This chapter traces Paul Cullen’s attempt to obstruct the establishment of formal diplomatic relations between Britain and the Holy See, the turmoil leading up to the flight of Pius IX and the establishment of the Roman Republic, and Cullen’s own experience of Rome during the republican occupation, before turning to his uexpected and unwelcome appointment as archbishop of Armagh.

Leonida Montanari would not repent even as the blade fell. Neither would his colleague Angelo Targhini, who declared his continuing devotion to the principles that had led them both to the Roman guillotine in late November 1825. His only regret was that on his death his soul would ‘be dissolved into nothing’. The men were founding members of a secret society – ‘something like that of the freemasons’, Paul Cullen reported to his uncle James – and had attempted to murder a colleague whom they suspected of being an informer. They were quickly captured by the papal authorities, tried, and condemned to death.1 Their execution made an impression on Cullen, who seems to have attended in person. (His account follows very closely the much later memoir of ‘Mastro Titta’, the papal executioner and sometime painted umbrella salesman.)2 The men died, he wrote disgustedly, ‘in the most frightful manner possible’. By this he meant not their decapitation, but rather their stubborn defiance. They had spent the morning of their doom arguing ‘against the truth of the Christian religion and the immortality of the soul’ and had then preached their atheism from the scaffold. It had all ‘caused a great sensation among the Romans’, he concluded.3

This introduces the key themes of Spirituality in Mind, including the concept of entanglement and the importance of attentiveness as both a spiritual practice and a clinical skill. Whereas many books on psychiatry by psychiatrists emphasise controversies and fears, the intention here is to focus on spirituality as casting light on what patients most desire. This book is different from other books on spirituality and psychiatry by virtue of engagement with the humanities (especially theology and religious studies), its concern with the ‘ordinary theology’ of patients and its attention to the invisible assumptions of pragmatic atheism. This does not mean that atheists or agnostics are less likely to be spiritually attentive than those who are spiritual/religious (not infrequently the reverse may be true) and the situated perspective of the author, and of all psychiatrists, is highlighted. An outline of the book as a whole is provided, some clarifications are given in regard to vocabulary (notably in respect of ‘patients’ and ‘theology’) and general remarks are made concerning the clinical case studies.

This explores the phenomenon of auditory verbal hallucinations (AVHs) as an example of entanglements of spirituality and psychopathology, and looks at ‘spiritually significant voices’ (identified by those who hear them as having spiritual/religious significance). Some have proposed making a differential diagnosis between ‘genuine’ spiritual experiences and mental illness, but the criteria for making such distinctions can be controversial and misleading, based on a false presupposition that the two are mutually exclusive. Research shows that patients identify some experiences as both part of an illness and spiritually significant. Patients with a psychiatric diagnosis are often subjected to epistemic injustice, wherein their claim to know things (e.g. spiritually) is discredited owing to prejudice associated with their diagnosis. A case study explores entanglement of spirituality with AVHs and considers implications for assessment/treatment. Voices of this kind may be meaningful for those who hear them, whether or not associated with a diagnosis, and affirmation of this and patients’ positive spiritual coping, where possible, can be a positive factor in promoting recovery.

The spirituality of the psychiatrist is important because of the way that it may impact the well-being of the psychiatrist, clinical practice and the understanding of psychiatry more widely. In some cases, it may influence a psychiatrist’s sense of vocation to be a psychiatrist. The case study in this chapter draws on the author’s own experience of the ways in which spirituality and formation as a psychiatrist were entangled during training. Three historical examples are offered of different ways in which religion and psychiatry might be entangled in the life, work and thought of psychiatrists: a pragmatic atheism (Maudsley), religion understood as pathology (Freud) and religion as beneficial to mental flourishing (Jung). Three more recent examples are then considered, one of a Christian attempt to integrate theology and psychiatry (Frank Lake), one of reflections on how Buddhism influences practice as a psychiatrist (Mark Epstein) and one of a personal encounter of a psychiatrist with shamanism (Olga Kharitidi).

A case study of a patient diagnosed with obsessive-compulsive disorder demonstrates the entanglements of phenomenology of spirituality and psychopathology, and the implications of failing to properly understand the importance of these entanglements when planning treatment. The concepts of entanglement, pragmatic atheism, spirituality and religion are introduced. Spirituality and religion are both complex and contested concepts which elude simple definition, but a person-centred holistic model of psychiatry requires giving attention to the whole person, ‘body, mind and spirit’. The biopsychosocial model does not explicitly address spirituality, but spirituality is entangled with the biological, psychological and social aspects of the matrix. The chapter discusses the secular context within which psychiatry is generally seen to be practised (at least in the Western world), the perceived tension between science and religion that it often evokes, the nature of psychiatry as concerned with the study and treatment of mental illnesses, and the way in which these illnesses affect our self-understanding and identity as human beings.

This illustrates the theme of patient-centred spirituality by way of two case studies: one of a clinical encounter of the author with a patient in which neither spirituality nor religion was explicitly mentioned, and another in which the author was asked to see a patient because of a specifically religious concern. The first of these is interpreted in light of the work on spirituality in psychotherapy undertaken by Jeremy Holmes who, in turn, takes up the thinking of Donald Winnicott about transitional space. Spirituality is concerned with an ability to adopt a viewpoint outside oneself and to develop humility and a ‘negative capability’. The published views of patients suggest that spirituality/religion are explicitly important to many, even in a secular country like the UK, and that they would like them to be taken into account in treatment. It is proposed that there is ‘no such thing as a patient’, only encounters between human beings, one of whom is professionally identified as a physician (psychiatrist) and one as a patient. The authenticity of the human encounter, albeit within certain professional constraints, forms the basis for an effective therapeutic alliance.

It is proposed that spirituality and psychiatry, commonly held to be separate concerns, are in fact deeply entangled and inseparable. Meaning-making, an important concern of spirituality, is important to human well-being and needs to be taken more seriously by psychiatry. The damage done by historical antagonisms between psychiatry and religion needs to be undone by affirmation of spiritual concerns within psychiatric practice and by closer partnerships between psychiatry and faith communities. Professional boundaries need to be understood not as protecting psychiatry as secular space (which many religious patients find hostile to their spiritual concerns) but as protecting safe therapeutic space within which psychological recovery and spiritual growth may occur. Psychiatrists need to develop an interest in clinical theology, as a way of understanding the ordinary theological concerns of patients (including their ‘atheologies’). Psychiatry needs to be more spiritually attentive – to shed light on what patients desire spiritually and psychologically – rather than focussing only on the metaphorical shadows of psychopathology. Psychiatry needs to keep spirituality in mind.

Psychiatrists have responded nationally and internationally to the growing scientific evidence on spirituality and psychiatry and to concerns about bad professional practice, by developing good practice guidelines/policies and by way of continuing professional development initiatives (special interest groups, conferences, etc.). Professional boundaries have historically been understood as keeping psychiatry, as a secular concern, separate from patients’ spiritual and religious concerns. However, as earlier chapters demonstrated, this is unrealistic in light of the entanglements of spirituality and psychiatry, and unlikely to be helpful for many patients. It does not address the importance of religion to patients worldwide or the transition in Western countries from a secular to a post-secular age. The Jungian concept of temenos is taken up as a way of understanding boundaries as protecting safe therapeutic spaces for psychological and spiritual transformation. Boundaries in clinical practice are thus created not to keep the psychological and spiritual domains separate but to protect a safe psychological and spiritual space within which positive therapeutic change may occur.

Broader debates about possible ways of addressing the tensions between science and theology/religion have not often been applied to psychiatry, and yet it is to a large extent scientific research on spirituality and mental health over recent decades that has generated current interest in the importance of spirituality to psychiatry. The four models of relationship between science and religion, developed by Ian Barbour – conflict, independence, dialogue and integration – each have their correlates in the literature on spirituality and psychiatry. However, in clinical practice it is the ‘ordinary’ theology of patients that assumes greater importance than the formal, or academic, theology of philosophical debate. As an example of the importance of a kind of ordinary theology which has been subjected to scientific research, the concept of God images is explored. It is proposed that, in the course of assessment and treatment, a kind of ‘clinical theology’ is needed, in which psychiatrists take into account inner representations of God and other ordinary theological beliefs which inform understanding of a patient’s illness and spirituality.