Catholic Medical Quarterly

The Journal of the Catholic Medical Association (UK)

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Catholic Medical Quarterly Volume 75(1) February 2025

A Chaplain’s Guide to supporting patients who experience delusions and hallucinations with religious content

Rev Mr Paul Green BA (Hons); BSc (Hons), MSc, PG Dip CBT, PG Cert Chaplaincy, FHEA,

Parish Deacon at Holy Rood, Barnsley
and Chaplain at Kendray Hospital.

The problems experienced by patients who experience hallucinations and delusions with religious content (DRC) will be familiar to many chaplains. These symptoms are relatively common in people with mania or psychosis and are associated with poorer clinical outcomes and higher levels of dangerousness. (1) However, it is important to avoid pathologizing ordinary religious experiences and chaplains can play a role in helping clinicians to distinguish non-clinical phenomena from symptoms which require treatment. (2) Cook et al conducted a study of 58 people who reported hearing spiritually significant voices that generally occurred during prayer and most respondents ascribed a divine origin to the voice. Only a minority had previously experienced mental health problems, predominantly anxiety and PTSD rather than psychosis. (3) The authors agree with Cullinan et al that voice-hearing is a common phenomenon which may easily be confused with psychopathology. (4)

There are several factors to consider when trying to distinguish between clinical and non-clinical phenomena. If a person experiences negative religious coping, emotional problems, conflict with their faith community, expresses maladaptive beliefs that are rejected by other adherents and ascribes their experiences to divine punishment or demonic influence, then psychosis may be present. Similarly, religious beliefs that are persecutory or messianic might suggest the presence of delusions. (5) By contrast, non-clinical voice-hearing and spiritual beliefs will often be found comforting and affirmed within religious communities. Neuropsychologists de Leede-Smith and Barkus agree that the emotional valence of voice-hearing is important ‘with a negative emotional appraisal of the voice having a predictive value of 86% for the presence of psychotic disorder.’ (6) Voice hearers with psychosis generally experience higher frequency, less control and derogatory rather than positive content whereas distress or dysfunction rarely occur in non-clinical cases. [7]

Cook points out that greater plurality of religious belief in western societies is a complicating factor. This makes it more difficult to define when the spiritually significant nature of a person’s experiences has become problematic. (8) Cullinan et al emphasise that clinicians should recognise the limitations of their role and offer a chaplaincy referral as soon as possible. (9) M’Lis Clark and Harrison argue that this can help to identify cases where delusional content differs from spiritual/ religious beliefs that are normative in the patient’s own culture. (10) van Holten offers a pastoral/theological framework to assist chaplains discern the meaning that patients ascribe to their experiences of DRC, emphasising that their role is not to diagnose but to determine whether what is expressed is valid within a given religious framework. (11) He outlines a series of principles to guide the assessment process:

1)         Coherence and consistency

A lack of coherence and consistency in a person’s beliefs with conflicting assumptions and an eclectic use of religious language/symbolism may indicate that the spiritual interpretation is invalid.

2)         Credibility and practicability

If the beliefs expressed are incongruent with estab­lished and generally accepted s scientific truths and with what the person believes in other areas of his/her own life, this may indicate invalidity. If living with these beliefs results in bizarre and problematic behaviours, the content should be viewed as problematic.

3)         Relevance and intelligibility

A spirituality focused excessively on the activities of angels/demons, and which does not evolve or adapt in response to new knowledge may isolate a person from his/her own culture and be considered invalid within the framework arising from it.

4)         Continuity and normativity

An emphasis on originality risks departing from the heritage of faith within a person’s own tradition. Religious belief is not simply an individual affair but is embedded in a community and a historical process. Ideas which transgress normative boundaries of belief and practice, isolate people and produce dysfunctional behaviours should be considered invalid.

5)    Conceptual competence

If words and images from sacred scriptures are taken too literally and out of context, there will be a loss of the reality shared with other believers. Valid spiritual beliefs rely on a competent use of religious concepts and imagery.

6)    Certainty

Faith should not result in a dogmatic certainty that leaves no room for doubt of any kind, and which is indifferent to criticism, scientific findings, everyday knowledge and what is commonly held to be true within one’s own tradition. Beliefs held in this way may be considered irrational and invalid. [12]

It is important for both chaplains and clinicians to assess DRC and associated hallucinations holistically, to listen to the patient and take his/her perspective seriously. The phenomenon of ‘epistemic injustice’ occurs ‘when a person is given less credence than they deserve, often because of the prejudices of others.’(13) Crichton et al warn of the danger that mental health patients may be regarded as objects of enquiry rather than participants in a search for the correct diagnosis and treatment. This inevitably results in their views not being listened to or taken seriously. (14) Miller Tate identifies ‘contributory injustice’ in which those who are marginalised are unable to contribute to a collective understanding of an issue because their knowledge is dismissed by others. (15) He refers to research in which ‘Participants were frustrated at a perceived rigidity in their clinicians’ perspectives on voice-hearing, which emphasised neurological explanations and interventions as well as diagnostic categorisation that was judged to be inflexible and unsuited to understanding service users’ experiences of voice-hearing in any depth.’ (16)

Patients who hear voices and maintain problematic beliefs will find these experiences meaningful, irrespective of whether they form part of a mental illness or not so dismissing what they say is likely to alienate them. (17) Moreover, Bentall has outlined both a psychosocial model of psychosis (18) and a comprehensive critique of biomedical treatments, arguing that medication needs to be used with more caution in at least some cases.(19) The use of CBT as a treatment modality should certainly be considered (20) and the Hearing Voices Network can provide clinicians with an alternative perspective via use of its resources. Discussion of these issues in Schwartz rounds and participation in groups where patients explore their experiences of psychosis can help both chaplains and clinicians enhance their own practice. (21)

A holistic assessment of DRC and associated hallucinations will require input from both clinicians and chaplaincy services. This should include an open dialogue to explore the patient’s experiences and the impact these have had. It will then be possible to distinguish clinical problems triggering dysfunction from spiritual experiences that are helpful. Involving a healthcare chaplain at an early stage in the assessment process can facilitate positive religious coping and avoid pathologizing beliefs that are not clinically significant.