Since its inception in the middle of last year, the Psychiatry and Spirituality Forum at the University of California, Irvine, has grown from about 20 members to 130. The forum, unique in America, if not the world, has attracted an unusual following of Buddhist monks, Catholic priests, rabbis, psychiatrists, physicians, social workers and scientists. Founder and director of the forum is Dr Aaron Kheriaty, assistant clinical professor of psychiatry at UC Irvine. In this email interview with MercatorNet he talks about the connection between mental health and spiritual convictions.

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MercatorNet: There seems to be an awful lot of mental illness around the world: the WHO attributes a third of all disability to psychiatric conditions, and there are 800,000 suicides a year. Is it just coincidental that these numbers coexist with increasing material prosperity and diminishing religious faith?

Aaron Kheriaty: The burden of mental illness worldwide is indeed tremendous. Because of the social stigma against the mentally ill, their suffering and disability often remain hidden. There does seem to be a relationship between rising rates of certain mental illnesses and broad social and cultural changes-including diminishing religious observance. Despite our material prosperity and recent technological advances, rates of suicide, depression, substance abuse, and other mental and behavioural disorders are paradoxically rising. In his observations on America, the nineteenth century thinker Alexis de Tocqueville observed that we have this strange propensity to remain anxious and dissatisfied, even amidst the most abundant material prosperity. Modern technology has provided many good things, but it has not delivered greater mental health or happiness. We have advanced in terms of medication treatments for some mental illnesses, but solutions at the medical or biological level address only one aspect of very complex problems, in which psychological, social, and spiritual factors also play an important role.

I am a physician who has the highest respect for the benefits offered
by modern science, modern medicine, and the other healing methods of
psychiatry such as psychotherapy. I believe that because God created
the world, all truth is one. Therefore, the truths of science can never
contradict the truths of revealed religion, when both are properly
understood and interpreted. Therefore, I am a "both-and", rather than
an "either-or" thinker. When a patient who is a religious believer asks
me whether they should pray more or take a medication to help with an
episode of major depressive disorder, my answer is "yes" to both.

The uniquely human tragedy of suicide illustrates this phenomenon. A hundred years ago, the great sociologist Emil Durkheim wrote a classic study on the subject, in which he observed that high suicide rates are a key indicator of social disintegration. He found an inverse relationship between suicide and social connectedness. Durkheim also recognized that religious institutions fostered social solidarity in ways that reduced suicide risk among religious believers. He found that suicide rates were significantly lower in those countries with more robust religious observance. Predominantly Catholic countries also seemed to have lower rates than Protestant countries, which he attributed to Protestantism's relative stress on individualism, as compared to a Catholic emphasis on corporate forms of worship that shaped culture differently.

Durkheim's findings have been replicated in several studies since his day. It is now widely accepted among psychiatrists that religious belief and practice lowers the risk of suicide. In addition to the social support provided by religious institutions, other recent studies show that religious belief and flourishing religious institutions protect against suicide in ways that go beyond providing non-specific social support. Other factors include moral prohibitions against suicide found in Judaism, Christianity, and other religious traditions. In addition, religion often protects against despair and demoralization in the midst of suffering, through fostering meaning, hope, and a sense of one's personal vocation. So there are several factors that lower the risk of suicide among religious believers. Research on substance abuse, impulsivity, and violence also show that religious belief and practice lower the risk of these behavioural disorders.

MercatorNet: From his experience as a Jew in a concentration camp, Victor Frankl came to the conclusion that suffering can have meaning. This is an idea common to religious traditions but not very popular today. Do we need religion or something similar to cope with suffering, which is unavoidable in human life?

Aaron Kheriaty: I hesitate to speak of "religion" in the abstract. In a sense, there is no such thing as religion; there are only religions, each of which has different answers to questions about suffering and meaning. I have never met anyone who believes in "religion", but I have met a lot of Jews, Christians, Muslims, Hindus, and Buddhists. These religions may very well have some elements in common, but to group them all under one abstract term can be somewhat misleading.

Consider the different approaches to suffering found in different religions. For a Buddhist, suffering is actually an illusion -- in the last analysis, it is not real. The solution to suffering, according to Buddhism, is to detach oneself in such a way that one frees oneself from the illusion of suffering. Contrast this with Judaism, which offers the figure of suffering Job, who hopes in God in the midst of his suffering. Nowhere is it suggested that Job's suffering -- or the suffering expressed by the Psalmist, or the suffering of the Israelites while enslaved in Egypt -- nowhere is it suggested that this suffering is, at bottom, an illusion. It is real, and because it is real this suffering calls forth hope in God's deliverance, hope in the promises made by the Prophets, and an expectation of a future Messiah. Finally, we can contrast these views of suffering with that proposed by Christianity. For Christians, as for Jews, suffering is real. It not only calls for hope of future deliverance, but it sees suffering itself as redemptive. The Christian's suffering takes on meaning when it is united to the suffering of Jesus Christ on the Cross; it is precisely here that one's salvation is found. So it should be clear from these contrasts that there is no single "religious" answer to coping with suffering. On the other hand, it seems that all religions attempt, in their own way, to address the universal problem of human suffering.

It seems to me that it is the religions of the world that have grappled most deeply with the question of suffering, and have offered the most compelling answers to coping with suffering (some more compelling than others). I think, in the end, we do need religious faith to adequately endure suffering. Consider the approach to suffering currently on offer from secular humanism, whose proposal is to someday eliminate all suffering through purely technological means. While this is not possible (and it will never be completely possible), the backup plan seems to be to eliminate the one who is suffering, by means of euthanasia or assisted suicide. This seems to me to be a rather primitive form of denial; it pales in comparison to notions of redemptive suffering found among many religious believers. If we are looking for pragmatic ways to "cope", non-religious answers to suffering appear rather pale and thin compared to religious responses that do not shrink from or ignore the reality of human suffering.

MercatorNet: Does religious faith, or any belief system, guarantee that a person will remain free of mental illness?

Aaron Kheriaty: Absolutely not. Unfortunately, this is a mistaken idea that circulates among some religious believers. It is a notion that needs to be put to rest. Just as with physical illnesses, sometimes a person's behaviours (e.g., overeating or smoking) can contribute to their disease (e.g., lung cancer). But it certainly does not follow that all physical illnesses can be prevented with the right behaviours or beliefs. So also with mental illnesses. Some of the entities currently classified as mental disorders are best understood as diseases in the strict sense of the term; they result from disordered biological or genetic factors that lie outside one's control. Disorders like schizophrenia or bipolar disorder (formerly called manic-depression), although manifested at the psychological or behavioural level, have very strong genetic and neurobiological causes, and cannot be prevented or cured through belief or will power alone.

Other mental illnesses result from being at the far end of a normally distributed trait-like low intelligence, or personality traits that lie on the extreme end of a spectrum. Again, these traits are influenced by factors like genetics and early environmental influences, which lie outside one's control or are not dependent upon religious faith. Other mental disorders are the result of trauma, terrifying life experiences, or injuries to the brain -- none of which can be prevented by any belief system. Throughout history, many saints and people of heroic virtue suffered from mental illness of one sort or another. If we do not recognize this, we run the risk of uncharitably and unjustly stigmatising those who suffer from mental illness.

MercatorNet: In some people, mental illness expresses itself partly as religious mania. What is happening here, and is there a remedy?

Aaron Kheriaty: Psychotic states found in schizophrenia, or manic states found in bipolar disorder, can often be characterized by "hyper-religious" delusions (fixed false beliefs) or hallucinations (perceptions without external stimuli). A manic person may claim to hear the voice of angels, or to be a prophet sent on a mission to save the world. What is happening here is that the unfortunate person suffering from these mental disorders is in a state where their mental life is disintegrating. They are experiencing intense and very unusual thoughts, emotions, and perceptions, which others around them are not experiencing. It is terrifying to believe that one's own mind may be coming unglued -- that one is hearing or seeing things that others do not see or hear, for example. The mind has a tendency toward attaining unity, integration, and meaning. We try to make sense out of our experiences, even when these experiences are pathological or terribly bizarre.

So a person who has grown up in a culture with religious or supernatural concepts readily available will often reach for these concepts to make sense out of these terrifying, highly unusual experiences. "I'm hearing a voice that no one else hears -- so I must be receiving special messages from God." A person who grows up in a non-Christian culture, or who knows little about Christianity, will not develop the delusional belief that he is Jesus or John the Baptist. Rather, the content of his delusion will be drawn from his own religious or cultural concepts, which might appear to explain his experiences. With these illnesses, it is the form of the thinking that is disordered; the particular content of the thinking is dependent on one's own cultural or religious upbringing, knowledge, or background. It is quite clear to anyone that talks to a person with hyper-religious psychosis or religious mania that something has clearly gone wrong with this person's thinking and behaviour. It is not simply a matter of someone suddenly becoming more religious, but of a person losing their capacity for rational thought, which may be expressed in terms and ideas borrowed from religion.

Is there a remedy? Yes, fortunately modern medical science has developed antipsychotic and mood stabilizing medications that can often be remarkably effective in correcting and stabilizing even these dramatic thought and mood disorders. With the right medication treatment, and a stable, supportive environment, someone with severe mania or psychosis (religious or otherwise) can be helped to a remarkable degree.

MercatorNet: You have undertaken a three-year study of the history of psychiatry and the attitudes of its leading figures towards religion and spirituality. We might guess they would be largely negative. Is that what you expected to find?

Aaron Kheriaty: I expected to find negative (or indifferent) attitudes in general, and with a few exceptions, this is what I have found so far. The founding father of psychoanalysis, Sigmund Freud, taught that religion was not only false, it was an illness, a form of psychopathology -- the "universal obsessive neurosis of mankind". For Freud, religion was a childish regression; God was simply a wish-fulfilling projection from our unconscious. Most other psychoanalysts during the first half of the 20th Century followed Freud in thinking that religious faith was pathological, though they may have been too polite to unmask their patient's religious beliefs. One exception would be Freud's heterodox disciple, Carl Jung, who appeared on the surface to be less hostile toward religion. But Jung strongly opposed Judeo-Christian beliefs, and proposed a Gnostic system in which God and man are ultimately indistinguishable. For Jung, God and other sacred ideas were housed in the collective unconscious of humanity. So his psychology became an attic where spiritual dilettantes could search for religious knick-knacks that suited their temperament.

In mid-century, psychoanalysis began to lose influence. Behaviourism, led by John Watson and later B.F. Skinner, began its ascendancy, and influenced psychiatry in other directions. The research findings of the behaviourists were interesting, so far as they went, but the theory was reductionist in the extreme: all mental concepts were done away with. Mental health and illness were nothing but the result of environmental inputs that, in a completely deterministic way, produced behavioural outputs. Obviously religion was thrown out here, along with all other concepts that did not fit within the extremely narrow paradigm of what was considered "behavioural science".

The humanistic psychology movement of the 1970's tried to remedy some of the perceived deficiencies both in psychoanalysis and behaviourism. But it was led by therapists disaffected with religion, who offered their own theory of human flourishing characterized in large part by hostility toward religious values and morals. A cult of the self grew out of the theories of Rogers, Maslow, Fromm, and others. Concepts like "self-esteem," or goals such as "peak experiences," replaced virtues cultivated by religious or ascetical practices. Western culture was influenced by these movements from psychoanalysis to so-called humanistic psychology, in what has been dubbed the triumph of the therapeutic: psychological man (who carefully counts his satisfactions and dissatisfactions) has replaced religious man (who sacrifices himself for a noble ideal) as our dominant character type.

Finally, in our own day, the cognitive and neuroscientific turn has rescued the brain from the behaviourists, but has focused on human mental life from a purely biological perspective. This can also tend toward reductionist and materialistic interpretations, if its limits are not appreciated. Great benefits have come from our rapidly expanding knowledge of the brain at the cellular and molecular level. I am involved in research of this kind, and there is no doubt that biological psychiatry has much to offer in terms of treatments for mental illness. But we humans are more than biological beings. And if we continue to ignore the psychological and spiritual dimensions of the human person, our perspectives in psychiatry will remain truncated and incomplete.

MercatorNet: What about today's psychiatrists -- do they approve of your initiative?

Aaron Kheriaty: So far, the response to the Psychiatry and Spirituality Forum has been nothing but positive. I imagine there must be some critics out there, but so far, my colleagues in psychiatry have been very supportive of this project, even if they have no interest in participating themselves. The University of California, Irvine, and our Department of Psychiatry, have been tremendously helpful, and the Templeton Foundation and its affiliate institutes have been very generous in assisting this project. I have been approached by psychiatrists, scientists, scholars, clergy, and religious leaders from our University, the local community, and beyond, who tell me that they have been interested in the relationship between psychiatry, religion, and spirituality for many years, and are delighted to find others who share their professional and personal interests. We have psychiatry residents applying here who are attracted to our program because of this project. Other schools in the United States have expressed interest in starting similar programs, and researchers from as far away as Iran have contacted me to collaborate on research projects. The time seemed to be right for this project, and the positive response has been surprisingly edifying.

MercatorNet: You say that modern psychiatry has much to offer religious believers. Could you unpack that idea for us?

Aaron Kheriaty: I am a physician who has the highest respect for the benefits offered by modern science, modern medicine, and the other healing methods of psychiatry such as psychotherapy. I believe that because God created the world, all truth is one. Therefore, the truths of science can never contradict the truths of revealed religion, when both are properly understood and interpreted. Therefore, I am a "both-and", rather than an "either-or" thinker. When a patient who is a religious believer asks me whether they should pray more or take a medication to help with an episode of major depressive disorder, my answer is "yes" to both. This is an illness whose causes may be a complex combination of biological, psychological, social, and spiritual factors. Therefore, the treatment should encompass all of the above.

So modern psychiatry has much to offer religious believers in the same sense that modern cardiology has much to offer religious believers-we have medical remedies for disease, illness, and suffering that afflict people, including people of devout religious faith. Beyond this, I think, psychiatry and its related psychological sciences have insights gleaned through research, clinical experience, and careful observation, that shed light on perennial questions about human nature. These are questions addressed by the great religious and philosophical traditions, and the answers to these questions can be enriched by insights from modern science and medicine.

MercatorNet: Members of your forum are also doing a study on the long-term effects of prayer and meditation on the brain. What is already known from research on this subject? What does your own experience suggest?

Aaron Kheriaty: Most of the research so far has looked at state-dependent brain activity during times of prayer or meditation. This basically means that we take a snapshot of the brain, typically through functional imaging techniques like SPECT, PET, or functional MRI scans, to see what is happening in the moment when one is praying or meditating. Aside from the obvious challenge of entering into a state of mystical contemplation while lying in a loud and claustrophobic MRI machine, it is not yet clear exactly what wisdom is gained from such studies. That such-and-such area of the brain (e.g., the temporal lobe) is active during times of prayer or meditation tells us very little about such religious or spiritual activities. This research has also been subjected to the corrosive acid of reductionist interpretation along purely materialist lines: "Contemplative prayer is nothing but discharges in this parietal region of the brain," or "Religious mystics like Teresa of Avila must have suffered from temporal lobe epilepsy." I have very little patience for this sort of thing. This is not to say that such scientific research must be interpreted in this way, nor does it deny that there may be valuable insights gained from these studies.

Our own proposed brain research project, led by Dr Adrian Preda, takes a somewhat different approach, which may be more fruitful. We plan to study not just state-dependent snapshots of what is happening during periods of mediation or prayer. Rather, we will try to measure structural changes of the brain, which result from many years of engaging regularly in such practices. Our hypothesis is that habitual prayer and meditation may have integrating effects on various parts of the brain. These structural integrations have been associated (in other research) with superior mental and emotional health and functioning.

We will compare three groups: Hindu Yoga meditators, Christian contemplatives from religious orders, and a control group of "meditation-naïve" subjects. We are predicting important integrative structural brain differences between the meditators and non-meditators. In addition, we suspect there may be measurable differences between the two meditation groups, rooted in differences of the theory and practice. The Yoga meditators have techniques focused on mental awareness of bodily states such as breathing. The Christian contemplatives have techniques focused on awareness of the presence of a personal God beyond oneself, with whom one engages in an intimate "I-Thou" dialogue. These differences may result in differences at the level of brain structure and functioning.

This is research that may coincide with insights from virtue ethics and related philosophical or theological theories. The ethics of Aristotle or Aquinas, for example, posits that repeated behaviours over a long period of time will result in changes inscribed on our nature that predispose us to virtuous action. Our research may shed light on measurable changes at the biological level which strengthen mental states or behaviours, as they are practiced repetitively over time. We may see that prayer and meditation not only activate certain areas of the brain, but that such activity changes a person at the biological level, and these changes predispose to better mental functioning.

MercatorNet: The forum sponsors lectures covering religious and spiritual issues for all psychiatric residents during the first three years of training. Do they respond well to the subject? Do they bring much personal experience and conviction to it?

Aaron Kheriaty: After medical school, residency training equips the physician for practice in a particular specialty. The residents in our program at UCI have responded very well to the lectures, case conferences, grand rounds, and supervision that we have integrated into training. This curriculum addresses religious or spiritual issues that commonly arise in a clinical context. Most residents have already encountered patients whose thoughts, emotions, and behaviours (the bread and butter of psychiatry!) are profoundly influenced by the patient's religious and spiritual beliefs and practices. Often, patients will seek a psychiatrist who shares, or at least respects and understands, their religious, spiritual, and moral convictions. Residents with clinical experience are already aware that such training is valuable in their clinical work. Many of them have a personal interest in this area, stemming from their own religious or spiritual background.

MercatorNet: Your forum is unique so far -- is this idea going to catch on?

Aaron Kheriaty: I hope so. My experience so far suggests that it might catch on elsewhere. If this happens, this will, I hope, produce mutual benefits for psychiatrists, clergy, and religious leaders who are all dedicated to promoting health, happiness, virtue, and human flourishing.

Dr Aaron Kheriaty is assistant clinical professor of psychiatry at the University of California, Irvine, and director of the university's Psychiatry and Spirituality Forum. He can be contacted at [email protected]