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“THE SICK SOUL” AND BEYOND – Religious interpretations of mental distress Samuel Pfeifer Clinic Sonnenhalde, Riehen Switzerland Psychiatric Clinic Sonnenhalde, Basel Founded in 1900 by a protestant order (Diakonissenhaus Riehen) Open doors – no restraint

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“THE SICK SOUL” AND BEYOND – Religious interpretations of mental distress Samuel PfeiferClinic Sonnenhalde, RiehenSwitzerland

psychiatric clinic sonnenhalde basel
Psychiatric Clinic Sonnenhalde, Basel

Founded in 1900 by a protestant order (Diakonissenhaus Riehen)

Open doors – no restraint

Professional clinical psychiatry combined with Christian values

Teaching hospital of the University of Basel

the sick soul william james
„The sick soul“ (William James)
  • Those persons who cannot so swiftly throw off the burden of the consciousness of evil, but are congenitally fated to suffer from its presence.
  • …for whom evil is no mere relation of the subject to particular outer things but something more radical and general, a wrongness or vice in his essential nature, which no alteration of the environment, or any superficial rearrangement of the inner self, can cure, and which requires a supernatural remedy.”
three conditions
Three conditions
  • Melancholy – depression
  • Obsessive-scrupulous doubt
  • Panic fear
  • No reference to psychotic disorders and delusional states
  • No reference to dissociative states
descriptive approach
Descriptive approach
  • “Please observe that I am not pretending to judge any of these attitudes. I am only describing their variety.”

William James, p. 144



A) Definitions

B) Causal attributions

C) Psychodynamics and Spiritual Interpretations

D) Clinical Implications



An attitude directed towards the intangibly transcendental (God). For the spiritual person this is the source and the goal of his or her life, fundamentally influencing his or her way of living, responsibility and ethics.

(modified after Scharfetter 1999)

  • incidents and experiences are interpreted in a religious context
  • The interpretation relates to causality and change (therapy) of problems.
  • Subjective experience is perceived in a comprehensive spiritual context
causal attribution
Causal attribution

Tolstoy, Confessions

  • “The questions of ‘Why’ and ‘What for?’ beset him more frequently – These questions of ‘Why’ and ‘Wherefore’ and ‘What for’ found no response.”
  • William James


causal attribution11
Causal attribution

Locus of Control

  • Internal (spiritual life, personal effort)
  • External (affliction, oppression, curse)



  • Stable (personal discipline, effective protection)
  • Variable (actual condition, reliability of others)

Effects (Weiner)

  • Coping or
  • Hopelessness
  • Cooperation and Empathy or
  • Blame and Rejection

STUDY: Causal Attributions in Schizophrenia (Angermeyer & Klusmann, 1988)

Five areas:

  • Psychosocial burden
  • family
  • Personal problems
  • Biological factors
  • „Esoteric“ factors

Eur Arch Psychiatr Neurol Sci 238:47-54 (1988)



  • Broken home
  • lack of parental love
  • father was too strict
  • parents had too high expectations
  • overprotective mother
  • hostile-rejective attitude of parents

Personal Problems

  • evading daily problems
  • lack of will power
  • alcohol and drugs
  • too intelligent
  • too ambitious
  • general failure

Eur Arch Psychiatr Neurol Sci 238:47-54 (1988)


«Esoteric Problems»

Angermeyer & Klusmann (1988)

Eur Arch Psychiatr Neurol Sci 238:47-54

  • Lack of vitamins
  • Environmental pollution
  • Possession by evil spirits
  • Detrimental radiation
  • Divine punishment
  • Unfavorable Horoscope
  • Open Question 1,0 %
  • Possible Cause 54,9 %
  • (Very) Probable Cause 22,3 %
  • Evil spirits:
  • Possible Cause 10,9 %
  • (Very) Probable Cause 3,1 %

“Occult Bondage”

Pfeifer S. (1994)

Belief in demons and exorcism. An empirical study of 343 psychiatric patients in Switzerland. British Journal of Medical Psychology 67:247–258

  • 343 Patients (114 m, 229 f)
  • all were religious
  • mainline church (cath, ref.) 139
  • Trad. free churches (TFC) 164
  • Char. free churches (CFC) 40
  • Schizophrenia 60
  • Depression 87
  • Anxiety Disorders 56
  • Personality Disorder 65
  • Adjustment Disorder 75

“Occult Bondage”

Pfeifer S. (1994)

Belief in demons and exorcism. An empirical study of 343 psychiatric patients in Switzerland. British Journal of Medical Psychology 67:247–258

  • Occult Bondage 37,6 %as possible cause
  • Ritual of deliverance 30,3 %performed
  • Significant correlation with
  • Diagnosis (p < 0.01)
  • Religious affiliation (p < 0.005)

Mosaic of Causal Attributions


Conflicts fromIndividualExperience

Cultural Traditions

Alternative Body Theoriesand Diets


Pfister, S. & Thiel, S. (1999). Religiosität und subjektive Krankheitstheorie. Eine empirische Untersuchung bei 53 psychiatrischen PatienInnen. Dissertation Medizinische Fakultät der Universität Bern.

Spiritual and Magical Beliefs



The Bio-Psycho-Social Modeland Spiritualization


Forms of Spiritualization

  • Spiritual forms of intrapsychic communication: „I talk to God; God talks to me.“
  • Spiritual interpretation of natural desires and unadjusted behavior
  • Spiritual interpretation of distress (mentally and somatic); i.e. causal attribution without delusional aspects
  • Religious delusions

Functions of Spiritualization

  • Interpretation (Causal attribution)e.g. „oppression“ as a reason for sleep disorders
  • Defense mechanismse.g. prayer meeting instead of behavioral change --- e.g. spiritual justification of wishful thinking
  • Copinge.g. prophetic words of encouragement / subjective relief through “rebuking spirits”

A continuum of intensity

Empathy possible

  • failure to attain a religious ideal:e.g. „I am not praying enough!“e.g. „I feel abandoned by God“e.g. „I am damaging my Karma!“


  • demon of pride, lust etc. (unacceptable drives and behaviors are attributed to demons)
  • Demons as cause of sleep disorders, nightmares, obsessional thoughts etc.

Forms of Spiritual Therapy(in the Christian context *)

*) wide variations in other religious cultures

  • Traditional and common: Prayer, Confession, Communion / Eucharist, Blessing through the Laying of Hands.
  • Transitional Objects and Protection against Evil: Pictures of Saints, Amulets, Holy Cross, protecting objects etc.
  • Religious Activities: Pilgrimage, participation in religious festivals, religious exercises, visiting special healers.
  • Forms of Counseling: „Imagery“, Prophecy, Deliverance, „Rebuking evil forces“ (self or others), Exorcism.


  • Mixture of spiritual support
  • with popular superstition (especially in catholic and orthodox context)
  • with PsychoanalyticPopular Psychology (e.g. in the charismatic literature)

Dealing with Spiritualization

1. Assessment

  • “Approaching the unfamiliar with respect helps us to gain understanding”
  • Explanatory Model or secondary phenomenon?
  • Delusion or Subculture?
  • Psychodynamics: Positive Coping or Dysfunctional Defense Mechanism?
  • Which therapeutic consequences result from the religious interpretation of the problem? (traditionally Christian, magical, dramatic)

Dealing with Spiritualization - 2

2. Evaluation

  • In cooperation with the client / patient
  • Different forms of “religious style”
  • Personal integrity of the therapist
  • Theological evaluation is not primary concern of therapy


  • What is the influence of religious interpretations on symptom relief, coping with life events and psychosocial development of the patient / client?



Results of Spiritualization

Symptom Relief

Personal freedom -- Interpersonal Relations -- Coping


3. Therapeutic strategies

  • Develop a supportive therapeutic setting in collaboration with the patient
  • Spirituality as part of a comprehensive model of illness and coping.
  • Cooperation with counselor / pastor (if possible)
  • Psycho-education: Religious life can be affected by mental illness (e.g. depression)
  • Image: out-of-tune piano
  • Determine functional and dysfunctional aspects of spiritual interpretation
  • „Agree to disagree“

Indicators of functional spirituality

  • Improves self-confidence (based on confidence in God)
  • Enables mature patterns of relating to others
  • Enhances coping with life’s demands
  • Preserves the awareness and the awe of the ultimate spiritual reality, God.
  • The construction of meaning on the background of sub-cultural values is a universal phenomenon.
  • Help-seeking behavior
  • Physicians, healers and counselors are unwitting partners in health care
  • Cultural sensitivity
  • Utilizing functional aspects of religion in a patient‘s coping process