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Psychosis, Psychiatry and Psychospiritual Considerations: Engaging and Better Understanding the Madness and Spiritual Emergence Nexus - reviewed by Chris Cook
Psychosis, Psychiatry and Psychospiritual Considerations: Engaging and Better Understanding the Madness and Spiritual Emergence Nexus, by Brian Spittles, Aeon, London, pb, 377pp, £39.99
www.rcpsych.ac.uk/members/special-interest-groups/spirituality/newsletters-and-book-reviews
Book review for the website of the Spirituality & Psychiatry Special Interest Group of the Royal College of Psychiatrists
In this published version of his PhD thesis, Brian Spittles challenges psychiatry on three fronts:
That it should go beyond its “materialist assumptions” to bring “psychospiritual considerations within its epistemological remit” (p3)
That psychosis should not be considered psychopathological and primarily biological in origin.
That psychotic experiences should not be considered fundamentally incomprehensible.
The term “psychospiritual” is used to denote a spectrum of phenomena and experiences, including the “spiritual”, “metaphysical”, “transpersonal”, and “mystical” (p7). It is used also to acknowledge the intimate connection between the spiritual and the psychological and is employed as a foundational term throughout the book. Whilst it is true that the spiritual cannot really be spoken about without reference to the psychological, it is not necessarily so the other way around and so I found this a bit confusing. However, it might well be argued that this is preferable to a biopsychosocial model which routinely fails to reference the spiritual, and it is this failure of psychiatry to address the spiritual which the book robustly criticises. The book further – and quite rightly in my view – criticises psychiatry for its history of generally either ignoring or pathologizing the psychospiritual, especially in relation to psychosis.
After introducing these challenges, and considering the nature of the psychospiritual domain, the book goes on to address the “psychosis-psychospiritual nexus” in four “focal settings”:
The psychiatric view of psychosis
A history of the psychospiritual within psychiatry
A content analysis of attempts to distinguish the psychospiritual from the psychopathological
An argument that the psychospiritual and the psychopathological are indistinguishable
In Focal Setting One, close attention is given both to a historical perspective of the concept of psychosis within psychiatry, and a critique of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM). In Focal Setting Two, there is consideration of a range of ways in which psychiatry has dabbled with the psychospiritual, including the work of Richard M. Bucke on cosmic consciousness, the emergence of “metapsychiatry” in the USA in the 1970s, the 1976 Group for the Advancement of Psychiatry Report on mysticism, the field of neurotheology, and the introduction in DSM-IV of a V code for spiritual/religious problems. For members of the Spirituality and Psychiatry Special Interest Group (SPSIG) of the Royal College of Psychiatrists, things get particularly interesting in Chapter 7 where two pages are devoted to SPSIG. This is especially notable given the heavily North American focus of the rest of this focal setting, but it is also encouraging to read the author’s warm praise for our SIG. He writes:
Overall, the SPSIG exemplifies the capacity for mainstream psychiatry to seriously investigate psychospiritual matters in relation to psychopathology and psychosis. The robust example set by this mainstream psychiatric entity dispels the prevailing clinical view that psychospiritual matters are beyond the investigative remit of medical psychiatry. (p105)
Focal Setting Three undertakes a historical review, and then a content analysis, of ways in which the psychospiritual and psychopathological have been discerned to be distinguishable. The content analysis takes as its starting point the 2009 study by de Menezes and Moreira-Almeida in which nine criteria were developed as a basis for distinguishing spiritual from psychotic (and dissociative) experiences. Spittles goes on to identify 193 criteria, from 70 different texts, said to be indicative of psychotic rather than psychospiritual experiences. The top nine criteria are then examined in turn, each being found inadequate to the task. It is concluded, at the very end of Focal Setting Three that it is “seemingly impossible” to distinguish psychotic from psychospiritual experiences (p179).
In Focal Setting Four, Auditory verbal hallucinations and delusions are, in particular, called into question as diagnostic criteria for psychosis. Cross-cultural studies are used to argue that what is deemed psychotic in the west is deemed normal in other parts of the world. This contention is based on studies of traditional healers, shamans, and the phenomenon of spirit possession. A penultimate chapter on spirit possession and psychosis as understood within Tibetan Buddhist psychiatry (Chapter 13) is presented as providing an exemplary holistic understanding within which psychosis is found to be “essentially psychospiritual in nature and aetiology” (p231) Surprisingly, given the conclusions of Focal Setting Three, it is argued here that psychosis can be distinguished from (other) psychospiritual experiences after all, but only because of the open, heuristic and fundamentally psychospiritual approach that Tibetan Buddhist psychiatry adopts.
The fundamental argument within this book – that psychiatry needs to take spirituality more seriously – is one that I’m sure all members of SPSIG would resonate with. Buddhist psychiatrists might be especially interested in 13, although I find it hard to imagine how such a model could ever be applied in a health care setting such as that of the NHS. Culture is important, and Tibet and the UK are very different, culturally as well as religiously. For most members of SPSIG, there is a lot to like in this book, but also much that will be controversial and will not find universal agreement. For example, I share the author’s concerns about the idea of distinguishing between spiritual experiences and psychosis, but not for the same reasons. I would suggest that it is a form of epistemic injustice to propose that someone cannot be having a genuine spiritual experience just because they are suffering from a mental disorder, but that is a far cry from suggesting that all psychosis has psycho spiritual origins and does not (in my view) mean that psychosis should not be considered psychopathological.
All things considered, this book is one which should be of interest to all members of SPSIG, and to others interested in spirituality and psychiatry. It is controversial, but also a very interesting read, and I hope that it will provoke a critical and constructive debate about the relationship between spirituality and psychosis.
Christopher C.H. Cook
Emeritus Professor
Institute for Medical Humanities
Durham University
23 January 2024
Psychosis, Psychiatry and Psychospiritual Considerations: Engaging and Better Understanding the Madness and Spiritual Emergence Nexus, by Brian Spittles, Aeon, London, pb, 377pp, £39.99
www.rcpsych.ac.uk/members/special-interest-groups/spirituality/newsletters-and-book-reviews
Book review for the website of the Spirituality & Psychiatry Special Interest Group of the Royal College of Psychiatrists
In this published version of his PhD thesis, Brian Spittles challenges psychiatry on three fronts:
That it should go beyond its “materialist assumptions” to bring “psychospiritual considerations within its epistemological remit” (p3)
That psychosis should not be considered psychopathological and primarily biological in origin.
That psychotic experiences should not be considered fundamentally incomprehensible.
The term “psychospiritual” is used to denote a spectrum of phenomena and experiences, including the “spiritual”, “metaphysical”, “transpersonal”, and “mystical” (p7). It is used also to acknowledge the intimate connection between the spiritual and the psychological and is employed as a foundational term throughout the book. Whilst it is true that the spiritual cannot really be spoken about without reference to the psychological, it is not necessarily so the other way around and so I found this a bit confusing. However, it might well be argued that this is preferable to a biopsychosocial model which routinely fails to reference the spiritual, and it is this failure of psychiatry to address the spiritual which the book robustly criticises. The book further – and quite rightly in my view – criticises psychiatry for its history of generally either ignoring or pathologizing the psychospiritual, especially in relation to psychosis.
After introducing these challenges, and considering the nature of the psychospiritual domain, the book goes on to address the “psychosis-psychospiritual nexus” in four “focal settings”:
The psychiatric view of psychosis
A history of the psychospiritual within psychiatry
A content analysis of attempts to distinguish the psychospiritual from the psychopathological
An argument that the psychospiritual and the psychopathological are indistinguishable
In Focal Setting One, close attention is given both to a historical perspective of the concept of psychosis within psychiatry, and a critique of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM). In Focal Setting Two, there is consideration of a range of ways in which psychiatry has dabbled with the psychospiritual, including the work of Richard M. Bucke on cosmic consciousness, the emergence of “metapsychiatry” in the USA in the 1970s, the 1976 Group for the Advancement of Psychiatry Report on mysticism, the field of neurotheology, and the introduction in DSM-IV of a V code for spiritual/religious problems. For members of the Spirituality and Psychiatry Special Interest Group (SPSIG) of the Royal College of Psychiatrists, things get particularly interesting in Chapter 7 where two pages are devoted to SPSIG. This is especially notable given the heavily North American focus of the rest of this focal setting, but it is also encouraging to read the author’s warm praise for our SIG. He writes:
Overall, the SPSIG exemplifies the capacity for mainstream psychiatry to seriously investigate psychospiritual matters in relation to psychopathology and psychosis. The robust example set by this mainstream psychiatric entity dispels the prevailing clinical view that psychospiritual matters are beyond the investigative remit of medical psychiatry. (p105)
Focal Setting Three undertakes a historical review, and then a content analysis, of ways in which the psychospiritual and psychopathological have been discerned to be distinguishable. The content analysis takes as its starting point the 2009 study by de Menezes and Moreira-Almeida in which nine criteria were developed as a basis for distinguishing spiritual from psychotic (and dissociative) experiences. Spittles goes on to identify 193 criteria, from 70 different texts, said to be indicative of psychotic rather than psychospiritual experiences. The top nine criteria are then examined in turn, each being found inadequate to the task. It is concluded, at the very end of Focal Setting Three that it is “seemingly impossible” to distinguish psychotic from psychospiritual experiences (p179).
In Focal Setting Four, Auditory verbal hallucinations and delusions are, in particular, called into question as diagnostic criteria for psychosis. Cross-cultural studies are used to argue that what is deemed psychotic in the west is deemed normal in other parts of the world. This contention is based on studies of traditional healers, shamans, and the phenomenon of spirit possession. A penultimate chapter on spirit possession and psychosis as understood within Tibetan Buddhist psychiatry (Chapter 13) is presented as providing an exemplary holistic understanding within which psychosis is found to be “essentially psychospiritual in nature and aetiology” (p231) Surprisingly, given the conclusions of Focal Setting Three, it is argued here that psychosis can be distinguished from (other) psychospiritual experiences after all, but only because of the open, heuristic and fundamentally psychospiritual approach that Tibetan Buddhist psychiatry adopts.
The fundamental argument within this book – that psychiatry needs to take spirituality more seriously – is one that I’m sure all members of SPSIG would resonate with. Buddhist psychiatrists might be especially interested in 13, although I find it hard to imagine how such a model could ever be applied in a health care setting such as that of the NHS. Culture is important, and Tibet and the UK are very different, culturally as well as religiously. For most members of SPSIG, there is a lot to like in this book, but also much that will be controversial and will not find universal agreement. For example, I share the author’s concerns about the idea of distinguishing between spiritual experiences and psychosis, but not for the same reasons. I would suggest that it is a form of epistemic injustice to propose that someone cannot be having a genuine spiritual experience just because they are suffering from a mental disorder, but that is a far cry from suggesting that all psychosis has psycho spiritual origins and does not (in my view) mean that psychosis should not be considered psychopathological.
All things considered, this book is one which should be of interest to all members of SPSIG, and to others interested in spirituality and psychiatry. It is controversial, but also a very interesting read, and I hope that it will provoke a critical and constructive debate about the relationship between spirituality and psychosis.
Christopher C.H. Cook
Emeritus Professor
Institute for Medical Humanities
Durham University
23 January 2024