Christian theology is centrally concerned with discourse about God and, in relation to this, the human condition, whether in prayer, by way of reason, or by way of faith. Psychiatry, in contrast, is centrally concerned with the human condition, first as a branch of medical practice devoted to the relief of suffering, and then as a multidisciplinary scientific field devoted to understanding the aetiology, manifestation, and treatment of mental disorders. Theology and psychiatry are thus both concerned with the human condition but have different primary concerns and methodologies.
There is a surprising dearth of literature on the interdisciplinary engagement of theology and psychiatry with each other. There is a large scientific literature on spirituality, religion, and mental health, but this is almost entirely lacking in any theological reflection. There is a significant literature on theology and psychology (see, for example, Callaway and Strawn 2020; Watts 2002), although this has mainly emerged over the last two decades or so. In contrast, psychiatry and mental health have received very little theological attention, and psychiatry almost completely ignores theology. This state of affairs may have arisen for a variety of historical reasons and reflects, to some extent, the broader interdisciplinary tensions between science and theology. Given the extensive debates between scientists and theologians in relation to such topics as evolution and cosmology, it is surprising that the very practical issues of psychiatry and mental health, impacting upon the lives of millions of people in every nation of the world, have received so little attention. It is perhaps less surprising that psychiatry neglects theology, given its different priorities. Nonetheless, one might expect that the patient-centred focus of psychiatry would seek to understand how worldviews – including theologies – might impact upon the mental, social, and physical wellbeing of patients. Such worldviews may also impact the way in which psychiatrists pursue their vocation and relate to their patients.
This article will first address the important issue of theological anthropology (itself a huge field) in relation to the very different anthropological assumptions (often implicit rather than explicit) of psychiatry and will then very briefly outline the historical context within which tensions and antagonisms arose between theology and psychiatry.
There are various possible starting points for interdisciplinary engagement. Starting with the Bible, relatively little is said in Judeo-Christian scripture about mental illness. However, references to mental illness, where they do occur, are important and have sometimes been influential in the wider debates. Similarly, psychiatrists have had some interesting (if not always well informed) things to say about biblical characters. Starting with the modern taxonomy of mental disorders, there have been some interesting recent theological studies addressing specific diagnostic categories, which undercut some of the over-generalizations that sometimes arise with a higher-level overview of the relationship between theology and psychiatry. This would appear to be a promising area for future research.
Many of the interdisciplinary issues between theology and psychiatry are similar to those between theology and psychology, and a more friendly but nonetheless critical dialogue would seem to be the most promising way forward for future work. However, there are differences. Much of the current interest in theology and psychiatry, such as it is, arises from the practical implications for care of patients. Psychiatry and faith are rarely addressed in an integrated fashion in treatment planning, so that patients are left to work out for themselves how to relate their faith to their mental health condition. Some of these practical concerns will be considered below, first from the perspective of scientific research and clinical services, and then from the perspective of the Christian churches.
This article will not seek to review the extensive literature on the philosophy of psychiatry or the cognitive science of religion, but it is important to be aware of some of the other debates that touch upon the present subject matter. For example, it has been argued that there are continuities between religious cognition and the cognition associated with mental disorders (McCauley and Graham 2020). Such a contention, particularly where it presents religious thought as a ‘by-product’ of cognitive psychological processes, moves the focus away from (theological) meaning onto the psychological processes (in health and disorder) whereby meaning is constructed (Powell and Cook 2021). The focus here, in relation to theology and psychiatry, presumes that the human quest for meaning is nonetheless both valid and realisable, and that there is theological meaning to be found both in health and in mental disorder.
2 Mind and soul in theology and psychiatry
Theology and psychiatry share a concern with subjective experience of the self, but each has its own vocabulary and methodology for exploring the nature and meaning of this subjectivity, and its own ultimate purpose in doing so. Moreover, these vocabularies overlap in such a way as to obscure both their common concerns and their different interests.
Psychiatry is, broadly speaking, concerned with both mind and brain. Within psychiatry there are those who place more emphasis on one or the other, but there is a general understanding that the two are closely related and must be understood together. Etymologically, the word ‘psychiatry’ (along with cognate disciplines such as psychotherapy) implies an interest in healing of the ‘psyche’, usually translated as ‘soul’ in English, but psyche may be variously understood as the mind, or as the essence of the human being. For many psychiatrists, the mind is understood as what the brain does. Research has shown consistent associations of mental events with brain events, but causal relationships are complex and reductive explanations are neither necessary nor helpful. In practice, a methodological dualism allows space for both psychological and physical interventions without prejudice to the views of those who hold to a reductive physicalism (Pernu 2021).
In recent years, psychiatry has become increasingly interested in the spiritual dimension of human experience (Cook and Powell 2022), but the word ‘soul’ is rarely used in clinical practice or in research and most psychiatrists are wary of the dualism that it might be taken to imply. The standard biopsychosocial model of understanding psychiatric and other medical conditions is now commonly expanded to be a biopsychosocial-spiritual model (Kuhn 1988; McKee and Chappel 1992; Galbadage et al. 2020), but there is little or no consensus as to exactly what the ‘spirit’ is, and a general suspicion that it cannot be objectively studied in scientific research.
Theology has traditionally had a lot to say about the soul, albeit the commonly held Western concept of an immortal soul which has a potentially separate existence from a human body owes much to Platonism (Murphy 2011) and is arguably not Christian (or, at least, not biblical) in origin. Christian theological anthropologies may take a variety of different forms, within which mind and soul may be equated, or else held to be separate entities. There is generally little discussion of the brain, although recent interdisciplinary engagements between science and theology have, to some extent, remedied this neglect. Ultimately, the concern of theology is with the human in relationship with God, a concern which many patients in secular mental health services have found difficult or impossible to discuss with mental health professionals without fear of an unsympathetic response.
Some common ground between psychiatry and theology may be found in terms of their respective acknowledgement of the importance of narrative for human self-understanding (Cook 2016a). The stories that we tell about ourselves, and that psychiatrists and priests help people to tell about themselves, are stories ‘of mind and soul’ (Cook, Powell, and Sims 2016). For clinical and pastoral practice, the philosophical complexities are less important than the self-understanding of the person seeking help, and this usually (although not necessarily always) takes the form of a narrative account of experiences, events, and identity within which spiritual and mental concerns are more or less inextricable from each other.
Whilst a patient-centred approach, including an emphasis on narrative, may be helpful in practice, more thoroughgoing attempts to find a non-reductive bridge between academic discourses of psychiatry and theology (and neuroscience, anthropology, and philosophy) have included a search for a ‘third discourse’, such as that proposed by Michael Wong (2019), drawing on the hermeneutical thinking of Paul Ricoeur. Wong’s solution involves a ‘multi-layered’ approach which accepts semantic dualism, whilst avoiding ontological dualism, in which no particular disciplinary discourse is privileged above any other. However, this problem goes well beyond the particular concerns of theology and psychiatry and addresses broader issues of the relationship between the humanities and the medical sciences that are not solved simply by dialogue or by interdisciplinary engagement, or even, perhaps, a third discourse of the kind that Wong proposes. Rather, in the field of the critical medical humanities, it is acknowledged that there is an ‘entanglement’ of perspectives in which different disciplines have influenced each other in complex ways. This is arguably nowhere more evident than it is between the disciplines of psychiatry and theology, each of which has been substantially influenced by the other over the last century or more. An active crossing of disciplinary boundaries is required in order to adopt a perspective which privileges interdisciplinarity and averts the epistemic injustice which patients have often suffered as a result of such entanglements in the past (Cook 2023).
3 Theology and psychiatry – a brief history
Historically, people suffering from what we would now call mental disorders, were cared for (if they received care at all) within a religious context. In Europe, this was usually provided by religious orders. For example, the Alexian brothers cared for mentally sick men at their monastery in Cologne from as early as 560 CE. An Islamic asylum was established at Fez, in North Africa, in the seventh century. In the later Middle Ages the Spanish philosopher Juan Luis Vives (1493–1540) emphasized the importance of a humane approach to the treatment of mental illness.
In the Middle Ages, it is often said, mental illness was attributed to demon possession (Forcén and Forcén 2014). Perhaps more correctly, some cases of demon possession would appear to have been what we would now identify as mental disorder. However, the extent to which such misattribution may have occurred is not completely clear, was probably variable from place to place and in different sections of society, and may have been overemphasized (Kroll 1973).
Thinking about care for the mentally ill gradually became separated from theological thinking in the eighteenth and nineteenth centuries. As science increasingly emerged as the dominant approach to understanding mind and brain, the influence of theology receded. The influence of Christians as providers of care continued. For example, the Quaker William Tuke (1732–1822) established the Retreat at York in 1791 as a place where people suffering from mental illness could be more humanely cared for. However, other figures within this new ‘moral approach’ to the care of the insane were not motivated in the same way by religious ideals.
The origins of psychiatry as we know it now may be traced to the early nineteenth century, and in particular to developments in the brain sciences. Increasingly mental disorders were being explained on a biological basis and this evoked a tendency to reductionism that left a lasting and unhelpful influence upon psychiatry. By the late nineteenth century, through the work of Pierre Janet (1859–1947) and others, attention turned also to the unconscious processes that lay behind some human behaviour and mental disorders. Others, such as Bénédict-Augustin Morel (1809–1873), focused on the influence of inherited characteristics. Increasingly, theology was both excluded from, and seen as unnecessary to, any serious thinking about the causes and treatment of mental illness.
In this context, the work of Sigmund Freud (1856–1939) on the one hand, and behaviourism on the other, only served to further increase the rift between theology and psychiatry. For Freud, religion was an illusion (this did not necessarily mean it was false) and a form of neurosis. For the behaviourists, notably Ivan Pavlov (1849–1936) and B. F. Skinner (1904–1990), human behaviour was explicable on the basis of, respectively, classical and operant conditioning (processes of learning by reinforcement seen in other animals, and not unique to human beings). By the middle of the twentieth century, when biological psychiatry was also in the ascendent, for many in the field of mental health, there was little sense that religious beliefs contributed anything valuable to the understanding or treatment of psychiatric disorders. If anything, religion was seen as an unhelpful influence. True, psychiatrists did not agree amongst themselves on many things (Clare 1980), but (with a few notable exceptions) they did mostly agree on this.
Things began to change in the second half of the twentieth century. Largely, this seems to have been the result of empirical research which increasingly showed that spirituality and religion are generally beneficial for mental wellbeing. Mental health service users, and some mental health professionals, also became increasingly vocal and spoke of their wish that spiritual and religious needs should be dealt with more sympathetically and sensitively in the context of the provision of care (Macmin and Foskett 2004). The prevailing biopsychosocial model was increasingly extended, with some proposing a biopsychosocial-spiritual model (Kuhn 1988), and others talking of a paradigm shift towards inclusion of the spiritual dimension of human wellbeing (Culliford 2002). This did not necessarily mean that theology was in dialogue with psychiatry, but it did create a context in which such a dialogue could be opened up.
5 Interdisciplinary engagement between theology and psychiatry
Constructive and critical engagements between theology and psychiatry in the modern period have been few and far between. On the one hand, there have been conservative, literal, and fundamentalist attempts to dismiss the insights of psychiatry more or less completely (e.g. the biblical counselling model of Jay Adams 1970). On the other, there has been the almost total assimilation of mental health sciences within which theology and biblical studies are seen as having little to contribute, which led many clergy in the mid-twentieth century to train as counsellors and therapists within a largely secular model (e.g. the Westminster Pastoral Foundation). Where attempts have been made to find a more balanced engagement, these have often not endured. For example, the clinical theology movement, pioneered by Frank Lake (1914–1982), a psychiatrist and Anglican priest, seems to have drawn much on Lake’s personal charisma as a teacher and lecturer (Campbell 2019). Whilst the movement continues today as the Bridge Pastoral Foundation, it has had almost no influence upon mainstream psychiatry and only marginal influence upon pastoral care.
More generally, theology and psychiatry have tended to keep themselves apart, each conducting their own analysis of the human condition with very little attention to contributions by the other discipline. There are some who argue in support of this state of affairs, especially in relation to the need for psychiatry to respect professional boundaries in clinical practice (Poole 2020). Arguments against include pragmatic considerations, such as the pressure from users of mental health services for a more integrated approach, and also those from a biblical theology which finds a more integrated approach to mental health and faith, within both Hebrew scripture and the life and ministry of Jesus (Cook 2020c). Wider interdisciplinary engagements between science and theology have tended to neglect the mental health sciences, but this is now beginning to change (Cook 2020b; Watts 2018).
Where there has been theological engagement with psychiatry, this has not always been positive. For example, there are those who argue that mental distress is due to sin, lack of faith, or demonic influence (Webb 2012; 2017; Scrutton 2015b; 2015a). Such views seem to be more commonly encountered in evangelical and fundamentalist churches and rarely find support in academic theological discourse. However, they are very influential in some Christian circles, variously arguing that symptoms of mental disorder such as anxiety are explicitly referred to in scripture as sinful (at least on the basis of a certain interpretation of the texts), or that they are due to lack of faith, or that they are otherwise a result of sinful behaviour (failing to live according to biblical teachings). Such views unfortunately resonate with those who, by the very nature of their illness, easily experience symptoms of mental illness (guilt, anxiety, etc.) as being their own fault, thus making things worse rather than better.
There has been more in-depth and critical engagement between theology and psychiatry in relation to various specific mental disorders, and it is to these that we now turn.
5.1 Affective disorders
Affective disorders include a variety of conditions, variously classified, which range from relatively mild experiences of depression or elation (which are arguably a normal part of the human condition) to very severe disturbances of mood which demonstrate features of psychosis (see below). Sometimes these disturbances show a cyclical or fluctuating picture with elements of both elation and depression (notably in bipolar disorder, formerly known as manic depression), but more often they result in shorter or longer periods of enduring and sustained mood disturbance, notably in what is commonly referred to as ‘clinical’ or ‘major’ depressive disorder. Amidst such conditions, for people of faith, pervasive negative cognitions may include a sense of personal guilt and worthlessness in God’s eyes, or else a belief that God has abandoned them, or is absent and remote.
Affective disorders, and in particular depression, are common in the population at large and overlap with the universal human experience of sadness and joy (the former being distinguished from the latter mainly by degree and by impairment of functioning). Some would argue that psychiatry has been unhelpful in labelling – and stigmatizing – much normal human experience in this way. On the other hand, some such experiences are so severe as to make continued day to day functioning impossible and go beyond what most people would consider ‘normal’ fluctuations of mood. Because of this overlap, and because such experiences of disordered mood have a very long history, they are easily identified within scripture. Saul has thus been ‘diagnosed’ as suffering from bipolar disorder, and Elijah is said to have been depressed following his confrontation with the priests of Baal (1 Kgs 19). The Psalms are full of accounts of experiences of sorrow, sadness, despair, dejection, and other emotional struggles, all explored within the context of faith in Yahweh (Brueggemann 2020). The book of Job engages with the struggle to find hope and meaning in relationship to God amidst adversity and suffering.
The fundamental issues at stake in these scriptural accounts include questions of Christian hope and salvation. Why is it that God sometimes seems to deliver his people from oppression (as, for example, in the Exodus narratives) and at other times abandons them (as in Jesus’ cry of dereliction from the cross)? Even when salvation is experienced, why is it so often delayed? How is faith to be maintained when God seems absent? Perhaps the most profound exploration of these questions, in the pre-modern period, was made by St John of the Cross (1542–1591). In his poem and commentary on the ‘Dark Night’, he explores these questions at length. John’s most in-depth engagement with these issues arose from his own imprisonment and cruel treatment by other Christians and so they bring together both his personal experiences and his reflections on the scholastic theology of his time. They have been taken up in recent times by various psychiatrists, notably Gerald May (2003) and, in her empirical research on Augustinian nuns, Gloria Durà-Vilà (2016). Both John himself, and the psychiatrists who have more recently engaged with his work, confront the question of how such experiences relate to clinical depression (or, as John would call it, melancholy). Some (including John) would seek to distinguish the two. Others would see them as overlapping in some, if not all, cases. A depressive illness may or may not be the context for a ‘dark night’ experience. A dark night experience may or may not be associated with features of depression.
Recent theological debate has engaged with a variety of different ways of understanding depression. Thus, for example, Anastasia Scrutton (2015b) has explored models of understanding depression as spiritual illness, as spiritual health or as potentially transformative. Fraser Watts has proposed that depression may be helpfully understood as a meaningful part of a spiritual journey (Watts 2018). Jessica Coblentz, emphasizing the diversity of first person experiences, develops a theology of depression as a kind of wilderness experience (Coblentz 2022). Others have proposed that treatment of depression with medication may lead to a kind of hyponarrativity within which the individual suffers a loss of meaning as much due to the treatment as the underlying condition (Hauptman 2015). For John Swinton, based upon his empirical qualitative research, depression may be the context within which Christian discipleship grapples with the seeming absence of a God who hides (Swinton 2020). In all of these ways, theology provides a helpful corrective to the tendency of psychiatry (especially biological psychiatry) to focus on phenomenology, signs and symptoms, diagnosis and treatment, at the expense of narrative, meaning, and life in context – especially, but not only, the context of relationship with God.
In research on bipolar affective disorder, undertaken by Eva Ouwehand and others (2018) in the Netherlands, patients reported that their spiritual and religious experiences during episodes of illness were both authentic and related to the disorder, thus undermining the often promoted view that a distinction should be made between authentic spiritual experience and experiences related to psychopathology (see also section 5.3).
Addiction has attracted more theological interest than most psychiatric disorders, perhaps because of its pervasive visibility across time and cultures, and the way in which it draws attention to the fundamentally human interior struggle between competing desires. Historically, as for example in Hebrew and Christian scripture, much of the attention has been given to alcohol as an addictive agent, and alcohol has indeed been a ‘favourite drug’ for much of human history in many parts of the world. However, there are many other substances which are prone to misuse and addiction (opioid drugs, stimulants, hallucinogens, etc.) and the concept has been further extended to behaviours which do not involve exogenous substances (although, of course, they do involve release of endogenous chemicals such as endorphins or dopamine). Such behavioural patterns of addiction are much debated, and if stretched too far, the concept of addiction is arguably devalued. However, gambling, eating, sexual behaviour, relationships, shopping, and computer gaming can all be understood as appetitive behaviours which demonstrate similar psychological features of addiction to those observed in drug dependence.
The study of addiction is an interdisciplinary endeavour which has explored a wide variety of different models of understanding, from learned behaviour (understanding addictive behaviour as individually conditioned and socially reinforced), through to the disease concept of Alcoholics Anonymous (AA) and other twelve-step mutual help groups. Similarly, theology has adopted a variety of different models of understanding which may also – broadly speaking – be understood on a spectrum from ‘addiction as sin’ through to ‘sin as addiction’ (Cook 2006: 16–20). On the one hand, addiction is understood as sinful behaviour no different in principle to other vices such as lying or stealing. On the other hand, a wide variety of sinful behaviours may be understood as showing similar characteristics to addiction, whereby they gain power in a person’s life and a loss of choice and freedom is experienced. On this basis, one might say, all sin is a form of addiction, it is the human condition. On the one hand, there are dangers of Pelagianism, and on the other hand determinism, and neither model is very satisfactory. A more complex and nuanced approach is taken by Linda Mercadante (1996) in her book Victims and Sinners. As the title suggests, addicts are, at the same time, both victims of life circumstances of various kinds, but also sinners (like the rest of us) who have, in their responses, turned away from God.
In Alcohol, Addiction and Christian Ethics, Christopher Cook draws together both scientific and theological thinking about addiction, in historical context (Cook 2006). Drawing on the phenomenological parallels between addiction and the divided self (as portrayed in Rom 7) and the divided will (as elaborated by Augustine of Hippo), he proposes that theology does indeed offer a helpful explanatory account of the nature of addiction. On the one hand, addiction is an instance of the universal human condition, but on the other hand, and at the same time, it is in various ways a distinctive problem which potentially benefits from a range of medical responses, including medication, and mutual help programmes such as those offered by AA. Addiction particularly benefits from a spiritual approach because treatment (at least according to AA and similar approaches) involves a turning towards a higher power or (in Christian terms) grace, for help from something/someone beyond the self.
Historically, addiction provides an example of the broader way in which there has been a pervasive and far-reaching medicalization of conditions that were previously understood in purely theological terms. Thus, ‘chronic inebriety’, understood as a vice in Christian terms up until the late eighteenth century, was by the end of the twentieth century understood in medical terms as alcohol addiction, or alcohol dependence. Largely due to the influence of the Twelve Step programme of AA and its sister organizations, there has been a greater enduring recognition of the need to address spiritual needs in treatment of addiction than there has in the case of most other mental disorders.
AA was founded in Akron, Ohio, in 1935 by two men who recognized that they were (to use the language that they themselves preferred) alcoholics. The help that they found in meeting with each other, and with other alcoholics, was eventually formulated as the twelve ‘steps’, by way of which they had found recovery from their addiction. Their programme of recovery drew upon the principles of the Oxford Group (led by the episcopalian priest Samuel Shoemaker [1893–1963]), William James’ The Varieties of Religious Experience (James 1902), and a correspondence between one of the founders (Bill Wilson) and the psychiatrist Carl Jung (Wilson and Jung 1987). In a letter to Wilson, Jung argued that sometimes the only way out of addiction was through a spiritual experience. Jung summarized this in the Latin phrase spiritus contra spiritum (spirit against spirit).
The spirituality of the early AA groups was distinctively Christian (B. 1995) but as the groups increasingly sought to offer help to people of all faiths and none a ‘spiritual but not religious’ approach to recovery was adopted. Members of AA are free to understand their higher power in a variety of ways. For many this may be, in traditional theological terms, God. For others it may be the wider group or AA movement, or something else. The important thing is that it is not the individual member. As it says in the second step, members came to believe that they needed ‘a power greater’ than themselves in order to find their way to recovery. This power (reflecting the influence of William James) was ‘God as we understood him’, not the God of traditional dogmatic theology, whether Christian or otherwise.
AA has been hugely successful, now having more than two million members in around 180 nations worldwide. Sister organizations now address addiction to a wide range of other substances and behaviours (e.g. Narcotics Anonymous, Gamblers Anonymous, etc.), as well as the needs of family members (Alanon, Families Anonymous, etc.). For some, AA remains too Christian/religious and there have been various attempts to create groups that avoid all reference to God (e.g. Secular Organizations for Sobriety). For others it is not Christian enough, and there have been various attempts either to rewrite the steps in explicitly Christian terms (e.g. ‘Christian twelve steps’), or else to provide a bridge between the twelve steps model and Christian churches (e.g. Overcomers Outreach).
Psychosis is a difficult concept to define. The key features, according to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (2013), known as DSM-5, are:
- Disorganized thinking (e.g. loosening of associations)
- Grossly disorganized or abnormal motor behaviour (e.g. catatonia)
- Negative symptoms (e.g. flattening of affect and loss of volition)
Despite this apparent objectivity, we now know that many psychotic-like features may be identified in members of the population who are functioning well and not diagnosed with a psychotic disorder. The two features most often considered central to psychosis – delusions and hallucinations – are particularly problematic. Possible definitions of delusion easily include many of the beliefs that are widely held by religious people, or other cultural groups, and so such beliefs are explicitly excluded in most definitions employed by psychiatrists. Hallucinations are not uncommonly experienced by many religious people, albeit then referred to as ‘visions’ or ‘locutions’. The Bible, especially when read uncritically and unsympathetically, can easily be found to include various people who could be said to have experienced delusions or hallucinations (and also various forms of thought disorder and abnormal motor behaviour). Similarly, various saints and mystics through the ages have been retrospectively diagnosed by some psychiatrists as suffering from psychosis.
In addition to the similarities between positive religious experiences and psychosis, much attention has been devoted to the relationship between demon possession and psychosis. As indicated above, it is in fact somewhat surprising to the psychiatrist that this question might arise at all, given that most of the New Testament accounts do not in any way clinically resemble mental illness. Similarly, to many theologians, the question also does not arise. Where the reading of scripture adopts an approach of demythologization within which demon possession is understood not literally, but rather in restated rational terms, any relationship between demon possession and mental illness is merely to do with the different ways in which differing historical and cultural contexts understand a common phenomenon. For others, however, there is a differential diagnosis to be made – between psychosis and demon possession – in which the demonic is understood to mimic mental illness but yet to be distinguishable from it (Sall 1976). The basis for such an approach is rarely subject to critical analysis, and appears to be highly culturally determined, but is less uncommon in the (supposedly secular) Western world than one might imagine.
A diagnosis of a psychotic disorder, such as schizophrenia, is associated with stigma, prejudice, and exclusion. It is also associated with epistemic injustice (Crichton, Carel, and Kidd 2017). People suffering from such conditions are not only viewed negatively within society but their claim to know anything that others should take seriously is discredited. They are silenced within society. John Swinton (2020) has suggested that, in response, we need to find a kind of epistemic generosity which allows us to listen differently, and more respectfully, to what people with psychosis have to say. This is not to say that we are to be gullible, or that we must agree with delusional beliefs, but rather that we must view people suffering from psychosis as more than people with a brain disorder; they are people who should be listened to and taken seriously. Even if we agree to disagree about delusional beliefs, this does not mean that we should disregard their testimony on other matters, or that they have not had meaningful spiritual experiences.
As with the negative religious experience of demon possession, there has been a tendency in some circles to address the supposed problem of the similarities between psychosis and positive religious experience by developing criteria to be employed in differential diagnosis (De Menezes and Moreira-Almeida 2009). Thus, psychosis and ‘genuine’ spiritual experience become mutually exclusive categories. The validity of this approach is debatable, and it is not at all clear why someone may not be psychotic and also having a genuine spiritual experience. It would appear to be a clear-cut case of the epistemic injustice to which Swinton and others refer: if you have this diagnosis, your spiritual experiences are not to be taken seriously. However, in a group of patients suffering from bipolar disorder in the Netherlands, Ouwehande and others (2018) showed that a significant proportion continued to identify some of their spiritual experiences amidst psychotic episodes as being spiritually meaningful even after they had recovered. Even where the suffering associated with psychosis appears meaningless, and perhaps especially there, Christian theologians have asserted that there may indeed be ‘meaning in madness’ (Foskett 1987). This meaning is often highly individualized on the one hand (significant only for the individual), or else highly generalized on the other (as just one part of the wider experiences of human suffering). Nonetheless, such experiences are not meaningless.
An influential figure in the quest to find meaning amidst psychosis was Anton Boisen (1876–1965), the founder of the Clinical Pastoral Education movement (Asquith 1982). Boisen, a Presbyterian (and later Congregational) minister experienced two psychotic episodes, diagnosed at the time as catatonic schizophrenia. Boisen came to understand psychosis (or, at least, the kind of episode of illness that he had experienced) and religious experience alike as meaningful and as potentially positive, healing (or ‘reorganizing’) experiences. Based heavily upon his own experience, Boisen stressed the theological value of a careful study of human experience or, as he referred to it, ‘living human documents’. There has been debate about the actual diagnosis of Boisen’s illness (North and Clements 1981) and it was certainly not representative of the more severe forms of schizophrenia. Whilst personal meaning can often be found amidst psychosis, if one looks carefully, this is a long way from finding wider theological value in such experiences. Boisen left an important legacy to pastoral theology, in terms of giving careful attention to human experience, but his legacy in terms of a theology of psychosis is debatable and has not been widely adopted.
The value of a diagnostic approach to mental disorders has long been questioned (e.g. Hessamfar 2015) and much recent research has taken a more dimensional or phenomenological approach. This has in turn influenced the thinking of philosophers and theologians. The difficulty of distinguishing religious belief from delusions, for example, has received considerable attention. For the new atheists, such as Richard Dawkins – disregarding long psychiatric tradition to the contrary – religious beliefs (which, in his view, are false and unshakable even when confronted with contradictory evidence) are delusional. Conservative responses to this approach have re-emphasized the traditional need to exclude religious belief from the definition of what may be considered delusional (Sims 2009). George Graham, taking a philosophical approach, has argued (without almost no historical-critical attention to the Genesis texts) that Abraham was deluded when he believed that God was telling him to sacrifice his son (Graham 2015). He develops a five-factor approach to religious delusions which, he proposes, contain the following elements:
- Over-engagement (or over-investment, or over-identification) with religious beliefs
- Harmful consequences
- Resistance to criticism/challenge
- Faulty belief formation and ‘normative misjudgement’
- Impaired ‘reflective self-control’
To a large extent these are features of all delusions and singling out religious delusions for attention in this way tends to exacerbate the problem. It again runs the risk of epistemic injustice, in which the claim of the other to have knowledge of (religious) things is discredited.
Focusing on the phenomenon of voice hearing, Cook has taken a multidisciplinary approach, within which what we know about the science of hearing voices can be reconciled with both the biblical record, and Christian tradition, without denying the possibility of genuine revelation (Cook 2018; 2020a). Rather than proposing the need for differential diagnosis, Cook argues that all such experiences need to be subjected to a process of spiritual discernment. The genuineness, or theological value, of the experience rests not upon whether the person concerned is suffering from a mental disorder but, rather, upon judgements as to whether the supposed voice (or thought) is theologically consonant with what we might understand to be ‘the voice of God’. This is, of course, no small matter and is not easy to judge. It raises again all the same issues of possible epistemic injustice (discussed above) in relation to assertions by others that they are recipients of divine revelation. However, it moves the conversation into the domain of spiritual direction rather than systematic theology, and away from an imposition of psychiatric criteria as the ultimate basis for what may be claimed to be true or false in respect of the meaningfulness of perception like experiences. It allows the possibility of drawing upon theologically critical traditions of discernment, such as those offered within the spiritual exercises of Ignatius of Loyola (1491–1556), or – even more radically – upon traditions within which caution is expressed towards all perception-like experiences in favour of a more contemplative approach to the encounter with God (e.g. as in John of the Cross).
5.4 Other psychiatric disorders
There has been a limited and variable degree of theological engagement with other psychiatric disorders. We shall consider here, briefly, anxiety disorders, eating disorders, and dementia.
Anxiety – rather like depression – is a topic that arises in biblical and theological scholarship insofar as it is a part of the human condition, experienced by all, but which also appears in psychiatry under a heading of ‘anxiety disorders’ (which are variously classified; Cook 2021). Much more has been written about the former than the latter. Religious scrupulosity, which is sometimes a component of obsessive-compulsive disorder, takes the form of a persistent sense of anxiety, doubt, and guilt around actual or imagined, usually minor, sins, omissions, and faults contrary to religious morality (Ciarrocchi 1995). It may also manifest as excessive concern about details of religious observance and prayer. Various well-known saints and theologians appear to have been afflicted by scrupulosity (e.g. Martin Luther, Ignatius Loyola, and John Bunyan), and yet it has received less theological attention than one might expect. Medical accounts of the experience of guilt, both within scrupulosity and affective disorders, raise serious theological and ethical questions. It is quite possible to feel guilty when, in fact, one should not. Equally, in other conditions (notably antisocial personality disorder) it is possible to remain free from feelings of guilt when, in fact, most people would consider the person concerned both culpable and blame-worthy.
Theological interest in eating disorders has largely revolved around historical questions as to whether the asceticism of some medieval saints and mystics may resemble, or be identical to, what we now refer to as anorexia nervosa. Catherine of Siena (1347–1380), for example, to the concern and admonition of those around her, by her mid-to-late twenties was eating almost nothing at all and engaged in self-induced vomiting (Bell 1985). Such behaviour was, however, amenable to various interpretations. For some it was seen as evidence of holiness; for others it was the work of the devil, or even evidence of demon possession. From the eighteenth century onwards, medical narratives were increasingly adopted in favour of accounts of either holiness or possession. In the face of this transition, some cases of survival despite prolonged starvation were judged miraculous, but even these ‘miraculous maidens’ were increasingly identified as either deceitful or hysterical (Vandereycken and Deth 1994). A range of possible spiritual explanations for self-starvation increasingly gave way to a range of possible medical explanations.
Dementia may arise as a result of various conditions, the most common being Alzheimer’s disease and multi-infarct (or vascular) dementia (Cook 2016a). It comprises a broad range of, usually progressive, cognitive, and functional impairments which strike at the very heart of human experience and personhood. There is some evidence that religious practice slows the decline of cognitive function associated with Alzheimer’s disease. For John Swinton (2012), dementia forces us to reconsider our understanding of the nature of time and highlights the importance of living in the present moment. The processes of impairment, loss, dislocation, isolation, decline, and death that typically characterize dementia represent a kind of self-emptying, or kenosis, which has resonance with the experiences of Christ in incarnation and crucifixion. For Christian theology, there is a paradox whereby these immanent experiences of human ‘emptying’ evoke a theology of the cross in which God is understood to participate in human suffering. In the immanent experience of dementia, in each present moment, there is yet the possibility of an encounter with divine transcendence.
6 How does it work in practice?
In practice, over a period of perhaps two or three centuries, spiritual and medical care for people suffering from mental disorders increasingly diverged. By the early twentieth century a scientific approach, associated with increasing clinical specialism, gave rise to the medical profession of psychiatry more or less as we now know it. Within psychiatry there has always been dissent. In particular, there are those who take a more biological approach to treatment of brain disorders whilst others place a more psychological, or psychotherapeutic, emphasis on care of the mind. Others have taken even more critical stances, raising fundamental questions about the very concept of mental illness and the nature of psychiatric care (Cummins 2017). Until the latter part of the twentieth century, however, spiritual care (if provided at all) was largely the domain of chaplains, clergy, and spiritual directors. Only over the last three decades or so have these boundaries begun to erode, so that some now speak of a biopsychosocial-spiritual model of care (Kuhn 1988; McKee and Chappel 1992). Notwithstanding these important advances, there is an ongoing and vigorous debate amongst mental health professionals as to whether and how the spiritual dimensions of care should be addressed (Cook 2013a). Meanwhile, within the Christian churches, there is often a lingering suspicion of psychiatry and an ignorance about the nature of mental illness.
6.1 Spirituality and psychiatry in clinical practice
A variety of factors have contributed to the increasing attention that has been given to spirituality within clinical practice over the last three or four decades. Amongst these, the growing research evidence base and the voice of mental health service users have been particularly significant.
Increasingly, scientific research has shown that spirituality/religion are good for mental health (Bonelli and Koenig 2013). There are now thousands of studies in this domain. Earlier studies were of poor methodological quality, and the strength of the relationship is probably not as great as many people imagine. There are also some circumstances (e.g. cults and ‘pathological’ forms of spirituality) in which spirituality/religion may have an adverse influence. However, overall, there is evidence that spirituality/religion need to be taken scientifically seriously. At the same time, the voice of users of mental health services has increasingly been seen as important. Patients and carers have made clear that they want to be able to talk about spiritual/religious concerns with their mental health professionals, and that they do not find it helpful when these concerns are ‘pathologized’, or attributed to their illness, rather than being taken seriously (Macmin and Foskett 2004).
Increasingly, spirituality is distinguished from religion in clinical practice, in research, and in everyday life. In research, spirituality has proven difficult to disentangle from the psychological variables that it is purported to influence, and so research attention has focused more and more on religiosity (Koenig 2008). At the same time, spirituality has proven to be the useful term in clinical practice, being generally more inclusive. In many Western nations there are those who identify as ‘spiritual but not religious’ (Mercadante 2014), and spirituality is not only a concern of those who identify with one of the world’s major faith traditions.
There are various ways in which the perspectives of psychiatry and religion (including the Christian religion) can be integrated in practice (Balboni, Puchalski, and Peteet 2014). Psychiatrists can take a broader view of their work, in which spiritual and existential concerns are addressed. Psychiatrists, chaplains, and clergy can beneficially work together in a more collaborative manner. Finally (although it is less clear how this would work in practice), healthcare might take a more plural, and less secular, approach within which different spiritual and cultural traditions are allowed greater influence in shaping treatment and service delivery.
Notwithstanding this rapprochement and growth of interest in spirituality/religion in mental healthcare, there is continuing debate about what good clinical practice should look like and how to maintain appropriate professional boundaries (Cook 2020d). Many mental health professionals do not feel equipped to deal with spiritual/religious issues. It has been argued that health service provision is a secular concern and that a clear boundary should be maintained over and against the domain of spirituality and religion. (Against this, many religious people do not find secular space a safe environment within which to discuss their spiritual concerns.) Examples of bad practice also show that there is a need to maintain boundaries between personal and professional values. The consulting room is not the place within which professionals should be, intentionally or inadvertently, putting pressure upon patients to change their beliefs. This is not only a concern about religious proselytizing, but also about imposition of an atheistic or agnostic worldview. In response to these concerns, there are now a growing number of statements of good professional practice and policy, for example from the Royal College of Psychiatrists (2013) and the World Psychiatric Association (Moreira-Almeida et al. 2016).
There are also theological concerns about these trends, albeit these seem to be voiced less often. In Heal Thyself: Spirituality, Medicine, and the Distortion of Christianity, Joel Shuman and Keith Meador (2003) reflect on the instrumentalization of religion, and the commodification of health and happiness, whereby spirituality and religion become a means to a therapeutic end in which God is domesticated. Seeking to regain a focus on the incarnation and the cross, they argue that Christianity, far from seeking to deliver Christians from the limits of bodily existence, actually embraces the possibility – indeed the likelihood – of suffering for those who seek to participate in the life of Christ. This is not to say that Christians may not pray for healing – including the healing of mental illness – or that healing is not a good thing to seek, but rather that God is not simply there for the purpose of providing it. In contrast, psychiatry (and medicine more widely) is precisely there for the purpose of human flourishing. In a similar way, although with less attention to the healthcare dimension, Jeremy Carrette and Richard King (2005) have written about the commodification of spirituality for corporate ends. Some of what appears in the spiritual marketplace is directed not only towards healing, but also to the purpose of financial profit. None of this means that it is not good that spirituality and religion are now being taken more seriously within psychiatry and mental healthcare. However, Christian theology offers a realignment and critique of priorities which the current medical, scientific, and professional literature often lacks. Theology and psychiatry exist for different ends.
6.2 Mental health and the Christian churches
The Christian church has a long history of providing care for people suffering from mental illness, dating back to the fourth century. However, as noted above, divergences between medical and religious approaches, from the late eighteenth century onwards, increasingly left responsibility for provision of care (at least in the West) in secular medical hands. The legacy of this for Christian churches has been one of misunderstanding, stigma, and mistrust, but also a fragmentation of views, with some Christian groups taking a more integrative approach and others keeping a distance from medical and scientific understandings of mental health issues. Negatively, there is evidence that in some churches Christians understand mental disorders as being caused either by sin or the Devil (Stanford 2007; Wesselmann and Graziano 2010). Positively, in other churches, there is evidence of less negative and rejecting attitudes than amongst the general population (Gray 2001).
Attitudes, teaching, and practices seem to vary depending upon tradition and theology, but not necessarily denomination. Thus, for example, in one survey of 446 evangelical Christians with personal or family experience of mental distress, almost one third had received teaching that more or less exclusively spiritualized mental distress (Lloyd and Waller 2020). Despite this, most respondents endorsed secular interventions and recognized non-spiritual causes of their distress, and a little over a half reported positive engagement with their churches. In another survey, fundamentalism (but not Christian orthodoxy) was significantly associated with stigmatizing attitudes towards mental disorder (Adams et al. 2018). Qualitative research suggests that the relationships are complicated, and that evangelical faith can have negative consequences for mental wellbeing but can also be helpful in alleviating distress. Attitudes are changing, and it would appear that evangelical churches may be moving towards a more integrated understanding of mental distress (Lloyd and Hutchinson 2022).
Christian clergy are often a first line of help for those who suffer from psychological distress, including mental illness, but they are not always well trained for this role and do not always refer on appropriately to mental health professionals. Training, and willingness to refer, do not generally seem to be related to denominational differences but do vary across national contexts (with greater willingness to refer in the UK than in the USA) and with some clergy showing more willingness to refer than others (Stanford and Philpott 2011; Wood, Watson, and Hayter 2011; WanderWaal, Hernandez, and Sandman 2012; Heseltine-Carp and Hoskins 2020). Psychiatrists are even less likely to refer their patients to clergy than are clergy to psychiatrists. Although collaboration between clergy and mental health professionals is often encouraged (see, e.g. Moreira-Almeida et al. 2016; Kehoe and Dell 2021), there are those who feel that while dialogue is a good thing there is also a need for clear boundaries in practice (Leavey, Durà-Vilà, and King 2012).
Marcia Webb has suggested that a reformulation of Christian theology of mental illness is needed, within which she focuses on themes of ‘heroism in frailty’ (emphasizing the mundane courage needed amidst mental illness), ‘freedom in finitude’ (human growth takes time), ‘complexity in disorder’ (the distortions of good in a fallen world), and ‘the stranger in our midst’ (the presence of Christ with those who are estranged by mental illness). More broadly, she suggests that a reassessment of the passibility of God is required, and that there needs to be more emphasis on the God who suffers with and for us in Christ (Webb 2012). These are helpful suggestions, but there are many different psychiatric diagnoses and, as Webb acknowledges, it is dangerous to overgeneralize. There are also many different Christian theologies of evil, health, and healing, each with its own emphasis, context, and tradition. Whereas Webb affirms links between the suffering associated with mental illness and the sufferings of Christ, others emphasize the cultural, theological, and spiritual links between mental illness and demon possession.
Belief in demon possession is widespread around the world and is clearly shaped by different cultural understandings of the nature of reality (Goodman 1988). This was a feature of early Christianity, although the belief was also influenced by both culture and Jewish theology. Understandings of the nature of the link between demon possession and mental illness, if any, have varied widely. There seems to have been some discussion, according to the synoptic gospel texts, as to whether Jesus was either mentally ill or possessed; those who were sympathetic (his family) tending to take the former view, and those who were antagonistic (the religious authorities) the latter (Mark 3:21–22). Generally, historically and culturally, it would seem that the two categories – mental illness and demon possession – have almost always been distinguished. Nonetheless, there are those who argue (with some evidence) that mental illness may frequently have been misidentified as demon possession in medieval Europe. Whatever the historical understandings may have been, some Christians continue to find demonic explanations today for conditions that Western medical science would now classify as mental disorders (Rosik 2003; Irmak 2014). Given the evidence that exorcism may sometimes cause psychological harm, there is a need for more research (Rosik 1997).
Notwithstanding the diversity of theological approaches, there are many examples of positive engagement of Christian churches with the mental health needs of their congregations and wider society. These often have a practical edge, based in pastoral concern, and sometimes in the experience of individual Christians suffering from mental health problems. The charity Renew Wellbeing, for example, is working with hundreds of churches in England on the basis of three undergirding principles: being present, being prayerful, and being in partnership (Rice 2021). Sanctuary Mental Health Ministries works collaboratively, internationally, and ecumenically, with theologians, mental health professionals, and people with lived experience of mental health problems to develop educational resources for the churches.