summary response

© 2010 by The Johns Hopkins University Press

Evocative

Peter J. Verhagen

Keywords: levels of analysis, science and religion, phi- losophy of religion, religious/spiritual experience

I n 2006, two Dutch psychiatric residents and their residency training director reported on a small qualitative survey among 13 psychiatrists

working in their mental health institution. The psychiatrists were interviewed about their attitude toward religion and spirituality. The interviewers were especially interested in the role religion plays according to the psychiatrists in the relationship between psychiatrists and patient (Fiselier et al. 2006). The theme is not new, and it still evokes a lot of controversy, considering the turmoil the well-known authority and opinion leader in this field of inquiry Koenig recently provoked with his editorial in Psychiatric Bulletin (Koenig 2008; Correspondence 2008). Reporting on counter- transference, the interviewers quote a few, in their view, rather typical statements: “If one learns that a patient is a believer, that patient’s estimated IQ will actually be rated 20 IQ points lower” (p. 384). It seems that around half of these 13 psychiatrists attribute negative qualities to the religious patient. Nevertheless, these psychiatrists claim to be on the alert for their negative countertransference; a likely statement, indeed! In fact, the whole idea was to get more information about the basic assumptions as part of the self-view and professionalism of these psychiatrists, and the possible religious origin of their basic assumptions like trust, hope, related- ness, validation, and responsibility. Seventy-five percent said that the therapeutic relationship was

partly founded on religious ideas and principles. The question Koenig posed in the title of his

editorial—“What Should Psychiatrists Do?”— should be preceded by another: “What should psychiatrists try to learn?” The contribution by Rushed to help forward the ongoing difficulties in the relationship between religion, religious ex- perience, and psychiatry is an excellent example of what psychiatrists should try to learn and un- derstand. I would like to mention (very briefly) three issues: four different levels of analysis, sci- ence and religion, the rehabilitation of religious experience.

Levels of Analysis Rashed’s contribution shows very clearly that

psychiatric thinking can be differentiated into levels of knowledge or degrees of abstraction, embedded in distinct practices and located on different places.

The first level is the level of daily experience, for example, the religious experience of Femi. It is the story the patient tells, including his or her idiosyncratic experiences and constructs with regard to self and self image, and how he or she explains or justifies his life experience, and so on. According to Rashed, the subject creates “a nar- rative that can accommodate those experiences, preferably in terms that are consistent with their personal biography. Biomedical language is only one possible language in this process,” (p. 199) and can in fact be used by the patient himself. It is already here that the problem starts. The so-called ‘hyponarrativity’ of the DSM tradition

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forecloses more or less the opportunity to listen to this story, especially when not just the patient but above all the professional is too much bounded to his language. Rashed directs our attention to the second and third levels of analysis. On a clinical level, the professional reconstructs the story into a clinical case and case formulation. The case formulation elaborates on the identified disorder, the discerned patterns in the story of the patient, his sociocultural context, and the clinician–patient relationship from a categorical description and classification to a personalized perspective, which furthermore leads to taking therapeutic action. The difficult task here is to transpose the unique story and situation of this particular patient to general rules and concepts. In the case of Femi, the daily routine by which ‘criterion B’ and ‘cultural congruence’ as general rules are (not) practiced, falls short in the uniqueness of his story, and makes it almost impossible to ask questions like the author poses. His analysis on the third level, the scientific level, is illuminating. It is on this level that a clinical question or problem is formulated in terms of affective, cognitive, interpersonal, so- ciocultural, and spiritual processes. Fourth, on a meta-theoretical level we describe the premises of theoretical models. Psychiatrists need to be aware of this differentiation of levels of analysis to grasp and understand these four types of knowledge (Glas 1996).

Science and Religion In fact, Femi’s religious experience poses a

critical question to psychiatric thinking on all four levels. Aristotle formulated the idea of astonish- ment as common starting point of philosophical or scientific thinking (Jüngel 2003, 156, 274f). A miracle as a sudden phenomenon evokes astonish- ment, possibly a skeptical surprise, or a critical and receptive observation. However, there are also elements of fear and awe—awe at the unknown, a respect for the mysterious. This strangeness holds in his view an element of annoyance, or scandal, if one would like to use St. Paul’s expression. The motive for this annoyance is the fact that the issue, I am being confronted with, is something ‘out of its place.’ It is ‘atopos,’ which means out of place, and also unusual, uncommon. What science is doing,

or philosophy in terms of Aristotle, is to restore order, to locate the proper place for the issue ‘out of place’ in that order. And as a result of this phi- losophizing, in a proper sense, the astonishment from the beginning becomes resolved; astonish- ment is brought to an end. It is at this very point that we discover a principal difference between science and religion, reason and faith. Because in religion and spirituality, in faith and spiritual conviction, the astonishment, again as common point of departure, never disappears, and stays far from any necessity of becoming resolved. On the contrary, theology starts with astonishment, and certainly that astonishment is evoked by something ‘out of place.’ That is even to say, depending on the religious or spiritual tradition one is adherent to, evoked by something that has no place in this world altogether. It is even possible, on the level a daily experience, that due to the burden of emo- tional distress one becomes an ‘atopos’ to himself. It might be an experience of being annoyed, of being skeptical about something one did not ask for, and still it is there. The astonishment becomes bewilderment or dizzying anxiety that needs to be rejected and avoided. Femi’s experience poses an ‘atopos,’ telling us something about the way people are struggling in a downward spiral of distress or an upward spiral of well-being with life, to live in a more exemplary and self-fulfilling, really more than adjusted way. Routine psychiatry eliminates the ‘atopos’ with the use of ‘criterion B,’ and ‘cultural congruence.’ By doing so, it misses the challenge to evaluate and deepen its constructs as Rashed clearly demonstrates.

Rehabilitation of Religious Experience

The rather anecdotal vignette I started with illustrates that religious and spiritual convictions and experiences can be evaluated as ‘guilty until proven innocent,’ especially by psychiatrists in their daily clinical routine (second level). Since James’s characterization of mystic experiences (in- effability, noetic quality, transiency, and passivity), the idea has taken root that religious experiences are extraordinary experiences. However, in real life that is not the case. Most religious experi-

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ences are interpretations of normal experiences (first level). That is what religious upbringing, rituals, and prayer are meant for: to teach people to see and to interpret their experiences with ‘eyes of faith’ and to help people find a way of getting through the unruliness of life. Femi seems to be trained in that way. We are all familiar with the fact ‘psycho’-sciences look for a naturalistic understanding (third level). That is, of course, not the only type of explanation the philosophy of religion looks for. However, the philosophy of religion is also aware of some sort of ‘cultural congruence’ criterion. Religious interpretations of life experience are not immune to criticism. Within religious traditions, it remains a point of ‘discernment of spirits’ whether an interpretation is valid or not (Brümmer 2002). The article by Jackson and Fulford (1997), still worth reading, illustrates a certain rehabilitation of religious ex- perience. The ‘guilty until proven innocent’ has changed into ‘innocent until proven guilty.’ And that is a very interesting development (not only in psychiatric thinking, but also in society at large). Their contribution and the ongoing discussion in this journal helped forward by Rashed illustrates, again, that the critical questions religious experi- ences (and values in general) evoke help to open up scientific and psychiatric thinking and reasoning about certain concepts and so-called ‘state of the art’ rules. That has nothing whatsoever to do with any kind of religious or worldview expansionism. It is the necessary step to bring our thinking and reasoning to the fourth level of analysis.

Rashed’s plea for an open-ended process of communication is worth laying to heart. How-

ever, it seems necessary to me that psychiatrists need to understand how they are related to their knowledge. It is what the theologian LeRon Shults (2003) calls ‘the fiduciary structure’ of a person, ‘the knower’s faith in (or “boundness to”) knowledge.

References Brümmer, V. 2002. On three ways to justify religious

beliefs. Ars Disputandi. The online Journal for Phi- losophy of Religion. Available: www.arsdisputandi. org/. Accessed January 12, 2009.

Correspondence. 2008. Psychiatric Bulletin 32:356– 8.

Fiselier, J. A., A. E. Waal, and J. van der Spijker. 2006. Psychiater, patiënt en religie: meer dan coping alleen [Psychiatrist, patient and religion: More than simply coping]. Tijdschrift voor Psychiatrie 48:383–6.

Glas, G. 1996. Psyche and faith—Beyond professional- ism. In Psyche and faith. Beyond professionalism, ed. P. J. Verhagen, G. Glas, 167–184. Zoetermeer: Uitgeverij Boekencentrum.

Jackson, M., and K. W. M. Fulford. 1997. Spiritual experience and psychopathology. Philosophy, Psy- chiatry, & Psychology 4:41–65.

Jüngel, E. 2003. Ganz Werden. Theologische Eröter- ungen V. Tübingen: Mohr Siebeck.

Koenig, H. G. 2008. Religion and mental health: What should psychiatrists do? Psychiatric Bulletin 32:201–3.

LeRon Shults, F. 2003. Reforming theological anthro- pology. After the philosophical turn to relationality. Grand Rapids, MI: William B. Eerdmans Publishing Company.

Rashed, M. 2010. Religious experience and psychia- try: Analysis of the conflict and proposal for a way forward. Philosophy, Psychiatry, & Psychology 17, no. 3:185–204.