Society of Clinical Psychiatrists

Religion , its psychological aspects, and its practice may affect mental health. Beliefs about mental illness and its treatment may be closely tied to beliefs about sin and suffering and views that mental illness may result from some kind of separation from the divine , or even possession , by evil (Loewenthal, 1995 ) . With the phenomenological approach of religion making its appearance , Jung ( 1938 ) went so far as to suggest that religion is not only a sociological or historical phenomenon but that it has a profound psychological significance . Although Jung argues that the phenomena are true thoughts , these can be understood by relating these to " collective unconscious " , a psychic reality shared by all humans . Campion and Bhugra ( 1994 ) found that 75% of their psychiatric patients had consulted religious healers about possession and similar findings have been reported from other parts of India . On the other hand , while looking at possession syndromes , Teja et al. ( 1970 ) and Verma et al. ( 1970 ) reported that these conditions were seen in women , and were largely hysterical in origin .

It is possible that an interaction of the therapist's religious views and that of psychiatric patient's , in some cultures with emphasis on religious matters, may cause conflict . This may plausibly suggest that psychiatric patients ' religious beliefs, at least in some cases, should be taken into consideration while making a clinical diagnosis, treating and planning future management of these cases .

Symbolic Healing

Healing that does not rely on any physical or pharmacological treatments for its efficacy, but rather on language, ritual and the manipulation of powerful cultural symbols. It includes the more traditional folk or religious healing and also the various types of "talk therapy" common in the West such as psychoanalysis, psychotherapy and counselling.

Before healing can take place, a number of conditions must be fulfilled :

1 - The healer must have a coherent system of explanation, or frame of reference, for the origin, and nature, of the problem, and how it can be dealt with. Dow calls this the mythic world - a model of experiential reality, whose elements represent solutions to personal human problems, and which is composed of culturally specific beliefs, metaphors and idioms. It may consist, for example, of a belief that malign "spirits" (or intra -psychic conflicts) are responsible for mental illness and extreme emotional states. In many cases the mythic world is common to most members of the group but it may also be created de novo by some charismatic healer or be shared by a tiny group of adherents, as in religions and talk therapies.

2 - The mythic world must include what Kleinman describes as a symbolic bridge between personal experience, social relations, and cultural meanings. That is, the suffering individuals in that society must be able to understand their own situation, and its resolution, in terms of its imagery and symbols ( such as spirit possession, or intra-psychic conflict ).

In many cases these symbols are already familiar to these individuals and emerge from the depths of their cultural experience.

3 - When a suffering individual consults a healer, the healer aims to activate this "symbolic bridge" by convincing the clients that their own problem is explicable in terms of the symbols of the mythic world. That is, the patients have to be persuaded that their suffering can be re-defined as for example, evidence of "spirit possession", "neurosis", or "evil eye affliction" . Thus the healer aims at this stage is to get the patient to accept a particularization of the general mythic world as a valid model of the patient's experiences.

4 - Once patient and healer have reached this consensus, the healer needs to get the patient emotionally as well as intellectually - attached to the symbols of their mythic world. That is, before therapeutic change can take place, patients must feel emotionally involved in the healing process, and must see these symbols (whether they are "spirits" or "intrapsychic conflicts" ) as relating to them personally, and to their situation. This is done by interpreting a patient's excess rage as evidence of "possession" by an angry, evil spirit , or of severe inner "conflicts" dating from childhood, or by interpreting feelings of depression as being due to "soul loss".

5 - The healer now begins to guide therapeutic changes by manipulating symbols of their mythic world. For example, having identified the "spirit" possessing the patient, he goes through a complex ritual of exorcism , at the end of which the anxious patients are reassured that the "spirit" has left them, and they can now resume their normal life. Or, they may be reassured by a psychotherapist that they have at last "worked through" certain archaic, inner conflicts.

Kleinman points out that the "healing" as sacred or secular ritual, achieves its efficacy through the transformation of experience. The patients learn to re-evaluate and "reframe" their past and present experiences. Furthermore, Kleinman sees the process, and the symbols used within it, as a way of linking the patient's self ( both psychologically and physical ) to the social relations and cultural concerns of the wider society. In many cases, the symbols that achieve this are not only the conceptual symbols of the mythic world, but also the more tangible "ritual" symbols.

6 - The "healed" patients have acquired a new way of conceptualizing their experiences in symbolic terms , and a new way of functioning - both of them confirmed by the healer . In the process , they have also acquired a newly fashioned narrative of their past and present , and their likely future . Whether this narrative is short ( as in spirit exorcisms ) or lengthy ( as in psychoanalysis ) it summarizes what had happened to them, and why , and how the healer was able to restore them to happiness or health .

The setting of symbolic healing

Symbolic healing usually takes place at specified times , and in specified places . The setting itself plays a crucial role in the healing process ; setting the stage , creating a mood of expectation , and giving information to the clients about the healers - especially their interests , background , the source of their power and what they believe in . For example , patients entering Sigmund Freud's consulting rooms in Vienna or London , would find the desk and shelves filled with artifacts of ancient Greece , Rome and Egypt , reflecting his interest in the clients' early , hidden childhood experiences , and his remark that the analyst's work "resembles to a great extent an archaeologist's excavation of some dwelling place that has been destroyed and buried ". In religious healing , the setting may be a church , a temple , a shrine , a tomb , the home of a religious healer , or a sacred place of pilgrimage In many Arab countries , the families of people with severe mental problems ( frequently blamed on "evil eye" , sorcery or possession by jinns) often turns first to forms of ritual healing . These may include visits to the tombs of famous sheikhs , consultations with a respected sheikh or master ( Al-Asyad ) , the use of amulets containing holy verses , and purification rituals , which involve drinking or washing in water that has been washed off Koranic verses , written on a plate . Whether symbolic healing is sacred or secular , the setting in which it occurs , and the ritual symbols used within it , are both crucial parts of the healing process ; playing an essential , though non - verbal , role in the creation of the mythic world , in terms of which healing will take place.

The efficacy of symbolic healing

It is difficult to evaluate the efficacy of different forms of symbolic healing, since definitions of therapeutic success vary among them .

For example , in a detailed study of healing in a spiritual temple in rural Mexico , Finkler found that it was ineffective for the psychoses , but useful for "neurotic disorders" , psychophysiological problems and somatised syndromes . It enabled patients to abandon their sick roles , return to normal behaviour , and eliminate the feeling of "being sick" . Similarly , in a study of therapeutic outcomes from a Taiwanese healer or tang - ki , Kleinman found that symbolic healing was mainly effective for episodes of neurosis and somatisation , and its value more in healing the "illness" than in curing the "disease" . It was effective in fitting the illness episode into a wider context , explaining it in familiar terms , mobilizing social support about the victim , and reaffirming basic values and group cohesion , thus reducing anxiety in both the victims and their families .

Most anthropologists agree therefore that , for whatever reason , many people are helped by symbolic healing , whether religious or secular .

Healing , however is not identical to "curing" , especially in the case of severe psychosis , or physical disability . Individuals , and their families , may feel that they have been "healed" , even though they have not yet been "cured" in conventional psychiatric or medical terms . This distinction is clearer in some forms of religious healing , such as "faith healing" .

As Csordas points out , there are crucial differences between secular healing ( with its mind - body dualism ) , such as medicine or psychotherapy, and religious healing ( with its tripartite division of the mind - body - spirit) In his study of Catholic Charismatic healing in the USA , he describes their four distinct types of healing :

n. physical healing of bodily illness

n. inner healing of emotional scars or mental illness

n. deliverance from the adverse effects of demons or evil spirits

n. spiritual healing of the soul injured by sin , primarily by means of the Sacrament Of Reconciliation ( confession )

Even if the first three fail , in a particular case , and the person remains mentally or physically ill , spiritual healing is still possible - as what Csordas calls "a hedge against the failure of healing prayer" .

Religion's positive effect on mental health has been well documented. One route is through social support. Brown and Harris (1978) highlighted the importance of social support when they showed that having a confidant acted as a protective factor against the onset of depression. Marcia (1966) has suggested that religious or ideological commitment is a major part of identity formation.

Religious organizations and social networks have, as a very important function, the provision of social support of all kinds. There is evidence that religiosity goes along with perceived social support ( McIntosh, Silver and Wortman, 1993).

Based on Durkheim, there have been a number of reports suggesting a protective effect of religion against suicide. Where religious groups are organised with a good infrastructure and strong primary group ties, the greater protective effects of religion against suicide are enhanced. More evidence comes from a study of American parents coping with the loss of a child from SIDS (sudden infant death syndrome). Religious participation and importance of religion were assessed three weeks after the death of the baby. Both religious participation and importance of religion related to greater well-being and lower distress 18 months after the death.

In a different religious-cultural context, Shams and Jackson (1993) studied Moslem men of Asian origin living in Britain. This study showed that the distressing effects of unemployment were mitigated by religiosity. The benefits of contact with other Moslems around the mosque, and engagement in both structured and informal social contact is likely to foster the affirmation of identity threatened by unemployment. Thus, stress-buffering social effects of religiosity are suggested and found to be partly the result of social support, both emotional and practical.

Social support is said to enhance well-being via feelings of acceptance, identity and shared purpose, self esteem, and feelings of coping. Another positive effect on mental health, is through spiritual support . Maton (1989) described three aspects to spiritual support :

- emotional : experience of the divine care

- intimacy : experience of a close personal relationship

- faith : feeling that trust is essential to coping

Maton looked at relations between perceived spiritual support and measures of mental health (well-being, self esteem and lack of depression) in American adults. Some were undergoing or had undergone severe stress, and in this group, spiritual support was related to measures of mental health. Subjects not under stress showed no such relationship.It is possible that stress induces turning to God. This is suggested by remarkable data summarized by Argyle and Beit-Hallahmi (1975). They summarize several surveys of the effects of battle and other war experiences on US army veterans of the Second World War. Prayer was most commonly mentioned of all cognitive strategies as being helpful "when the going was tough" (Stouffer et al., 1949). The more severe the stress, the more prayer was found to be helpful. Parker and Brown (1982) grouped prayer with problem solving behaviours as a coping strategy. The perceived effectiveness of prayer was related to the extent to which it was actually used in coping with crises. Parker and Brown (1986) included prayer as one of many possible strategies for coping with negative events and feelings. It was associated (statistically) with help seeking behaviour. A group of clinically depressed subjects were studied on three occasions. Help seeking was not associated with improvement in expression scores i.e there was no relationship between the use of prayer and improvement, in a group of depressed patients. The strongest finding of the study was that self consolatory behaviours (such as eating, drinking alcohol and spending money) were associated with a worsening of depression. It is to note that the study does not look at the "pure" effects of prayer directly. A study which showed some positive effects of prayer was reported by Finney and Maloney (1985). Prayer was used as an adjunct to psychotherapy, with helpful effects in the clients studied. Loewenthal and Goldblatt looked at regular prayer and the saying of psalms in a sample of Anglo-Jewish women, and found that the latter went along with lower depressed mood.

There has been very little work on the effects of religious experiences on mental health. The main types of experiences are the following :

·. Mystical and contemplative : these involve a quiet person, a comparatively still body and a feeling of communion with the divine .

·. Ecstatic : here the person is usually not quiet and the body is very active, and the dominant feelings are excitement and of being moved by the divine.

Ecstasies include possessions and trances, glossolalia and feelings of being moved by the spirit. Demographic and anthropological evidence suggests that ecstasies are more commonly experienced by deprived, disadvantaged or oppressed groups ( Holm , 1983 ). I.M.Lewis (1971) concluded that in peripheral cults it was almost exclusively women who were possessed.

·. Other : these include near-death and out-of-body experiences, states such as spirit possession and strong feelings of religious preparation by the person, and involve an intense awareness of spirituality, for example that the soul has left the body and is meeting the souls of other people who have died or that the body has been taken over by the soul of someone who has died.

Mystical states may appear to come out of the blue. A major research effort by the Hardy-founded Religious Experience Research Unit in Oxford was to describe these states and some of the conditions in which they occurred. Mystical states may be deliberately fostered and encouraged. Various religious disciplines ( prayer, contemplation, fasting and others ) may induce greater religious awareness.

In Stace's (1960) book, mystical states are seen as having the following qualities.

·. Noetic : the experience is seen as a source of valid knowledge, not just a pleasant or inspiring experience.

·. Holiness : this does not necessarily carry any theological connotations; it means that the experience is seen as special and sacrosanct by the individual.

·. Positive affect : though the experience is profound, it is not generally seen as frightening and is rather seen as positive.

Stace also distinguishes between extroversive mysticism, involving a sense of "life" in all things and their unity and introvertive mysticism involving timeless and spaceless qualities and a dissolution of the sense of self.

Spilka, Hood and Gorsuch (1985) stress that mystical experiences are more likely to be reported by intrinsically religious people because they value them and have attributional framework which enables them to interpret them as meaningful. It is important to distinguish mystical states from psychopathological conditions. Meadows and Kahoe (1984) discussed some suggestions drawing parallels between some mystical and religious ecstatic states and some psycho-pathological states notably schizophrenia. Both states involve the rejection of something bad, a feeling of alienation and disappointment in interpersonal relationships, and the construction of a more gratifying reality, but the mystical experience is consciously controlled and prepared for.

Mysticism involves an expansion of consciousness, rather than an involuntary fleeing from an unbearable reality. Nevertheless there have reports of psychotic breakdowns following altered states of consciousness, often drug induced.

Pahnke's (1966) study of committed Christians who were involved after careful supportive psychological and religious preparation supportive psychological and religious preparation, in an intense group religious experience on Good Friday. Some of the group had been administered psychedelic drugs, others a placebo.

The main outcome measures were based on Stace's criteria for mystical experience (noetic experience, transcending time and space). The psychedelically drugged subjects scored higher on these shortly after there experience. But in the longer term, several months later, both groups reported changes (improvements) in their outlook, to an equal extent .

Looking at the psychopathological distinction between the disturbed thinking of the schizophrenic patient and the description of internal experience of a person with strong religious beliefs , there appears to be some important differences :

Religious experiences are usually regarded by the believer as being metaphorical or spiritual ; the physical boundaries of self are not invaded , which is not the case with the schizophrenic patient .

Schizophrenic delusions and hallucinations are associated with a loss of ego boundaries and are based upon delusional evidence, but there is no change in the boundaries of self in other areas of his experience for the religious believer and his belief is based upon his source of religious authority .

Religious experiences provoke sustained meaningful, goal directed activity, whereas the behaviour that results from schizophrenic experience is often unreasonable in that it does not follow logically from the experience; is bizarre in flouting popular customs; is concrete in making spiritual values physical; and tends to trivialize the sublime.

Religious beliefs are held alongside the possibility of religious doubts; in this they are like other abstract concepts. Schizophrenic delusions and hallucinations are accepted without doubt.

The difference between the concrete thinking of organic psychosyndromes and that occurring in schizophrenia was described by Cameron (1944) who considered that the schizophrenic is unable to preserve conceptual boundaries . This he called the over-inclusive thinking.

There is a breakdown in the way the schizophrenic thinks of the boundary between himself and the outside world so that he can no longer accurately discriminate between the two. Crossing the line between the ego experience of "self" and failure to identify inner experiences , considering thought, perception and activity ; could possibly be explained by "dwelling of the thoughts" whether initiated by the person's will or induced . It is possible that repetitive thinking and preoccupation leads the genetically predisposed person (in the study, schizophrenic patient in remission) into a vicious circle of thoughts at the end of which he becomes trapped. In that case thought preoccupation and disorder, which the patient displays, would rather be considered as the triggering factor for the illness.

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