Professor Gerrit Glas
University Medical Centre, Utrecht, Netherlands
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Professor Gerrit Glas explained that he is a consultant
psychiatrist and Professor of Philosophy at the University Medical
Centre, Utrecht. He is involved in many groups at the interfaces of
philosophy, theology and mental health. The paper was a
concentrated sumMary of a lot of knowledge profitably given to
detailed exposition. This would require knowledge of the
references, which are therefore provided in full. (The text was
read; the full text of the talk is available from christopher@findlay.u-net.com).
Gerrit began with a comment on the apparent strangeness of
psychiatry's renewed interest in religion precisely at a time when
it had reached a measure of scientific status. After presenting a
brief history of the socio-cultural and philosophical developments
of which psychiatry is a part, he highlighted possible areas of
concern for religion and psychiatry and showed how this related to
the present concerns of patients with reference to a typology of
anxiety. His conclusions for the future of psychiatry were
challenging.
How did psychiatry and religion become separated?
For ages it was self evident that persons with mental disorder
not only needed physical treatment but also raised religious
concerns. Although spirituality and healing were closely related in
the original personage of the priest, psychiatry and religion
diverged deeply from the early nineteenth century onwards. It was
part of a wider cultural development described by sociologists like
Max Weber as 'modernisation'. This was characterised by increasing
specialisation, the separation of means and goals, the separation
of facts and values and the subjective from the objective. This
leads to the popularisation of a so-called scientific world-view.
Psychiatry developed its own language of description and
classification and, later, a model of disease similar to the
somatic disease model. Modernisation was dependent on scientific
and technical advances, which led to a division in the different
parts of the production process and to an 'engineering model' of
medical practice.
With specialisation came professionalisation and secularisation.
Instrumental actions were seen as value-neutral; only goals were
value-laden. Medical activities became disconnected from more
global notions of their purpose and meaning. Medical practice was
reduced to the mere application of scientific insights and
findings. The hard core of medicine, in this view, consists of
objective facts, and the effective, efficient and morally neutral
use of technical procedures. These facts are produced by the
application of experimental methods and are therefore regarded as
abstract and value-free by nature. The experience of illness, on
the other hand, and the values that are involved in medical
practice, should all be relegated to the realm of subjective
experience and personal meaning construction. Religion was also
relegated to the sphere of subjectivity, so that religion and
psychiatry were separated. Psychiatry was associated with the
objective, morally neutral application of scientific knowledge and
religion was transferred to the realm of mere subjective
appreciation and strictly personal choice.
So why the renewed interest of psychiatrists in religion?
- This could be seen as an extension of the process of
specialisation and professionalisation. Religion may be seen as a
special interest, like cross-cultural or women's issues.
- A response to the influx of people from the third world and
Balkan countries, which hold more strongly to their religious
convictions than those brought up in the West.
- Could there be an underlying tension or uneasiness about what
could be considered as 'the heart of our profession'? Psychiatrists
may themselves believe that their current practice is too limited.
It could be more than the application of cognitive instruments.
Perhaps psychiatry's aim is not primarily cognitive, but social,
moral and even existential.
Societal urges and constraints are continually at the table of
psychiatry and cannot be avoided. The rise of anti-psychiatry,
patient movements in the seventies and eighties, alternative
healing practices and dropouts from conventional treatment may mean
that psychiatrists' exclusion of the moral is not working. In
everyday practice, psychiatric and existential aspects are almost
always interwoven. Existential aspects affect the way symptoms are
experienced and expressed. A too narrow conception of
psychopathology excludes this existential layer. Conceptual
elimination of existential and/or spiritual aspects, may ultimately
lead psychiatrists to lose their patients because the patients do
not feel understood. Reducing suffering to disease is not an
adequate response for patients.
Some areas of concern
1. Education - ourselves learning and teaching
our trainees to address the existential and spiritual needs of our
patients, including:
Knowledge:
- basic knowledge of major belief systems
- knowledge about the developmental, experiential, and mental
health consequences of religious experiences
Skills
- improvement of interviewing skills
- improvement of diagnostic skills with respect to people having
all kinds of religious backgrounds
- therapeutic skills
Attitudes
- systematic reflection on the professional's own belief system
(atheism included) and the influence of it on his or her
functioning
- analysis of transference and counter-transference issues
- empathy
(There already has been a lot of work on courses in psychiatry
and religion in the United States, particularly by David Larson and
Francis Lu. The National Institute of Healthcare Research awarded
14 residency programs with the John Templeton Foundation
Spirituality and Medicine award in 1998 and 1999.)
2. Epidemiology
-
- In which way and to what extent is the incidence and course of
psychiatric disorder in the population influenced by one's
religious background?
- Are there modifying variables (salience; stability of religious
convictions)?
Research in the Netherlands illustrates this. Braam conducted a
large epidemiological study in which elderly people were
investigated with respect to the incidence and course of
depression. The course of depression is positively affected by
salience of religious belief in a number of associated conditions -
chronic disease, pain and functional impairment. Neeleman conducted
a large cross-sectional epidemiological study and found that
religious affiliation offered a relative protection to the
occurrence of psychiatric morbidity. Interestingly, there also
seems to be an effect of age. Religiously affiliated men and women
both showed less morbidity. However, the effect seems strongest in
men, whereas the effect in the women group disappeared with age. It
is difficult to explain this finding. One could think, here, of
course of factors associated with growing older. Neeleman has
suggested that the protective value of religious affiliation
diminishes with the increase in age at conversion. The later people
are converted, the more unstable they are, which would contribute
to a diminishing effect of religious affiliation.
3. Psychopathology
- instances of religious psychopathology (e.g., dissociative
states)
- issues in the differential diagnosis between religion and
psychiatric disorder; (the grey zones between saintliness,
asceticism and anorexia nervosa; or between delusion and religious
conviction; or between religious belief and magical thinking in
obsessive-compulsive disorder; or between religiously inspired
habits and behaviours, and personality disorder)
- the multi-layered nature of psychopathology: underneath or
behind the layer of symptoms and complaints there are often
relational problems and/or psychodynamic conflicts; these, in their
turn, not infrequently have spiritual roots, or, at least, have a
spiritual dimension
- how does religion protect against or dispose to psychiatric
disorder? Pargament's extensive research on religion and coping
should be mentioned here. The concept of salience.
4. Clinical and treatment issues
- How does religion affect the way the patient interprets his
problems and apprehends what is said in the consulting room?
- But, the other way around too; how does psychopathology affect
the way the patient apprehends his religion?
- In what way can religion be 'used' in psychotherapy and
psychosocial treatment?
5. Special issues
- psychodynamics of religious groups (cults, sects; Marc
Gallanter)
- the psychology of the charismatic leadership
- faith healing rituals
- religion and trauma
- religion and substance abuse
What the patient needs - recognition of the interwoven-ness of
symptoms and existential issues
Gerrit suggested that psychiatry currently excludes too much
that is central in everyday practice. In illustration of this he
presented some of his own work on anxiety (Glas 1991, 1996, 2001).
Central to this are three closely connected ideas:
- that religious or existential issues are central in the lives
of at least some of our patients - in any case many more than
clinicians are inclined to think;
- that the way in which these religious issues and their dynamics
are expressed is intricately interwoven with the process of symptom
formation;
- that the religious dimension is not some ephemeral intuition
but a structural dimension of human existence, which may affect all
layers of human functioning, also in psychopathology.
In other words: underneath or behind the layer of symptoms there
are not only relational and psychodynamic conflicts - a fact which
is commonly acknowledged - but also manifestations of a disturbance
in a still deeper dimension of ultimate concern, which is central
to the person and his or her life project.
The psychopathology of anxiety offers an excellent illustration
of what is meant here. Careful listening to the patient reveals
that apart from the objective and subjective symptoms of anxiety
there is another dimension of anxiety, highlighting the fact that
anxiety may also be seen as an embodiment or immediate expression
of the way the person relates to him/herself. This dimension of
anxiety is not primarily a fear of a particular situation, future
abandonment, for instance. It refers to a basic level of
relatedness to oneself and to the world, i.e., a state of
fundamental disconnectedness, of which the other anxiety symptoms
are an expression. Anxiety, then, is not (only) based on the
anticipation of a future state of being rejected. It is not
primarily a warning signal. At the level we are speaking of here,
anxiety is the immediate expression of a pervasive sense of
unconnectedness that affects all relations, the I-self relationship
included.
The table provides an overview of the basic anxieties classified
according to an underlying theme and its reference to a particular
structural dimension. These are:
Anxiety related to loss of structure (chaos)
referring to the incapacity to maintain a relationship to oneself
and/or the world. Things that once looked familiar now change into
strange, unfamiliar, and threatening objects.
Anxiety related to existence as such,
representing a horror of the brute fact of one's existence, or a
disgust of the world. (Sometimes this horror, or disgust, is
directed to one's body, for instance, in cases of anorexia
nervosa.) The theme of these anxieties is the facticity of life
(its matter-of-factness). Life does not offer any promise.
Everything seems to be neutral. One's inner experience feels
frozen.
Anxieties related to the theme of lack of
safety. The person experiences the world as insecure and
inhospitable. One may think, here, of the intense terror and
desperation after physical or technological disaster.
Anxiety that centres around the theme of unconnectedness
or isolation is perhaps the pre-eminent fundamental
anxiety. What prevails is a tormenting feeling of distance, the
awareness of an unbridgeable gap, whether others are present or
not.
Anxiety related to the theme of doubt and incapacity to
make choices. This anxiety becomes apparent when a person
is not able to cope with the irrevocability of decisions that must
be made. The person tries to avoid to make choices. Accordingly,
this anxiety represents an inability to commit oneself when this is
required.
Anxiety related to meaninglessness (or
absurdity) is well known from existentialist and
post-modern prose. It derives from the lack of (a) a feeling of
mastery of one's existence; and (b) the experience of
meaningfulness (dedication, vitality). Both sides are closely
connected. This anxiety refers to what Kierkegaard calls the
possibility of being forgotten or lost in the universe (Kierkegaard
1837, Vol. I, 100; cited via Kierkegaard 1844/1980, 171).
Death anxiety. The concept of death anxiety
again does not primarily refer to the fact of one's (own) death or
to the process of dying. On the contrary, it refers to anxiety as
an expression of the openness toward one's finitude and mortality.
It consists of honestly and authentically facing the possibility of
one's own death. Anxiety, conceived in this way, is closely
connected with life itself.
|
Typology of Basic
Anxieties, Their Themes and Underlying Structure
|
| Type |
Theme |
Structure |
| Anxiety related to loss of structure |
Chaos |
I - self relationship |
| Anxiety related to existence as such |
Facticity |
Capacity to shape one's existence |
| Anxiety related to lack of safety |
Vulnerability |
Physical protection |
| Anxiety related to unconnectedness |
Isolation |
Affective connectedness |
| Anxiety related to doubt & incapacity to choose |
Irrevocability |
Historicity; capacity to will |
| Anxiety related to meaninglessness |
Absurdity |
Mastery; capacity to entrust |
| Anxiety related to death |
Non-existence |
Openness; capacity to transcend |
Conclusions
- The subject of psychiatry and religion is not merely an area of
special interest, it also demands for a re-thinking of the
foundations and boundaries of the psychiatric profession.
- Further development of the field is demanded, especially in the
area of education and improvement of clinical skills; however,
there is also an urgent need for further research, empirical as
well as conceptual.
- Patients need psychiatrists who recognize that psychopathology
in its strict sense is interwoven with spiritual and religious
issues.
- This asks for a new and richer nosology, in which justice is
done to structural conditions of which spiritual and religious
functioning is one of the expressions.
References
Bhugra, D, (Ed.) (1996) Psychiatry and religion. Context,
consensus and controversies. London: Routledge
Boehnlein, J.K. (Ed.) (2000) Psychiatry and religion. The
convergence of mind and spirit. Washington: American Psychiatric
Press
Fulford, K.W.M. (1996) Psychiatry and Religion - extending the
limits of tolerance. In: Bhugra D. (Ed.), Psychiatry and religion.
Context, consensus and controversies. London: Routledge 5-22
Galanter, M. (1999) Cults, faith, healing, and coercion. Oxford:
Oxford University Press, (second edition).
Glas,G. (1991) Concepten van angst en angststoornissen. Een
psychiatrische en vakfilosofische studie. Amsterdam/Lisse: Swets
& Zeitlinger
Glas,G. (2001) Angst - beleving, structuur, macht. Boom:
Meppel/Amsterdam, W. James,W. (1902) The Varieties of Religious
Experience. NY: Longmans, Green & Co. [repr. Penguin Books,
1982]
Koenig,H.G. (Ed.) (1998) Handbook of religion and mental health.
San Diego: Academic Press
Scott Richards,P.& Bergin,A.E. (1997) A spiritual strategy
for counselling and psychotherapy. Washington: American
Psychological Association
Shafranske, E. (Ed.) (1996) Religion and the clinical practice
of psychology. Washington: American Psychological Association
Verhagen,P.J & Glas,G. (Eds.) (1996), Psyche and Faith.
Beyond Professionalism. Zoetermeer: Boekencentrum