International conference on Church Care for Mentally Ill People

Below are papers read at the International conference "Church care for mentally ill people: religious mystical experience and mental health"
November 7-8, 2019, Moscow (continuation)

Repentance, Confession and Depressive Delusion

Archpriest Iliya Odyakov

By God's will for almost quarter of a century I have served as a hospital priest at the Academy of Sciences' Mental Health Research Center (MHRC) and at the same time as a pastor in several parish churches in Moscow. Due to widespread depressive illnesses in society, in each of those places I have encountered various forms of their manifestations. These encounters may happen in both heart-to-heart talks and, more often, at Confession. In any case, I see an attempt to make Confession as a regret for a committed sin and to express a fear of the future.

So I would like to highlight a few issues.

In the biblical understanding, repentance is literarily "a change of mind", "a change of thoughts", the awareness of one's sins against God, people and oneself. Repentance is accompanied by both a radical reconsideration of one's particular views and one's system of values as a whole. Repentance is always a constructive action. "Turn from your evil ways, each one of you, and reform your ways and your actions", Prophet Jeremiah exclaims (Jer. 18:11). Repentance always precedes Confession and accompanies it. It can be both a transient action and a lifetime process.

Confession is an external expression of Repentance. It is made when, standing before a priest as a witness from the community of the faithful, one confesses one's sinful thoughts, feelings or actions. St. James calls, "Confess your sins to each other and pray for each other so that you may be healed" (James 5:16). The external forms of the sacrament of Confession that we use today have been known since the 3d century. Thus, the holy martyr Methodius of Patara points to the need always to "show to priests [your] heart's mischief" [1].

Today, for those who live an active Christian life, the need for Confession is its integral part. According to the well-known spiritual father of the 19th century, St. Ignatius (Bryanchaninov), it is "a fervent repentance of the heart, a thirst for purification caused by the feeling of holiness" [2]. Confession is often short in time but sacramental in significance.

Undoubtedly, this is a kind of ideal attitude to Confession. More often, in making Confession one seeks to express in words one's pain and shame for a committed evil action, to add a lot of details about the circumstances of these sins and numerous complaints about one's life in all its manifestations. And, certainly, one sets forth a description of the physical and spiritual painful states causing one's anxiety, burden, torments and suffering.

It is my conviction that the right tactics of spiritual care is that a priest cannot ignore the flow of the pain poured out at the analogion, since for a believer the form of Confession as a Sacrament is the only way for pouring out his or her distressing thoughts and feelings.

And now a task may well arise before the confessor as to how to distinguish a real lament about one's sins and a fervent desire to change one's life from a pretended feeling of sinfulness without any intention to live a different life. Regrettably I have to testify that more often than not it is just an attempt to make Confession only in form, without real Repentance. I will repeat however, this discernment is especially important in encounters with those who show basic symptoms of mental illnesses when they are similar to - speaking in terms of Christian asceticism - passions. Therefore, the knowledge of mental disorders and patters of their progress is of great importance for a priest.

This knowledge makes it possible to distinguish, so to say, "seeds from thorns", to distinguish what is really the subject of Confession together with the accomplishment of the feat of Repentance from what has to do with an illness and is neither a sin nor an area of the personal responsibility of an ill person.

One of such "thorns", weeds of the sacrament of Repentance is depressive delusion since it always arises from an unhealthy basis. This state is always connected with a disorder of thinking. Modern medicine describes delusion as a set of unhealthy ideas, notions and conclusions reflecting reality in a distorted way. Patients in delusion are completely confident of the validity of their mistaken ideas; by no means can they be dissuaded by an outsider. Their delirious constructions are extremely important, bright and important to them; they influence the whole thinking process and define words and actions of the sick.

A depressive delusion is always emotionally negative; it is guided by pessimistic stances against the background of apathy, loss of interests, feeling of guilt, uneasiness, anxiety and other manifestations of mood disturbance.

Most often, a priest would encounter the delusion of sinfulness, self-condemnation without any evident reason. In the consciousness of a repentant, the remembrance of some past, often inessential, trespasses are transformed into the feeling of a grave guilt before God. An ill one considers oneself guilty of almost everything, beginning from the statement that "in sin did my mother conceive me" (Ps. 51:7) to the unshakeable confidence that all one's subsequent life after the birth was a continuous chain of "dark deeds and dirty crimes". "There is no sin I have not committed". "By my sins I am guilty of the illness and death of my loved ones, relatives, friends, neighbours, pets". "The moment I think up something evil it happens"; I have committed "the most amoral things indecent to say about loud".

It is important to remember here that true Repentance presupposes not only the feeling and awareness of one's sinfulness ("showing the roguery of the soul") but, according to St. Methodius of Potara, also "the thirst for purification" with a hope for God's granting mercy and strength "to rectify one's ways".

Whereas delusional ideas show literarily one's possession with one's sinfulness and absolute confidence in that it is impossible both for God to forgive one's sins and for one to change one's fallen state.

A different firm conviction of oneself being a full nonentity is called the delusion of self-humiliation. Typical expressions heard at Confession are these: "I am good for nothing", "in life I have done nothing good", "I am a burden on everyone", "I am a bad son, husband, parent, worker, etc.", "my whole life is a continuous chain of mistakes", "I am not worthy of being called a human being", "But I am a worm and not a man, scorned by everyone, despised by the people" (Ps. 22:6), "I am an outcast", "I provoke disgust among those around", "I cannot fulfil myself anywhere", "I take a place in a church, monastery, hospital in vain", "I have disgraced the human race".

It can also be said here that everybody around seems pointing to this purposelessness: the attitude, looks, words of one's own people, neighbours, colleagues, parishioners, the priest - all, "even saints from icons or Christ Himself looking at me from the cross with condemnation and disdain".

In the delusion of self-humiliation, there is almost a complete absence of the ability to be aware of one's own positive qualities and to accept oneself as "a lost sheep" or "a prodigal son".

In addition, this unhealthy humiliating self-appraisal sometimes provokes a corresponding behavior: "The worse and more unworthily I behave, the more I feel soothed". "I am that same dog who always comes back to his spew".

At the same time, the depressive psychosis is often accompanied with the oppressive expectation of an inevitable punishment: "There is no penalty on the earth and in hell that would be adequate to my sins".

This can amount to manifestations of sensual delusion when everything around appears to be apocalyptically changed, with an arising feeling of "the Last Judgement" happening to a repentant here and now. In both reality and nightmares, one sees the deceased, coffins and death in its various manifestations, as well as demons dragging the soul to hell, etc.

Sometimes an ill person demands an immediate "fair judgement" and "deserved punishment" not from God but now from people. This state often leads to false confessions during Confession and at home ("I was not faithful", "I am a thief", "I am a murderer"), when one's inessential mistakes and misdeeds are presented as "crimes".

It often happens that a repentant with such delusional ideas would speak of imposing various punishments on himself: "strict fasting" (food without meat but with bread and water alone), wearing fetters, rejecting home comforts and electricity, sleeping on bare floor, taking food from a waste bin, wearing minimal clothes even during frosts, self-inflicting wounds, mutilation up to suicide. All this is almost always accompanied with a literarily fierce prayer (especially at nighttime) and obsession with making the sign of cross and sprinkling holy water.

A particular form of depressive delusion is the so-called hypochondriacal delusion. Characteristic of it is the delusional belief that one is afflicted with a lethal decease and the continious fear of an early death in agony.

Thus, one of the women parishioners would ask weekly for a benediction to be given for a consultation with yet another specialist and for undertaking still another analysis for cancer, AIDS and leprosy. She was stopped only by an insistent advice of the priest to see a psychiatrist.

At the same time, I have sometimes heard from a man who looks physically quite well that his internals are atrophied: "there is nothing to breathe with because my lungs have gone rotten", "there is no heart at all", "no thoughts because my brain has dried up", "that is why a prayer sticks". On the other hand, the man may be really ill with something but he ignores this real illness concentrating fully on an imaginary one. This form of delusion is called the delusion of negation.

I cannot help mentioning still another manifestation of depressive delusion. It is a false belief that "I am made ill by an evil will (for instance, that of my mother-in-law)", "the evil eye has been put on me", "I have been cursed", "bedevilled", "bewitched". It results either in a search for and persecution of the one who "infected" me, or in numerous visits to sorcerers, "old witches" or a resort to various forms of exorcism and repetition of special prayers.

Several times I encountered the assertion that it is not only one's own family who are suffering from "the terrible cardinal sin" committed by the repentant but also "the whole world is suffering because of it" since there is no limit in time or space for his guilt. "I am poisoning the whole nature by my breath", "I am cursed by the whole world", "Everything around has suddenly died and I am to blame for it".

Therefore, when in the process of Confession or in a confidential talk a priest encounters the characteristic features of depression, especially in its acute form, he should be guided by a number of rules to help a believer rather than to aggravate the severity of his illness.

• A priest on no account should agree with delusional ideas, so to say, "not to let them in himself", or support the ideas of self-blame, unhealthy belief in the sinfulness, guilt and inevitability of a punishment.
• At the same time, he should not express horror and indignation at what he has heard. He must not try to argue, to talk a repentant out of his delusion, to prove anything, to ask clarifying questions. It is not only useless but can also aggravate the existing disorder.
• It is necessary to show patience and to hear out calmly and attentively all the beliefs of an ill person.
• Whenever possible, he should pray together with a repentant.
• At the same time he should try to involve the family of an ill person to explain them the pathological nature of their loved one and the need for anyone with a depressive illusion to undergo an in-patient psychiatric treatment. Otherwise, it all can have an early and terrible outcome.

References

1. Священномученик Мефодий Олимпийский, епископ Патарский. К [С]истелию о проказе. Глава 6, пар. 4. [St Methodius of Olympus. On leprosy, to Sistelius. Chapter 6.4] URL: https://azbyka.ru/otechnik/Mefodij_Olimpijskij/k_istely_o_prokaze/ (дата обращения: 7.11.2019).
2. Святитель Игнатий (Брянчанинов). В помощь кающимся [St Ignatius (Brianchaninov). Instructions to Repentants].

Psychiatric support in distinguishing vocation and in crisis situations of monks and priests

Cornaggia Cesare Maria, Psychiatrist - Associate Professor of the Department of Medicine and Surgery, University of Milano Bicocca, Italy

I intend to carry out the topic entrusted to me, starting from my clinical experience, mainly taking cue from some clinical episodes that I hope will make my thoughts more concrete.

I am going to report some of the cases that I am right now working with in Italy in order to make my ideas and theories as clear as possible.

As it's known, the plane of mental functioning, which we could also call psychological or emotional, must be, in our clinical experience as psychiatrists, very distinct from the plane of spirituality, although we know how these two planes are very close, so much so that sometimes they can be imbricated, particularly in situations where we are dealing with consecrated people.

As psychiatrists, we are called to look at and to take care of the person as a whole, and therefore of his body, which for us is the brain with all its biological influences, and of his mind, or psyche, with all his thoughts, his impulses, his emotions, his instances and deep conflicts.

Everything that belongs to spirituality is absolutely accepted by us, but it is part of a different level, which concerns the relationship that the person has with God (the God who is not an internal construction of a projected piece of Self, but is Another-than-Self that the person meets and interacts with).

I would like to start with two examples and work together on these.

First example: the person I have in front of me could tell me that he lives a time of great closure in respect to the future, a time in which he lives his present without being able to project anything of himself into perspectives that go beyond the present day. I could think that person is suffering from depression. But I could also think that that person lives a great spiritual difficulty, since only the certainty of our relationship with God makes us widen our gaze towards the future.

Without God, in fact, the future cannot exist. Modern society shows this very well. In its attempt to expel God, it moves in a dispersion of human relationships, defined by Bauman as liquid, so that the relational incapacity and the confusion about the future leads to what some authors call the epoch of the post-human, where the emerging pathology can be defined as the pathology of desire.

By "pathology of desire" I mean the inability to desire, which is followed by the substitution of desire with cravings, as shown to us by Benasayag and Schmidt. The inability to desire, or even the simple reduction of desire, is the consequence and expression of a fall of the Ego.

The word "desire" leads me to stop at some reflections, which, in my opinion, strongly enter the moment of the decision, for example, for a priestly or monastic vocation. The man is born and structured as a desiring subject, therefore desire is a fundamental component of a healthy Ego, as well as an indispensable resource for his human and spiritual journey. A vocational choice, which could appear to be characterized by withdrawal, for example from sex, cannot be understood as a renunciation of desire, but must be considered as the expression of a desire that proposes itself as greater than any other, including that of sex.

Let's stay on the examples and work on a second one, this time addressing not the future, but the past: the person in front of me tells me that he continually torments himself by remembering his childhood traumas, without being able to trust that something different than what happened in the past may happen for him. As a psychiatrist, I could imagine that this person cannot resolve his deep conflict and that he needs a long psychotherapy. At the same time, I could also think that that person has not met or wanted to meet a vital experience and that he prefers to remain anchored to the habit of continually (and narcissistically) retracing his misadventures in order not to face life, excluding the possibility of beauty (read: of God) for himself.

But then, how can I proceed in front of these two examples? What can help me, as a psychiatrist, who meets that person at that moment, distinguish the before mentioned levels (psychic and spiritual)?

I believe that, in this regard, after talking about desire, we need to talk about freedom. These are the two key-words in the thought that I will try to develop.

By the word "freedom" I mean the ability to stand before reality, knowing how to put all his own deep needs, impulses, emotions, and so on, in front of the reality, not excluding any of its constituent factors. It is from this freedom that desire is born, as an expression of a correspondence between one's internal needs and the reality before him. This ability is a psychological ability, that is, the person must be able to interact with his own internal world and with his own external world. Phenomenologists would talk about the two alterities that man must know how to communicate with.

Forgive the Gospel reference: let us think about the Samaritan woman at the well. Jesus does not ask her very much, what she was doing, but he looks direct to her desire (which the Samaritan woman had in mind): the water of life. Jesus responds to her desire not asking for anything else, especially not judging and not investigating that much (as a psychiatrist would do). The Samaritan woman, specularly, sees that what she has before her corresponds to her desire, without being minimally tied down by her past errors. In essence, the Samaritan woman is able to see what is in front of her, to identify her desire, without being blocked by her past. This allowed her the experience of change.

So, what we have to look at, in the cases described above, for example, is where the desire of the other stands and if this desire is free to express itself.

Therefore, in the first case, I will be careful if the person has the ability to look at himself and his future, or if his gaze is blocked. In the second case, I will look at whether the person has the ability to separate himself from his history, as very often our freedom arises from the ability to separate us from the ties of our past.

This is because we need, I would like to say, the "blessing" of the other, the loving acceptance (of "you are well the way you are"), that the father of the prodigal son taught us. The son was able to return to his father's house, because he was expected by his father, and, at the same time, because he was capable of recognizing, both his father as father, and his own desire of him.

In this regard, I am reminded of a large number of my patients, who, with increasing frequency, bring me, as a central issue of their problems, that of non-recognition. We are all born needy of the creative gaze of the other (needy to be, as mentioned, expected by the father). Think of the meeting between the "unnamed" and Federigo Borromeo in the Manzoni's novel "the Betrothed" or that of Nathanael with Jesus, or at the same meeting of the Samaritan woman, where the gaze of the other signifies for them to experience who they really are.

My patients, in the vast majority of cases, bring me the traumatic experience of never having been looked at.

But the obstinate need to be recognized can lead to develop unexpected dependencies or to undertake paths that, over time, could prove to be false, precisely because they are chosen on the basis of a dearth and not of a free desire. I speak about the choice of both marriage and consecration.

This point introduces us to the first moment in which aspects of psychic fragility and aspects of spiritual lability could be confused. I speak of the moment of vocational choice, be it virginal consecration or marriage.

I like to say this: before marrying or before choosing for a monastery or the priesthood, a person should have "forgiven" his parents. By this I mean, that he should have loosened the ties we talked about earlier, the ties of his past, of betrayals, of disappointments or of anything else. This is not a spiritual problem, but a psychic ability that must be matured. The price, if not, is to carry around, sometimes forever, the person's own conflicts. Even worse, and more often, the person would make a choice based on his own conflicts, perhaps deluding himself that the choice would solve them, and this would produce nothing but the sure wrecking of his own choice.

By this I do not mean that a person, to marry or to make a monastic choice, must be psychologically perfect. How many great neurotics have been good parents, and how many consecrated men who became saints would have been, perhaps by us psychiatrists, hospitalized in an asylum! What I mean is that the psychological space of freedom and desire must be safeguarded.

To explain myself I will give an example: a young man who has experienced poor recognition from his original context, therefore with an inadequate perspective of himself, a low self-esteem or confidence in being loved, meets a particularly charismatic priest, that looks at him, welcomes and empowers him. This young man could, probably, before this his first experience of recognition, suddenly experience a life of great openness and self-discovery, which could however be confused with an actual encounter with a monastic call. What is essential to look at in such a situation? It is necessary to understand if that young man, at that moment, is living both freedom and desire, in other words if he is communicating with the two "alterities" mentioned above.

In fact, it could happen that we find ourselves in front of a young man who, having found his first gratifying experience with that priest and being afraid of not being able to live others, chooses, perhaps without full awareness, to follow the monastic life. In this case, however, we would be facing the reduction of desire and not its opening.

Two brief observations. In front of two married persons in crisis, it is very useful to look at their first moment of their history, their first infatuation. If it was a true meeting, it remains a resource. In the same way, for a consecrated person, it is essential to discover the first evidence when he or she was called by Christ as happened to Gedeone. If he or she does not discover this past evidence, it is very probable that he or she goes away.

This is not very different from what happens at the moment of a temporary or definitive "crisis".

Let us present an example: I have been called in a cloistered convent because a novice, in the convent for over two years, has begun to present serious discomfort in terms of anxiety, irritation, sensation of suffocation, generic depressive-like symptoms and almost epileptic-like crises, actually hysteriform-type. The novice mistress was rebuking this young woman quite strongly, considering these things an expression of a sort of insufficiently humble adherence to the rule. At the interview, which took place in a special space, I realized that the young woman was very irritated and reactive, made little reference to her questions or problems, but appeared to be vindictive, as if the others were not understanding her. I wondered, at that point, if the symptoms of anxiety, of claustrophobia were not the expression of her need to go out, and the hysterical crisis, that is a totally bodily expression, was nothing but a way to voice what she was absolutely unable to say, in particular to herself, meaning that she wanted to go out. After about 2-3 years, I learned that this young woman had found another place, not enclosed, in which she lived, in another form, her vocation.

Our body, in fact, can often be an expression of our unsaid discomfort, especially when our emotions cannot be understood and expressed.

The "crisis" can manifest itself in many ways, and what must remain at the center of attention is always the globality of the person. Many times the "crisis" is expressed with a "falling in love", and this infatuation, very often more imaginary than real, can be an expression of two situations:

• the first is when the infatuation is the result of a new experience of recognition, of being valued, desired, considered beautiful by another, as an experience that makes the person totally lose the aderence to reality, bringing back a trauma of non-recognition, perhaps unresolved and dormant over the years;
• the second situation is when the infatuation represents a pretext or an incentive to get out of no longer gratifying situation, and this also happens very often in marriages.

What are we facing in both the situations above? We are facing a confusion of desire, obviously not well determined, at least in several cases, since the beginning.

The confusion of desire, I believe, is also the basis of many scandals emerging today in the Church.

In fact, in both the situations mentioned above, we are still facing relationships of dependence, that is, of non-separation with respect to the original traumas, that produce a context of affective confusion. The intervention that we psychiatrists can do is to help the person read his own story and release his desire, in order to allow him to experiment or re-experience his freedom.

Allow me, in this regard, to cite Anna, a young consecrated woman who has come to my observation after two infatuations, with rather ill and very similar patterns. After a short journey together, she told me:

"With you I understood the confusion that arises when one experiences an affection-dependence ... which is to keep very distinct from the affective relationship with Christ ... the dependence made me a slave, for example, I was feeling ill if a text message did not arrive from him ... the affection with Christ is at a level that does not lead to an obsession, where the world begins and ends in that particular detail, the text message ... in the obsession I felt alone, in the affection with Christ I feel now strong and free ... when the psychological tie was stronger than me, it was as if I had a limp and could not run ... but now I feel that I have the possibility to do something about it, so it is my choice, I can get on my knees and pray ... having named the psychological deficiencies I had, and having become aware of them, in the work with you, gave me a freedom that I finally can use in my relationship with Christ and this relationship is made new ... I realized that to make a real experience with Jesus we need to be free ... to name things is to take a distance and look at things from the outside ... ".

This is why I spoke about freedom earlier. It seems to me that the task of us professionals, when and if we succeed, is to dissolve the ties of freedom (even in terms of sick mental functions), so that the exercise of freedom opens up access to spirituality.

Let's go back to the second example given at the beginning, that of the person who is unable to break away from his traumatic past and remains anchored to the trauma. This person, as a result, is a slave to the recognition of others, he lives waiting for the approval of the other because he does not have a sufficient identity on his own without it. The psychiatrist would say: he cannot change his perspective because he has not yet elaborated the trauma; a spiritual vision would question whether, in addition to this or in place of this, he does not have a lack of faith, in the sense that he does not know how to speak with Jesus present, meaning with Him who truly recognizes him today with the merciful gaze of the father (for which John Paul II invited us not to be afraid).

But then, when does this person need a psychiatric or psychological intervention? That is, when, as mentioned before, is there a lack of freedom? When his traumatic experience produced an incapacity for him to go out of himself and to dialogue with the other-than-Self, therefore also with God. If we do not recognize this incapacity and we blame the person for the "fault" of the crisis, attributing it to his insufficient faith, we can risk to become advocates of a terrible further violence (see the novice mistress of the previous story).

The ability to relate to the otherthan-Self originates in all of us in our very first relational experiences, when our identity and trust are formed. Trust that will serve us in every step of our life. We learn to live our self-confidence (that belief that something good in and for us can happen) within the narrow track that exists between the recognition and the betrayal we received from our original figures.

Let's start with another example. One day a young patient told me: "I changed when I started to understand that I was loved without the need to be a reason for this ... and that was what I didn't believe possible in my life ... only then I became aware of myself ... I could understand that I had never been happy and that I could be happy ... ".

This patient showed me that is the experience of love (recognition) that produces change, in all of us. We must, however, be able to have this experience, that is, to have a sufficient degree of trust (precisely born between recognition and betrayal). If as children we have not had the opportunity to live sufficiently well this experience with paternity and maternity, as Winnicott would put it, we grow and live as structurally deficient (Father Luigi Giussani used the term "handicapped"), until we manage to live it again in the present. This is what can happen during the psychotherapy, which can allow the person to perceive that for himself joy is possible, with the experience of an ever increasing trust, as Spivak stated.

What do I mean by the term "structurally deficient"? I try to explain it through a passage written by Sandro: "I cry, I'm sad. I pray. I cry. A feeling of loneliness invades me. A feeling of death owns me. I pray ... I feel everything as distant ... I hope to find peace at the end of the rosary. I was wrong. Nothing fills this dearth ... But how many faces does this dearth have? ... perhaps, most of all, I miss myself ... ". Freedom, in a case like this, cannot be brought into play, it is coerced, blocked, tied. I could say: The Ego is lacking, person fails to pass from being a lacking subject, as ontologically the man is, to be a desiring subject. And it is on this that we have to work on.

Sandro, in particular, is still stuck between his need to be recognized and his ability to open up to the world. My task now, I hope to succeed, is to open him to the possibility of entering a dialogue with the other-than-him, to re-experience trust in himself, raising back high his gaze. After that, he will be able to bring his freedom into play.

In conclusion, I consider psychiatric support very often useful for consecrated people, if it has the ability and humility to remain within the boundaries dictated by its technique. The technique would widen the horizons of the other, allowing him to put into play the two key-words used by me, freedom and desire, essential to be open and receptive to spirituality.

Let me do a final provocation, which is the difference between a psychological and a spiritual intervention? Using the words before taken into consideration and looking at the examples before done, I think there is a very close difference, as both are directed and oriented to the human. When I speak of reduction of capacity, I also think that a person may have a reduction, but not a total exclusion of both freedom and desire.

Session "Church Care for Mentally Ill People"

On January 25, 2020, a workshop of the XXVIII International Christmas Educational Readings was held on the theme 'Church care for mentally ill people', at the Moscow Patriarchate's department for external church relations. The meeting was organized by DECR and the Inter-Council Presence Commission for church education and diakonia, in which there is a working group for pastoral care of mental patients.

The meeting was chaired by Metropolitan Sergiy of Voronezh and Liski. The workshop was supervised by Ms. Margarita Nelyubova, secretary of the Commission for church education and diakonia and DECR staff member.

It was attended by 42 participants - clergy and laity of the Russian Orthodox Church, psychiatrists, specialists from the Metal Health Research Center (MHRC) of the Russian Academy of Sciences (RAS), Serbsky State Scientific Center for Social and Forensic Psychiatry, medical doctors, Church social workers.

The meeting opened with a speech by Metropolitan Sergiy of Voronezh and Liski on "Psychiatry and Religion. The Way to Dialogue", in which he dwelt on the evolution of relations between Christianity and psychiatry over the past few centuries and noted the growing cooperation between the Church and medicine over the past decades. He emphasized the importance of the work of the section "Spirituality, Religion and Psychiatry" of the World Psychiatric Association and stressed the important role of the Scientific Center for Mental Health of the Russian Academy of Sciences for the development of dialogue between psychiatry and religion in Russia. Metropolitan Sergiy spoke about international conferences, which were held in 2018 and 2019 in Moscow with the blessing of His Holiness Patriarch Kirill of Moscow and all Russia, and on the initiative of the Commission for church education and diakonia of the Inter-Council Presence of the Russian Orthodox Church; the meetings were devoted to the problematic of pastoral care for mentally ill people. "All the experts who spoke at these forums were unanimous that health and spiritual life are two different, but not opposite, realities. It would be a mistake to claim that spiritual life always requires good mental health. A disease can become a special condition that allows a person to approach God and feel His love ... It is incorrect to think that only with good health one can do worthy deeds before God. Illnesses and sufferings, always present in human life, are mysteriously included into the plan of divine salvation", Metropolitan Sergiy stated.

Metropolitan Sergiy emphasized: "A simplified interpretation of mental illness as punishment from God is unacceptable: the Lord does not want evil and disease. It is with patience and without pretence to an immediate understanding of the meaning of mental illness, that one has to consider it as something that occurs in our life by God's connivance. "Everyone who deals with mentally ill people - doctors, family, pastors - must remember that "the mentally ill person has the right not only to be considered the image of God, but also to be treated as such."

Archpriest Victor Gusev, a cleric of the hospital church Mother of God the Healer at the MHRC, made a presentation on "Experience of pastoral care for patients in a mental hospital". He noted that the main task of the priest is to "help a person in a state of illness to continue his conscious growth towards God". Scientific studies at the MHRC have shown that it is possible to implement this approach: "Orthodox patients retain both the composition and structure of the axiological sphere during the illness, which is not observed in unbelieving patients". The priest helps the patient in understanding the meaning of the disease that occurred to him; supports him and "guides" towards the graceful help of God: prayer, sacraments; fosters ill person's own activity at this stage of his salvation. "Pastoral care for mentally ill people has its specifics and puts special demands on priests. So, the priest must understand the realities of psychopathology, have an idea about the methods and nature of treatment, and about the effect of psychotropic drugs. He should also show special attention and sensitivity to the patient, take special responsibility for his words and actions; and not only for his own words, but for how the patient perceives them due to his illness and how he uses them. "

G.I. Kopeiko, deputy director of the MHRC spoke on "Psychotic states with delusional ideas with religious content". He noted: "In the lives of patients suffering from mental illness, religious beliefs and views are of great importance and often play a positive role. However, pathological pseudo-religiosity, which forms alongside the mental illness, is characterized by various forms of distortion of the traditional religious faith." In the early stages of the disease, the pathological pseudo-religiosity manifests itself in predominant religious constructions that on the outside seem to be similar to the exaggerated manifestations of traditional religiosity, but the behavior of patients acquires the character of rude, pathological or ridiculous acts that reflect their pseudo-religious views. Gradually, predominant ideas that had the character of a religious worldview are transformed into a religious delusion, which is not determined by the personality's configuration and the content of which is in sharp contradiction with religious traditions objectively existing in society. According to the research studies conducted it the MHRC, "one in ten patients with delusions of religious content revealed behavior of an outspoken antisocial and / or antisocial character."

He stated that a priest "must have knowledge in the field of psychiatry in order to be able to differentiate the conditions of pathological pseudo-religiosity from the traditional religious faith and be able to provide adequate pastoral care and support to such patients, along with specialized medical care". The speaker gave criteria for distinguishing traditional religious faith from religious delirium. Criteria of traditional religious faith: "Believers are largely guided by the conciliar and church opinion; in most cases, they maintain close contact with the religious community and their own spiritual father; they have confidence in the church hierarchy; their religious faith is characterized, on the one hand, by the observance of canons, and on the other, it is lively, and dynamic in nature, which helps an individual to adapt to stressful situations and to life; the personality of the believer has no temperament changes, has no deformity signs, is harmonious, integral, corresponds to the social norm. "

Criteria of religious delirium: "Mental disorder has a plot of pseudo-religious concepts, which, as a rule, contradict the canonical principles and contribute to alienation from people who adhere to traditional values for this society, as well as from their own family; most often, patients do not maintain contact with the religious community, and they usually don't have a spiritual father; they often have a negative attitude towards traditional religious institutions; religious delusions reveal a low criticality level, rigidity and forms a specific delusional behavior; patients demonstrate traits of personality defect. "

In conclusion G.I. Kopeiko noted : "Special psycho-educational work is needed among clergy and students of theological schools. We believe that close cooperation between psychiatrists and clergy is necessary, following the path of mutual assistance, mutual respect and exchange of experience in the treatment of the mentally ill".

V. G. Kaleda, MD, deputy director of the MHRC, head of the department of juvenile psychiatry spoke on "Mental disorders of adolescence - diagnostics and medical and social assistance." In particular, he noted that due to the psychological specifics of adolescence, "the usual for adolescents characteristics may acquire the character of symptoms of a psychiatric illness". V.G. Kaleda emphasized that, according to scientific research, about 25% of all young men experience severe depression in their teenage years. Moreover, the state of depression can be invisible to people around and even for the family of the young person, and no one knows about his condition until the young man suddenly jumps out of the window. One of the age-specific syndromes is the "metaphysical intoxication syndrome", when "religious views acquire a predominant character", which is fraught with suicidal risks.

These and other characteristics of adolescence must be taken into account by pastors when providing spiritual assistance to adolescents: you need to talk with them very carefully, you need to carefully look at the behavior of the young man, his words, arguments about the meaning of life, offenses, you need to remember that people in the adolescent period, on the one hand, require a lot of attention, and, on the other hand, need clear reference points in life.

O.A. Borisova, Ph.D, senior researcher in the Department of special forms of mental pathology, MHRC, in her report "Apocalyptic views and religious delirium of the end of the world" noted that the expectation of Christ's Second Coming and the end of this world was characteristic of Christians since the early centuries of our era. The reason for a special attitude to this event is associated in the first place with the expectation of the Heavenly Kingdom and for this reason the desire to be properly prepared for this meeting is natural for a believer.

However, through centuries the notion of apocalypses began to take other meanings as well, for instance, as a catastrophe of a universal scale that does not have any religious meaning. O.A. Borisova presented a long list of various predictions of the end of the world made by various people in various historical periods. More than once this led to grave consequences. The speaker listed cases of mass suicides caused by an expectation of the end of the world. In Russia, the idea of the coming of the rule of antichrist became dominant among Old Believers since the second half of the 17th century. After the church reform introduced by Patriarch Nikon, some of them were convinced that they were experiencing the real end of the world, and the only means of safeguarding the robe of Baptism from defilement was believed to be found in martyrdom. They interpreted the self-immolation as the second Baptism. Then the speaker listed the cases of mass suicides committed in anticipation of the end of the world in the 20th century.

At the end of the 20th century, the decision to assign individuals the taxpayer identification number of the Russian Federation (TIN) provoked a great deal of incidents that required that the problem should be studied by the scientific community.

As a peculiarity characteristic of such patients driven by the ideas of the end of the world, the author pointed to a contradiction between their behavior and the beliefs they held. In following the traditional rules of church life (regular church attendance, participation in sacraments. continued relations with parishioners and sometimes even active participation in community life) they did not mentioned at their confession the particular opinion they held with regard to a link between the TIN and the end of the world. The eschatological conditions of such patients can be assessed as a delusional disorder of paranoiac level.

The apocalyptical delirium is accompanied with expressions of fear of an imminent threat. The patients live with the feeling that the world is collapsing, sometimes they became aggressive. Their inadequate behavior during an attack of illness can have unpredictable consequences. O.A. Borisova named two categories of delirium - "apocalyptic" and "eschatological" - and explained their differences, which are important for specialists to consider in order to predict the socially dangerous consequences of patient behavior.

Archpriest Ilya Odyakov, a cleric of the hospital church Mother of God the Healer at the MHRC RAS delivered a paper on "The Sacrament of Repentance and depressive delirium". He noted that it is necessary to distinguish between "a genuine lamentation about one's sins and a desire to improve" and the "stream of pain" that is often poured out at the confession stool by mentally ill people. Such people must "never be stopped", father Ilya believes, but one needs to understand that the "delirium of sinfulness, self-humiliation and self-flagellation" (in the extreme: "the whole world suffers from my sin"), delirium of self-incrimination and hunger for self-punishment (dangerous auto-aggression, suicidal thoughts), nosomania (expectation of an imminent death) - all this is far from true repentance. The speaker offered a number of recommendations for clergy who are facing similar cases: the priest should in no case agree with delusional ideas or support ideas of self-flagellation. At the same time, he should not express horror and indignation at what he heard. In no case should he try to argue, persuade, prove anything, and ask clarifying questions. He needs to be patient, listen calmly, and pray together.He should try to involve the relatives of the patient, explain to them the pathological nature of his experiences and convince them of the need for medical treatment.

Prof. Shamrey V.K., Ph.D., Honored Doctor of the Russian Federation, Head of the Department of Psychiatry, S. M. Kirov Military Medical Academy, Chief Psychiatrist of the Ministry of Defense of the Russian Federation spoke about teaching the foundations of Orthodoxy to students of medical universities and, more generally, about the formation of the "spiritual environment of the Academy", noting that the foundations of this environment were laid back in the 19th century. Talking about the history of the Military Medical Academy, about the churches that were on its territory, V.K. Shamrey emphasized that the Academy was the only military educational institution that had a department of theology and where spiritual and moral traditions have been always preserved. And this situation was largely due to the fact that most of the employees either originated from the families of clergy, or had theological education. Talking about the life of the academy in our time, Professor Shamrey, in particular, noted that the students are taught the basics of Orthodoxy, they learn about Orthodox army traditions. The students of the Academy have also choir singing courses, ringer art, Church Slavonic lessons, pilgrimages for military service personnel. The S. M. Kirov Academy has the position of assistant specialist for work with believers among military personnel. Contacts with the St. Petersburg Theological Seminary allowed military medical doctors to organize what the professor calls "cross-training": seminary students come to the Academy with lectures on Orthodoxy, and psychiatrists teach them about the basics of their science.

Prof. E.S. Kurasov, Ph.D., the S.M. Kirov Military Medical Academy chair of psychiatry, spoke about modern approaches to the treatment of mental illnesses. He gave a historical exposure, presenting the main stages of the development of psychiatry, approaches to the treatment of mental illness in the past and today. The speaker paid special attention to spiritually-oriented psychotherapy, which, according to him, is "a merged of the activity of a doctor and a priest confessor."

M.A. Palchikov, Ph.D, associate professor of the Department of Psychiatry, N.N. Burdenko Voronezh State Medical University spoke on the issue on interaction of psychiatrists and clergy in the diagnostics and treatment of mental disorders. According to him, often people with mental disorders do not immediately go to the doctor, but first turn to the church for help. Since mental disorders are associated with a high risk of suicide, one of the main tasks of the interaction of a psychiatrist and a clergyman is to reduce suicidal risks. Comparing depression as a disease and sloth as a sinful condition, he noted that the medical symptoms of depression are mentioned by the Holy Fathers in their considerations about the sin of sloth. With the help of medications, one cannot get rid of sin, but one can get a significant improvement in depression. "By working with the patient's worldview, we reduce the risk of relapse after the pharmacotherapy is stopped... One of the most effective methods of influencing this sphere is Christianity", the speaker emphasized. According to him, patients who have suffered psychotic states with religious experiences, require particular attention: ideas of sinfulness, chosenness, extra-zealous fulfillment of church requirements, etc. can hide manifestations of the disease. In such cases, the priest should have "psychiatric alertness", try to understand the underlying feelings and motives of the parishioner and, if necessary, send him to see a psychiatrist. It is important to understand that mental disorder is not an obstacle for pious spiritual life.

N.V. Lazko and O.A. Rusakovskaya, specialists of P.V. Serbsky State Scientific Center for Social and Forensic Psychiatry of the Ministry of Health of Russia presented a report on the "World of "Special" People (about residents of psychoneurological institutions)". The spoke about the results of monitoring of psychoneurological institutions (PNI) in a number of Russian regions in 2019 that revealed problems whicht can be largely resolved through the participation of religious communities in the life of "special" people". Of particular importance is the spiritual accompaniment of those living in PNI. "Currently, in a number of territories ... there are house churches, chapels as well as parish churches located close by PNI, where the residents of an institution can participate in worship and attend to Sacraments ...

A program of spiritual education for residents has been developed, which includes organization of religious processions from the institution to nearby parish churches, conversations that in simple terms explain the history of churches, etc. " All this has a very beneficial effect on the condition of people, "who for the most part cannot live on their own and stay for many years in shared housing facilities; it gives them the opportunity, each on their own level of understanding, to feel the fullness and value of the life given to him by God." The speakers urged to pay special attention to the personnel issue - the appointment of a clergyman who would permanently support a specific PNI, its residents and employees. The "rotation" of such priests is undesirable due to the specific of perception by the PNI residents, their "childish" affection for those who are friendly with them.

Concluding the session, Metropolitan Sergiy of Voronezh and Liski noted that such meetings on the issue of Church care for mentally ill people, which have been held during the annual Christmas Readings for several years, help to establish mutual understanding and cooperation between clergy and medical doctors and show an example of such cooperation.

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Below is the speech of Metropolitan Sergiy of Voronezh and Liski at the opening of the session

Psychiatry and religion. Ways to dialogue

I cordially greet all of you, dear brothers and sisters!

Participation of representatives of clergy and medical doctors in our session "Church Care for the Mentally Ill People" has become a good tradition, testifying to the growing cooperation between the Church and medicine on the most pressing issues of our time, which affect our entire modern society.

The relationship between Christianity and psychiatry over the past few centuries has been uneasy. In many respects, this is due to the fact that psychiatry was influenced by simplified naturalistic ideas about the soul, which did not correspond to the Christian understanding. In addition, materialistic founders of this medical discipline sometimes took an open anti-religious position. So, at the beginning of the 20th century, Sigmund Freud, in his work "The Future of an Illusion," considered religious beliefs as a special form of collective neurosis. The author came to the conclusion that all religious faiths are "illusions", and in the future they will inevitably disappear.

The attitude of the psychiatric community towards religion has changed significantly at the end of the last century. Establishing of the Section on Religion, Spirituality and Psychiatry of the World Psychiatric Association demonstrated to doctors the importance of religion for mental health. Recently, this reputable medical organization approved the Position Statement on its positive attitude to religious issues in psychiatry, which has become an expression of the increasing social and academic importance of religion for health. Numerous scientific studies have now been published, which confirm an improvement in the condition of patients under the influence of religious life. The importance of religion is registered in psychotherapy and psychiatry in alleviating depression and stress, in reduction of anxiety. The positive role of religion in the rehabilitation of patients with drug addiction has been proved.

The dialogue between psychiatry and religion in Russia in recent decades has been organized through efforts of specialists of the Scientific Center for Mental Health, which held the very first International Conference on "Religiosity and Clinical Psychiatry" on April 20-21, 2017. This forum was attended by 356 people from 16 territories of the Russian Federation, as well as representatives of other countries. This meeting was a unique event in the life of Russian psychiatry, which made it possible to gather leading experts exploring religiosity and psychiatry at a leading clinical research institution.

With the blessing of His Holiness Patriarch Kirill of Moscow and all Russia, and on the initiative of the Commission for Church Education and Diaconia of the Inter-Council Presence of the Russian Orthodox Church on November 13-14, 2018 and November 7-8, 2019, international conferences on Church care for the mentally ill people was held in Moscow. During these conferences, issues of pastoral work with mentally ill people, as well as the dialogue of the Church and medicine in the field of mental health, were discussed. The conference was attended by scientists, psychiatrists, clergy of the Russian Orthodox Church, experienced in pastoral care for the mentally ill, employees of the Scientific Center for Mental Health, representatives of various Christian faiths from Russia, Kazakhstan, Belarus, Cyprus, Spain, Great Britain, Italy, the Netherlands, USA interested in professional discussion the relationship of religious experience and mental health.

All the experts who spoke at these forums were unanimous that health and spiritual life are two different, but not opposing, realities. It would be a mistake to assert that spiritual life always requires good mental health. A disease can become a special condition that allows a person to approach God and feel His love. This phenomenon, well known in physical illnesses, is also true for psychiatric conditions. The history of the Orthodox Church and pastoral practice indicate that there are many patients who are not strong physically and mentally. However, they have enough willpower to fulfill divine will. It is wrong to think that only with good health can one do worthy deeds before God. Diseases and sufferings, always present in human life, are mysteriously included in the plan of divine salvation. Man dies in himself in order to live in God. But this process does not depend on favorable or unfavorable mental circumstances. Of course, health is a good condition that must be maintained and strengthen to maintain the quality of human life, to serve God and people. However, on the path to holiness, to which man is called, it is important not to gain health, but to abandon everything that prevents the gifts of the Holy Spirit from manifesting in us. God's mercy does not depend on the condition of human nature, but only on the will of the Holy Spirit that "blows where it wishes" (John 3:8). Thus, grace can act in a mentally ill person. Only sin is an obstacle to the operation of God's grace.

On the other hand, a disease that can contribute to salvation, at the same time, can make it difficult for a person to maintain the lifestyle necessary in his profession. For priestly service, in particular, it is necessary to take into account the state of health, which must correspond to the chosen path. Attention should be paid to such character traits as excessive shyness, excessive uncertainty, a tendency to isolation, sociophobia, lack of self-control, obsessive thoughts, perfectionism, a tendency to voluntarism, as these character traits can signal of a psychiatric pathology. While deciding whether a person complies with the duties assigned to him, one should be confident about the state of his health, and not hope that the negative traits of character will disappear with time.

Religious life can and should become part of the assistance provided to a person suffering from a mental illness. Its purpose is to preserve the integrity of the individual through his standing before God. Orthodoxy is not just a system of reasoning or norms of behavior, it is a way of living. Orthodoxy as a religion is not indifferent to mental health, because it radically determines the form of human being. Leaving aside the issue of religious sects and differences between the main traditional religions, we can say that the Orthodox tradition contains several foundations that favor mental health, among them love and hope. Human life becomes deeper and stronger in the context of love and reaches its true fullness in hope. Love and hope contribute to stability, unity and harmony of mental activity and, therefore, are factors contributing to mental health. These Christian virtues also help the medical staff of psychiatric clinics to maintain mental health and prevent professional burnout. Especially if doctors participate in the liturgical life of the Church.

The family plays a fundamental role in the treatment of mentally ill people. Family members can help the patient by avoiding psychological pressure and not obliging the patient to do what he does not want to do. They will help to follow the doctor's prescriptions. Show true compassion with the sick person, without deceiving him. Not many people will be able to achieve such an attitude towards the mentally ill people without God and the Church. For this it is necessary, first of all, to change oneself. First, one has to remember that the ill person continues to be the Image of God. At the same time, the mentally ill person has the right not only to be considered the image of God, but also the right to be treated as such. Secondly, it is with with patience and without pretensions to an immediate understanding of the meaning of mental illness, that one has to approach a mental illness as something which occurs in our life with the connivance of God. A simplified interpretation of mental illness as a punishment of God is unacceptable: the Lord does not want evil and disease. Finally, communicating with the patient, one needs to carefully watch what he needs in order to help him. It is important that the relatives accompanying the patient have an understanding of the disease, its origin and prognosis, what they, together with doctors and clergy, can do for the ill person. For this, it is important to maintain a relationship with the doctor constantly, and not only at the beginning of treatment. This contact is especially important for the clergy, who should be aware of those periods of illness when pastoral care can be most effective.

The program of our meeting today is very interesting. We will discuss the experience of the clergy and the particularities of pastoral ministry in medical mental institutions, we will talk about the continuous and complementary assistance provided by psychiatrists and priests, about issues of education in the field of pastoral psychiatry, and we will learn the opinion of specialists on the development of a dialogue between psychiatry and medicine. I hope that one of the fruits of the work of this session will be the further development of medical-Orthodox cooperation in this field.

I wish you good health, God's blessings and fruitful work!