Objectives—To discover what dementia sufferers feel is wrong with them; what they have been told and by whom, and what they wish to know about their illness.Background—Ethical guidelines regarding telling truth appear to be equivocal. Declarations of cognitively intact subjects, attitudes of family members and current psychiatric practice all vary, but no previous research has been published concerning what patients with dementia would in fact like to know about their diagnosis and prognosis.Design—Questionnaire study of the patients' opinions.Setting—Old Age Psychiatry Service (...) in Worcester.Participants—30 consecutive patients with dementia.Results—The quality of information received has been poor and many patients have no opportunity to discuss their illness with anybody. Despite that almost half of the participants in this study had adequate insight and a majority declared that they would like to know more about their predicament.Conclusions—Although many patients would like to know the truth, the rights of those who do not want to know should also be respected. Therefore the diagnosis of dementia should not be routinely disclosed but health care professionals should seek to understand their patients' preferences and act appropriately according to their choice. (shrink)

The boundary between spiritual experience and mental disorder remains unclear and should invite collaboration between psychiatry and other disciplines, including theology. Jackson and Fulford (1997), using the tools of analytic philosophy, have proposed a model allowing principled differentiation between spiritual experience and psychotic symptoms based on the personal values of the subject, a cognitive problem-solving model. Spiritual experience is described as positively evaluated psychotic experience, which enables the subject to do more than he or she normally does. In the present (...) paper, it is claimed that values and actions cannot alone always discriminate between religious experience and psychopathology. With reference to three case studies, drawn from the practice of one of us, it is argued that spirituality is not all about experience and that it cannot be understood without reference to the subject's personal history and spiritual tradition, however implicit or fragmented. This approach would allow an account of ordinary religious experience in those who have suffered ego disablement during mental illness. Drawing primarily on the Christian tradition, we argue that the use of theological criteria may allow levels of discrimination between spiritual experience and mental disorder not allowed for by philosophical psychopathology. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.4 (2002) 349-351 [Access article in PDF] Mystical States or Mystical Life?Buddhist, Christian, and Hindu Perspectives Marek Marzanski and Mark Bratton THIS IS AN ORIGINAL and conceptually precise paper. It is a significant attempt to bring religion and psychiatry into conversation. With particular reference to three Oriental epistemologies—Tibetan and Zen Buddhism and Tantric Hinduism—Caroline Brett seeks to offer a means of differentiating mystical states from (...) psychotic ones. She is critical of reductionism in modern psychiatry that seeks either to elide religious experience into psychopathology, or seeks too sharp a distinction between them. Brett claims, by implication, to offer a more fundamental level of discrimination between religious experience and psychopathology than the "cognitive problem-solving model" that Jackson and Fulford propose (1997a).In both mystical and psychotic states, the author argues, there are radical alterations in the structure of experience. Psychotic states, however, result from failures to complete, or, at least, to negotiate smoothly, the transition from a commitment to an epistemology based on illusory reality to one structured according to ultimate reality—a reality that is brought into focus through an alignment of transcendent vision and mundane cognition. Although this epistemological "stuck-ness" can manifest itself in action as destructive behavior, for example, psychological isolation or social and occupational dysfunction, the basis of the distinction between mystical and psychotic states lies in real differences in the states themselves.In our view, there is a tendency in much psychiatric and theological literature to homogenize mystical states and to treat experiences that (arguably) occur on a number of different levels as if they were on the same level. It is still widely thought that a mystical consciousness can somehow be abstracted from the religious traditions out of which this consciousness emerges. It is assumed that we can talk about experience in abstraction from the shared consciousness produced by schooling in a specific historical religion (Shannon 1985, 493). Thus, the altered mystical state of a Zen Master or Saint Teresa of Avila in ecstasy are regarded as identical states of consciousness. Yet it is far from clear that mystical states can be talked about without explicit reference to the language and tradition in which the self is formed, or, in terms that would have different meanings in Abrahamic and Oriental religious traditions, un-selfed. [End Page 349]There is a related tendency to regard religious doctrines as attempts to interpret mystical experience, as second-order reflections on the language of experience, as if religious doctrines were local religious dialects into which core experiences could be translated. We suggest, rather, that there is an iterative relationship between a mystical experience and the religious framework out of which it emerges. Religious doctrines are better seen as sets of instructions designed to guide the movement of prayer, and the movement of prayer, in turn, exemplifies the religious doctrine that shapes it.So could mystical states within the framework of Tibetan and Zen Buddhism and Tantric Hinduism better be understood as exemplification's of the worldviews of those particular religious traditions? For example, the relinquishing of ego structures, the dissolution of subject/object boundaries, the yielding of the contrastive identity between experience and the world, and progress toward undifferentiated union of the self with the cosmic self, seem to exemplify the monist cosmology associated with some of those traditions. By the same token, the psychotic state could be interpreted as an exemplification of an existential stance that has for some reason defected from the movement toward transcendental cognition. The point is that the "real differences" Brett identifies in the two states cannot be understood apart from the religious epistemology and doctrines, which those states, positively or negatively, exemplify. "So far 'from mystical states' being a sort of paradigm of certainty, they have authority only within a frame of reference which is believed in on quite other grounds and are therefore properly to be tested according to their consistency with this" (Williams 1991, 149)The force of Brett's paper, like Jackson and Fulford, is to identify the boundaries... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.4 (2002) 383-385 [Access article in PDF] Minding Your Language:A Response to Caroline Brett and Stephen Sykes Marek Marzanski and Mark Bratton THE PAPER BY Jackson and Fulford (1997), to which ours is a preliminary response, has opened up an important and much-needed conversation on the borderlands of theology, philosophy, and psychiatry. We are deeply grateful for lapidary and attentive responses to our paper from (...) Caroline Brett and Stephen Sykes, in which each have affirmed the value of this conversation, but also indicated the issues that need to be thought through in greater depth. Sykes makes the point, quite rightly in our view, that the language of both theology and psychiatry are needed to illuminate the gray area between spirituality and mental disorder. Part of the difficulty, perhaps, has been the tendencies of theologians and psychiatrists alike either to speak past each other's shoulders or to refuse to engage in conversation at all (Watts 2002).Both commentators have accurately represented the core arguments of our thesis: that genuine spirituality may involve ego disablement and that positively evaluated psychotic, action-enhancing experiences are not, by definition, spiritual. They also both agree that religious traditions may offer resources that help discrimination at the borderlands of theology and psychiatry, beyond the reach of descriptive psychopathology. However, Brett has helpfully drawn attention to a number of possible weak spots that deserve further reflection:the distinction between breaking downand breaking throughand the possible continuing value of using the criterion of preserved or enhanced functionality; our failure to appreciate the precision with which Jackson and Fulford use the language of psychosis; and the uncertain clinical value of a schema that only allows an assessment of the contribution of an experience to spiritual reorientation after the event.Although it is not appropriate in the form of a final response to engage with these issues in depth, we thought that a few brief observations might be in order. Breaking Down and Breaking Through Brett's distinction between breaking down and breaking through is helpful but may disintegrate where the breaking down itself is considered to be constitutive of spiritual experience. The Pauline insight "for when I am weak; then I am strong" (2 Cor. 12:10, New Revised Standard Version [NRSV] 1989) finds vivid expression, for example, in the life of the Abbe Marie-Joseph Huvelin (Williams 1994). This Parisian curate, with chronic [End Page 383] and debilitating ill health and an almost unrelieved sense of personal worthlessness that bordered on despair, managed to transmit hope to an astonishing range of people who came to him for spiritual direction. There was no obvious, schematic breaking through the rigors of ego disablement to sunlit uplands of ethical conviction or renewed sense of vocation. It is by no means clear that he would have wished his predicament on anyone else, let alone himself, notwithstanding the fruitfulness of his ministry. The breaking down was arguably part of his life-long vocation and it perhaps stretches the meaning of action enhancement a little too far to use it encompass the often paradoxical nature of sanctity. The Language of Psychosis An important feature of good conversation is mindfulness in the way language is used and guardedness against misrepresenting the position of one's conversation partner. The expression of our discomfort with the application of the language of psychosis to spiritual experience was perhaps designed primarily to signpost our concern with certain reductive and assimilating tendencies in modern psychiatry. Perhaps psychotic may be used with precision and designed to draw attention to the complexities of discriminating at the borderlands of theology and psychiatry. Words, nonetheless, have resonance—philosophically and culturally—that radiate well beyond the boundaries of precise usage. The same could be said of Brett's use of anomalous, which might refer to a range of phenomena that most people would regard as abnormal: hallucinations, synesthaesia, out-and of-body, past-life, and near-death experiences. It is legitimate, we contend, to draw attention to these resonances even if they stray... (shrink)