Praying man

In the twilight of his life, as storm clouds gathered over Europe, Sigmund Freud began the most ambitious and controversial analysis of his career. With Civilisation and its Discontents, Freud put all humankind on the couch, and the neurosis he sought to expel was religion. Psychiatry’s relationship with God has been fractious ever since.

While most of Freud’s ideas collect dust in the mindscape of psychiatry, retrieved only to be ogled as historical oddities, his censure of religion as “mass delusion” and “wish-fulfillment” endures. The spectre of the old master silently slides through our assumptions – invisible, unchallenged – whispering stern counsel from the past.

Freud believed that religion derived from the oceanic sense – a feeling of oneness and eternity that reflected a return to infancy, a time when the ego blended seamlessly with the external world [1]. Love was a similar fusion between two egos.

Freud’s seemingly revolutionary ideas were largely rehashed theology from St Augustine fifteen centuries earlier, but smartly dressed in pseudoscientific jargon. Augustine also saw the religious experience as a glimpse of an earlier state of fusion: for him it was the unfallen state of unity with God, to which we all yearn to return: “our hearts are restless, Lord, until we rest in Thee”.

Augustine’s oceanic sense is not the ego’s regression to infantilism, but a momentary awareness of its intended splendour. Other traditions have similar ideas, such as the Buddhist concept of Nirvana in which the self becomes “one with everything”.

Examples of Freud’s influence abound. I recall a patient admitted to a major hospital where the triage team diagnosed a manic episode and cited “religious themes” as key symptoms. The next day I discovered that the man was indeed elevated, but his only “religious themes” were requests to see a chaplain. For days, the nursing handover intoned that he was “still expressing religious themes”. When he finally saw the chaplain, handover cheerily reported that he was “no longer expressing religious themes.” Of note here is that nowhere in the DSM are religious themes a symptom. In fact, the DSM explicitly excludes religious beliefs from its definition of delusions. Yet the staff airily assumed that even “themes” were a sign of his illness.

Religion alone seems to fall in this blind spot: any handover referencing the Oedipus complex, death drive or anal fixation would meet bemused silence, at best. Meanwhile clinicians happily use the term “religiosity” (meaning overt religious talk or behaviour) and always as a sign of mental disturbance. Again not in the DSM. Psychiatrists routinely ask about religious ideas when they suspect an episode of mania, but I have never known one to ask about waning faith when they suspect depression. The assumption is unstated but ascendant: religion points to pathology.

Why does Freud linger here alone? Religious people, when unwell, most certainly express religious themes. Repeatedly hearing them may bolster a mindset that would otherwise have faded, especially since society shuns overt religious talk as taboo. Any example from the ward neatly slots into Freud’s conception, and certainly none of his other ideas leap so readily from what patient says.

One memorable example was an old Greek man who set his sheets on fire while trying to light a cigarette. As smoke billowed from his room, he reclined amid the flames and declared to the frantic nurses that the fire was “glorious” and that “God would fix it”. Anyone on shift that day had “God” and “psychosis” indelibly welded in memory. The man was undoubtedly in the throes of psychosis, but for reasons that had nothing to do with being religious. When discharged a few weeks later, he no longer saw himself as impervious to fire, but he was just as religious as he was.

Another case was a man found walking barefoot on the Princes Highway, declaring to police that he was on the way to Mecca. He was still every inch the devout Muslim when his illness resolved, although hoping to complete his pilgrimage by more conventional means.

With careers awash with cases such as these, it is little wonder that psychiatrists are the least religious of all medical specialists, so too it seems with psych nurses. Yet the mindset introduces an invisible barrier between clinicians and their patients, who – on average – are far more religious. Just like the doctor’s joke that an alcoholic is someone that drinks more than you do, faith’s rarity among clinicians might skew their perception of what constitutes normal. Even regular piety can seem unusual, and any deviation from normal on a psych ward is a magnet for diagnostic labels.

Rarely is this phenomenon discussed, yet it is more than a quirk of the stats and not just for patients. A study this year showed that “religion / spirituality” protected nurses from emotional exhaustion and professional burnout [2]. Here lies one element behind the elevated rates of attrition found among psych clinicians.

While suspicion of religion may come naturally to the field, the mindset neglects something vital: symptoms appear through the prism of personality. A religious person with mania has their elevated thoughts tinged with religion, as well as losing the filter that usually keeps them private. A religious person with psychosis will latch on to familiar images to make sense of their experience, and a religious view is especially fitting for the disorientating lurch into a world hypercharged with meaning.

Even a non-religious person may crystallise religious imagery from their inner turmoil and suddenly start speaking of God and demons when they have never before. Religion is a natural mental template for experiences that are totally alien and other worldly. The patient rarely decides this himself; the process is automatic and unconscious. Others may produce entirely secular mental patterns, such as surveillance by government agencies or interference by aliens. Like when dreaming, the mind streamlines a chaotic stream of inputs into what it can, using whatever concepts it finds to hand.

A negative view of religion can be subtle, as I heard from colleague’s experience of psychotherapy. Any mention of his Catholic faith seemed to send a current through the chair of his therapist, who at one point surged into rare volubility to declare, “I’m trying to work out why you revere Mary so much.” He went on to hypothesise a variety of psychodynamic mechanisms while his patient just wanted to shout, “There’s no mystery, I’m Catholic!”

Distinguishing faith and pathology can be made more difficult that it should be, but even the most subtle cases can be clarified with the right help. Another colleague related the case of an old priest who was speaking voluminously about arcane matters of theology during a clinical interview. The psychiatrist had no idea whether this was psychosis or just his normal self. He called up the cathedral across the road and the archbishop said he would pop over. After five minutes with the priest the archbishop emerged to conclude, “Poor fellow has lost his mind.” The archbishop knew exactly where the man’s religion stopped and his illness began.

A week of treatment removed the psychosis while leaving his theology intact. Such examples show that religious themes often do appear with mental illness, but they are the usually the way the mind expresses its disturbance rather than the disturbance itself.

Psychiatrists are slowing casting off their inherited bias against religion. The influx of patients from diverse backgrounds has forced reassessment of ideas that fall outside the strictly rational mould. The first stage was seeing that some cultural beliefs seem bizarre to the Western mind but were nevertheless perfectly normal. That distinction in now enshrined in the DSM, but the more elusive stage is recognising religion as a fundamental aspect of what makes a person who they are. Just as mental illness is expressed through a person’s worldview, so too is mental health. Helping patients to recover or achieve their best relies on recognising that religion may be a crucial element of that “best”.

A pioneer in the area is A/Prof. David Rosmarin of Harvard Medical School who has developed a “Spirituality and Mental Health Program” at McLean Hospital in the United States. The program has adapted cognitive-behavioural therapy to focus on spirituality, and over 5000 patients have been treated with around 90% experiencing benefit. Rosmarin cites research that correlates religious belief with the thickness of the cerebral cortex, and his own studies have demonstrated that a belief in God leads to improved outcomes for acute psychiatric patients.

His work is an anomaly in a field governed by a rigidly secular approach. The American Psychological Association has a voluminous array of patient resources, none of which mentions spirituality. Rosmarin notes that of the 90,000 active projects funded by the National Institutes of Health, only one has spirituality in its title. Yet his results show that patients across all ages and demographics benefit from a spiritual approach, and especially those without religious affiliation – who surprisingly make up the largest group attending. Such people may be more drawn to a spiritual approach because it is otherwise lacking in their life.

Another intriguing finding was patients responding better to “religiously unaffiliated clinicians”, which is good news for a field with so many. Perhaps what is needed most of all is an open mind.

  1. Civilisation and its Discontents p. 13-14.
  2. Harris, S., Tao, H. The Impact of US Nurses’ Personal Religious and Spiritual Beliefs on Their Mental Well-Being and Burnout: A Path Analysis. J Relig Health (2021).