International conference on Church Care for Mentally Ill People

Below are papers read at the International conference on Church Care for Mentally Ill People
November 13-14, 2018, Moscow (continuation)

Peculiarities of Pastoral Care of Patients at a Psychiatric Facility

Archpriest Victor Gusev and archpriest Ilya Odyakov, clergy of the hospital Church in the name of the icon of Theotokos the Healer under the Research Centre of Mental Health, Russian Academy of Science

1. Introduction

The paper is on the practice of pastoral care of patients at a psychiatric hospital.

1.1. History of the Church

Our Church in the name of the icon of Theotokos the Healer was the first to be set up at a psychiatric hospital after the 1917 Revolution, on the initiative of the staff of the Research Centre of Mental Health, Russian Academy of Science. As early as 1989 priests Valery Larichev and Alexey Baburin started to take pastoral care of patients of the Centre. They both had been trained as medical doctors-psychiatrists and had good practical experience.

The hospital church was set up with the support of academic Marat E. Vartanyan, director of the Centre. The church was consecrated by Patriarch Alexey II in 1992.

We would like to use this opportunity to extend our gratitude to metropolitan Sergiy of Voronezh and Liska for being our patron at the early stages of our church. The department for the study of special forms of psychopathology is a direct result of that support; the stuff of the department has already addressed you; whereas we are the clergy of this church.

Late archimandrite Kyrill (Pavlov) blessed and continuously took care of our department. "The believers are also entitled to professional psychiatric help", he said at an early stage of our work.

Absence of free access is a peculiarity of our church.

1.2. Relations with Doctors

Relations with the doctors can be presented in two ways.

On the one hand, the church was set up on the initiative of a group of doctors and other staff members of the Centre. Currently we actively cooperate with the medical workers. A number of employees come to our church for continuous spiritual advice and support.

Besides that, access of patients to the church is administered by physician when they believe that the patient's state has become stable enough for receiving spiritual support from the Church.

For this reason, our church is mostly attended by people after seven to ten days at hospital as in-patients, when the acute mental status has been allayed and a potential threat of inadequate actions that may lead to sacrilege has been reduced to the minimum. When this period elapses, patients can actively partake of the church Sacraments.

In more complex cases the priests often speak with the doctors first; they do this either at a special meeting or when visiting patients in their wards.

On the other hand, we often encounter churchliness among many medical doctors and lack of or inadequate understanding by them of the meaning of faith and relations with God. In some extreme cases their attitude boils down to the statement 'you believe, this is the reason of your illness', or the doctor would not let their patients go to church under any possible condition (be that the patient's status or want).

In the best case they would consider faith, prayer, sacraments and God as an additional "resource" - along with medication - that helps the person to curb his or her illness. It is specifically hard to see such an attitude (to faith, prayer and God as a resource) in doctors who seem to be churched, since this is an attitude of a non-believer rather than of an Orthodox Christian. However, this is not so relevant to this topic.

2. Main Part

2.1. Main Forms of Care

The main forms of spiritual care and direction that have proven their strength and become traditional in our church are as following:

1. Divine worship, sacraments, sermons offer a possibility for the patients to actively participate in the mystical life of the Church;
2. Catechetical talk, a way to help understand the meaning of sacraments administered to the patients;
3. Pilgrimages offer a possibility for rehabilitation, setting up and expanding social ties during remission;
4. Pageants on church feasts as a way give support and carry on missionary work.

2.2. Peculiarities of the Worship Practice

In everything we do we take two factors into consideration: first, the patient's state; second, the regime established in the Centre as in a medical institution (time of checkup and administering treatment to patient, meals, rest time, etc.).

We reduce the time of divine worship since the patients are weak, as a rule, and in an altered state of consciousness because of their illness and medication. However, we try to offer specific beauty of worship to make up for a shortened canonical service. We use bell-ringing and homogeneous male choir singing the Byzantine chant.

With pastoral forgiveness we usually reduce Liturgical fasting to the last evening meal and abstention from smoking.

The Divine Liturgy is served daily.

Since the patients are most often in a challenging psychic state - they find it difficult to concentrate, they get weak and drowsy, impossible to read texts - the prayerful preparation to the Liturgy is limited either to their attending the Vespers, or an accommodated payer rule.

Considering the fact that we deal with mentally ill people, we offer the sacrament of extreme unction (Anointing of the Sick) once a month. Following the Russian Church tradition, which finds it reflection in the prayers of access, the sacrament is offered for healing the body and soul.

2.3. Pastoral Care

Speaking specifically about pastoral care, we should first elaborate on the approach and attitude to the patient and illness.

We believe that a genuine mental health is possible only when three aspects of man - spirit, soul and body - are in harmony with each other. It is the spiritual sphere that takes the lead out of the three, when in norm.

We remember that every person is an image of God. We also remember that deification is the mission of every person, i.e. it envisages such a transformation when they become capable of attaining the Heavenly Kingdom, with God's help. The life of man unfolds in the context of eternity. Another thing we remember, is that his/her personality is something that drives each and every man's life. It is the personality that sets a specific way of existence of man's nature. It is his/her personality that determines freedom and the way of man's existence in the face of illness.

Thus, we look at "man's health as an integrity of all aspects of human existence that inherently belong to the God-created nature of man by the goodness, wisdom and mercy of God. It is impossible to preserve mental health thinking merely of man's physical nature and psychosocial wellbeing and ignoring his/her moral and ascetic state, worldview and relationship with God" (Orthodox Christian Encyclopedia, art. Health).

Along with that, mental illnesses are man's states opposite to the one we have just described. They "show themselves through the inability to preserve the inner integrity, as well as through the failure to maintain a desirable emotional state, sanity of thought, behaviour and perception of the surrounding reality".

Thus, our main task is to help man to continue his conscious growth towards God even when he is ill. We are to help the person so that his/her progress towards God becomes a solid foundation for the development of his/her soul and body, that together form a unique unity.

Such an approach is feasible, which is proven by many years of practical experience in our Centre, on the one hand. On the other hand, the Centre has carried out some research, dedicated to peculiarities of patients' axiological sphere. These studies revealed that Orthodox Christian patients preserve both the content and structure of the axiological sphere during their illness, unlike nonreligious persons. The latter experience a significant shift in the content and structure of their axiological sphere when they fall ill. Since the former preserve the basics of their worldview, of their axiological sphere, they happen to be still capable of living a Christian life even during their mental illness. For this reason, it is possible to form their lives constructively in the context of movement towards God on the path of salvation even during mental illness. This context can and must be focal, core, on which basis relations are being formed and problems resolved, with regard to the person's meaning of existence during illness.

The main directions of such help in our understanding, are as following:

1. Help patients understand the meaning of their illness. The patient quite often is in need of such comprehension. And here are some important points:

• To begin with, it is important to help the person understand, that his/her illness does NOT mean that God has abandoned him/her. God still loves him/her and cares.
• It is important to help the person understand that illness does not tear that person away from God (as it happens in case of sin), but illness is a special way of bearing the Cross, which is given to the person for salvation, and brings him/her closer to God. It is an act of special Divine Providence. We should help the patient to consciously accept his/her illness as a path to grow towards God, as a path that is to be taken from now on, since it is God who placed him/her there.
• It is important to explain to the patient that illness may often have a favourable course.
• With this, God does not necessarily take away or eliminate the illness out of love. The fact that the illness persists, does not hinder attainment of holiness and salvation. Apostle Paul, St Ambrose of Optina, and St Syncletica may be referred to as examples.

This is a very important point, since patients pray to be healed and, if they do not receive healing, the issue becomes topical for them.

We never use or support the attitude to a mental illness as to a punishment for a sinful life or inherited sins. The patient, who experiences much suffering, primarily needs support and strengthening, rather than а rigorous rebuke.

2. Support to the patient and "bringing" him/her to God's Devine help: payer and sacraments. Here we should remind the patient that a Christian life means a continuous collaboration of man and God. Without special - in particular, Devine - help neither God can be attained, nor challenges of life be handled, nor life lived in a Christian way. For this reason, it is important to encourage and bolster patients both in their strive for grace-filled God's help through sacraments and forming their personal relations with God through the prayer.

We serve Divine Liturgy weekly in our church, and we advise our patients to take communion regularly, preferably at every service.

3. Wake the patient's own activity at this stage of his/her salvation. We said that man's path is that of collaboration between God and man. Speaking about Sacraments, we mean special help and a special act of God who is capable of accepting man; whereas here we focus on the activity of man himself, because people always - at least in a balanced, not acute, state - can offer something to oppose illness and do something that brings them closer to God. This is the moment that makes obvious the free will, granted to man by God. It is a presentation of their own conscious and focused activity. It is very important and often brings to positive results.

It is important to communicate two things to the patient:

1. Man CAN DO something on his/her OWN to counteract illness, because her/she is a free creature. Man is free to choose and decide how to live and treat himself, the world and his illness. This is the freedom that we discuss here. Man can do something on his/her own to become better and healthier. The patient can hardly do anything with his/her body and soul - it is the doctor's domain (who, by the way, is not omnipotent, has his own limitations and, from time to time, fails to provide a cure). However, we have mentioned that health is connected to all three, body, soul and spirit. It is in the domain of spirit that it is up to the patient how he/she is going to move forward and evolve. For this reason, the patient can act and develop, despite illness, strengthening and improving his/her overall health.

2. It is very important to understand and feel what exactly the person can do. It is no enough to say, "You can". It should be said, what exactly he/she can do and how this can be done. In this case our Church's experience of both piety and ascetism can be applied (naturally with a necessary adjustment to patients). What do we mean by this? Here are some examples that can help us understand which direction to go working with such patients.

It should be added, that each person is unique. Thus, approaches that we apply and advice that we give at this stage, are unique as well. Each time we search what can be accepted by the person we deal with. This is a creative and hardly formalized process.

St Ambrose of Optina said, that 'God does not demand much from an ailing man - enough if he bears his illness with confidence and, if he can, gives his thanks to God'. This confidence is a signal both of his trust in God and acceptance of His good Providence. Remember God's Providence and by force of faith keep one's trust in Him is a very major practical step undertaken on the path of following the will of God. This is the direction in which we should encourage patients.

Patience is a virtue, tightly connected with the abovesaid. No good thing can be done without it. Patient's attitude to illness looking forward to God is another important doing of a Christian, available to those who are ill. This is the direction in which we can also try urge the patients.

The ascetic practice of combating thoughts is also applicable in a number of cases. For instance, compulsive ideas and voices can be regarded as thoughts. One may try to weaken (or even overcome, which we have seen in our practice) influence of these symptoms of illness with the approach used for combating thoughts. In such a case it is necessary to explain to the patient - so that he/she understands and senses - what exactly is meant and suggest various ways of combating thoughts. This approach is feasible, and it works.

There is another possible approach to directing patients. Our Lord urges us to fulfill His commandments. Always and everywhere, regardless any circumstances, health or illness. In this sense, mental illness is not an excuse. It is just a special circumstance of the person's existence. Even when being ill, man is called to fulfill the commandments. By doing so, the person will demonstrate his/her faith, faithfulness and love to God, desire to be with Him. This is our most important action when following Christ. The invitation to fulfill God's commandments can be addressed to patients (under the condition that they have preserved critical attitude to what is being said and enough understanding) who are in delirium or hear voices. In other words, we try to guide the person to pay more attention to the commandments rather than the voices.

And the last point. Our Lord urges us to 'pray continuously'. In a number of cases, we can address this invitation to pray to the patients, encouraging them not to turn this in a mere formality of reading a text. We focus on the call for prayer, rather than on following their thoughts or images. The prayer may be of two kinds. To begin with, the patients are to pray for themselves, for their recovery, for help from God. Besides, they can pray for their neighbours, for each other, for their doctors as a manifestation of their hope and trust in God (the Only Healer of souls and bodies), who guides minds and souls of doctors (His earthly followers and disciples) working to bring cure.

I hope you understand that everything said above is just a few examples of possible ways of development. When we communicate with a real patient we take many factors into account, that were not marked here as important; for instance, understanding and 'feeling' the patient; awareness of his/her level of adequacy; understanding of the affected and intact parts of his/her soul (where we can lean on, and where we cannot); search for what he/she is capable of perceiving and doing; awareness of the realm of their possibility and forms of advice we can give them…

We as believers cannot but assert the reality of miracle in our lives. The miracle of healing, the miracle of transformation. They do happen. Here is an example.

A young woman of about 19-20 years with a five-year record of heroin addiction, stealing money and prostitution got into the Research Centre of Mental Health on a priest's recommendation who had accepted her in his community. Having observed the intensification of her depressive symptoms he asked our doctors for help. Every effort to treat her with medication, ECT and other means gave no result - her state continued to worsen. She obediently carried that cross. At some point of time I took her for Epiphany bathing rites to the Moskva-river. She went there only because of obedience, barely moving her feet and without any desire to live. After that pilgrimage and bathing in the ice-hole, the treatment plan that had not worked before, began to bring results. She came back to life within a short period of time, was released from the hospital with significant improvement and has been in steady remission for 20 years. She is a nun now.

On Confession

We should also add that at confession of mentally ill people priests should be very sensitive, taking peculiarities of illness into account and differentiating between what belongs to the illness in the patient's words (and in this context does not represent sin or belong to the sphere of personal responsibility) and what comes from their fallen soul and requires the priest's relevant response.

On Doctors and Illness

We believe, that priests and doctors see patients and their illness differently.

The doctor sees a suffering person and sets the main task of curing the illness to spare the patient of his/her suffering.

The priest sees an image of God in every person, perceiving him/her in the context of eternity and being aware that the main task for a man is to get into the likeness of God and enter the Heavenly Kingdom. The main task that a priest accomplishes is to help the person take the path in his/her life that will bring them to God, encourage them to grow into Him, no matter whether the person is ill or healthy.

Here is another point that we would like to make on some specific situations that we regularly run into when directing patients.

1. Quite often we have to "find a place for the doctor". The matter is that some patients - specifically not very churched or churched not in a quite right way - do not want to speak frankly with their doctor on a whole range of issues saying, "Why should I tell him what I open to the priest at confession? How dare he ask me about this?" Our task that we regularly run into is to help the patient find a correct attitude to the doctor.

2. Another challenge is to find proper wordings in a conversation with the doctor about his patient to communicate thoughts, actions and inclinations dangerous to the patient without breaking the seal of confession.

3. Respond to the patient's desire to stop taking medication (or partially reduce it) without informing the doctor. This is another situation we have to deal with regularly.

3. Conclusion

Pastoral care of mentally ill people has its obvious peculiarities and sets special requirements to the clergy. The priest is to be aware of psychopathologic realia, have understanding of the ways and nature of treatment and effect of psychotropic medication. He should also be particularly sensitive to the patient and take responsibility for his words and actions; more than that, not only for his words, but for the way the patient may perceive them because of his/her illness and use them.

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