By Donna Dickerson
When I was hired as a staff chaplain at a state mental hospital, I did not know how best to minister to the spiritual needs of our patients. My prior experience was largely end-of-life and crisis ministry at acute care hospitals and in hospice settings. But as a mental health chaplain, I found that my clients were suffering, but for the most part not from physical pain. I saw that they were frequently in acute spiritual distress, and that their spiritual needs were often closely linked with their mental illness.
The hospital where I work has an average patient census just short of 300, and it serves a vast area encompassing most of south and southwest Texas. Nearly half are forensic patients, either “NGRI” (not guilty by reason of insanity) or coming from jail to gain mental competency to stand trial for their offences. Their crimes may range from simple trespassing to homicide. Other patients are short-term or longer-term acute, geriatric, or residential patients from the community at large. About 10 percent are adolescents. I am the sole chaplain for the facility.
The National Institute of Mental Health estimates that 1 out of every 4 adults will experience some form of mental illness in their lifetime; likewise approximately 10 percent of children and adolescents. Stigma and shame often prevent persons from seeking treatment or asking for help. This can be especially true for those who consider themselves deeply religious.
Many of our patients return again and again (often within months or even days after discharge) largely due to inadequate support in the community. Often they are homeless with no family support system and few friends; some struggle with substance abuse in addition to their mental illness. For them, the hospital has become a “safe place” where they can reconnect with people they trust and have known for years. It is both home and sanctuary.
In south Texas, a majority of the population is Catholic, primarily Hispanic. A sizable minority comes from fundamentalist/evangelical Protestant backgrounds. Almost all are inactive in their church or faith group, although frequently they grew up in devout families. Many read Scripture regularly, however, and tend to interpret it quite literally, sometimes becoming fixated on certain problematic themes, which can become psychologically unhealthy. I call this “toxic religion” or “bad theology” (and yes, I realize this must come across as a value judgment). Much of my work here is gently coaxing these patients back to a more positive religious perspective, by offering “spiritual wellness” groups and individual pastoral counseling.
Some patients may present as hyper-religious, with religious delusions dominating their entire world view. Sometimes problematic religious themes feed into their mental illness and vice versa. Individuals with major depression or bipolar illness sometimes exhibit an overwhelming concern with sinfulness and guilt. They can even feel that they deserve to die for past offenses or bad choices, leading to suicidal ideation. They may believe that God (or the devil) is punishing them, or that everything is predestined and therefore hopeless. Sometimes they will refuse medications because they are convinced God will heal them if their faith is strong enough — or conversely that God’s will is for them to suffer, and therefore taking medication is a rebellion against God.
Psychotic and delusional patients with schizophrenia seem to be especially fascinated by prophetic scriptures concerning the end of days, especially Revelation, but also Isaiah, Daniel, and Jeremiah. For many, the end times are imminent. Some believe they are Satan, the Antichrist, or “666” himself; others, one of the archangels, Jesus Christ returned, or the Prophet Mohammed. They may insist on seeing a priest for an exorcism, or ask for a curandero (traditional healer) to do a ritual cleansing of their room to remove demonic powers or evil spirits.
Some have auditory or visual hallucinations in which they are convinced that evil spirits or demons have cast spells or cursed them or are commanding them to do evil things. They may believe that others, especially family members, are demon-possessed. Some have acted upon these delusions and committed various offenses, even murder. They may have chosen to embrace their delusions to avoid taking personal responsibility, but I try not to psychoanalyze them. It is important that a chaplain respect their present state of mind and needs, including their religious delusions, neither confronting nor validating them. I do pass on relevant information that might be helpful to their treatment team, without violating pastoral confidentiality. Sometimes this can be a delicate ethical tightrope to tread.
Meeting the person “where they are” is particularly important when working with the mentally ill. It is essential to recognize that for a person with mental illness, this is their reality. I always try to see the person, not the diagnosis, and remember that they may have mental illness but they are not stupid. Many are incredibly intelligent and perceptive, and bristle at words or tones of voice that come across as patronizing or condescending. To avoid being unduly influenced by a person’s specific diagnosis or legal circumstances, I tend to review other practitioners’ chart notes after visiting the patient rather than before.
It is not helpful to try to talk a person with mental illness out of a particular delusion by using logic, reason, or theology, and in my opinion it could even violate the chaplain’s role. A non-judgmental presence and active listening can establish a much better pastoral relationship than talk ministry. For this reason I try to focus on spirituality rather than religion per se, to “walk with” that person as they seek their own path to spiritual wholeness and healing. My personal conviction that a given religious belief is “toxic” or “bad” theology does not give me the right to evangelize against it. As a person moves beyond crisis to wellness, they often discover for themselves how certain deeply held religious beliefs are working against their recovery, and they realize a deeper and more positive spirituality. Our job as mental health chaplains is to reflect God’s unconditional love and to support the patient’s spiritual journey, no matter how troubled, as companion and gentle guide.
Donna Dickerson, BCC, is a chaplain at San Antonio State Hospital in San Antonio, TX.
These observations are largely subjective, based on five years of personal experience. I encourage others to research these observations in hopes of furthering our understanding of the complex inter-relationship of mental illness and unhelpful religious belief systems.
Some existing publications of interest include:
Significance of the Chaplain within The Mental Health Care Team, Psychiatric Bulletin 2002.
Confidentiality and Mental Health/Chaplaincy Collaboration, University of Nebraska Public Policy Center, 2014.
The Chaplain as a Voice and Bridge for Mental Health Patients, PlainViews, 2014.