliver considerable mentalhealth care across the world and 54 percent ofmental health care in the United States. (4) Theirtraining at both the medical school and residencylevels should include religion-spiritualityeducation. Since 2000, the Templeton-GWISHprogram has given at least twenty awards toNorth American primary care residencies forcurricula in religion-spirituality. (18) This is adrop in the bucket compared to the number ofprimary care residencies, but these efforts are asolid start toward educating primary care practitioners.Less is known about religion-spiritualityeducation training of primary care physiciansworldwide, but the WPA-WFME advocates suchtraining. (1)4. WHO SHOULD BE TAUGHTRELIGION-SPIRITUALITYIN MENTAL HEALTH CARE?My answer to this question is simple: Any clinicianwho performs clinical mental healthevaluations or delivers mental health care needseducation in religion-spirituality. Most guidelinesare explicit about the need for training of psychiatristsand psychologists in religious- spiritualaspects of clinical care. This author advocatesreligion- spirituality training for clinical socialworkers, marriage and family therapists, inpatientpsychiatric nurses, inpatient and outpatientmental health counselors, advanced practice psychiatricnurses, emergency mental health workers,and substance abuse treatment workers.Because education on this topic has been scarce,postgraduate clinicians in these disciplines alsoneed education via CME courses.

346 Elizabeth S. Bowman5. WHAT SHOULD BE TAUGHT?5.1. Educational GoalsThe content of a curriculum depends on its educationalgoals, which are determined by the targetlearner population. I offer recommendationsfrom my experience teaching a religion-spiritualitycourse to psychiatry residents and from theModel Curriculum. (19) Three broad goals are keyfor all student clinicians who will provide psychologicalassessments and psychotherapy: (1) torecognize and distinguish pathological fromnormal religious and spiritual life; (2) to acquireskills, knowledge, and attitudes enabling themto deal therapeutically with religion-spiritualityin mental health care; and (3) to acquire clinicalcompetence in addressing religion/spiritualityin actual treatment settings. Although the broadeducational goals are identical for all disciplines,tailoring of content is indicated. Education ofpsychiatry residents should include religious attitudestoward medication and somatic treatmentsof mental illness, as well as toward psychologicaltherapies. Marriage and family therapy studentsespecially need education about religious grouppractices and beliefs about marriage, families,and sexuality. In the education of all mentalhealth clinicians, knowledge, but also skills andattitudes, need to be taught.Undergraduate course work in psychology,social work, and counseling also should requireeducation about religion-spirituality. The goalsfor undergraduates should be: (1) raising awarenessof the central role of religion and spiritualityin human life and society (sociology of religionspirituality);(2) communicating respect and basicknowledge about diverse religious traditions andspiritual practices (world religions); and (3) teachingevidence-based interrelationships betweenpsychology and religion- spirituality (psychologyof religion).5.2. Curricular Content“If there is one law of curricular development, itis that the material always exceeds the allottedcurricular time” (5) (p. 369). The amount of trainingtime given to religion-spirituality in a residencycurriculum is likely to be small, so prioritizingcontent is critically important. Content prioritiesshould be guided by the overall goal of assistingtrainees in recognizing normal and pathologicalreligious and spiritual life and assisting them indeveloping ethical and sensitive assessments andresponses. I recommend setting priorities andteaching in order of decreasing importance.Several approaches to teaching this topichave been published. Israeli psychiatrist Blass(75) , advocates a pragmatic teaching framework.He holds it is more effective to focus onteaching knowledge of phenomenology andinformation-gathering skills rather than broadknowledge of many religions. For instance, hesuggests teaching trainees the components thatdefine a delusion and the skills to seek collateralinformation from local informants (family,clergy, and other believers) on normativereligious beliefs. Blass’s approach to educationwould not include didactics on the content ofmajor faith groups.Canadians Grabovac and Ganeson (30) advocateteaching basics of major world religions andindigenous religion in their proposed elevensessionacademic curriculum for Canadian psychiatryresidents. Their recommendations forteaching on indigenous religion could be adaptedto African, South American, or Middle Easternsettings, but their curriculum, like the ModelCurriculum (19) is best suited to Europe andNorth America.Puchalski and Romer (79) suggest a simpleformula of content that fits into a single sessionof education and applies to medical students andprimary care health professionals: FICA. This is afour-question assessment of Faith , its Importance ,whether the person has a religious-spiritualCommunity , and how the person wants the providerto Address these issues as part of health care.Sample questions of the FICA model are availableat http://www.gwish.org. This approach canbe adapted for single or in-service CME presentationsor brief education for nurses and primarycare residents. Psychiatrists and psychologists

Teaching Religious and Spiritual Issues 347can use FICA, but need more religion-spiritualitytraining.Th is author recommends dividing contentfor clinical care students into three categoriesof decreasing priority: essential, important, andhelpful. (5) The content of these categories differsfrom the core modules of the Model Curriculum .First, teach essential information, then importantinformation if time permits, and finallyprovide helpful information in longer undergraduatepre-clinical courses. New instructorsdon’t have to re-invent the wheel to teach thistopic: The 105-page Model Curriculum is availablefor teaching psychiatry residents, psychologists,or social workers and would require only anupdated literature search for new mental healthreligionresearch data. The Model Curriculum istoo long to be taught in most residency curricula,but contains three core modules that wouldfit into most postgraduate clinical didactic programsand has optional modules (for example,trauma, gender issues, and substance abuse) forother settings.5.2.1. Essential ContentTh e goals of essential material are to helptrainees gain enough skills and comfort totake religious-spiritual histories from theirpatients and to mold attitudes with scientificdata on religion-spirituality. This author recommendsdividing this essential content intotwo sections: (1) general information on dataon religion- spirituality in health, and (2) gatheringand interpreting a religious/spiritual history.Address knowledge by teaching generalinformation that includes definitions of religion,spirituality, religious demographics in thesurrounding general population, and the gapin interest between mental health practitionersand the population (outlined in reference 20).Address attitudes and counter preconceivedbeliefs by including basic research data on therelationship of religion-spirituality to physicaland mental health. Teach essential skills bypresenting a live or recorded religious-spiritualhistory with a patient. Essential self-knowledgecan be gained by asking students to intervieweach other or present their personal religioushistory to a small student group. Appendix A ofthe Model Curriculum contains sample historyquestions; Appendix B contains criteria for evaluatinga religious biography. (19)5.2.2. Important ContentTh is author recommends three topics as highpriority after essential material has been covered.The most important is examination of psychodynamicsby which religion and spiritualityoperate to enable students to interpret clinicaldata. Trainees should learn the characteristicsof psychotic, neurotic, and healthy expression ofindividual religion-spirituality and the dynamicsof religious group processes. Importantmaterial includes ethical standards in addressingreligion-spirituality in treatment and caseexamples of therapeutic responses to religiousspiritualissues. Adult learners respond best topractical educational approaches, so this authoradvises using case examples of healthy and pathologicaluses of religion.( 80 , 81 )5.2.3. Helpful ContentHere we arrive at the luxury section forcurricula blessed with ample teaching time.This author recommends three topics. Mostimportant is further differential diagnosis ofreligious-spiritual material and psychodynamics,best taught via case discussion augmentedwith didactic instruction. Inpatient, psychiatricemergency workers, and primary carestudents will encounter religious material inpsychosis, mania, severe depression, substanceabuse, and organic brain illness. Psychiatrists,psychologists, and therapists conducting outpatientpsychotherapy will encounter thosetopics and neurotic and personality disordermanifestations of religion-spirituality. Clinicaltrainees are notoriously content-bound, so thisauthor highly recommends teaching simultaneousattention to religious-spiritual contentand process in small groups and individualsupervision.Second, this author recommends teachingreligious-spiritual development across the life

348 Elizabeth S. Bowmancycle, perhaps as part of a development course (19)(Module 3). This author has taught this materialby asking students to place themselves in Fowler’s(82) stages of religious development after presentingtheir own religious-spiritual histories.Development of conscience can be taught in childpsychiatry or psychology fellowships.( 83 , 84 )Third, for longer courses or curricula taughtacross years of clinical training, the eight accessorymodules of the Model Curriculum provideassistance. (19) Content (abuse issues, women’sissues, sects/cults, consultation-liaison, substanceabuse, and dynamics of God/Deity images)should be tailored to specific needs of trainingprograms and trainee levels. Many of these topicswill be optional and can be addressed in individualsupervision or in single sessions in othertraining courses.The amount of material available to teachtrainees need not be overwhelming if prioritiesare set and education is offered at multiple traininglevels and in different learning formats. Wenow turn to these topics.6. WHEN SHOULD RELIGION-SPIRITUALITY BE TAUGHT?Teaching is like an effective interpretation inpsychotherapy: it is helpful only when the contentand timing are both correct (p. 374). (5)Thus, religion-spirituality should be taught whentrainees are ready and able to use such learning.Content of education is linked to educationaltiming. Trainees need antecedent clinical knowledgeor experience to render a topic practical andrelevant.For psychiatry residents and psychologyinterns, no single “correct” approach exists; residencieshave successfully taught this material in“single dose” (one course) and “multiple dose”(graded exposure) formats. Because residents andinterns are doing clinical care, content should betailored to their current clinical level and type ofpatient. The ideal is to teach psychiatry residentsacross all years of training. In a single year ofpsychology internship, a single short course willlikely be more realistic.For four-year psychiatry residencies, thisauthor recommends the following: in the firstyear, teach definitions of religion-spirituality,basic data on religion and mental health, andmolding positive attitudes. For the second year,educate students in history-taking skills, personalreligious-spiritual histories, and differentialdiagnosis of healthy and unhealthy religionspirituality.In the third year, residents are readyfor a higher level of psychodynamic understandingof religious-spiritual life and groups, alongwith some special topics such as trauma or substanceabuse. In the fourth year, teach finer techniquesof addressing this topic in psychotherapyand additional special topics as listed above. Inundergraduate curricula, religion-spirituality willlikely be covered in upper-level university classesor in medical student clerkship didactics. Theauthor suggests trying different teaching strategiesto determine the best approach to specificprograms and students.In summary, adapt content to the availabletime and students’ needs. If one session is available,consider demonstrating the FICA approachto assessment (79) and discussing assigned readingon data about religion and spirituality inmental health. If four to ten teaching contacts areavailable, consider using the core modules of theModel Curriculum (19) or selected topics fromGrabovac & Ganesan’s (30) curriculum. For longercourses, consider use of the Model Curriculumsupplemented by chapters from recent books,including this volume.7. HOW RELIGION-SPIRITUALITYCAN BE TAUGHT: TEACHING FORMATSEducational formats, like timing, depend onthe training program and student population.Baccalaureate, master, and doctoral level preclinicaltraining programs for psychotherapists willneed a different format than medical/ psychiatricresidencies and psychology internships. Formatsare discussed in detail elsewhere. (5) The mostcommon format is didactic courses or seminars,but such time is often severely limited in postgraduateclinical training. Other brief teaching

Teaching Religious and Spiritual Issues 349formats can include offering intermittent inservicetraining to nurses and inpatient personnel(usually best if case-based), ongoing caseconferences, departmental Grand Rounds, filmclubs or journal club discussions, or CME formats.In training programs, brief formats havethe disadvantage of nonsystematic educationbut the advantage of high clinical relevance.Adult students need practical applications forlearning, so case material is essential in lectureformats. Clinical supervision of psychotherapyis ideal for teaching skills and attitudes towardreligion-spirituality, but faculty members withsuch interest and expertise may not be available.Teaching skills can be addressed in faculty developmentor provision of consultation to supervisors.Trainees learn best by doing, second best byobserving, and least from listening to lectures.In teaching a religion-spirituality course topsychiatry residents, it is valuable to includechaplains or chaplain students as co-learners.This author’s experience has been that exposureto clergy desensitizes residents to anxiety aboutinteracting with clergy, increases their respect forchaplains, and has led to more patient consultationrequests from residents to chaplains. Chaplainsoffer clinical viewpoints that enrich courses, andthey themselves benefit from increased psychiatricknowledge. This author’s residents gave highratings to inclusion of chaplains in their religionspiritualitycourse. Chaplains and communityclergy can serve as guest presenters or discussantsin trainee education, especially in sessionson the clergy’s religion.Formats for post-training education caninclude CME lectures, CME courses that includeliterature and case discussions, or ongoing casediscussion/peer supervision groups to developcollegial support. These groups can develop theskills of colleagues who could eventually becomea team of faculty for trainee courses.7.1. Post-Learning Evaluationof Educational EffectivenessEvaluation of educational offerings is helpfulto answer the question of whether teachingreligion-spirituality to trainees is effective inimproving patient care. Evaluation also providesessential feedback to help faculty improve teachingskills and understand how to modify curricula.A sample evaluation form is available in theModel Curriculum for adaptation. (19)8. WHO CAN TEACH RELIGION-SPIRITUALITY TO TRAINEES?Th is topic can be taught by anyone with a passionfor providing this education, with goodclinical skills, experience with religious patients,a willingness to invest time in choosing andteaching a curriculum or single session, and awillingness to bring an even-handed nonsectarianapproach to education. One need not be apublished expert, an accomplished teacher, orresearcher to teach religion-spirituality effectively.Moses succeeded in freeing the Israelitefrom Egypt despite his protestations of being apuny public speaker (Exod. 6:12, 30). (85) Allteachers have to begin their development somewhere.This author began as an inexperiencedjunior faculty member teaching a short coursefor residents.If you are interested in teaching this topic, don’tlet self-doubt stop you. You don’t have to teachalone. Moses and Aaron teamed up with Godto teach Pharaoh (Exod. 5–14). (86) Psychiatristscan gather a multidisciplinary team of clergy,psychologists, nurses, or other clinicians todevelop and teach this topic. An interfaith groupof teachers is ideal to avoid sectarian bias in educationand maximize acceptance of an educationalproposal. Use the array of resources now availablein your area, including the Model Curriculum ,(19)recent books,( 46 , 87 , 88 ) and assessment instruments.(89) Resources are available to teachreligion- spirituality in programs oriented towardpsychoanalysis,(90–92) cognitive-behavioral treatments,(93)and psychobiology. (93) Programs andfaculty in resource-poor situations can use theInternet for educational resources available fromGWISH,(18) the Templeton Foundation,(37) andthe WPA. (22)

350 Elizabeth S. Bowman9. DEALING WITH LIMITATIONSAND RESISTANCE TO CURRICULARINTEGRATIONFaculty or clinicians who attempt to teach mentalhealth clinicians about religion-spirituality willinevitably run into some resistance from students,faculty, program directors, or entire institutions.Most resistance is due to ignorance or countertransferenceissues. Ignorance can be counteredwith persistent education about the universalityof religious-spiritual concerns in patients.Countertransference resistances in students andadministrators alike generally fall into the categoriesof personal discomfort with this topic orunresolved religious-spiritual conflicts. Passivetrainee resistance of “forgetting” to assess religioncan be dealt with directly in individual supervision.Discussion of countertransference to thistopic should also be part of individual supervision.Overt skepticism about religion-spiritualityteaching by administrators can be countered withprovision of data on religion-spirituality andmental health and by gently expressing wondermentthat any scientist would be unwilling to lookat data on any clinical topic. This author suggestsmaintaining an explicitly scientific approach toresistance to inclusion of religion-spirituality incurricula. Resistance to education on religionspiritualitymust be addressed if educationalefforts are to occur or be effective.Be persistent in confronting resistance.Remember, Moses and Aaron did not succeed thefirst three times they asked Pharaoh to free theIsraelite slaves (Exod. 5–14). (86) Several approachesmay be necessary to get religion-spirituality intotrainee or undergraduate curricula. (5, page 377).ACKNOWLEDGMENTThe author thanks author and editor LethaDawson Scanzoni for invaluable assistance withInternet research.REFERENCES1. World Psychiatric Association and WorldFederation for Medical Education (WPA-WFME) .Core Curriculum in Psychiatry for Medical Students .Geneva: WPA; 1993 –1999.2. L ars on DB , Hohmann A A , Kessler LG , Me adorKG , B oyd JH , Mc Sher r y E . The couch and thecloth: the need for linkage . Hosp CommunityPsychiatry . 1988; 39 (10):1064–1068.3. Beitman BD . Pastoral counseling centers: a challengeto community mental health centers . HospCommunity Psychiatry. 1982; 33 :486.4. R e g ier DA , G oldb erg J D , Taub e C A . The defacto U.S. mental health services system: a publichealth perspective . Arch Gen Psychiatry.1978 ; 35 :685–693.5. Bowman ES. Integrating religion into the educationof mental health professionals. In: KoenigHG, ed. Handbook of Religion and Mental Health .San Diego : Academic Press;1988 :367–378.6. Krol l J , She ehan W. R el i g ious b el iefs and pr ac t ic esamong 152 psychiatric inpatients in Minnesota .Am J Psychiatry. 1994 ; 146 :67–72.7. Pargament , KI . The Psychology of Religion andCoping . New York : Guilford; 1997 .8. King DE , Bushw ick B. B el iefs and att itudes of hos -pital inpatients about faith healing and prayer . JFam Pract. 1994; 39 (4):349–352.9. Ko enig , HG , C ohen H J , Bl a z er D G , e t a l.Religious coping and depression among elderlyhospitalized medically ill men . Am J Psychiatry.1992; 149 :1693–1700.10. Accreditation Council for Graduate MedicalEducation (ACGME) . Special Requirementsfor Residency Training in Psychiatry . Chicago :Accreditation Council for Graduate MedicalEducation ; 1994 :11–12, 18. http://www.acgme.org/ . Accessed May 23, 2008.11. Royal College of Physicians and Surgeons ofCanada (RCPSC) . Specialty Training Requirementsin Psychiatry . Ottawa, ON : Royal College ofPhysicians and Surgeons of Canada; 2007 a. http://rcpsc.medical.org/information/index.php?specialty=165&submit=Select . Accessed May 20, 2008.12. Royal College of Physicians (RCP) . A Competency-Based Curriculum for Specialist Training inPsychiatry. Specialist Module in Adult Psychiatry .London : Royal College of Psychiatrists; 2006 .13. American Psychological Association . Guidelinesand Principles for Accreditation of Programs inProfessional Psychology . Washington, DC :American Psychological Association; 2000 .14. American Psychiatric Association (APA). TaskForce Report No. 10: Psychiatrist’s (sic) Viewpointson Religion and Their Services to ReligiousInstitutions and the Ministry . Washington, DC :APA Press; 1975 .15. American Psychiatric Association (APA) .Guidelines regarding possible conflict betweenpsychiatrists’ religious commitments and psychiatricpractice . Am J Psychiatry . 1990 ; 147 :542.16. American Psychiatric Association (APA) . ThePrinciples of Medical Ethics With AnnotationsEspecially Applicable to Psychiatry . Arlington, VA:

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UAE\ Universities & TechnologyInstitutes\United Arab Emirates University\College of Medicine and Health Sciences\Department of Psychiatry and BehaviouralSciences. 2002 . www.arabdecision.org/show_func_3_12_22_1_6_4160.htm. Accessed June 4,2008.69. Trappler B , Greenberg S , Friedman S . Treatmentof Hassidic Jewish patients in a general hospitalmedical-psychiatric unit . Psychiatric Serv.1995; 46 (8):833–835.70. Israel Ministry of Health . 1999 . http://www.mfa.gov.il/MFA/MFAArchive/1990_1999/1999/10/Ministry+of+Health.htm?DisplayMode=print .Accessed December 11, 2008.71. Enosh ( Israel Mental Health Association ). 2008 .http://members.tripod.com/Goldin_Yarik/about_amuta_e.htm . Accessed June 8, 2008.72. Barak , P. Forensic psychiatry in Israel . PsychiatrBull. 2002 ; 26 :143–145.73. Tel Aviv University . Sackler Faculty of Medicine .Tel Aviv, Israel. 2008 . http://med.tau.ac.il/cme/english.asp . Accessed June 4, 2008.74. Hadassah University Medical Center . Jerusalem:Hadassah Hebrew University. 2008 . http://www.hadassah.org.il/ . Accessed May 31, 2008.75. B lass DM . A pragmatic approach to teachingpsychiatry residents the assessment and treatmentof religious patients . Acad Psychiatry.2007; 31 :25–31.76. Lev-Ran S , Fennig S. Points to ponder regardingcontemporary psychiatric training in Israel . IsraeliJ Psychiatry Related Sci. 2007 ; 44 (3):187–193.77. Puchalski CM . Spirituality and medicine: curricula inmedical education . J Cancer Edu. 2006 ;21(1):14–18;also, see John Templeton Foundation CapabilitiesReport . West Conshohocken, PA: TempletonFoundation ; 2006:68.78. Puchalski CM , Larson DP , Lu FG . Spirituality inpsychiatry residency training programs . Int RevPsychiatry. 2001; 13 :131–138.79. Puchalski CM , Romer AL . Taking a spiritual historyallows clinicians to understand patients morefully . J Palliat Med. 2000; 3 :129–137.80. Battista JR . Offensive spirituality and spiritualdefenses. 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Teaching Religious and Spiritual Issues 35382. Fowler JW . Stages of Faith . San Francisco : Harper &Row; 1981 .83. Stillwell BA , Galvin M , Kopta SM , Padgett RJ .Moralization of attachment, a fourth domain ofconscience functioning . J Am Academy ChildAdolescent Psychiatry. 1997; 36 :1140–1147.84. Gilligan C . In a Different Voice . Cambridge, MA :Harvard University Press; 1982 .85. American Bible Society . In the Holy Bible . New York :American Bible Society ; 1995:70–71.86. American Bible Society. In Hioly Bible . New york:American Bible Society; 1995: 68–81.87. Miller WR . Integrating Spirituality into Treatment.Resources for Practitioners . Washington : AmericanPsychological Association; 1999 .88. Koenig , HD . Handbook of Religion and MentalHealth . San Diego : Academic Press; 1998 .89. Hill PC , Hood RW, eds. Measures of Religiosity .Birmingham, AL : Religious Education Press; 1999 .90. Meissner WW. Psychoanalysis and ReligiousExperience . New Haven, CT : Yale University Press;1984 .91. Black DM, ed. Psychoanalysis and Religion in the21st Century . New York : Routledge; 2006 .92. Jones JW, ed. Contemporary Psychoanalysis andReligion . New Haven, CT : Yale; 1991 .93. Finn M , Gartner J, eds. Object Relations Theoryand Religion . Westport, CO : Praeger; 1992 .94. Newberg A , D’Aquili E , Rause V . Why God Won’tGo Away . New York : Ballantine; 2001 .

23 Conclusion: Summary of What Clinicians Need to KnowPHILIPPE HUGUELET AND HAROLD G. KOENIGIn editing this book, our desire was to provide clinicianswith knowledge about religion and mentalhealth that would be useful in the treatment ofpatients with psychiatric disorders. In addition,we thought that clinicians would also find usefulinformation on more theoretical issues such ashistory, neurobiology, and theology as they relateto psychiatry.1. OVERVIEWA growing scientific literature based on religionand psychiatry has allowed rapid progressin the integration of religion into psychiatry.Despite this progress, the integration of relevantreligious issues into clinical practice will likelymeet resistance for many years to come. There issome question, however, about whether conceptssuch as well-being, meaning, or even recoverybelong exclusively to the domain of conventionalpsychiatry. (1) In their description of the complexinteractions between religion and psychiatry,Palouzian and Park (2) define a multilevelinterdisciplinary paradigm, which, as mentionedin the introduction, should accommodate manydimensions of psychology and psychiatry, butalso other domains like evolutionary biology,neurosciences, anthropology, philosophy, andother allied areas of science. A thorough discussionof these conceptual issues is far beyond thescope of the present book. However, this complexityand multidisciplinarity may be viewedas richness, which is reflected in the diversity ofperspectives presented in this book.Thus, we hope that, despite a certain levelof subjectivity, the diversity of approachesexpressed here has at least exposed readers tothe multidisciplinary nature of this interactionbetween religion and mental health care. Inthe case of the treatments described, we do notendorse all approaches presented here. However,clinicians should know that these approachesexist so that they can refer patients for the appropriatetreatment when necessary or be able toanswer patients when they ask for advice aboutparticipating in such treatments.Of course, because we are psychiatrists, wehave put more emphasis on psychiatric issues(rather that anthropological, theological, or historicalones). This book has been written primarilyfor psychiatrists who want to know moreabout religion and how to integrate it into clinicalpractice. Other mental health professionalswho interact with psychiatrists and treat thosewith mental illness, such as psychologists, counselors,sociologists, chaplains, or other membersof the clergy, may also benefit from this book.We hope that it has been written in a way thatwill be useful to professionals from a variety ofbackgrounds. The goal is to help build bridgesbetween all of that it will enhance the care ofpatients, who are unique in their humanness,suffering, and worldview.With this in mind, let’s recall and highlight themain points that readers should take away fromeach of the chapters in this book.2. HISTORICAL CONSIDERATIONSThe first part of the book aims to provide knowledgeabout history, theology, and neurobiology.The chapter on historical considerationsexamines the relationships between insanityand religion, medicine and theology, treatment354

Conclusion: Summary of What Clinicians Need to Know 355and ritual. Focusing primarily on care providedin Christian environments in Europe and NorthAmerica, the author describes the way psychiatricillness is featured in the Bible and thenreviews the worldview and healing practices ofthe ancient Greeks. Early church authors (forexample, John Chrysostom) generally had a viewof madness that incorporated a spiritual perspective,while also acknowledging the physical influences.Religious approaches to mental illness inthe Middle Ages are detailed through a descriptionof the Leechbook of Bald. This book distinguishesbetween demon possession and lunacy.The physician is encouraged to treat the demonpossessed,as well as lunatics, with herbal concoctions.During the Renaissance, those dealing withthe mentally ill moved further away from solelyrelying on supernatural explanations. ReginaldScott in England, for example, explained that peoplewho are sad or distressed suffer from a naturalmalady and not from supernatural influences. Amore secular medical approach to mental illnessdeveloped later during the Enlightenment (eighteenthcentury). Those dealing with the mentallyill began separating religious causes fromother causes. (For example, see Robert Burton’sAnatomy of Melancholy , 1621.) (3) The nineteenthcentury was marked by the creation ofasylums. Sometimes these reforms were drivenby a religious motive – as in England at the YorkRetreat. In other cases, they were prompted by arationalist/secular reform motive as in the caseof Philippe Pinel and his reforms in France at theSalpetrière. Sometimes the reasons for humanereforms were a mixture of religious and secularmotivation, as at the South Carolina LunaticAsylum in Columbia, South Carolina. Duringthe latter part of the nineteenth century, psychiatryin Europe and the United States began to leantoward a view of mental illness that was morerationalistic and focused on heredity and biology.The most important influence of the twentiethcentury was the work of Sigmund Freud(1856–1939), who viewed religion as a shareddelusion, helpful for some, harmful for others,but ultimately something that was an indicator ofpsychological immaturity.3. THEOLOGYThe chapter on theological considerations givesinsight as to how a theologian may consider mentalillness and the clinicians treating it. This providesclinicians with an idea of how mental illnessmight be understood by members of the clergy.According to the author, reductionism should beavoided and the religious backgrounds of patientsconsidered in assessment and treatment. Religionshould not be considered only for its therapeuticpossibilities. An informed theological perspectiveon a patient’s beliefs and dispositions may help theclinician better understand how such beliefs anddispositions relate to a particular patient’s mentalillness. Those beliefs and dispositions may follow“naturally” from the patient’s religious commitments,or they may have become distorted andintertwined with their psychiatric pathology. Oneshould not forget, however, that active mentalillness of various kinds is not incompatible withorthodox religious belief. The author emphasizesthat clinicians should address religion in its particularity,such as Judaism, Christianity, or Islam,rather than religion in general, even if manyreligious systems share some resemblances. Theauthor describes two challenges facing cliniciansconfronted with Christianity. The first concernsthe connotation that some religious patients haveconcerning the category “mental” illness. Indeed,clinicians may have to contend with religiouspatients who are suspicious of and even hostiletoward the idea of modern psychiatry. Conceptsunderstood in modern psychiatry such as thedistinction between the spiritual and the physical,the body and the soul, or the natural and thesupernatural, are, from the perspective of scripture,deeply problematic and useful only in a limitedsense. The second challenge is the questionof why suffering afflicts good and faithful people.In philosophy, this corresponds to the problem oftheodicy (from the Greek theos , “god,” and dikē ,“justice”), which is typically posed in the form ofa question: “Why does a benevolent, all- powerfulGod allow the innocent to suffer?” From the perspectiveof scripture, “why” questions about sicknessand suffering are almost always the wrong

356 Philippe Huguelet and Harold G. Koenigplace to begin. God is fundamentally supposedto be non-coercive with respect to the humanwill; God entices us by attraction rather than bypushing us from behind. The human capacity tochoose God’s will naturally implies the freedomto choose against God’s will as well. Christian traditioncalls the act of choosing against God’s willsin and suggests that it is sin that is the cause ofvarious forms of suffering. Thus, suffering is oneof the most obvious effects of sin, not in the sensethat God punishes sinners by making them suffer,but in the sense that sin is in a variety of ways itsown punishment. In other words, the natural consequencesof sin result in suffering and pain, notin the full and flourishing life that God intended.4. THE BIBLEThe Bible is composed of many individual bookswritten by men whom Jews and Christians believewere divinely inspired. Judaism and Christianityare Bible-based religions and neither could havesurvived by oral tradition alone. The Bible is themost globally influential and widely read bookever written. Thus, being such a vast and complicatedbook, it is important to provide clinicianswith insight into these writings that are likely toinfluence their patients.Many religions (including those based onthe Bible) may use sin and guilt as methods thatinfluence their members’ behavior, as well asthe way that symptoms of psychiatric illness areexpressed.The Judeo-Christian tradition has been asignificant force in defining the “natural” roleof Western women. Unfortunately, the Biblewas written and edited over the course of morethan a thousand years in a largely male-dominatedsociety so that no consistent feminine“model” emerges (except figures such as Debraand Ruth in the Old Testament, and Mary inthe New Testament). Overall, women in the OldTestament were valued primarily as mothers, aswas typical in Middle Eastern society in the secondmillennium BC. Some negative portrayals ofwomen, described as a man’s possession whoserole was to be silent or described as the seductiveand manipulative person are found throughoutthe “wisdom” literature of the Hebrews. Suchscriptures have been used by men to rationalizeabusive behavior, even in Western countries.This chapter also discusses homosexuality,an issue that divides societies and families. TheBook of Levitical Laws, as well as other scriptures,condemns homosexual behavior. Christians arenot obligated to follow these laws, yet many continueto condemn homosexuality (based on thewritings of the Apostle Paul), even though mostpsychiatrists no longer consider it to be a mentaldisorder.The history of Christian religious healing isreviewed and demonstrates that sick individualswho participate in religious rituals may feel betterpsychologically and physically, at least temporarily.However, some self-serving Christian healerscan also be viewed as charlatans. Due to its complexity,the Bible can often be interpreted to suitmany purposes by those who wish to justify theiractions or manipulate the actions of others forpersonal gain. Nevertheless, the mentally ill oftenread the Bible to reaffirm their faith in a God whopersonally cares for them and is always presentfor them. In their reading, they may discover apassage that relates to their experiences and hasspecial meaning to them that helps them to continueliving and enables them to function.5. NEUROPSYCHIATRYEmotions, thoughts, and behaviors have theirorigin in the brain. Besides questions about therelationship of the soul to the brain, it is importantto know what neuroscientists have discoveredabout religion.For example, brain-imaging studies haveshown that regions of the brain associated withmystical and spiritual experiences are located inthe frontal and temporal lobes. However, suchresearch is not always consistent, and reportsmay differ depending on the particular researchgroup reporting.Neurotransmitters are chemicals that relaymessages between the neurons in the brainacross a gap called a synapse. Some benefits of

Conclusion: Summary of What Clinicians Need to Know 357praying and meditation on psychiatric disorderscould be explained by a modulation of the neurotransmitterserotonin (5-HT). The involvementof the 5-HT system in spiritual experiencesis supported by observations that drugs knownto perturb the 5-HT system (LSD, psilocybin)can induce spiritual-like experiences. Given itsimportance in many personality traits, emotionssuch as anger, depression, and psychoticillness, the neurotransmitter dopamine has alsobeen investigated as playing a role in spiritualexperience. Of note, dopaminergic neuronsare also under the control of the 5-HT system.Research has shown an activation of the dopaminergicreceptors in the striatum during meditation,indicating an increased level of dopaminein this region during such religious activity.Some studies also show increased activity inGABA (the main inhibitory neurotransmitterin the brain) during meditation. This possiblyreflects increased GABA activity in the brainlinked to the deafferentation observed duringmeditation practice. From a genetic perspective,there is some evidence that human psychologicaltraits, and possibly the capacity to have spiritualexperiences, are stable over time and influencedby genetic factors. Not surprisingly, researchershave focused their analyses on genes and geneticpolymorphisms mainly related to 5-HT anddopaminergic systems. Some researchers havepostulated that religious beliefs could be geneticallydriven and, rightly or wrongly, have consideredspirituality as a component of personality.For example, self-transcendence encompassesseveral aspects of religious behavior, subjectiveexperience, and the way an individual perceivesthe world. There is evidence that the capacity ofthe person to experience self-transcendence maypartly depend on genetic influences.Recently, research has been focusing on geneenvironmentinteractions is, or GxE, as part of anew comprehensive model of psychiatric disorders.GxE typically occurs when the effects of oneenvironmental factor on the individual is dependanton his or her genotype. Spirituality andreligiousness are examples of complex traits thatcould be understood in this way. Environmentalfactors, including hormone levels (as a reflectionof gender), diet, drugs, geographical region oforigin, and so on, may play a role in the expressionof spirituality.6. PSYCHOSISIn this and following chapters we consideredclinical issues as they relate to specific psychiatricconditions. Psychosis is an example wherereligion and mental illness may interact due tothe fact that some patients have delusions withreligious content. This may have led to the à prioriconclusion that religion is harmful to patientswith psychosis.Yet recent research indicates that patientswith illnesses such as schizophrenia, delusionaldepression, or bipolar disorder are able to reconstructa life worth living despite their disablingdelusions or negative symptoms. Religiousinvolvement may help these patients find ways ofregaining hope as well as developing meaningfulactivities and social roles.Indeed, religious coping appears to be importantfor a large majority of patients with psychosis.Religion provides these patients with a positivesense of self, guidelines for interpersonal behavior,and resources to cope with their symptoms.With regard to the negative effects of religionin psychotic disorder, it is possible that, at leastin some cases, religion may predispose individualsto exacerbations of illness due to its arousal ofintense emotional experiences (religious conversion,for example) that may be disorienting andworsen psychotic illness.No specific guidelines exist in the scientificliterature on how to incorporate religious issuesinto the individual care of patients with psychosis,although some clues on how to intervenehave been provided as follows.First, although it appears that many patientshave religious beliefs and pray alone, they areoften not involved in religious community activities.They repeat in religious settings what happensin other areas of their lives because theyhave problems creating and maintaining an interpersonaland social network. This area can be a

358 Philippe Huguelet and Harold G. Koenigfocus of treatment, because these deficits couldbe overcome with proper treatment.Psychotherapeutic work might also addressother issues such as spiritual crisis, identity building,and meaning.Group therapy approaches that involve spiritualityhave been developed, at least in the UnitedStates. Other programs may exist elsewhere,but they have not been reported in the literature.Some groups are more supportive and lessorganized and/or psychodynamically oriented;others are more structured, based on behavioralcognitiveprinciples. A group format has someadvantages over individual treatment not only interms of costs but also in terms of the opportunitiesfor interaction among patients.For psychotic disorders, perhaps even morethan for other mental conditions, explanatorymodels may vary across culture and religiousbackground. Assessing the patient’s explanatorymodel is thus important to overcome barriers totreatment.7. HALLUCINATIONS AND DELUSIONSHallucinations and delusions are considered ina separate chapter, because these symptoms mayarise in various psychiatric disorders. A delusionis a false belief based on incorrect inferencesabout external reality, a false belief whichis firmly held despite what almost everyone elsebelieves and despite what constitutes incontrovertibleand obvious evidence to the contrary.The discontinuity between pathology and normalityhas been challenged by epidemiologicalstudies finding that delusions are present in thegeneral population. It has been shown that 10 to28 percent of the general population experiencesdelusions, whereas the prevalence of psychosisremains at around 1 percent.Religious delusions have been described in allmajor cultures across the continents. However,prevalence differs according to the country andsociocultural context. The prevalence of religiousdelusions varies widely not only with geography,but also with time. Also, political changeand technological progress impact the content ofdelusions. In the United States, among psychiatricpatients hospitalized in emergency wards,the rate of religious delusions in one study was36 percent for patients with schizophrenia, butthese symptoms were also observed amongpatients with bipolar disorder (33 percent),other psychotic disorder (26 percent), alcoholor drug disorder (17 percent), and depression(14 percent).Religious delusions may also lead to violentbehavior. Aggression and homicides havebeen perpetrated by religiously deluded people,as they have been by nonreligiously deludedpersons.Religious delusions have also been associatedwith poorer outcome in some studies, althoughnot in others. People with religious delusionshave been found in some studies to be moreseverely ill, with more hallucinations for a longerperiod of time. However, the association betweenreligious delusion and a poorer outcome seemsto be controversial. Further research is needed tobetter understand this phenomenon. Is religiousdelusion in itself a marker of the severity of thepathology?Abnormal perceptual experiences (that is,hallucinations) are not restricted to psychiatricpatients either, and may occur in any sensorymodality (for example, auditory, visual, olfactory,gustatory, and tactile). In the United Kingdom,the annual prevalence of auditory or visual hallucinationsis 4 percent in the general population,with only one out of eight people with hallucinationsmeeting criteria for a psychiatric diagnosis.The basic mechanism of hallucinations lies inthe inability to differentiate an internal from anexternal stimulus. Delusions and hallucinationsoften go together. This association may be partlydue to the fact that some delusions come about inorder to give meaning to hallucinations.For clinicians, it is important to be able todifferentiate religious delusions from “normal”faith. How can we distinguish a religious belieffrom a religious delusion?The more implausible, unfounded, stronglyheld, not shared by others, distressing, and preoccupyinga belief is, the more likely it is to be

Conclusion: Summary of What Clinicians Need to Know 359considered a delusion. Yet, disentangling beliefsfrom delusions may be tricky.Three criteria can help to make thisdistinction:1 The experience reported by the patient givesthe impression that it is a delusion.2 Other psychiatric symptoms are present.3 The outcome of the experience seems morelike the evolution of a mental illness, ratherthan that of a life-enhancing experience.In the management of patients with religiousdelusions, clinicians need cultural sensitivity tobe respectful and to differentiate between functionaland dysfunctional beliefs. The question isnot if the belief is true or false, because this is notthe central question in delusions with religiouscontent. Rather, the clinician has to decide ifthe behaviors associated with the delusion and/or hallucination are dysfunctional therapeuticintervention and require or not. If so, the treatmentof the delusion should be standard for suchsymptoms, including medication, psychotherapy,and social support, while helping the individualdetermine what the belief means in his or hercurrent life situation.8. MOOD DISORDERSAND BEREAVEMENTReligion can be related to depression in variousways, either increasing vulnerability or promotingrecovery. Although studies rarely address clinicalsamples, there is evidence that religiousnessmay improve depression outcomes. However,more and more studies demonstrate that depressivesymptoms are often accompanied by religiousdiscontent manifested as negative feelingstoward God or a sense of having been abandonedby God. Also, people involved in religion may bemore likely to report feelings of guilt, even thoughthis may reflect more about their perceived moralstandards and religious upbringing than aboutpathological guilt.In its myths and beliefs, religion has a greatpotential for helping people cope with the endof life bereavement, and with. In this context,the relationship with God may provide comfortif a loved one dies and help compensate for thelack of a love relationship. A meta-analysis onthe relationship between religious and spiritualbeliefs and bereavement showed that about halfthe studies reported benefits. Beyond a “directeffect,” religious and spiritual beliefs could havean impact on other aspects besides depressivesymptoms, such as autonomy, personal growth,or engagement in social activities.The relationship between religiousness and thetwo poles of the bipolar disorder spectrum mayfollow the vulnerability-stress model. There is littleevidence on how religiousness is related to thepresentation and course of bipolar disorder. It ishypothesized that religiousness itself may becomea subject of mood swings, but it could also evokedisillusionment in the patient and suspicion inthe clinician. Regarding the relationship betweenfacets of religiousness and bipolar disorder, fouraspects deserve special mention:1 Symptom formation : Do aspects of religiousnesssuch as the religious tradition influencethe emergence of religious insights and emotionsduring the manic state?2 Religious experiences during mania : Bipolarpatients sometimes cherish the memory oftheir enlightened state or spiritual discoveries,irrespective of the negative consequences oftheir manic episodes.3 Religious preoccupations as early signs : Whenbipolar patients intensify their religiousinvolvement, this may in turn lead to religiousand spiritual preoccupations.4 Disillusionment with religion : In the depressivestate and the symptom-free interval,disillusionment with religion and spiritualitymay be experienced. This may interfere with aperson’s ability to cope with a chronic mentaldisorder and represent an additional loss inlife, the loss of trust in one’s religion.Suicide statistics show that, to a limited extent,religiousness can be protective. Besides the rolethat social integration plays in lowering suicide

360 Philippe Huguelet and Harold G. Koenigrates in regions with higher levels of religiousaffiliation, religious beliefs are associated withlimited tolerance of suicide. Yet it seems thatonly a few core religious beliefs (for example, inan afterlife) and prayer help prevent suicide.Mental problems in general and mood disordersin particular often raise questions about themeaning of life. Without going into the field oftheology, there are two practical ways to includereligion and spirituality in clinical contacts withpatients with mood disorders. The first is byexamining whether religious or spiritual ideasmanifest themselves as psychiatric symptoms orseem to color the expression of symptoms. Thesecond is by establishing a mutual understandingof how spirituality and religiousness representa relevant domain in life. This can facilitate thetherapeutic relationship, and at some time in thetreatment phase, may lead to a referral to a pastoralcounselor.9. SUBSTANCE ABUSESpirituality and religiosity are well-known protectivefactors that consistently predict lowerrates of alcohol and drug abuse. Spiritualitymay reduce behavioral risks through the promotionof a healthier lifestyle and by expandingthe social support network. The inverserelationship between spirituality and substanceuse is further supported by research on therole of spirituality in recovery. Substance usemoves the individual away from rather thantoward purpose in life and connection to others.Thus, one path out of addiction is to findmeaning and purpose through involvement inreligion. Hope can be found in the discovery ofa power greater than one’s self and an opennessto that which is beyond the realm of humanunderstanding.In twelve-step programs such as AlcoholicsAnonymous (AA), members engage in specificbehaviors to facilitate spiritual growth. Learningthrough modeling occurs as members share theirexperiences of “strength and hope” and workwith a sponsor who has an understanding of thespiritual nature of the program.Research also supports the role of meditation,service to others, and celebration as an interventionin the treatment of addiction.Spirituality directly affects substance use,and likewise, spirituality itself is enhanced byattending programs such as AA. Do preexistingspiritual/religious beliefs and practices enhancethe likelihood that a person will use spiritualbasedinterventions? Recent evidence indicatesthat atheists attending AA may reap the samebenefit as religious and spiritual alcoholics.How can the issue of spirituality be raised inaddiction treatment? Open questions are a goodplace to start. However, clinicians should keepin mind that spiritual exploration too early intreatment may be counterproductive. Indeed, theclinician often needs to address other needs firstbefore moving on to spiritual aspects of care.10. ANXIETY DISORDERSWhen worry and tension are present over timeand symptoms become so intense that they interferewith a person’s ability to function at work orin social relationships, then an anxiety disorderis said to be present. The disorders addressed inthis chapter include generalized anxiety disorder,panic disorder, posttraumatic stress disorder,obsessive-compulsive disorder, and phobia.Some studies show that the greater the religiousinvolvement, the greater the anxiety. Thisis particularly true when religion manifests itselfas either extrinsic religiousness (where religiousinvolvement is motivated by external concernsother than religion, such as economic or socialgoals) or as negative religious coping (whereGod is seen as punishing, distant, abandoning,or powerless). Whether it is the religion that isdriving the anxiety, or the anxiety that is drivingthe religious expression is difficult to determine.In contrast, intrinsic religiosity, where religiousinvolvement is an end in itself, is often inverselyrelated to anxiety.Thus, although religion can potentiallyincrease anxiety, there is also evidence that suggestsa protective effect for religion. Also, studieshave found that anxiety symptoms may often

Conclusion: Summary of What Clinicians Need to Know 361decrease following religious conversion or rededicationto religion.Religious interventions appear to be effectivein patients with a generalized anxiety disorder(according to three randomized, controlled trialsinvolving religious interventions, two Muslimbasedand one Tao-based).For panic disorder, religious involvement mayhelp to relieve panic symptoms, particularly whenaccompanied by traditional psychotherapy.Religion is a source of coping for many personssuffering from severe trauma. Patients withposttraumatic stress disorder may have symptomsthat are particularly persistent and unresponsiveto therapy if their religious worldviewhas been affected and their faith weakened or lost(that is, spiritual injury), necessitating that thisbe addressed in therapy.For obsessive-compulsive disorder (OCD),the role of religion warrants a careful examination.Indeed, like delusions, OCD symptomsmay involve a religious dimension. Researchshows that religiosity is significantly correlatedwith the severity of OCD symptoms. But thereis no relationship between religiosity and generalanxiety, social anxiety, or depressive symptoms,suggesting some degree of specificity forthe relationship between religion and severity ofOCD symptoms at least within OCD patients.Nevertheless, because such associations arereported almost exclusively in cross-sectionalstudies, it is not possible to say whether religiosityaggravates OCD symptoms in OCD patientsor whether OCD symptoms lead to greater religiosity(and the measures of OCD severity, inthese studies, may be confounded with items thattap traditional religious values). When religiousobsessions and compulsions are present, thesepatients may have a worse prognosis. Althougha form of faith-based cognitive therapy has beendeveloped to help treat religious patients withOCD, it is not clear that this treatment is as effectivein OCD patients with religious obsessions.Beyond a careful spiritual assessment, cliniciansshould support the patient’s religious beliefsunless obviously pathological. If appropriate, thetherapist may provide the patient with a list ofscriptures to meditate on or to repeat when facingsituations that arouse anxiety. Certain scriptureswithin Christianity instruct people to dwellon the positive, not the negative. Other worldreligions have similar teachings that build confidenceand may calm the anxious person. Thetype of therapy chosen, of course, should matchthe religion of the patient.If religious beliefs are being used neuroticallyto obstruct needed changes or psychologicalinsights, a different tact should be taken. After atherapeutic relationship has been established, thepsychiatrist may need to gently challenge thosebeliefs. Before doing so, however, it may be bestto seek consultation with or referral to a pastoralcounselor with training to address such issues.11. DISSOCIATIVE DISORDERSDissociative symptoms may occur in many psychiatricconditions. Due to the scope of this book,dissociative trance disorder has been emphasized.Although dissociative trance disorders,especially possession disorder, are common, littlesystematic research into this phenomenon hasbeen carried out in psychiatry.The experience of being “possessed” by anotherentity holds different meanings in different cultures.Explaining the phenomenon of possessionas a dissociative symptom with religious contenthas contrasted with certain religious interpretations,which may describe possession as resultingfrom invasion of the body by spiritual forces.The Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition ( DSM-IV ) places pathologicalpossession in the category of possessiontrances under the diagnosis of dissociativedisorder not otherwise specified (Code F 44.9).Many societies around the world have one ormore forms of possession belief. When a personin these societies complains of being possessed,the traditional intervention is exorcismor manipulation. Exorcism describes a ritual thatis intended to expel the negative force or forces.Manipulation involves rituals that seek to integratethe negative forces within the personality.Exorcism can be understood as religious coping,

362 Philippe Huguelet and Harold G. Koenigwith God, gods, or good spirits pitted againstdemons, whereas manipulation can be understoodas a from of religious coping that involvescompromise with those demons.How can psychiatrists and religious authoritiescooperate when treating such patients? Whatshould the clergy or religious authority (priest,pastor, exorcist, or shaman) be responsible for andwhat should the psychiatrist be responsible for?The efficacy of the intervention largely dependson the extent to which the possessed person andhis or her family accept the underlying explanationfor the particular approach. The psychiatristshould attempt to establish links between the twoworlds of meanings. The challenge is to include(if possible) the patient’s worldview, the spiritualcounselor’s worldview, and the clinician’s worldviewin the discussion. An ethnopsychiatricconsultation can also be helpful. During such asession, a psychiatrist and co-therapists from thepatient’s cultural-religious background meet withthe patient to discuss his symptoms and specificproblems. The goal is to allow both participants,the psychiatrist as well as the patient, to continuethe treatment without each being locked into hisor her own system of reference.12. SELF-IDENTITYThe “self ” represents how individuals think ofthemselves over the long term. The feeling ofidentity, the feeling of “being oneself,” and theindividual’s self-image are the result of an ongoingprocess of construction. This process is ultimatelyculture dependent.Parental figures are the first figures that theperson identifies with. The attachment relationshipis a foundation and a vector for theinternalization of the parental figures. Theseparental figures are stable and formative in asecure attachment; they are much less formativewhen the forms of attachment are insecure andbuilt on anxiety.Later, religious figures can play the role ofattachment figures, because they offer a securerelational bond. God, priests, pastors, or membersof the religious community can be attachmentfigures. Thus, in various religious traditions,exemplary figures contribute to the foundationsof identity. For example, identity can be built bycomplete or partial appropriation of the figuresfound in religious belief systems or, on the contrary,by antagonistic reaction to these figures.Also, religious rites may influence identification.Religion/spirituality can help restore identitywhen facing threatening conditions such asthose experienced by patients with severe mentalsymptoms. However, religious experiencescan also disturb and destabilize. Thus, keepinga critical eye on the role played by the religiousdimension in identity construction is important.In a multicultural context, the medical treatmentshould aim to construct a therapeutic frameworkbased on a conception of the self that is consistentwith the cultural tradition of the patient.13. PERSONALITY DISORDERSA personality disorder (PD) represents a rigidand ongoing pattern of thoughts and behaviorsthat deviate markedly from the expectations ofthe patient’s culture and social group. What is therelationship between personality disorders andreligion?There are many personality traits. Recentresearch has discovered that the majority of thesetraits cluster themselves around five broaderdimensions. This is known as the Five FactorModel of Personality (FFM). Research has shownthat spirituality and religiousness represent qualitiesthat are distinct from the FFM domains.What is the role of spirituality in treatingPDs?Patients with a schizotypal PD can be helpedto foster a connection to the transcendent thathelps them to gain a sense of self and develop abetter sense of personal support. Involvement insupportive religious communities can also helpbreak down the stigmas associated with having apsychiatric label and provide increased personalmeaning.Spiritual techniques can help to promote moreinternally stable emotional states in patients withborderline and narcissistic PD (for example, by

Conclusion: Summary of What Clinicians Need to Know 363using dialectical-behavior therapy techniques).Psychospiritual interventions can help thesepatients create for themselves an inner mentalstate that is dynamic, attractive, peaceful, andcreative. For the narcissistic PD, developing arelationship with God could serve a useful intrapsychicobject that provides personal securityenabling him or her to counter the inner vulnerabilitiesthat compromise the narcissist fromdeveloping and maintaining healthy interpersonalrelationships.Spiritually oriented psychotherapy could alsobe a powerful intervention for antisocial PDs .Spirituality can sometimes be useful in promotingauthenticity, moral and social capacity, anda greater faith in life. Creating an awareness ofsocial responsibility may work against the moremanipulative, selfish orientation that characterizesthis disorder.Overall, spirituality can be a useful therapeuticresource for treating personality disordersbecause it serves as an antidote to narcissism.Committing to a larger vision allows individualsto find personal stability and coherence, evenduring times of difficulty.Although addressing religious issues has anumber of positive benefits, one must also beaware of the potential adverse affects it may have.Religious crisis may have an impact on psychosocialfunctioning. Spirituality is sometimes asource of pain, guilt, or exclusion. Some patientswith antisocial traits may use spiritual informationto manipulate others.14. LIAISON PSYCHIATRYMedical physicians consult psychiatrists in acutemedical or surgical settings for patients sufferingfrom anxiety, depression, psychosis, somatoformdisorders, pain, PTSD, substance abuse, delirium,agitation, psychosis, and dementia. Given themany losses and life changes that physical illnesscan cause, it is not surprising that depressive disordersare common in hospital settings. Becauseemotional disorders in medical patients are oftena direct result of inability to cope with those lifechanges and loss, mental health specialists shouldseek out resources that can help patients adjustsuccessfully.In such a context, religion may be a powerfulcoping resource for some patients. Religiousbeliefs may help medical patients reframe theirlosses in a more positive light and give them asense of purpose and meaning. Research hasshown that religious coping is associated withmore rapid adaptation to medical illness anddisability.In other cases, religious beliefs may be asymptom of depression or other emotional illness.For example, the medical patient mayexplain the extreme guilt and sadness stemmingfrom a depressive disorder as the result of havingcommitted an “unpardonable” sin. Also, religiousbeliefs may delay psychiatric care by encouragingtreatments within the faith community, whichmay not recognize the need for professional psychiatriccare.Chronic medical illness is associated withhigh rates of suicide. Religious and spiritualbeliefs often help people to cope with the painand suffering that leads to suicidal thinking, andthey provide hope and meaning that can preventsuicide. Also, religious involvement increases thelikelihood that persons with suicidal thoughts willobtain timely psychiatric care. For the severely ill,spiritual well-being provides substantial protectionagainst end-of-life despair. Patients withactive religious beliefs are less likely to have positiveattitudes toward assisted suicide.Hospitalized patients with medical illnessmay have a variety of worries and fears. Religiousworries may center on concerns about salvation,fear of hell, or guilt over becoming sick.Religious beliefs may influence the type and theseverity of anxiety that patients experience. Somemay become preoccupied by religious worriesor become involved in religious behaviors suchas compulsive prayer or repeated confessions.Others may use religious beliefs and behaviorsin healthy ways to cope with the anxiety due tomedical illness.There is little systematic evidence for a relationshipbetween somatization disorder andreligious involvement, although cases where this

364 Philippe Huguelet and Harold G. Koenigoccurs are highly publicized. Examples of physicalmanifestations of psychological conflictsrelated to religion include the phenomenon ofstigmata, where a physical wound (or bleeding)appears spontaneously in the same location asthe wounds suffered by Jesus, or the “faint” thatoccurs when someone is “slain in the spirit” at aPentecostal healing service.Religious beliefs – particularly if rigid and inflexible– may worsen pain, but more often, patientsturn to religion in an attempt to cope with pain. Inchronic pain patients, mindfulness meditation (aBuddhist practice) as part of a stress-reduction andrelaxation program (SRRP) has produced a significantreduction in pain, mood disturbance, andother psychological symptoms. Religious involvementmay also help to reduce the complicationsseen in chronic pain patients, including substanceabuse and pain medication addiction.When patients with dementia have a religiousbackground, engaging the patient in rituals orprayers may help to reduce agitation and increasecooperation. Religion can also help patients copewith the stress involved in the development ofdementia, especially during the early stages whenpatients still have insight into what is happeningto them. There is also some surprising evidencethat religious involvement may slow the developmentof cognitive impairment in Alzheimer’sdisease and perhaps even slow the natural progressionof memory loss with aging.What can liaison clinicians do? In a few words:Take a spiritual history; show respect for all religiousor spiritual beliefs and practices that aresupportive for patients; actively support healthyreligious practices; anticipate religious resistanceto psychiatric treatments; use religious beliefs incounseling, as appropriate; and if necessary, seekcollaboration with chaplains, pastoral counsellors,or community clergy.15. COMMUNITY PSYCHIATRYAbout one quarter of people with a psychiatricdiagnosis will have first sought help from clergy.This warrants an understanding of the role thatclergy play in counseling, as well as an attemptto collaborate with clergy when treating religiouspatients.Barriers to psychiatric treatment include socialstigma, self stigma, cost issues, or explanatorymodels outside the medical realm. Cliniciansoften have few relationships with religious professionals,and the reverse is also true. To overcomethis problem, the author encourages the establishmentof forums that invite leaders in the spiritual,psychiatric, and medical communities together toconsider models of referral and collaboration.Sometimes spiritual themes may help toreduce the stigma associated with mental illness(examples of depression in the Bible, forexample). Conversely, some religious perspectivesmight add to stigma by (like some medicalmodels) labeling the illness in a narrow andnegative way (that is, depression resulting fromnot having sufficient faith in God).Religious professionals can help to inform clinicianson various aspects of the patient’s illness:Spiritual leaders might know some commonpractices within their own traditions that help;they may provide information about culture andregional norms influencing individual mentalhealth; or a faith-based counselor may help withtransference issues (for example, when askedabout one’s own spiritual orientation).How is it possible to improve communication/referrals?Both clinicians and spiritual leaders can beassisted by supervision (even if it is foreign to oneor the other).Training programs (for example, continuingeducation) that blend spiritual and psychologicalinsight in training and case discussions are likelyto help professionals on both sides.Building referral networks can help individualizecare. This involves knowing what the otherthinks and knows about each other’s respectivedomains.More generally, professionals should be awarethat healing usually stems from multiple elements,not only those of our field!And finally, it should be remembered thatpastoral counselors are professionals with specifictraining and a code of ethics.

Conclusion: Summary of What Clinicians Need to Know 36516. SPIRITUAL ASSESSMENTA spiritual assessment is the first step for the psychiatristwho wants to address or consider religiousor spiritual issues in his or her practice.Most chapters of this book emphasize this point.The reasons for assessing the religiousness/spirituality of patients are numerous. Religionand spirituality are considered cultural factorsinfluencing the process of diagnosis and treatment.Religion and mental health depend heavilyon one another. Sometimes, patients do not benefitfrom psychiatric treatment because the primaryproblem involves religious beliefs or spiritual crisesthat may have led to the emotional, behavioral,or social disturbances. Also, in a patient-centeredapproach, examining the individual’s spiritualand religious history is a therapeutic tool in itself.Patients will appreciate the doctor’s sensitivityand feel understood and respected.Religion is a multidimensional construct,strongly influenced by the cultural context.During the screening phase of the spiritual assessment,clinicians should develop an outline of thepatient’s spiritual and religious history. Therefore,the following domains should be explored:■■■■■■■■■religious background (patient and significantothers)evolution of spirituality over the lifetimeinfluence of psychiatric disorder on religion/spiritualitycurrent spiritual/religious beliefs andpracticesprivate religious practicesreligious preference (in the sense of a social orcultural identity)the patient’s relationships with members ofthe religious communitysupport received from the religiouscommunitysubjective importance of religion in lifeFor patients in whom religion is important,addressing the following issues should determinehow religion is used to cope with the illness:■the spiritual meaning of the illness■■■the role of religion in coping with symptomsreligious coping style (for example, selfdirecting,deferral, or collaborative style)synergy/incompatibility of religious beliefswith psychiatric careOf course, all spiritual orientations must berespected when addressing religion/spiritualitywith patients, including a professed absence ofbelief.17. INTEGRATINGS SPIRITUALITY INTOTHERAPYThis section of the book focuses in therapeuticissues. The first chapter examines the integrationos spirituality into therapy, and is followed by achapter discussing explanatory models of mentalillness and then by three chapters describing differenttypes of religious therapies from Christian,Muslim, and Buddhist perspectives.Numerous treatment programs exist thatinclude religious components. These can involvea comprehensive array of services, be in a groupformat, or involve individual (psycho-) therapy.Clinicians working on the front lines should befamiliar with some of these approaches so thatthey can refer patients if needed or give adviceregarding such treatments. When working withpatients with severe mental disorders in Westerncountries, psychiatrists are often criticized foronly giving medications without providing morewhole person treatments. Patients sometimescomplain that one or another specific approach isnot available (for example, the so-called “Soteriaparadigm” (4) ). Knowing what the patient istalking about may improve the dialogue thatclinicians have with patients. For instance, psychiatristsshould know that the Buddhist-based“Windhorse” program involves taking medication,even if one of the aims of treatment is tominimize medication dose.In many places, group interventions involvingspirituality/religion have been conducted incommunity mental health practices. Researchhas provided some data on their efficacy. Anumber of hospitals and outpatient facilities

366 Philippe Huguelet and Harold G. Koenighave implemented a holistic and interdisciplinarymodel for therapy based on an “extended”bio-psycho- social model. In such settings, thepastoral/spiritual counselor may be involvedin the interdisciplinary team, with rightsand responsibilities similar to that of othertherapists.The chapter on integrating spirituality intotherapy includes detailed information aboutone such program in Langenthal, Switzerland.Patients who request such treatment are providedwith both state-of-the-art psychiatric andpsychological treatment plus spiritual treatment,where the goals of therapy focus on regaininghope and meaning, strengthening the relationshipwith God, or working toward forgiveness inbroken relationships. Psycho-educational groupmeetings are offered that focus on the integrationof therapeutic and spiritual aspects of care,emphasizing the benefit and importance of religiousand spiritual coping. There are also spiritualsinging and music groups, art therapy, anddiscussion groups, often led by a pastoral counselor.Spiritual issues such as unhealthy beliefsare also challenged from both a spiritual and apsychotherapeutic view in counseling.Families taking care of patients with mentaldisorders often face a heavy burden. Research hasgenerally found that religiosity among caregiversis linked to enhanced adjustment. Family membersoften turn to religion to cope with the stressof caring for an ill family member. The authoremphasizes how religiosity may contribute tothe well-being of caregivers by expanding theircapacity and motivation for self-care.18. EXPLANATORY MODELS MENTALILLNESS AND ITS TREATMENTOver the course of history, a number of theoreticalissues concerning the causes of mental disorders(or explanatory models) have preoccupiedthe mental health field. People who are sufferingtend to explain their disease according to collectivelyelaborated social constructions, which cannotbe reduced to mere institutional or medicaldefinitions. These explanations include severaldimensions of a religious, collective, existential,emotional, and sentimental nature.When clinicians meet with their patients,there are actually two different cultural and spiritualperspectives to reconcile through communication,confrontation, and sometimes evennegotiation. Furthermore, as compared withWestern societies, people in developing countries(and minority groups living within developedcountries) seem to attach more importanceto the symbolic and spiritual side of the disease.The different understandings of the disease mayinfluence treatment choices as they are developedby patients. Chronic mental disorders area major reason why patients seek out alternativetherapies.Clinicians can deal with this issue by carefullyconsidering patients’ explanatory modelsfor their psychiatric disorders. Religious beliefscan have either a positive or negative impact onadherence to the treatment. Sometimes, medicaltreatment may enter into conflict with the teachingsof religious groups.Even if the patient’s account of the situationmay be perceived as irrational or inconsistent,clinicians should try to build bridges betweentheir own explanatory models and those ofpatients. Even neuropharmacology can be presentedas related to God’s creation. Nobody canprove it, but nobody can disprove it either! Inthis way, an explanatory model that takes bothpositions into account can be “negotiated” withthe patient. This is especially important becauseevidence suggests that patients are more satisfiedwhen their psychiatrist shares their modelof understanding distress and treatment.19. PSYCHOTHERAPY FROM ACHRISTIAN PERSPECTIVEChristian forms of psychotherapy seek to transformthe mind of the believer so that they can findmeaning and purpose in their relationship withGod. They use the teachings found in the Bibleand integrate them with current secular concepts.Christian psychotherapy involves belief ina cosmology (an explanation as to why things are

Conclusion: Summary of What Clinicians Need to Know 367as they are, where it all comes from, and wherewe come from), a futurology (an extrapolation ofthe past into the future), values (what is good andwhat is evil), and knowledge. Christians believethat man is composed of three functional units:body, soul, and spirit.Mental disorders are viewed as the consequenceof man’s alienation from God (that is, sin,either original sin or individual sin), which leadsto an alienation from society as well. Duringtherapy, the patient must be reconciled with Godand continue to transform as he matures in hisfaith. Therapists consider that God’s interventionmakes it possible to heal wounds from eventsthat have occurred in the past as they are relivedin the present. Depending on the circumstances,the therapy can be short-term or long-term. Thetherapist has to learn about the patient’s consciousand subconscious mental conflicts. Byresponding to the patient in ways that do notreward the behaviors that produce pain and anxiety,the therapist helps to bring about extinctionor inhibition of such behaviors. He must thenteach new behavioral patterns by using Biblicalguidelines.20. PSYCHOTHERAPY FROM AN ISLAMICPERSPECTIVEBecause Muslims are a minority in most Westerncountries, they are usually stereotyped. Islamhas different laws regarding some of the rightsand duties of men and women, which may notbe accepted by Western clinicians (for example,conditions for women). Therapists should havesome knowledge of Islam, or admit to a lack ofknowledge about the patient’s culture or religion,to establish a positive therapeutic alliance.From an Islamic perspective, religious psychotherapymay be used if religious conflictsare an important part of the patient’s problems.Moreover, a religious technique should be trulymeaningful to the patient. Concepts involvingreligious considerations, such as belief in anafterlife or guilt management, can be used.Islamic concepts may be used by specialistsin cognitive behavioral therapy (CBT) byworking with reference to religious themes tochallenge dysfunctional beliefs in the same waythat dysfunctional assumptions (or schemata)are modified in secular CBT. Both dysfunctionalthoughts and behaviors can be altered accordingto these principles. For instance, Islamicrules stating that husbands should respect theirwives and should not oppress them can be effectivelyused when treating abusive husbands.21. PSYCHIATRIC CARE USINGBUDDHIST PRINCIPLESThe Windhorse Therapy is an example of a comprehensivetherapy based on the Buddhist understandingof fundamental health and wellness,while integrating applicable Western psychology.The goal of the treatment is recovery by “discoveringand synchronizing with one’s own fundamentalhealth.” To create a recovery environment,a team is assembled that is made up of the clinicians,the client, and whenever possible, the family.Clients live in a house with a housemate whois part of a treatment team. There are clinicianson the team who spend time with the client on aregularly scheduled basis, doing a wide variety ofactivities. These activities are elements of an individuallytailored environment to help the personlive in an ordinary and healthy way. The client maywork, see friends and family, and be part of thenormal community in which he or she lives. Theschedule usually includes meeting with a psychotherapistand with a psychiatrist if medications areused. There is a system of meetings that all membersof the team, including the client and his orher family, participate in. Most treatments last sixmonths to two years. Windhorse Therapy is primarilydesigned for individuals with chronic disorderssuch as schizophrenia. Applying Buddhistprinciples such as those used in mindfulness, (5)patients learn to tolerate how it feels to be awarein the present moment and how it feels to be withwhatever is going on in one’s life without self-consciousjudgment. With this come “islands of clarity,”which may appear progressively in the midstof psychosis. Healthy self-love, a basic life energy,is supposed to be the result.

368 Philippe Huguelet and Harold G. KoenigWhat can programs such as WindhorseTherapy bring to patients with severe mental disorders?The goal of current secular approachesfor these disorders is recovery. With this kindof care, aiming at recovery is not always an easytask, because motivating patients often involvesrepetitive activities that are often felt to be stigmatizing.Also, antipsychotic medications, evensecond-generation antipsychotics, are sometimespoorly tolerated by patients. Environments likeWindhorse can bring together the conditionsthat are likely to help patients initiate activitiesand reduce stress, which in turn is likely to reducemedication needs. As with Christian or Muslimpsychotherapy, this treatment should only beused after explaining the underlying Buddhistprinciples on which it is based, and it should onlybe suggested for patients who would be willing toembark on such a therapy.22. PSYCHIATRIC EDUCATIONBeyond reading books and papers, there shouldbe education about religion for psychiatrists, aswell as education about psychiatry/psychologyfor clergy and chaplains. Rationales for teachingreligion-spirituality are detailed throughout thisbook. Currently, educational guidelines for psychiatryresidents recommend teaching sensitivityto religious and cultural issues and trainingthat ensures a minimum degree of competencyin these areas. Education on this topic shouldtake place early in the training curriculum forstudents and post-graduate trainees, to form lifelongattitudes and habits. Training programs forpsychiatrists, medical students, or psychologistsexist in North America, in some parts of Europe,and in Australia. There is little information abouttraining programs in most countries in Africa,the Middle East, and Asia.All clinicians involved in mental health careshould receive training on religion/spirituality.Three broad goals are: (1) to recognize and distinguishpathological from normal religious and spiritualexpressions, (2) to acquire therapeutic skills,knowledge, and attitudes to deal with religionspiritualityissues in mental health care, and (3) toacquire clinical competence in addressing religion/spirituality in actual treatment settings. Essentialcontent should include: (a) general informationabout research relating to religion/spirituality inhealth and (b) gathering and interpreting informationabout the religious/spiritual history. If possible,the curriculum could include more specificnotions such as religious/spiritual developmentover the lifetime and techniques of addressingthis topic in psychotherapy. Didactic courses andseminars are the most common formats, but otherbrief teaching formats can also be implemented,such as intermittent in-service training.When trying to implement a training programon religion/spirituality, one may expect torun into some resistance from students, faculty,program directors, or entire institutions, mostresistance being due to ignorance or countertransferenceissues.REFERENCES1. Hol loway F . Is t here a s c ienc e of re c over y and do es itmatter? Advan Psychiatr Treat. 2008 ; 14 : 245– 247.2. Pa louzi an RF , Park C L . Handbook of the Psychologyof Religion and Spirituality . New York : GuilfordPress; 2005 .3. Bur ton R . Anatomie de la Mélancolie, trad. fr. parB. Hoepffner, préface de J. Starobinsky, postface de J .Pigeaud, Paris: José Corti; 2000 .4. C a lton T , Fer r iter M , Hub and N , Sp and ler H . Asystematic review of the Soteria paradigm for thetreatment of people diagnosed with schizophrenia. Schizophr Bull. 2008 ; 34 : 181– 192.5. L inehan MM . Cognitive Behavioral Treatmentof Borderline Personality Disorder . New York :Guilford Press; 1993 .

IndexAA. See Acoholics AnonymousAAPC. See American Association ofPastoral Counselorsabbot, abbess, 220ACGME. See American MedicalAssociation’s AccreditationCouncil for Graduate MedicalEducationactivating protein-2 (AP-2), 57–58active rGE, 60acute, chronic pain, 191Adams, Reverend Eltor, 221addiction. See substance abusedisordersaffective attunement, 160Africa, 340–342aggression, aggressive behavior5-HT and, 51delusions, hallucinations and, 83neuroanatomy and, 51agreeableness, 174Ahmed, Sameera, 218Alcoholics Anonymous (AA), 16 , 114 ,118–119 , 207 , 360altruistic suicide, 107Alzheimer’s disease, 206American Association of PastoralCounselors (AAPC), 219 ,229–230code of ethics, 229–230c onfidentiality statement, 229–230American Journal of Insanity, 81American Journal of Psychiatry , 16 ,81 , 207American Medical Association’sAccreditation Council forGraduate Medical Education(ACGME), 335 , 338American Psychiatric Association(APA), 233 , 335American Psychiatric Association’sDiagnostic and Statistical Manual,43American Psychiatry Association, 15American Psychological Association,333 , 335–336Anatomy of Melancholy (Burton), 12ancient world, 7–9 , 269Anderson, Neil, 296anger types, 176anomic suicide, 107Antisocial Personality Disorder(APD), 184–185anxiety, anxiety disorders, 205–206 ,360–361 . See also generalizedanxiety disorderanxiety in medical settings, 199–201assessment, 136–137case examples, 133–136clinical practice applications,136–137devout and prayerful, 134–135GAD, 130Islamic psychotherapy and, 311–313lifetime prevalence, 128lost faith, 134meditation, prayer and, 199National Comorbidity SurveyReplication, 128nocturnal panic, 133–134normal anxiety vs., 128OCD, 131–132PD, 130–131phobia, 132–133prevalence, 128PTSD, 131religion and specific disorders,130–136religion as cause, 129religion as comfort, 129–130trouble crossing streets, 135–136the worrier, 133anxiety disorders, treatment, 137–140CBT, 138–139challenging unhealthy religion,140–142encouraging/prescribing religion,140inquiry, 137–138IPT, 139–140pastoral referral or consultation, 142spiritual assessment, 137–138support, 138supportive therapy, 138utilizing beliefs, 138AP-2. See activating protein-2APD. See Antisocial PersonalityDisorderAquinas, Thomas, 27Arab Board of Psychiatry, 342Arab/Muslim communities, 218Asclepius cult, 7–8Assessment of Spirituality andReligious Sentiments (ASPIRES)scale, 179–181attachment, 163–164attachment theory, 105 , 163–164auditory hallucinations, 52, 88–89Australia, 340Australian Journal of Medicine, 340autonomic nervous system , 50–51Avoidant PD, 177–178Axis II disorders . See also specificdisordersAPD treatment, 184–185Borderline PD treatment, 184DBT for, 184FFM and, 176–178NPD treatment, 184Prayer Fulfillment and, 186Schizotypal PD treatment, 183–184spirituality role in treatment,183–185Baxter, Richard, 10–11BCDS. See Brief Carroll DepressionScaleBDZ. See benzodiazepinesbehaviorists, 285benzodiazepines (BDZ), 200bereavement, 104–105 , 359–360Bergin, A. E., 339Berlin Charité, 81Bible, 356basic facts, 32God and, 33–35healing and, 44–46homosexuality and, 42–43madness and, 6–7marriage and, 39–42problematic themes, 32–47sin, guilt and, 35–37solace and, 46–47teacher, 220teachings of, 296–297women’s issues, 37–39bio-psycho-social therapy model, 247bio-psycho-social-religious spiritualpsychiatric model, 2bipolar disorders, 97delusion with religion and, 106kindling phenomenon, 105religious preoccupations and, 106religiousness, manic phase, 106religiousness, phases, 105–107studies, 106–107symptom formation, 106bishop, 220B on ho effer, Dietrich, 28369

370 IndexBorderline PD treatment, 184boundary spanners, 218–219Branch Davidians, 34Brief Carroll Depression Scale (BCDS),194Brigham, Amariah, 15Buddhist tradition. See WindhorseTherapyBurton, Richard, 12Calvinism, 102–103Canada, 336–337care providers, 216–217 . See alsospiritual providersCartesian dualism, 24–25CBT. See cognitive behavioral therapyCenter for Spirituality, Theology andHealth (CSTH), 264chaplain, 220–221Charcot, Jean-Martin, 201–202childhood, self-identity in, 160Chinese Taoist-based cognitive therapy(CTCP), 200Christian Daily Faith, 21A Christian Directory (Baxter), 10–11Christian psychotherapy, 283 , 366–367alienation from God, 287–288Christian interventions, 293–300confession, repentance, forgivenessand, 297–298deliverance and, 299discipleship and, 294Evangelism and, 293–294exhortation and, 298–299fundamental theses, 284–285healing of memories and, 295–296health concept of, 288Holy Spirit and, 299–300mode of change in, 288prayer, 295primary tools, methods, 289–290secular vs., 283–284spiritual disease and, 292–293teachings of Bible and, 296–297thematic dimensions of, 287therapist/patient relationship, 291therapist’s role and stance, 291–292therapist’s task in, 289time approach, focus in, 288–289treatment model, 291treatment type, duration, 289worship and, 297Chrysostom, John, 8–9church attendance, 101 , 104Church of Christian Science, 45Civilization and Its Discontents(Freud), 16CL psychiatry. See consultation-liaisonpsychiatryclinical practice. See spiritual/religiousassessment See clinical practiceClinical Research Evaluation Facility(CREF), 255–256clinicians, medical practitioners,279–280clergy and, 3patient concerns and, 3psychiatric training, 3religious involvement of, 3role of, 3theological challenges for, 23–24Cloninger hypothesis, 57 , 60cognitive behavioral therapy (CBT),138–139 , 245–246collective symbolization, 166–167College of Psychiatrists and Surgeonsof Pakistan (CPSP), 343College of Psychiatrists of the Collegesof Medicine of South Africa, 341Committee on Psychiatry and Religionof the Group for the Advancementof Psychiatry, 16community psychiatry, 364confession, repentance andforgiveness, 297–298conjunctive faith, 111conscience, 36consultation-liaison (CL) psychiatry,363–364chaplains, pastoral counselors,community clergy collaboration,212patient religious beliefs respect, 211patient religious beliefs support, 211psychodynamic insights acquisition,210–211religion/spirituality role in, 193–194religious belief as symptom and, 193religious beliefs utilization, 211–212religious beliefs/activitiesencouragement, prescription, 212spiritual history assessment, 210spiritual history assessment, othersources, 210Coping, 72–78 , 99 , 194 , 203–205 , 244 ,245 , 248–252with illness, 191 , 239–240negative religious coping, 103positive coping, 72–73style, 239–240with symptoms, 239Council of Elvira, 40Council of Trent, 40CPSP. See College of Psychiatrists andSurgeons of PakistanCREF. See Clinical ResearchEvaluation FacilityCSTH. See Center for Spirituality,Theology and HealthCTCP. See Chinese Taoist-basedcognitive therapycult of Asclepius, 7–8cults, cult leaders, 34cultural-linguistics, 22–23culture-bound syndromes, 202–203CYP2C19. See cytochrome P450 C219cytochrome P450 C219 (CYP2C19), 58Dante, 36DBT. See Dialectical-Behavior TherapyDDNOS. See dissociative disorder nototherwise specifieddeacon, 220death and dying, 105definitions, 1deliverance, 299delusions and hallucinations, 358–359abnormal perceptual experiencerole, 87aggressive behavior and, 83association of, 89auditory hallucinations, 52 , 88–89clinical applications, 90–94clinicians, category confusion, 91context function, 92cultural factors, 82delusion as dysfunctional belief,90–91delusion content, 84delusion defined, 85–86delusion formation, conservation,86–87delusion models, 83–89description, 81–83exculpation, dis-egoificationfunction, 92–93explanation function, 92functional impact, 92hallucination defined, 88–89historical accounts, 81historical periods and, 82internet delusions, 82James on, 81PDI, 86politics, technology and, 82prevalence, 82prognosis, outcome, 83PSE and, 84psychodynamic considerations,92–93religion/psychopathologydisentanglement, 90religious delusion defined, 83–84schizophrenia and, 82–83self-injury and, 83treatment considerations, 93–94wish-fulfillment, significancefunction, 93dementia, agitation, behavioraldisturbance, 205–206demonization, obsession, 292–293depression, 193attachment theory and, 105bereavement and, 104–105church attendance and, 101 , 104diagnostic phase, 109guilt and, 102humor and, 104life-course perspectives, 103–104meta-analyses, 100–101Pentecostals and, 103pietistic orthodox Calvinism and,102–103prayer and, 101 , 104prevalence, 97recovery from, 101–102religion and, 98 , 100–103 , 194–195religious discontent and, 103religiousness and, 99sense of belonging and, 104stages of grief and, 104

Index 371vulnerability-stress model, 98world wide, 97Descartes, René, NaNA Description of the Retreat (Tuke), 13Devereux, Georges, 156Dialectical-Behavior Therapy (DBT),184DID. See dissociative identity disorderdisability, 191–192disavowed self, 161discipleship, 294Discourse on Method (Descartes), 25Discoverie of Witchcraft (Scott), 10dissociative amnesia (DA), 147dissociative disorder not otherwisespecified (DDNOS), 147dissociative disorders, 292–293 ,361–362anthropological criticism, 145 ,154–155case studies, 149–154culture and, 145 , 148DA, 147diagnosis distribution, 148–149DID, 147DSM-IV, ICD-10 classification,147–148ethnopsychiatric consultations,156–157exorcism and, 147exorcism vs. manipulation, 148family, friends and, 150historical perspective, 146–147lifetime prevalence, 145possession, cultural context, 148prevalence, 145psychiatrists, religious authoritiescollaboration, 155–156dissociative identity disorder (DID),147dopamine, 49 , 52dopamine receptor 4 (DRD4), 57DRD4. See dopamine receptor 4Durkheim, Émile, 107Eastern traditions, 67 , 204 , 274Eddy, Mary, 45Edinburgh World Conference onMedical Education, 334education. See religion/spiritualitytraininge go. See self-identityegotistic suicide, 107Egypt, 342elder, 220energy and sleep, 191English Puritans, 9–12Enlightenment period, 12–13environmental factors, 60ethnopsychiatric consultations,156–157Evangelism, 293–294evangelist, 220evocative rGE, 59–60exhortation, 298–299exorcism, 147 , 148experiential-expressivism, 22experientialists, 285extraversion, 174extrinsic religion, 1f ait hconjunctive, 111individuative-reflective, 111intuitive-projective, 111lost, 134mythic-literal, 111synthetic-conventional, 111universalizing, 111Faith-Based Initiative in BehavioralHealth, 218faith-based organizations, 252false self, 161family, 192family caregivers, 250–252The Family Youth Institute, 218fatalistic suicides, 107father, father figure, 162fear, 205–206FFM. See Five-Factor Model ofPersonality5-HT. See serotonin5-HT transporter. See genes,personality, spirituality5-HT1A. See serotonin receptor 1A5-HTTLPR. See serotonin-transporterlinkedpolymorphic region5-hydroxytryptanine (5-HT). SeeserotoninFive-Factor Model of Personality(FFM), 362agreeableness, 174anger types and, 176Avoidant PD and, 177–178Axis II disorders and, 176–178conscientiousness, 174development of, 174–176diagnosis and treatment,motivational qualities, 178effi cacy of, 175–176extraversion, 174neuroticism, 174numinous constructs and, 173openness to experience, 174PD scales and, 177–178research, literature, 174–175SCID-IIP and, 177SNAP and, 181TABP and, 176Fletcher, A., 120Fowler, James, 110–111Freud, Sigmund, 15–16Freudian psychology, 21 , 161–163Freudian theory, 161–163frontal lobe, limbic system, parietallobe, 50The Future of Religion (Freud), 16GABA, 51GAD. See generalized anxietydisorderGDS. See Geriatric Depression Scalegene-environment interaction (GxE)active rGE, 60evocative rGE, 59–60gene-environment correlation,59–60passive rGE, 59religious beliefs and, 58–60generalized anxiety disorder (GAD),130 , 199–200BDZ therapy for, 200CTCP for, 200RCP for, 200genes, personality, spirituality, 52–585-HT transporter and, 555-HT1A and, 53–545-HTTLPR and, 55AP-2 and, 57–58Cloninger hypothesis, 57 , 60CYP2C19 polymorphisms and, 58DRD4 polymorphisms and, 56genetic polymorphism, 54–56neurotransmitter receptor and, 53personality trait, endo-phenotypeand, 52–53SSRIs and, 55TCI and, 53genetic polymorphism, 54–56George Washington Institute forSpirituality and Health (GWISH),337Geriatric Depression Scale (GDS), 194Gnosticism, 25God in the Bible, 33–35grief, 109–110Griesinger, Wilhelm, 14–15guilt, 35–37 , 276GW I SH . See George WashingtonInstitute for Spirituality and HealthGxE. See gene-environment interactionhallucinations. See delusions andhallucinationsHamilton Depression Rating Scale(HDRS), 194Handbook of Psychotherapy andReligious Diversity (Richards,Bergin), 339Hawthorne, Nathaniel, 36HDRS. See Hamilton DepressionRating Scalehealer, 220healing, 44–46healing of memories, 295–296health and vigor, 191Health Professions Council of SouthAfrica, 341Heinroth, Johann, 14Hippocratic medicine, 8historical conflicts, 3historical considerations, 354–355holistic care, 2Hollywood Mental Health Center,253–255Holocaust, 33Holy Spirit, 299–300homosexuality, 42–43human nature, 285humility, 275humor, 104

372 IndexIdeler, K. W., 81idem- vs. ipse-identity, 159identification process, 161–163imam, 220impulsivity, aggression, 51India, 217individuative-reflective faith, 111Inferno (Dante), 36Influence of Religion Upon the Healthand Physical Welfare of Mankind(Brigham), 15Institute of Psychiatry, Ain ShamesUniversity, 342Institute of Traditional Medicine, 341intercessory prayer ministry (IPM),205International Association of MuslimPsychologists, 342internet delusions, 82interpersonal psychotherapy (IPT),139–140interpersonal relationships, 160intrinsic religion, 1intuitive-projective faith, 111IPM. See intercessory prayer ministryIPT. See interpersonal psychotherapyIran, 342–343Iraq, 343Isl ambasics, 302–304branches of, 303Koran and, 302laws, flexibility of, 303physicians credit in, 310pillars of, 302prayer and, 308–309rules of, 303Shias, 303stereotypes, 301suicide and, 310Sunnis, 303women and, 304Islamic psychotherapy, 218 , 367afterlife and, 312anxiety, 311–313belief in afterlife and, 307common factors, initial assessment,304–307counter-transference, therapist’smisunderstandings, 304country of origin and, 306daily usual activities, reward and, 308death of beloved and, 308depression treatment and, 307–311diseases, disabilities and, 308extended family and, 315feelings vs. sin and, 309–310female Muslim client and, 304–305God’s wisdom, love and, 311good and evil in, 314good vs. bad deeds and, 309grave anxiety and, 312guilt feelings and, 309–310hopelessness, suicide and, 310interpersonal problems and, 313–315Jinns, 301 , 312–313knowledge of culture, religion and,306loneliness and, 311marriage duties and, 314–315mental illness and, 67mercy, beneficence of God and, 309negative, positive clues and, 306non-Muslim therapists, 303oppression, forgiveness and, 313–314polygamy and, 315poverty and, 307–308prayer and, 308–309probable losses belief and, 312probable punishment belief and, 312RCP, GAD and, 200reinforcement, 305–306reliance on God and, 312religious techniques use and, 307saints as examples in, 310–311sensitivity to others and, 313September 11 and, 301similarities, differences, 306sin and, 309thanks to God and, 311therapy effectiveness, 302therapy reactions, 306thoughts, punishment and, 309transference and, 305warm greetings and, 305women and, 304 , 315Israel, 344–345Israel Medical Association, 344James, William, 15 , 45 , 81 , 119Jinns, 301 , 312–313Jones, Jim, 34Jordon, 343Journal of Muslim Mental Health, 342Journal of the American MedicalAssociation, 203Jung, Carl, 160 , 226Kabat-Zinn study, 204–205Kenya, 341kindling phenomenon, bipolardisorders, 105Koran, 302language, 22–23lay-leader, 220Le Suicide (Durkheim), 107Lebanon, 343Lebanon Hosptial for Mental andNervous Disorders, 343Leechbook of Bald, 9liaison psychiatry. See consultationliaisonpsychiatrylife after death, 105life goals, 192 , 275Lindbeck, George, 22Living Free in Christ (Anderson), 296lost faith, 134madnessin ancient world, 7–9Bible and, 6–7cult of Asclepius and, 7–8English Puritans and, 9–12Enlightenment and, 12–13late nineteenth, twentieth centuryand, 15–17modern medical approach, 13–15naturalistic clinical approach, 9–12in New Testament, 7in Old Testament, 7religious traditions and, 6secular medical approach, 12–13Makerere University Faculty ofMedicine, 340Malawi, 342mania, diagnostic phase, 109–110marriage, 39–42 , 314–315McCullough, M. E., 103–104medical illnessacute, chronic pain, 191anxiety in medical settings, 199–201coping with, 191culture-bound syndrome, 202–203depressive disorders and, 193family, society roles, 192GAD and, 199–200increase in disability, 191–192life goals and, 192loss of energy and sleep, 191loss of health and vigor, 191making positive difference and, 192purpose, meaning in life and,192–193religion, depression and, 194–195social relationships and, 192somatoform disorders, 201–202suicidal thoughts, behavior, 195–199timely psychiatric care, 197–199work loss and, 192Medical Inquiries and ObservationsUpon the Diseases of the Mind(Rush), 13–14meditation, spiritual experience, 1995-HT1A, 53–54GABA and, 51GxE and, 58–60neurobiological basis, 50–52neuropsychiatry and, 51psychiatry and, 51–52memory healing, 295–296mental disorders, mental illness . Seealso specific disordersancient world, 7–9 , 269in developing countries, 271–272diverse representations of, 272–273goal in life, balance and, 275historical perspective on, 269Middle Ages, Europe, 9 , 26919th century, 269religious beliefs, views on life and, 275religious/spiritual coping, researchfindings, 248–252Renaissance period, 26917th, 18th centuries, 269social representations of disease and,269–271spiritual perspectives on, 244–247spiritual representation of treatmentand, 277

Index 373mental health care programs, therapy,252–260 , 365extended bio-psycho-social modelof, 247family caregivers and, 250–252holistic, interdisciplinary model for,247–248integrating spirituality in, 366interdisciplinary approach to, 248religion/spirituality as burden, 248religion/spirituality as main resource,247–248religious communities, faith-basedorganizations and, 252religious, non-religious therapistsand, 245–247spirituality, recovery perspective,244–245treatment representation/explanatory models, 366treatments involving religion,366–368Mental Hygiene (Ray), 15Mental Illness ministries, 264Menuba, Father Elias, 217–218Middle Ages, Europe, 9 , 269Middle East, 342Milton, John, 36minister, 220Model Curriculum for PsychiatricResidency Training Programs:Religion and Spirituality in ClinicalCare. A Course Outline, 338model of care, 2monk, 220mood disorders, 359–360 . See alsospecific disordersclinical applications, 108–110connecting, abridging personal stylesand, 110delusions, hallucinations and, 81diagnostic phase, 109–110Fowler’s Stages of Faith and, 110–111mainframe of empirical findings, 108spectrum of, 97Morocco, 342mother, mother figure, 160–161 ,161–162MUHAS. See Muhimbili University ofHealth and Allied SciencesMuhimbili University of Health andAllied Sciences (MUHAS), 340multidisciplinary/multilevelpsychiatric model, 2music, 297mystical delusion, 3mythic-literal faith, 111NA. See Narcotics AnonymousNairobi University School of Medicine(NUSOM), 341NAMI. See National Alliance onMental Illnessnarcissism. See self-identityNarcissistic Personality Disorder(NPD), 184Narcotics Anonymous (NA), 207Naropa University, 318Nathan Kline Institute, 255–256National Alliance on Mental Illness(NAMI), 252 , 264National Comorbidity SurveyReplication, 128National Institute for HealthcareResearch (NIHR), 337National Institutes of Mental Health(NIMH) Epidemiologic CatchmentArea survey, 201 , 209–210National Surveys on Drug Use andHealth, 209naturalistic clinical approach, 9–12nature of man, 285negative religious coping, 103neuroanatomyaggression and, 51autonomic nervous system, otherrelated systems, 50–51frontal lobe, limbic system, parietallobe, 50meditation, spiritual experience,psychiatry and, 51–52temporal lobe, 50neurobiology, 50–52neuropsychiatry, 51 , 356–357neuroticism, 174neurotransmitters, 48–49 . See alsospecific neurotransmittersNew Religious Movement, 86Nigeria, 217–218NIHR. See National Institute forHealthcare ResearchNPD. See Narcissistic PersonalityDisordernuminous constructs, 173 , 174 ,186–187 . See also specific typesNUSOM. See Nairobi UniversitySchool of Medicineobsession, 292–293obsessive-compulsive disorder (OCD),131–132 , 361O CD. See obsessive-compulsivedisorderopenness to experience, 174Oration to the Greeks (Tatian), 9pain, 203–205Eastern religions and, 204IPM intervention for, 205Kabat-Zinn study, 204–205religious beliefs and, 203resolution, perceptual reduction of,204–205secondary complications reduction,204SSRP intervention and, 204Pakistan, 343–344Pakistan Medical and Dental Council(PMDC), 343Palestinian territory, 344panic at night, 133–134panic disorder (PD), 130–131Paradise Lost (Milton), 36parental roles, 164–165parenting, 60partial identification, 162passive rGE, 59pastor, 220pastoral counselors, 212 , 219 , 221Pathways to Promise, 264patient(s)alternative therapy use by, 274beliefs, theology, theologicalperspectives, 21b enefits, religion/spiritualitytraining, 333category stigmatization, delusionsand hallucinations, 91–92Christian psychotherapy, therapist/patient relationship, 291comfort, SR assessment, 240coping style, SR assessment, 239–240coping with illness, SR assessment,239–240coping with symptoms, SRassessment, 239courage, hope, growth, 276current beliefs and practices, SRassessment, 237experience of illness, SR assessment,237guilt, 276humility, 275with mood disorders, delusions,hallucinations, 81patient concerns, clinicians, medicalpractitioners, 3private religious practices, SRassessment, 237religiosity, Islamic psychotherapy,306religious beliefs, CL psychiatry, 211religious centrality, SR assessment,238–239religious community relationship, SRassessment, 240religious delirium, 277religious preference, SR assessment,237religious resistance, CL psychiatry,210–211satisfaction, SR assessment, 234schizophrenia care, 68spiritual aspects of being ill, 275–277spiritual representation of disease by,276–277S/R saliency, 240–242PD. See panic disorder See personalitydisorderPDI. See Peters Delusions InventoryPentecostal Church, 46 , 103Percy, Walker, 21p ers ona lit y, 6 0personality disorder (PD), 362–363Avoidant PD, 177–178DSM-IV definition, 173PD scales, 177–178prevalence, 173Schizoid PD, 177–178socioeconomic costs, 173–174Peters Delusions Inventory (PDI), 86

374 IndexPhilo of Alexandria, 42phobia, 132–133Pinel, Philippe, 12–13PMDC. See Pakistan Medical andDental CouncilPodvol, Edward, 317 , 318polygamy, 315possession, possession states. Seedissociative disorderspost-traumatic stress disorder (PTSD),131pr ayeramount of, 207–208children, adolescents and, 104Christian, 295intercessory, 46Islamic, 308–309personal, 199physical, psychological parametersand, 51private vs. public, 101Prayer Fulfillment, 186preacher, 220Present State Examination (PSE), 84priest, 220primary identification, 161–162private self, 161Project MATCH, 121PSE. See Present State Examinationpsychiatric modelsbio-psycho-social-religious/spiritual, 2multidisciplinary/multilevelpsychiatric model, 160psychiatry training. See religion/spirituality trainingpsychology training. See religion/spirituality trainingpsychosis, 357–358affective states, mood disorders vs., 67causes, biological vs. psychosocial, 67Christian views of, 66–67community treatment programs, 69cost of care, 67–68defined, 66in developing countries, 77–78Eastern traditions, 67ethnic minority groups and, 78group therapy, clinical implications,76–77human suffering and, 67–68impact, 67–68individual treatment for, 69 , 75–76infectious causes, 66Islamic views of, 67multicultural perspective, 77–7819th century European and, 67paradigm for understanding, 68–69psychosis and religion, 65–66clinical correlates, 73–78harmful influence, 70–71ne gat ive effects, 73outcome, 71–72positive coping, 72–73psychiatry, history, 66–67religion as coping factor, 72–74religion as precipitant, 70SMG and, 77spirituality, integrative view, 75spirituality, treatment role, 69–70substance abuse and, 74–75suicidal behaviors and, 74treatment outcome, 71–72psychotherapy, psychiatric care . Seealso Christian psychotherapybio-psycho-social-religious/spiritualmodel, 2holistic, 2multidisciplinary/multilevel modelof, 2prayer and, 207–208psychiatric consultation reasons,190–191religion as deterrent to, 207–208religion as facilitator of, 208–210secular models, 283–284PTSD. See post-traumatic stressdisorderpurpose, meaning in life, 192–193Puthiyadom, Father Thomas, 217Quakers, 13Rabbi Hillel, 38Ray, Issac, 15RC. See Religious CrisisRCI. See Religious Coping IndexRCP. See religious cognitivepsychotherapy See Royal College ofPsychiatristsRCT. See religious cognitive-behavioraltherapyReligion and the Clinical Practice ofPsychology (Shafrankse), 339religion as coping factor, 99 , 194 , 244pain and, 203–205in psychosis, 72–74in psychosis, clinical correlates, 73–78in psychosis, negative effects, 73in psychosis, positive coping, 72–73RCI, 194substance abuse, 74–75suffering and, 203–205suicidal behaviors, 74symptom-related stress and, 245religion, religious belief . See also f ait hdefined, 1 , 84–85depression and, 98 , 100–103 ,194–195discontent and, 103as emotional disorder cause, 193–194as emotional disorder symptom, 193extrinsic vs. intrinsic, 1interference vs. mutual benefit,medical treatment, 277–279multilevel interdisciplinary paradigmof, 2multiple dimensions of, 2pain and, 203in psychosis, harmful influence,70–71as psychosis precipitant, 70religious activities as environmentalfactors, 60religious conversion, 2religious struggle, 103religion/spirituality trainingACGME guidelines, 335in Africa, 340–342American psychiatrists’ guidelines,334–335APA guidelines, 335audience for, 345in Australia, 340in Canada, 336–337for colleagues in training, 333content of, 346curricular content of, 346–348curricular integration, limitationsand resistance, 350data limitations, 336educational goals of, 346educational standards, 334–336in Egypt, 342in Iran, 342–343in Iraq, 343in Israel, 344–345John Templeton Foundation and,337–338in Jordon, 343in Kenya, 341in Lebanon, 343in Malawi, 342medical students and, 344for mental health field, 333in Middle East, 342in Morocco, 342in Pakistan, 343–344in Palestinian territory, 344for primary care physicians, 345psychologists’ education standards,335–336psychology training, USA andCanada, 338–339rationale for, 332–334RCP guidelines, 335RSPCS guidelines, 335in Saudi Arabia, 344in South Africa, 341students, trainees, 333–334in Syria, 344in Tanzania, 340–341teacher qualifications for, 349teaching formats, 348–349timing of, 348training content, 336in UAE, 344in Uganda, 340in USA, 337–339worldwide, 332Religiosity Index (RI), 179religious cognitive psychotherapy(RCP), 200religious cognitive-behavioral therapy(RCT), 245–246religious communities, 252Religious Coping Index (RCI), 194Religious Crisis (RC), 179religious delusions, hallucinations. Seedelusions and hallucinationsreligiousness

Index 375ASPIRES scale, 179–181defining, measuring, 178–179depression and, 99depression recovery and, 101–102as multidimensional contract, 98object-relational aspects of Godand, 99prayer and, 101religious coping and, 99spirituality vs., 179Research Institute for Spirituality andHealth (RISH), 264RI. See Religiosity IndexRichards, P. S., 339Ricoeur, Paul, 159rights of passage, 166RISH. See Research Institute forSpirituality and HealthRogers, Timothy, 11Ross, Kübler, 104Royal College of Physicians andSurgeons of Canada (RSPCS), 335Royal College of Psychiatrists (RCP),16 , 335RSPCS. See Royal College ofPhysicians and Surgeons of CanadaRush, Benjamin, 13–14Saudi Arabia, 344The Scarlet Letter (Hawthorne), 36Schedule for Nonadaptive andAdaptive Personality (SNAP), 181Schizoid PD, 177–178schizophrenia, 67–68delusions, hallucinations and, 82–83dopamine and, 52pharmacological treatment, 68psychosociological approaches, 68stress-vulnerability model, 68Schizotypal PD treatment, 183–184SCID-IIP. See Structured ClinicalInterview for DSM-IV PersonalityDisorders Screening QuestionnaireScott, Reginald, 10secondary identification, 162selective serotonin reuptake inhibitors(SSRIs), 55self-identity, 362affective attunement and, 160attachment, identification and,163–164attachment, religious figures and, 164case studies, 167–170in childhood, 160collective dimension, 165–166collective symbolization and, 166–167construction, development of, 158 ,160–161definition, 159–160disavowed self and, 161false self and, 161father and, 162Freudian theory, 161–163idem- vs. ipse-identity, 159identification process, 161–163individual and group, 165–166interpersonal relationships and, 160Jung and, 160mother and, 160–161 , 161–162multicultural perspective, 171parental roles, religious figures and,164–165partial identification and, 162primary identification, 161–162private self and, 161religion/spirituality impact on,170–171religion/spirituality role in, 158–159rights of passage and, 166secondary identification and, 162sense of core self and, 161sense of subjective self and, 161sense of verbal self and, 161social self and, 161true self and, 161sense of belonging, 104serotonin (5-HT), 49 , 55autonomic nervous system and, 51impulsivity, aggression and, 51location, 49psychoactive drugs and, 149–154role, 49serotonin receptor 1A (5-HT1A), 53–54serotonin-transporter-linkedpolymorphic region(5-HTTLPR), 55SGM-Clinical Langenthal, 258–260Shafrankse, E. J., 339Shia, 303sin, 27–28 , 35–37 , 292SMG. See Spirituality Matters GroupSNAP. See Schedule for Nonadaptiveand Adaptive PersonalitySober for Good (Fletcher), 120social relationships, 192social roles, 192social self, 161solace, 46–47somatoform disorders, 201–202South Africa, 341spiritual assessment, 365spiritual community, 215in Arab/Muslim countries, 218in India, 217in Nigeria, 217–218in Trinidad and Tobago, 221spiritual disease, 292–293spiritual guide, advisor, 220Spiritual Issues PsychoeducationalGroup, 256–258spiritual providers, 3 . See also specificpeopleboundary spanners, 218–219intentional collaboration, training,supervision, 225–226quality, access, 221–223reasons to refer, 223–225referral network, 226–227resources, 229–230spirituality/psychiatry, commonissues, 227–229titles, 220–221training models for, 225–226types, getting to know, 218–221Spiritual Transcendence Scale (STS),179spiritualityASPIRES scale, 179–181Axis II disorders, treatment and,183–185curative power of, 185–186defined, 1 , 115defining, measuring, 178–179religiousness vs., 179Spirituality & Health, 201Spirituality Matters Group (SMG), 77 ,255–256spirituality, religiousness andpsychotherapy relations, 181–183spiritual/religious (SR) assessmentassessment parameters, screeningquestions, 234–235cultural sensitivity and, 233neglect, 232–233psychiatric consultation and,233–234purpose of, 233–234religion and mental healthinterdependence, 233spiritual/religious (SR) assessment,clinical practice, 232 , 235–240community religious practices and,237religion, psychiatric care synergy,240religious community support, 238religious/spiritual history, 237semi-structured interview guide, 240spiritual meaning of illness and, 239S/R assessment. See spiritual/religiousassessmentSSRIs. See selective serotonin reuptakeinhibitorsSSRP. See Stress-Reduction andRelaxation ProgramStages of Faith (Fowler), 110–111Stern, Daniel, 160stigmata, 202Stress-Reduction and RelaxationProgram (SSRP), 204Structured Clinical Interview forDSM-IV Personality DisordersScreening Questionnaire(SCID-IIP), 177STS. See Spiritual Transcendence Scalesubstance abuse, 360Substance Abuse and Mental HealthServices Administration, 222substance abuse disorders, 206–207AA and, 118–119 , 119–120addiction development, spiritualityrole, 115–117clinicians, 122–123empirical findings, 118–120Project MATCH, 121religion as coping factor, 74–75spirituality as protective factor,research, 119spirituality in clinical context, 122–125theoretical rationale, 115–11712 step programs, 114 , 118

376 Indexsubstance abuse disorders, addictionrecoveryspiritual transformations, 118–119spirituality role, 117–118substance abuse disorders, addictiontreatmentacceptance, 119–120assessment as treatment, 124case studies, 124–125meditation, 119prayer, 119profound spiritual transformation,124–125referring out, 125research on spiritual disciplines,119–120spirituality discussion, 123–124substance abuse disorders, substanceabuse reductionspirituality as dependent variable, 121spirituality as independent variable,120–121spirituality as mediator variable,121–122spirituality as moderator variable, 121spirituality role, 120–122suffering, 26–28 , 28–29 , 67–68 , 203–205suicide, suicidal behaviors, 195–199altruistic suicide, 107anomic suicide, 107cross-national findings, 107diagnostic phase, 110egotistic suicide, 107empirical findings, 107–108fatalistic suicides, 107religion as coping factor, 74Roman Catholics vs. liberalProtestants, 107sociological perspectives, 107timely psychiatric care, 197–199Sunni, 303supportive therapy, anxiety disorders,138symptom formationbipolar disorders, 106synthetic-conventional faith, 111Syria, 344TABP. See Type A Behavior PatternTanzania, 340–341Tatian, 9TCI. See Temperamental andCharacter InventoryTemperamental and CharacterInventory (TCI), 53temple, tribal leader, 220Templeton Foundation, 337–338temporal lobe, 50theodicy, 26–28theology, theological perspectives,355–356Cartesian dualism, 24–25Christian Daily Office, 21common heritage, narratives, 22cultural-linguistic framework and,22–23defined, 20experiential-expressivism, 22Freudian psychology and, 21Gnosticism, 25neuroscience, pharmacology and,2 4orthodox faith and, 21–22redemption, resurrection, 28religion and religions, 22–23sin, 27–28suffering, 26–28suffering, healing, people of God,28–29tension, conversation, 23–26theology and tradition, 20–22theomania, 81t her apy. See mental health careprograms, therapytraining. See religion/spiritualitytrainingTreatise on Insanity (Pinel), 13Trinidad and Tobago, 221Trosse, George, 11–12trouble crossing streets, 135–136Trouble of Mind and the Disease ofMelancholy (Rogers), 11true self, 161Trungpa, Chogyam, 317 , 318Tuke, Samuel, 1312-step programs, 2–3 , 16 , 114 , 118Type A Behavior Pattern (TABP), 176UAE, 344Uganda, 340universalizing faith, 111USA, 337–339The Varieties of Religious Developmentin Adulthood (McCullough),103–104The Varieties of Religious Experience(James), 15 , 45 , 119vulnerability-stress model, 98WFME. See World Federation forMedical EvaluationWindhorse Therapy, 367basic attendance in, 321–322basis of, 317case study, 324–330clinician roles in, 322contemplative roots of, 319–320development, 317family meeting in, 324group Windorse phenomenon, 324historical roots, 318house meeting in, 323meetings in, 323–324mutual recovery in, 323overview of, 317–318process, 317–318recovery environment of, 320–321supervision meeting in, 323therapeutic elements, roles,321–324therapeutic foundations of,318–319therapist-friend relationship in,322–323The Witch’s Hammer, 39women’s issues, 37–39 , 42 , 304 , 348work loss, 192World Federation for MedicalEvaluation (WFME), 342World Islamic Association for MentalHealth, 342World Psychiatric Association, 16 ,333 , 334worldview, 284worldwide, 332worrier, 133worship, 297York R et re at , 1 3