Religion, spirituality and psychotic disorders

Background: Religion is often included in the beliefs and experiences of psychotic patients, and therefore becomes the target of psychiatric interventions. Objectives: This article examines religious beliefs and activities among nonpsychotic persons in the United States, Brazil and other areas of the world; discusses historical factors contributing to the wall of separation between religion and psychiatry today; reviews studies on the prevalence of religious delusions in patients with schizophrenia, bipolar disorder, and other severe mental disorders; discusses how clinicians can distinguish pathological from non-pathological religious involvement; explores how persons with severe mental illness use non-pathological religious beliefs to cope with their disorder; examines the effects of religious involvement on disease course, psychotic exacerbations, and hospitalization; and describes religious or spiritual interventions that may assist in treatment. Methods: Literature review. Findings: While about one-third of psychoses have religious delusions, not all religious experiences are psychotic. In fact, they may even have positive effects on the course of severe mental illness, forcing clinicians to make a decision on whether to treat religious beliefs and discourage religious experiences, or to support them. Conclusions: Clinicians should understand the negative and positive roles that religion plays in those with psychotic disorders. Koenig, H.G. / Rev. Psiq. Clín. 34, supl 1; 40-48, 2007 Key-words: Religion, psychosis, coping. Correspondence address: Harold G. Koenig. Box 3400, Duke University Medical Center, Durham, NC 27710, EUA. E-mail: [email protected] Psychiatrists often treat patients with psychotic disorders who are religious or spiritual in some way. Most scientifically trained psychiatrists and other mental health professionals believe in a scientific, secular worldview. Sigmund Freud thought that religion caused neurotic and possibly even psychotic symptoms. In Future of an Illusion, Freud (1927) wrote: “Religion would thus be the universal obsessional neurosis of humanity... If this view is right, it is to be supposed that a turning-away from religion is bound to occur with the fatal inevitability of a process of growth...If, on the one hand, religion brings with it obsessional restrictions, exactly as an individual obsessional neurosis does, on the other hand, it comprises a system of wishful illusions together with a disavowal of reality, such as we find in an isolated form nowhere else but amentia, in a state of blissful hallucinatory confusion...” Thus, Freud thought that religious beliefs were rooted in fantasy and illusion and could be responsible for the development of psychosis (although Freud never directly attributed psychosis to religion, only neurosis). This negative view of religion in the mental health field has continued into modern times with the writings of persons like Albert Ellis (1988) and Wendell Watters (1992), who have emphasized the irrational nature of religious beliefs and their potential harm. The personal religious beliefs of psychiatrists and psychologists (especially when compared to those of the general population) likewise reflect the secular and generally negative views toward religion that are prevalent within the profession (Neeleman & King, 1993; Curlin et al, 2005). For years, religious persons were portrayed as examples of psychiatric illness in diagnostic manuals (prior to DSM-IV) (Larson et al., 1993). This negative perspective regarding religion, however, was not based on systematic research or careful objective observation. Rather, it was based on the personal opinions and clinical experience of powerful and influential persons within the psychiatric academia, who had little experience with healthy religion. Just as mental health professionals have not valued the role that religion plays in the lives of those with and without mental illness, so too religious communities have developed negative attitudes toward psychologists 41 Koenig, H.G. / Rev. Psiq. Clín. 34, supl 1; 40-48, 2007 and psychiatrists, who are often seen as either unhelpful or evening threatening to deeply held beliefs that are central to their worldviews. This conflict, in fact, has led to numerous high profile legal cases in the United States, where religious communities did not refer members with severe mental illness for psychiatric care, with devastating results (Whitley, 2006). Both sides are at fault here, not just religious communities, since both sides have contributed to the wall that separates healing practices of religious from mental health communities. In the last 20 years, more attention has been paid to the scientific study of religion and its relationship to mental health and mental illness. Although much work remains to be done, evidence has been accumulating to help provide more objective answers to questions such as the following. What is the relationship between religion, spirituality and psychosis? Are psychotic persons more likely to be religious? Does religion lead to psychosis? Does psychosis lead to religion? Can religious conversion precipitate psychosis? Can psychosis precipitate religious conversion? How common are religious delusions among those who are psychotic? How does one differentiate “normal” religious or spiritual experiences from psychotic symptoms? What effect does religious involvement have on the course and outcome of psychotic disorders? What effect does psychosis have on persons’ religious or spiritual beliefs? These are important questions that are just now starting to be answered by systematic research. Religious belief and behavior: how common? In order to understand the relationship between religion, spirituality and pathological psychosis, it is first important to appreciate how common religious involvement is among “normal” persons living in North and South America. For example, in the United States (U.S.), the latest Gallup Poll (May 8-11, 2006) found that 73% are “convinced God exists” and another 19% say that God “probably exists”; in contrast, 3% say that they are convinced that God does not exist and 4% that God probably doesn’t exist, but they are not sure (Newport, 2006a). Interestingly, it is young people (ages 18 to 29 years) who are most likely to say that they are convinced God exists or probably exists. Those with more education and higher incomes, however, are less likely to believe in God. The same Gallup survey above found that 77% of people in the U.S. believe that the Bible is the actual word of God (28%) or the inspired word of God (49%) (Newport, 2006b). Persons who were older, had less education, or those from the southern U.S. were more likely to believe in the Divine origin of the Bible. In terms of religious behaviors, based on 11,050 interviews conducted between 2002 and 2005, Gallup polls found that 45% of persons in the U.S. attend religious services weekly or almost every week (Newport, 2006c). Older adults are more likely to attend than younger adults, and women are more likely to attend than men. With regard to prayer, Gallup polls since the 1930’s have shown that 9 out of 10 persons in the United States pray, with 84% engaged in conversational prayer, 52% in meditative prayer (quietly thinking about God, trying to listen to God), 42% in petitionary prayer (asking God for something), and 19% in ritual prayer (reading from a book of prayers or reciting memorized prayers) (Gallup, 2003). What about South America? Although there is no comparable detailed Gallup Poll data, the World Health Organization surveyed 5,087 persons in 18 countries, including 225 in Argentina, 493 in Brazil (Porto Alegre and Santa Maria), and 251 in Uruguay (Saxena, 2006). Among Christian countries outside of Africa, Brazil had the highest percentage of respondents who indicated they were “moderately” or “very much – extremely” religious (80 to 90%), similar to if not greater than religious involvement described above in the United States. Thus, “normal” Americans – whether they come from the north or the south – are often very religious. Furthermore, there is evidence that people become even more religious when they are sick, whether physically or mentally. In situations of high psychological stress, religion is often used to help cope with or adapt to the distressing circumstances. People cry out to God for help; they pray; they perform religious rituals; or they seek comfort and support from members of their religious communities. For example, 90% of persons in the United States turned to religion as a way of coping with the September 11th terrorist attacks in New York City (Schuster et al., 2001). Thus, it should not be surprising to find that persons in America who are psychotic and suffering from severe and persistent mental illness (i.e., highly stressful conditions) may also be quite religious. In the rest of the paper, I will examine how religious beliefs, practices and experiences influence the clinical presentation, assessment, course and outcome of mental disorders with psychosis. First, I will review research that describes the presentation and prevalence of religious delusions, the prevalence of “normal” religious beliefs, experiences and practices in psychotic persons, and the relationship between religious conversion and psychosis. 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. 42 Koenig, H.G. / Rev. Psiq. Clín. 34, supl 1; 40-48, 2007