Grief, loss and suffering are unavoidable components of life; in fact, they’re such common experiences that numerous books, treatment programs and theories have been developed to help people cope during these tough times. When misfortune affects others, we express condolences, offer encouragement, perhaps even quote from sacred texts.

However, when the tragedy is our own, we are sometimes left asking, “Why did this happen to me?” Regardless of what faith or spirituality you might identify with, for those who believe in a higher power, questioning how such a powerful force could allow incredible suffering is a shared experience.

Interestingly, it is often in times of trial that many people make decisive judgments about their commitment to faith or spirituality. Some grow in their devotion to a higher power, while others angrily discount or even renounce their faith – wondering why a benevolent and powerful being could allow such pain and misery.

SCIDs and suffering

In my work conducting the Structured Clinical Interview for the DSM (SCID), I frequently encounter patients who are questioning their faith – they may mention offhandedly that they no longer believe in a god, or that they lost their faith after experiencing incredible tragedy. For these patients, Menninger’s chaplain, Rev. Salvador Delmundo, Jr., can prove to be a vital resource, offering guidance and support while they struggle with questions about their spiritual beliefs and experiences and wonder how it all fits together with their mental health and overall wellbeing.

In an effort to answer some of the more common questions, I spoke with Rev. Delmundo, who shared some of the initial questions he asks patients struggling to answer “How could God allow this to happen to me?” He stated that he asks patients about their god images – thoughts, assumptions and feelings evoked when they include God or the thought of a higher power in their conversations. Learning about a patient’s feelings toward their faith helps him create a picture of how the patient defines his or her faith connection.

The importance of challenging assumptions

For some, a higher power is a benevolent force – a being that offers strength and comfort in times of need. For others, their god is defined by strength and power – a being that is all powerful and thus has the ability to prevent suffering. Rev. Delmundo references Harold Kushner, author of When Bad Things Happen to Good People, as he discusses the benefits of seeing God as a “benevolent being,” one that is comforting and loving in times of suffering. Seeing one’s higher power in this manner takes the focus off of “why did this happen” and refocuses on “how can I get through this.”

Rev. Delmundo stated that one way he engages patients in conversations is by helping them identify and dispel the assumptions about God that don’t work for them. He explained that we don’t question our assumptions about faith until they stop working. For example, the assumption that because one is faithful/spiritual/religious their God will/should protect them from pain and suffering is questioned when suffering occurs.

Asking oneself “how is this assumption working for you?” when thinking about your own spiritual beliefs can shed light on how spirituality shapes your experiences. One way we can “unfreeze” assumptions is by simply rephrasing them into questions. This requires one to switch into a curious frame of mind in order to see if recent experiences support the belief or if one is mistaken in the belief.

Helping yourself

Rev. Delmundo suggests the following for those struggling with spiritual questions in the context of recent tragedy or loss:

1. Locate a support network, which can be family, friends or a faith community.
2. Resist the temptation to immediately assign meaning to what has happened (in the context of grief, one’s judgment is often clouded and assigning meaning can cause one to be resentful in the long run).
3. Listen to other people’s perspectives on what has happened to you and don’t limit yourself to clichés.

For patients struggling to make sense of their experiences, the counseling and guidance from the chaplain can be very beneficial. If you don’t have access to such resources, asking yourself “Who is my God?” and “How is this working for me?” may reveal more about the way in which you experience your faith and provide more guidance into how you can better utilize your beliefs as a strength in times of suffering.

Editor’s note: If you enjoyed this post, check out Heather’s other recent blog posts:

• Pseudologia fantastica: the truth about pathological liars
• Narcissism works for me
• Experiences with the paranormal: differentiating between spirituality and psychopathology

Have you ever made a wish that came true? Or considered Fate or Providence to be at play when someone or something entered your life at an opportune time? What about dreaming about an event that intriguingly played out in real life? Have you ever mourned the passing of a loved one, only to inexplicably feel their presence?

Most people probably identify with such experiences, and many would assign value or meaning to them—perhaps identifying them as divine intervention, believing in the gift of clairvoyance or feeling a special connection with the spiritual realm. Such experiences can impact an individual’s life by providing reassurance, guidance or a stronger sense of spirituality.

Is it possible that people’s stories about miracles or spiritual encounters are merely symptomatic expressions of something more ominous—a psychiatric illness perhaps? From a diagnostic viewpoint, such experiences may be labeled “magical thinking,” “delusional” or “psychotic.” Could they be chalked up to a diagnostic label? And how do clinicians have the authority to make this determination—especially as they interpret such experiences through their own spiritual (or agnostic) lens?

A matter of perspective

The issue of spirituality versus psychopathology seems to be a matter of perspective. Overvalued ideas about one’s spiritual belief system can be interpreted by others as symptoms of a personality disorder or psychosis. How do we differentiate between healthy spirituality and psychopathology? The Diagnostic and Statistical Manual of Mental Disorders (DSM) offers some guidance, defining delusional beliefs as beliefs “not ordinarily accepted by other members of the person’s culture or subculture.” However, with ever-increasing spiritual sects, it can be difficult for the clinician to know what beliefs might be shared. Additionally, the DSM references the level of impairment, context of behavior or belief and symptoms that may be substance-induced. Thus, isolated experiences that are not part of a broad pattern of disturbance should not be diagnosed.

At times a patient’s spiritual beliefs can interfere (from the clinician’s perspective) with their ability to function in a social, occupational or academic setting. These cases can be challenging to filter through the diagnostic decision tree, especially when it seems as though no one can know for sure the extent of truth to any unusual experience.

For example, I met with a patient who had a strong sense that he was “different” from others; he believed he had lived many past lives and had a special connection with the world that most people he encountered could never understand. He described countless “messages from the universe” directing him in his everyday activities. 

From a diagnostic perspective his descriptions bordered on quirky if not impairing. He became quite concerned with physical symptoms, such as feeling like his body was being taken over by an unexplained force, which doctors could not explain. He continually found hidden meanings in TV commercials or friends’ comments that most would consider ordinary experiences. Although he was able to function for the most part independently, he maintained an outlook on the world that made it difficult for him to relate to others and ultimately caused rifts in his relationships.    

SCID platform

The topic of unusual events, or what some define as paranormal or supernatural phenomena, is not typically at the forefront of most clinical discussions between patients and clinicians, in part because they are not of primary concern for patients seeking treatment. However, in my role conducting the Structured Clinical Interview for the DSM Disorders (SCID), I have a platform for discussing them.

In the psychotic symptoms module is a question about unusual religious experiences. Inevitably, patients pause before asking, “What do you mean by unusual?” At this point a dialogue ensues regarding a patient’s personal experience with the supernatural (however they choose to define it) and their interpretation of this experience. The question “Have you ever had visions or seen things others couldn’t see?” sometimes elicits responses about encounters with apparitions of deceased loved ones or patients hearing their name being called or seeing menacing, dark entities. 

In the schizotypal personality disorder module are questions about experiences with the supernatural, unseen forces and unusual perceptional experiences. Interestingly, many patients will disclose personal experiences, such as encountering an animal they believe is the spirit of a deceased relative or describing an ability to predict events that others cannot. Some patients report being guided by entities not of this world—or being protected from near fatal situations by inexplicable forces. Such experiences, while unexplainable, may have a profound impact on their outlook for the future or their belief in forces that transcend our worldly knowledge. 

I am always struck by patients’ initial hesitancy in sharing these extraordinary events; however, I understand discussing them during a diagnostic interview can seem more stigmatizing than normalizing. I find interesting patients’ insistence on presenting their story with the disclaimer,

“This probably means I’m crazy, but….”

It seems as though there is a tendency in the mental health field to dismiss such occurrences as not only strange but indicative of psychiatric illness, implied, in part, by the fact that such questions even exist in the SCID. At times patients decline further elaboration because their experience is deeply personal and meaningful and fear a diagnostic label or quizzical reaction would be demeaning. 

James vs. Freud

The topic of supernatural experiences is nothing new in psychology. In fact, psychologist and philosopher William James wrote about an enormous range of spiritual experiences in The Varieties of Religious Experience: A Study in Human Nature. James believed in an unseen reality and that mystical experiences contributed to a more fulfilling life. Rather than categorizing them as pathological, James sought to include spirituality as a healthy component of psychological functioning. James recounts examples of patients’ mystical encounters in which they felt connected to a higher power through events that ranged from auditory experiences of God talking to them to inexplicable physical energies. 

In contrast to James, Sigmund Freud tended to pathologize religion and religious experiences. In The Future of an Illusion, he depicted religion as a manmade illusion created in an attempt to control human instincts (cannibalism, incest and desire to hurt or kill one another). Freud, an outspoken atheist, likened religious practices to neurosis, claiming that humankind had an obsessive need for protection which could only be achieved through a relationship with a father figure (God). Unlike James, Freud viewed spiritual beliefs and experiences as illusions, in part because they lacked scientific explanation. The opposing viewpoints of James and Freud reflect the significant divergence in clinical perception regarding spiritual experiences that persists to this day. 

So is it psychotic or on the fringe of psychosis to believe in a spiritual connection with a deceased loved one? Should you be diagnosed with schizotypal personality disorder if you believe that ordinary things in your life are meant to give you a special message? The answer is a resounding…it depends. Schizotypal personality disorder is diagnosed not on the basis of isolated experiences or quirky beliefs, but rather on a cluster of problematic traits. Psychotic disorders are diagnosed on the basis of a major break with reality and significant impairment in functioning. It is unlikely that science will ever be able to make an absolute distinction between what is symptomatic of psychopathology and what is merely an aspect of diverse human experience. This illustrates the significant influence of cultural considerations on diagnoses and demonstrates that diagnoses cannot be reduced to a science. Ultimately, we must rely on human judgment, which makes my work all the more intriguing.