PSYCHOTIC (A-)THEISM ? The cognitive dilemmas of two psychiatric episodes

Neurotic religiosity is relatively well documented.  Oceans of cases are presented and analyzed (see among others Corveleyn,  in press).  Theoretical models for understanding are well elaborated (Vergote, 1988;   Wallance, 1981;  Rizutto, 1989; Bradford &  Spero, 1990).   Case studies in psychotic religiosity or rather ”religious experiences during psychotic episodes” are observed and theoretically worked through (Rokeach, 1964;  Boisen, 1936,1960;  Gallenmore, 1969;  Gettis, 1987;  Kushner, 1967).  If one uses MEDLASH or other computerized library systems there is however a relatively low rate of published studies dealing with psychoses and religion. In crosscultural psychology as well as in anthropology and in history of religon, however, the question of shamans, prophets etc. are regularily discussed in terms of psychopathology. The nosology and the genesis of the psychotic state and differential criteria for diagnoses are not well established in spite of DSM III. There are still many different and partially contradictory perspectives as to the psychological structure and treatment of psychotic illnesses; psychoanalytic (Freud, 1928, 1911), the object-relational models (Podvoll, 1979;  Smith & Handelmann, 1990; Ståhlberg, in press),  as well as Jungian and  phenomenological traditions ( Bradford, 1984).

This means that valid and functional models or theories in the clinical setting  seem to be very varied. The future of knowledge in psychopathology of religion presumely needs to start in sociology of knowledge. When the basic concepts of mental illness are understood as social constructions rather than universals or invariances, they can be related to culturally and mythologically defined worldviews and to the contents of altered states of consciousness (Wikström, 1989,1990, 1991).  Through such a procedure it might be possible that we can get access to a transculturally valid understanding of the religious mythologies, rituals and models of behaviour, (Geertz, 1973; Hallowell 1970)  in relation to what we  –  in our society – label as mental illnesses like psychoses, borderline personalities or neuroses (Lowe, 1955, 1954;  Ndtei, 1990).
Two cases
In this paper I would like to limit strictly my aim. I will not try to solve the everlasting problem of the intrapsychic genesis of the psychotic religiosity or to scrutinize the role of the transitional object ”God” in the economy ot the total psychological energy. I think that is possible only in a therapeutic setting and during the interaction between patient and therapist in long-term psychotherapy. It asks for another scientific design.
Instead I would like to present two cases, the first more elaborated and the second more cursory due to the fragility of the clinical material. However, religion was for both patients  the main cognitive kernel around which their effort to grasp reality was built. Case A was diagnosed as suffering from melancholic depression,   affective disorder with dysphoric mood  and loss of interest and pleasure in almost all usual activites. The feelings of worthlessness, self-reproach and excessive guilt were focused on the loss of faith in God, which was very anxiety provoking for this pious priest. He was hospitalized for two  months. The main treatments were pharmacological and ECT. The psychotherapist´s focus was supportive rather than reconstructive.
Case B ´recieved the diagnosis: ”brief reactive psychoses”. The clinical picture involved emotional turmoil, partly incoheren thinking and partial loss of associations, delusions and infrequent hallucination. The triggering factor was the sudden death of a son. The content of the psychotic ideas was religious. This was frightening and confusing for B, who was a  convinced, researching Marxistic atheist with no former religious interest.  It challenged her own symbolic universe.  After the psychotic episode she first tried to reintergrate and include  the experiences in her former atheistic Weltanschauhung, but turned later to an anonymous religiosity with traits of Jungian mythology.
Both A and B found themselves cought in a cognitive trap when their former worldview was questioned.  The transcendental apriori – which was included  by A and excluded  by B  – was changed into its opposite during A:s  depressiv and B:s psychotic episode. The challenging of the prepsychotic symbolic universe and the effort to restructure it or to find a new  world view was the focus  of my interviews.
Method, material and aim
I asked the staff in one psychiatric clinic for patients who:
– had very elaborated prepsychotic theologies or meanings-systems  before the hospitalization,
– were diagnosed preliminarily as ”psychotic or depressive episode” with no former psychiatric contacts,
– were not described as neurotic or borderline
–  were expected by the medical staff to need a short treatment period
Out of this material – which I still am collecting as part of a project –  I have choosen two patients. The main reason for choosing these two is that their journeys through the psychotic episode illustrate one important dimension I have found also among other similar  cases: the cognitive dilemma of de- and reconstruction of a strong symbolic universe due to the pathological changes of moods.
I made in-depthinteviews with patients A and B two days after the hospitalization, and then one time per week during a two-months period. I interviewed the therapist (C) three days after hospitalization and once weekly during the treatment, and I interviewed representatives of  formalized worldviews:  the hospital chaplain (D); a  collegue to case A from the same parish (E); and lastly a good friend of case B, a leading marxist representative (F).
As I intended to keep myself free from being drawing into a therapeutic relation, I just let the persons speak around the theme: absence of God and  a sudden transcendent feeling. I made no therapeutic intervention and just asked for the completing of questions.  Here the methodology is weak – of course the interest that I offered to the patients and the staff ”disturbed” so to speak the interaction and I become perhaps a part of the very cognitive trap I was trying to understand. The ideal would presumely have been to record all the therapies  in order to  be as objective as possible. However, this was impossible because of the paranoid trait involved in both case A and B.  I found myself in a position where I either got no material at all from these cases, or had only secondary interview material where I tried to reach ”on-line validity” (Kvale, 1989).
In describing these cases I´d like to elucidate the interaction between the patient, the psychotherapist and the representatives from the ideological social context to which the patient belonged before the illness.
In these interactions I would like to discuss one aspect; the way the  psychotherapist used or did not use the religious content of the psychotic experience of the patient (in these two cases the absolute absence and the absolute presence of a transcendent God) and:
– relate it to the meaning-system of the social structure to which the patient belongs,
– support the patient to look for new legitimating or interpretative  symbolic, linguistic systems in  order to cognitively  grasp his feelings,
– interact with representatives of the patients ordinary symbolic universe – either atheistic or  christian,
– relate the religious content of the psychotic breakthrough to the patient´s own elaborated´,  conscious god-representation,
– take into  consideration the intrapsychological structure and dynamics, i.e. the  function of the god representation  in the patient´s total psychological economy.
I leave the question of the therapeutic outcome of the treatment. Instead I link together two coexisting theoretical perspectives; sociology of knowledge and psychodynamic theory (Wikström 1990, 1991).
Psychotic atheism ?  Case A
Case A is a clergyman, aged  43, married for 18 years, four children, and fulltime parish priest for 16 years. There have been no former medical or psychiatric contacts. He is recommended psychiatric help from his friends and relatives. During the intake interview he describes deep sadness, suicidal  thoughts and  lethargy. He is tired and in  bad shape. During his university time he had been a little depressed at periods. He says that he has always loved his job, his parish and his church. When I meet him he is sitting very calmly, he is psychomotoric retarded and complains of a diminished ability to think and to concentrate. His face has the typical melancholic expression. Now and then he becomes involved if we talk about the bishop, the religious situation in the society or of his parish. But he regularly returns to a feeling of worthlessness. He says he is a burden for his family  and  he blames himself that the frequencey of church attenders has decreased.
The kernel in his description of his depression is, however, strongly related to the concept of God. He describes that God – the one and the only that he has lived for and wanted to serve – has now disappeared. When he talks of the absence – or rather his clear insights that God is really dead or nonexistent – he describes an intense and frightening desperation. The living God  experienced as an acting partner has, in his mind during the  melancholia, turned into an mere idea, a cosmic  fantasy. He describes a feeling of emptiness. He knows by heart and can  reproduce the mystical theology. He is familiar with concepts like the ”Dark Night of the Soul” or the ”Cloud of Unknowing”, experiences that St. John of the Cross and other mystics have described.  But his own sadness and his loss of faith have made it impossible to connect this theological framework. The silence-of-God-model provided by his own mystical cognitive map  does not help him to grasp his situation.  The theological interpretive schema  is disappearing as a relevant key for understanding his own melancholia and – as hehas said- his ”cosmic loneliness”.  God seems now not to be real but absent, he has never been there. During a period of approximately one month the main content of the melancholic thoughts has been a lack of the presence to God. As a consequence the main emotion has not been  anxiety, but grief and  guilt. He feels like a traitor if he proceeds as a non-believing Christian pastor.
If we leave aside the intrapsychological dynamics behind the emptying of the godrepresentation´s homeostatic function (Smith &Handelmann 1990) and just look upon the problem from a cognitive perspective, we can see that neither the emotional nor the the intellectual  support of the god image is there. Independant of the psychodynamic or biological genesis of this melancholia he is trapped in  cognitive dissonance. The question is how this dissonance is focused and used by the therapist.
Changes of interpretation
The grieving of the ”lost God” was however turned into relief and even to a smal degree happiness. During the depressive episode A gradually switched from an anxiety-ridden effort to understand his situation in terms of a theological, symbolic universe that included an axiom that  God exists and can disappear to a worldview that provided no image whatsoever of a transcendental structure outside of man. He was reliefed when he came to the philosophical conclusion that man basically is and always has been alone. During a onemonth period he met a co-patient very well read in existentialism and surrealism. He become, on a cognitive level, well aquainted with a sophisticated and elaborated atheism. When he studied Camus, the myth of Sisyfos, and talked about himself in terms of the absurdity of the world -these concepts seemed to him to be more adequate descriptions of what he really felt than his former theological meaning-system. Bertrand Russel´s critique of  religious thought cognitively  grasped his emotional situation more adequately  than his Christian frames.  When he studied Freud´s The Future of an Illusion he interpreted his own belief in God as a pure compensation of loneliness feelings depending derived from mother-deprivation from his childhood.  The destruction of  the fantasy of a living God seemed now to him a part of a maturing process, to see reality as absurd was now more consonant with his own self-experience. This atheistic period lasted approximately one month.
A and the therapist  C,  differentiated between the two qualities in A´s feelings:   longing for something that has been and now has disappeared (the faith) i. e. grief  and  the expanding good feeling,(A had earlier been trapped in a mistake and now he had started on a  more true journey to himself).
One could follow how one cognitive frame of reference to interprete the silence of God was replaced by another frame:  the atheistic or agnostic structure. However, nothing seemed to have happened with his own understanding of the intrapsychological structure and function of his present or absent godrepresentation. The cognitive restructuralization through the atheistic worldview was therefore, according to C,  interpreted  as an unconscious defence strategy. A demonstrated no insight, no effort to understand how the absence of God was related to the absence or precence of other major objects in his internal world.
The therapist thought  of A´s intellectual move from a religious to a nonreligious map of reality as one way of working with his feelings, but only on the secondary level. A gets from this a primary gain. In that sense his agnostic or atheistic perspective is, according to the therapist´, apremature solution on a cognitive level. The elaboration of the emotional structure of his godrepresentation was however not ”used” as a part of  the therapeutic process. The attending psychiatrist claimed that a deeper working- through perspective was contra-effectiv in this type of endogen depression.
What made this case problematic, and heigtened A´s cognitive dilemma was that he carried himself in a social role. As a professional he was an actor inside the plausibility structure where the reality of a living God is an axiom. He represents,  through his position as pastor, a symbolic universe that is maintained through the social structure of his church.
Loosening of his feelings of closeness to God  brings him problems on two separate levels. It shakes his foundations that his social identity is not in harmony with his personal, new ideological identity. The more he understand his own feelings in terms of an agnostic or atheistic worldview, the more he must question his own social or institutional identity.
In other words, the elaborated cognitive way to handle the absence of God inside the church become less personally relevant than the extrainstitutional understanding;  but this way had in its turn less social support due to A´s professional status.
What was remarkable and supported the interpretation óf ”atheist worldview as defence”, was that after the overwhelming sadness slowly disappeared and the guilt-feelings diminished due to the medical treatment,  A returned again to his former Christian belief. His one-monthatheism was then in his own terms,  turned into ”an important episode in his spiritual development”. In a follow-up interview after one year he described the period mainly in terms  the Christian spiritual way.   His social identity as a theologican and churchman excluded a pure atheistic selfunderstandning. His atheistic month is viewed as a pure psychotic episode. This means that the post-psychotic understanding of the loss-of- faih-experience  now is understood in terms of science, not theology.  His theological status as a professional interpreter of the spiritual life now has included his own experience. The radical question of a truly empty universe is denied as too challenging.
To handle a cognitive dilemma
The patient was confronted with three person´s reactions to his own struggle with the cognitive part of the lost faith.
The  therapist, C, mainly listened emphatically and asked for more details and tried to be supportive rather than re´-educative in his interventions. He mirrored an agnostic or permissive perspective in relation to A´s feeling of the absence of God´. He helped the patient to work through  his sorrow. He did not explain the absence either in terms of pathology  (depressive symtom) or theology  (a  part of God´s good guidance). Instead C tried to ”use” the relation to God to unfold an unconscious meaning. In terms of  an intrapsychological dynamic he tried to help  A to understand  the  regressive, transitional  function of the lost object ”God”. In this process one of the first steps   was to interprete the relation between a cognitive and an emotional understanding of a presence or absence of ”a person” in general. The switch from theist to atheist and then back to theist position was seen as a defensive manoeuvre on a secondary level.
The psychotherapist  understood the atheism of the patient in terms of a working-throughprocess. His intention was to support A to return to his former intra-Christian understanding, but bringing into his former worldview a more elaborated emotional understanding of the dynamics behind his religious symbol system, a second naivité.(Ricoeur 1965, 28). The reason behind this was pragmatic, C claimed. The socialization into the church and priesthood and the emotional function of his God – as an internal transitional object in this very social structure – had more chance to survive than an isolated,  cognitive and intellectual  grasping of  the emptying of  God´s support. In the psychotherapist´s own opinion however, he did not manage to help the patient discover a deeper emotional understanding.
The hospital chaplain D was much aquainted with the psychoanalytical thinking around religious problems. He intended,  according to his way of explaining what was going on in his meeting with A, to just remain on the secondary intellectual or dogmatic level and work with the patient´s feeling but in terms of theology. He claimed as C that in this type of depression it was not his intention to  work ´towards uncovering but to remain supportive inside A´s own symblic universe. This means that he listened to A´s atheistic thinking concentrated on A´s was elaboration of his feelings inside the religious symbolic universe.
The parish priest E can be understood as a representative of the plausibility structure of the symbolic universe to which A belonged. He said he was not competent to go further into the emotional, dynamic structure of the patient. He claimed to represent the real Christ who was always living. He explained very clearly and in a very emphatic way that God could not ”really” disappear –  only in the ”experience” of a certain person. If God disappeared for a person this was due to a conscious intention of  the living God. The feeling of loneliness and  emptiness is, according to his way of explaining, not a proof  of a non-existing God. Instead the longing was an upside-down symbol of the presence of  this very longed-for God. This abbreviated form of theologia negativa was presented during E´s meetings with A. He did not pray together with A but always left him with the promises that  he intended to pray for him. A said that he felt moved and comforted by the nearness of E. In the atheistic period he cognitively could not understand E´s arguments.
To summarize: During the depressive period the ideological content of A:s worldview was challenged. He could not experience emotional support of his former symbolic universe.  An atheistic selfunderstanding provided for a few weeks a new and more plausible world view than a religious. This had however weak social and intellectual supports from both the therapists and the pastors side. After the hospitalization he returned to his former systems of thoughts.
Psychothic  theism ?  (case B).
B is a woman aged 47. She is married with three children. She is a teacher and has been  socialized since early childhood into a Marxistic and atheistic culture. She had written extensivly critical essays on religion and had claimed that religiosity was an immature and suppressive effort of the bourgouise to manipulate the masses. B recieved the diagnosis: schizoaffectiv psychotic episode or a angst-glückpsychose  with slightly megalomania and intense delusional ideas. The religious ideas were built into a conceptual framework that became very elaborated. She created a kind of mythological system of her own. The psychotic episode lasted  about three weeks. She did not allow anyone to question her reality. Neither the psychotherapist C nor the pastor D were allowed to talk to her. The only deeper relation she permitted was another patient, a former librarian, well-read in psychology and now diagnosed as borderline with psychotic features.
It was mainly a red color that had mysterious overtones. The red color seemed to her very bright and shining. She had an intense feeling that the color could speak to her and wanted her to tell other her visions. She heard voices and during one period she became convinced that she got messages from God. The red color of the flowers in the garden and of a carpet in the corridor of the hospital she reported: ”whispers her name”. At first she was frightened. But later she told the staff that ”God now is very close to her”. She claims  that red is the color of God´s love. She read the ”Gospel according to St John” and the ”Revelations”. She also borrowed a book of Swedenborg from the hospitals library in order to make her own experience clear to herself.
She began painting excessivly. But she had also an immence need to understand what was going on and read through the nights.  She was very much fantasizing about the red color  of her Marxistic symbolism in relation to the red color of ”the blood of Christ shed for her”.  She was looking for a frame where  her experiences  would be neither reduced nor pressed into a formal meaning-system like Marxism or Christianity.
During the acute episode she was very upset and unclear. Psychodynamic treatment was seen as contratherapeutic. Mainly pharmacological help was provided. The doctors and the psychotherapist were just listening to her efforts to try to combine her earlier atheism with her new ”revelation”. Her  own paraperceptions were mainly understood in terms of psychopathology. No one, not even the pastor,  took her ideas of a ”transcendent superhuman reality” at face value or met her in her effort to understand its relation to her former militant  atheism or her reading of the gospel. It was just understood as a part of a hallucinatory system.
From political atheism to Jungian mythology
My interviews with her were undertaken mainly after the episode, since she was very suspicious during the acute weeks. She understood afterwords ”that she has been very sick”. Stones and bricks  in the wall had been talking to her, heaven was crying when it was raining, and the houses were laughing through the doors. All these experiences she afterwards understood as a sign of a mental illness. But what remained very difficult for her was that her dogmatic atheism was challenged through these strong experiences. She did not understand this part of the delusions in terms of the scientific symbolic universe  – as psychotic hallucinations. A remnant remained unexplained and she therefore searched for a permissive ontological legitimation system. Her former atheism could not include a transcendent reality.  But on the other hand she was very reluctant to describe her feelings in terms of a systematized or institutionalized theological world view.
In her effort to understand what had been going on in her own mind, she had many  discussions with a Jungian psychotherapist whom she met after the hospitalization. The theories of archetypes, and especially that she had ”lived” a myth of the eternal burning fire according to the Parsic mythology in India became for her an illumination and a confirmation of Jung´s theory. The Jungan- interested therapist  made her aware of Jung´s autobiography. Through reading his history she ”got a model” of what she herself had experienced. As she became aquainted with other people interested in Jung  she came into living contact with a perspective that was neither atheistic nor theistic but transcendental in a more general way. It was also not connected to a more elaborated and dogmatic worldview such as the one she had accused formerly (the Christian) or applauded (the Marxistic). F finds it very hard to see how  B completely abandoned her Marxist-atheism so suddenly. Even after one year he thinks that her new interest and conviction of another transcendent realm must be understood as a residue of her hallucinatory episode.
B:s ”journey through madness” can be described in terms of cognitive restructuralization on a secondary level due to the strong ”mystical” experiences during the episode. In her case, however,  the loosening of the ties to the marxist plausibility structure became  necessary for her.  In another way than A, B  could not  interpret her bliss experience deriving from an angst-glückpsychose in terms of her former symbolic universe. It became a necessity for her to build that into a new worldwiew.
In comparision to the depressive patient, her bliss experience – an euphoric feeling  with strongly perceptual qualities –  made her more activein searching for new significant others to support her and seek for analogous symbolic expressions  to her own .  She could not find it in classical Christian theology or churches but in the psychomythology of C.G. Jung. She was attracted to the Jungians noninstitutionalized way of  thinking about religiosity.
During the acute period she had a feeling that she was the sister of Christ. But this was a secret that she kept very strictly.  Through treatment with tryptizol and trilaphon this megalomanic idea disappeared, she founds them afterwords untrue. But the main experience never left her;  the red color remained a door of perception, a sign of blessing. The red color punctuated her marxistic and atheistic framework and forced her to reformulate her self-understanding in terms of an undogmatic, private transcendentalism like  Jung´s.
The hospital chaplain D looked upon her experience as part of a delusional idea, but he also used his own intra-theologcial frame of reference and interpreted her experiences  as a ”signal of transcendence”.  Neither he nor the therapist C got into the question of the intra-psychological dynamics behind her fantasies. The pastor confirmed indirectly  her feeling of being in contact with a trancendent, mystical Other. She accepted his interpreation that the transcendent character of her experience stemmed from a suprahumane world; but she could not accept his personification and  theological elaboration of  the phenomena.
This is  why she turned towards Jungian thinking as a religious system. The concepts of archetypes and mandala and above all the mythology of the transcending Self seemed be cognitive frames could grasp  best  that what she had felt.  She abandoned her former positivism, but also the  Christian transcendentalism.
Summary and discussion
The psychotic episodes disturbe´d the two patient´s formal, elaborated worldviews. Through the melancholic depression, the affects that supported the main content of A´s symbolic universe dried up:  God seemed to disappear. In the psychotic episode of B, the atheist worldview was punctured. This created on a cognitive level, a dissonance. The cognitive stress was however not in focus and not elaborated in its own terms by either  the psychiatrists or the psychotherapists. The patients were left alone with their effort to cope with a cognitive-ideological conflict. The staff reduced, in my opinion the overt religious conflict to psychopathology or to the  derivatives of  unconscious problems. The philosophical or theological trap was ignored through its labeling as a (necessary) defensive maneuvers.
The  main trait of the depressive disorder for A  was affective. Neither the theological content or its main Gestalt – God – nor social relations (friends, parish etc.) were nourished by emotional support. When the affects returned, A returned to his former social structure.  In my opinion it seems that the psychotic delusions described by B in a more effective way can be seen as a cognitive ”new” experience that ”asked for” a reformulated – not-positivistic – worldview. And as the cognitive ”breakthrougn” was so strong it supported B to look for new significant others that could confirm her experiences as ”true”. Seen from the perspectives of sociology of knowledge, her ”insights” were confirmated and given continual support from a new plausibility structure.
The cases illustrate two perspectives. One, that an intense psychotic episode sometimes includes a de- and reconstruction of the socially-constructed map of a patient´s reality. In this process therapists and  formal representatives of the patient´s theological/political map of reality must cooperate. To reduce a strong religious experience in a mental illness to biochemistry or psychodynamics makes it impossible to see the world- ( and self-) construing and -maintaining role of a theologicial/political symbolic universe. But the opposite is also the case. To take the religious worldview at face, cognitive value, without understanding its psychodynamic role,  does not heal a patient. The hermeneutics of suspicion must cooperate with the heremeneutics of  reconstruction. Of course I do not claim that philosophy or theology is the task of the psychotherapist.  However therapeutic professionals also need to understand and take into consideration the role of the patient´s symbolic universe.
I propose a new branch´of investigation; ”Clinical Psychology of Religion”, dedicated to developing theoretical models, empirical data and  clinical guidelines for interpreting ethical, practical and therapeutic problems arising on the border between religion and psychopathology in a clinical context.  This branch must include a deepening of  philosophical, sociocultural and psychiatric theory as well as an elaborated discourse of the interaction among  therapists, rabbis and pastors. Seen from a multireligious and multicultural society this must be done in terms of religonswissenschaft and clinical psychology rather than in terms of theology or pastoral care.