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Newsletter, March 2019

International conference on Church Care for Mentally Ill People

Below are papers read at the International conference on Church Care for Mentally Ill People
November 13-14, 2018, Moscow (continuation)

Religiosity and depressive disorders in elderly people

Peter G. Coleman, Emeritus Professor of Psychogerontology, University of Southampton, England, UK

Since I was young, thanks I think to the closeness I felt to my grandmothers, I have always been fascinated by old age, both the challenges it brings as well as its achievements, expressed above all in concern for future generations. Ageing usually involves considerable loss, physical, social and psychological, but it is also true that most elderly people cope remarkably well with these changes, at least until the very last stages of extreme weakness and frailty. Even then much can be done to support them through what is after all a natural stage of life and to help them face death with serenity.

I have worked throughout my career as a psychologist in departments of gerontology and geriatric medicine, first in the Netherlands and then back in England where I had been educated. When I came to work in a medical school in Southampton more than 40 years ago I was closely involved in evaluating the new forms of specialist psychogeriatric services then being opened in particular areas of the UK. These services were based on new principles: a recognition of the close interaction between physical and mental illness in older people; encouragement of early referral to the service by the patient's general medical practitioner (GP); a careful diagnosis, particularly in discriminating functional depressive disorders from organic brain disorders; active and continuing treatment of any depressive element in a person's illness; and regular and programmed support to those suffering from forms of dementia, including as well their family carers. (Sadly, in more recent years the previous high standards of such services have declined as the UK National Health Service has failed to respond adequately to the rising numbers of elderly people in the population.)

This presentation is focused on depression rather than dementia. Neither should be thought of as inevitable products of ageing but as conditions to be defeated and managed by good quality care. Dementia is a form of neurological disease and becomes more common in later life but depression does not have such a clear relationship with age. In fact major psychotic depressive disorder is less common among the older groups of the population. Rather what is more prevalent, at least in modern societies, is an increase in chronic disorders of low mood, where persons experience life as no longer worth living or just too much effort, accompanied by a generalised loss of meaning in life. To no longer perceive value in life can be seen as a weakness of the person but it is also the responsibility of the family, community and society in which the older person lives. Religion is as we know one of the great providers of meaning and value, providing perspectives on life that transcend individual decline and death.

Although good psychogeriatric care has always acknowledged the need to attend to the spiritual needs of patients who displayed strong religious affiliations, there was little understanding of how important religious faith and practice were in sustaining human recovery from illness and in maintaining psychological well-being. The situation has now changed as a result of the considerable growth in studies on the subject of ageing, mental health and religion over the last twenty years, particularly in North America, but also elsewhere (Koenig, King & Carson, 2012; Coleman, Schr?der-Butterfill and Spreadbury, 2016). This consistently shows the health and well-being benefits of faith and practice throughout life, but also tending to increase in importance as persons come closer to death in the final years of their lives. Analyses of the results of large scale studies attribute the main influence of religious faith on health to the provision of meaning through life changes, and secondarily to the social support it provides not only through life's stresses but to the maintenance of a lively and healthy faith in the face of inevitable doubts and questioning.

Ageing and religion in Western Europe

However while the importance of meaning in life and the role of spiritual belief is better understood nowadays, traditional religious beliefs are increasingly discounted in the UK and much of Western Europe. These countries have experienced a declining religiosity within their populations, a dramatic loss of faith which has begun to affect even their older members (Coleman and Mills, 2019). These changes have been attributed to the cultural and social upheavals which began to challenge authority, and especially religious authority, beginning in the 1960s. In our longitudinal study of the well-being of persons over 65 years in the city of Southampton which we began in 1977 we recorded how the numbers attributing importance to religious faith dropped from 70% to below 50% as the sample aged over the following 10-15 years. Although there was no further change as the sample aged further into their 80s and 90s, there was also no recovery of faith. We caught this trend in its early stages. It is not uncommon now to observe persons in their 80s questioning and arguing against important elements of the Christian faith in which they were educated in childhood.

As a result of the loss of religious belief in these populations research questions have shifted from investigating the particular benefits of religious faith to comparative studies of meaning giving by different types of "world views" (Lazarus and Lazarus, 2006). Do for example different belief systems provide equivalent moral and psychological support in the trials of later life? For example the well-known biological scientist and campaigner for atheism Richard Dawkins has proposed that a scientific and atheistic based set of beliefs can give rise to a 'world view' that fulfils the same four basic functions in people's lives that religions traditionally fulfil - 'explanation, exhortation, consolation and inspiration' (Dawkins, 2006, p. 347). The same type of questions can be raised about forms of Eastern spirituality and practice very popular now among many younger people in the West and well-represented as well in the post Second World War 'baby boom' birth generations now reaching retirement age. They came to adulthood amid the shifting fashions of the 1960-70s including the introduction of Asian teaching on reincarnation and the practice of mantra based meditation. Islam too is also now well represented in Western European countries. As a result research on ageing, belief and spirituality is beginning to give as much attention to these alternative 'world-views' and belief systems as to traditional Judaeo-Christian belief (Manning, 2019) .

I have recently attended a British Psychological Society's working group on the contribution of psychology to end of life care, and the issues raised there are important for all age groups. There is much more research evidence available now on the psychology of very late life. It appears that previously successful modes of psychological adaptation as assimilation and accommodation fail at this stage of life to be as effective as in the earlier stages of ageing. Low mood and depression increase in prevalence accordingly (Coleman, 2017). There is rising social pressure for forms of assisted dying to be legalised and for use of methods of medication that even very recently would not have been countenanced. There is a dramatic return to favour of the use of psychedelic drugs like LSD that achieved such popularity in the 1960s as ways of enhancing or freeing consciousness to its new use of sending terminally ill persons into other states of being where the painful reality of their situation is masked by hopefully euphoric images and sensations (Pollan, 2018). With the huge expansion expected in the population over 85 years of the age in the coming years questions on the choices of ways of living and dying in the last stages of life will become major ethical questions for all of our societies.

Comparisons between Eastern and Western Europe

Over the last twenty years I have been fortunate to have been able to conduct research on mental health and ageing in Eastern Europe first in Russia and the Ukraine and more recently in Bulgaria and Romania. All of these societies experienced, as you very well know, an enforced loss of access to religious life earlier in the 20th century. Together with colleagues, especially Dr Ignat Petrov, psychogeriatician in Sofia, I have conducted studies on the experience of depression in late life in Bulgaria and Romania. Religious practitioners in both countries suffered persecution in the last century, similarly to that of the Soviet Union, if over a shorter period and of lesser severity. Bulgaria is of particular interest both in regard to changes in religious practice and depressive illness. Perhaps learning from the Soviet experience, the post-war Bulgarian government applied a much more subtle but seemingly more effective long term strategy of undermining Church practice and vocations following seizure of power after WWII. It also worked hard on providing alternative secular forms of ritual to accompany the key transitions of life. By comparison Romanian persecution of religious practitioners although having severe consequences on the lives of particular individuals was not as systematic nor as destructive of religious practice.

In our studies of Bulgarian and Romanian villages we identified high rates of depression. In large part of course this can be understood in terms of the decay of traditional village life, outmigration of younger people to larger cities and abroad, and a decline in health service provision. But religious faith and practice also appears to play a significant role. Our comparative studies with similar villages in Bulgaria and Romania examined the influence of supportive factors, including religious faith and practice, in sustaining morale and preventing depressive states. We also applied a measure of strength of belief in a spiritual power outside of the self which had been developed for use in psychiatric services in London's increasingly multi-ethnic and multi-faith communities.

As we expected religious practice was much higher and depression much lower in the Romanian situations. My colleague Dr Petrov had also conducted studies of rates of depression among older people in the same villages in the 1970s, so it is possible to make comparisons. There had been almost a tripling of rates in the intervening 35 years, with one in two of the population over 65 years in these villages now showing indications of likely clinical depression. We were also able in Bulgaria to conduct a follow-up study over one year retracing those who had been visited the year before. Those who had evidenced a strong degree of religious faith and practice showed better recovery from depression a year later (a finding also observed in North American studies) (Coleman et al, 2011).

In a subsequent study we obtained funding to investigate experience as well as memories of religious and non-religious ritual in Bulgaria and Romania as well as the UK over the last seventy and more years, thus from before the rise to power of atheistic communism in Eastern Europe and from a time of greater religiosity also in Western Europe. Our interviews on religious life, prayer and ritual, with those in the oldest age groups, who had come to an established religious practice before the establishment of atheistic rule in 1944, showed that they had by and large retained their faith, endured hardship as a consequence of retaining their faith, and in our interviews were able to display many examples of effective religious coping in later life. Many had also succeeded in passing on their faith to children and grandchildren, often by surreptitious means. By comparison some of those brought up in the Christian faith in the UK were experiencing distress in the latter part of their lives because of the loss as well as changing character of religious practice. Others had found ways of reconciling themselves to the changed nature of society and the new forms of ritual practice both religious and non-religious. Bulgarians by contrast had rejected the non-religious rituals proposed by the communist authorities and had returned strongly to traditional religious rituals for births, marriages and deaths (Coleman, Grama & Petrov, 2013).

Bereavement, religion and depression

In the remainder of this report I want to focus on the experience of bereavement, one of the major sources of depression in later life, its impact on older people generally underestimated and with important implications for pastoral practice. In our longitudinal study of ageing in Southampton which I referred to earlier (Coleman, Ivani-Chalian and Robinson, 2015) we noted how a number of our participants reported losing their faith or stopping religious practice after their spouse died. Persons would refer to questioning things they had previously accepted and no longer finding answers. Also divorce was commonly referred to as a source of distancing from the faith of their childhood. Men elaborated less about their religious attitudes but one man provided a very explicit account of the disappointment he experienced in his church after his wife died: I felt very let down with religion, because I was always brought up in the Church of England …… After the funeral the parson just said "cheerio, I'm off", and nobody even bothered whether I was alright or not …..

The suggestion of an association between the experience of spousal bereavement in later life and declining church attendance and allegiance was part of the motivation for seeking funding for an in depth investigation of the subject of religious faith and adjustment to bereavement from the UK's government funded 'Growing Older' research programme (1999-2003). We obtained permission to approach bereaved spouses over the age of 60 years from general medical practices from the first anniversary of the death, and interviewed them three times over the course of the succeeding year. Survivors were also followed up a further six years later. In the course of these interviews we explored both the experience of bereavement and the role played by their religious, spiritual or philosophical attitudes to life and death.

Although the sample we collected was small (n=26) analysis of the results produced a surprisingly strong impression of a curvilinear association between indices of well-being and strength of spiritual belief (Coleman et al, 2007). The latter was assessed by a five item measure of belief in a transcendent spiritual power which could influence their lives. Those who expressed weak to moderate belief were more likely to indicate low levels of expressed meaning in life and symptoms of depression than those who expressed secure religious beliefs or securely held non-religious attitudes. But obtaining such security of attitude, whether religious or irreligious, appears to be far from common and liable to break down in the face of losses such as bereavement.

Two case examples of bereaved older women may illustrate the different consequences of a secure and an insecure faith in response to their husbands' deaths. The first had encountered two stages of bereavement, the actual physical death of her spouse following a gradual psychological separation as a result of his long and progressive dementing illness. She expressed a confidence in God's continuous presence in her life through the difficulties which faced her. Like many of the other older people in this sample she tended to believe that these challenges had been planned for her to undergo beforehand. But whereas others spoke of the role of 'fate' or 'destiny' she referred to the providence of a personal God. Such strong personal faith was often rooted in key personal influences in early life. She referred to her mother saying to her: He never gives you a cross without Him knowing you can carry it.

The second woman had also experienced successive losses but these had led to her gradually losing the faith of her childhood. She could not comprehend how there could be a God who cared for each individual person who ever lived. She continued to go to church in the hope of recovering her faith: I hear the church bells ringing and I think if you don't go today you're never going to believe in any of it again, so you'd better go and see …. I'm hoping that He might give me some kind of sign but I don't know what it is. She envied the strong faith she imagined she saw in her fellow parishioners but sadly never spoke with them or with the religious minister about her doubts, nor would consider the possibility of spiritual counselling. She remained stuck in an internal dialogue with her doubts. This woman like many of the others who were losing or had lost their faith said she could not reconcile belief in a good God with the reality of unfair suffering she had experienced in her own live and that of others. She remained depressed, without a sense of meaning in life and in her own words 'not at peace with her beliefs'.

A brief mention of our bereavement study in SAGA Magazine, a specialist magazine for older people, led to many readers writing to us with their comments. Over a period of seven months more than a hundred letters were sent to the research team, many long and detailed. A large proportion included narratives of disillusionment with the church and with the Christian faith often as a result of lack of support especially following bereavement and watching close relatives suffer. They also commonly expressed the wish to be better consulted and their concerns taken more seriously by their religious ministers (Mills, Speck, & Coleman, 2011).

Bereavement of spouse appears to be an especially critical testing time for religious faith and as a consequence it is one of the more revealing contexts for studying belief in action. A subsequent study in a Roman Catholic parish in the south of England analysed the various benefits a strong religious faith brought to persons who were bereaved. These included: 'benevolent religious cognitions' about the loved person's relationship with God which provided a positive perspective on their experience of loss; 'biblical assurances' in gospel passages, psalms and elsewhere in the Old and New Testaments which they were able to draw on and repeat to themselves to reinforce acceptance of their beliefs; 'religious ritual' during church services which helped them both to regulate their emotions and to express their sense of closeness to the deceased person; 'spiritual capital' in the opportunities church membership provided for new activities, contacts and roles for the bereaved person within the church community (Spreadbury & Coleman, 2011).

Concluding comments: believing and disbelieving in the last stages of life

Our studies have implications for pastoral work. Firstly clergy need to realize that an older person may be more questioning of his or her faith than they imagine. It is easy to assume that an elderly people should have a secure faith after a whole lifetime of attending church services but this is not necessarily so. Older people have more time to reflect on their lives and the state of the world and their thoughts may lead them to question Christian doctrines. Job's question - 'how can a good and powerful God permit evil?' - is ever present and may well become more acute with age. Serious crises of faith can be precipitated by tragic events within their families, such as early bereavements and seeing loved ones suffer in ways which appear unjust. In our studies we interviewed persons who had come to see God as imperfect or as limited in His power. Belief in an impersonal and overriding fate or destiny determining each person's life was also common.

Christianity of course does not pretend to provide a ready intellectual answer to the question why a good and omnipotent Creator should allow evil. This is hidden in the mystery of the origins of evil in an invisible spiritual world given freedom by God, as mankind was as well, to act in harmony or in opposition to God. Instead our Christian faith provides a triumphal response to evil in the incarnation of Christ, Son of God, His life, His ministry, His death and His glorious resurrection. But this faith has to be communicated effectively. Older people nowadays as much as younger people need to believe in ways that they can accept rather than only on the words of external authority. Faith is not the same as certain knowledge and inevitably involves times of doubt. It requires trust in God to reach the deeper commitment required. But still this trust has to be made understandable, first ideally in the child's original family context of loving parents, but throughout life right until advanced old age in the response of those who care for them. We always need to be reminded by others and to remind ourselves that God is good and loves mankind.

Church communities should be alert to the needs of those in their midst who are in distress. Those with signs of mental and spiritual suffering should be listened to with loving care. There should be greater acceptance inside the Church of those questioning and 'wrestling with faith'. Ageing can be a time not only of mourning and lament, but also of complaint, protest and even anger against God. Despite their negative appearances these latter emotions can all be signs of ultimate hope and trust in God, urging His action to transform a painful situation. The Church's liturgies with their regular use of the powerful Hebrew psalms, alternating between distress, protest, trust and hope mirror these natural human emotions wonderfully well. They should regularly be on our lips together with the most loved Gospel passages and the Church's wise commentaries on them. But above all people at the end of their lives should not be left alone to struggle in silence with their doubts.

References

Coleman, P.G., McKiernan, F., Mills, M. and Speck, P. (2007). In sure and uncertain faith: belief and coping with loss of spouse in later life. Ageing and Society, 27: 869-890.

Coleman, P.G., Carare, R.O., Petrov, I., Forbes, E., Saigal, A., Spreadbury, J.H., Yap, A. & Kendrick, T. (2011). Spiritual belief, social support, physical functioning and depression among older people in Bulgaria and Romania. Aging & Mental Health, 15:327-333.

Coleman, P.G., Grama, S. & Petrov, I.C. (2013). Ritual in the changing lives of the very old. In P.G.Coleman, D. Koleva, & J. Bornat, J. (Eds.) Ageing, ritual and social change: comparing the secular and religious in Eastern and Western Europe. (pp. 229-246). Farnham, Surrey: Ashgate.

Coleman, P.G., Koleva, D. & Bornat, J. (Eds.) (2013). Ageing, ritual and social change: comparing the secular and religious in Eastern and Western Europe. Farnham, Surrey: Ashgate.

Coleman, P.G., Ivani-Chalian, C. & Robinson, M. (2015). Self and meaning in the lives of older people: case studies over twenty years. Cambridge: Cambridge University Press.

Coleman, P.G., Schroder-Butterfill, E. & Spreadbury, J.H. (2016). Religion, spirituality and aging. In V.L Bengtson & R.A. Settersten, Jr. (Eds.), Handbook of theories of aging. Third edition. (pp.577-598). New York: Springer Publishing Company.

Coleman, P.G. (2017). Development and adaptation in advanced old age. In P.G.Coleman and A. O'Hanlon, Aging and development: social and emotional perspectives. (pp. 131-188). London: Routledge.

Coleman, P.G. & Mills, M.A. (2019). Uncertain faith in later life: studies of the last religious generations in England (UK). In V.L.Bengtson & M. Silverstein (Eds.), New dimensions in research on spirituality, religion and aging. New York: Routledge (in press).

Dawkins, R. (2006). The God delusion. London: Bantam Books.

Koenig, H., King, D., and Carson, V. (2012). Handbook of religion and health. New York: Oxford University Press

Krause, N. (2019). How religion affects health: views from midway through an odyssey. In V.L.Bengtson & M. Silverstein (Eds.), New dimensions in research on spirituality, religion and aging. New York: Routledge (in press).

Lazarus, R.S. & Lazarus, B.N. (2006). Coping with aging. New York: Oxford University Press.

Manning, C. (2019). Meaning making narratives among non-religious individuals facing the end of life. In V.L.Bengtson & M. Silverstein (Eds.), New dimensions in research on spirituality, religion and aging. New York: Routledge (in press).

Mills, M.A., Speck, P. and Coleman, P.G. (2011). Listening and enabling the sharing of beliefs and values in later life. In P.G.Coleman & Colleagues, Belief and ageing: spiritual pathways in later life. (pp. 35-58). Bristol: The Policy Press.

Pollan, M. (2018). How to change your mind: the new science of psychedelics. London: Allen Lane.

Spreadbury, J.H. & Coleman, P.G. (2011). Religious responses in coping with spousal bereavement In P.G.Coleman & Colleagues, Belief and ageing: spiritual pathways in later life. (pp. 79-96). Bristol: The Policy Press.

Religiosity and Psychopathology in Children and Adolescents

Dr. Panayiota Mama Agapiou

Revered Fathers, dear colleagues, friends, rejoice!

I think this is the best greeting for such a forum. This is how our Lord Jesus Christ welcomed the Myrrh Bearers after His glorious resurrection, according to the Gospel of St. Matthew (Matt.28:8-9). The verb rejoice in Greek means experience joy, which is very similar to the greeting that St. Seraphim of Sarov used to welcome every believer, "Christ is risen, my joy!", since he saw the image of God, i.e. the source of joy, in every human being.

It is a great honour and pleasure for me to participate in this conference. I came here from Cyprus, a small island in the Mediterranean with a centuries-old Orthodox Christian tradition dating back to the Apostolic times. Holy Apostle Barnabas of the Seventy and Apostle Paul's co-worker is the heavenly patron of Cyprus. I experience special joy here in Moscow, since it is the town of St. Matrona, whom I love dearly and venerate, as well as of many other saints of our common Orthodox Church, for we are all brothers and sisters in Christ Jesus; He is the vine, and we are branches, as Apostle and Evangelist John says (John 15:5).

Since I began to talk about my journey, let me make another stop in the homeland of democracy, Athens, where we shall visit the Athens Academy and see a picturesque image of the personified Sciences on the facade of the Kapodystria National University of Athens. It is worth noting that Medicine and Theology are depicted here conversing with each other. Closeness between them is obvious and symbolically shows that both sciences are sisters in the work of cognition and healing of man.

Today we celebrate the Holy Unmercenaries Cosmas and Damian, who, together with many other saints-patrons of medical science, clearly echo with the words of the Old Testament, "Doctors and medicines are given by God!"(Sirach 38:4-7).

The Greek word "θεραπευω" consists of two roots - "θερμο" (adj. hot, warm) and "απτω" (verb, touch) - and means "touch someone with warmth". This is exactly what we try to do in child psychiatry - to touch the child's and his/her family's problems with warmth. This is what makes child psychiatry so special: it is not only a child or teenager who is sick, but the whole family, because the minor is an immediate member thereof and partly depends on it.

Following this introduction, I would like to turn directly to the topic of my presentation, which is divided into four parts for the purpose of our discussion. (Here I would like to share one challenge with you, which I experience daily as a clinical doctor when grouping together various medical cases I encountered in different hospitals where I have worked for the past 18 years. Doing so, I feel that I am destroying the uniqueness of a personality, because each person is unique and, therefore, each case is special. This is what the theology of our Holy Fathers teaches us; biology proves this; and mental health sciences - psychiatry and psychology - substantiate this. However, I had to carry out such a systematization due to the peculiarities of the presentational format, choosing, where it was suitable for better perception, just one example that combines a number of features and therefore can serve as a backdrop for various clinical cases).

These sections deal with the following issues:

  1. Normal stages of psycho-emotional development, which can be burdened by sins or mistakes that religious people believe necessary to limit in order to protect their children's spiritual development.
  2. Cases mistakenly perceived as expressions of religiosity, but actually psychopathological in their presentations.
  3. Heterogeneous group of adolescents with suicidal behaviour (usually cutting themselves on different parts of the body).
  4. Family-based spiritual care - the importance of parent-child relationship in building children's personal relationship with God.

Part 1. Normal stages in the psycho-emotional development of children and adolescents, as well as conditions in children and/or adolescents that cause anxiety among religious parents that their child breaks Christian commandments

A child or teenager is not a diminished copy of an adult, but they have their own special stages of psycho-emotional development, which would be good for us to know. Take the following as a guideline to help us better understand our topic: as adults, we should put ourselves in the shoes of the younger people to look at their problems, especially those related to growth, and then help them, using our mature function. This empathy experience will help us better understand their reality so that we, as adult believers, could continue to surround them with care. The leading mark to us on this path of condescension that we are called to take, is our Saviour Jesus Christ, who, being the Divine Word, has condescended to us and taken on the human nature through incarnation.

I will not go into detail, because time does not permit me, but I will limit myself to those stages or states that can be interpreted as errors of spiritual life, their wrong identification can cause even greater problems for the shaping psyche of a child or teenager.

When an adult believer (parent, catechist, teacher, or priest) feels that a child or young person is breaking a commandment, the situation often raises a particular concern in the former and a hasty desire to expose and punish the latter in order to prevent a repetition of the sin. In particular, the fifth ("Honour thy father and thy mother: that thy days may be long upon the land which the Lord thy God giveth thee"), seventh ("Thou shalt not steal"), ninth ("Thou shalt not bear false witness against your neighbour") or tenth ("Thou shalt not covet … any thing that is thy neighbour's") commandment. These are the ones that encourage us to oppose the child or young person in order to correct some of their sins. This also includes states of selfishness and narcissism, as well as other states that encourage us to belligerently oppose child's or young person's possible self-indulgence, motivating our position that egoism and pride are deadly sins. But is this always the case? Is this always situation of a blatant passion that need to be eradicated?

Let us take a closer look at this issue and examine a few situations which, at first glance, could be interpreted in the above way, being not actually related to passions and sins, but rather to completely different states.

1. Some Special Cases of Child's Lie

Transitional Object. I shall share with you an excerpt from a mother's diary about her daughter's relationship and play with her teddy bear. The mother mentions that when Katerina was 14 months old, she got a big teddy bear, at the age of 16 months she would take it everywhere around the house with her, and at the age of 18 months she would fall sleep with it in her crib. When at the age of 21 months she was given a child safety seat, the girl began to put the toy in it as well. Three months later, Katerina began to read fairy tales to the teddy bear. However, when the girl was the 30 months old, her mother made the following note: "Katerina drew on the walls. When we asked her who had done that, she replied, "Teddy bear, and I gonna punish him". The days after that incident, Katerina was getting more and more angry with the teddy bear and scolded him, "Don't ever do it again, or I won't read you any more fairy tales at night"".

In adults' terms, Katerina lies, because she does not want to take responsibility for what she did and shifts the blame on the teddy bear. What does this mean for her? The cited fragment from the dairy shows that the toy has taken a special place in her life, and a special connection has formed between them; her reactions prove this. Little by little it has become her "man", and she does not feel alone any more. The teddy bear does not only satisfy Katerina's needs in communication and love, but it has turned into a very appropriate recipient of the little girl's anxiety and fear. This is what D. Winnicott calls a transitional object. It refers to a toy or some other inanimate object with which a child has a strong emotional connection and through which he or she realizes his or her desires and needs. This is the child's first "acquisition" and "creation" outside his or her body, with which all significant things can be associated - ideas, emotions, aspirations, fears. It represents the infant's transition from the state of "co-existence" with his/her mother to the state of "relationship" with his/her mother, helping the child to become increasingly independent and experience his or her own essence, according to D. Winnicott.

The transitional object is a bridge between the inner and outer reality. From all this, we may conclude that if we perceive this naughtiness with the teddy bear only as a lie that needs to be limited or as an incipient passion that needs to be eradicated, then we miss a precious opportunity to use the teddy bear to talk about the feelings of the naughty girl; if we take a different approach this will help the girl to avoid doing such things and many others in the future, which could otherwise remain obscured from us.

Fantasy Misuse by Children of Pre-school and Primary School Age. To some extent, fantasy is something predictable and even welcomed, as it helps to shape critical thinking through a symbolic process. Children's rich imagination, as a positive prove of their creativity, encourages them to make stories, exaggerate facts or add fantastic elements. However, this often goes beyond realistic narratives, as if the child does not feel the boundary between reality and fiction. It may be necessary to have an expert's point of view on what makes the child so excessively imaginative. But certainly, this should not be seen as a lie, because the child has not yet developed the sense of self-awareness and can be confused.

Children's Lie. In the eyes of children, their lies are as serious as those of adults; they are not made for fun or a joke. At this age, imitation and identification with parents is very strong. Therefore, when we hear a lie from a child, we must first of all look at ourselves honestly and critically at how often we tell lie ourselves; and not only when we lie to our child, but also in his/her presence to others. If we are sure that this should be ruled out in our particular case, then it is even more worth asking ourselves what makes our child lie. Usually children are afraid, often fairly, that they will be chastised or even beaten up. Therefore, lying in this case is similar to self-defense, and before limiting it, we need to think about what kind of relationship we want to build with our children: their only and first goal is to create good relationships with us.

Sudden Lies at the Adolescent Age. The reasons are often linked with the changes that take place at this stage of adolescent development. A teen begins to look for their personal identity, begins to distance himself from his parents, strives for independence and seeks his identity as a person rather than as an extension of his parents. This distancing and search for independence can take quite a long time and is often quite painful. Even if there have been close relations between the teenager and his/her parents, and he/she shares everything with them, he has a completely natural need to gradually create his personal space (internal and external). If we deny this need and do not allow his individuality to be formed, then the lie becomes an equivalent form of this inner space.

2. Cases of Apparent Breach of the Fifth Commandment

Assertion of a Teenager's Independence. It has been previously noted, children make special efforts to gain their autonomy and independence during adolescence. On this path, they oppose any form of power to demonstrate their ability to do so. Their parents are the first adults to whom they apply this impulse. If parents perceive this position of a teenager as an expression of disrespect for themselves, rather than an immature way of communicating with them, they miss a valuable opportunity to help the teenager in becoming mature.

Nervousness and irritation with signs of resistance to parents are tantamount to depression in childhood and adolescence. Depression in children and adolescents does not manifest itself in the same way as in adults, but signs of resistance to parents, irritation and nervousness are often taken for disobedience and disrespect, because of ignorance of the parents or other adults around the child. However, these children need help of a mental health professional.

Attention Deficit / Hyperactivity Disorder (ADHD). ADHD often manifests itself in disobedience, violation of boundaries and rules, irritation and resistance. However, this is not an expression of disrespect for parents or disobedience. Such behaviour suggests that it is more difficult for a child to concentrate and complete a task or fulfil some work in a satisfactory way, while breaking the rules is associated with an increase in impulsiveness compared with the general population, which in its turn is due to the child's lower concentration of attention. In such situations, it is an application of a specific medicine that helps to improve concentration by making the child more obedient and focused on tasks that are given to him/her.

3. Cases of seemingly selfish behaviour associated with a developmental stage in a child's life, or some form of psychopathology?

Adolescent Narcissism. Narcissism, where a young person turns to himself or herself, acting in a self-centered way because they feel vulnerable and unprotected, is characteristic of an early adolescence, i.e. from 12 to 14 years of age. By criticizing this defense and not understanding the teen's vulnerability, we leave them unprotected from the intactness of their own adolescent psyche.

Autistic spectrum: difficulties in socialization and understanding other people's feelings.This is another condition that deserves special attention, for it concerns a whole group of children and adolescents.

I cannot forget one teenager with the Asperger syndrome who said to me, "I'm not a bad person, I simply don't understand how people feel...".

Part 2. Cases mistakenly perceived as expressions of religiosity which are in fact presentations of psychopathological conditions

Cases of psychogenic anorexia in religious families, which can be confused with the virtue of harnessing the passion of gluttony at an early stage. Athena is an excellent ninth grade student and attends catechetical classes at her parish weekly. She has been reducing the amount of food she eats for several months already, since she believes that a Christian should be moderate in food and ascetical in everything. She also restricted types of food during the Lent, eating only fruits and vegetables. She lost a lot of weight, and three months after she stopped menstruating. In spite of this, she believed herself to be fat, and on the Easter day she refused to break fast with everyone, later confessing that she had thrown away her food and did not eat the meat that had been served. She was referred to us by the local bishop, her parents' father-confessor, because he had realized that this was an illness, rather than true abstinence, because abstinence mortifies passions, not the body.

Cases of depression in religious believers, in which self-mortification, joylessness and a negative image of oneself are interpreted as remembrance about death, self-condemnation and awareness of vanity of being. Elpida, a 10th grade student from a deeply religious family, where the lives of saints were constantly presented as role models, children were instructed to be just like them, emphasizing the fact that the saints wept day and night over their sins, constantly grieved them, and thus attained grace from God. These conversations about the lives of saints took place not in a benignant atmosphere, but under pressure. Elpida attended her classes lately very tired, without desire to learn. Her academic progress had worsened, and she saw no point in further schooling, because, as she said, life was fruitless. She often cried for no reason and said that she would better die, for this would bring her closer to Christ and salvation. At first, her parents thought she was a mature child who followed her family's instructions. She avoided peer groups, saying she did not see any point in communicating with them, and felt bored with them. In a while, her parents realized that something was wrong and brought her to our ward. We confirmed that she was in depression and needed medication and psychotherapeutic treatment. Among other things, she also admitted that she would have committed suicide had she not been held back by the consciousness that this was a sin.

Obsessive-compulsive disorder, which can be mistaken for exceptional piety or other manifestations of spiritual life. Ten-year-old Nicholas, before he does anything, makes the sign of the cross three times. If he loses count, he repeats it from the beginning; he is often not sure if he has made the sign of the cross three times and repeats it until he is sure that the number is correct. He thinks that if he doesn't do the right number of times, something bad will happen to his family; so, he is protecting them. Gradually Nikolas stopped leaving his house, as his classmates found him strange and became ashamed of his behaviour. When his parents brought him to our ward, it was clear to us that his actions were a compulsive disorder.

Another case: nine-year-old Antony describes the following, "I see demons around me in a female form. The only way to drive them away is to wash my hands".

At this age, children's obsessions often take the form of repetitive images, and because of their immaturity they cannot distinguish them from reality. In both cases, we worked through psychotherapeutic methods - more specifically, family psychotherapy - which gave a fairly positive result as children were under 12.

Psychosis with Obsessive Ideas with Religious Content. Janis is a 14-year-old boy. Before he came to us, he had recently begun to withdraw in his room, refused to take shower, and said that he heard voices of the different saints who were opening up the future to him. Being sure that Nicholas was possessed with a demon, his parents first brought him to a priest for exorcism. Fortunately, the priest realized that the child's mental health needed to be examined, and asked his parents to contact us. When he was brought to us, it was discovered that Janis was psychotic; a course of medication was prescribed to the boy with a very good result.

The four described cases have one feature in common that distinguishes psychopathology from a virtue - anxiety. In all these cases, anyone who tried to stop the children's strange behaviour, would meet strong resistance; and if the children obeyed, it was not easy for them and triggered much anxiety.

A virtue drives anxiety, according to the tradition of patristic theology and asceticism. Depression leads to despondency, whereas the virtue of self-condemnation brings the person to the hope in God and joy that despite many of my faults, God's love is so great that it covers and forgives my wrongdoings, as Metropolitan Anthony of Surozh (Bloom) said, "If God has created each of us and brought us into this tragic world in which we live, He has done so because He believes in us, He has trust and hope in us". Moreover, the symptoms in the 4 cases above contradict the age norm we expect to see in the respective age groups, and interfere with the normal life and activities of these children. It should be remembered that if a teenager falls out of his or her age group pattern, regardless of the reasons they give, we must study these reasons with particular care.

Before I conclude this part, I would like to point out the following: another feature of a mental illness of a child or adolescent is a loss of their ability to enjoy simple and everyday things. We try to breathe life back into them through psychotherapy, to give value to something simple and prosaic.

As an example, I will cite the case of one girl who was at hospital with psychogenic anorexia. One morning, a nurse put a beautiful rose on the girl's bedstand. The girl was delighted with the nurse's gesture and brought the flower to the session with the doctor. "See how many beautiful things you've forgotten that surround you? And you let anorexia steal your thoughts?", I said. I asked her to bring this present to our next session. The next day, the flower didn't look so attractive anymore, and Athena was clearly upset. At the end of our session, I said, "See, Athena, ... and you are like this rose ... By refusing to eat, you fade ..." That was the point when she started to fight anorexia.

Part 3. Heterogeneous group of adolescents with suicidal behaviour (usually cutting themselves on different parts of the body)

As I mentioned, this is a heterogeneous group of teenagers. The number of cases of clinical depression is low; the purpose of suicidal behaviour is to alleviate a strong feeling of sadness experienced by the child. Religiosity and faith in Christ in this group are strong deterrents against the implementation of obsessive suicidal thoughts.

A small part of this group, which in recent years has a tendency to grow, is represented by teenagers who belong to a certain subculture: they listen to heavy rock, are pessimistic about life, look for contacts with the other world, some of them wear black and refer themselves to Satanists; skulls, desperate people, knives and blood are the leitmotif on their web pages. When they are in our hospital, they are not allowed to listen to the hard rock in their spare time, because we have noticed its negative impact. At the same time, we try to awaken their desire to create: children's ideas and initiatives to decorate the premises of the hospital, do arts and crafts. The children are encouraged to redirect their activity into the creative sphere, which is often an important component of psychotherapy. Thus, they discover other aspects of themselves that were previously unknown to them, and feel that they are meaningful. As a consequence, the need in the subculture as a factor that distinguishes them from the others, subsides. One should not forget that man was granted creativity as he was made in "God's image", and God is the Creator.

The group consists primarily of children who describe relationships with their parents, mainly with their mothers, as charged with conflict. When asked why they cut their veins, they would say, "At this point I feel alive... The physical pain I experience helps to release the feeling of empty inside me". We may conclude that these teenagers failed to receive sufficient emotional support in their childhood, not because their parents neglected them, but for various reasons that interest was expressed in a wrong way. These adolescents need family therapy more than medication.

Part 4. Family pastoral care, the importance of parent-child relationships in the formation of children's personal relationships with God

In conclusion, I would like to touch upon the important topic of family pastoral care. Here I shall cite a 19-year-old boy who, before leaving from home to continue his education, told me, "I am very lucky. My parents have been able to teach me how to build a relationship with God, through the example of our family relationship, because He is our common Father ... It is very challenging to be a parent, because the child builds his relationship with God along the line of his relationship with his parents..." Frankly speaking, this young man's words surprised me very much, they were like a gulp of fresh air for me. He gave voice to what we know as experts: a child's relationship with God is the relationship he has learned to build with his parents.

If the child believes that his/her parent is a strict judge who continuously punishes the slightest sin, then God will also be a strict judge for the child, punishing and constantly controlling. If, however, the parents have understanding and limit their child's freedom caring for his/her safety, rather than with the idea to forbid pleasures, then the God's commandments will be fulfilled willingly and with responsibility. When we accept the child with his/her mistakes and covering them up, it makes them easier to follow the path of repentance, for they know that this path leads to the loving arms of the Father.

Parental spiritual care should therefore contribute to the establishment of proper relationship with children on the basis of love, which will be a great contribution to their development and will prevent psychopathological developments. To this end, the Churches of Greece and Cyprus have established parenting schools where psychologists and psychiatrists are invited. These schools are venues for various seminars, lectures and, if necessary, individual sessions on relevant issues. For example, on the eve of my departure to this conference I gave a talk to young parents on "How to Reveal the Family's Creative Potential", at one of our parishes right after the Divine Liturgy.

I would like to conclude with the words by St. John of Kronstadt, "Saying 'Our Father', we must believe and remember that the Heavenly Father always remembers about us and will never forget us, for even a good earthly father does not forget and cares about his children. "I will not forget you, the Lord says" (Isaiah 49:15). "For your heavenly Father knows that you need all these things" (Matt 6:32). Plant these words in your heart! Remember that your heavenly Father always surrounds you with love and care, and is your Father not in vain. The Father is not a name without meaning or power, but a name with full meaning and power" (St. John of Kronstadt, On Prayer: Selected Writings. VII on the Lord's Prayer, [св., прав. Иоанн Кронштадтский. О молитве: выборки из его писаний. VII О молитве Господней, 78]).

Pastoral Psychiatry as Challenge of Our Times (New Subject in Theological Schools Curriculum)

V. G. Kaleda

Pastoral psychiatry is an interdisciplinary course on the main manifestations, patterns of progression, and causes of mental illnesses, as well as peculiarities of pastoral care of persons suffering from them.

The purpose of the course is to prepare future priests for pastoral care for people with mental disorders.

Course objectives are to give an overview of symptoms of mental disorders, teach how to recognize the main symptoms, outline the peculiarities of pastoral and medical approach to such patients, and shape the principles of pastoral tactics in case of particular manifestations of mental illness.

Priests continuously come across people with mental disorders in their everyday practice. The prevalence rate of mental disorders is very high. Approximately 20-25% of the population have behavioural and mental disorders, according to WHO. Depression currently affects about 9-20% of the population (about 300 million people), schizophrenia - about 1%, dementia - about 2%, personality disorders (character traits that affect the person and others) - one person in three, neurotic symptoms occur in 10-20%. In some cases, these illnesses can coexist. About 4 million people - approx. 2.8% of the RF population - sought psychiatric help in 2015-2017, according to the official data [1]. Approximately 5.6% of the population in the Russian Federation need help of a psychiatrist and/or psychotherapist, with mental disorders occurring in 14-15% of the Russian population, according to the Scientific Center for Mental Health (SCMH) [2]. WHO cites data on a higher prevalence of mental disorders, which is apparently due to the fact that the diagnostic criteria used at MHRC are more stringent.

The Church is a place of healing, so it is there that mentally ill people often come; and many come in crisis situations. It is a known fact, that religious people regard some events in their lives as a sign that God gives them, encouraging them to turn to the Church. Along with this, many mental disorders have a religious overtone. If we take a small parish of about 100 people, there will be 1-2 persons with various forms of schizophrenia - both hallucinatory and delusional disorders, among the parishioners; 10-20% may have depression, including a severe one, which will definitely require help of a psychiatrist; about 10% of the parishioners will have a personality disorder, previously called psychopathy. It is notable that some books on pastoral theology say that hysterical persons are a cross for both the pastor and the Orthodox community.

Students at theological schools who plan to become priests often do not expect that they will find many people in their parish with mental health problems, not just spiritual issues. The priest must be prepared for such challenges, because in some cases, the priest's words may determine not only the parishioner's spiritual life, but also their life in general. There have been numerous cases when an unthoughtfully said word by a priest led to most sad, irreversible and tragic consequences. However, we can also remember many cases when a priest was the first and only person who noticed a serious mental pathology and timely referred the person to a psychiatrist, thus saving the person's life.

Currently, a number of higher educational institutions of the Russian Orthodox Church offer a special subject, Pastoral Psychiatry. The concept of this subject was developed by professor of theology archimandrite Cyprian (Kern) and professor of psychiatry Dmitry Melekhov. They were contemporaries, both born in 1899. One of them taught pastoral theology at St. Sergius Orthodox Theological Institute in Paris, the other was one of the most prominent Russian psychiatrists of the 20th century and founders of social psychiatry. In 1957 Fr Cyprian published a Guide on Orthodox Pastoral Ministry [3], where a special chapter, called Pastoral Psychiatry, was included for the first time. It reads that "there are states of mind that do not belong to the categories of moral theology and are not included in the concept of good and evil, virtue and sin. They are those depths of the soul that belong to the field of psychopathology, rather than asceticism". A pastor should read at least 1-2 books on pastoral psychiatry in order "not to judge as a sin in a man what is in fact nothing but a tragic distortion of mental life, a mystery, not a sin, a mysterious depth of the soul, rather than moral corruption".

Archimandrite Cyprian spoke ironically of priests who are straightforward in their attempt to thrust everything into the categories of good or evil with ease and put everything under the category of diabolic possession. Familiarity with scientific data will make the pastor more cautious in his moral judgements. Such a clergyman, having learned a lot, will not make wrong steps and give wrong advice in doubtful cases which raise concern.

This idea was later repeated by another famous clergyman, a military surgeon, metropolitan Anthony (Bloom). He wrote that the priest cannot act as a professional psychiatrist, but he must have knowledge of how a mental illness manifests itself, and that the state of mind of a religious mentally ill person casts shadow on everything, including their life in the Church, which is what priests should remember. A priest should be able to distinguish between an illness and a true mystical experience [4].

Prof. D.E. Melekhov wrote Psychiatry and problems of spiritual life. This work was the fruit of his last decade. Although the book stayed unfinished, he had written and formulated the basic concept. His work was first published in 1980 in samizdat [dissident self-published books in the USSR], then was included without attribution in Volume 8 of the Priest's Handbook [5], and later was repeatedly reprinted. Prof. Melekhov was a true enthusiast of his ministry to the mentally ill. He wrote, "My main sphere is in everyday work, like for a monk his monastic obedience ... to work means to pray".

Dmitry Melekhov was born in a priest's family in the Ryazan province, both his grandfathers were priests. He always remained a deeply religious, spiritual man and belonged to the Orthodox Christian intelligentsia, which was not numerous in our country in those years. He suffered twice for his faith: the first time he was arrested as a member of the Christian student movement in 1923, the second time, in 1933, when he was already a medical doctor. In some miraculous way this did not prevent him from becoming director of one of the leading institutions - the Moscow Research Centre of Psychiatry under the RSFSR Ministry of Health in the 1950s. He was one of the outstanding Russian psychiatrists of the 20th century; his works have not lost their relevance, and they are still quoted. He followed the concept of trichotomy in his understanding of the human person - man consists of the spirit, soul and body, which are inextricably linked. This gives ground for identifying the spheres of competence of doctors: those dealing with the body (physicians, neurologists, etc.), psychiatrists, and spiritual doctors, priests, i.e. each of the specialists should be engaged in the sphere of their competence.

Prof. D.E. Melekhov emphasized the importance of distinguishing between religious experiences of the mentally ill as a sign of illness, false mysticism, and normal, healthy religious experiences as a manifestation of healthy mysticism, and believed that the patient's religious experiences were a powerful therapeutic factor against the illness. While rehabilitating a mentally ill person, a psychiatrist should rely on the healthy islets of his life and personality, he wrote, religious faith being one of the most important of such islets. It is their faith that helps many patients to compensate for the defect (the term used in psychiatry with respect to some schizophrenia manifestations) and to preserve the core of the personality, although the person may be disabled.

Prof. D.E. Melekhov noted, that in some cases spiritual experience could become a source of positive spiritual experience for people with mental disorders. Metropolitan Antony (Bloom) shared a rather interesting case from his pre-war practice: an icon painter in the Paris Orthodox Christian community had developed a mental disorder. He began to hear voices and had episodes of inadequate exaltation and grotesquery. The clergy tried to administer the sacrament of extreme unction, etc. Ignoring protests of others, Father Antony advised to take the icon painter to a psychiatrist and offer the patient a course of electroconvulsive therapy, saying that "The only thing I know - although it may seem cynical to you - that the electric current will not harm the devil, if it is a case of possession. And if it is an illness, our friend will recover". So, the patient was taken to a psychiatrist, and an ECT course was applied to the former, which helped him recover from his psychotic state. The most paradoxical thing, according to metropolitan Antony, was that after the illness the iconographer began to paint more mature, profound, heartfelt images [4].

Prof. D.E. Melekhov wrote that in case of borderline disorders it was necessary to find not only a psychiatric, but also a spiritual diagnosis. The father-confessor, as well as the religious psychiatrist, must understand that a person's mental suffering has spiritual and moral roots and is subject to religious treatment, i.e. it is necessary to refer the person to experience of the Church and the clergy. At the same time, he should identify what has a biological nature and falls under the competence of psychiatrists. A psychiatrist, in his turn, should not treat any religious experience as a pathology or delusion, and, regardless of his personal religious beliefs, should treat the patient's experience with great respect. Many of our patients, especially with endogenic diagnoses, lose their ability to work, and 25 - 30 year olds acquire a disability status. The only place where they can find meaning in life is in the religious worldview, the importance of which can hardly be overestimated for the rehabilitation of patients. Awareness of the importance of religious values for patients led to the opening of a church at the Scientific Center for Mental Health, which was consecrated by His Holiness Patriarch Alexiy II in 1992. Prof. D.E. Melekhov's concept is reflected in the official document - Bases of the Social Concept of the Russian Orthodox Church [6], where the concept of trichotomy of the human person is explained and a clear delineation between the spheres of competence of a priest and psychiatrist is given.

Unfortunately, only a few institutions of higher education have introduced the course Pastoral Psychiatry. This course has been taught at the Moscow Theological Academy since the mid-1990s. St Tikhon Orthodox University has offered this course since 2003. In addition, this subject is included in the curricula of the Sretenskaya Theological Seminary and the Theological Seminary in Belgorod; it was also taught at the Kiev Theological Academy for some time.

The Pastoral Psychiatry course is designed for a year. Only those students who plan to become priests are admitted to the classes. Tutorials are designed in such a way that students have an opportunity to attend supervision of clinical cases. One can talk a lot about depression and argue whether it is an illness or a sin of despondency, and the patient "needs to pull himself together". However, when students see a particular patient, his or her suffering, they will remember for a lifetime the image of a sick person suffering from mental illness. So, when they come across such a case in their pastoral practice, they will already have firsthand experience and own understanding how to act in a particular situation. It is not uncommon for some students to be skeptical at first, but at the end of the course we come to a common understanding of certain situations. Students see patients with a broad range of mental health conditions, including delusion of possession. The course pursues the goal of coming to a common understanding of the patient, because the priest and the Orthodox Christian psychiatrist should not have opposing views on the illness.

The Pastoral Psychiatry course consists of two main parts. The first part includes study of the main manifestations (symptoms and syndromes) of mental disorders (depression, mania, phobias, obsessions, delusions, illusions, hallucinations, etc.) in comparison with some states of the spirit (sadness, despondency, possession by an evil spirit, etc.). The second part includes study of the main mental illnesses, their most important manifestations, patterns, peculiarities of pastoral care for mentally ill people. All mental illnesses presented during the course of pastoral psychiatry can be divided into four groups: borderline, endogenic, organic, addictive (impulse disorders), and pathology of mental development.

The first group of illnesses consists of the most common psychiatric disorders, which the parish priest may come across most often. These are so-called borderline disorders, which include neurotic disorders (phobic anxiety, obsessive-compulsive), a variety of personality disorders (psychopathy), psychogenic (reactive) illnesses. Mental disorders associated with somatic pathology (oncology, myocardial infarction, AIDS, rheumatic disorders, etc.) are also included in this group.

The second group of mental illnesses is called endogenic disorders (i.e. pathological processes in a body caused by inner (endogenic) factors, rather than by external factors, such as infections, psychoactive substances, stressful situations, etc.). These include affective disorders (bipolar affective disorder, recurrent depressive disorder, cyclothymia, dysthymia) and various forms of schizophrenia. The underlying pathogenesis (i.e. causes) of these conditions is a genetic predisposition. Scientific studies of recent decades have revealed in these diseases some abnormalities that can be detected during molecular genetic, magnetic resonance, neuropsychological, immunological and some other types of clinical and biological research.

The third group consists of illnesses caused by organic processes in the brain, which are registered in neurophysiological (EEG) tests and neuroimaging procedure. This group includes atrophic conditions of old and senile age, mental disorders in case of injuries and brain tumours, consequences of neuroinfections, as well as Alzheimer dementia with associated disorders and genuine genetic epilepsy. Some of the illnesses in this group belong to endogenic organic diseases under some modern classifications.

The fourth group of illnesses is formed by addictive disorders (alcoholism, drug addiction, substance abuse and non-chemical addictions - gambling, computer addiction, etc.), which are characterized by the formation of pathological dependence with pronounced medical and social consequences. The modern international experience of therapy of these conditions proves high efficiency of psychotherapeutic methods based on the development of the spiritual dimension and formation of religiosity [7, 8].

The pathology of mental development includes various forms of congenital dementia and mental retardation (oligophrenia), as well as autistic spectrum disorders.

Sexual disorders (transsexuality, exhibitionism, sadomasochism, homosexuality, paedophilia, etc.) are singled out as a separate group.

Future priests need to be aware of the main symptoms of mental illness, however making a diagnosis is not part of their job. They simply need to understand that a certain person's behaviour and experiences are not normal religious experiences with some peculiarities characteristic of this particular person. A priest should generally be aware of the pastoral approach to mentally ill people and understand which tactics he should pursue as a priest with mentally ill people with various expressions of a mental pathology.

The tutorials deal with the main symptoms of mental disorders and focus on the peculiarities of their display in persons with a religious worldview. For instance, ideas of self-accusation are characteristic of depression, hence, religious people will develop ideas of specific sinfulness. And this is not the sinfulness, which every person living a spiritual life finds in himself. In this case, it is an excessive, pathological feeling of their own sinfulness (psychiatry even uses the term delirium of sinfulness). Believers in depression can also experience the state of lifeless indifference. Such people say that they pray continuously, but "the heavens are silent", they do not feel any response.

The priest should be aware of general patterns of the most common mental illnesses, so that he could understand how the person's condition will affect his or her future life. For example, if psychosis of schizophrenic nature develops, it is necessary to know that the illness is chronic, seizure-like and with a high risk of relapse, so the person needs preventive therapy. With this in mind, the priest should understand what can happen to this person. It is often with the priest's blessing that Orthodox Christian patients take medicines. After all, many of our patients do not recognize themselves as mentally ill, and their treatment and, consequently, improvement of quality of their lives becomes possible only thanks to the authority of the Church.

At the tutorials we discuss causes of mental illness, biological, psychological and social factors triggering mental illness, as well as basic approaches to treatment, so that the priest becomes equipped with an understanding of how these illnesses are treated, what medication is available, how medicines work, and what are their possible side effects. We also talk about the distortion of spiritual life in case of mental illnesses.

When we diagnose mental disorders, the diagnostics should be adequate. There are two extremes - hyperdiagnostics and hypodiagnostics. In the first case, all human mental experiences are viewed through the prism of psychiatry, as part of a psychiatric diagnosis. There have been cases, when priests referred their spiritual children to a psychiatrist for consultation, and no mental illness was identified. However, it is always better to be on the safe side. Hypodiagnostics is the other extreme, the problem that is common for our society, not only for the Church. People often try to explain psychiatric problems from a psychological or spiritual point of view. For example, even delusional disorders and infantile autism are sometimes interpreted as a kind of coping mechanism. Sometimes we find priests explaining mental disorders as a result of personal sin and ancestral sins, etc. and force such people to confess more thoroughly, thus plunging them into psychopathological experiences.

The priest should help his spiritual child to understand that experiences of the latter are painful and not spiritually mystical, and to show that the illness is given to him/her for a certain purpose, the purpose of salvation. Neither the Kingdom of God nor communicant membership in the life of the Church is closed for a mentally ill person. The priest should help the sick person to contact mental health professionals. There are examples when the priest not only encouraged his parishioner to go to a doctor, but personally took his spiritual child to a psychiatrist. Along with this we must understand, that the priest has no right to interfere in medical prescriptions. This is stated in the Bases of the Social Concept of the Russian Orthodox Church. Unfortunately, there have been such cases, although it is beyond the priest's competence, he has neither proper training, nor legal right for this.

We should also note a special role that the church community plays for many of our Orthodox Christian patients. It is in the community that they experience themselves as full members not only of the Church, but also of society. It is there that they find spiritual support. Mentally ill people fulfil some assignments in many churches, gaining spiritual and social support. Priests threat these illnesses and peculiarities of such patients with understanding. If possible, a social worker should be appointed to assist such a person in his/her difficult life.

When we talk about cooperation between a psychiatrist and a priest, it should be noted that in many cases they should join their efforts assisting a mentally ill person. When the person is in a state of acute psychosis, psychomotor agitation, the priest needs not strive to administer communion to the patient at any cost, this may even be dangerous. It is the psychiatrist who takes the lead at the acute stage of a mental illness. A pre-revolutionary job description for the medical staff of one of the hospitals contained, among other things, an instruction for the hospital priest that he could invite patients to participate in the Sacraments only on the doctor's recommendation, when the patient had been brought in a relatively balanced state. The priest's role is enormous during remission, when spiritual and mental life needs to be normalized.

Educational work in psychiatry should be carried out not only among students, but also among the clergy at various pastoral seminars, capacity-building training for the clergy and even for bishops. This has already been practiced. It is also necessary to introduce psychiatrists into the basics of religion, structural organization of a religious community, understanding of the role of a father-confessor for an Orthodox Christian patient.

Spiritual torment - "the soul is aching" - is worse than physical suffering. In a state of severe depression, the patient feels him/herself at the very bottom of a deep abyss, from where nothing is visible, everything that has been important is devalued, and all connections seem to be severed. It is notable that the level of suicide is particularly high among these patients. Many patients with mental disorders feel rejected by society because of their peculiarities, and, indeed, society often turns its back on them. Our task is to learn to "treat them with the same understanding, kindness and thoughtfulness, as well as with the same straightforwardness as mentally healthy people", Russian psychiatrist P.B. Gannushkin wrote.

Every person, according to metropolitan Anthony (Bloom), is an image of God, an icon that can be "partially disfigured ... Nevertheless, it is a work of the Great Master before us". Let us keep this in mind.

References

  1. N.K. Demcheva and others. Coverage of the RF population and Federal Regions with psychiatric help in 2015-2017 [Демчева Н.К. и др. Обеспеченность психиатрической помощью населения Российской Федерации и Федеральных округов в 2015-2017 годы // Психическое здоровье, 2018, №6, 10-19].
  2. Guidelines to psychiatry in 2 volumes, edit. by A.S. Tiganov [Руководство по психиатрии в 2-х томах, под редакцией А.С.Тиганова, М., 2012].
  3. Archimandrite Cyprian (Kern), Orthodox Pastoral Ministry [Киприан (Керн), архим. Православное пастырское служение. Париж, 1957. 255 с.].
  4. Antony (Bloom), Metropolitan of Surozh. On Mental and Bodily Illnesses [Антоний (Блум), митр. Сурожский. О болезни душевной и телесной. URL: https://www.liveinternet.ru/users/rayusha/post250128031/].
  5. Priest's Handbook, Moscow Patriarchate, 1988 [Настольной книги священнослужителя, т.8. Издание Московской Патриархии, Москва, 1988, с.304-332].
  6. Bases of the Social Concept of the Russian Orthodox Church [Основы социальной концепции Русской Православной Церкви. Раздел ХI.5.]
  7. Rev. Fr. Alexey Baburin, Orthodox Christian Psychotherapeutic Approach to Prevention and Heating Addictions [Бабурин Алексей, прот. Православный психотерапевтический подход в профилактике и врачевании пристрастий // Церковь и медицина. 2010. № 5. С. 24-27].
  8. Forcehimes A. A., Tonigan J. S. Spirituality and Substance Use Disorders // Religion and Spirituality in Psychiatry / Edited by Ph. Huguelet, H. G. Koenig. Cambridge University Press, 2009. p. 114-127.

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