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The psychotic person does not usually have insight into the incredible nature of his or her claims, and may even embellish them, whereas the non-psychotic person usually admits the extraordinary or unbelievable nature of his or her claims. Furthermore, the psychotic person will have difficult establishing "intersubjective reality" with other persons in their psychosocial or religious environment, particularly since they will have other symptoms of psychotic illness that impair with their ability to relate to others.

However, psychotic and mystical states may have some much overlap that it is difficult to distinguish one from the other without long-term follow-up and careful observation over time. Psychiatrist Andrew Sims from Great Britain has provided a set of criteria that may be used in distinguishing persons with religious or spiritual beliefs from those with religious delusions. These criteria include aspects common to the diagnostic distinctions already described above.

Sims notes that for religious delusions: These criteria have already been used in studies by Siddle and colleagues, which have provided evidence for their validity Siddle et al. There is general agreement, then, that specific criteria exist that can help to distinguish the mentally ill person with psychosis from the devoutly religious person having mystical experiences. The religious person has insight into the extraordinary nature of their claims, is usually part of a group of people who share their beliefs and experiences culturally appropriate , does not have other symptoms of mental illness that affect their thought processes, is able to maintain a job and stay out of legal problems, does not harm himself or herself, and usually has a positive outcome over time.

Of course, however, there is always the possibility that a mentally ill person even those with psychotic illness will have religious beliefs and mystical experiences that are culturally normative and may in fact help that person cope better with their mental illness. A number of studies suggest that religious beliefs are used to cope with the extreme stress that mental illness can cause. In fact, the majority of patients spent nearly half of the time trying to cope with their illness in religious activities.

Patients with chronic schizophrenia or schizoaffective disorder were more likely than patients with affective disorders to utilize religious coping. In another study, this one conducted over the Internet, investigators examined alternative health practices of persons with schizophrenia, bipolar disorder, or major depression Russinova et al. Studies in Europe and other more secularized part of the world, report conflicting findings concerning the prevalence of religious coping, depending on the particular study cited.

Likewise, a study of 79 psychiatric patients in New South Wales near Australia found dependence on spiritual beliefs widespread. In the above study, religious coping appeared to impact outcomes in a positive way, since it was associated with greater insight and compliance. Numerous other studies also report a positive influence of non-delusional religious involvement on the course of severe mental illness.

Over 50 years ago, Schofield and colleagues reported that regular church attendance was one of 13 factors associated with a good prognosis in patients with schizophrenia Schofield et al. Those from urban areas were less likely to be re-hospitalized if their families encouraged religious worship during hospitalization. In the overall sample, lack of religious affiliation was associated with a greater risk of re-admission, particularly when compared to Catholic patients. In the largest study to date, outpatients with schizophrenia were followed for two years, examining factors related to hospitalization for worsening psychosis Verghese et al.

Patients who reported a decrease in religious activities at baseline experienced a more rapid deterioration over time.

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This study was conducted in India among a largely Hindu patient population. In a study that took place in secular European country of Sweden, investigators studied 88 patients with adolescent-onset psychotic disorders, most of whom had schizophrenia. Religious involvement was among the factors that predicted fewer suicide attempts along with good family relationships and better health. In fact, when investigators controlled for anxiety and depression, the only variable that predicted fewer suicide attempts was satisfaction with religious belief.

Finally, in a study that examined response to treatment during 4 weeks of hospitalization in patients with schizophrenia, neither level of religious activity nor the presence of religious delusions adversely affected response to treatment compared to other patients Siddle et al. In that study, patients with religious delusions had more severe illness and greater functional disability than other patients.

Clearly, more studies are needed that carefully measure both delusional and non-delusional religious activity at baseline and carefully follow changes in religious involvement and interest during hospitalization, after discharge, and after anti-psychotic drug treatment. Since many patients with severe mental disorder use religion to cope with their illness, it may be that religious or spiritual interventions could prove helpful.

Fallot describes how the spiritual needs of patients with severe mental disorder can be addressed as part of their treatment. Recommended interventions include taking a spiritual history, addressing spiritual needs in individual psychotherapy once the illness is stabilized, connecting the patient to faith communities and spiritual resources, and conducting spiritually oriented group therapy in outpatient and inpatient settings.

There is concern, though, that such interventions may interfere with or complicate the recovery of persons with severe mental disorder, especially if religious delusions or hallucinations are present. Although the research is clearly at an early stage, studies to date do not find that such approaches worsen or exacerbate psychotic illness, especially when applied in a thoughtful, sensitive manner.

I will now review some of these studies, with a focus on spiritually based group therapy that has the potential to provide support, reduce isolation, and address common spiritual concerns of patients with severe mental disorder. Phillips and colleagues describe a 7-week semi-structured psycho-educational program provided in a group therapy format designed specifically for person with severe mental disorder.

In a typical session, participants discuss religious resources, spiritual struggles, forgiveness, and hope. Kehoe describes another program based on her experiences over nearly two decades doing spiritual-based group therapy with psychiatric patients. Taking a psychodynamic-oriented approach, she reports spiritual-based group therapy fosters tolerance, self-awareness, and exploration of value systems.

According to Phillips and Kehoe, members of these groups experience increased understanding of feelings, comfort derived from having spiritual concerns addressed, and increased social connections to others. These groups are typically held in psychiatric outpatient settings and day treatment centers and include from 6 to 12 members. Spiritual interventions that take a more individualized approach have also been described. The results indicated that, compared to a control patients, those receiving the spiritual intervention became more able to express their concerns verbally, ventilate anger and frustration, and deal with inner feelings and emotions.


These patients were also more motivated to make changes in their lives, demonstrated more appropriate affect, and complained less about somatic symptoms. Outcomes were largely qualitative.

Researchers administered this intervention in an open trial format to 28 patients. After the treatment, participants showed an increase in perceived spiritual support, but it had no effect on depression, hopelessness, self-esteem, or purpose in life. In none of the above studies did researchers observe any worsening of symptoms with spiritual approaches. Research in countries outside the U.

In one study conducted in Southern India, investigators describe the effects of spending time in a Hindu temple the spiritual intervention Raguram et al, Built over the grave of a revered Hindu teacher, the temple had become known locally as a healing shrine for people with mental illness. Researchers at the National Institute of Mental Health and Neurosciences in Bangalore studied 31 consecutive subjects coming to the temple for help. Subjects lived in the temple for an average of 6 weeks 1 to 24 weeks.

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The BPRS was administered on entry into the temple and on leaving it. Before and after scores showed a drop in BPRS scores from They hypothesized that improvements with spiritual approaches could explain the better outcomes for schizophrenia seen in traditional societies. Spiritual approaches, however, do not always benefit those with severe mental disorder. At least one study has reported an association between spiritual healing practices and schizophrenic relapses. Subjects were matched for age, gender and duration of illness.

Relapses over an month period were retrospectively examined. In this study, spiritual healing was defined as "excessive use of prayers; reading verses of the Koran or the Bible as a form of counseling based on religious relevance for at least an hour a day ; excessive attendance at Mosques or Churches for solitary or group meditations more than 5 times a week ; attending sessions that included the use of witchcraft or related methods ever and attending rituals including exorcism and Zar processions ever.

Thus, it appears that not all spiritual healing practices are equal in terms of benefits. No spiritual interventions, either individual or group format, have yet to be objectively and rigorously tested for efficacy and safety in randomized clinical trials. Persons with severe and persistent mental illness often present for treatment with religious delusions.

Non-psychotic religious belief and activity is also quite common among persons with severe mental illness, and these are often used to cope with the severe psychosocial stress caused by such illness. This is particularly important since non-psychotic religious involvement may have a positive impact on the course of illness and frequency of psychotic exacerbations, and so deserves support and encouragement by clinicians.

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Religious delusions, on the other hand, may portent a worse prognosis and so should be vigorously treated. Unfortunately, there is much about the relationship between religion and psychotic illness that remains unknown, suggesting the need for more research. What is already known, however, justifies at least some tentative steps forward.

Taking a careful spiritual history, supporting non-psychotic religious involvement, and considering spiritual group interventions for patients who are so inclined seem like reasonable next steps. American Journal of Psychiatry Journal of Psychological Studies 13;; Journal of the National Medical Association Journal of General Internal Medicine Rev Bras Psiquatr 21 3: Australasian Psychiatry 10 1: International Review of Psychiatry 13 2: Future of an illusion.

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Hogarth Press, London, p. Psychiatry Research 1: American Journal of Sociology Multicentre collaborative study of factors associated with the course and outcome of schizophrenia. Nordic Journal of Psychiatry Psychiatric Services 50 8: Eur Arch Psychiatry Clin Neurosci Psychosocial Rehabilitation Journal 18 3: Schizophrophrenia Research 30, 27 Journal of Transpersonal Psychology 17 2: Perceptual and Motor Skills 60 3: Rev Bras Psiquiatr 22 2: Acta Psychiatrica Scandinavia International Journal of Social Psychiatry Smith College Studies in Social Work 67 2: British Journal of Clinical Psychology Community Mental Health Journal 38 6: Journal of Psychiatric Practice 7 3: Psychiatry Research 3: International Journal of Psychophysiology British Medical Journal American Journal of Public Health 92 Social Science and Medicine 62 6: Journal of Consultation Psychology New England Journal of Medicine Psychosocial Rehabilitation Journal 16 3: Tokyo versus Vienna versus Tubingen Germany.

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