1. “THE SICK SOUL” AND BEYOND – Religious interpretations of mental distress Samuel Pfeifer Clinic Sonnenhalde, Riehen Switzerland

2. Psychiatric Clinic Sonnenhalde, Basel Founded in 1900 by a protestant order (Diakonissenhaus Riehen) Open doors – no restraint Professional clinical psychiatry combined with Christian values Teaching hospital of the University of Basel

3. „The sick soul“ (William James)  Those persons who cannot so swiftly throw off the burden of the consciousness of evil, but are congenitally fated to suffer from its presence.  …for whom evil is no mere relation of the subject to particular outer things but something more radical and general, a wrongness or vice in his essential nature, which no alteration of the environment, or any superficial rearrangement of the inner self, can cure, and which requires a supernatural remedy.”

4. Three conditions  Melancholy – depression  Obsessive-scrupulous doubt  Panic fear  No reference to psychotic disorders and delusional states  No reference to dissociative states

5. Descriptive approach  “Please observe that I am not pretending to judge any of these attitudes. I am only describing their variety.” William James, p. 144

6. Heinrich Füssli (1741 - 1825) Nightmare

7. Overview A) Definitions B) Causal attributions C) Psychodynamics and Spiritual Interpretations D) Clinical Implications

8. Spirituality An attitude directed towards the intangibly transcendental (God). For the spiritual person this is the source and the goal of his or her life, fundamentally influencing his or her way of living, responsibility and ethics. (modified after Scharfetter 1999)

9. Spiritualization  incidents and experiences are interpreted in a religious context  The interpretation relates to causality and change (therapy) of problems.  Subjective experience is perceived in a comprehensive spiritual context

10. WHY? Causal attribution Tolstoy, Confessions  “The questions of ‘Why’ and ‘What for?’ beset him more frequently – These questions of ‘Why’ and ‘Wherefore’ and ‘What for’ found no response.”  William James

11. WHY? Causal attribution Locus of Control  Internal (spiritual life, personal effort)  External (affliction, oppression, curse) Stability  Stable (personal discipline, effective protection)  Variable (actual condition, reliability of others)

12. Effects (Weiner)  Coping or  Hopelessness  Cooperation and Empathy or  Blame and Rejection

13. STUDY: Causal Attributions in Schizophrenia (Angermeyer & Klusmann, 1988) Five areas:  Psychosocial burden  family  Personal problems  Biological factors  „Esoteric“ factors Eur Arch Psychiatr Neurol Sci 238:47-54 (1988)

14. Family  Broken home  lack of parental love  father was too strict  parents had too high expectations  overprotective mother  hostile-rejective attitude of parents  evading daily problems  lack of will power  alcohol and drugs  too intelligent  too ambitious  general failure Personal Problems Eur Arch Psychiatr Neurol Sci 238:47-54 (1988)

15. «Esoteric Problems»  Lack of vitamins  Environmental pollution  Possession by evil spirits  Detrimental radiation  Divine punishment  Unfavorable Horoscope  Open Question1,0 %  Possible Cause54,9 %  (Very) Probable Cause22,3 % Evil spirits:  Possible Cause10,9 %  (Very) Probable Cause3,1 % Angermeyer & Klusmann (1988) Eur Arch Psychiatr Neurol Sci 238:47-54

16. “Occult Bondage”  343 Patients (114 m, 229 f)  all were religious  mainline church (cath, ref.)139  Trad. free churches (TFC)164  Char. free churches (CFC)40  Schizophrenia60  Depression87  Anxiety Disorders56  Personality Disorder65  Adjustment Disorder 75 Pfeifer S. (1994) Belief in demons and exorcism. An empirical study of 343 psychiatric patients in Switzerland. British Journal of Medical Psychology 67:247–258

17. “Occult Bondage”  Occult Bondage37,6 % as possible cause  Ritual of deliverance30,3 % performed Significant correlation with  Diagnosis (p < 0.01)  Religious affiliation (p < 0.005) Pfeifer S. (1994) Belief in demons and exorcism. An empirical study of 343 psychiatric patients in Switzerland. British Journal of Medical Psychology 67:247–258

18. Belief in demonic causality (in percent)

19. Bio-psycho-social Model Mosaic of Causal Attributions Conflicts from Individual Experience Cultural Traditions Alternative Body Theories and Diets Religious Convictions Spiritual and Magical Beliefs Pfister, S. & Thiel, S. (1999). Religiosität und subjektive Krankheitstheorie. Eine empirische Untersuchung bei 53 psychiatrischen PatienInnen. Dissertation Medizinische Fakultät der Universität Bern.

20. Spiritual interpretation The Bio-Psycho-Social Model and Spiritualization

21. Forms of Spiritualization  Spiritual forms of intrapsychic communication: „I talk to God; God talks to me.“  Spiritual interpretation of natural desires and unadjusted behavior  Spiritual interpretation of distress (mentally and somatic); i.e. causal attribution without delusional aspects  Religious delusions

22. Functions of Spiritualization  Interpretation (Causal attribution) e.g. „oppression“ as a reason for sleep disorders  Defense mechanisms e.g. prayer meeting instead of behavioral change --- e.g. spiritual justification of wishful thinking  Coping e.g. prophetic words of encouragement / subjective relief through “rebuking spirits”

23. A continuum of intensity Empathy possible  failure to attain a religious ideal: e.g. „I am not praying enough!“ e.g. „I feel abandoned by God“ e.g. „I am damaging my Karma!“ Extreme  demon of pride, lust etc. (unacceptable drives and behaviors are attributed to demons)  Demons as cause of sleep disorders, nightmares, obsessional thoughts etc.

24. Forms of Spiritual Therapy (in the Christian context *)  Traditional and common: Prayer, Confession, Communion / Eucharist, Blessing through the Laying of Hands.  Transitional Objects and Protection against Evil: Pictures of Saints, Amulets, Holy Cross, protecting objects etc.  Religious Activities: Pilgrimage, participation in religious festivals, religious exercises, visiting special healers.  Forms of Counseling: „Imagery“, Prophecy, Deliverance, „Rebuking evil forces“ (self or others), Exorcism. *) wide variations in other religious cultures

25. Contamination Mixture of spiritual support  with popular superstition (especially in catholic and orthodox context)  with Psychoanalytic Popular Psychology (e.g. in the charismatic literature)

26. Dealing with Spiritualization 1. Assessment  “Approaching the unfamiliar with respect helps us to gain understanding”  Explanatory Model or secondary phenomenon?  Delusion or Subculture?  Psychodynamics: Positive Coping or Dysfunctional Defense Mechanism?  Which therapeutic consequences result from the religious interpretation of the problem? (traditionally Christian, magical, dramatic)

27. Dealing with Spiritualization - 2 2. Evaluation  In cooperation with the client / patient  Different forms of “religious style”  Personal integrity of the therapist  Theological evaluation is not primary concern of therapy IMPORTANT QUESTION:  What is the influence of religious interpretations on symptom relief, coping with life events and psychosocial development of the patient / client?

28. Symptom Relief Personal freedom -- Interpersonal Relations -- Coping Outcome negative Outcome positive Results of Spiritualization

29. 3. Therapeutic strategies  Develop a supportive therapeutic setting in collaboration with the patient  Spirituality as part of a comprehensive model of illness and coping.  Cooperation with counselor / pastor (if possible)  Psycho-education: Religious life can be affected by mental illness (e.g. depression)  Image: out-of-tune piano  Determine functional and dysfunctional aspects of spiritual interpretation  „Agree to disagree“

30. Indicators of functional spirituality  Improves self-confidence (based on confidence in God)  Enables mature patterns of relating to others  Enhances coping with life’s demands  Preserves the awareness and the awe of the ultimate spiritual reality, God.

31. Conclusions  The construction of meaning on the background of sub-cultural values is a universal phenomenon.  Help-seeking behavior  Physicians, healers and counselors are unwitting partners in health care  Cultural sensitivity  Utilizing functional aspects of religion in a patient‘s coping process

32. Download www.samuelpfeifer.com