International conference on Church Care for Mentally Ill People

Below are papers read at the International conference "Church care for mentally ill people: religious mystical experience and mental health"
November 7-8, 2019, Moscow (continuation)

Bipolar disorder and religious experiences

Eva Ouwehand

Introduction

I am honored to be able to share with you some results of my Ph.D. project on bipolar disorder and religious experiences. I studied theology in the eighties and I am a hospital chaplain in mental health care since 1988 and minister of the Protestant Church in the Netherlands. In our country we have a situation that spiritual care is part of all hospital care, paid by insurance companies or the government. Our country is very secularized in the sense that about two thirds of the population has no affiliation with a religious institution (church or mosque), and somewhat less than half of the population do not consider themselves as religious or spiritual. At the same time, all kinds of individualized spirituality are blossoming everywhere. This context definitely colors the results of the study that probably will be different in Russia.

As a hospital chaplain I often have met people with bipolar disorder who were admitted to the hospital and narrated about their religious experiences. My Ph.D. research started with the question how patients, when they would have been recovered, would evaluate their religious experiences when they were stable.

Research questions

The general research question of the study was:

This question was divided into various sub-questions pertaining to the different types of religious experiences that people with bipolar disorder might have. Second, about the ways they interpreted the experiences they had had during mania and depression. And third, how often such experiences and interpretations occurred and whether they were statistically related to the disorder and to religiousness of the patients.

Bipolar disorder

Bipolar disorder (BD) is a mental illness with a prevalence of 1-2% of the population. Previously it was named manic depressive illness. Bipolar disorders are characterized by two distinctive features: polarity and cyclicity. Manic or hypomanic episodes alternate with depressive episodes, with symptom-free periods in between, in a recurring cyclic rhythm. Mania, and hypomania to a lesser extent, are characterized by an elevated and expansive, sometimes irritable mood, often accompanied by feelings of grandiosity and excessive talkativeness, a decreased need for sleep, a flight of ideas and a drive for excessive action with often painful consequences. The two main variants of the illness are bipolar I disorder, characterized by the occurrence of mania and bipolar II disorder, characterized by hypomania. Mania implies more severe dysfunction in social life than hypomania and can have psychotic features. Persons with bipolar I disorder are more often hospitalized than patients with bipolar II disorder. However, the social and psychological burden of depression in both types of the illness is severe.

Theoretical framework

The theoretical framework of the study starts with the work of Kleinman (1988, 1991), a psychiatrist and cultural anthropologist. He discerns three types of explanatory models for illness experiences. His concept of explanatory models is applied to religious experiences related to BD in the present study.

1. Personal explanatory models refer to the ways patients themselves and their relatives explain illness experiences, in this case religious experiences related to bipolar disorder. Personal explanatory models often have religious or spiritual aspects. To give an example: Someone may have an experience of the presence of God in an evolving mania. A psychiatrist probably would view this as a hallucination.
2. The second type of explanatory model Kleinman refers to folk theories about health and illness. These are theories present in a society that explain illness in often more holistic ways than the medical model; it can be alternative medicine or healing theories in Churches or popular devotion and practices in churches etc.
3. The third type pertains to the bio-medical model that clinicians use in their daily work: the practitioner's or psychiatrist's perspective on the illness, knowledge about nosology and etiology of diseases, course of the illness and possible treatment.

To give an example of an explanatory model: When persons become manic, they often feel a lot of energy and warmth and persons affiliated to new spirituality explain this phenomenon as a kundalini experience, an experience of strong energy going up and down the spine. It is part of kundalini yoga and the concept originates in the Upanishads, philosophical writings in Hindu tradition. A psychiatrist however, may diagnose this phenomenon as a developing mania. Conflicts or disagreement about treatment, for example about medication, is reported in some studies into BD and religiousness (Mitchell & Romans, 2003, Stroppa & Moreira Almeida, 2013). For patients themselves discernment between pathology and authentic religiosity is an issue, according to the qualitative study of Michalak and colleagues (2006).

Methods

The study was of mixed method design, with a 34 qualitative interviews about religious experiences and interpretations thereof, and a quantitative part consisting of a questionnaire built on the qualitative results. Interviews, part of the analysis and writing was conducted both by a hospital chaplain and psychiatrist trainees. The questionnaire was conducted at a specialized department for BD of Altrecht Mental Health Care in the Netherlands (number of respondents N=196).

Results

Table 1 shows the religious characteristics of the qualitative and quantitative samples compared to the general population of the Netherlands.

Table 1. Religious characteristics of the qualitative and quantitative samples, compared to the general population.

¹God in the Netherlands, 2015, published in Bernts & Berghuijs 2016.

²Often mentioned together with another affiliation.

³As in God in the Netherlands, high importance means a summation of the scores for very high importance and high importance on a Likert scale from 1-4.

Religious experiences in mania and their lasting influence

In the YouTube video https://www.youtube.com/watch?v=MxrGvWr2zMg the results of the qualitative part of the study is shown.

Table 2 shows different kinds of religious experiences (qualitative results, left column), their frequency in the quantitative part of the study and their frequency during mania (self-reported). In the right column you can see for some experiences how often they occur in the general population. Now you can easily say: those experiences are simply symptoms of mania, they are no real religious experiences.

Table 2. Types of religious experiences in mania, and frequencies compared to the general population (Ouwehand et al. 2019). Qualitative indicators - N=34; Quantitative indicators - N=196.

In table 3, the assessment of participants of the lasting influence of religious experiences is shown. Lasting influence on people's lives is an indication for the religious nature of the experience. In all religious and spiritual traditions the transformative power of religious experience is stressed. William James (1902/1908) considered the fruits of religious experiences as an important criterion for their authenticity.

Table 3. Types of RE and their self-reported lasting influence (LI) (Ouwehand et al. 2019). Qualitative indicators - N=34; Quantitative indicators - N=196.

I will highlight two experiences: the experiences of unity or mystical experiences that can be compared to the general population. And the experience of feeling to be an important religious person. This is the experience that most clearly looks like a delusion of grandeur from a psychiatric view. And indeed, participants themselves did not assess it very often as a religious experience that had lasting influence on their lives. In table 2 and 3 you can see that mystical experiences are occurring twice as often in people with BD than in the general population. They are definitely related to the disorder, as they occur in 66% of the persons with such an experience during mania. Yet half of the persons with a mystical experience view them as having lasting influence on their lives. This is very different from the experience of being an important religious person, which is assessed as occurring during mania by 89% of the persons with such an experience. Yet only one fifth of them considers this experience as having lasting influence on their lives. This shows that:

1. Religious experiences related to the disorder can have both pathological and religious features.
2. Persons with BD evaluate their experiences when they are recovered and discern themselves between those pathological and religious features.

Absence of religiosity during depression

In table 4 it is shown that the most occurring experience during depression was the experience of absence of any form of faith or spirituality and secondly, the experience of the absence of the God. You can also see how much this was assessed as having lasting influence on the lives of respondents. During depression, former judgments about the nature of religious experiences that had happened during mania, were often put into question by participants. Religious doubt was an important theme in the interviews during depression.

Table 4. Religious experiences during depression (Ouwehand et al. 2019). Qualitative indicators - N=34; Quantitative indicators - N=196.

Explanatory models for religious experiences

After having had these experiences, many people start a religious quest about their significance. Table 5 shows the various explanatory models participants used to interpret their experiences. Most frequent were a view wherein religious experiences, even when they had occurred during mania, were seen as part of spiritual development and a view wherein the experiences could have both pathological and spiritual features.

Table 5. Frequencies of types of explanations of R/S experiences during illness episodes of bipolar disorder in a Dutch bipolar outpatient sample (Ouwehand et al. 2020).

¹Includes participants who reported they had had religious or spiritual experiences during illness episodes.

Conclusions

The religious quest related to religious experiences in illness-episodes, leads to (increased) religious involvement, especially in new spirituality, in some of this patient group.

The content of religious experiences that occur during mania is often not distinguishable from religious experiences described in the literature in the field of the sociology or psychology of religion; they are part of the religious idiom of a society.

Some experiences resemble psychiatric categories.

Existential suffering is clearly present during depression in bipolar disorder, but it is not always described in religious terms. It is experienced as an absence of the divine, but by others as an absence of religious experiences or of religiosity in general, the more so when people are more religious.

The process of interpretation of religious experiences is a continuous, never finalized process, influenced by mood swings, course of the disorder, original and present religiousness of the person and communication with others: relatives, mental health professionals, clergy. The lasting influence of experiences must be seen in the light of this process over the years.

The stable period is an excellent opportunity to reflect on religious experiences that have happened in illness episodes and the lasting influence thereof. Religiousness appears to be of influence in evaluating the experiences as having lasting influence.

The main conclusion is that people with BD can have experiences related to mania that have religious significance for them on the long term. The evaluation of this significance is important for pastoral care to find a balanced attitude towards such experiences.

Pastoral issues

• non-recognition or underestimation of pathology;
• overvaluing of religious experiences;
• excessive or intense religious practice;
• reducing religious experiences to pathology;
• religious identity in the context of mood swings;
• finding balance between different aspects of religiosity;
• deviant experiences from a religious tradition;
• the right moment for reflection;
• vocations;
• stigma/isolation of persons with mental disorders.

References:

1. James, W. (1902/1908). The varieties of religious experience. A study in human nature. New York, London, Bombay: Longmans, Green, And Co. URL: https://archive.org/details/
2. Kleinman, A. (1988). The illness narratives. New York, NY: Basic Books.
3. Kleinman, A. (1991). Rethinking psychiatry. From cultural category to personal experience. New York: The Free Press.
4. Michalak, E. E., Yatham, L. N., Kolesar, S., & Lam, R. W. (2006). Bipolar disorder and quality of life: A patient-centered perspective. Quality of Life Research, 15, 25-37. URL: www. ncbi.nlm.nih.gov/pubmed/16411028.
5. Mitchell, L., & Romans, S. (2003). Spiritual beliefs in bipolar affective disorder: Their relevance for illness management // Journal of Affective Disorders, 75, 247-257. doi: 10.1016/S0165-0327(02)00055-1.
6. Ouwehand, E., Wong, K., Boeije, H., & Braam, A. (2014). Revelation, delusion or disillusion: subjective interpretation of religious and spiritual experiences in bipolar disorder // Mental Health, Religion and Culture, 17(6), 615-628.
7. Ouwehand, E., Muthert, J.K., Zock, T.H., Boeije, H. & Braam, A.W. (2018). Sweet Delight and Endless Night: A Qualitative Exploration of Ordinary and Extraordinary Religious and Spiritual Experiences in Bipolar Disorder // The International Journal for the Psychology of Religion, 28(1), 31-54.
8. Ouwehand, E., Braam, A.W., Renes, J.W., Muthert, J.K., Stolp, H.A., Garritsen, H.H., & Zock, T.H. (2019). Prevalence of religious and spiritual experiences and the perceived influence thereof in patients with bipolar disorder in a Dutch specialist outpatient center // The Journal of Nervous and Mental Disease, 207(4), 291-299.
9. Ouwehand, E., Zock, T.H., Muthert, J.K., Boeije, H., & Braam, A.W. (2019a). The Awful Rowing Toward God. Interpretation of Religious Experiences by Individuals with Bipolar Disorder // Pastoral Psychology 68 (4): 437 462.
10. Ouwehand, E., Braam, A.W., Renes, J.W., Muthert, J.K., Zock, T.H. (2020). Holy Apparition or Hyperreligiosity. Prevalence of Explanatory Models for Religious and Spiritual Experiences in Patients with Bipolar Disorder and their Associations with Religiousness // Pastoral Psychology, 69, 29-45.
11. Stroppa, A., & Moreira-Almeida, A. (2013). Religiosity, mood symptoms and quality of life in bipolar disorder // Bipolar Disorders, 15, 385-393. doi: 10.1111/bdi.12069.