Abstract
Three papers published last year in Australasian Psychiatry demonstrate an increasing acknowledgement of the importance of religion and spirituality to psychiatry. 1– 3 A number of common points emerges from the papers. First, that the spiritual dimension is an essential aspect of human nature, which has largely been pathologized or ignored by psychiatry. Second, that rapprochement with religion should be sought if psychiatry wishes to be a complete, maximally effective and holistic healing method, and for the demonstrable benefit of patients. Third, that some progress has been made towards incorporating empirically testable spiritual practices, such as the taking of a spiritual history as part of psychiatric examination 2 and the selective use of Buddhist methods in cognitive behavioural therapy. 3
Halasz suggests a much more ambitious project with his proposal to reclaim psychiatry's soul and reinstate the psyche in psychiatry, by study of ‘the “anatomy”, “biochemistry”, “physiology” and “dynamics” of the soul’. 1 As his paper suggests, such a vast and complex exercise must quickly address fundamental problems of ontology and epistemology, and particularly what Halasz sees as the core conflict between religion and psychiatry, the question of what constitutes rational explanation. It is not entirely accurate to say that revelation and miracles are the ultimate basis of all religious knowledge 1 (the essential Buddhist teachings about the self and enlightenment are not inherently supernatural, the tradition of natural religion has a long and honourable history in Western theology, a leading New Zealand theologian imagines a future religion in which God is recognized as a human construction 4 ). It is nevertheless true that much religious knowledge and practice includes a belief and faith in the supernatural, whereas scientific knowledge demands empirical observation and rigorous testing of hypotheses. How are such different beliefs to be integrated into the teachings of psychiatry?
EPISTEMOLOGICAL GAP BETWEEN RELIGION AND PSYCHIATRY
Many psychiatrists and perhaps the majority of patients hold beliefs in the reality of some aspects of the supernatural; precisely the source of the conflict, at a personal level, to which Halasz refers. However, it also is probable that the majority of psychiatrists, while wholly sympathetic to the moral, humanistic and holistic aspects of religion, find it difficult to accept supernatural causes of phenomena, particularly of mental functions, for which there are more parsimonious natural explanations; certainly this scepticism is implicit in most medical teaching.
This dilemma arises often enough in clinical practice, where a patient expresses preference for a spiritual explanation and treatment of phenomena that the psychiatrist sees clearly as based in mental illness. How then should the psychiatrist respond, while maintaining respect for both the patient's beliefs and for empirical medical truth? The common current practice is to pursue a dual pathway, the psychiatrist offering orthodox scientific opinion and treatment where these are acceptable, otherwise deferring to the patient's religious preferences, unless there clearly is an issue of dangerousness. But is this truly an integration of the scientific and the religious or simply strategic eclecticism? And at what cost to intellectual integrity, of the individual psychiatrist, and of psychiatry as a whole?
The dilemma is not resolved by the now repeated observation that spiritual experiences may accompany a variety of empirically demonstrable changes in normal brain function, as well as occurring in the presence of psychopathology. This simply demonstrates that spiritual experiences, such as a feeling of oneness with the universe or a sudden revelation of profound truth, may be part of the normal repertoire of brain function and conscious experience. If this is the soul, it appears to have a common neurophysiological origin. That to some the occurrence of such spiritual experiences is also an act of God, or suggests the existence of a supernatural source of knowledge, while to others it is a marvelous emergent property of organized matter but no more, simply highlights the conceptual conflict with which we are grappling. Kant's solution to his recognition that human knowledge inevitably is constructed and constrained by the inherent capacity of our brains was to postulate the existence of a transcendent realm of knowledge apprehended only by faith (he was a committed Christian). Whether it is possible for contemporary psychiatrists to accept this notion on faith remains the dilemma.
A PLACE FOR INTELLECTUAL PLURALISM?
Some doubt that in our present state of knowledge true integration of religion and science is either desirable or possible. Fulford notes that psychiatry has tended to ignore religion and identify with science in a ‘one-sided understanding of its own nature’. 5 He defines two equally important functions of personhood: engagement in the natural world of causal law (the realm of science) and in the moral world of free action (the realm of religion). In Fulford's view, these two may be genuinely immiscible. This being so, he believes that to understand and treat the whole person, psychiatry must engage equally in both of these worlds ‘not by conflation, nor by reductive elimination of one or the other, but by way of an active dialectic’.
Stephen Jay Gould (a self-described agnostic Jew), referring to Pope John Paul II's 1996 statement that man's physical evolution is now an established fact, compatible with Catholic doctrine, but that the immortal soul arises in each person by a process of divine infusion, advocated a principle of non-overlapping magisteria (NOMA). 6 According to the NOMA principle, religion and science are not in opposition but occupy separate domains of teaching and knowledge (‘magisteria’), each of which can be understood only on its own terms. These magisteria should properly engage in respectful discourse rather than dispute, aspiring towards a common goal of wisdom. This theme is elaborated by King who expressed alarm at the contemporary trend for science, armed especially with what have been interpreted as spiritual insights from the boundaries of quantum mechanics and chaos theory, to advance ‘imperialistically’ into the world of spirit, where he believes it does not fit or belong. 7
One consequence of psychiatry's strong identification with science is the implicit assumption that it should actively aspire to a coherent, internally consistent knowledge base, exemplified by the high value placed on evidence-based methodology at the expense of the anecdotal and discursive. Although few doubt the strength of the evidencebased approach, many would question the weighting it is given in current psychiatric literature, teaching and practice. Clearly, any attempt to reclaim psychiatry's soul must involve a challenge to narrow scientism, and indeed must necessarily imply a willingness to embrace some degree of intellectual pluralism (the dialectic of Fulford, the non-overlapping magisteria of Gould) along with the cultural and religious pluralism that any genuine attempt at integrating the spiritual into psychiatry demands.
In truth, psychiatry has always been as much an eclectic and practical art as it is a science. Despite great and unresolved problems, the beginnings of a rapprochement with religion have been made, a trend that is unlikely to be reversed. As we move further towards this rapprochement, and in order to systematize psychiatric knowledge of religion and spirituality, it may be useful to use a schema such as that suggested by the psychologist and prolific writer on spiritual issues, Ken Wilber. 8 He proposes four overlapping and interrelated domains of knowledge and research, concerning the internal and external experiences, first of individuals, then of society:(i) the ‘I’, the subjective consciousness, the personal experience of spirituality; (ii) the ‘It’, the brain and organism, the scientific study of neurophysiology; (iii) the ‘We’, the cultural and world view, including shared spirituality, organized religion and theological doctrine; and (iv) the ‘Its’, the social system and environment. This approach emphasizes the absolute necessity to recognize and integrate each of these domains, if a full understanding of religion in all its manifestations is to be gained, but at the same time allows for a more focused, analytical study of its parts.
Wilber's expansive approach to spirituality, with his willingness to go well beyond the empirical, may be anathema to many psychiatrists. Some may be most comfortable with a position of spiritual agnosticism, weighing the evidence and arguments as they arise. Others will come to understand more of the range of religious beliefs and experiences that occur, while maintaining their own faith. But psychiatry as a whole can only benefit if the concepts and vocabulary of religion and spirituality are more widely known and discussed among its practitioners, if conceptual, cultural and personal challenges 9 are addressed, and if progress continues towards a genuine rapprochement.