Pastoral Care with People with Thought Disorders

Post Author: Ali Van Kuiken

For most church pastors, it can be intimidating to consider giving pastoral care to someone with a psychotic disorder, such as schizophrenia, or someone who is paranoid. People who face a diagnosis of a psychotic disorder make up approximately 1% of the adult population in the United States. The vast majority of people with such a diagnosis are able to manage their symptoms and utilize outpatient or short-term in-patient treatments. You will likely encounter someone who has had a non-reality based experience in their life.  Having a basic awareness of how to interact with them and how to best deliver pastoral care will serve you well in ministry.

Delusions and Hallucinations: Know the Difference

First, it can help to know the difference between two major types of psychosis: delusions and hallucinations. A delusion is a non-reality based belief. For instance, if I believed I were the Virgin Mary, that would be a delusion. A hallucination is a non-reality based sensation. For instance, it would be a hallucination if I heard the voice of the Virgin Mary or if I saw her. Hallucinations can involve any of the five senses including taste, touch, and smell. To the person experiencing the hallucination, what they are experiencing is real. They are not “making it up.” The reason it is called a hallucination and not an experience is because they are the only one experiencing it. This raises all sorts of interesting questions about religious experiences, especially mystical ones, and how we interpret them. While not the subject of this article, it is worth noting that some people report their experiences as religious even though they are otherwise labeled as psychotic. Some guiding questions I give to people struggling with this is to ask if the experience lines up with Christian teaching and tradition, if it draws the person closer to God and to other people, or if it causes harm to themselves or others.

A hallucination is a non-reality based sensation, whereas a delusion is a non-reality based belief.

Validate the Valid

This is a principle of Dialectical Behavioral Therapy (DBT), a treatment clinically shown to be effective for persons struggling with certain personality disorders. The Rev. Miriam Diephouse-McMillan writes about DBT here. When working with someone who is sharing something with us that we cannot broadly validate, whether a behavior of self-harm or something not reality-based, there is always something from what they’re sharing that we can validate. The trick is figuring out which is which. For example, during  my first summer interning as a chaplain at a psychiatric hospital, I encountered a woman who experienced delusions of other patients and staff stealing her body parts. She often asked me to pray that her heart would be returned to her body. I was faced with a dilemma: how could I validate her experience without colluding with her and her delusion? My supervisors helped me realize that I could validate the emotional experience without praying that her heart be returned to her body. So I began to consider what it would be like to think that someone else had my physical heart, how that would be disorienting; I wouldn’t feel like my full, complete self. This is then what I focused on in prayer: that God would help restore her to a sense of herself, to wholeness and peace. I also prayed that she would find a way to live peacefully with her fellow patients and staff when she felt unsafe. 

When in doubt about what is valid about what someone is sharing, it is useful to remember that emotions are always valid. Emotions are always based in reality.

Know that Religious Experience and Illness can be Confused

A person who has a psychotic disorder may have sincerely held religious beliefs and practice. And at the same time, their engagement of faith may be mixed up with their mental illness. This can be confusing for them and for those seeking to give them pastoral and spiritual care. However, it is beneficial to continue to model the aspects of their faith that are reality-based and to draw attention to that with that person. For example, I have worked with patients who believed they were God and who, at the same time, enjoyed attending church services and participating in Bible studies. Some kept this information quiet, having learned that others tend to respond negatively when they mentioned their delusion. When they finally shared it with me,  I felt free to affirm that I believe that they believe that, while at the same time telling them I had a different viewpoint. I’ve found that if I show respect, a difference of opinion and viewpoint is often accepted. 

Dialogue May Be Confusing and Hard to Follow

One feature of someone with a psychotic disorder diagnosis is that their conversation may be hard to follow. They may speak rapidly or simply in a narrative form that is not logical and coherent. It can be helpful to notice this is happening so that you can let go of the expectation that it needs to make sense. And it can give you some freedom to provide structure for the person you are speaking to. Sometimes a person is unable to structure their thoughts in their head and they need help organizing them. 

Providing pastoral care to someone with a psychotic disorder may be a new experience, but just like providing care to anyone with a particular struggle, the same attitude of openness, curiosity and love can go a long way to providing that care. A person with a mental illness may behave in unexpected ways, however a big part of destigmatization is realizing how much we all have in common. Especially how their struggles are not so “other” after all.