ArticlePDF Available

Religious Experience and Psychiatry: Analysis of the Conflict and Proposal for a Way Forward



Attempts to distinguish religious from pathological psychotic states have received considerable attention in the recent literature. It has been proposed that the distinction can be drawn in terms of subjects’ evaluation of their experiences and ultimately outcome, conceived of as action enhancement or failure. Such an approach does not take in to account the contexts where the meaning of ‘good’ or ‘bad’ outcome are defined and hence are an overriding factor in subjects’ evaluations of psychotic experiences. This suggests a need to examine the contribution of these contexts to the process of evaluation. In this paper, and with reference to an illustrative case study, I attend to psychiatry—an authority on unusual experience and belief—demonstrating an essential conflict between religious experiences and the assumptions and procedures of psychiatric practice. It is argued that the theoretical commitments of psychiatric science, the values embedded in the social dysfunction criterion, and a deficient understanding of culture promote the pathologization of unusual experiences and contribute to the generation of negative outcomes. I conclude with a proposed solution: by adopting an open-ended process of communication with the aim of achieving a degree of linguistic resonance among the involved parties, clinicians would be fostering mutual change rather than one-sided judgment. This would increase the chances of securing agreement and would put us in a better position to plan noncoercive intervention. Implications of the proposed approach for diagnosis and management of risk are discussed.
Religious Experience and Psychiatry: Analysis of the Conflict
and Proposal for a Way Forward
Mohammed Abouelleil Rashed
Philosophy, Psychiatry, & Psychology, Volume 17, Number 3,
September 2010, pp. 185-204 (Article)
Published by The Johns Hopkins University Press
For additional information about this article
Access Provided by University College London (UCL) at 12/10/10 2:41AM GMT
© 2010 by The Johns Hopkins University Press
Religious Experience
and Psychiatry:
Analysis of the Conflict
and Proposal for a Way
Mohammed Abouelleil Rashed
Abstract: Attempts to distinguish religious from
pathological psychotic states have received considerable
attention in the recent literature. It has been proposed
that the distinction can be drawn in terms of subjects’
evaluation of their experiences and ultimately outcome,
conceived of as action enhancement or failure. Such an
approach does not take in to account the contexts where
the meaning of ‘good’ or ‘bad’ outcome are defined and
hence are an overriding factor in subjects’ evaluations of
psychotic experiences. This suggests a need to examine
the contribution of these contexts to the process of
evaluation. In this paper, and with reference to an illus-
trative case study, I attend to psychiatry—an authority
on unusual experience and belief—demonstrating an
essential conflict between religious experiences and the
assumptions and procedures of psychiatric practice. It is
argued that the theoretical commitments of psychiatric
science, the values embedded in the social dysfunction
criterion, and a deficient understanding of culture
promote the pathologization of unusual experiences
and contribute to the generation of negative outcomes.
I conclude with a proposed solution: by adopting an
open-ended process of communication with the aim of
achieving a degree of linguistic resonance among the
involved parties, clinicians would be fostering mutual
change rather than one-sided judgment. This would in-
crease the chances of securing agreement and would put
us in a better position to plan noncoercive intervention.
Implications of the proposed approach for diagnosis
and management of risk are discussed.
Keywords: spiritual experience, psychosis, harm,
values, social dysfunction, cultural congruence, com-
munication, linguistic resonance
The enlarging domain of psychiatric
intervention is frequently associated with
the undue medicalization of unusual
experiences. In such a climate, it becomes of ut-
most importance to carefully choose appropriate
candidates for the psychiatric gaze. This suggests
a need to draw a distinction between religious
experiences (with psychotic form) and pathologi-
cal psychotic experiences. As Jackson and Fulford
(1997) maintain, “spiritual experiences, whether
welcome or unwelcome, and whether or not they
are psychotic in form, have nothing (directly) to
do with medicine. It would be quite wrong, then,
to “treat” spiritual psychotic experiences with
neuroleptic drugs, just as it is quite wrong to
“treat” political dissidents as though they were
ill” (p. 42). The distinction, however, is a difficult
one to make.
As early as 1902, William James recognized that
certain varieties of religious experiences share im-
portant areas of correspondence with psychotic ill-
186 PPP / Vol. 17, No. 3 / September 2010
ness (James 1902). He considered mystical experi-
ences and insanity to spring from the same “mental
level,” where “seraph and snake abide there side
by side” (p. 411). He wrote that there are certain
features common to both states, such as a sense
of ineffable importance in otherwise insignificant
events, voices, visions, and control by external
powers, but whereas in the former the dominant
emotions are consoling, the meanings optimistic
and the powers ultimately benevolent, in the latter
the emotions are negative, the meanings dreadful
and the powers malevolent (p. 410). James consid-
ered religious experience to come from a “wider
self,” a self-conscious, non-human life. A strategy
James employed to support this notion was to
consider the fruits of religious experience. On this
account, the positive fruits of religious experience
are an indication of its divine origin, and serve to
separate these experiences from those associated
with what he called ‘insanity.’
The issue was revisited by the philosopher and
psychiatrist M. Drury (1996), who acknowledged
the similarity between some religious states and
‘madness.’ Drury, however, did not consider the
‘fruits of the experience’ to be sufficient for making
the distinction, because that brings forth the in-
tractable difficulty of deciding what consequences
count as positive and according to whom.
We could consider the recent debate on this is-
sue, specifically the influential account of Jackson
and Fulford (1997), as an attempt to solve the
intractable difficulty Drury alluded to. Jackson
and Fulford (1997, 2002) maintain that we can-
not make the distinction between spiritual and
pathological psychotic phenomena (good and bad
psychosis) by appealing to form or content of the
experience and an account that places the experi-
ence in the agent’s field of action becomes neces-
sary. Good or bad from that perspective “concerns
the way in which [the phenomena] are embedded
in the structure of the values and beliefs by which
the actions of the subjects concerned are defined”
(2002, 388). In spiritual psychotic phenomena
action is enhanced, whereas in pathological states
there is a radical failure of action (Jackson and
Fulford 1997, 55).
An important critique of Jackson and Fulford’s
account was put forward by Marzanski and
Bratton (2002). They argue that spiritual experi-
ence should not be confined to the “benign and
supportive” because that eliminates the suffering
that, in some theological traditions, is recognized
as an essential part of the (ultimately good) spiri-
tual journey (p. 367). Spiritual experience, then,
need not be action enhancing (in a materialist
manner) and may in fact be associated with dis-
empowerment of the subject. Furthermore, even
if an anomalous experience is action enhancing
that does not necessarily make it spiritual. The
distinction between spiritual experience and “men-
tal disorder,” therefore, requires a “theological
criterion” (p. 368). However, restricting such a
judgment to theological criteria, as Jackson and
Fulford (2002) maintain, “begs the question of
whose theology we are to bring to the task—the
client’s, the clinician’s, that of the wider culture,
or that of the subculture?” (p. 389). This is a
valid criticism, but the essence of Marzanski and
Bratton’s argument prevails: understanding what
constitutes a good or bad outcome—in fact, the
very meaning of good and bad—requires an appeal
to consensual (and relative) values, and these val-
ues are—ultimately—over and above the subjects’
evaluation of their own experiences. Even if an
experience is action enhancing—within the frame-
work of the subject’s values and beliefs—we are
still left with overarching contextual factors that
determine how the consequences of these actions
will be received, and whether such consequences
will be considered ‘good’ or ‘bad.’
Essentially, then, whether an experience is
spiritual or pathological transcends the confines of
individuals’ incorporation of experiences in their
framework of values and beliefs and involves a
process of communication with their (sub)cultural
group and—crucially—the relevant authorities
(theological, medical, etc.). If we accept that, then
the question is not “whose theology we bring to
the task” but, more generally, what interpreta-
tive frameworks are available for the subject and
how the aforementioned parties respond to those
interpretations and to the consequent outcomes. In
other words we must attend to context and to the
process of communication as it is there that the ex-
perience is evaluated and the outcome determined.
To the extent that this process is open ended and
Rashed / Religious Experience and Psychiatry 187
aimed at securing some common ground among
the involved parties, we can expect a convergence
of values, a potential for positive outcomes, and—
in a clinical context—the possibility of noncoercive
This paper, therefore, takes off where the afore-
mentioned debate ends: the realization that an
appeal to some independent authority (theological,
medical, etc.) is an inevitable aspect of the process
whereby experiences and actions are evaluated.
Insofar as this is true, it becomes important to ex-
amine the assumptions and procedures underlying
the practices of these authorities with the purpose
of ascertaining their effects on the process. In
writing this paper, I have two purposes in mind.
The first is to examine psychiatry, an authority
on unusual experience and belief. The diagnostic
process in psychiatry frequently hampers the
possibility for an open-ended process of commu-
nication for reasons to do with (1) the implicit
prioritization of materialist values embedded in the
psychiatric manuals’ social dysfunction criterion,
(2) a theory that remains secure in an empiricist/
positivist framework, thus devaluing claims of
alternative origins to (psychotic) experience, and
(3) a misapplication of the cultural congruence
criterion. These three factors—if not explicitly at-
tended to—may be implicated in the generation of
negative outcomes, of harm. Preceding the above
is a brief case study of a young man undergoing
what he believed to be religious experiences; the
case will serve as a constant reference point to the
ensuing discussion.
The second purpose in writing this paper is to
propose a way out of this conflict. This requires
a shift from assessing a verbal report of an ex-
perience in terms of its representational truth to
thinking of it as a description that stands or falls
according to how well it resonates with the wider
community generally and the involved parties
specifically. Within such a perspective, an open-
ended process of communication conducted with
the purpose of achieving a degree of linguistic
resonance among the involved parties becomes an
essential prerequisite for noncoercive, respectful
The Case of Femi
Femi is a 29-year-old man who was born in a
West African country. He has been living with his
father in the United Kingdom for the past 15 years.
Two years before this episode, his mother left the
family and returned to Africa, an incident that he
insisted had no negative bearing on him. Before
coming to the attention of mental health services,
he was reportedly in good health and had no past
medical or psychiatric history. His circumstances
are no different from many other people of his
age and social standing: after completing high
school, he did a number of jobs until he finally
settled in the sales section of a department store.
He has several close friends and recently had been
in a relationship. According to both Femi and his
father, he has always been religious. He attended
weekly sermons at a Pentecostal church in London,
his father’s church, and seemed inclined to adjust
his life to Christian teaching.
Two months before admission, he began miss-
ing the weekly sermons and instead would spend
long hours reading the Bible. He became disillu-
sioned with his church, describing their sermons
as “empty” and “uninspiring.” Around that time,
he got in touch with another church in his native
country, one that emphasized a personal under-
standing of God through experience. He began
a gradual process of isolating himself, engrossed
in reading and listening to recorded sermons. He
got rid of many of his possessions, justifying that
by saying he wants to purify himself of material
needs. He stopped going to work and made a habit
of daily extended walks. He avoided going to his
father’s church, claiming that there is no point or
value in going there anymore. Four weeks before
admission, he began to have intense experiences
where he would hear God talking to him, consol-
ing, advising, and at times ordering him to get rid
of his possessions. He began having a direct expe-
rience of the ‘Spirit’ in his body, to the point—at
times—of feeling “taken over.” He surrendered
to these experiences and did not doubt their au-
thenticity at any moment. His father was hugely
concerned by these experiences and by what he
described as an unexplainable and sudden change
in behavior. He tried to dissuade him from pursu-
188 PPP / Vol. 17, No. 3 / September 2010
ing these new-found practices and appealed for
support from the London-based church. His father
and the church pastor considered Femi’s behavior
to be harmful, excessive, and not endorsed by the
church. A few days before admission, he began a
prolonged fasting episode to “further cleanse his
soul.” He was physically challenged by the fasting
and was found confused and disoriented in a pub-
lic place, upon which—after police intervention—
an ambulance was called and a mental health act
assessment arranged.
When he was assessed by the psychiatrist and
social worker he said that for the past 4 weeks
he had been in direct communion with God, that
God had spoken to him telling him to get rid of
his belongings, give up his job, fast, and change
his life as a way of getting closer to ‘Divine truth.’
When the clinicians challenged the authenticity of
the voice, he responded that he has no doubts it
is from God, that he hears it in the space around
him, and that it is entirely separate from his self.
He also reported, upon direct questioning, that
he sometimes experiences his actions as directly
controlled by God, that occasionally his actual
movements cease to be under his volitional con-
trol and are ‘imbued with the Spirit.’ This was
particularly so on his extended walks: he would
suddenly find himself embarking on a walk, and
would literally feel the ‘Spirit’ moving his body.
He said that he finally understands what God is
and felt on to something significant in his life. He
was considered to present with second-person
auditory hallucinations, command hallucinations,
volitional passivity, and significant risk to self in
the context of recent social/occupational deteriora-
tion and in the absence of validation by his father
and the church and was consequently placed under
section ‘2’ of the mental health act.
After admission, he continued to resist all forms
of treatment. He was unable to grasp the reason
for his incarceration and considered the whole
process to be a test from God. One week into the
admission and after mental state assessments and
nursing observations confirmed the persistence of
the previously mentioned psychotic symptoms,
the clinicians were convinced that a diagnosis of
‘acute psychotic episode’ is justified, upon which
treatment was enforced on him. A number of days
later, he finally accepted treatment, and 2 weeks
after that he acknowledged, for the first time, that
he might have been ill. In terms of his symptoms,
he no longer heard the voice of God, no longer
felt the expectancy of a major change in his life,
and was transformed to an unsure young man:
unmotivated and apathetic.
Justifying Psychiatric
Intervention: Social
Dysfunction and the Absence
of Cultural Congruence
According to the DSM-IV (American Psychi-
atric Association [APA], 1994) the presence of
psychotic symptoms (Criterion A) and social/occu-
pational dysfunction (Criterion B) are sufficient to
warrant one of the different ‘Schizophrenia group’
diagnoses. In the absence of social dysfunction an
individual experiencing psychotic phenomena does
not, by definition, ‘have’ a disorder and would
probably fall some where along the psychosis
continuum with a designation of ‘benign psychotic
experience.’ In Femi’s case however, the presence
of social/occupational dysfunction is obvious, at
least if we subscribe to the DSM-IV’s definition
of dysfunction: “for a significant portion of the
time since the onset of the disturbance, one or
more major areas of functioning such as work,
interpersonal relations, or self-care are markedly
below the level achieved prior to the onset” (APA
1994, 285). In his case, we have dysfunction in all
of these areas: he stopped work, gave up seeing
his friends, and fasting compromised his health.
Functional deterioration in his case was probably
a result of several factors: profound engagement
in his experiences, a direct consequence of hearing
the voice of God telling him to do certain things,
and the alienating response of his father and the
London church. The inclusion of Criterion B in
the DSM-IV serves the function of isolating ‘bad’
or ‘harmful’ psychotic experiences. However, does
the presence of social/occupational dysfunction
justify psychiatric intervention in his case? If we
have a closer look at ‘Criterion B,’ we can uncover
the following assumptions. (1) Social dysfunction
is some how related to the psychotic symptoms.
(2) Social dysfunction is equated with harm (for
Rashed / Religious Experience and Psychiatry 189
now broadly defined as an experience of suffer-
ing or incapacity). (3) The origin of harm can be
traced back to the person. Let us consider these
In certain cases, the relation between social
dysfunction and psychotic symptoms seems
straightforward. A previously well-adapted and
functioning individual who has consistently suc-
ceeded in interpersonal relations, academic and
occupational performance, and who develops
psychotic symptoms while simultaneously deterio-
rating in all these aspects can be fairly judged to
have done so as a consequence of the symptoms.
A psychiatrist then, it could be argued, is entirely
justified in treating a ‘paranoid psychotic,’ just as
they are justified in treating Femi. The story would
go like this: A person presents with psychotic
symptoms in the context of functional impairment,
functional impairment is equated with harm, we
therefore have a ‘problem’ that requires interven-
tion, and because the culprits are the psychotic
symptoms we need to treat those symptoms, hence
psychiatric intervention to treat the psychosis. The
problem—diagnostically speaking—lies at the
stage where the presence of ‘harm’ is established.
This is where the lines are drawn as to who is or
is not appropriate for psychiatric intervention.
A second factor justifying psychiatric interven-
tion has to do with the absence of cultural valida-
tion. The inclusion of ‘culture’ in the DSM-IV as
one of the issues to attend to in diagnosis no doubt
reflects the authors’ commitment to constructing
a manual with universal applicability. Beliefs and
experiences that are considered normal (or at least
permissible) by a certain culture should not be
considered pathological even if they are phenom-
enologically similar to the psychiatrists’ delusions
and hallucinations. Hence, the various warnings
scattered throughout the DSM-IV: religious beliefs
are not delusions if “ordinarily accepted by other
members of the person’s culture or subculture (i.e.
it is not an article of religious faith)” (APA 1994,
xxiv), and “hallucinations may . . . be a normal
part of religious experience in certain cultural con-
texts” (APA 1994, 275). Although we can regard
hearing God’s voice or seeing the Virgin Mary as,
respectively, auditory and visual hallucinations,
we should not consider them pathological if they
are a normal part of religious experience in certain
‘Cultural congruence,’ as I would call it, rel-
egates the judgment of the presence of psycho-
pathology from the psychiatrist to the cultural
group. In the case of Femi, this entailed consult-
ing his father and the original Pentecostal church
and asking them if his experiences and behavior
are normal or abnormal by their own standards:
they confirmed the latter. This seems to satisfy the
DSM-IV’s cultural congruence criterion and adds
to the conviction that Femi is ‘ill.’ Furthermore, the
absence of cultural validation—in this account—
is implicitly linked to harm by virtue of the fact
that experiences and beliefs that fail to elicit the
approval of the patient’s cultural peers must be ab-
normal and therefore—by definition—harmful.
Far from assisting clinicians in detecting the
presence of harm, however, these two fundamen-
tal aspects of the diagnostic process—as I argue
below—may in fact contribute to the generation
of harm, rendering pathological what might have
been otherwise. Before considering how this may
come about, we need to elaborate the notion of
Generation of Harm and the
Conflict between Religious
Experience and Psychiatry
Harm and the Origin Thereof
Harm can, of course, be inflicted on others. This
is not my concern; harm to others brings about
a wholly different set of considerations, mainly
moral and legal, and is not the topic of this paper.
My focus is on harm that affects a person. Harm—
for our purposes—can be broadly defined as an
experience of suffering (excluding suffering that
is imposed by others): social isolation, inability to
perform desired actions or pursue goals, failures at
projects one undertakes, direct threats to physical
integrity and so on. Harm can be more specifically
defined as a negatively evaluated experience of in-
capacity, where incapacity is defined as a failure of
intentional action (Jackson and Fulford 1997, 54).
There is, therefore, the possibility that functional
failure (objectively determined) may not coincide
190 PPP / Vol. 17, No. 3 / September 2010
with harm if the experience of incapacity is posi-
tively evaluated. In physical disorders, however,
‘functional failure’ and ‘action failure’ usually
coincide, which excludes the need to separate
both (Jackson and Fulford 1997, 54). A fractured
femur constitutes a functional failure and results
in incapacity, the experience of which will most
likely be negatively evaluated by the subject, hence
the presence of harm.
With psychotic phenomena, however, there
are different matters to consider. Psychotic phe-
nomena are not pathological in themselves: if we
consider psychotic phenomena (including certain
religious experiences) as part of an adaptive
problem-solving process that gets activated at
times of “existential crises” to resolve the tension
that acted as the trigger by offering new insights
or a “paradigm shift” for the individual (Jackson
2001, 2007; Jackson and Fulford 1997), then
we no longer need to look for ‘pathology’ at the
origin of the symptoms but, rather, at what is
done with them (what the consequences are). We
cannot, therefore, talk of functional failure as the
mark of pathology and, as Jackson and Fulford
(1997) argue, an ‘action failure’ account becomes
According to an influential model (Frith 1992;
Frith and Done 1988), psychotic phenomena
involve a reduction in agency and that, by the
definition stated, involves incapacity manifest in
subjects’ inability to recognize their self-generated
thoughts, actions and intentions as their own.1
The manner whereby such experiences are evalu-
ated determines whether action enhancement or
action failure (and therefore harm) ensues. Such
an evaluation depends on how the experience is
embedded within the framework of values and
beliefs of the individuals concerned” (Jackson and
Fulford 1997, 54). The manner a person evaluates
a psychotic experience depends on their preexist-
ing values and beliefs and, crucially, on context
and response of others; and that includes the val-
ues and beliefs of all those involved. These factors
all influence outcome and determine whether the
subject’s experience of incapacity is negatively or
positively evaluated and, therefore, whether action
failure or enhancement results. ‘Harm,’ then, is a
consequence of the interaction of several factors
and hardly, as the DSM-IV seems to implicitly
assume, secondary to a pathological cause to be
found in the person (1997, 52).
Returning to the case of Femi, we would find
that social/occupational dysfunction as defined
in the DSM-IV did exist from the outset. Harm,
however, came into the picture and was firmly es-
tablished after his involuntary hospitalization and
forced treatment. As far as Femi was concerned,
his negatively evaluated experience of incapacity
began when he was locked in hospital.2 Obviously,
restricting someone’s physical freedom results in
suffering, but in his case there was the additional
invalidation of his experiences and the manner
where by he was forced to abandon his religious
project. That is most evident in this utterance after
several days of treatment: “You say I am ill and
the voice I am hearing is not from God. Am I ill?”
His experiences, thus, have become a problem for
him. The response of the psychiatric authority and
to a lesser extent his father (despite Femi’s initial
resistance) transformed what was a positively
evaluated experience to a negatively evaluated
experience; there lies the origin of harm. Now I am
not denying that Femi and other people undergo-
ing intense religious experiences do need support
and help, the question is where they should get
it from. In another context, Femi might have re-
ceived support from a religious community, one
for example that respected the value he attached
to the experience while understanding that he was
particularly vulnerable at that time.
But let us go back to the situation at hand: the
crucial moment in a person’s psychiatric admis-
sion is when harm is judged to be present. And as
I mentioned, harm is a consequence of several in-
teracting personal, social, and contextual factors.
That there is—at the origin of harm—a conflict
between the involved parties is to be expected
but that this conflict goes unexamined and the
patient is considered the ‘problem’ is a recipe for
forced treatment and the like. Furthermore, when
a person is ‘in’ the psychiatric system, harm is no
longer the determining factor; their mental state is
scrutinized and any beliefs or experiences judged
to be abnormal are subjected to change. The
moment of assessment and diagnosis is therefore
crucial. Here is Derek Bolton commenting on how
Rashed / Religious Experience and Psychiatry 191
the process of diagnosis should be, at a time when
we are realizing the social (as opposed to biologi-
cal) nature of mental disorder:
What appears now is fundamentally a matter of personal
and social values to be negotiated by various stakehold-
ers. The implication of these changes in assumptions
is that in assessment for treatment the primary focus
would not be identification and diagnosis of ‘disorder’
but rather negotiation of values and motivation for
change. (Bolton 2004, 3)
The task in the remainder of this section is to
elaborate the various sources of the aforemen-
tioned conflict as they unfold in the diagnostic
process. The first set of problems is directly related
to a conflict of values, a conflict encouraged by the
empiricist/positivist nature of psychiatric theory
and by the prioritization of materialist values over
values associated with religious accomplishment.
The second set of problems is related to conflict
arising from the misapplication of the cultural
congruence criterion. The implication of these
sources of conflict for the patient are invalidation
by the involved parties and in certain cases inap-
propriate hospitalization, two factors that thwart
the potential for a positive evaluation of psychotic
experience and are, therefore—if we accept that
harm is a consequence of several interacting
personal, social and contextual factors—directly
implicated in the generation of harm.
A Conflict of Values
Here’s a story.
A man saves another man who was sinking into a slimy
pond, thereby risking his own life. Now they are both
lying on the edge of the pond, out of breath, exhausted.
The rescued man says: “You idiot! Why did you do that?
I live in there!” (Tarkovsky and Guerra 1983)
The conflict can be broken down to two strands:
(1) A disagreement on the proper description and
true origin of what he experienced, and hence the
value of that experience. (2) A disagreement on the
priority of religious values over values associated
with social and material accomplishment.3
The Value of Experience (and a Digression on
Karl Jaspers’ (1959/1997) distinction between
explanation and understanding was an attempt
to separate the search for causes from the quest
for meaning. It was also an attempt to preserve
a domain of objectivity for scientific facts and to
distance this domain from that of values: scien-
tific inquiry should not be subject to the whims
of us humans; the project of science should not
depend on what we consider worthy, beautiful,
or important. These distinctions have slowly col-
lapsed along the decades and we are now at a point
were we must face the intrusion of values in our
scientific endeavors and acknowledge the validity
of other interpretative disciplines in understanding
the world. The story of this collapse is a long and
winding one (see, for example, Fulford 1996), and
I will not attend to it in detail. The implications
are, however, significant; here is Peter Bracken:
Because natural science has been shown to progress on
the basis of certain historically and socially grounded
‘choices’ it has been argued that it, like the disciplines
classified as human sciences, also contains a hermeneutic
dimension. (1993, 267)
We simply can no longer afford to maintain a
strict separation between facts and values, nor is
a simple reduction of one into the other helpful in
any sense. Such a reduction, as Fulford explains
in relation to psychiatry, means that mental disor-
ders will either be conceived off wholly as moral
categories (e.g., Szasz 1960) or as value-free dis-
ease categories; as biological psychiatrists would
want them to be (Fulford 1996, 14–15). What we
need to do is to tolerate what Littlewood (1996)
calls an “ironic simultaneity”: neither explaining
(as the uncovering of facts) or understanding (as
the elaboration of values) is completely true or
completely false; both approaches may be “taken
as a valid map of reality, constructed for a par-
ticular purpose, and each remains grounded in its
customary procedures whilst entailing the other”
(p. 191).
Psychiatric theory, however, remains embedded
in an empiricist and positivist framework. The
elimination of values from our understanding of
mental illness is not just philosophically unten-
able, but can also seriously hamper our ability
to understand the experiences of others. This is
because in psychiatric theory we find a species
of explanation that is wholly reductionist, which
allows no meanings to be associated with the
experiences of people (apart, of course, from the
192 PPP / Vol. 17, No. 3 / September 2010
meanings and hidden values associated with the
reductionist explanations themselves). But what
other species of explanation are there?
Proudfoot (1985) distinguishes between ex-
planatory and descriptive reduction. In explana-
tory reduction, we are “offering an explanation
of an experience in terms that are not those of
the subject and that might not meet with his ap-
proval” (p. 197), but we are still identifying the
experience under the description by which the
subject identifies it: what we are trying to explain
is precisely the experience of ‘hearing the voice of
God’ and not a biochemical imbalance or a hallu-
cination. Explanations that attempt to account for
a religious experience in terms of the phenomena
of the natural world are of this variety. These
explanations might leave the theological aspect
of the experience unaffected.
When Durkheim (1965/1976) was writing
about religion, he was not claiming that religion
is nothing but the projection of the power of the
social order over a deity; he was trying to explain
why religion holds power over people by avoiding
reference to any supernatural explanations. But
his explanation still left room for God, religious
symbols, ritual, practice, and, of course, religious
experience. We might agree or disagree with
Durkheim’s explanation; his explanation stands
or falls according to how well it accounts for the
evidence. That leaves his explanation on a par
with those derived from psychology, anthropol-
ogy, physiology, and even theology. Theologians,
for example, can agree with naturalistic expla-
nations without feeling threatened in any way.
After all, they can simply assert that God works
through the phenomena of the natural world and
an exhaustive naturalistic explanation does not
preclude His influence (Griffith-Dickson 2000).
Strategies that invoke ‘explanatory reduction’ do
not eliminate the possibility of ‘meaning-seeking’
on behalf of the subject. That is for two reasons.
(1) The experience is identified in the subject’s own
terms; that is, it still is an experience of God. (2)
The explanation leaves room for the experience
to have a theological value.
Descriptive reduction, on the other hand, is
when an experience is identified under a different
description from that of the subject. As Proud-
foot (1985) maintains, “to identify an experience
in nonreligious terms when the subject himself
describes it in religious terms is to misidentify the
experience, or to attend to another experience al-
together” (p. 196). To describe Femi’s experiences
of hearing the voice of God by reference only to
‘biochemical imbalance’ or ‘hallucination’ is to
mis-describe and “lose the identifying characteris-
tics of those experiences” (Proudfoot 1985). Such
explanations purport to give the origin or cause of
the experience and tend to limit its meaning and
significance to that; biomedical explanations of
psychiatry are reductionist in this sense.
This is clearly evident when we consider the
centrality of the form/content distinction in psy-
chiatric diagnosis; form is what is essential to
diagnosis in psychiatry (Sims 2003). The content
of Femi’s assertion that he is hearing the voice of
God was considered irrelevant to the diagnostic
process, but the form—here a hallucination—was
the key to supporting a diagnosis of ‘psychotic
episode.’ Content, on the other hand, is vari-
able; a factor of the patient’s beliefs and cultural
background. The assumption in psychiatry is that
form is universal and, ultimately, reducible to the
biopsychological phenomena. But in redescribing
his experiences in terms of an ‘abnormal form,’ we
have certainly lost the identifying characteristics
of the experience and are dealing with something
else altogether. This may hamper any further un-
derstanding of his experiences, an understanding
that can inform us why he (specifically) had an
experience of hearing the voice of God (not just
a hallucination) at this time and place. Such an
understanding can certainly include ‘biological
changes,’ just as it could include biographical,
social, historical, and cultural factors.
A descriptive reduction carries the implication
of sabotaging his own attempts at finding meaning
in his experiences. When considering a religious
experience, we cannot separate the value or mean-
ing of the experience from the perceived cause of
the experience (in this case explanation and under-
standing are opposite sides of the same coin). For
Femi, the voice he heard came from God and the
value of the experience cannot be separated from
that. His experiences were, initially, interpreted as
action guiding and positive insofar as they came
Rashed / Religious Experience and Psychiatry 193
from God, especially if you consider, as he did, that
whatever comes from God is intrinsically valued.
But they were also extrinsically valued because the
consequences where expected to be positive.
From a psychiatric point of view, he was hav-
ing a ‘psychotic episode,’ proximally caused by a
‘biopsychological disturbance.’ Furthermore, this
assessment of the ‘true’ cause of his experiences
was considered to be a matter of scientific fact and
certainly not subject to the values of psychiatric
science. After all, as a science, psychiatry is dedi-
cated to the discovery of the supposedly objective,
universal, and secular reality of mental illness.
There are problems with this position: we can only
speak of ‘biopsychological disturbances’ after we
have isolated the subject matter for intervention,
here the psychotic symptoms. But the judgment
that these symptoms are pathological has already
been made on other grounds. As Bolton (2000)
maintains, a judgment of disorder is usually made
through social unacceptability or “radical incom-
prehensibility,” whence then the talk of ‘biopsy-
chological disturbance’? At most we can only talk
of a number of factors (social, political, cultural,
psychological, and biological) that resulted in this
patient sitting in this room with that psychiatrist
at a certain time and place. The notion of a ‘biop-
sychological disturbance’ is not a value-free one;
it is invoked to account for what are essentially
socially undesirable or un-understandable behav-
iors or beliefs, the negative evaluation of which
is then transported to the theory of the probable
cause of the offending behavior or belief. The use
of the word ‘disturbance’ is therefore a reflection
of a relative/negative social judgment and not of
an objective and value-free state of affairs.
If we insist that his experiences are caused by
‘biopsychological disturbances,’ we are exporting
the value we attach to the supposed true cause of
the experience on to the experience itself. In es-
sence, it’s a process of value imposition. Let me
explain. Consider a building; you can attach to it
certain aesthetic values pertaining to form, beauty,
elegance, and simplicity. But then you learn that
contrary to what you thought, it was not built
from natural mud bricks (a material you consider
beautiful), but is made from prefabricated panels
(a material you consider inferior). Would that
change your aesthetic evaluation of the building as
a whole? It might, even though the building is still
beautiful and elegant by your own criteria. The
way we value an experience or an object, however,
is frequently affected by what we believe to be
constitutive of it. In considering an experience to
be caused by a ‘biopsychological disturbance’ we
are, by definition, devaluing the experience. And
in hospitalizing and treating a person like Femi,
we are forcing the negative value we place on the
experiences on to him.
A Matter of Priorities: Religious
Transformation Versus Social/Material
The DSM-IV (APA 1994) specifies work, inter-
personal relations, and self-care as three areas that
should feature in an assessment of function. These
factors have been taken somewhat too literally by
certain drug manufacturers who feature in their
drug promotion advertisements a colorful graphic
illustration of ‘functional impairment’: a wallet, a
teddy bear, and a shaving razor; presumably denot-
ing work, interpersonal relations, and self-care,
respectively. Hathaway (2003) suggested adding
other areas of functioning, specifically we should
include ‘clinically significant religious impairment’
as another area of functioning that could be com-
promised by mental disorder. Clinically significant
religious impairment is defined as a “reduced abil-
ity to perform religious activities, achieve religious
goals, or to experience religious states, due to a
psychological disorder” (p. 114).
But why should we stop there? After all, there
are so many other areas of functioning that mat-
ter to people but are not included in the DSM-IV.
Wouldn’t mental disorder affect a subject’s ability
for aesthetic appreciation? The point I am trying
to make is that the inclusion of these three areas
in the DSM-IV assessment of function must reflect
certain values as to what matters in life, which in
this case are inherently materialist. The question
then becomes if there are cases where these values
must be suspended to allow for potentialities that
are valued in a different context. Or, to be more
precise, should religious transformation be al-
lowed to continue even if it results in functional
deterioration as defined by the DSM?
194 PPP / Vol. 17, No. 3 / September 2010
It is well known that intense religious experienc-
es and involvement can result in social isolation,
absence from work, and deterioration in self-care.
Ascetics are actively encouraged by many religious
traditions to forego material and social accom-
plishment. There is no question of outcome here;
or, more precisely, the outcome does not have to
be measured in terms of material success or social
achievement. That is, we cannot assess whether an
ascetic should be allowed to continue in her way
of life only if that way of life can yield positive
outcomes. That is an empirical question and can
only be answered with reference to a certain set of
values and with the benefit of hindsight. It might
be the case that, according to her (and maybe her
religious tradition), the positive outcome is to get
‘closer to Divine truth’ at the expense of all forms
of social and material accomplishment.
If we existed in a culture that allowed ‘experi-
ences on a journey,’ the situation with Femi might
have been different. For better or for worse, he
might have been encouraged to pursue his religious
goals and maybe even supported through his in-
tense experiences. That, however, would not have
been possible. At the heart of the DSM-IV’s func-
tional assessment is an implicit prioritization of a
set of values that reflect a material (as opposed to
spiritual) outlook on what should matter in life.
In objection to this line of thought, it could
argued that ‘religious experiences and transfor-
mation that result in social and occupational
dysfunction are only unvalued if they are associ-
ated with a mental disorder; the critical point is to
determine the presence of disorder. If the ascetic I
am referring to above has a mental disorder, then
we have grounds for treatment.’ But that is exactly
the problem: as I have attempted to show, the judg-
ment of disorder is affected by the values implicit
in the diagnostic manuals, the values of all those
concerned, and the theoretical commitments of
psychiatry. When these values and commitments
are made explicit, there might not be disorder in
some cases of ‘mental disorder.’
Misapplication of the Cultural
Congruence Criterion
They called me mad, and I called them mad, and damn
them they outvoted me. (Nathaniel Lee, quoted in
Porter 1991)
To be able to apply the cultural congruence cri-
terion, clinicians need to (1) determine a relevant
cultural reference point, (2) seek the judgment
of cultural peers, and (3) accept the assumption
that absence of cultural validation is sufficient to
declare pathology. There are problems with each
of these points.
How Do We Determine a Subject’s Cultural
It is important to have a vision of what ‘culture’
is before we can talk of a ‘person’s cultural group.’
We can consider culture as “shared symbols and
meanings that people create in the process of social
interaction” (Jenkins and Barrett 2004, 5). Our
experience of the world and of our selves, our
interpretations of events, and our orientation in
action and thinking are all mediated and shaped
by culture (Ibid). Culture, therefore, includes
religion, as it does all other symbolic institutions.
But these symbols and meanings are not static,
reified entities and neither is the human agent. The
interaction between people and symbols at the cul-
tural level is characterized by reflexivity; it leaves
both changed. Shelly Ortner (1996) captures this
accurately in her account of the process whereby
cultural groups such as ‘women’ and ‘minorities’
are created. Such cultural categories or “histori-
cal subjects” are constructed and subjected to the
“cultural and historical discourses within which
they operate.” The human agent responds to the
world as given to them and could enact, resist,
negotiate, and ultimately—possibly—change the
world and re-produce new cultural categories.
But in so doing they also define themselves and
negotiate their own personal identity.
If we consider the DSM-IV cultural congru-
ence criterion, we would find that the sense in
which culture is used is, roughly, that of a ‘label’:
if subject A belongs to culture A, then should her
experiences violate the standards of culture A, we
can make a judgment of pathology. Two things
need to be presupposed if such a criterion is to
be of any value: (1) that there is a well-defined,
circumscribed cultural group that would serve
as a reference point, and (2) that the subject is
a perfectly well-adapted member of that group.
How can we determine that? In the case of Femi,
for example, there are multiple cultural influ-
Rashed / Religious Experience and Psychiatry 195
ences: there is his native West-African country,
Pentecostal Christianity (different churches), and
the influences of being a West African living in
London. To be able to judge whether his experi-
ences are normal or abnormal by appeal to cultural
congruence, we need to examine all the cultural
influences he had been subjected to and determine
to what degree he accepted, imbibed, resisted, or
negotiated these influences. Interestingly, in his
case, the church he had been in contact with in his
native country did consider his experiences to be a
normal part of spiritual development and actively
encouraged him. Then again, if we embrace this
fact and consider his experiences to be normal we
would be negating all other cultural influences in
his life.
Broad-brush cultural categorizations are insuf-
ficient to determine a person’s cultural belonging.
Even minor exposures to different cultures can
induce significant changes in a person’s basic sense
of self to the extent of affecting core self-processes
such as thinking, feeling, and agency. A recent
demonstration of this—in the case of psychosis—
is in John Barrett’s (2004) work with the Iban,
an indigenous people of Malaysia. Barrett found
that thought insertion was not part of the Iban
psychotic experience. He demonstrated that the
Iban concept of thinking is very different from
that found in the ‘West,’ and that the distinction
between thought and speech is not as explicit.
Despite a culturally sensitive re-translation of the
PSE-10 (the Present-State Examination), the idea
of ‘thought insertion’—of other beings knowing
your private thoughts—was nonsensical to the
Iban and was not part of the psychotic experience
(2004, 95–99). Interestingly, Barrett interviewed
subjects from the Iban population who were suf-
fering with psychosis and who have been exposed
to education and Christian teaching. He found
that these subjects did experience thought inser-
tion. The hypothesis he suggested was that these
subjects have been exposed to a cultural context
(the experience of an omnipotent, omniscient God)
in which it was possible that private thoughts can
be known by an outside entity (2004, 103).
The point is that the power of the cultural
congruence criterion collapses once we consider
the interaction between subject and culture to be
a reflexive process that can fundamentally alter
the person’s experience. If we classify a person as
a member of a specific cultural group, we would
be disregarding all the other influences he/she had
been exposed to, and at a time where multiple
cultural influences are available in our social
worlds this is simply untenable. To be able to use
culture as a reference point, we need to engage in a
painstaking examination of the myriad influences
a person has been subjected to, only then can we
begin to make a fair judgment.
The Commitments of the Cultural Group
and How That Shapes Their Judgments of
Before we can accept the opinion of the father
or the church with regards to the abnormality
of Femi’s experiences, we need to consider what
commitments they bring to the process. Femi’s
father, himself a very religious man, did not worry
too much about how we, the psychiatrists, would
treat his son. He wanted him “back to how he
was,” and that entailed resuming church atten-
dance with him, going to work, helping with the
expenses, and so on. This reminds me of a brief
case study (Littlewood and Lipsedge 2004) of
Chaim, a 14-year-old boy in an ultra-orthodox
Jewish family in London. His parents considered
his withdrawal from reading Talmudic texts and
his un-orthodox beliefs and wishes to be a sign of
mental illness. The family doctor (who was an or-
thodox Jew himself) concurred and was convinced
the boy had schizophrenia. On further examina-
tion and on visiting the household, the authors
found that the problem lies in the conflict created
by the boy’s wish to transcend the narrow limits
of ultra-orthodox life and to pursue different life-
styles offered by the wider community he exists in.
For his deeply religious parents, that wish was in
itself a sign that their boy had gone ‘mad.’ Chaim’s
family and Femi’s father had a huge investment
in wanting their children to return to how they
were. The transgressions committed by Chaim
and Femi were never seen as alternative possibili-
ties that could be pursued; rather, the thought of
a radically different way of life became, for the
families, the conviction that their children were
ill. Essentially, then, there was a conflict of values
between the family and the child committing the
transgression, a conflict immediately obscured the
196 PPP / Vol. 17, No. 3 / September 2010
moment the child was nominated as the source of
the problem and considered ill.
The church itself has its own commitments. In
asking Femi’s original church if his experiences
are abnormal, we are in effect asking them to
tell us whether they consider his religiosity to be
healthy or unhealthy (where unhealthy, in this
context, usually means ‘a consequence of mental
illness’). As Littlewood and Lipsedge (2004) point
out, it has not always been a task of a church to
make a distinction between healthy and unhealthy
religiosity; in fact, they argue, it is quite a recent
development. Larger churches do not want conflict
with the domain reserved for science and aim at
‘accommodating’ the opinions and judgments of
medical professionals (Littlewood and Lipsedge
2004, 187). Smaller sects, however, consider the
move to accommodate medicine as a threat and
are willing to take matters of healing in to their
own hands (Ibid.).
Here, then, we can partly understand why the
London-based church considered Femi’s experi-
ences abnormal, whereas the church in his native
country—isolated from the political influences
in an advanced capitalist nation—encouraged
him. Surely their ‘theological criteria’ for judg-
ing religious experiences differed but also, and
importantly, the contexts within which the two
churches operated were different and that carried
with it different commitments that affected their
Where Should We Look for “Congruence”?
Congruence is present if members of the cul-
tural group validate the experiences and beliefs
of the subject. In the case of Femi, both his father
and the London church considered his experiences
(of hearing the voice of God and feeling controlled
by God) to violate the boundary of ‘allowable’
experiences, even in a religious context. I argue,
however, that in assessing congruence we should
not be confined to mere validation or otherwise by
the group, and must consider, instead, whether the
experiences are permissible within the culturally
accepted epistemology. Let me explain.
Here is a brief account of the beliefs of the
Lakota tribe, a Plains Indian tribe:
Any encounter with a deceased relative is construed by
the Lakota as a sign of misfortune, usually a warning to
prepare for one’s approaching death. . . . When a person
hears the ancestral voice, he or she is called by name
or by the appropriate kin term. . . . In some cases, the
voice says, “Come!” . . . Usually, however, the person
who hears the voice prepares, together with his or her
kin, for his or her death. (Spiro 2001, 222)
It is culturally normative for the Lakota to hear
the voice of the deceased. This would seem to be
a paradigmatic case of the kind of experiences and
beliefs that the DSM-IV wants us to save from
the label of ‘psychopathology.’ Indeed here is the
DSM-IV sourcebook:
Many Plains Indians [the Lakota are a Plains Indian
tribe] hear the voice of a recently deceased relative
calling them from the after-world. The experience is
normative and without pathological sequelae for mem-
bers of these communities, and therefore by definition
cannot be abnormal. On the other hand, for an adult
white North American, it might well be a hallucination
with serious mental health consequences (Kleinman et
al. 1997, 868–869)
This account brings forth two questions: why
is the Lakota-Indian experience of hearing the
voice of a deceased relative normative? Why is
a similar experience in a white North American
pathological? The maintenance of such an experi-
ence in the Lakota Indians points to two things:
that the experiences are constituted in different
individuals through similar routes, and that they
are permissible within the culturally accepted
epistemology. The Lakota Indians believe in an
afterworld, they believe that deceased relatives
and ancestors can communicate to them in this
world, they believe that this communication can
be a voice, and when that happens they consider
themselves to possess a piece of information from
the afterworld, they then act accordingly. Hear-
ing the voice of the deceased is therefore not only
possible on a wide-scale among them, but is also
entirely normative as it falls within their own
epistemological boundaries.
On the other hand, encountering a white North
American having a similar experience usually
evokes worry in most of us. Her experience vio-
lates our deeply held epistemological convictions
and represents a clear error. Similarly, a Lakota
Indian who reports hearing the voice of his (living)
Rashed / Religious Experience and Psychiatry 197
absent son might be considered by the group to be
having an abnormal experience: their epistemology
accounts for a deceased relative talking to you, and
not for hearing the voice of living people when they
are not around. I would, therefore, argue that in
assessing the cultural congruence of an experience
we should go beyond mere validation and try to
consider whether it is permissible within the episte-
mology of the cultural group. If group A believe in
a supernatural order and allow that God can talk
to people and at times control their actions and
thoughts, then surely a subject—whom we have
good reason to believe is an adapted member of
group A—having precisely those experiences can-
not be considered to be culturally errant.
I can be accused, however, of conflating belief
and experience. It could be argued that although it
is normative for group A to believe that God can
talk to people, it is nevertheless still abnormal to
have a psychological experience of hearing God’s
voice. Melford Spiro (2001) makes this point in
relation to the Lakota Indians and argues that
although the Indian’s belief in ancestors calling
from the afterworld is culturally normative, the
actual experience of hearing a voice is psychologi-
cally abnormal because it “confuses an event in
the inner world with one in the outer world” and
“constitutes a failure in reality testing” which in
his view makes the experience itself pathological
“whatever its sequelae” (p. 223).
Spiro seems to be making two errors here: first,
he assumes that belief and experience are wholly
independent entities and fails to appreciate that
experience is constituted in large measure by pre-
existing beliefs and concepts (Proudfoot 1985).5
It is unlikely, for example, that the Lakota Indians
would hear the voice of deceased relatives had it
not been for the prior existence of beliefs in the
afterworld and the ability of ancestors to com-
municate from it. Hence, it is a contradiction to
say that the belief is culturally normative while the
experience (which is in large measure constituted
by the beliefs) is abnormal.
Second, he is importing the assumptions of a
certain epistemological tradition and applying
them in a different culture as universal standards
the violation of which is sufficient to constitute
pathology. Of course, Spiro’s motivation is to
oppose normative cultural relativism by arguing
for universal, extra-cultural (here scientific) stan-
dards for judging experience. But in doing so he
is missing the point: what makes an experience
‘pathological’ or ‘abnormal’ is in large measure a
complex judgment that involves social and cultural
norms, the response of others, the appraisal of the
subject, the values of all those involved and finally
the outcome of the experience. It is not a detached
judgment that can simply be made by appeal to
some universal standard according to which ‘the
confusion of an event in the inner world with one
in the outer world’ is sufficient for pathology.
With this understanding of cultural congruence
at hand we can reconsider Femi; are his experienc-
es culturally congruent? To answer this question,
we need to examine his cultural groups’ beliefs
and the epistemological boundaries they place on
experience. Not surprisingly such an examination
would reveal that by the standards of his father,
his London-based church, and the church in his
native country he is culturally congruent; for all
believe that God can talk to you, order you to do
things, talk through you (talking in tongues), and
even control you.
The psychiatric commitment to an empiri-
cist/positivist approach to unusual experiences
involves a redescription of those experiences in
secular/biomedical terms. This redescription may
not meet the approval of the patient, especially if
those experiences are apprehended in a religious
framework. Furthermore, in attending to unusual
experiences in a biomedical language that empha-
sizes ‘disorder,’ ‘disturbance,’ and so on, clinicians
are—in effect—imposing the negative values as-
sociated with these terms on to the experiences,
which plays a negative role in any subsequent
evaluations of those experiences and contributes to
the generation of harm. A closely related problem
pertains to the prioritization of materialist values
embedded in the DSM-IV’s functional assessment
over values associated with religious accomplish-
ment. This has the effect of narrowing down the
scope of function to a number of factors related
to material accomplishment, allowing clinicians to
declare the presence of ‘social and occupational
dysfunction’ in neglect to other areas of function-
ing that are valued by the patient.
198 PPP / Vol. 17, No. 3 / September 2010
Finally, and as I attempted to demonstrate in
the previous subsection, once we unpack the cul-
tural congruence criterion, it no longer does the
work it is supposed to do, which is to separate
normal from abnormal beliefs and experiences by
appeal to the subject’s cultural group. The man-
ner the cultural congruence criterion is applied,
however, obscures this fundamental point. If the
three problems discussed—broad-brush cultural
categorizations, unexamined commitments of
cultural peers, and a tendency to accept absence of
validation as sufficient for judging ‘abnormality’—
are not attended to, absence of cultural congru-
ence is hastily declared. This adds to the clinical
conviction that the patient is ‘ill,’ thus promoting
further invalidation and justifying inappropriate
hospital treatment, factors—as indicated earlier—
implicated in the generation of harm.
‘The Danger of Words’
So far, I have attempted to demonstrate the
problems with the diagnostic process, specifically
how the assumptions and procedures of this pro-
cess are, in certain cases, directly implicated in the
generation of harm. How can we get out of this
conflict? I propose that a way out is to engage the
patient in an open-ended process of communica-
tion conducted with the purpose of achieving a
degree of linguistic resonance among the involved
parties. This would include—but would not be
limited to—agreement on some form of explana-
tory and meaning-giving framework. But for this
to work we require a conceptual shift to the effect
of assessing a verbal report of an experience not in
terms of its representational truth but in terms of
how well it resonates with other parties involved
in the process and, more generally, with society.
A Deeply Embedded Epistemological
The psychiatrist and social worker who did
the mental health act assessment on Femi simply
did not believe him. There was no question of
God really talking to him despite his sincerity
and conviction in asserting so. His experiences
constitute an ‘epistemological fault’ and cannot
yield knowledge about the world. The DSM-IV
and indeed the whole of psychiatric theory are
riddled with certain epistemological assumptions.
As Sadler (2005) emphasizes, Western biomedicine
and its offshoot psychiatry “put(s) a high valence
on truth” where research is “based on the idea
that the truths of how the world works are found
through the formulation of hypotheses that are
tested through experience and observation”
(273–274; emphasis added). It obviously matters
what kind of experiences are to count as valid.
The scientific (and psychiatric) worldview is,
roughly, of a mind-independent reality; our task
is to represent it as accurately as possible. Truth
within this reality would be of a correspondence
type; we would have true knowledge about the
world if we are able to represent reality faithfully
and accurately. The project of epistemology then
is to pinpoint and defend certain privileged repre-
sentations (Rorty 1980).6 Candidates for these rep-
resentations have been, traditionally, basic sense
experience and conceptual/analytic truths. The
logical-positivists of the Vienna Circle endorsed
such a position (McGrath 1998). They proposed
that only two types of statements are meaning-
ful: those that can be verified by experience and
observation, and those that are true by virtue of
their meaning (analytic statements). With these
two kinds of ‘privileged representations,’ we can
derive a complete picture of the world. Psychotic
experiences cannot, therefore, be characterized
as states of ‘knowing’; they violate the accepted
routes of epistemic access.
This view of epistemology—and with it our
understanding of what a verbal report of an
experience means—has been challenged over the
past few decades. In Philosophy and the Mirror
of Nature, Richard Rorty (1980) traces the chal-
lenge to traditional epistemology back to Sellars
(1956/1997), Quine (1953/1980), and Wittgen-
stein (1953/1996). According to Rorty, both Sell-
ars and Quine reach the same conclusion—that
knowledge is inseparable from the social practice
of justifying our beliefs to other fellow humans
and is not a matter of ‘accuracy of representation.’
They do so, however, by attacking different strands
of the logical-positivists’ position.
Sellars attacked the idea that there is a basic
given in experience, a given that is then articulated
Rashed / Religious Experience and Psychiatry 199
and described. Launching his attack at sense-
data empiricism he argued that the senses do not
‘give’ us facts; rather, knowledge presupposes the
prior existence of concepts and learning. In this
view, epistemic discourse is irreducibly normative
(Rosenberg 2006). He wrote:
In characterizing an episode or state as that of know-
ing, we are not giving an empirical description of that
episode or state; we are placing it in the logical space
of reasons, of justifying and being able to justify what
one says. (Sellars 1956/1997, sec. 36)
Quine attacked the notion of analyticity, that
there are statements true by virtue of meaning
alone.7 The claim that no statements are immune
from revision implies that analytic statements
cease to be ‘privileged representations.’ Together,
the work of Sellars and Quine brought down the
logical-positivists faith in sense-data empiricism
and analyticity. Wittgenstein (1953/1996) was
able to illuminate our understanding of what a
verbal report of an experience means and how that
relates to knowledge after the idea of knowledge
as ‘accuracy of representation’ is discarded.8 Here
we have the idea of knowledge as truths grounded
in certain linguistic practices. When we report an
experience we are giving a description of it—an
interpretation—that stands or falls according to
how well it resonates with the wider community
we exist in and not on the basis of how well it
represents some independent reality (whether
internal or external) accurately. These observa-
tions have decisive implications on how we view
psychotic experience.
Psychosis, Community, and Choice of
If we assess a psychotic experience by attending
to the language it is expressed in and not limiting
ourselves to whether it corresponds to an inde-
pendent reality (through privileged epistemologi-
cal routes), we can begin to uncover the sources
of conflict—and agreement—between the person
having those experiences and their community,
including the psychiatric authority. It has been
long recognized that subjects undergoing psychotic
experiences are engaged in an active process of
‘meaning-finding’ as a way of making sense of
disturbing sensations and experiences (Kleinman
1980; Lindow 1986; Larsen 2004). This amounts
to the subject creating a narrative that can accom-
modate those experiences, preferably in terms
that are consistent with her personal biography.
Biomedical language is only one possible language
in this process.
A subject can talk about her psychotic experi-
ences in biomedical terms, invoking notions of
‘neurochemical imbalance’ and ‘brain distur-
bances.’ She can adopt psychological language
using terms such as ‘conflict,’ ‘ego strength,’ ‘com-
pensation,’ or ‘coping strategies.’ But she can also
invoke religious, spiritual, or existential language
in making sense of her experiences. What language
is chosen depends on the available resources in that
individual’s life, resources drawn from the wider
cultural and subcultural repertoire. As Larsen
(2004) says, the choice of explanation (language)
will depend on the subject’s “social positioning:
influences from institutions, public media and
social networks” (p. 465).
The degree of ‘linguistic resonance’ the subject
encounters with the wider culture determines to
a large extent how her choice of language will
be received, whether it will be validated, and
therefore whether it will serve the dual function
of explaining her experiences within a coherent
narrative while allowing her to find acceptance
in the community she exists in. Of course, differ-
ent people have different degrees of flexibility in
negotiating and renegotiating the language they
use to talk about their experiences. An explana-
tion that is dogmatically held to despite finding no
resonance in the individual’s culture may very well
be considered delusional (Larsen 2004).
Here, we have the possibility that any explana-
tion can be ‘delusional’ in the sense outlined if it
finds no resonance in the cultural group and is
dogmatically held to. I recall a patient who in-
sisted that all his problems are a consequence of
‘neurochemical imbalance’ despite the professional
opinion that his problems are better explained
and dealt with in a psychological framework.
Yet a psychotic patient who adopts biomedical
language is usually considered to have insight and
his hallucinations become ‘pseudo-hallucinations.’
Similarly, in a religious context, it is at least a pos-
200 PPP / Vol. 17, No. 3 / September 2010
sibility that using biomedical language to account
for the experience of ‘hearing the voice of God’
will be highly unacceptable as a replacement for
religious language.
Communication, Linguistic Resonance,
and the Fate of Diagnosis
Let us return to the case of Femi. The language
he used to talk about his experiences found reso-
nance only with the church he was in contact with
in his native country. The psychiatric team deemed
his explanations false. The focus in treatment was
partly to enable him to gain ‘Primary Insight,’
which amounts to a convergence of the inferences
he drew from his experiences to match those of the
professionals’ opinions.9 That meant that he had
to forego the explanation that God had spoken to
him and adopt instead a biomedical language that
emphasizes disturbance, disorder, and pathology.
But why—left to his own devices and not forced
to change—would he swap from a religious to a
nonreligious (here biomedical) language if there
are no practical advantages to be gained? In other
words, he must have a motivation to change and
that cannot be brought about (although the change
itself can of course be) through involuntary hos-
pitalization and forced treatment.
My proposal, then, hinges on the possibility
of an open-ended process of communication, a
process that involves all the parties that have a
stake in the problem: typically that would include
the patient, members of the influential social circle
(family, religious figures, etc.), and mental health
professionals, the latter—considering the current
institutional arrangements—playing a crucial
mediating role. The moment of contact between
these parties would not be motivated by a quest
for the truth, the truth in an empiricist/positivist
sense, but would be a striving toward some com-
mon ground that would unite the mental health
professional and the patient and, importantly, a
ground that unites the patient with the society they
exist in. To achieve this, we need first to realize
that part of the crisis lies in the fact that different
languages and their associated values are adopted
by the involved parties to attend to the problem.
A way out of this crisis is for all parties to engage
in a process of communication that involves an
attempt to modify the language they use to talk
about the problem. It would not do, for example,
to insist that regardless of what the patient asserts,
the voice she hears is a hallucination, a symptom
of a psychotic disorder; instead, we need to adopt
the patient’s own language, and frame the problem
in terms that would meet her approval. This would
inevitably involve some sort of agreement on ‘what
is going on,’ on a meaning-giving and explanatory
framework, the whole process thus placing us in
a much more productive position both in terms
of agreeing on a course of noncoercive, respectful
intervention and in working with the patient in
finding out why the language she adopts to talk
about her experiences does not meet the approval
of others.10
What place does diagnosis have in such a pro-
cess? Within the advanced perspective, diagnosis
is a linguistic practice parallel with all others.
As such, whether or not to adopt a nosological/
medical framework is a question that can only be
answered in the context of an open-ended process
of communication. If this process leads to agree-
ment on a religious framework then we can begin
to think of pastoral care and so on, if it leads to a
biomedical framework, then imparting a diagnosis
and hospital psychiatry may be appropriate; if it
leads to a psychological framework, then a psy-
chological formulation and a therapeutic context
may be required, and so on.
It remains a pressing reality, however, that
regardless of where conceptual work takes us
we remain confronted by existing institutions
and problems that require urgent intervention,
usually through the available institutions. In our
society, the main one happens to be psychiatry. I
have argued that diagnosis should not be the main
priority in every case, and that it should only be
adopted—as I discussed above—if an open-ended
process of communication leads to agreement on a
nosological/medical framework. That being said,
and as I just mentioned, psychiatry happens to be
the main port of call for psychologically distressed
individuals, as such it may be wiser—so long as the
current institutional arrangements remain—not
to abandon diagnosis all together but to use the
existing nosological framework to secure the kind
of help and support the patient needs. In the case
Rashed / Religious Experience and Psychiatry 201
of Femi, for example, and after agreement that a
religious framework is the most appropriate for
his problems, a DSM-IV (APA 1994) diagnosis of
V62.89 (religious or spiritual problem) could be
provided only to facilitate a combined hospital/
church input and support. What we should avoid,
however, is the imposition of a diagnostic category
regardless of all other considerations. The hope
remains for a plurality of institutions, with psy-
chiatry having no privileged position in relation
to religious, psychological, and other avenues of
care. That may alleviate the need for diagnosis
altogether (in those cases where a nosological/
medical framework is deemed inappropriate),
especially if care could be arranged through
alternative means without the requirement of a
legitimating diagnosis.
Communication, Linguistic Resonance,
and Risk
In the preceding account I have been assuming
that an open-ended process of communication
will inevitably lead to some form of agreement.
We know, of course, that that may not always be
the case. What are we to do if, despite best inten-
tions and open negotiations, linguistic resonance
cannot be achieved, complete agreement cannot be
secured, and conflicts of values persist? The most
obvious and extreme cases are patients intent on
killing themselves, are engaged in a course of ac-
tion that will lead to that, or if they are intent on
hurting someone else.
Essentially, then, the question is: if my proposal
is adopted, what are we to do with risk? Typi-
cally, involuntary hospitalization under section
‘2’ of the mental health act is brought about if a
patient qualifies for a ‘mental disorder of a nature
or degree that warrants detention’ in addition to
actual or perceived risk to self or others. Earlier
(p. 189) I made the point that harm to others is not
my concern, that being harm to self experienced
as suffering, incapacity, or in extreme cases threats
to physical integrity or survival. In any case we
still can—with relative ease—get ‘risk to others’
out of the way. To do so we could argue, along
with others, that protection of the public is a legal
and police matter that psychiatrists could do well
to take a back seat in implementing—if only to
suppress claims of the use of psychiatry as a tool
for social control—or, at least, to implement it
knowing in advance that imposing a diagnosis
to justify incarceration may lie contrary to the
patients’ best interests (see, for example, Bolton
[2008, 233–237]).
In the case of actual or perceived risk to self,
specifically risk of serious self-neglect, risk of com-
pleted suicide, and risk of fatal self-harm, there are
different matters to consider. The question here is:
if we accept my proposal, at what point would in-
voluntary hospitalization be recommended in such
cases? To narrow it down, we need to consider two
scenarios, assuming that in all of them an open-
ended process of communication was allowed
to occur, linguistic resonance attempted, and the
values of all the involved parties have been laid
bare. The first possibility is that this process has
led to partial agreement on what to do. It might
be the case (think of an alternative to the manner
the case of Femi was handled) that the involved
parties agree the problem should be managed in a
religious framework in which case threats to self
posed by excessive fasting or self-neglect would
be handled; in other words, we enlist the help of
a suitable and agreed upon authority. The second
possibility is when the process fails; despite best
intentions and open negotiations, linguistic reso-
nance cannot be achieved and conflicts of values
persist (think of a psychotic patient with command
hallucinations telling her to kill herself). In such a
situation, I am unable to think of a ‘way out’ that
would not involve an appeal to some independent
ground to decide what to do (see Jackson and Ful-
ford [1997, 57]). This may involve an appeal—on
absolute moral grounds—that we should not allow
a person to kill herself, coupled with an apprecia-
tion that that person would not have attempted
to do so had it not been for intrusive and possibly
temporary hallucinations.
In principle, then, the proposed approach can
be adopted and carried through, knowing that in
certain instances and despite all attempts agree-
ment may not be reached. What to do when that
happens is a difficult but separate question.
202 PPP / Vol. 17, No. 3 / September 2010
The assumptions and procedures of the diag-
nostic process in psychiatry are—in certain cases—
implicated in the generation of harm. Moreover,
this seems to be due to problems embedded in the
process itself rather than the incompetence of one
clinician or another. If we reformulate the clinical
encounter as, essentially, a meeting of divergent
linguistic practices we place the encounter on
an important first step: a quest for agreement. It
may seem that accepting the proposed approach
would render the important vocation of helping
the distressed vulnerable to an ‘anything goes’
relativism. As I see it, however, the moment of
contact between mental health professionals, pa-
tients and other involved parties is not a quest for
the truth; it is an attempt to transcend any form
of explanatory, value-imposing framework—be it
biomedical, psychological, etc.—that neglects the
subject’s personal values, for a framework that—as
far as possible—secures the agreement of all. This
must be the minimum standard for the generation
of noncoercive and respectful intervention, and
is therefore what we should aim for. Theoretical
endeavors—attempts to explain psychotic phe-
nomena in biological or psychological terms for
example—are of course important, but they are
important in so far as securing agreement on some
such account provides ground for intervention that
meets the approval of the patient.
Finally, from the perspective charted in this
paper, there is no difference between a religious
experience (with psychotic phenomenology) and
other psychotic experiences over and above the
language used to talk about the experience. An
appreciation of the ‘danger of words’ would show
that to be a significant difference, after all a simple
change from religious to biomedical language can
change the whole future of a person. Whether
adopting a religious outlook will lead to a benign
or malign outcome for those undergoing experi-
ences with psychotic phenomenology cannot be
established before hand, and indeed is not wholly
determined by the clinical encounter. But to avoid
transforming this encounter into one of the factors
implicated in the generation of malign outcomes,
clinicians need to engage the patient in an open-
ended process of communication and to forego
one-sided judgment.
This paper has benefited from the comments of
three anonymous referees.
1. When we speak of reduction of agency in this
context, we are referring to certain mental states—
inner speech and thoughts—that lack the sense of
being internally generated or willed by the subject. If
we think about ‘voices’ in this way, we could meet the
objections of certain thinkers who might argue that
we are ignoring the possibility that God might be re-
ally talking to the person. I choose to remain agnostic
about such a possibility and to attend instead to the
phenomena conceived off in a naturalistic way, that is,
as inner speech and thoughts that lack the usual sense
of agency and therefore come to be experienced as
external. That being said, I do not see a contradiction
between a phenomenon involving reduction in agency
while being valued in certain religious traditions. In
other words I use ‘reduction in agency’ in a nonevalu-
ative sense, as a way of describing an essential aspect
of a certain experience. The fact that certain religious
traditions encourage a relinquishing of personal agency
to a higher power is consistent with thinking of certain
states as involving reduction in agency. (See Dein and
Littlewood [2007] for a similar point).
2. I maintain that, by definition, his experiences
involve incapacity. However, there is no ‘harm’ at this
stage, where harm is defined as a ‘negatively evalu-
ated experience of incapacity.’ Harm depends on how
he evaluates his experiences and the point is that this
evaluation is inextricably bound to how others respond.
Hence, the crucial importance of attending to the values
of all the involved parties—including the psychiatric
authority—and to the procedures of the diagnostic
process before making any final decisions as to the
origin of harm.
3. Two aspects of values are relevant for the purposes
of this paper: values describe a quality of something,
they determine a thing’s worth and they function to
guide and influence peoples actions (Sadler 2005). Val-
ues can be intrinsic, in which case we value a thing in
and off itself, or extrinsic in which case we value a thing
because of the desirable consequences it brings (Ibid.).
4. Indeed had the context been different, he might
have been hailed as a spiritual figure. See, for example,
Littlewood and Lispsedge (2004) and Littlewood (1997)
for a discussion of some factors that may transform
psychopathology [in the medical sense] to religious
5. Proudfoot (1985) takes as a starting point for his
position the ideas of Immanuel Kant in his Critique of
Practical Reason (1956). Kant demonstrated that the
mind is active in experience and that objects of our
Rashed / Religious Experience and Psychiatry 203
experience cannot be grasped in themselves but only
through the “forms of sense and the categories that
structure the judgments we make” (Proudfoot 1985, 3).
Kant’s position with regards to metaphysical specula-
tion is well known: whereas experience is shaped by the
forms of sense and categories of judgment, these forms
and categories cannot yield knowledge that transcends
our experience. In that sense, certain concepts (God,
for example) refer to objects that we can not have any
knowledge about. But although that might be the case,
these concepts are still fundamental in constituting
certain experiences. Religious concepts and beliefs, as
Proudfoot maintains, are formative; they shape emo-
tions and experiences.
6. The idea of ‘Man’ as an ‘epistemological subject’
has occupied the foreground in philosophy since Des-
cartes. Here we have a human being conceived as “an
intellect that registers sense-data, makes propositions,
reasons, and seeks the certainty of intellectual knowl-
edge” (Barrett 1962/1990, 276).
7. According to the logical-positivists, the truth of
analytic statements is guaranteed a priori, because the
meaning of such statements is fixed by the conventions
of language. Quine was able to show that no statement
is immune from revision; hence no statement is purely
analytic. A statement such as, “A straight line is the
shortest distance between two points” would seem to
be true by virtue of meaning. But that only holds in a
Euclidean world; with the advent of the theory of rela-
tivity we have come to learn of the curvature of space/
time; hence, the statement above is actually false.
8. Wittgenstein’s beetle is especially illuminating
Suppose everyone had a box with something
in it: we call it a ‘beetle.’ No one can look into
anyone else’s box, and everyone says he knows
what a beetle is only by looking at his beetle.
Here it would be quite possible for everyone to
have something different in his box. One might
even imagine such a thing constantly changing.
But suppose the word ‘beetle’ had a use in these
people’s language? If so it would not be used as
the name of a thing. The thing in the box has no
place in the language-game at all; not even as
a something: for the box might even be empty.
(Wittgenstein 1953/1996, sec. 293).
In reporting a beetle (or a headache) we are referring to
“whatever is in the box,” which might very well be com-
pletely different from what is in other people’s boxes.
But the purpose of the word ‘beetle’ (or headache) is
not to refer to an identical object (or brain state) that I
and other people have but to refer to whatever is in the
box (i.e. to an introspectively reportable change in the
nervous system) and that might widely differ between
you and me. To extend the analogy further, we have
been taught to use the word beetle under certain circum-
stances, its part of a ‘language-game,’ as such whether
or not we are using the word accurately depends on a
linguistic community and the inferences they permit to
and from such experiences.
9. Insight is generally considered to be a multidi-
mensional and continuous construct. It involves rec-
ognition by the patient that they are suffering from a
mental illness, an ability to label unusual mental states
as pathological and agreement on the attribution of
proper causes to symptoms (David 1990; Amador and
Strauss 1993). In practical terms, these dimensions all
involve a discrepancy between the patient’s opinion
(concerning their mental states) and the opinions of the
professionals, and it is this aspect of insight that I am
referring to here as ‘Primary Insight.’
10. This last point recalls the concept of ‘secondary
insight,’ which I take as referring to the subject’s ability
to take an observer view of herself and to appreciate
that she might have deviated from consensual opinion
in what she is asserting. In working with the patient
toward secondary insight, we develop, with the patient,
an understanding of why other people (the relevant [sub]
cultural group) might find her experiences and the lan-
guage she uses to talk about them unusual or bizarre.
Amador, X., and D. Strauss. 1993. Poor insight in
schizophrenia. Psychiatric Quarterly 64:305–18.
American Psychiatric Association (APA). 1994. Diag-
nostic and statistical manual of mental disorders,
4th edition. New York: American Psychiatric As-
Barrett, R. 2004. Kurt Schneider in Borneo: Do first
rank symptoms apply to the Iban? In Schizophrenia,
culture & subjectivity, ed. J. Jenkins, and R. Barrett,
87–109. Cambridge: Cambridge University Press.
———. 1962/1990. Irrational man: A study in existen-
tial philosophy. New York: Anchor Books.
Bolton, D. 2000. Continuing commentary: Alternatives
to disorder. Philosophy, Psychiatry, & Psychology
7, no. 2:141–53.
———. 2004. Values in the definition of mental disor-
der. Psychiatry 3, no. 3:2–4.
———. 2008. What is mental disorder? Oxford: Uni-
versity Press.
Bracken, P. 1993. Post-empiricism and psychiatry:
Meaning and methodology in cross-cultural research.
Social Science and Medicine 36, no. 3:265–72.
David, A. 1990. Insight & psychosis. British Journal of
Psychiatry 156:798–808.
Dein, S., and R. Littlewood. 2007. The voice of God.
Anthropology & Medicine 14, no. 2:213–28.
Drury, M. 1996. The danger of words and writings on
Wittgenstein. Bristol: Thoemmes Press.
204 PPP / Vol. 17, No. 3 / September 2010
Durkheim, E. 1965/1976. The elementary forms of
religious life. London: Harper Collins.
Frith, C. 1992. The cognitive neuropsychology of
schizophrenia. Hillsdale, NJ: Lawrence Erlbaum
Frith, C., and D. Done. 1988. Towards a neuropsychol-
ogy of schizophrenia. British Journal of Psychiatry
Fulford, K. W. M. 1996. Religion & psychiatry: Extend-
ing the limits of tolerance. In Psychiatry and religion:
Context, consensus and controversies, ed. D. Bhugra,
5–22. London: Routledge.
Griffith-Dickson, G. 2000. Human and divine: An in-
troduction to the philosophy of religious experience.
London: Duckworth.
Hathaway, W. 2003. Clinically significant religious
impairment. Mental Health, Religion and Culture
6, no. 2:113–29.
Jackson, M. 2001. Psychotic and spiritual experience: A
case study comparison. In Psychosis and spirituality:
Exploring the new frontier, ed. I. Clarke, 165–90.
London: Whurr Publishers Ltd.
———. 2007. The clinician’s illusion and benign
psychosis. In Reconceiving schizophrenia, ed. M.
Chung, K. W. M. Fulford, and G. Graham, 235–54.
Oxford: University Press.
Jackson, M., and K. W. M. Fulford. 1997. Spiritual ex-
perience & psychopathology. Philosophy, Psychiatry,
& Psychology 4, no. 1:41–65.
———. 2002. Psychosis good and bad: Values-based
practice and the distinction between pathological
and nonpathological forms of psychotic experi-
ence. Philosophy, Psychiatry, & Psychology 9, no.
James, W. 1902. The varieties of religious experience.
Glasgow: Collins.
Jaspers, K. 1959/1997. General psychopathology. Lon-
don: The John Hopkins University Press.
Jenkins, J., and R. Barrett. 2004. Introduction. In
Schizophrenia, culture & subjectivity, ed. J. Jenkins
and R. Barrett, 1–28. Cambridge: Cambridge Uni-
versity Press.
Kant, I. 1956. Critique of practical reason. Indianapolis:
Kleinman, A. 1980. Patients and healers in the context
of culture: An exploration of the borderland between
anthropology, medicine, and psychiatry. Berkeley:
University of California Press.
Kleinman. A., D. L. Parrone, H. Fabrega, B. Good,
and J. E. Mezzich. 1997. Culture in DSM-IV. In
DSM-IV sourcebook, volume 3, ed. T. Widiger, A.
Frances, H. Pincus, R. Ross, M. First, and W. Davis,
867–83. Washington, DC: American Psychiatric
Larsen, J. 2004. Finding meaning in first episode
psychosis: Experience, agency and the cultural
repertoire. Medical Anthropology Quarterly 18,
no. 4:447–71.
Littlewood, R. 1996. Psychopathology, embodiment
and religious innovation: An historical instance.
In Psychiatry and religion: Context, consensus and
controversies, ed. D. Bhugra, 178–97. London:
———. 1997. Commentary on “Spiritual experience
and psychopathology.” Philosophy, Psychiatry, &
Psychology 4, no. 1:67–73.
Littlewood, R., and M. Lipsedge. 2004. Aliens & alien-
ists: Ethnic minorities & psychiatry. New York:
Lindow, V. 1986. The social consequences of seeing a
psychiatrist. Ph.D. thesis. University of Bristol.
Marzanski, M., and M. Bratton. 2002. Psychopatho-
logical symptoms and religious experience: A critique
of Jackson and Fulford. Philosophy, Psychiatry, &
Psychology 9, no. 4:359–71.
McGrath, A. 1998. Science & religion: An introduction.
Oxford: Blackwell.
Ortner, S. 1996. Making gender: The politics and erotics
of culture. Boston: Beacon Press.
Porter, R. 1991. The Faber book of madness. London:
Faber & Faber.
Proudfoot, W. 1985. Religious experience. Berkeley:
University of California Press.
Quine, W. 1953/1980. From a logical point of view.
Cambridge: Harvard University Press.
Rorty, R. 1980. Philosophy and the mirror of nature.
Oxford: Basil Blackwell.
Rosenberg, J. 2006. Wilfrid Sellars. Stanford Encyclo-
paedia of Philosophy. Available online: http://plato.
Sadler, J. 2005. Values & psychiatric diagnosis. Oxford:
University Press.
Sellars, W. 1956/1997. Empiricism and the philosophy
of mind, ed. R. Brandom. Cambridge: Harvard
University Press.
Sims, A. 2003. Symptoms in the mind. Philadelphia:
Spiro, M. 2001. Cultural determinism, Cultural relativ-
ism and the comparative study of psychopathology.
Ethos 29, no. 2: 218–34.
Szasz, T. 1960. The myth of mental illness. American
Psychologist 15:113–8.
Tarkovsky, A., and T. Guerra. 1983. Nostalgia. Artificial
Eye 033 DVD. Distributed by World Cinema Ltd.
Wittgenstein, L. 1953/1996. Philosophical investiga-
tions. Oxford: Blackwell Publishers.
... Other approaches to differential diagnosis have emphasized associated features such as duration, distress, functional impairment, or cultural compatibility (Jackson and Fulford, 1997;Littlewood, 1997;Dein, 2012). Researchers adopting these approaches also tend to acknowledge the importance of social and cultural factors in the appraisal of experiences (Rashed, 2010;Dein, 2012;Taylor and Murray, 2012). Jackson and Fulford (1997), for example, identify eight criteria, one of which is based on primary phenomenological features (visual versus auditory hallucinations), while the other seven are based on secondary features that indicate whether the experience is: (1) "acceptable to sub-cultural group" or has "bizarre content"; (2) viewed "as mental contents" or "as veridical perceptions"; (3) accompanied by "possibility of doubt" with "insight present" or is lacking insight; (4) of "brief " or "extended duration"; (5) "volitional" or "involitional"; (6) "other oriented" or "self-oriented"; and (7) "life enhancing" or leads to "deterioration." ...
... 55). However, their reliance on the action criterion has also been challenged (Marzanski and Bratton, 2002;Rashed, 2010). Vieten and Scammell (2015) follow the Grofs by including the classic list of ten spiritual emergencies. ...
... Together this shows it can be difficult to generalize about how to apply differential diagnosis in certain local contexts, as these criteria often have to be negotiated in relation to the other emic frameworks held by members of communities. Thus, while these criteria remain useful, they cannot be applied in all cases as self-evident rules for determining the nature of an experience (Marzanski and Bratton, 2002;Rashed, 2010). ...
Full-text available
Studies in the psychology and phenomenology of religious experience have long acknowledged similarities with various forms of psychopathology. Consequently, it has been important for religious practitioners and mental health professionals to establish criteria by which religious, spiritual, or mystical experiences can be differentiated from psychopathological experiences. Many previous attempts at differential diagnosis have been based on limited textual accounts of mystical experience or on outdated theoretical studies of mysticism. In contrast, this study presents qualitative data from contemporary Buddhist meditation practitioners and teachers to identify salient features that can be used to guide differential diagnosis. The use of certain existing criteria is complicated by Buddhist worldviews that some difficult or distressing experiences may be expected as a part of progress on the contemplative path. This paper argues that it is important to expand the framework for assessment in both scholarly and clinical contexts to include not only criteria for determining normative fit with religious experience or with psychopathology, but also for determining need for intervention, whether religious or clinical. Qualitative data from Buddhist communities shows that there is a wider range of experiences that are evaluated as potentially warranting intervention than has previously been discussed. Decision making around these experiences often takes into account contextual factors when determining appraisals or need for intervention. This is in line with person-centered approaches in mental health care that emphasize the importance of considering the interpersonal and cultural dynamics that inevitably constitute the context in which experiences are evaluated and rendered meaningful.
... Finally, we identified a significant body of literature on the differential diagnosis between pathological and healthy NOEs driven by theoretical perspectives (Brett, 2002;Dein, 2010Dein, , 2017Evrard, 2013Evrard, , 2014Fulford & Jackson, 1997;Harrison, 2009;Johnson & Friedman, 2008;Lukoff, 1985;Margolis & Elifson, 1983;Marzanski & Bratton, 2002;Maurano & Albuquerque, 2019;Ojalammi, 2019;Phillips III et al., 2009;Pierre, 2001;Pirta, 2014;Rashed, 2010;Saver & Rabin, 1997;Taves & Barlev, 2022;Woods & Wilkinson, 2017). As these discussions were typically removed from empirical findings, we did not delve further into these points because a more detailed analysis of these theoretical arguments would have moved beyond the scope of our systematic review of empirical links between NOEs and mental health. ...
Full-text available
Throughout history, people have reported nonordinary experiences (NOEs) such as feelings of oneness with the universe and hearing voices. Although these experiences form the basis of several spiritual and religious traditions, experiencing NOEs may create stress and uncertainty among those who experience such events. To provide a more systematic overview of the research linking NOEs with mental health, we present a systematic review of studies focusing on NOEs, well-being and mental health indicators. In a search of ProQuest and PsycInfo, we identified 725 references, of which 157 reported empirical data and were included in our review. Overall, the studies reviewed suggest that the relationship between NOEs and mental health is complex, varying according to a series of psychological and social factors. In particular, they suggest that appraisal processes play a fundamental role in the mental health outcomes of these experiences. However, we also highlight important methodological challenges such as the conceptual overlap between NOEs and well-being or psychopathological constructs, the conflation between experiences and appraisal processes in the assessment procedure, and the need for clearer assessment of the duration, controllability, impact on daily functioning and general context of the experiences. We provide a qualitative summary of empirical evidence and main themes of research and make recommendations for future investigation.
... These issues are often undervalued at the time of psychiatric assessment but, in that process, there are problems related to a conflict of values, a conflict that may be aggravated by the empiricist/positivist nature of psychiatric theory and by the prioritization of materialist values over values associated with religious accomplishment [5]. ...
Full-text available
Religious and spiritual experiences can appear in mental health practice as far as they often structure what aspects of psychopathological phenomena are present, sometimes making it difficult to determine whether some experiences should be classified as symptoms of a psychiatric disorder or crises within spiritual life. We present a clinical vignette of a 62-year-old sacristan who was admitted to the Psychiatric Emergency Room for suicidal thoughts in the context of physical sequelae of a cardiac episode. He confessed that, in the process of coping with his illness, he had a distressing experience of guilt and of losing his religious faith and shared the intention to take his own life by hanging himself. Themes that emerge in the discussion include issues related to the boundaries of psychiatric diagnosis, the spiritual dimension of mental health and the values that underlie clinical decision-making regarding a suicidal individual. Incorporating religious and spiritual perspectives in the clinical assessment of patients is essential to understand individual’s framework of cultural values and social attitudes on disease.
... This cultural context includes identities, roles, values, goals, norms, and expectations, some of which are explicit but many of which may remain tacit or implicit until they are highlighted by a challenge or conflict. Thus, assessing the meaning of unusual or distressing experiences requires not just information about explicit cultural norms and values, but also modes of dialogical engagement that allow the individual and others to explore and negotiate the meaning of experiences (Rashed, 2010). In the mental health literature, the conditions for this are sometimes framed as "cultural safety" and clearly depend on addressing hierarchies of power that may result in the silencing of challenging or divergent perspectives (Kirmayer et al., 2016a). ...
Challenging meditation experiences have been documented in Buddhist literature, in psychological research, and in a recent qualitative study by the authors. Some of the central questions in the investigation of this topic are: How are meditation-related challenges to be interpreted or appraised? Through which processes are experiences determined to be expected or "normative" aspects of contemplative development versus undesirable "adverse effects" or psychopathology? And is it possible to differentiate or disambiguate the two? A review of available research suggests that distinguishing between experiences that are religious or mystical and those that indicate psychopathology depends on detailed knowledge of the specific contexts in which these experiences occur. Furthermore, research that specifically examines meditation-related challenges shows that interpretations, causal explanations, and recommended responses are often negotiated between practitioners and other people in their practice settings and larger social communities. This chapter considers some of the social dynamics of these appraisal processes and explores some of the consequences of adopting different appraisals. However, because there can be a lack of consensus around how experiences should be interpreted or appraised, a more useful question may be: What type of support does this particular experience require? Systematic attention to social context can both inform research on meditation-related challenges and provide guidance on the issues surrounding their appraisal and management in both clinical and non-clinical contexts.
... These shared meanings may influence not only when I believe myself to be unwell and what response I consider is required, but may also shape my experiences, actually contributing to whether or not I feel unwell or in need of help in the given circumstances. 7 It is important not to overstate the homogeneity of cultural meanings within a group. I may not endorse all supposedly shared beliefs and values of all contexts I inhabit, and it will be difficult to make predictions about my beliefs and values by surveying the community in which I live. ...
Full-text available
This paper presents a debate in which the authors participated at the World Psychiatric Association conference in Cape Town, South Africa in November 2016. Professor van Staden acted as chair and here, as at the debate, provides a rationale for debating a topic that many of those involved in mental health believe to be decided. The discussion that ensued demonstrated, however, that while the arguments have moved on they have not ceased. Who won? Well that depends how you look at it. A few in the audience shifted position towards the motion but the majority remained opposed. What do you think? Declaration of interest None.
Full-text available
In this paper, I identify a unique form of hermeneutical injustice that occurs when individuals are denied the opportunity to interpret their own experiences within their own religious framework. Specifically, I argue that this injustice can be observed in cases where the possibility of a genuine religious experience in a patient is dismissed solely based on a medical diagnosis. The issue is not solely the absence of a valid interpretation; it's the dominance and exclusivity of a particular perspective that creates a significant power imbalance. To begin, I introduce the concept of hermeneutical injustice and its applications in psychiatry, discussing the developments in this field. I highlight how voice-hearers are often victims of such injustices but also draw attention to the literature's oversight regarding the harm caused when someone's personal interpretation of their experiences is completely disregarded due to the overwhelming influence of medical views. To illustrate this, I present a case that exemplifies the negative impact on patients diagnosed with psychotic symptoms containing religious content. I argue that depriving individuals of the ability to find meaning in their experiences constitutes a profound form of hermeneutical injustice. I reference studies exploring how anomalous experiences can be reframed through a religious lens and integrated into a more normalized framework. Finally, I draw insights from a successful case, emphasizing the importance of hermeneutical justice by promoting respect for first-person authority and embracing hermeneutical flexibility. These attitudes can contribute to a more equitable and just understanding of diverse human experiences.
Full-text available
Critics who are concerned over the epistemological status of psychiatric diagnoses often describe them as being constructed. In contrast, those critics usually see symptoms as relatively epistemologically unproblematic. In this paper I show that symptoms are also constructed. To do this I draw upon the demarcation between data and phenomena. I relate this distinction to psychiatry by portraying behaviour of individuals as data and symptoms as phenomena. I then draw upon philosophers who consider phenomena to be constructed to argue that symptoms are also constructed. Rather than being ready made in the world I show how symptoms are constructs we apply to the world. I highlight this with a historical example and describe methodological constraints on symptom construction. I show the epistemic problems with psychiatric diagnoses are also applicable to symptoms. Following this, I suggest that critics of psychiatric diagnoses should extend their criticism to symptoms or, if they still believe symptoms are relatively epistemologically unproblematic, should rethink their concerns over psychiatric diagnoses.
Full-text available
Central to the identity of modern medical specialities, including psychiatry, is the notion of hypostatic abstraction: doctors treat conditions or disorders, which are conceived of as 'things' that people 'have'. Mad activism rejects this notion and hence challenges psychiatry's identity as a medical speciality. This paper elaborates the challenge of Mad activism and develops the hypostatic abstraction as applied to medicine. For psychiatry to maintain its identity as a medical speciality while accommodating the challenge of Mad activism, it must develop an additional conception of the clinical encounter. Towards elaborating this conception, this paper raises two basic questions that frame the encounter: What kind of understanding of the situation should the clinical encounter aim for? What is the therapeutic aim of the encounter as a whole? It proposes that the concepts of ‘secondary insight’ (as the aim of understanding) and of ‘identity-making’ (as a therapeutic aim) can allow the clinical encounter to proceed in a way that accommodates the challenge of Mad activism.
Psychiatry and Religious Studies have common interests in extreme and extraordinary states when articulated in the languages of religions. For Religious Studies the problems with the category of religious experience are philosophical and profound; whilst the resurgence of interest in religion by psychiatrists (three meta-analyses in the past five years) has not repaired the damaging legacy of reductionist interpretations. In this paper I adopt an interdisciplinary approach to the religious experience discourse. From psychiatry I apply the new idea of Disruption, which makes its first appearance in the US psychiatric textbook DSM-5 (APA, 2013); and the older Biopsychosocial model (Engel, 1977). From Physiology I apply the language of ‘ictal’ (Adachi, 2002, 2010) to privilege a dynamic idea of time. These concepts involve particular epistemological presuppositions and, as this is an interdisciplinary, rather than a multidisciplinary contribution, these will be critically developed. The approach I propose provides a way of holistically addressing the categories of Mysticism, Possession and Altered States of Consciousness, as acute or extreme categories of experience. I propose that the idea of ‘Disruption’ can act as a pre-interpretive placeholder for a real existential experience which might (or might not) result in a non-pathological diagnosis of religious experience. The outcome depends on the socialisation of interpretation. I hope to show that the idea that there might be alternative interpretations removes the need for a sui generis defence of religious experience. By insisting on a biopsychosocial approach within an ictal framework, a way beyond the linguistic impasse of interpretation is proposed; the essentialism, implicit in the mysticism discourse, is questioned; and the non-medicalisation of Possession confirmed. The limitations of this paper point to the opportunity for further conversations between interested parties, including people with experiences of Disruption.
Full-text available
At a time when different groups in society are achieving notable gains in respect and rights, activists in mental health and proponents of mad positive approaches, such as Mad Pride, are coming up against considerable challenges. A particular issue is the commonly held view that madness is inherently disabling and cannot form the grounds for identity or culture. This paper responds to the challenge by developing two bulwarks against the tendency to assume too readily the view that madness is inherently disabling: the first arises from the normative nature of disability judgements, and the second from the implications of political activism in terms of being a social subject. In the process of arguing for these two bulwarks, the paper explores the basic structure of the social model of disability in the context of debates on naturalism and normativism; the applicability of the social model to madness; and the difference between physical and mental disabilities in terms of the unintelligibility often attributed to the latter. Article:
In 1960, I coined the phrase “MYTH OF MENTAL ILLNESS” to identify the intrinsically metaphoric nature of the idea of mental illness, to alert the public to the dangers of viewing distressed and distressing behaviors as diseases, and to undermine the moral legitimacy of psychiatric excuses and coercions. The claim that mental illnesses do not exist was not intended to imply that distressing personal experiences and deviant behaviors do not exist. Anxiety and depression, conflict and crime exist, and indeed are intrinsic to the human condition. But they are not diseases. We classify them as diseases in order to medicalize (mis)behaviors to our profit or at our peril.