When psychiatrists are forced to deal with religion in daily practice

The Forum on religion and mental illness published in the February 2013 issue of World Psychiatry is a useful one. It reminds us of the necessity for psychiatrists to assess the religious/spiritual life of their patients and sometimes to include religious references in the case management of mental illness 1-4. In many developed countries, it is easier to ask questions about the intimate sexual life of patients than questions about their religious/spiritual one. This reluctance to address religion and spirituality usually originates from patients themselves. On the contrary, in many low and middle income countries (LAMIC), religion is imposed as a necessary component by most patients and families and the reluctance comes from psychiatrists. The context is usually that of a traditional society (mostly rural and patriarchal, closeness to mother nature, vivid ancient beliefs…), progressively transforming itself into a modern way of life in cities. In these cases, the psychiatrist is often forced to deal with the religious beliefs of the patient and the family one way or another, despite his/her reluctance. A good example of that is the belief in “jinn” in Islamic countries. The vast majority of Muslim communities considered some decades ago, and many still do, that epilepsy and some acute manifestations of mental illness are secondary to possession by spirits called “jinn”. The concept of “jinn” is clearly mentioned in the Koran, the holy book of Muslims. Therefore, for many people in these countries, not to believe in these entities and their possessive action would be to shed doubt on the word of God. The traditional treatment proposed to patients suffering from epilepsy and other perceived possession states would be then to read the Koran, to visit tombs of saints, and to refrain from taking medication. Some two decades ago, a patient suffering from epilepsy was asked in a saint's tomb near Marrakech, Morocco to stop her medication. She was severely burned when she fell into a fire during a fit and almost died when she fell into a small river nearby during another fit. The psychiatrist had to explain that she had an organic disease of the brain that absolutely necessitated an antiepileptic treatment. The psychiatrist did not forbid visits to saints' tombs or wearing talismans, but asked her not to stop the medication. Another patient having a schizoaffective disorder was exorcised by a traditional healer who asked him to stop his medications and gave him a “certificate of exorcism”. The consequence was another psychotic episode during which the patient destroyed furniture in his workplace, for which the patient was condemned to 3 months in jail. The question of “jinn” is often put forward by patients or families as an explanation for many mental disorder manifestations (hallucinations, neurotic fits, nightmares, manic episodes). These patients and families sometimes directly ask psychiatrists about whether they have the same religious frame of reference. The question is also asked by journalists when talking about mental disorders. Having had to deal with such situations many times, I decided to address this issue in a more modern way. Instead of keeping the magical, supernatural, mythological approach of the “jinn” as the dominant explanation during the psychiatric interview, I suggested another interpretation to the patients: “According to Koran, ‘jinn' are living beings, invisible; they can be good or bad, and they may be harmful if they enter the body (which is a kind of possession). This can be compared to microbes, bacteria and viruses”. An episode of the life of the prophet Mohamed is also given to the patients and their families which reinforces this theory. The reaction to this proposed explanation of the mysterious force, the “jinn”, was first surprise, then acceptance, and we then started talking about other aspects of the illness: symptoms, diagnosis, family and social aspects of the illness, treatment. It is crystal clear that such an explanation will not be accepted by everybody and that some would completely refuse this modern way of looking at an ancient concept, a concept which was in existence long before the arrival of Islam. But we have about one billion and a half Muslims on this planet who believe in such entities because they are part of the holy book, and many would put them forward to explain a somatic or a psychiatric illness. Not to address this issue one way or another may hamper the doctor-patient relationship. For example, a patient who is convinced that his hallucinations come from jinn possessing him might hear less voices or no voice at all after a few weeks of treatment with an antipsychotic. The psychiatrist's comment might be “If you don't hear ‘jinn' anymore, this might mean that they are sensitive to the action of medication; what do you think?”. It is useful to remind ourselves that 80% of the total population of the world live in LAMIC for whom religious/spiritual beliefs are an essential part of the everyday life of very many patients. The reluctance to address religion and spirituality will grow in LAMIC in the future, but for the time being, psychiatrists in these countries must keep them in mind when helping their patients. Driss Moussaoui Faculty of Medicine and Pharmacy, Hassan II University, Casablanca, Morocco