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)

Religious experience and mental health in studies of Russian psychiatrists

Kaleda V. G.

The problem of an analysis of religious experience and mental health and relations between psychiatry and religion has been in the center of almost the whole history of Russian psychiatry beginning from the first textbook on psychiatry written by P.A. Butkovsky (1934) to today's studies. The topicality of an analysis of the problem of religion's influence on mental health is determined by the socio-political transformations which have happened in our country in the last decades and which have been accompanied by an increasing number of people who count themselves belonging to religious confessions and by a growing role given to religious values by people with mental disorders.

The Church is associated with the history of care for mentally ill people. Monasteries and churches were the first institutions in which people with mental disorders could find support and consolation. The historians of the 20th and 21st century Russian psychiatry ¹ single out a special "monastery" stage that covered the period from the 11th to the 13th century. As T.I. Yudin noted (1951), "precisely the high unique culture led to the high original development of monastery medicine, including psychiatry". It was in the monasteries, that various forms of mental disorders were described for the first time. By the end of the 11th century, three centuries before the opening of Bedlam (St. Mary of Bethlehem) in London, the treatment and care of ill people in the Kiev Monastery of the Caves had reached such a high level that a special facility ("cave") was allotted to "wild" patients.

The care of mentally ill people in monasteries, which originally developed spontaneously, later was legalized by state regulations. The first such regulation was issued in 1551 when under Ivan the Terrible the Council of One Hundred Chapters worked out an article on the need of care for the poor and sick mentioning among them those "who are possessed by the devil and deprived of reason". They were to be put up in monasteries "so that they may not stand in the way of the healthy" and "may be brought to reason or led to the truth". In 1723, Peter the Great forbade sending "the foolish" to monasteries and charged the Chief Magistrate with the duty to arrange hospitals. However, due to a lack of such, in the consequent decades, the mentally sick were still sent to monasteries. In 1775, when Russia was divided into provinces, Public Care Boards were established, which opened mental wards in hospitals and built special houses for the insane.

In 1834, the first manual written by P.A. Butkovsky on psychiatry was published in Russian entitled "Mental Illnesses Expounded in Accordance with the Principles of the Present Teaching of Psychiatry in General and Particular Theoretical and Practical Content". In the theoretical part of the manual, the author, proceeding from Christian anthropology, identifies in man, along with his body and soul, a spiritual component - "the spirit is a thinking and discerning principle of the soul through which we study and learn the truth, the universe and our own nature". Describing some endogenous psychotic conditions by the term "sophistry" (paraphrosyne), he gives a description of their prodromal stage of which religious bigotry and fanaticism may be typical with their "philosophizing and speculating on the chasms of human knowledge, foolish… incited by the passion of reading the Bible…". As some researchers note², what we have in his works is the first description to be given in literature on psychiatry to the phenomenon of "metaphysical intoxication", which was to be described in more detail by Theodor Ziehen as late as in 1924.

The problem of religiosity had never been an object of a special psychiatric study. However, this problem was indirectly touched upon by some Russian scientists. F. Kondratyev (2012) poses this problem in an expressly sharp way. What should be the modern man's attitude to religiosity? Is it his prejudice, mistake, mental defectiveness, pathology or is it his emotional richness, lofty spirituality, mental fullness while a lack of religiosity implies exactly spiritual defectiveness?" S.S. Korsakov (1901) noted, "The religious feeling is more or less inherent in every normal human being", while he considered atheism to be a sharp manifestation of secret religiosity. V.P. Osipov (1923) singled out among the characteristics of moral insanity not only a lack of moral sense but also other lofty feelings, aesthetical and religious. A.A. Portnov (1967), in a polemic with the idea of Sigmund Freud (1959) that "religion is the common human neurosis of obsession", contended that religion cannot be considered a mental illness but a complex multiform social phenomenon.

The issues of psychopathology and clinical mental diseases with a religious content are reflected in the studies of many Russian psychiatrists. In classical Russian manuals on psychiatry³ following V. Grizenger (1867), descriptions were given of psychotic states with a religious delirium. S.S. Korsakov pointed out that those inclined to mysticism from their childhood are prone to religious paranoia. The delirious period is characterized by rapid development of the idea of magnificence, a delirium of holiness, closeness to the godhead while the ideas of magnificence are also manifested in the ideal of persecution (hostile influence of evil spirits, people of other faiths, the antichrist. F.E. Rybakov (1916) described a religious paraphrenia in which "a period of the delusion of meaning and appraisal, surpassing a period of the delusion of persecution, ends in a delusion of magnificence…", while the process of disease ends in imbecility.

A special place in studies of Russian psychiatrists of the late 19th - early 20th centuries is occupied by the phenomenon of hysterics ("shrieking"), a special state observed in the Orthodox religious environment, predominantly in village churches and some monasteries in central Russia. This problem was dealt with by many psychiatrists⁴. A special study of this phenomenon was carried out by N.B. Krainsky (1900). In the preface to it, V.M. Bekhterev noted that the basis for these states was determined by the hysterical neurosis (1900). F.E. Rybakov (1916) considered this phenomenon as part of a hysterical derilium the attacks of which with a demonic content of delirious ideas were more often observed among underdeveloped and superstitious people who were not observed to have unhealthy manifestations after the end of the attack until a new one. V.F. Chizh (1911) noted that the initial insanity among hysterical people essentially had nothing to do with real paranoia but a religious delirium in these cases was almost always based on an illusion of the senses and on allegoric explanations of anesthesias and paresthesias.

In a research made by M.S. Uryupina (1972) on the syndrome of possession by "evil spirits" (hiccups) among northern peoples in Russia, references were made to the elements of heathenism with a belief in magicians, and this syndrome was considered to be a combination of pathological ideas of evil eye and possession with somatic illusions and sometimes bodily hallucinations and very peculiar speech motor paroxysms. This phenomenon is considered in the structure of hysterical hypochondriac states, with its expression sometimes reaching the psychotic level in a neurotic reaction, hysterical psychosis, hysterical-neurotic and reactive delusional pathological development of personality.

A decline in the relevance of religion in social life since the late 19th century and in the 20th century brought down the number of psychoses with a mystical content while the rest of religious plots were formed mostly in the framework of traditional religions. In the last three decades, there has been an increase in the number of psychotic states with religious delusion, including the development of absurd quasi-religious ideas propagated by various new cultic entities⁵.

V.E. Pashkovsky (2007, 2017) detected in the structure of psychotic states a high occurrence of not only traditional religious but also archaic views based on superstitions and magical idea. In this connection, he singled out a religious-archaic delusion complex (RADC) which includes the following variety of delusion: mystical, messianic, reformist, sinfulness, magic and possession. He pointed out that modification of the religious component during a delusional psychosis goes from a normal religious experience to its chaotic transformation expressed on the level of perception, intellect and behaviour - all including incompatible and manifold mystical or occult ideas. The delusional behaviour of patients with the RADC is characterized with a broad range of expressions beginning from a disordered drift towards non-uniform para-religious and occult assemblages in the initial period of delusional psychosis to rough and brutal forms. The height of the RADC psychotic manifestation falls on the young age from 20 to 25 and on the period from 36 to 40 years of age with a considerable prevalence of these psychoses among women (74,5%).

According to the data of some researches⁶, the inclusion of religious-archaic ideas in the structure of delusional experiences determines a more severe progress of paranoid schizophrenia, which is correspondent to the findings of some foreign researches⁷.

A special place in the work of Russian psychiatrists is given to the syndrome of possession⁸ characterized by a combination the delirium of possession with other forms of the delusional complex and physical hallucinations.

Among the problems, that are insufficiently developed, there is the issue of identification of factors conditioning the formation of delusional ideas with a religious content in the structure of psychotic disorders. P.M. Logutinenko (2014) singled out the experience of mental induction - an appeal to healers, paranormalists, sorcerers at the initial state of the illness. The researches of specifics of the religious delusion with endogenic attacks in the young age, confirm that relevant to its formation is one's previous religiosity, including the presence of a predominant religious outlook of "metaphysical intoxication" kind⁹. At the same time, among such patients, the duration of pre-manifestation stage - the period of "untreated psychosis" and hospitalization, proved to be longer. Noticeable is the tendency to a growing level of religiosity after an attack, which is especially characteristic of attacks with formation of a delusional plot through an interpretative mechanism (with a delusion of sinfulness and devil possession).

The works of Russian psychiatrists also reflect the phenomenon of "metaphysical (religious or philosophical) intoxication" implying domination characteristic exclusively of young people in a mental life affectively charged with one-sided intellectual activity, which sometimes comes to possess all one's thoughts and actions¹⁰. The basic components of this state are predominant disorders, a unilaterally intensified attraction to cognitive activity (spiritual attractions, according to Griesinger, Jaspers) and affective disorders. In their researches, L.B. Dubnitsky in 1977, M.Ya. Tsutsulkovsky, et al, in 1992, singled out the following four basic versions of this syndrome: 1) classical, characterized by the even expression of basic structural components, which is found mostly in the personality schizoid disorder; 2) affective version (with prevalent predominant formations of affective nature), found mostly in atypical pubertal attack; 3) autistic version (with domination of ideational disorder and schizoid disorder of personality; 4) a version with the predominant component of unilaterally intensified "spiritual attraction", found mostly at the initial state of paroxysmal schizophrenia.

A number of researchers¹¹, point to the phenomenon of a distorted religious life among the mentally ill with developing "a morbidly distorted interpretation of particular dogmata" with a lack of sensual depth in understanding the essence of religious actions, with a distortion of critical attitude to one's own personality and formation of a pathological religious behaviour inconsistent with the criteria of harmonious and healthy faith¹². At the same time, they point to the repression of aspirations for a full-fledged spiritual life by an exaggerated performance of religious rituals. This phenomenon is registered against the background of preserved psychopathological symptoms.

It should be pointed out that whereas in the foreign scientific literature of the last century, there was an active research into relationship between religion and psychiatry, and its impact on the human mental health was analysed, it was not characteristic of Russian psychiatry due to then predominant Marxist-Leninist philosophy. Actually, Prof. Dmitry Melekhov (1899-1979) was the only Russian psychiatrist who focused on this problem. He was the most prominent psychiatrist of the last century, known as one of the founders of social psychiatry who did much to work out the theoretical and practical foundations of rehabilitation of the mentally ill. His work "Psychiatry and Issues of Spiritual Life" (1970), in which he, following P.A. Butkovsky (1834), proceeded from the trichotomic understanding of human personality, has become a fundamental guideline in the area of religious psychopathology of human personality for today's generation of psychiatrists. He understood the spiritual sphere as an area of ultimate moral values. Accordingly, he conditionally separated the spheres of competence between somatologists, psychiatrists and priests. In the opinion of a number of modern researchers¹³ the trichotomy of body-soul-spirit introduced to the literature on psychiatry by D. Melekhov should be adopted and assimilated in scientific and practical psychiatry. They point out that religiosity and religious faith represent the most important components of the spiritual sphere, and the human personality should be considered in the unity of its physical and spiritual-mental organization¹⁴. At the same time, the question is posed about the need to add a bio-psycho-social strategy to a bio-psycho-spiritual psychiatry¹⁵. On the basis of the trichotomic understanding of human personality, D. Melekhov wrote in 1979 that it was necessary in some cases to give a patient a "spiritual diagnose", with the diagnose of "spiritual crisis of personality" being justified and servicing as an addition to the psychiatric diagnosis and that in some cases a spiritual recovery could lead to a psychiatric and physical recovery.

In many studies, the need is noted for a psychiatrist doctor to have an idea about religious views and peculiarities of patients' spiritual life¹⁶. Thus, P.I. Sidorov called to give more attention to patients' religious experiences¹⁷, while F.V. Kondratiev (2017) pointed out that the religious sphere is uniquely individual and expresses the personality essence. I shall \ quote the statement on this problem by the great Austrian psychiatrist Viktor Fankl, "The spiritual dimension cannot be ignored as precisely it makes us human beings".

D. Melekhov (1979) pointed to the twofold nature of religious experience among the mentally ill: on one hand, in case of pathology, it can be an immediate reflection of symptoms of an illness, while on the other, it can be a manifestation of a healthy personality and then, even if there is an illness, religious faith helps an ill person to resist the illness process, adjust to it and compensate the defects instilled by the illness in the personality of a patient. Therefore, D. Melekhov was one of the first at the modern stage of the development of Russian psychiatry to consider religious faith as the most important personal resource for conducting rehabilitation measures. He formulated this attitude on the basis of his clinical experience since he had no opportunity to make a scientific research in the last century 60s and 70s. However, his thesis has been reconfirmed in many clinical researches today.

In a special study into the role of religious coping strategies in rehabilitating the mentally ill, G. Kopeiko and others (2016), on the basis of comparison made between the value-meaning structure of the personality of patients with a religious and non-religious outlooks and their juxtaposition with corresponding groups of healthy people, various types of confessionally oriented coping strategies were established for people with schizophrenia. The researchers believed that the religious factor should be taken into account as a potential resource that can be used by a patient suffering from a decease and other existential stresses. This research also conformed the position taken by a number of foreign researches¹⁸, i.e., that religion (including spirituality and religiosity) is very important in the life of patients suffering from schizophrenia and the schyzo-affective disorder.

Today's Russian researchers¹⁹ also point to the relevance of religious strategies of coping among patients with anxiety and depression disorders and disaster relations at a late age. Besides they underscore the great risk of forming a pathological reaction resulting in a depressive disorder among those who do not use religious resources to overcome crisis situations²⁰. At the same time, the strategies of religious coping should not be used in isolation but as one of the means and ways of supporting the ill persons as part of complex approach to their rehabilitation²¹. A number of authors²² emphasize that the psychotherapeutic method in various models cannot include religiosity and basic religions, cannot be assimilated or used in both theory and practice. In the opinion of B.A. Voskresensky (2007), religious faith helps soften the decease and for this reason, it is important that religious components should be included in the psychotherapy of the mentally ill. It should be noted that V.M. Bekhterev (1994) did recognize the possibility for a religious impact of suggestion and self-suggestion against the background of religious exaltation states. Some psychiatrists single out Orthodox psychotherapy as a separate type of psychotherapy²³. Some researchers²⁴ recognize traditional Orthodox religious communities as "alternative support systems", a leading type of social support in which the emotional, problem-oriented support is fully accepted by the surrounding.

In many researches, religious faith is viewed as an anti-suicidal factor, as most of traditional religions strictly prohibit suicide²⁵. In this connection, the high psycho-preventive and psychotherapeutic potential of religious values can be used in programs for preventing suicidal behaviour. At the same time, it is pointed out that some religions, which are not widely spread in our country, as well as some sectarian trends, not just permit but even encourage suicides²⁶.

The Russian psychiatric literature highlights, that faith along with the psychotherapeutic, makes also the pathogenic impact on psyche²⁷. Thus, in A.A. Portnova's study made together with M.I. Shakhnovich, the leading Soviet specialists in "scientific atheism" (1967), asserts, "in the spirit of time", an extremely negative influence made by religion on mental health and attributes not only a pathoplastic but also pathogenic role to religious beliefs. Most researchers²⁸ point to the pathogenic influence made on psyche by some sects with destructive cults. A similar point of view was held by P.B. Gannushkin (1901). A description of the psychopathology of mental disorders arising in religious sects, in which religious "vigils" are accompanied with ecstatic states with attraction disorders, is given in his special article on "Voluptuousness, Cruelty and Religion". S.S. Korsakov (1901) noted, "Religion in itself has no influence on mental illnesses but religious fanaticism and superstitions cause mental illnesses. The belonging to some sects, in which religious cult is combined with a strong emotional excitement amounting to ecstasy, contribute to the development of mental illnesses". This statement was confirmed by today's foreign researches²⁹, in which it is shown that the further an individual religious experience diverts from traditional religious norms the higher the risk of developing a mental disorder. Several authors³⁰ point out to the high frequency of mental deviations among those who belong to certain non-traditional religious organizations using psycho-technologies that make a destructive impact on the mental health of their members. They consider these disorders to be a result of psychological manipulations they were subjected to in the cult and to correspond to the criteria of "dependent personality disorder" (F60.97 according to ICD-10). At the same time, as the researchers note, among those involved in the activity of sects, there are many people with already existing mental disorders, and participation in some of these organizations is a triggering factor contributing to their exacerbation.

In an analysis of the religiosity of a patient, it is important to ascertain the time of its emergence in relation to the manifestation of mental disorders³¹. P.M. Logutinenko posed a question of the need to collect the religious anamnesis with a separate identification of traditional religious experience and the experience of extreme mental induction (appeal to healers, sorcerers, psychics, etc.). At the same time, a religious faith in case of its emergence after mental symptoms can be both genuine and pathological with a religious vocabulary and one's own rituals and in some cases can lead to the initiation of new cults³².

Many researchers³³ point to the underdeveloped problem of distinguishing an individual non-pathological religious experience from mental illnesses with a religious content and to a lack of assessment criteria of religious-mystical states out of the framework of mental disorders. The complexity of the problem lies in that religiosity and psychopathological symptoms often intertwine and co-exist concurrently³⁴. At the same time, many point to the complexity of this differentiation, especially in case of a religious ecstasy state, which V.P. Osipov (1923) viewed as a pathological disorder while indicating that the borderlines between a pathological affect in the form of ecstasy and a similar physiological affect are difficult to define.

V.E. Pashkovsky and I.M. Zislin (2005), who regard the recognition of the fact of existence of special religious-mystical states different from psychosis as a most important achievement of the psychiatry in the last decades (in American literature these states are designated as "spiritual emergency"), affirmed that despite a similar plot of experiences, ecstatic mood, existence of a changed perception, these states are essentially different. Their differentiation is possible on the basis of the traditional clinical-psychopathological approach with a collected anamnesis (existence of a previous religious experience), examination of the mental state (existence of accompanying psychopathological disorder) and analysis of personal constitution peculiarities. At the same time, in a number of cases, similar religious-mystical states should be assessed as versions of religious experience, while in other cases as psychotic states. The right assessment of religious plots as delusional is enhanced if they do not correspond to the religious-cultural traditions to which a patient belongs³⁵. F.V. Kodratyev noted that a religious feeling can be "anthropogenic" (i.e., artificial by human design) and exalted up to the feeling of visual communication with divine or satanic images".

As an instrument for researching into the role of religiosity/spirituality in the development of mental disorders, mechanisms of coping, effectiveness of psychotherapeutic interventions and overcoming consequences of a mental trauma, a Russian version of the questionnaire MI-RSWB (the Multidimensional Inventory for Religious/Spiritual Well-Being (MI-RSWB) with its good psychometric properties is offered³⁶.

In today's Russian literature³⁷, there is a discussion on the so-called neuro-theology based on attempts to create neuro-biological models of religious faith, that is, to establish a correlation between processes in the nervous system and subjective spiritual experience and to construct hypotheses for explaining this phenomenon with the use of neurophysiological, neuro-visualizational and neuro-chemical approached for the analysis of neurobiological processes going on in the brain during various religious-mystical states. A hypothesis is offered about the existence of certain biologically active compounds that can work as triggers of religious experiences³⁸. According to Russian authors, these studies go beyond strictly scientific researches, are quasi-scientific, have a low heuristic potential and actually explain almost nothing.

Several Russian psychiatrists deal separately with the problem of the medical staff's attitude to patients' religious views. Thus, D. Melekhov (1979) pointed to the need for a respectful attitude of doctors to the religious sphere of patients and raised the problem of advanced training of psychiatrists in peculiarities of religious outlook and attitude. V.F. Kondratyev (2012) emphasized that a psychiatrist should not seek to correct the spiritual life of a patient since it cannot produce a result but only cause a negative reaction. It should be pointed out that today's foreign researches also pose the question of whether specialists of the mental health services need to have an elementary knowledge of religious doctrines and rituals and take into account the structure of religious communities³⁹. Many Russian authors underscore the importance of cooperation between psychiatrists and priests in treating mental patients with a religious outlook⁴⁰, while noting, as Yu.S. Savenko (2013) points out, that even their cooperation by default considerably enhances the effectivity of the therapy. A special mention is made about the productivity of cooperation in a number of cases involving an Orthodox psychotherapist⁴¹.

According to a number of psychiatrists, in many cases religion represents an important and primary resource addressed by patients and their relatives in encountering a serious chronic or lethal decease⁴². In this connection, a question is posed at present about the need for a special psycho-educational work to be carried out among the clergy concerning mental disorders' basic manifestations and patterns of progress⁴³. The first educational aid for pastoral psychiatry was written by D.E. Melekhov. Unlike the study by K. Schneider (1929) "Towards Introduction to Religious Psychopathology", it, along with a description of mental pathology, contains a perception of the decease and the attitude to it from Christian perspective. He formulated the conception of a special course on "Pastoral Psychiatry" for Orthodox educational institutions. It is noteworthy that by that time Prof Archimandrite Cyprian (Kern), in his special handbook on pastoral service, already had a separate chapter on this problem. In recent years, modern educational aids on psychiatry have been written, adapted for future clergy⁴⁴.

In analysing the role of religious-philosophical guidelines in the professional work of psychiatrists, a conclusion was made that their availability enhances the adaptive potential of professional work⁴⁵, while pointing out that the level of religiosity among psychiatrists is comparatively lower than that of the population as a whole⁴⁶.

A "religious renaissance" that has taken place in the last decades in Russia with a higher proportion of persons with a religious outlook among the mentally sick poses the question of the need for conducting special studies into differentiation between pathological and normal religiosity and for a possibility of using the religious resource of a person in psychotherapeutic work. There are still many underdeveloped aspects of endogenic mental illnesses with a religious plot in delusional disorders including conditions for their formation, peculiarities of psychopathology and formation of remissions with a predominant religious outlook, peculiarities of distorted religious life in patients with a mental pathology including a consideration for the age factor and gender distinctions. The results of many foreign studies on this problem cannot be fully taken in consideration in the work with similar patients due to the existence of respective religious-cultural differences. Especially urgent is the conduct of special psycho-educational programs for workers of religious organizations with regard to manifestations of mental pathology and for specialists of mental health services with regard to basic religious traditions and peculiarities of work with patients with a religious outlook. All this justifies the posing of a question of the need to separate in the general psychopathology of mental disorders a special section on religious psychopathology.

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³Корсаков С.С.,1901; Сербский В.П.,1912; Сикорский И.А., 1910 [Korsakov S. S., 1901; Serbsky V.P., 1912; Sikorsky I. A., 1910].

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⁴²Сидоров П.И., 2015; Борисова О.А., Казьмина О.Ю., Копейко Г.И., 2016; Каледа В.Г., 2008 [Sidorov P.I., 2015; Borisova O.A., Kazmina O.Yu., Kopeiko G.I., 2016; Kaleda V.G., 2008 ].

⁴³Мелехов Д.Е., 1979; Воскресенский Б.А., 2016; Каледа В.Г., 2012, 2017; Тупикин Р.В., Осипова Н.Н., 2019 [Melekhov D.E., 1979; Voskresensky B.A., 2016; Kaleda V.G., 2012, 2017; Tupikin R.V., Osipova N.N., 2019].

⁴⁴Воскресенский Б.А.,2016; Каледа В.Г., 2018 [Voskresensky B.A., 2016; Kaleda V.G., 2018].

⁴⁵Башмакова О.В., Семенихин Д.Г., 2017 [Bashmakova O.V., Semenikhin D.G., 2017].

⁴⁶Shafranske E.P., 2000.

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