This is a book about psychiatry. A lot of books about psychiatry, even by psychiatrists, tend to foreground its difficulties, controversies and detractions. Thomas Szasz (Reference Szasz1962) notoriously, and with apparently little understanding of the positive role of myth in human well-being, questioned the very existence of psychiatry in The Myth of Mental Illness.Footnote ¹ Anthony Clare’s book was famously about Psychiatry in Dissent (Clare, Reference Clare1980). More recently, Tom Burns (Reference Burns2014) has written about Our Necessary Shadow and Ben Cave (Reference Cave2023) about What We Fear Most. My friend Gwen Adshead, a forensic psychiatrist, referring to her work with patients who are also offenders, wrote about The Devil You Know (Adshead and Horne, Reference Adshead and Horne2021). In conversation with some critics of psychiatry, it can feel as though it is psychiatrists themselves who are the devils, and yet psychiatry is dedicated to helping others, and to bringing healing and recovery from the suffering of mental illness.

Following in this tradition of psychiatrists writing about psychiatry, I am also seeking to draw attention to one of the issues over which psychiatry is ‘in dissent’, and, although – unlike Szasz – I think that the concept of mental illness is a useful one in pursuit of relieving human distress, I am also wanting to question some of the fundamental assumptions that psychiatry makes. We have lots of dissent, not least in relation to the place of spirituality in psychiatry, and yet we too often do not look as critically as we might at the assumptions that we make, as psychiatrists, about psychiatry and about what it is that our patients really want from us. Like our patients, we have our shadows and our fears. We are human beings too, and this influences the ways in which we go about our work. I see this not as a fatal flaw but, rather, as an all too often unrealised asset.

This book proposes a positive vision of the core concerns of psychiatry as understood through the lens of spirituality. It is not about what we fear most – it is about what we desire most. Although I will talk about the metaphorical shadows, because it is the task of psychiatry to address them, my aim is to say more about the light that casts them. Of course, our fears and our desires, shadows and light, are not unrelated. We fear that we will lose, or fail to find, what we desire. The opposite of what we value most highly may be experienced as a ‘necessary shadow’ or may be demonised. A focus on signs and symptoms of illness is a natural tendency of medicine, since our patients come to us asking for help with their problems, which we traditionally refer to as their ‘presenting complaints’. However, most of them are not complaining, they are seeking recovery. They do not want their lives to be focussed on what has gone wrong; they want to be well. Psychiatry, I am suggesting, should have this positive goal of human flourishing firmly in mind when making a diagnosis or developing a treatment plan. This positive therapeutic endeavour is, I suggest, inextricably connected with spirituality.

Spirituality and Psychiatry

This book is about spirituality and psychiatry. There have been a large number of such books over recent years, and it may well be asked why we need another one. My first answer to that question is that many of the other, very excellent, books (e.g., Huguelet and Koenig, Reference Huguelet and Koenig2009; Moreira-Almeida et al., Reference Moreira-Almeida, Mosqueiro and Bhugra2021) focus primarily on the science. Whilst I will address the scientific research evidence here, and the empirical evidence base is important, I believe that we need to be much more interdisciplinary in engagement with perspectives from the humanities, especially theology and religious studies. Scientific research on spirituality and psychiatry has often focussed on what is most easily measurable rather than what is most meaningful; I’m hoping to redirect our attention to the spiritual quest for meaning.

Secondly, my intention is to show that spirituality is not an optional extra, or something that has simply been neglected, or even something that has statistical significance and so should be taken more seriously; rather, it actually is a core concern of psychiatry. When psychiatry appears to be ignoring spirituality, or excluding it, or when voices are heard pleading that it should not be forgotten, what has actually happened is that psychiatry has adopted a particular theological stance – an ‘atheology’. Psychiatry is not, and never has been, neutral or disinterested in relation to spirituality and religion. Rather, it has imposed a pragmatic atheism which is so much taken for granted that it has become virtually invisible, except to those patients for whom it causes distress. My aim in this book is to make these invisible assumptions visible in order that they may be critically reconsidered.

Spirituality and religion are notoriously difficult terms to define, and we shall consider their contested utility in Chapter 1. They are important, insofar as this book is concerned, because they refer, however imprecisely, to aspects of human experience and meaning-making which are perceived as deeply important to most people worldwide. Even in more secular Western countries, amongst which the UK ranks highly, there are many who consider themselves spiritual but not religious (SBNR) (Mercadante, Reference Mercadante2014) and yet others who might not identify as spiritual or religious but for whom key aspects of spirituality (e.g., transcendent relationships, meaning and purpose in life) are still very important. Many others continue to find traditional religious ways of belonging and believing vital to expressing what matters most to them. For people in any of these groups, when they request help from mental health services, problems can arise, and some of their core concerns in life may be misunderstood, neglected or pathologised. Key resources which offer potentially positive support for recovery are thereby ignored, sidelined or else become part of the clinical problem rather than its solution.

My Perspective as Author

I am writing as a psychiatrist. I trained in general psychiatry and addictions psychiatry, but most of my clinical work was in the latter subspeciality. For many of my patients, spiritual pathways to recovery were literally life-transforming. For all of my patients who were psychologically and/or physiologically dependent upon substances, fundamental questions arose about whether there was anything that they valued more than the object of their addiction. The salience of addictive patterns of behaviour is such that it tends to erode everything else in life: family, work, morality, identity and self-worth. Recovery depends upon finding something that matters more than the object of addiction. I was therefore always interested to know, ‘What matters most to you?’ I received many and varied answers to this existential question, mostly not in traditionally religious terms, but for patients in recovery, priorities in life had always had to take a complete change of direction, away from substances and behaviours that were destructive of life and towards the things that gave life.

I am writing not only as a psychiatrist. I am a Christian. I am an honorary chaplain in the Tees, Esk and Wear Valleys NHS Foundation Trust, a priest in the Church of England and an Emeritus Professor in the Institute for Medical Humanities at Durham University. All of these things have shaped my perspectives on psychiatry but also, and perhaps even more, my experiences of illness as a patient and a carer (about which I say more in Chapter 2). I have concluded that spirituality is a core clinical concern for all areas of medicine, not only psychiatry. It is not an ‘optional extra’ or simply a ‘special interest’ that is relevant only occasionally. I have reached that conclusion as I have faced illnesses and crises in my own life, and in the lives of those I have loved, as well as in the course of caring for others, pastorally and clinically. Whilst my own narratives have been shaped by my Christian spirituality, I am aware that others use a different vocabulary, and I seek always to be sensitive to this. However, clinicians and clergy often resort to a professional or religious vocabulary which obscures rather than supports processes of personal reflection on suffering. It is important that, as psychiatrists, we are able to present a human face to our patients, and that we do not only act as scientists or technicians.

The Themes of This Book

My contention in this book is that psychiatry is deeply entangled with spirituality, religion and theology. The entanglements of psychiatry with spirituality, theology and faith are far-reaching and influence the views of both clinicians and patients, whether or not they are consciously aware of it. I have therefore illustrated the clinical relevance of these entanglements by the inclusion within each chapter of case studies, engagement with professional practice and examples drawn from experience. I have also addressed the relevant academic literature on spirituality and psychiatry, including – but not only – the scientific evidence base. I want to show that the humanities, especially theology and religious studies, have an important contribution to make. My overall aim, and therefore the central theme of the book, has been to show that spirituality is – whether explicitly acknowledged or not – a core concern of psychiatry, psychiatrists and patients, and thus crucial to patient-centred practice.

The notion of ‘entanglement’, as used in this book, is obviously metaphorical, seeking to convey a sense of how interrelated and mixed up psychiatry is with spirituality, theology and related disciplines. Perhaps less obviously, as I will explore in Chapter 1, the metaphor derives from research in the critical medical humanities, and I believe that psychiatry needs to engage much more seriously with understandings of the human condition drawn from non-scientific disciplines. The metaphor is employed here in order to show that it is not only undesirable to try to keep the domains of spirituality and psychiatry separate (because this would be to the detriment of patients); it is in fact impossible because they address significantly overlapping concerns. In support of this argument, the book raises some fundamental questions about the nature and practice of psychiatry.

One of the problems with texts on spirituality and psychiatry (including Spirituality and Psychiatry – Cook and Powell, Reference Cook and Powell2022) is the tendency to avoid theology almost completely. This may be justified as being respectful of the theological pluralism amongst readers, clinicians, patients and others. However, the effect of this is to deny theology its disciplinary voice, and to treat specific religious beliefs as unimportant because – implicitly – they are presumed to lack explanatory power. Ironically, avoiding discussion of theology actually assumes and imposes a particular theological stance – the stance of atheism. The approach in the present volume, in contrast, will be to draw on some theological themes of broad relevance across traditions (e.g., image of God, prayer, spirit possession) and, where appropriate, to give specific examples from different faith traditions. It will also emphasise the concept of ‘ordinary’ theology (Astley and Francis, Reference Astley and Francis2013), especially the theology of patients, as more important in clinical practice than the theologies of academia or religious institutions. What I will not be doing here is to engage in a specifically Christian theology of psychiatry, although I have done that elsewhere (Cook, Reference Cook and Wolfe2023b).

Religion (as distinct from spirituality) will also be an important theme in this book. I do not share the very negative and superficial view of religion espoused by Thomas Szasz and others. When Szasz suggests that ‘man conceives of God in his own image’ (Szasz, Reference Szasz1962, p.179), he is making a psychologically valid observation, albeit not a theologically original one. (The idea dates back at least to the work of the German philosopher Ludwig Feuerbach (1804–1872) – Beyers, Reference Beyers2022.) The idea that God ‘is a kind of superman’, as Szasz asserts (p.179), is a common trope of some strands of atheism, but not one that would be taken seriously by academic theologians. In practice, even in ordinary theology, most images of God are much more complex than this (and will be considered in Chapter 4).

A crucial theme is that of the giving of attention as both a spiritual practice and a clinical skill. As I have explored in Chapter 7, prayer, mindfulness and silence all have a spiritual quality which is fundamentally concerned with attentiveness, and as I reflect back on my own clinical career I think that it has been this quality of attentiveness that has been a central concern of both my spirituality and my professional practice. I have not always been good at it, but I hope I have got better as I have been helped by patients and colleagues to learn to pay attention to the things that matter. However, there are different ways of paying attention, and we all too often revert to a scientific, academic kind of attentiveness which neglects spiritual values. My hope, then, is that psychiatry can become more spiritually attentive, without losing its attentiveness to the sciences of mind and brain. In order to reflect this, I have tried in each chapter to give both a reflective, integrative attention to the relevant clinical and human concerns, as well as an evidence-based and scientific attention to the academic literature.

A final theme is that of the secular, or post-secular, context within which all of these other themes are being considered, at least by readers in the Western world. (I am well aware that for some readers elsewhere in the world the context in which they work will be that not of secularity but of a religious worldview formed by one of the major faith traditions, such as Christianity or Islam. Nonetheless, the global context is still one in which secularism must be addressed as it has been so influential upon the origins and development of the discipline of psychiatry internationally.) Secularity, and its relationship to psychiatry, will be considered especially in Chapters 1 and 8, but will also appear from time to time elsewhere in the book. It has, however, been proposed that we are now entering a post-secular modernity within which religion cannot be ignored, given its historic influences on the values and traditions of supposedly secular societies, its impact upon international politics and its ongoing importance in the lives of ‘believing citizens’ (Habermas, Reference Habermas2008). Post-secularism has its implications for psychiatry, to which we will return in Chapter 8. However, the whole book is in effect a reflection on what a post-secular psychiatry might look like once its entanglements with religion and spirituality are exposed and acknowledged.

The themes of the book therefore include, centrally, attentiveness to spirituality, its entanglements with psychiatry, and the ordinary theology of patients, all in the context of post-secular modernity. I keep returning to the question of what psychiatry is all about. Whereas Tom Burns (Reference Burns2014) has framed this in terms of a shadow, and Ben Cave (Reference Cave2023) in terms of what we fear most, I increasingly think that it is really about what we desire most, about the light that casts the shadow rather than the shadow itself, even if the shadows have much to teach us about the nature of light. For most of human history, and for most cultures, our deepest desires have usually been expressed in terms of what we now call ‘religion’ or ‘spirituality’. When we experience fear that we may lose hope of attaining these deepest desires, or when we find ourselves in their shadows, we might call on a psychiatrist or on a priest for help, but we hope that they will get us back on track in search of what we most desire. Spiritually attentive psychiatry, as I have called it later in the book, maintains that positive vision of the human quest, whatever vocabulary we may use in trying to articulate it.

The Shape of This Book

This book is intended to be complementary to the second edition of Spirituality and Psychiatry (Cook and Powell, Reference Cook and Powell2022), without duplicating the material covered in that volume. It draws on topics and examples which were either not covered in that volume or else only addressed there in passing. These include the importance of engagement with the critical medical humanities (especially theology and the study of spirituality), the spirituality of the psychiatrist, the hearing of spiritually significant voices, and demon possession. However, the intention in doing this has not been merely to fill in the gaps left by Spirituality and Psychiatry, but rather to paint a picture of how spirituality and psychiatry are interrelated. It is a completely different kind of book. The shape of this book is therefore not constructed around either the diagnostic categories of psychiatry or its subspeciality interests.

Because this book is a single-author work, unlike Spirituality and Psychiatry, I have been able to paint a picture of psychiatry as I see it. This is a more personal, integrated and (I hope) creative perspective, pushing some of the boundaries. My portrait of psychiatry will, I expect, be controversial in places and will not necessarily reflect a likeness that all psychiatrists will recognise. However, I believe that it is also completely in accord with the holistic model of psychiatry presented within the Silver Guide to the revised curricula of the Royal College of Psychiatrists (RCPsych, 2022). What I am presenting here is a personal vision of how that holistic model of psychiatry might look in practice. Whilst I am questioning the assumptions that we make about spirituality in psychiatry, and proposing different ways of seeing and doing things, this is ultimately about seeking a holistic, patient-centred understanding of psychiatry in its wider human context. As such, I hope that it will be recognisable for psychiatrists and patients of all faiths or none. Where there is dissent, I hope that it will generate constructive discussion.

In order to paint this person-centred picture of psychiatry, and after exploring some of the core themes of the book in more depth in Chapter 1, I turn in Chapter 2 to the spirituality of the psychiatrist. This may seem an odd way to go about painting a picture in which I see patients as central, but I don’t think we can understand our patients properly if we are not first and last able to be self-reflective about the way in which we handle our own spirituality, as human beings and as a profession. It is thus only in Chapter 3 that I get to the heart of what I think patient-centred spirituality is really all about.

In Chapter 4 I turn to the complex interdisciplinary relationship between the science of psychiatry and theology. I think that one of the reasons that we struggle to see the importance of spirituality to psychiatry is that (at least in the Western world) we have lost sight of the ways in which the European Enlightenment has distorted our understanding of the formal academic engagement between science and theology. Even more importantly, we have lost sight of the ways in which ‘ordinary’ theology affects the thinking of patients about their faith and their illness. In order to illustrate the importance of this, I have again had to be selective, and I have chosen the important topic of God image as illustrative of the wider concerns of what I am calling here ‘clinical theology’.

Chapters 5 and 6 are, respectively, about psychiatric phenomenology and spiritual struggles. Because each of these topics really deserves a book all to itself, I have chosen specific examples to illustrate the broader themes. Chapter 5 is therefore based on my work on auditory verbal hallucinations (and especially spiritually significant voices), and Chapter 6 is based on a case study of a patient who believed that he was possessed by evil spirits. So much more could be written about entanglements of spirituality with other aspects of psychiatric phenomenology than hallucinations, and possession states are only one of many kinds of spiritual struggle. Nonetheless, I hope that they illustrate some of the broader themes to which I am trying to draw attention in this book. Spirituality is intimately interwoven with psychiatric phenomenology, whether implicitly or explicitly, and spiritual struggles of diverse kinds become entangled with mental illness in a complex, bidirectional interrelationship.

Clinical psychiatry is all about finding ways to bring healing and to facilitate processes of recovery. In Chapter 7 I have therefore turned to spiritual interventions, or treatments. I have again tried to focus on some of the topics which I think have been neglected, in this case the question of giving careful attention in psychiatry, and the importance of silence as both a spiritual and a psychological practice. However, I have also addressed here the controversial topic of prayer and the much-discussed employment of mindfulness as a spiritual treatment in psychiatry. Patients want to know that we are giving them our careful attention, and there is a spiritual dimension to this careful attentiveness which may be helpfully (or unhelpfully) expressed in prayer, mindfulness and silence. I am proposing a spiritually attentive and patient-centred approach to psychiatry, within which prayer, mindfulness and silence each have their proper place.

Finally, in Chapter 8, I consider the ways in which psychiatrists manage spirituality professionally, especially in relation to boundaries. When it comes to affirming the importance of spirituality in psychiatry, boundaries have so often been seen as the problem, whereas in fact I see them as the solution. Psychiatry is – or should be – concerned with creating safe clinical spaces within which positive spiritual and psychological transformation can take place. These safe spaces are paradoxically less, not more, easily created in a secular society than in a religious one. However, in the post-secular age that we are now entering, we need to look again at the boundaries that create and protect these safe therapeutic spaces. The important boundaries are often seen as being professional and social, whereas I believe that they are primarily inner and psychological. They are also not there as natural features, dividing the landscape like walls or fences; rather, they are clinically created with the purpose of integration. Whilst this may sound paradoxical and somewhat counter-intuitive, I hope that the picture will nonetheless become clear in this final chapter.

The shape of this book is therefore not moulded by psychiatric taxonomies, by neuroscience or by any of the other chapter headings of traditional psychiatric textbooks; rather, it is formed by the spiritual challenges facing patients and their psychiatrists in clinical context, their phenomenology, their boundaries and their entanglements.

Psychiatrists

I want to make clear at the outset that I am not in any way suggesting that atheist or agnostic psychiatrists are not as good at attending to spiritual concerns in clinical practice, compared with their religious colleagues. Nor am I writing only for those who consider themselves to be either spiritual or religious (or both). I have huge regard for the clinical and spiritual sensitivities of many who do not share my Christian worldview. There is no ‘view from nowhere’ and we all approach our clinical and academic work from a particular, situated and personal viewpoint. Over the years, I have personally received more complaints from patients about proselytising by atheist and agnostic psychiatrists than I have about proselytising for particular spiritual or religious beliefs. However, there are atheist psychiatrists who are very sensitive to the spiritual concerns of their patients, and there are religious psychiatrists who are very insensitive.

We are all prone to slip into our own comfortable ways of viewing things, and to imagine that others would be better off if they viewed things as we do. I have often been approached by Christians saying that they would like to see a Christian psychiatrist (one example of which is given in Chapter 3) and I almost always say that they need to see a good psychiatrist, not necessarily a Christian one. I believe that what is needed is spiritually attentive clinical care, and that this can be provided by any good psychiatrist, regardless of his or her spiritual/religious beliefs, or lack of them. So, my core message in this book is that psychiatrists, whoever they may be, need to keep spirituality in mind, and that this is central to a person-centred, holistic understanding of what psychiatry is all about.

Readers of This Book

As I write this book, my main intended audience is psychiatrists, both trainees and consultants. However, I hope that the book will have wider appeal amongst all who are concerned about mental health, the allied mental health professions, especially mental health chaplains, and patients who want to reflect critically on their experiences of mental illness and psychiatric care. I’m hoping that the book will facilitate reflection on clinical work, provoke debate within the field and encourage creative and critical thinking about the relationship of spirituality to the biopsychosocial model in a pluralistic and global psychiatric environment.

Vocabulary

A few words may be in order with regard to vocabulary. As was the case when I was editing Spirituality and Psychiatry (Cook, Reference Cook, Cook and Powell2022c, p.xxii), I have chosen to use the word ‘patient’ to refer to those who experience mental illness and seek help from psychiatrists. This word generally seems to be preferred by patients themselves, although, unsurprisingly, there are those who prefer other terms, such as ‘service users’ or ‘experts by experience’. I prefer ‘patient’ because I am a patient (as well as a doctor) myself, albeit not a psychiatric patient, and the tendency to avoid the term in our particular area of medicine seems to me to express a subtle form of stigma against mental illness. The word ‘patient’ also has etymological connections with a spiritual virtue of patience, which is consonant with the positive message of spirituality that I wish to convey in the book. For similar reasons, I will use terminology of mental illness or mental disorder rather than the euphemisms which seek to avoid implication of a medical model. All of this is in support of a vision of patient-centred medicine in which patients are people, and in which doctors and patients share a common humanity in which we all face our own experiences of illness and suffering in body, mind and spirit.

As I hope may already be clear, when I employ the word ‘theology’ I am including atheism and agnosticism as theological perspectives which need to be taken seriously. I therefore have a very broad view of what constitutes theology, within which one view is that there is no God, a view that we might refer to as ‘atheology’. Similarly, spirituality encompasses a wide range of worldviews including atheistic spiritualities, those who identify as SBNR and the spiritualities associated with the world’s major religions. To some extent, then, it is worldviews that I am concerned with, in a broad sense: ‘A worldview is a collection of attitudes, values, stories and expectations about the world around us, which inform our every thought and action’ (Gray, Reference Gray2011, p.58). Worldviews do not only derive from spirituality and religion, but it is the spiritual and theological aspects of worldviews that I will be most concerned with in this book, in relation to psychiatry.

Case Studies

Finally, a word of explanation is in order in regard to the clinical material presented in this book. I have employed various strategies in order to ensure that cases cannot be recognised. This has included changing identifying details and amalgamating different cases into one. Some of the stories relate to patients whom I saw many decades ago. However, some issues are seemingly universal. In a public lecture that I gave a few years ago, I invented an entirely imaginary case study in order to illustrate some of the issues that arise in relation to religious faith and depression. I told a story of a completely fictional patient, whom I called Agnes. A woman whom I had never met before came forward after the lecture and said, ‘I am Agnes!’ It is therefore entirely likely that some readers may recognise themselves, or people whom they know, in the clinical examples that I have given in this book, but this will only be because the issues concerned have wide currency and are far from unusual.

With hindsight, I wish that I had kept better records of my clinical encounters over the years. Ben Cave’s book, cited in my opening paragraph, is an excellent example of how helpful this can be. I’d like to go back and review in detail how my attitudes have changed and to reflect again on clinical encounters earlier in my career in the light of what I have learnt in the years that have followed. However, the memories that endure are the lessons that my patients taught me about suffering, spirituality and how to be a better psychiatrist. Also enduring are the important clinical lessons that I learnt from my consultants when I was a trainee, and later from my clinical colleagues in my peer group, and in the Spirituality and Psychiatry Special Interest Group (SPSIG) at the Royal College of Psychiatrists. These were usually not about things that you get asked about in membership examinations for the RCPsych, but they are about things that make the difference between being merely an adequate psychiatrist and a really good one. They were about compassion, humanity, wisdom and spiritual attentiveness. Even if there are shadows in psychiatry, there is also a lot of light.