Second, I will discuss issues related to the diagnosis of psychosis in religious persons, seeking to separate out culturally normative religious belief and practice from psychotic symptoms. Third, I will examine the use of religion by persons with severe mental illness to cope with their conditions, and explore how psychotic and non-psychotic religious beliefs and practices influence the outcome and course of mental disorders with psychosis. Finally, I will discuss spiritual interventions that may facilitate the treatment of persons with severe mental illness with psychosis.
How common are religious delusions found among persons with psychotic disorders? Prevalence rates depend on the particular psychotic disorder and the location in the world where the person lives.
Spirituality and mental health
In the United States, a number of studies have examined religious delusions in patients with schizophrenia or bipolar disorder. Compared to other delusions, religious delusions appeared to be held with greater conviction than other delusions. Patients with religious delusions had more severe hallucinations and bizarre delusions, had poorer functioning, a longer duration of illness, and were taking more anti-psychotic medication than other patients.
A few studies have also examined religious delusions among psychiatric patients in Brazil. It is better for you to lose one part of your body than for your whole body to be thrown into hell. Six cases were seen within a year period at a Brazilian university hospital. In the only systematic study of psychiatric patients conducted thus far in Brazil, researchers examined consecutive admissions to a general psychiatric hospital Dantas et al. To identify religious content, an item was added to the BPRS-extended form.
Patients with all psychiatric diagnoses were included, not just those with psychotic disorders. Investigators report that A strong correlation was found between manic symptoms and religious experiences. What is the origin of religious delusions? Religious delusions exist on a continuum between the normal beliefs of healthy individuals and the fantastic beliefs of the psychotic patients.
However, attempts to locate the origin of religious delusions in the brain have not revealed findings that are consistent with neuroimaging research described above. The only study to date, to my knowledge, suggested that religious delusions result from a combination of over-activity of the left temporal lobe and under-activity of the left occipital lobe Puri et al.
Thus, until more research is done, the neuroanatomical origin of religious delusions remains uncertain. To what extent are persons with severe and persistent mental illness involved in non-psychotic religious activity? Are they any more prevalent in those with severe mental illness than in normal, healthy populations?
A number of studies provide information in this regard.
Unclear in this study, as in most studies, is how investigators distinguished "normal" religious activity from religious delusions or other pathological expressions of religious activity. Studies in Great Britain have also consistently found an association between religious involvement and psychotic symptoms. Neeleman and Lewis compared religious practices, beliefs, attitudes, and experiences of 21 outpatients with chronic schizophrenia, 52 non-psychotic psychiatric outpatients, and 26 normal controls with physical health problems London.
Patients with schizophrenia reported more religious experiences and attitudes but not religious practices compared to control patients with psychiatric and medical illness. Feldman and Rust also found a positive relationship between religiousness and schizotypal thinking in a sample of 67 patients with schizophrenia compared to normal controls London.
Faith and mental health : religious resources for healing
Some of the best and most detailed information on schizophrenia and religious involvement comes from the work of Siddle and colleagues at North Manchester General Hospital in Great Britain. These investigators report positive correlation between religious delusions and religious activity in inpatients with schizophrenia. Patients with religious delusions scored significantly higher on self-assessed religiosity and doctrinal orthodoxy than those without religious delusions.
These researchers acknowledged difficulty distinguishing psychotic expressions of religious involvement from non-psychotic expressions. Several studies have found that involvement in New Religious Movements NRM may either be the cause or the result of psychotic-like traits or symptoms. For example, one study compared the strength of religious belief between non-psychotic and 88 psychotic patients hospitalized at a psychiatric facility in Illinois Armstrong et al.
Non-psychotic patients had stronger religious believes that psychotic patients in Catholic and Protestant patients, but the opposite was true for Unitarian patients. A second study compared converts to Judaism and Catholicism with converts to Bahai and Hare Krishna religions 10 converts to each tradition Ullman, In a third study, Peters and colleagues compared scores on a delusional ideas inventory between 45 normal non-religious persons, 38 normal Christians, 26 normal members of Hare Krishna and Druid religions, and 33 psychiatric inpatients with delusions 27 with schizophrenia London, England Peters et al.
Much attention has also been paid to the role that religious conversion itself regardless of specific religious group may be involved in either the etiology of psychosis or the result of psychosis itself. The speed at which conversion takes place may be particularly important in this regard.
William James wrote that sudden conversion was more likely to occur in the "sick soul" than in the "healthy minded. Sudden religious conversion may be quite different from conversion that occurs more gradually, "in the course of real maturing For example, in perhaps the largest study of religious conversion to date, Heirich surveyed generally healthy persons recently converted to Catholicism, compared to controls.
Faith and Mental Health: Religious Resources for Healing – Harold G. Koenig
The most relevant factors involved in bringing on conversion were discussions with friends, relatives, or religious professionals, not stressful circumstances. Several studies suggest that religious activity or religious interest changes follow rather than precede psychotic breakdown. This may reflect an increased turning to religion to cope with the stress of schizophrenic symptoms in a highly religious population.
In a second study, investigators examined patients with first-onset schizophrenia from four ethnic groups in Great Britain: Trinidadian, London White, London Asian, and London African-Caribbean. They found that many of these persons had converted to a new religion after their diagnosis. Researchers suggested that these conversions were at least partly an attempt to regain self-control as their self-concept began to change with the emergence of schizophrenic symptoms Bhugra, In that study, it was clear that religious conversion occurred secondary to the development of psychosis, rather than vice-versa.
In religious environments such as India, the United States, or Latin American countries, how does the clinician distinguish normal, culturally appropriate religious beliefs from psychotic symptoms? Unfortunately, it is not always so easy. A delusion is defined as a fixed, false belief that the person cannot be dissuaded from no matter how much evidence to the contrary. The atheist may readily believe that the religious person suffers from a fixed, false belief, so this depends to some extent on the worldview of the person judging the particular belief.
Likewise, deeply religious non-psychotic persons may talk about hearing the voice of God or experiencing a religious vision, such as occurred in Medjugorje, Bosnia-Hercegovina. However, as noted earlier, religious delusions occur in persons with psychosis more than one-quarter to one-third of the time, and may be used to determine whether or not a psychosis is present.
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Thus, distinguishing religious beliefs and experiences from those that are psychotic becomes an urgent dilemma for the clinician. Pierre describes several ways to distinguish normal from psychotic religious experiences. If social or occupational functioning are not impaired, then the religious belief or experience is not pathological. Related to impairment of function is loss of the ability to hold down a job, legal problems with police or due to failure to fulfill obligations, homicidal or suicidal threats and behaviors, and problems with thinking clearly.
The healthy religious person with mystical experiences, on the other hand, will often have a positive outcome over time such as increases in psychological or spiritual maturity and growth. Others have reinforced the emphasis on ability to function, and have pointed out other distinguishing features Lukoff, The psychotic person does not usually have insight into the incredible nature of his or her claims, and may even embellish them, whereas the non-psychotic person usually admits the extraordinary or unbelievable nature of his or her claims.
Furthermore, the psychotic person will have difficult establishing "intersubjective reality" with other persons in their psychosocial or religious environment, particularly since they will have other symptoms of psychotic illness that impair with their ability to relate to others.
However, psychotic and mystical states may have some much overlap that it is difficult to distinguish one from the other without long-term follow-up and careful observation over time. Psychiatrist Andrew Sims from Great Britain has provided a set of criteria that may be used in distinguishing persons with religious or spiritual beliefs from those with religious delusions. These criteria include aspects common to the diagnostic distinctions already described above.
Sims notes that for religious delusions:. These criteria have already been used in studies by Siddle and colleagues, which have provided evidence for their validity Siddle et al. There is general agreement, then, that specific criteria exist that can help to distinguish the mentally ill person with psychosis from the devoutly religious person having mystical experiences.
The religious person has insight into the extraordinary nature of their claims, is usually part of a group of people who share their beliefs and experiences culturally appropriate , does not have other symptoms of mental illness that affect their thought processes, is able to maintain a job and stay out of legal problems, does not harm himself or herself, and usually has a positive outcome over time.
Of course, however, there is always the possibility that a mentally ill person even those with psychotic illness will have religious beliefs and mystical experiences that are culturally normative and may in fact help that person cope better with their mental illness. A number of studies suggest that religious beliefs are used to cope with the extreme stress that mental illness can cause.
In fact, the majority of patients spent nearly half of the time trying to cope with their illness in religious activities. Patients with chronic schizophrenia or schizoaffective disorder were more likely than patients with affective disorders to utilize religious coping. In another study, this one conducted over the Internet, investigators examined alternative health practices of persons with schizophrenia, bipolar disorder, or major depression Russinova et al.
Studies in Europe and other more secularized part of the world, report conflicting findings concerning the prevalence of religious coping, depending on the particular study cited. Likewise, a study of 79 psychiatric patients in New South Wales near Australia found dependence on spiritual beliefs widespread. In the above study, religious coping appeared to impact outcomes in a positive way, since it was associated with greater insight and compliance.
Numerous other studies also report a positive influence of non-delusional religious involvement on the course of severe mental illness. Over 50 years ago, Schofield and colleagues reported that regular church attendance was one of 13 factors associated with a good prognosis in patients with schizophrenia Schofield et al.
Those from urban areas were less likely to be re-hospitalized if their families encouraged religious worship during hospitalization. In the overall sample, lack of religious affiliation was associated with a greater risk of re-admission, particularly when compared to Catholic patients. In the largest study to date, outpatients with schizophrenia were followed for two years, examining factors related to hospitalization for worsening psychosis Verghese et al.
Patients who reported a decrease in religious activities at baseline experienced a more rapid deterioration over time. This study was conducted in India among a largely Hindu patient population. In a study that took place in secular European country of Sweden, investigators studied 88 patients with adolescent-onset psychotic disorders, most of whom had schizophrenia.
Religious involvement was among the factors that predicted fewer suicide attempts along with good family relationships and better health. In fact, when investigators controlled for anxiety and depression, the only variable that predicted fewer suicide attempts was satisfaction with religious belief. Finally, in a study that examined response to treatment during 4 weeks of hospitalization in patients with schizophrenia, neither level of religious activity nor the presence of religious delusions adversely affected response to treatment compared to other patients Siddle et al.
In that study, patients with religious delusions had more severe illness and greater functional disability than other patients. Clearly, more studies are needed that carefully measure both delusional and non-delusional religious activity at baseline and carefully follow changes in religious involvement and interest during hospitalization, after discharge, and after anti-psychotic drug treatment. Since many patients with severe mental disorder use religion to cope with their illness, it may be that religious or spiritual interventions could prove helpful.
Fallot describes how the spiritual needs of patients with severe mental disorder can be addressed as part of their treatment. Recommended interventions include taking a spiritual history, addressing spiritual needs in individual psychotherapy once the illness is stabilized, connecting the patient to faith communities and spiritual resources, and conducting spiritually oriented group therapy in outpatient and inpatient settings. There is concern, though, that such interventions may interfere with or complicate the recovery of persons with severe mental disorder, especially if religious delusions or hallucinations are present.
Although the research is clearly at an early stage, studies to date do not find that such approaches worsen or exacerbate psychotic illness, especially when applied in a thoughtful, sensitive manner. I will now review some of these studies, with a focus on spiritually based group therapy that has the potential to provide support, reduce isolation, and address common spiritual concerns of patients with severe mental disorder.
Phillips and colleagues describe a 7-week semi-structured psycho-educational program provided in a group therapy format designed specifically for person with severe mental disorder. In a typical session, participants discuss religious resources, spiritual struggles, forgiveness, and hope. Kehoe describes another program based on her experiences over nearly two decades doing spiritual-based group therapy with psychiatric patients.
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Taking a psychodynamic-oriented approach, she reports spiritual-based group therapy fosters tolerance, self-awareness, and exploration of value systems. According to Phillips and Kehoe, members of these groups experience increased understanding of feelings, comfort derived from having spiritual concerns addressed, and increased social connections to others. These groups are typically held in psychiatric outpatient settings and day treatment centers and include from 6 to 12 members. Spiritual interventions that take a more individualized approach have also been described.
The results indicated that, compared to a control patients, those receiving the spiritual intervention became more able to express their concerns verbally, ventilate anger and frustration, and deal with inner feelings and emotions.
Spiritual Concerns | Pathways to Promise
These patients were also more motivated to make changes in their lives, demonstrated more appropriate affect, and complained less about somatic symptoms. Outcomes were largely qualitative.
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Researchers administered this intervention in an open trial format to 28 patients. After the treatment, participants showed an increase in perceived spiritual support, but it had no effect on depression, hopelessness, self-esteem, or purpose in life. In none of the above studies did researchers observe any worsening of symptoms with spiritual approaches. Research in countries outside the U. In one study conducted in Southern India, investigators describe the effects of spending time in a Hindu temple the spiritual intervention Raguram et al, Built over the grave of a revered Hindu teacher, the temple had become known locally as a healing shrine for people with mental illness.
Researchers at the National Institute of Mental Health and Neurosciences in Bangalore studied 31 consecutive subjects coming to the temple for help. Subjects lived in the temple for an average of 6 weeks 1 to 24 weeks. The BPRS was administered on entry into the temple and on leaving it. Before and after scores showed a drop in BPRS scores from They hypothesized that improvements with spiritual approaches could explain the better outcomes for schizophrenia seen in traditional societies.
Spiritual approaches, however, do not always benefit those with severe mental disorder. At least one study has reported an association between spiritual healing practices and schizophrenic relapses. Subjects were matched for age, gender and duration of illness.
A helpful way to begin is to be asked "Would you say you are spiritual or religious in any way? Please tell me how. A gentle, unhurried approach is important — at its best, exploring spiritual issues can be therapeutic in itself. What is your life all about? Emotional stress is often caused by a loss, or the threat of loss. Have you had any major losses or bereavements or suffered abuse? How has this affected you? Do you feel that you belong and that you are valued? Do you feel safe and respected? Are you and other people able to communicate clearly and freely? Do you feel that there is a spiritual aspect to your current situation?
Would it help to involve a chaplain, or someone from your faith community? What needs to be understood about your religious background? What do the next few weeks hold for you? What about the next few months or years? Are you worried about death and dying, or about the possibility of an afterlife? Would you want to discuss this more? What are your main fears about the future? Do you feel the need for forgiveness about anything? What, if anything, gives you hope? How could you best be helped to get it? Is there someone caring for you with whom you can explore your concerns?
Over recent years there has been increasing interest in treatments that include the spiritual dimension. Spiritual practices can help us to develop the better parts of ourselves. They can help us to become more creative, patient, persistent, honest, kind, compassionate, wise, calm, hopeful and joyful. These are all part of the best health care. This means that the giver and receiver both get something from what happens, that if you help another person, you help yourself. Many carers naturally develop spiritual skills and values over time as a result of their commitment to those for whom they care.
Those being cared for, in turn, can often give help to others in distress. Spirituality is deeply personal. Try to discover what works best for you. A three-part daily routine can be helpful:. You can find out about spiritual practices and traditions from a wide range of religious organisations. Secular spiritual activities are increasingly available and popular. For example, many complementary therapies have a spiritual or holistic element that is not part of any particular religion.
The internet, especially internet bookshops, the local yellow pages, health food shops and bookstores are all good places to look. There is also a wide range of papers about spirituality and mental health that can be downloaded from the publications archive of the Spirituality and Psychiatry Special Interest Group.
Buy this leaflet Print this page Share this page facebook twitter linkedin. Disclaimer This webpage provides information, not advice. What is spirituality? How is spirituality different from religion? What is spiritual health care? What difference can spirituality make? This has enabled them to accept and live with continuing problems or to make changes where possible. A spiritual assessment. Sometimes, a professional may want to use a questionnaire. They will want to find out: what helpful knowledge or strengths do you have that can be encouraged?
Setting the scene What is your life all about? The past Emotional stress is often caused by a loss, or the threat of loss. The present Do you feel that you belong and that you are valued? The future What do the next few weeks hold for you? Spiritual practices. These span a wide range, from the religious to non-religious. Spiritually-informed therapies. Spiritual values and skills. How to start.
Education and research. Further information. Further reading Barker P. Butler-Bowen T.