RELIGION AND SPIRITUALITY

RELIGION AND Spirituality and psychosis

SPIRITUALITY

Nicholas Keks and Russell D’Souza

Objective: To examine a few links between spirituality and psychosis

through illustrative cases.

Conclusions: Psychoses exact a terrible toll on people. In approximately

half the patients there is an enduring loss of richness of personality – the so-
called deficit syndrome. Many people with psychoses attempt and complete
suicide. Spirituality may be critical for dealing with the assault that psych-
oses effects on identity and personality. It may also help in coping with
devastating loss. Religion and spirituality may replace some of the loss,
and may also play a key role in psychotherapeutic support and recovery.
However, religion can also be a source of pain, guilt and exclusion, and
religious themes may also play a negative role in psychopathology.

Key words: psychiatry, psychosis, religion, spirituality.

Science without religion is lame, religion without science is blind.

Albert Einstein 1

S
pirituality finds its way into the psychoses in a number of ways.
It has been found that spirituality is critical for coping with illness
for many patients. An episode of psychosis is a profound assault on
one’s personality, identity, self-esteem and confidence. During the
recovery phase, when patients are regaining insight and re-connecting
with their environment and relationships, spirituality can greatly assist
with coming to terms with, and finding some meaning in, devastating
loss.
In those patients with a degree of deficit, where the appearance of
negative symptoms and cognitive dysfunction contributes to stigmatiza-
tion and abhorrent responses from many others, spirituality and partici-
pation in religion can assist by augmenting personality and one’s social
network. Patients can find support from others, and gain some meaning
in otherwise impoverished lives. The frequent rejecting responses of
‘normal’ individuals may be tempered by religious imperatives to be
accepting of those who are otherwise stigmatized and to treat patients
with dignity, compassion and generosity. Religious ritual can also assist
in guiding the behaviour of individuals who are otherwise internally
disorganized.
At times, within the realm of psychoses, spirituality may take on patholog-
Australasian Psychiatry • Vol 11, No 2 • June 2003

ical dimensions. Occasionally, religion can become a source of pain, guilt

Nicholas Keks
Director of Psychiatry, Box Hill Hospital, Box Hill, Vic., and
Professor of Psychiatry, Monash University, Clayton, Vic.,
Australia.
Russell D’Souza
Consultant Psychiatrist, Central East Area Mental Health
Service, Koonung Centre, Box Hill, Vic., and Senior Research
Fellow, Mental Health Research Institute of Victoria, Parkville,
Vic., Australia.
Correspondence: Professor Nicholas Keks, Upton House, Box
Hill Hospital, 131 Thames Street, Box Hill, Vic. 3128, Australia.
Email: nicholas.keks@boxhill.org.au
and exclusion. Resultant stressors can precipitate and perpetuate illness.
Religious themes may also be expressed directly in psychopathology.
Diagnosis can be notoriously difficult in such circumstances. Some
patients exhibit what might best be called ‘abnormal religious behaviour’
as a result of delusions, hallucinations or other psychopathology.
CASE 1: THE FADED FASHION DESIGNER
A 32-year-old woman was living alone and working as a part-time clerk.
She had previously been a fashion designer and had continued to look
for work in the field, but with the progression of her illness, her
professional skills had deteriorated. She had a 5-year history of schizo-
affective disorder, having been initially hospitalized for severe psychosis

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with two mild relapses subsequently. She had been
well maintained on risperidone for the past 2 years,
although at times she had experienced mild to mod-
erate depression. A previously gregarious woman
invariably involved in relationships, she had been
without a partner for the last 3 years.
The background history included father’s abandon-
ment of the family when the patient was aged 6. She
had been brought up in a Catholic environment
together with an older sister, who now also suffered
from psychosis. Mother died when the patient was 17
and the patient then suffered a protracted, depressive
grief reaction. Thereafter, she went through a ‘wild’
social period with promiscuity, drug use and an angry
rejection of her Catholic background. During a 5-year
treatment period, the patient had received psycho-
education, supportive, cognitive behavioural and
problem-solving therapies, and group therapy. In
therapy there had been initial problems establishing
trust, as well as ongoing use of cannabis and denial of
illness. Nevertheless, the patient had continued in
treatment. Two milder relapses were followed by a
period of depression where the patient suffered guilt
about her behaviour, expressed grief over the loss of
her mother, and attempted to come to terms with
her background. She resumed ties with the Catholic
Church, which helped her find acceptance and for-
giveness. She had since been much more positive in
the management of her illness, although somewhat
depressed by having awareness of her losses in skills
and socialization. She spoke of receiving support
from her faith in God and was enthusiastic about
religious ritual. The church social network substituted
for lost connections and activities. She felt guided by
religious values, such as the rejection of suicide, and
gained her sense of worth from helping others in
church activities.
CASE 2: THE ANTI-ABORTION
CAMPAIGNER
A 44-year-old single, unemployed man was living
alone. He had previously been living with an elderly
uncle who died 6 months ago. He had independent
means via an inheritance and had been ‘studying’
accounting for years. He had an 18-year history of
schizoaffective disorder with no hospitalizations
for some time, but continued to experience marked
mood fluctuations and chronic underlying psychosis
with persecutory delusional themes. He had been in
supportive psychotherapy for 4 years. He was being
treated with depot medication, in part because he
could not trust himself with oral therapy. The depot
antipsychotic needed to be augmented intermittently
by oral medication and mood stabilizers.
During episodes of psychotic depression, the patient
had been in torment over his ‘sins’, particularly
masturbation. He would react violently if it was
suggested to him that masturbation was normal.
When his mood was elevated, he would pursue anti-
abortion campaign activities, occasionally becoming
violent. He had delusions of grandeur relating to
themes of God. Occasionally, he demanded to know
if his treating psychiatrist was an abortionist. He had
also been banned by radio stations for making nui-
sance calls. When mildly depressed, he would be
most in touch with reality and would become aware
of his losses. The therapeutic relationship tended to
fluctuate and trust was highly variable. Part of the
therapeutic contract was to avoid direct action in
anti-abortion activism for reasons to do with his
personal safety. He agreed to the therapist’s sugges-
tion of constructive use of religious outlets at times of
crisis. The patient appreciated opportunities to edu-
cate his psychiatrist about Catholicism.
DISCUSSION
On the one hand, spiritual and religious themes, as
well as religious networks, can be helpful and con-
structive to patients. On the other hand, religious
themes can also be a highly problematic aspect of
psychopathology. It is essential that spirituality be
taken seriously in the supportive management of
patients with psychoses. Spirituality can be used
constructively to help recovery and reintegration
from psychosis and can also, in appropriate patients,
be helpful in the maintenance of support.
Destructive aspects of religion also need to be taken
seriously. It may sometimes be helpful to work in
collaboration with chaplains in such instances. Spir-
ituality and religion may be used to address hypo-
frontal deficits with respect to values, guidance,
rituals, behaviour, structure and relationships. Spirit-
uality may also be supportive for carers and may
provide the basis for professionals to work with
dignity and respect with their patients. Accordingly, Australasian Psychiatry • Vol 11, No 2 • June 2003
the spiritual needs of patients should constitute a
component of undergraduate and postgraduate
teaching in patient–doctor relationships.
REFERENCE
1. Einstein A. Out of My Later Years. New York: Philosophical Library, 1950.
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