Abstract

In lieu of an abstract, here is a brief excerpt of the content:Hermeneutical Injustice and Best PracticeAlasdair Coles, PhD, MRCP (bio)To a doctor who routinely sees people with psychosis and neurological conditions causing strange experiences, José Porcher’s paper is challenging and troubling.Challenging, because the accusation of hermeneutical injustice is accurate. In the hurly burly of the emergency department or a government outpatient clinic, doctors resort to reductionism, for the sake of urgent efficiency. A person becomes a “case of psychosis” and the immediate questions are: “Should they be admitted? Are they fit to make their own decisions? What medication should we prescribe?” In that context, spending time on analyzing the contents of the delusions, and acknowledging their meaning to the individual, is a luxury. Most doctors, burnt out by COVID and struggling to get people basic healthcare, will probably be unconcerned about hermeneutical injustice. But, disdain for the experience of psychosis leads to loss of trust between patient and doctor, as nicely illustrated by Heriot-Maitland, Knight, and Peters’ first patient. One consequence is that patients withhold information they imagine will not be well received by the medical profession. In my experience, of studying the rare entity of people with epilepsy that causes pleasurable or even religious experience, the patients have usually not discussed this with their doctor (Coles & Collicut, 2019) A tangible medical consequence is that their doctors are not aware of the risk of non-compliance with anticonvulsant drugs, so that they are at risk of serial seizures or even sudden death.Porcher’s uncritical appreciation of the Avraham case worries me. Although one of the two therapists is described as “particularly well-versed in Jewish custom and lore” (Bilu et al., 1990), they are not believers. Yet, they take on priestly roles. For instance, after identifying Avraham’s “the Black” as a demon (“which the patient did not belie” [Bilu et al., p. 110]), they prescribe incantations based on Jewish exorcism rites. And, once Avraham was better, he and his wife attributed his “miraculous cure” to the therapists who they regarded as “pious and pure hearted” (Bilu et al., p. 116). Not only are Avraham’s secular therapists being disingenuous, it is dangerous for seculars to appropriate religious language, concepts, and customs. In particular, clumsy use of exorcism rituals can lead to long-term spiritual distress. Those ministers of religion who practice deliverance [exorcism] are highly trained, not least to respect the importance of asking for psychiatric [End Page 239] help. It is unwise not to return the professional favor. Avraham’s therapists should have called in a Jewish minister, trained in clinical pastoral care, to assist them.Key issues are raised by Porcher’s analysis of the Femi case. Femi presented with a psychosis that included religious content. This is common (Sofou et al., 2021): religious imagery is present in 5% to 50% of cases of psychosis, assessed by repeated studies across multiple cultures. The medical team concluded Femi had a psychosis, because his symptoms caused him harm (social isolation, absence from work). Porcher rightly condemns Femi’s therapists because they undermined his dignity, by invalidating his experience of God. And Porcher goes on to state the “both–and” view, that something can be psychopathology and a religious experience. So far so good. But what Porcher does not allow is that some people experience psychoses with very harmful and dark religious imagery, invalidation of which is therapeutic. So, when Porcher asks “what could ever justify someone in the judgment that someone’s religious experiences are illegitimate?” the answer is: compassion. Schizophrenia is not fun. And the disease causes hallucinations that have no relation to reality; to the person I saw recently who believed her clothes were eating her, how helpful would it be to validate the nonsense of clothes with teeth? It follows that some religious delusions may be just that. And people are helped by knowing that. That is the reality of care of the deluded patient. For those therapists who just assume all religious content is inauthentic, Porcher’s article stands as a useful corrective. But assuming the opposite may be as harmful or more. There has to be judgement somewhere along the line. Best practice is that this is done...