How it looks from the other side

Belief in God, in particular God with whom one can have a relationship and to whom one can pray, makes no sense to a nonbeliever. It is a phenomenon that, for such people, has to be explained away somehow - yet none of the explanations are wholly satisfactory.

Perhaps this believer is lying, deliberately and blatantly - but why and how can he keep it up? Perhaps believers are being 'brain-washed' by a theocracy that is more powerful politically and better educated than they. This may have happened through history but it cannot explain religious belief in the twenty-first century western world. Perhaps people are conforming with their peer group by acknowledging belief for their own advantage. Again, this has happened but it cannot explain the faith of most believers.

In desperation, many have claimed that religious belief is madness. When St Paul gave a detailed and rational explanation of his faith before the Roman authorities, Festus, the governor, said: 'You are out of your mind, Paul! Your great learning is driving you insane.' (2)

Freud claimed, in Moses and Monotheism, (3) that belief in a single God is delusional. More recently, the British publicist of science, Richard Dawkins, has claimed that God is delusion (4) - to be more accurate in making his point, he should have put it that belief in God is delusional. To put this construction at its simplest: religious belief is evidence of and causes mental illness. It is harmful to your mental health.

A long and acrimonious debate

Why should some philosophers and scientists, rational in other areas of life, leap to the conclusion that any person holding religious beliefs must be insane, or at least somewhat deranged? They have a historical foundation for this - a long and acrimonious debate going back to the sixteenth century. In the nineteenth century, scientific thinking led to the dictum: 'patients with so-called mental illnesses are really individuals with diseases of the nerves and brain'. (5) When psychiatry developed as an independent discipline within medicine in the twentieth century, it wanted to identify itself as being wholly scientific, and so dichotomy and hostility between psychiatry and the Church resulted. This became maximal in the mid-twentieth century.

What is delusion?

Understanding human beings lies in finding out what each significant part of their life means to them; what is their subjective experience. Some leaders of opinion have declared 'faith is delusion'. Faith will be experienced in various ways by different believers but always implies commitment and trust. 'Faith is being sure of what we hope for and certain of what we do not see...By faith we understand that the universe was formed at God's command.' (6)

The manifestations of mental illness are not chaotic or arbitrary but follow distinct patterns. The syndromes that we recognise in many medical conditions by physical examination are represented, in psychiatry, by groups of abnormalities in speech and behaviour that can only be ascertained by finding out what is the personal meaning of this experience for the sufferer. This process is called descriptive psychopathology and it is a skill that has to be developed by the psychiatrist. (7) One of the recurring 'patterns' of mental illness is the phenomenon that is called delusion.

Delusion

A false, unshakeable idea or belief,

out of keeping with the patient's educational, cultural and social background;

held with extraordinary conviction and subjective certainty

What is delusion? 'Delusion', in modern speech, is almost always a psychiatric word and a technical term. It always implies the possibility of psychiatric illness. In English law, delusion has been the cardinal feature of insanity for more than 200 years. (8) It is a mitigating circumstance and can convey diminished responsibility. It is within the professional competence of psychiatrists to deem what is, and is not, delusion.

The case of Nebuchadnezzar is an interesting study. He was king of Babylon about 605-562 BC and the account of his mental illness is recorded in the book of Daniel. (9) What we know is that the illness occurred in mid-career, probably mid-life. He had been highly effective as king beforehand, with no mention or evidence of mental illness. He had a premonitory dream about twelve months before onset. There were spiritual causes for his condition: 'sins and wickedness'. Onset was sudden when he said: 'Is not this the great Babylon I have built as the royal residence, by my mighty power and for the glory of my majesty?'. This could well be a delusion of grandeur. Psychosis lasted for seven months; he was driven away from people, lived with wild animals, and ate grass. There was self neglect with matted hair and nails like claws. Recovery was sudden: 'I raised my eyes towards heaven, and my sanity was restored'; it was full and he continued to reign. The spiritual message is: 'those who walk in pride [God] is able to humble'. Diagnosis can be debated, but bipolar affective disorder is the most likely. So, in psychiatry, delusion can only be investigated using the discipline of descriptive psychopathology, which is the systematic study of abnormal experience, cognition and behaviour based on observation and not preconceived theory. Descriptive psychopathology looks for subjective meaning to account for the patient's speech and actions - meaning belongs to the patient. 'Understanding' the patient is contrasted with 'explanation', which is the scientific method of observing from outside the processes of cause and effect, and forming hypotheses. Understanding is achieved via empathy; the professional uses her own capacity as a human being to experience for herself, feel herself into, what the patient is describing about himself, his thoughts and actions. Descriptive psychopathology is carried out through objective observation and understanding subjective experience through empathy (phenomenology).

To explore the question, 'Is faith delusion?' we need to look at the distinction between 'form' and 'content'. The patient is only concerned with the content of an experience: 'the nurses are stealing my money', whilst the doctor needs to be concerned with both form and content. 'Is my patient's belief that people are stealing from her 1) factual; 2) a misinterpretation; 3) delusion; or 4) some other abnormal form?' Content reflects the predominant concerns of the patient, for example, a person whose life has centred on money and fears of poverty, may well believe that she is being robbed. The form indicates the type of abnormality of mental experience; that is, the descriptive psychopathology, and this leads to diagnosis. It does matter whether this belief of the patient is a delusion or not, as, if it is, it implies the presence of a serious mental illness.

Delusion indicates mental illness

The content of delusion is described in everyday terms and experienced as a notion or assumption rather than a credal belief -'there are Russian tanks in New Street about to invade'. This has descriptive, physical certainty, which is not the nature of religious belief.

Out of keeping with educational, cultural and social background includes immediate (the local church community) as well as wider culture (a post-Christian society). There can be major differences in use of language and even understanding within Christianity between different denominations and church groups, as shown in public prayer. The person who prays from one sort of church background may always read prayers that have already been written down, and address God in a set form of words. Another, from a differing background, may always use extemporary prayer. An unsympathetic listener to either of these might believe that the person who prays out loud is mentally deranged - but it is not delusion; belief in prayer is shared within the church fellowship.

Held with extraordinary conviction and subjective certainty - A delusion is held on delusional grounds. A man knew, with absolute certainty, that his wife was being unfaithful to him. Subsequently, it transpired that she was being unfaithful at that time. However, this was still a delusion because the reason for his certainty was: 'When I came out of the house and passed the fifth lamp post on the right, it had gone out. Then, I knew with certainty that she was having an affair.'

Delusions are held without insight: If someone wonders if they are deluded or not, they almost certainly are not. A Christian colleague, after a long silence, said, 'I suppose the difference between delusion and faith is that delusion is held without any doubt, but religious belief is held with some doubts, or at least an understanding that others could have doubts about what I believe.'

Concrete thinking: Those with religious beliefs accept that some of their expressions are spiritual and not literal, for example, 'giving your heart to the Lord Jesus'. In some serious mental illnesses there is a literalness of expression and understanding. Abstractions and symbols are interpreted superficially without tact, finesse or any awareness of nuance: the patient is unable to free himself from what the words literally mean, excluding the more abstract ideas that are also conveyed. This abnormality is described as concrete thinking.

Religious belief cannot be delusion

Having looked at the nature of delusion in some detail, now I will affirm that religious faith is not and cannot be delusion. There are many accounts of religious belief and practice that seem to us bizarre, for example the Hebrew prophets Ezekiel and Isaiah. However, this does not make them delusional or even suffering from a psychiatric disorder. Often, knowledge of the cultural context will make them understandable. There are many reasons why religious belief, of itself, cannot and can never be identified as delusion. However, a person with religious belief may, whilst experiencing mental illness, suffer from a delusion. Such a delusion, in its content, may be religious, for example, a man believed that the devil was telling him to jump through the window. However, the form of delusion can never be religious belief for the following reasons:

• Religious beliefs do not fulfil the criteria for definition of delusion - they are not 'out of keeping with the person's educational, cultural and social background'.
• They are not held on demonstrably delusional grounds.
• Religious beliefs are spiritual, abstract, and not concrete - 'God within me' is not experienced as a tactile sensation.
• Religious beliefs are held with insight - it is understood that others will not necessarily share their beliefs.
• For religious people, bizarre thoughts and actions do not occur in other areas of life, not connected with religion.
• Religious ideas and predominant thinking is a description of content.

It needs to be stated repeatedly that although faith itself is not delusion, religious belief and delusion may occur in the same person at the same time. People with belief are not immune from mental illnesses, including psychoses. When they do concur, it does not mean that one caused the other and it is often possible to unravel the two experiences: 'This is delusion - evidence of mental illness', 'This is an unusual expression of religious experience'.

Could religion be a manifestation of other mental abnormality?

I hope that I have convinced you that faith can never be delusion - they are matter from different realms. Could faith, however, be identified with another psychiatric disorder or symptom: overvalued idea, culturally shared false belief, paranoid idea of self reference, pathological perception, abnormal mood state, disorder of volition?

Overvalued idea - a reasonable idea pursued beyond the bounds of reason.

Culturally shared false belief - irrational beliefs shared by a group of people.

Paranoid idea of self-reference - believing oneself to be persecuted.

Pathological perception - for example, auditory hallucination, but 'hearing the voice of God' is not necessarily auditory hallucination.

Abnormal mood state - such as anxiety or depression

Disorder of volition - disordered will or behaviour

All of these are unusual mental states and some of them are pathological. All of them can be associated with religious belief, but that is not the same as claiming that religion, per se, is or causes psychiatric disorder. Faith is not delusional, neither does it cause, of itself, any other psychiatric condition or symptom. Each of the above symptoms can be associated with religious belief and practice in a person for whom faith is important but there is no causal link between religion and developing psychopathology.

Each of the above could have as partial cause a religious situation or experience and each may result in the individual seeking and finding a religious experience. But that does not mean that belief is simply an example, or a consequence, of an underlying mental disorder. As discussed above, to clarify this relationship we need to use the psychopathological distinction between form and content. In psychiatric usage, form is the psychopathological entity demonstrated: delusion, depressed mood, anxious state. Content is the socio-cultural expression that concerns this individual: money, religion, status and so on.

Form and content is an important distinction to make. A man believed that he was 'at war with the Evil One', that everyone he met was either a friend or a foe, and that devils were talking about him, taunting him and commenting upon his thinking. This could be described as a 'religious delusion' but what does that mean? The form was both delusion (persecutory and religious), and auditory hallucination in the third person - hearing his own thoughts out loud. These are symptoms of schizophrenia. 'Religion' did not cause delusion, nor vice versa. Both religious expression and mental illness occurred in the same person.

Does faith damage your mental health?

Statements have been made by those hostile to religion that faith is harmful to health, especially mental health. Many psychiatrists used to assume this to be so, and the general public often thus regards it. These claims were based on prejudice or single cases: there are plenty of instances where an individual has been harmed by mistaken religious ideas. However, it requires epidemiological evidence to answer the question 'Does faith damage your health?'

Until the 1990s, there were very few good quality studies linking religious belief and practice to mental health outcomes. Since then there has been an explosion of research in this area. This has been drawn together in the monumental work:Religion and Health (10) which reviews more than 3,000 studies that correlate religious belief and practice with health outcomes. There is a strong correlation between religious involvement and better mental health. Religion and Health also has a large section concerned with physical health, and the advantages of religious involvement are found here also. (11)

These studies are all epidemiological in nature - based on large cohorts. In the individual case there are instances where belief has harmed mental health and hindered appropriate treatment. For example, a woman became severely depressed because her church leaders had 'disfellowshipped' her and she had consequently lost all her friends; another, a depressed man, was correctly prescribed antidepressant medication but refused it saying that he should trust God alone.

The advantageous effect of religious belief and practice on mental and physical health is one of the best-kept secrets in psychiatry, and medicine generally. If the findings of the huge volume of research on this topic had gone in the opposite direction and it had been found that religion damages your mental health, it would have been front page news in every newspaper in the land!

Consequences for Christian doctors

What are the consequences of all this for Christian doctors? No, faith is not delusion. If we are meticulous and use the word correctly (a false, unshakeable idea or belief, which is out of keeping with the patient's educational, cultural and social background and so on) the distinction between religious belief and delusion becomes absolute. Nor is belief, per se, evidence of any other psychiatric state or condition. Neither is religious belief harmful to mental health - the epidemiological evidence points substantially in the opposite direction. Religious belief and practice convey health benefits in the majority of outcome studies; the overwhelming evidence from the metaanalysis of multiple studies is that faith is beneficial for health.

Many doctors, and especially psychiatrists, have bought into the unsubstantiated claim that religion is bad for health. There have been many distressing complaints from past and present patients that their treating psychiatrist, has, during the course of psychiatric treatment, attacked their religious beliefs, recommending that they stop going to church and disassociate themselves from any religious affiliation. This has, of course, caused them enormous distress. It has sometimes been an expression of the psychiatrist's atheistic, secular views that amounts to an imposition of the psychiatrist's belief upon the patient.

In the past, disparaging a patient's Christian beliefs by psychiatrists was quite frequent to the extent that many church leaders discouraged their members from consulting a psychiatrist, sometimes to the considerable detriment of the potential patient. It occurs less often now, but it is disturbing that it still occurs at all. It has caused great distress to many Christian patients.

The General Medical Council (GMC) has published guidelines on personal beliefs; doctors may talk about their beliefs provided there is no proselytisation and the patient is not caused distress. (12) If a patient is distressed in their faith by an unbelieving doctor there is also a case for concern. The GMC comment on this was unequivocal: 'If a doctor was to put pressure on a patient to justify their (Christian) beliefs, and/or sought to impose their own (non-Christian) beliefs on a patient, then this would potentially represent an infringement of our Personal Beliefs guidance. We would consider the context and supporting evidence of the alleged infringement to see what action may be warranted.' (13) One warning issued by the GMC could potentially have an extremely beneficial effect for all subsequent patients.

Mentally ill patients are among the most vulnerable and deprived in our society and we have a duty of compassionate and well informed care. 'Inasmuch as ye did it to one of these my brethren, even these least, ye did it unto me'. (14)

Andrew Sims is Emeritus Professor of Psychiatry in Leeds and a past President of the Royal College of Psychiatrists.