Embedded in history

For much of recorded history, human beings have believed in a spiritual plane of existence that somehow interacts with people in their daily life. A fear of evil spirits and preoccupation with states of possession, whereby spirits enter and control a person, has waxed and waned in a cycle of fascination and disinterest. Human history has and continues to be suffused with evil and unacceptable happenings, whether they be brutal wars, atrocities or barbarous practices such as slavery. To use the word ‘evil’ as a noun implies almost a persistent state or a continuous force. The anthropologist Erika Bourguignon (Reference Bourguignon and Bourguignon1973) unearthed documented accounts of possession in about three quarters of 488 cultures surveyed. Belief in spirits, demons and other supernatural entities remains extremely common, even in countries where much of the population is well educated (Rice, Reference Rice2003). They have been studied across multiple academic disciplines and remain a topic of theological, as well as medical and scientific controversy. Notions of possession and exorcism are frequently subject to mockery, with ignorance and exaggeration continually competing with rationality and caution among humans.

Mental health professionals have long been aware that patients’ spiritual involvement and the religious context of their lives is important in relation to the clinical presentation and context of psychotic symptoms (Cook, Reference Cook2015). There is however a natural reluctance in patients and doctors to discuss deep religious convictions, especially in relation to views of causality that could be rejected by the doctor as superstitious (Spence, Reference Spence1992). The question as to whether religion and medicine should mix at all is a controversial one, despite the evidence that faith may contribute to positive health outcomes (Koenig, Reference Koenig2012). Indeed, many regulatory bodies such as the UK’s GMC prohibits doctors from expressing their beliefs to patients in ways that exploit their vulnerability or are likely to cause them distress (GMC, 2023). The guidance is also clear that doctors should only discuss their personal beliefs if a patient asks about them or indicates they would welcome such discussion. They must not put pressure on a patient to discuss or justify their beliefs or the absence of them.

Yet one of the most important services psychiatrists can provide is giving an opinion about whether someone experiencing “spiritual distress” or suffering that affects an individual’s spiritual wellbeing or belief system (McSherry and Ross, Reference McSherry and Ross2002), has a psychiatric, or indeed a medical basis. An empathic attitude with unconditional regard for religious values often opens the door for further exploration and ultimately diagnostic clarification. As the range of symptoms, both physical and psychological, which may be attributed to involuntary spirit possession is quite broad, there is no single psychiatric disorder under which these fit (Cardena et al. Reference Cardena, Van Duijl, Weiner, Terhune, Dell and O’Neill2009). Historically it is undoubtedly true though that many case of demonic possession have masked major psychiatric disorder (Tajima-Pozo et al. Reference Tajima-Pozo, Zambrano-Enriquez, de Anta, Moron, Carrasco, Lopez-Ibor and Diaz-Marsá2011).

How do we conceive of possession and what does it look like?

Kahn and Sahni (Reference Khan and Sahni2013) further define possession syndrome as “a paranormal diseased state in which a person is said to be possessed by a spirit, demon, animal, extraterrestrial being or disincarnate objects including God, resulting in noticeable changes in health, behaviour, and appearance.” Other authors have suggested viewing possession as a temporary alteration of consciousness, identity or behaviour attributed to possession by a spiritual force or another person (Cardena et al. Reference Cardena, Van Duijl, Weiner, Terhune, Dell and O’Neill2009). The most recent version of the Diagnostic and Statistical Manual of Mental Disorders (APA, 2013) references apparent possession under the diagnostic criteria of Dissociative Identity Disorder (DID) and describes “possession-form” presentations of DID as those in which appears “as if a ‘spirit’, supernatural being, or outside person has taken control of one’s mental processes or actions.” The possessing identities are said to be unwanted, involuntary, cause significant distress and are not part of broadly accepted cultural or religious practice. Above all there is the belief that certain symptoms are attributable to spirit possession. Such a belief may have the quality of an overvalued idea as opposed to a delusion, albeit one that may be reinforced by prevailing societal and cultural beliefs. This may imply that possession is essentially an aetiological factor, as opposed to a psychiatric diagnosis per se (Sanford, Reference Sanford2016).

The wide range of symptoms and their severity can imply the presence of other psychiatric diagnoses, especially psychotic illness such as schizophrenia where delusional thinking, hallucinatory experiences and/or feeling impulses that are experienced as being under the control of an external agent are commonplace. There is a paucity of research on delusions of possession. which can be viewed as a sub-category of religious delusions according to Pietkiewicz and colleagues (Reference Pietkiewicz, Klosinska and Tomlaski2021) with some authors estimating their presence in psychotic disorders in 20 – 40% of patients with psychosis, more often in women than men (Iida, Reference Iida1989). The distorted perception of having mental processes or actions controlled by supernatural powers is important in distinguishing delusions of possession from other forms of religious based delusions, where individuals identify themselves as religious heroes or maintain that they possess supernatural powers. Kopeyko et al. Reference Kopeyko, Borisova and Gedevani(2018) emphasise how possession delusions can be accompanied by other symptoms such as delusions of influence, hypochondriacal delusions, cenesthetic or olfactory hallucinations, depressed mood and even suicidal tendencies. Some guidelines do exist to help clinicians distinguish spiritual experiences from psychosis generally, with emphasis on overall psychological functioning, quality of thought, affect, level of insight, self-care and relationships and prior medical and psychiatric history (Bronn and McElwain, Reference Bronn and McElwain2015, Griffith, Reference Griffith2010).

Higher reports of childhood trauma, cannabis misuse, elevated dissociation scores are observed and other authors contend that the delusional content may be a direct reconstruction of traumatic experiences or indirectly refer to them as decontextualised memories (Peach et al. Reference Peach, Alvarez-Jiminez, Cropper, Sun and Bendall2019, Hardy, Reference Hardy2017). It is not surprising therefore that dissociative disorders may mimic clinical scenarios where delusions of possession are prominent. Alternative diagnostic hypotheses could therefore include severe and histrionically flavoured personality disorders (especially associated with trauma) (Moskowitz et al. Reference Moskowitz, Dorahy and Schafer2019), the different phases of bipolar mood disorder and unipolar depression or even seizure disorders, effects of illicit substances and Tourette’s syndrome.

Colleagues’ subjective experiences

Richard Gallagher, a New York based Psychiatrist has expounded on, in a non-scientific narrative discourse, a distinction between full demonic possession and external oppression (which is apparently a less intense form of demonic harassment with retained consciousness and greater emphasis on unexplained bodily symptoms) (Gallagher, Reference Gallagher2022). He also claims that “real demonic possession” can be objectively identified and differentiated from delusional ideation and what he terms “social hysteria” or malingering by a number of presenting demonic symptoms. In Gallaher’s opinion these include the ability to speak a number of foreign languages unknown to the person, paranormal or hidden knowledge about other people, a hostile, belligerent stance with extreme aversion to religious objects, places and references, extraordinary physical abilities and humanly impossible bodily movements including the rare levitation and supernormal strength. Such descriptions of possession appear somewhat stereotypical and lacking credibility, and Richard Gallagher offers no evidence for them. Gallagher, who has participated in ecclesiastical exorcisms, does acknowledge that many cases of apparent demonic possession are due to mental health difficulties or psychological and social factors and can be co-created by the social environment. There is also the possibility that criteria for demonic possession could be met in someone with an established mental illness and the two entities may not be mutually exclusive and can co-exist. He also concedes that although the “classic features” of possession are not always present, that they recur often enough in “serious possessions” to serve as “helpful diagnostic indicators” and believes that there is significant historical evidence of this.

Is exorcism a treatment and if so, how appropriate and effective is it?

At risk of stating the obvious, exorcism, if perceived to be a treatment modality, is different from many of the practices recognised in the Western medical model, in that it recognises the influence of external spiritual entities as the cause of the patient’s distress and the basis of a therapeutic intervention is the expulsion of such entities. Exorcism is currently practiced in many cultures, including the Western world, many of whose nations are inherently multi-cultural. Equally possession is not a ‘standalone’ clinical diagnosis that can be easily shoehorned into conventional, scientifically recognised categories of psychiatric diagnosis, having elements of dissociative disorder or even psychosis. Exorcism may be thought of therefore as an intervention for a spiritual problem for those who espouse and endorse the theological and spiritual framework underpinning the rite of exorcism. This criterion of personal belief, in addition to the exclusion of a medical or psychiatric cause appears to be the best determinant if an exorcism is appropriate or not. Despite exorcism not being recognized as a legitimate form of psychological treatment, there have been exceptional cases whereby a small number of psychiatrists and psychologists have practised exorcism rituals (Thomason, Reference Thomason2008).

While literature on exorcism is notable for a lack of detail regarding specific methods employed by exorcists, the limitations in exposing such practices to traditional scientific and experimental scrutiny must be acknowledged. Richard Gallagher states that “spirit entities are unlikely to cooperate with conditions found in experimental trials,” yet on the surface it is not unreasonable to look for video or audio recordings of accounts of possession experiences or even exorcism rituals, for both verification and standardisation purposes. Gallagher in his book however points instead to an accumulation of historical, sociological and anthropological research and detailed documented accounts of possession which are consistent. He decries continual demands for video recordings as indiscreet and “a violation of privacy” and dismisses the “methodological naturalism” of modern investigative methods as having any utility in exploration of the spirit world (Gallagher, Reference Gallagher2022 p12). In keeping with a scientific detachment expected of an experienced clinician, he also acknowledges the rarity of possession and how the vast majority of doctors and clergy will never encounter a genuine case. There are though some common exorcism methods and techniques that cross cultural and religious boundaries. Khan and Sahni (Reference Khan and Sahni2013 p 254) note the similarities between many exorcism techniques and the “psychotherapeutic principle of abreaction wherein undischarged and constrained emotion expressed covertly in the form of possession is released.” The detail of exorcism rituals, their procedures and methods could be subject to scientific scrutiny for their utility as a therapeutic technique if a ritual could be controlled for as many variables and confounders as possible (Thomason, Reference Thomason2008).

An example of an exorcism ritual that could lend itself to systematic study is that performed by priests of the Roman Catholic Church. These procedures were codified in a 1999 document entitled Exorcisms and Related Supplications and released in their entirety only to bishops and exorcists. Of the two types of exorcism rituals endorsed by the Catholic Church, ‘major exorcisms’ (for full demonic possession) are only to be performed by a specially trained priest with the permission of a bishop (United States Conference of Catholic Bishops, 2014) with minor exorcisms or deliverance rituals involving prayers to protect from or remove the influence of evil or sin in preparation for baptism or other ceremonies. The codified procedures for major exorcisms include readings from scriptures, prayers to God, commands aimed at the possessing spirit, sprinkling with blessed water, breathing on the afflicted person’s face and making the sign of the cross (USCCB, 2014). Prior to the conducting of the ritual, the priest initially carries out a discernment exercise to establish that all biomedical attempts to establish the cause of the possession have failed. Notably the Church encourages cooperation between exorcists and conventional medical practitioners to include input and evaluations from mental health professionals before an individual is declared possessed. The fact that this level of engagement between exorcists and mental health professionals is explicitly encouraged, along with the ability to examine methods and procedures standardised between exorcisms, could serve as a means for collecting patient information prior to the performance of exorcisms. It could also reduce the likelihood of conflicting diagnostic interpretations between psychiatric and religious professionals.

The evidence

In relation to evaluating evidence for the various forms of deliverance, from the earliest attempts to introduce placebo-controlled conditions to debunk the healing practices of mesmerism (undertaken by Benjamin Franklin and Antioine Lavoiser in 1784), there has been a persistent tension between belief and scepticism in the therapeutic benefits derived from ritual exorcism (Kaptchuk et al. Reference Kaptchuk, Kerr and Zanger2009). Empirical research assessing the benefits and risks of exorcism has yielded mixed results. In a literature review involving trance and possession disorders between 1988 and 2009, During et al. Reference During, Elahi, Taieb, Moro and Baubert(2011) analysed the data of 402 patients diagnosed with Dissociative Possession or Trance Disorder (from DSM-IV-TR) containing criteria involving attributions of symptoms to spirit possession. Of this cohort, only 7% underwent exorcism which resulted in mixed reports of efficacy, whereas 59% underwent some form of psychotherapy which yielded varying degrees of symptoms relief in all patients who completed treatment.

Abundant case reports and anecdotal accounts of the benefits of exorcism rituals even for conditions such as schizophrenia (Irmak, Reference Irmak2014), along with testimony from experienced professionals such as Richard Gallagher, on the surface demand to be taken seriously but lack objectivity and empirical rigour. While Sanford (Reference Sanford2016) agrees with the inconsistency noted when measuring the effects of exorcism on psychological health, he states that the usefulness in interpreting existing results is diminished due to a lack of attention given to understanding and differentiating the actual methods employed in exorcism procedures. Sanford concedes that exorcism may improve symptoms in some circumstances and that a cautious integration and greater mutual understanding between medical and religious professionals may be of benefit to patients. Pfeiffer (Reference Pfeifer1994) has made the important point that special attention should be given to those who experience therapeutic failure from exorcism rituals and that special scrutiny paid to factors which are felt to be universally helpful (e.g. fellowship groups, regular supportive counselling with a pastor or priest) and which are detrimental (especially rigid and coercive forms of counselling).

Avoidance of harm

Psychiatrists may be especially concerned about the risk of delaying appropriate diagnosis and treatment in cases of delusions of possession attributable to severe mental illness. Negative outcome, such as psychotic decompensation, is associated with the exclusion of medical treatment and coercive forms of exorcism (Pfeifer, Reference Pfeifer1994). Violent and abusive exorcisms have always existed, especially but not exclusively, in less developed societies (Giordan and Possami, Reference Giordan and Possami2016) where there is a consequent risk that mental illness can remain untreated with adverse consequences for illness trajectory, the general prognosis and the suffering and distress for the person and those around them. While tight regulation is in place for the exceptional practice of exorcism amongst adherents of Catholic and Anglican Christians, some faith groups practice exorcism rites more routinely as purification rituals and sometimes with a degree of coercion and violence. Ideally, authorised exorcism will never include any aggressive contact, touching in intimate areas or interaction which could be interpreted as having sexual connotations (Hall, Reference Hall2018). There has been increased debate within a Christian thinktank Theos in the U.K. expressing concerns in popular media that a growing recourse to exorcism rituals may lead to vulnerable people being harmed (Sherwood, Reference Sherwood2017). Other forms of abusive behaviour include exhortation of people with mental illness to discontinue medication on the basis that prayer alone is sufficient for emotional distress, that is only seen through a spiritual lens.

Clearly there is a need to debate, critique and scrutinise religious constructs of possession and practices such as exorcism rituals, owing to the considerable overlap in how beliefs regarding spirit possession and mental illness are construed, depending on the world view of the practitioner. Physicians and religious healers have likely been unwitting partners in managing distress about these issues for centuries.

Discussion - minds: open or closed?

Attending to the detail and history of someone’s spiritual beliefs can distinguish if presenting symptoms are culturally appropriate for them and may lead to different theories about causation, as well as being a template for thoughtful and concerned listening. Psychiatric diagnosis, oblivious to a person’s cultural and spiritual beliefs, may inadvertently dismiss or even ridicule a culturally significant approach to healing. An existing body of research has also suggested that religious individuals are less likely to come forward for mental health care when facing psychological difficulties (Lloyd and Kotera, Reference Lloyd and Kotera2021) and that religious individuals with fundamentalist beliefs are more likely to see mental illness as the outcome of a poorer relationship with God, sinful living or demonic activity (Lloyd and Panagopoulos, Reference Lloyd and Panagopoulos2023). Yet the finding that delusions of possession are a predictor for unfavourable prognosis and treatment outcomes is of particular concern (Kopeyko et al. Reference Kopeyko, Borisova and Gedevani2018) and highlights an imperative for accessing timely mental health care. Delay in presenting to healthcare providers and diversion to spiritual practitioners may be because being “possessed” may be perceived as less stigmatising, than being diagnosed with schizophrenia. A study from India for example revealed that 40% of patients with schizophrenia were encouraged by their families to accept such interpretations and participate in faith healing as opposed to seeking psychiatric help (Kulhara et al. Reference Kulhara, Avasthi and Sharma2000).

As evidence of an emerging common ground between spirituality and psychiatry, the Royal College of Psychiatrists Spirituality and Psychiatry Special Interest Group (one of the largest in the Royal College with currently over 5000 members) was founded in 1999 to respond to a growing call from patients to acknowledge the benefit of healthy religion and spirituality in their recovery (Gray, Reference Gray2018). On the basis that there is considerable diversity about how illness is perceived and that in many cases psychiatrists and religious healers do seem to share sufficient beliefs about psychological health to make cooperation possible and even potentially beneficial, then the question arises as to how or whether psychiatric and religious approaches in treating possession-like afflictions could interact (Scrutton, Reference Scrutton2015). The role of the psychiatrist therefore may simply be to exclude medical or psychiatric causes for such patients, with the person then deciding themselves if they should consult with an appropriate spiritual advisor. Such an advisor may or may not autonomously recommend an exorcism procedure as an alternative to, or in other cases concurrently with conventional psychiatric treatment, when this alone has yielded a sub-optimal response in more clear-cut cases of psychiatric diagnoses, such as treatment resistant schizophrenia. Commentators such as Sanford (Reference Sanford2016) believe it is justifiable and pragmatic to recommend, or at least not dissuade some people from undergoing exorcism, whilst being agnostic about the mechanisms behind exorcism rituals. Others advise against this approach citing a risk of secondary trauma (Lloyd, Reference Lloyd2021), while Exline et al. (Reference Exline, Pargament, Wilt and Harriott2021) endorse a benefit in providing a safe place for patients to discuss supernatural interventions: the pros and cons of pursuing them, as well as any effects they might experience. This assumes the psychiatrist is reasonably confident in the competencies of the person conducting the exorcism (which may not always be the case), as well as the nature of the rituals themselves to avoid the risk of causing harm to vulnerable and emotionally distressed people. It also assumes that the psychiatrist is comfortable in delegating elements of pluralistic healing to a person not conventionally a member of a multidisciplinary team and being open to the idea that religious beliefs, even in demonic possession, can inform a person-centred approach when the person themselves has expectations of benefit from a given ritual.

Michael Sersch a licenced psychotherapist in Wisconsin has recently published a treatise on possession and exorcism (Sersch, Reference Sersch2019) for clinicians and has useful recommendations for responding to patients who claim they are possessed. He asserts that any sort of exorcism, or intervention with the same intentions as exorcism, should only be performed by a qualified and experienced practitioner. He states that a person should only avail of this intervention if: they believe themselves to be possessed and in need of an exorcism without coercion from anyone else; they have a belief system that is consistent with belief in possession states (versus clear forms of psychosis) and if the ritual is conducted in a safe and respectful manner causing no harm to the person involved.