Vasily Glebovich Kaleda
In the January issue, the Journal of the Moscow Patriarchate published the first part of an interview with professor of psychiatry V.
Kaleda, author of the book “Fundamentals of Pastoral Psychiatry.” In it, the doctor spoke about the unfulfilled WHO forecasts and the most serious mental disorders encountered by priests in pastoral practice. In the February issue of the magazine, the reader will learn why psychopathic disorders can lead to crime if you do not pay attention to them, whether social networks contribute to the emergence of mental illnesses, and how a priest can prevent aggression in a conversation with a mentally ill person.
Social media threat or support?
Vasily Glebovich, are social networks capable of influencing the occurrence or development of mental illnesses?
Social networks play a dual role. On the one hand, for people who have problems with communication, they can become a significant support in life. This will sound paradoxical, but when analyzing the problem of preventing suicide among young people, it turned out that thanks to social networks, young people with communication problems find psychological and moral support. In this case, social networks play a very significant social role because they help a person solve such problems.
If a person is mentally healthy, then social networks are not dangerous for him and cannot cause any illness. Although, like live, traditional communication, a squabble on social networks in some cases can push someone to unpredictable actions, and even to a crime (there is a known case when in Volgograd, adult relatives of two schoolchildren quarreled in a parent chat, and one killed the other. Author .).
And if people had a fight on social networks, and then both of them stay awake and think about how to insult and ridicule the other in a more sophisticated way, can this lead to neurasthenia?
Let's just say that this is already a consequence of neurasthenia, and not its cause. If a person is already neurasthenic, then this will manifest itself on social networks. But these problems will undoubtedly make themselves felt during ordinary, live communication with the environment: with work colleagues, classmates, classmates. A social network is just one of the places of communication.
Your book “Fundamentals of Pastoral Psychiatry” writes very interestingly about personality disorders (psychopathy). There are 10 of their varieties. But when you read, you catch yourself thinking that it is written about “my beloved.” So it turns out I'm sick?
This is a standard situation when, reading textbooks on psychiatry, people begin to find all sorts of symptoms in themselves. When my classmates and I listened to a lecture on schizophrenia for the first time at medical school, most of us were very focused and did not pay attention to our neighbors. But then the lecture ended, we looked at each other and smiled: some diagnosed themselves, others diagnosed their neighbors. As for psychopathy, especially many people diagnose themselves or others.
The character of a psychologically prosperous person harmoniously combines very different traits. We can talk about psychopathy (see help) only when the personality is not harmonious, when certain character traits are too sharpened, cause a “distortion” of the personality, and interfere with the life of the person and those around him. In addition, these exaggerated traits determine the entire mental appearance of a person, manifesting themselves in all areas of life: at home, at work, with friends, and at the parish. For example, there are very sociable, hospitable people who easily get along with everyone. There are people who are absolutely self-sufficient, but for them the problem is to establish relationships with others and to join a new team. And when, for example, a child is not able to overcome this isolation, refuses to go to school because he cannot come to class and simply say “Good afternoon”, “Hello, hello” to his classmates, then we have to admit there is a problem. Or when a student refuses to go to college because he is unable to establish communication with his peers.
How can a priest diagnose these traits in his flock and figure out what is normal and what is not?
You can usually feel it. And the priest, as a rule, senses some anomalies in the character of his interlocutor. For example, in front of him is a certain young woman who vividly, colorfully, and with artistic details describes some personal spiritual experiences, some special spiritual states that indicate her exclusivity. How she went to the monastery, experienced something there, gained a unique spiritual experience. And this is a very exalted story. And the priest, most likely, will understand that in front of him is a lady with hysterical character traits. Another case is if a young man stands in front of the priest and finds it difficult to formulate his thoughts; he is shy and behaves very timidly. It is clear that he has different character traits. And if in the first case the lady’s spiritual experiences are not entirely normal and adequate, then in the second the priest must help the young man reveal his experiences.
Guide to action
Vasily Glebovich, thank you for your book “Fundamentals of Pastoral Psychiatry,” which will help priests better understand the mental illnesses of their flock. How did its idea come about and what goals did you set while working on it?
The decision to write the book “Fundamentals of Pastoral Psychiatry” came to me a long time ago, but with this I only fulfilled the behest of my father, Archpriest Gleb Kaleda. The fact is that in 1980, a book by one of the patriarchs of domestic, at that time Soviet, psychiatry, a deeply religious man, Professor Dmitry Evgenievich Melikhov, “Psychiatry, Issues of Spiritual Life,” was published in samizdat. In the preface, my father wrote that the work on it is not completed and requires continuation. And I took these words of my parent as some kind of guide to action. And the final understanding that I had to continue the work of Dmitry Evgenievich came already at medical institute, when I chose psychiatry as my future profession.
Indeed, my book was written primarily for clergy to help them care for people with mental disorders. This decision was made at the Moscow Patriarchate Publishing House from the very beginning. And, taking this opportunity, I would like to thank his staff, led by Bishop Nikolai of Balashikha, who did a lot of work in preparing this book. I wanted to summarize, on the one hand, the experience of my medical and scientific activities, and on the other, the experience of collaborating with priests and teaching pastoral psychiatry at the Orthodox St. Tikhon’s University for the Humanities.
In 2012, you said that in Russia 15.5% of the population suffers from mental disorders, while 7.5% need psychiatric help. And today you give other figures: 15% and 6% of Russians, respectively. Does this mean that the situation has improved?
We psychiatrists have no evidence that there is now a clear improvement in mental disorders. Rather, on the contrary, we need to talk about a certain increase in these ailments due to various stress factors that have been observed in society recently; the number of mental disorders in older people is also growing.
How ready is Russian psychiatry for this challenge?
Unfortunately, for a long time, funding for mental health care in our country was far from a priority and was carried out on a residual basis. Perhaps exactly the same trend occurs in other countries of the world. Therefore, to say that it corresponds to the challenges facing the psychiatric community is probably not entirely correct. And yet, in recent years there have been certain trends towards reform: the emphasis has been on increasing the outpatient level, various day hospitals and reducing inpatient psychiatric care. It is important to make receiving mental health care less stigmatized in the public consciousness. For example, in Moscow, for this purpose, as part of the reforms of psychiatric care, psychotherapy rooms have now been created in district clinics. People began to visit these offices and psychotherapy departments much more often. Therefore, I believe that the idea of bringing psychiatric care closer to general medicine is very promising and important. Recently, the Government of the Russian Federation issued an Order on improving mental health care and developed a specific action plan for 2020-2024. This document was adopted at the end of last year.
From psychopathy to crime
Did I understand correctly, your book should help the priest in solving two main issues: to understand that something is wrong with a person, and to figure out what exactly and how to help him?
Something like this, but with the amendment that the priest is not faced with the task of diagnosing the disease. It is important for him to understand that the experiences a person has are, in principle, painful. And then build further pastoral work with this person: try to devote more time to him, find some encouraging words, advise him to contact a specialist in the field of mental health, a psychologist, a psychiatrist. But you still need to clearly understand: the priest’s task is not just to refer his flock to a psychiatrist, but to try to help him accept the fact that he has a mental disorder, provide him with support in experiencing this sad discovery, show concern for his condition, sometimes call him, asking about his well-being, and in some cases, if a person goes to hospital, and visit him in the hospital. Let me emphasize this is very important. When we talk about mental illness, it is necessary to have a person under joint supervision by a priest and a psychiatrist. Moreover, at some stages of the disease, when the patient has a gross distortion of the perception of reality, the main role is played by the psychiatrist. And in others, when, for example, a person has suffered a psychotic state and is trying to return to his usual life, to recover, the main role is played by the priest, who can help from a spiritual point of view to comprehend the test sent to him in life.
If you don't pay attention to psychopathy, how can this end?
Psychopathy, we talked to you, is a character trait from which the person himself and (or) those around him suffer. That is, this is still an abnormal, pathological character, and therefore these character traits can lead a person to inappropriate actions. For example, the media sometimes talk about cases when a violent conflict suddenly arises between people because of some little thing. Someone at the wheel violated the rules, and in the resulting conflict a high-profile crime is committed, even murder. And completely spontaneously. In this case, it can be argued that the person who commits murder is psychologically unwell, and most likely unhealthy, he has pathological character traits, and cannot withstand ordinary stressful situations. Often people with such pathological character traits begin to abuse alcohol, drugs, and find themselves in some antisocial groups and companies.
"Mood Age"
You specialize in working with young people. What does a priest need to know about depression among young people?
Many modern studies indicate that approximately a quarter of people between the ages of 14 and 25 have experienced a depressive episode at least once[2].
Adolescence, as some classics of psychiatry call it, is the age of mood. When, due to growing up, the characteristics of brain maturation and a certain dissociation of the processes of excitation and inhibition in the central nervous system, depression very often occurs, depressive states that have their own characteristics. They very often do not resemble depression in adulthood. And it is very difficult for parents who do not understand this problem to diagnose depression in a teenager or young man, and often, unfortunately, at this age suicidal thoughts arise, which can lead to suicidal acts.
How can a priest figure this out?
In my book, a separate chapter is devoted to the problem of depression, which describes the symptoms of depression. Depression has varying degrees of severity. There are, so to speak, mild depression, moderate depression and severe depression. And the priest’s task, if a young man comes to him and at some point in the conversation speaks about specific symptoms of depression, is to understand how difficult it is for the young man to experience the sensations he describes. If they are quite pronounced, for example, a person talks about the loss of the meaning of life, the desire to fall asleep and not wake up, specific suicidal thoughts, a feeling of being abandoned by God, his petrified insensibility, then this person already has quite severe depression and needs the help of a psychiatrist. In such a situation, the priest should recommend that the person seek medical help from a psychiatrist.
Who are hyperthymas?
Among the different types of psychopathy, there is a completely unusual type of mental personality disorder, hyperthymic. Such people are called hyperthymic. What's wrong with them?
It would seem that these are happy people, bright, radiant. Hyperthymes are the soul of the company. They are lovers of life, always in a good mood, witty, energetic and enterprising. They are distinguished by erudition, generosity and warmth. They easily get along with people they don’t know well. But at the same time, alas, they are fickle, easily changing hobbies, and you cannot believe their promises, although at first it is almost impossible not to believe them. An important feature of hyperthyms is that, having taken on some serious business, they cannot complete it. You cannot start any labor-intensive, long-term projects with them, especially those requiring perseverance and consistency. Although they can cope quite well with difficult but short-term tasks that require “storm and attack”, which can be entrusted to them at the parish. For example, buy gifts for Christmas, organize a Christmas party. Such a person will organize the Christmas party with a bang and will be an excellent host. But if you ask him to organize and lead the renovation of the temple, hyperteam will be able to come to an agreement with the construction foreman, find the right people, etc., but will not be able to control their work for a long time.
As an example, I’ll tell you about one young man who, as soon as he appeared in Moscow (he came from another city), was accepted into many Orthodox families, and with open arms. Everywhere I found support, warm attention and goodwill. But a little time passed, and the doors of many, many houses where he had been received before were closed to him. Because he promised to help many people in this or that situation, he began to do something, but abandoned everything he was doing halfway. But again, you need to understand that he didn’t do this on purpose. Simply due to his character, he is able to carry out only clear and short instructions, but is not ready to solve complex, time-consuming tasks. This is his misfortune, he suffers from a peculiarity of his character. Therefore, hyperthyms often change jobs. In addition, due to their nature, it is difficult for such people to maintain stable family relationships. They fall in love, they fall in love easily, they are active, emotional, but at the same time divorce is the most common thing in their lives.
Is it possible to help here if a person is aware of his problem, but does not know how to cope with it?
Working with this person is primarily psychotherapeutic; a shepherd can handle this for his part. This is the case when the main role belongs not to the psychiatrist with the pills that he prescribes, but to the priest. This person needs to be taught obedience, help him develop certain, distinct life values, explain what humility is, and start working with him on this virtue. Because, most likely, if a person wants to overcome these characteristics of his character, humility will be in great demand.
We must understand that correcting a painfully distorted character may require a lifetime, as well as significant efforts and help from a sincerely interested person, a living example of how relationships between people can develop differently. Correcting character is always a great investment of effort on the part of all participants in the process. The first stage in this matter is the establishment of trusting, honest relationships. Moreover, even this can take more than one month, and for some types of psychopathy, more than one year. Having achieved the much-needed mutual trust (and only after that), you can try to demonstrate by example and support in a person those forms of behavior that were previously unfamiliar and inaccessible to him, approving and correcting if necessary. For example, let a person of a hyperthymic type feel the value of patience, orderliness, recognition of someone else's authority and leadership.
What role do relatives play in a priest’s work with flocks who have personality disorders? When should you contact your loved ones?
The range of mental disorders is very wide, and if a priest is dealing with teenagers and children, then the main information will be from relatives. The same applies to very elderly people with severe disorders of thinking and memory. But when this is an adult, independent person and his condition does not belong to the group of psychotic conditions, that is, those that disrupt contact with reality, then it is assumed that he himself is able to describe his experiences and states. If he adequately perceives reality and is able to listen to the advice of the priest, the help of relatives is not required. However, it can be useful, having reached a certain level of trust, to agree in advance with the person on emergency measures, for example, to discuss which of his loved ones can be contacted if his condition worsens so much that he loses control over it, and to exchange phone numbers with loved ones. If you cannot find the right words with a person who speaks in confession about some unusual experiences, that he hears voices in his head, that he is being watched all the time, or expresses thoughts about suicide, then the priest should tell his relatives about this.
Basic principles of pastoral work with mentally ill people and their families
Archpriest Vladimir Vorobyov, Ph.D. D., Doctor of Theology Honoris Causa of the Orthodox St. Sergius Theological Institute in Paris, rector of the Orthodox St. Tikhon Humanitarian University, professor:
The document “Pastoral care in the Russian Orthodox Church for the mentally ill” seems to me to be balanced, complete, and revealing of the topic. We need to take a more profound and sensitive approach to the sad situation that has developed in our country due to the century of atheism that has taken place. We have carried out a huge number of reforms in the education system in recent years. Moreover, the officials themselves, including the highest rank, note that these reforms are unsuccessful, have destructive consequences, and have not yielded anything valuable.
This situation is especially striking because despite such an abundance of reforms, the educational paradigm has remained the same - atheism and materialism. With great difficulty, we only managed to create an educational standard on a different basis based on theology. The remaining specialties are moving along an atheistic track. Psychology and psychiatry - in many ways too. Before the revolution, there was a clear understanding that the sciences of the soul are impossible without religion. During Soviet rule, psychology and psychiatry became different. They treat religion as something external. And we need to overcome this splitting.
It is important that attention to religious life is now being mobilized, and cooperation between doctors and the Church is being restored. Earlier, during the years of Soviet power, many psychiatrists perceived faith itself as a form of psychopathology, and some psychiatrists still think so. Personally, I feel the greatest gratitude to our believing psychiatrists - you can always turn to them for advice, send a person for consultation, and they will help. Another psychiatrist will consider any religious patient as a victim of a cult and will begin to treat him “for religion” - this is still practiced. It takes even more effort to finally change the minds of some doctors. Because there are specific cases in my practice when a psychiatrist does not understand the spiritual church life of a patient and this turns into a tragedy. A person's life is simply ruined.
Of course, all people should be loving, careful, and compassionate. First of all, this is expected of a priest. There are a lot of mentally ill people now. We even sometimes call ourselves a “branch of a psychiatric hospital,” because people with mental problems often come to the temple. Psychiatrists also send their patients to us for rehabilitation, and they do the right thing. You begin to think about how to help this particular person. First of all, he needs to be given a job. Which one? For example, cleaning the church. But here another problem arises: a mentally healthy person comes to the temple for the first time, and then he is met by a large group of crazy cleaning ladies.
It is important that the patient feels in the confessor fatherly care, love, understanding, compassion, and is disposed to trust. He must definitely feel the reliability of this relationship. That here, finally, he can be completely calm, here he will not be deceived or disappointed. It is important, of course, that the patient does not have aggression. Someone has to be calmed down. The path of a priest is a ministry of peace and love.
We must always try to include a person in the life of the community so that he is accepted as one of our own, even if he is sick. It’s like a family here - many families have sick children, and they are not kicked out. On the contrary, both parents and older brothers and sisters tinker with them even more carefully - this is useful for them themselves. In the same way, in a community where there are sick people, you need to remember them and take care of them. But there must be contact with a doctor. It is ideal if there is a psychiatrist in the community. Sometimes patients cannot control themselves, and then it is very important to build them some kind of rails along which they will move in their difficult life, without leaving the given trajectory. This is a kind of prosthesis - if a person does not have a leg, then with the help of a prosthesis he will be able to walk. Likewise, if there are problems with self-control, external boundaries can help. And they need to be clearly defined: this can be done, this cannot be done. This greatly helps those suffering from mental illness and builds their lives. Strictness, certainty and responsibility are necessary in dealing with them.
The relationship between the pastor and the patient should be natural. There should be no pretense, no need to pretend anything. Let everything be simple and clear. “So what if you’re sick? We are all sick in one way or another." Sometimes mental patients come and say that they do not want to take the drugs prescribed to them. “Why don’t you want to? - I say. – I have my own illnesses, so I take a whole handful of pills every day. If I don’t drink them, it will be worse for me.”
An important and difficult point is the relationship with the patient’s relatives. Even Saint Ignatius (Brianchaninov) noted that the parents of a sick daughter or sick son usually cannot accept that the child is sick and they just need to think about how to continue to live with this illness. They continue to fight, but precisely by insisting on denial. I have seen many such examples in my life: for example, a child has been diagnosed with mental retardation, but they continue to teach him. You tell them: “Because of his illness, he cannot study!” - “How will he live without a diploma?” “He doesn’t need a diploma, he won’t be able to work.” But relatives do not understand this or do not want to believe it. Apparently, the love of a loved one prevents you from adequately perceiving the condition of your child.
It is very important for the priest to try to establish contact with the patient’s relatives and somehow orient them towards a sober perception of what has been committed. This requires both persistence and commitment from the priest; he often has to spend a lot of time and effort on a specific case. It seems that during this time you can have time to communicate with ten healthy people. The main problem for a priest is that a sick person requires much more attention than a healthy parishioner. That is why priests often do not want to deal with the sick.
Bishop Panteleimon, Chairman of the Synodal Department for Church Charity and Social Service, before my eyes, significantly advanced the work of priests in caring for psychiatric hospitals. It is extremely difficult to minister in these hospitals. But now many priests regularly go to psychiatric hospitals. It is necessary that this service be a feat for the priest, which he would take upon himself, without shying away from this bearing of the cross. It is necessary to call for this, to explain the features of this ministry.
It is important for psychiatrists themselves to talk more about spiritual life. I had the good fortune to communicate with D.E. Melekhov. I sent some of my parishioners to him. I once attended his consultation. To the question addressed to him by patients, what kind of life should he lead now, Dmitry Evgenievich answered very simply: “Humble people do not suffer from mental illnesses, especially when it comes to severe pathologies. And if some acquired disorder has been diagnosed, then it is through humility that one can get rid of it.” Correct spiritual life alleviates the condition and often completely heals the mentally ill. It is in this direction that we need to work with mental patients, to guide them towards acquiring humility. Although it is difficult, with God all things are possible. This is what we do from confession to confession. I believe that the factor of spiritual life is largely decisive. The psychiatrist must cooperate with the confessor. We must help the suffering soul together.
Unbearable burdens
Could you explain how to distinguish painful manifestations in a person’s desire for salvation, when his spiritual and physical exploits should alert his confessor and loved ones?
The most important criterion for a normal spiritual life is the desire for spiritual growth. But spiritual growth is impossible without a person’s readiness to cultivate humility, love for others, and readiness to patiently endure the trials sent by fate. Any spiritual work is possible in the Church only under guidance, only through obedience. I think the most important criterion here is whether a person performs his spiritual work under the guidance of a confessor or at his own request, ignoring the advice of a confessor. One can recall the great ascetics of our Church; they always accomplished their feats under spiritual guidance. If a person does not listen to the priest from whom he is cared for and who has taken responsibility for him before God, but acts of his own free will, imposing on himself “unbearable burdens,” then we can assume that he has some kind of mental disorder.
One should also be wary of the fact that the desire for spiritual achievements manifests itself somehow abruptly and unexpectedly. It’s one thing when a person strived for God all his life, walked in small steps and towards the end of his life, already in adulthood, approached strict asceticism; This is within the generally accepted norm in Orthodoxy. And it’s completely different when this strong desire for asceticism appears suddenly, especially among young people.
Moreover, he does not hear or does not want to hear respected, more spiritually experienced people, ignores the concerns of his parents, does not want to listen to anyone, rushing towards the horizons of spiritual perfection that they themselves have set. But the fruits of true spiritual activity are love for one’s neighbor, which, unfortunately, is not observed in this case. There are cases when people, having taken upon themselves the feat of intense prayer and fasting, passed away. I remember a young man who died of exhaustion, having been admitted to the hospital in a very serious condition, he was on a drip, but it was too late. Neither the priest nor his relatives were able to understand in time that something abnormal was happening to the young man.
Unfulfilled forecast
Ten years ago, WHO predicted that in 2021 depression[1] would take first place in the morbidity structure. It will affect 60% of the world's population, and mortality from severe depression will take second place among the causes of suicide. Has the prophecy come true?
Fortunately, no. Although depression is indeed quite common. But at the same time, in recent years, the detection of mental disorders, in particular depression, has improved. Previously (we are talking about a period of about 40 years), if a person found himself in severe depression, they often did not understand what was wrong with him. It was believed that he simply could not or did not want to pull himself together. But today in society as a whole there is an understanding that depression is a serious illness. By the way, along with the detection of cases of depression in our country over the past 10 years, the number of suicides has also noticeably decreased. 20 years ago it was approximately 38 cases per 100 thousand people (about 60 thousand people per year), that is, the population of an entire city. And according to data for 2021, the number of suicides is approximately 11.6 per 100 thousand people (16,983 people per year).
In your opinion, why are the number of people suffering from depression increasing?
There are many reasons for this. In recent years, these have been stress factors, i.e. various stresses. These could be: divorce, death or serious illness of a loved one, disability, dismissal, conflict at work, general socio-economic uncertainty. In addition, people who live in large and noisy cities are more exposed to various types of stress and are not always ready to overcome their consequences. As a result, various neurotic disorders arise, including those from the spectrum of depression. Life expectancy increases, people age, and with age, due to the biological characteristics of brain aging, a significant number of people experience late-life depression.
I would like to remind you that the most important favorable factor that protects us from depression is family. In a family we feel more protected. And the fact that recently in the modern world there has been a loss of family values also, undoubtedly, leads to an increase in depression. The main thing is that many modern people lack clear life values and lack a formed worldview. This most holistic worldview, undoubtedly, is a religious worldview, within the framework of which a person has a clear understanding of the meaning of his life, the purpose of the suffering that befalls him. Therefore, believers, religious people, and this has been shown, by the way, in modern scientific research, turn out to be more stress-resistant. And the severity of their depression is much less than that of people who do not have a religious worldview.
Could you give a vivid life example of depression in a believer?
Yes, this is the suicide of Bishop Ioannikiy (Efremov) of Belgorod, whose life was tragically cut short in 1914. This case clearly proves that depression is a very serious medical problem, which can also arise in a deeply religious Orthodox person and sometimes manifests itself very severely. When you read his biography, you get the feeling that he is a real devotee of piety. He was the son of a priest, from childhood he strove to serve the Church, graduated from the seminary, and then performed various obediences. He was the rector of the Kyiv and then Tver theological seminaries. In 1905 he became Bishop of Belgorod, vicar of the Kursk diocese. And thanks to his labors, Bishop Joasaph (Gorlenko) of Belgorod was canonized. Bishop Ioannikiy collected a large number of notes from people who asked to pray at the grave of Joasaph, compiled and took part in distributing the akathist, and was one of the most prominent admirers of the memory of Bishop Joasaph; he was a real man of prayer. But at some point he suffered from severe depression. He retired and lived in the Nativity Monastery in the city of Putivl in Ukraine. As far as we know now, the melancholy that he experienced is accompanied by severe mental pain, it is perceived as physical pain in the region of the heart and is described in classical textbooks on psychiatry as precordial melancholy. The Optina elders were shocked when they learned that he had committed suicide. They said that this event “goes beyond all the limits we can see,” but at the same time it was clear to everyone that the man suffered from a severe mental illness. His body was placed in the church, covered with a bishop's mantle, and the funeral service was performed according to the bishop's rite. This event caused shock among the entire Russian Orthodox clergy. And although we are talking about depression in a deeply religious person, its influence on the psyche does not decrease because it has its own patterns and its own manifestations. And people who have suffered this severe melancholy say that it is stronger than a toothache.
For people of faith, a special manifestation of depression can often be a feeling of sinfulness, which acquires an inadequate character according to the degree of its manifestation. The symptoms are as follows: a person often complains of a feeling of being abandoned by God, a feeling of petrified insensibility, a feeling that he is praying, but is not receiving any response. Sometimes you even hear this from those who begin the Sacrament of the Eucharist. These sensations are characteristic of people who are deeply religious and in a state of depression. That is, such symptoms should tell the priest that a person has some kind of deviation. And, taking this opportunity, I want to emphasize that it is precisely this type of mental disorder, such as depression, that priests most often have to deal with today.
A special case
But communication with people with mental disabilities sometimes ends tragically for a priest. How to prevent such an outcome of a confession or conversation?
Unfortunately, there are no simple and reliable ways to prevent this. However, one must understand that the risk in this case is no greater than facing the aggression of mentally healthy criminals. The general rule when communicating with mentally ill people is not to provoke aggression by indiscriminate denial of their experiences, outright (and even more so rude, tactless) contradiction, enthusiastic argument or ridicule. It is better not to enter into arguments, let alone a squabble, to agree with something, to give in. You just need to nod: yes, yes, yes, okay, I see how hard it is for you, scared, probably very unpleasant when everyone around you doesn’t take you seriously, etc. As a rule, these people are in a state of delusional disorder, which is characterized by false inadequate conclusions. They arise on a painful basis and cannot be corrected. But the main thing here is to understand that, no matter what crazy state the patient is in, he perfectly feels how he is treated. With attention, respect, a feeling of love, a desire to help, or dismissively and mockingly. That is, first of all, we must try to share the emotional state of the patient, showing sympathy for his emotional experiences, but not necessarily focusing on their content. This is one possible scenario.
Another is when a crazy person commits a crime. One of the most famous examples is the murder of Pskov priest Pavel Adelgeim in 2013. This is a very clear case of incorrect behavior of the immediate environment of a mentally ill person. It is known that the killer (Sergei Pchelintsev) suffered from schizophrenia, he had auditory hallucinations and delusions of influence. And instead of organizing treatment and hospitalization in a psychiatric hospital during the period of exacerbation, they organized a trip for him to Father Paul, in the hope that the priest would help him with his kind words. Unfortunately, Father Pavel, despite his pastoral and life experience, also made a mistake. Apparently, he decided that he could find the right words for a person who is in acute psychosis. This is impossible. In a psychotic state, a person is completely in his inner world and is almost unable to perceive anything from the outside, and if he does perceive, he weaves it into his delusional plot. It was necessary to call an ambulance and forcibly admit the patient to a psychiatric hospital. The tragedy happened on the third day of Sergei Pchelintsev’s stay in the house of Father Pavel. This can be considered an example of a complete misunderstanding that there are mentally ill people who need serious treatment, and not a single famous priest can heal them with his word. Unfortunately, this tragedy is not isolated. There was a tragedy in Optina Pustyn in 1993 (triple murder. Author). There was the murder of Abbess Vasilisa (Bear) in 2021. Psychiatrists have also repeatedly become victims of their patients.
It must be understood that clergy (like other public figures and representatives of helping professions) have a special risk of being drawn into a delusional system and becoming the object of the patient’s psychotic experiences. You have to be prepared for this and try not to lose composure and as the highest degree of compassion for the unfortunate person. And yet, think in advance about options for behavior in an extreme situation. Up to the presence of an alarm, panic button, special applications on a mobile phone, etc.
Is there already any information about the impact of COVID-19 on the onset or progression of mental illness?
Yes, work is underway to collect and systematize such information. Many people who have had this infection experience anxiety and cognitive disorders (thought disorders). Many reported depression during their illness. One of my friends, very active, cheerful, always cheerful, suffered severe depression during her illness and admitted that at that moment she had suicidal thoughts. Moreover, she herself is a psychiatrist, now retired.
Some describe the appearance of a state of irritable weakness after an infection (this is part of a depressive state with unmotivated aggression towards the people around them).
Why are there practically no living, visual examples from your practice in the book?
My book is called “Essentials of Pastoral Psychiatry”, there is supposed to be another publication called “Pastoral Psychiatry”. In it I plan to collect the most striking excerpts from the medical history for each situation under consideration. True, it will be one and a half to two times larger in volume.
Interviewed by Alexey Reutsky
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In his practice, the priest communicates and provides pastoral assistance to people who have a difficult character, from which they themselves and those around them suffer. Such pronounced character anomalies are traditionally called psychopathy (personality disorders). There are more than 10 types of psychopathy, each of them has both specific features characteristic only of it, and common to several types. The most common types of psychopathy are: schizoid, hysterical, narcissistic, hyperthymic, anxious, impulsive, anancastic, borderline, constitutionally depressive, masochic, dependent. Read more about these personality disorders in the book by V.G. Kaleda “Fundamentals of Pastoral Psychiatry.”
Part 1
March 20, 2021 Source: Patriarchia.ru
Practical Guidelines for Church Care for the Mentally Ill
Professor Grigory Ivanovich Kopeiko, Deputy Director of the NCPC:
Let's consider the main indications for referral to a psychiatrist, i.e., the so-called emergency conditions of psychiatry. Most often, we doctors encounter depression. As a rule, 80% of mentally ill patients have this disorder. This can be moderate or severe depression with a pronounced feeling of melancholy, hopelessness, despair, especially if delusional ideas of self-blame, sinfulness, low value, impoverishment, auditory hallucinations appear, which may or may not correspond to the mood. Progressive states with so-called anti-vital thoughts, when a person thinks about death: how to commit suicide (suicidal thoughts). For religious people, as a rule, these states are experienced as abandonment of God, “petrified insensibility,” loss of the meaning of life, loss of hope in God’s mercy. This can be expressed in removing the cross from oneself, or in other similar actions. Such conditions require joint management of the patient by a priest and a psychiatrist. How to do it? The priest can carefully advise during confession: “You know, regarding what you are telling, there is a need to consult a doctor.” If a person is more conscious and understands that he is mentally ill, we can say directly: with a psychiatrist. Or you can invite relatives for a conversation and carefully say that a consultation with a psychiatrist is needed. There is such a depressive state as anxious raptus, it is important to notice it in time - with it a person rushes about, does not find a place for himself, and is in motor agitation. More often this pathology occurs in the elderly and senile age. Here, too, emergency psychiatric care is needed, including calling a psychiatric team to the temple, if this condition is detected in a given place.
It is imperative to consult a psychiatrist if there are “voices” both “inside the head” and outside. Especially if these conditions are repeated and long-lasting. This does not mean that the patient just heard a shout on the street, but that he constantly hears voices. They can disguise themselves so that he hears, for example, “the voices of Angels” or, conversely, “demonic whispers and demands.” We had one patient who said that she heard “the voice of Christ.” Delirium cannot be cured by any words, by any authority - delirium can only be treated with medicine. She was completely convinced that Christ Himself was speaking to her. And only after a long treatment at some point she said: “You know, Christ told me: “Take a knife and kill yourself in the heart,” then she realized that it was not Christ, but a disease. Auditory hallucinations - most often they are verbal - definitely require consultation with a psychiatrist. These hallucinations can praise the patient: how wonderful he is, how capable, how smart, and tomorrow demand: “jump out the window” or “rip your stomach open.” Most often, this is exactly how this transition from flattery to the command to destroy oneself occurs - with certain adjustments for mood, etc.
The next state is characterized by the presence of delusional ideas of special chosenness, messianism, and prophetic service. We had a patient who said: “I am the prophet Elijah, I came to announce the end of the world...” Or these could be ideas of persecution, but persecution, as a rule, comes from enemies who want to kill a person. Such patients make contact with a doctor because they are fleeing persecutors. Persecutors are traditionally the FSB, CIA, aliens, etc. Ideas of influence, when patients say that they are influenced by some kind of apparatus, or hypnosis, or something else, in more complex cases. Now work on a dissertation under the direction of Vasily Glebovich Kaleda on this topic is just being completed. Sometimes patients feel that a demon has entered them. These are patients with schizophrenia with special hallucinations of the so-called general feeling. Such conditions, of course, greatly frighten priests. Endless reprimands begin, the use of holy water, magic circles, the patients themselves somehow manipulate salt in order to expel the demon from themselves. Sometimes similar conditions arise among residents of monasteries. We had a monk from one of the northern monasteries who was convinced that there was a demon inside him that was strangling him from the inside. This story ended badly, he died - despite the course of treatment. For some reason he stopped taking his medication. These states with influence, with hallucinatory manifestations, with feelings of unreality, adjustment of the environment, or the so-called states of insight, insight, clairvoyance, which continue for a long time, also require consultation with a psychiatrist.
Conditions with refusal of food and water. In one of the monasteries we came across a young man, he was a laborer, no one really watched him: if he comes to a meal, he will come, no, no. The confessor did not know where and what he was doing when he was absent from the common meal. It ended with him having obsessive thoughts about his own sinfulness. To fight sin, he stopped eating, for three months he ate practically nothing, only drank water and could only eat bread. The first to sound the alarm was his mother, who was a thousand kilometers away, because he stopped answering her calls. When she arrived, he already had hunger swelling - like in besieged Leningrad, when people were swelling from hunger. When he was hospitalized, we connected him by mobile phone with the priest to whom he confessed, but it was useless; in this state, patients no longer listen to their confessors at all: “The confessor is wrong, he doesn’t understand...” The doctors in the intensive care unit suffered a lot with him. He died of cerebral edema. Not only were the arms and legs affected, but the brain also became swollen and death occurred. It was not possible to save this man. Such people lose obedience to the priest, confessor, and in relation to their own religious life they have an incredible conviction that they are right, which does not correspond to their spiritual and life experience in general. Their “ascetic deeds” go off scale to the levels of the ancient patericons, while they themselves have only been in the Church or somewhere close to the Church for only a year or two.
The following conditions that definitely require consultation with a psychiatrist are, on the contrary, pathological mood swings, so-called mania, which are expressed in reckless behavior. At the height of mania, patients are not capable of purposeful conscious activity. They are in chaotic activity, do not sleep at night, and eat little. This is a state of acute excitement, which, according to the international classification, lasts at least a week. A priest can see a person in this state, although such people are unlikely to go to confession, because they overestimate themselves, they feel like superhumans who can do anything, they have constant revelries, endless projects. It often happens that an exemplary family man, falling into such a manic state, begins to find himself many extramarital affairs. This condition requires medical consultation.
A “softer register” is obsessions of various kinds: for example, pollution, which is accompanied by ultra-frequent hand washing, various double-checks, etc. We also encounter thoughts of blasphemous content in the religious department of our Center. Patients have some blasphemous, offensive thoughts when they go to church and venerate a shrine - an icon, relics, approach communion - at this moment thoughts begin to swarm in their heads in the form of obscenities, thoughts can become confused, etc. d. Patients are very scared. These conditions also require consultation with a doctor. As a rule, what is happening is not necessarily connected with a religious plot, it can be panic attacks, for example, with the fear of dying - the so-called thanatophobia - when it seems that the heart may stop, bronchospasm will occur, etc. There is also a fear of going crazy - the so-called psychophobia. In these conditions, a person also requires medical attention.
And finally, we will consider the difficulties encountered in elderly and senile people, when progressive memory loss begins, a decrease in intellectual abilities, loss of professional and self-care skills, and impairment of speech and motor abilities. Some time ago, a professor of mathematics came to us; he once, being in intellectual shape, brilliantly, as they say, on the fly, extracted mathematical formulas during a conversation, made the most complex calculations in his mind. But gradually he began to develop late-life dementia, Alzheimer's disease - he began to forget what he once knew, which was always at his disposal. In some cases, we can only suspend some processes, not cure, as in the case of depression, but only slow down the development of the dementing process. Five to seven years later, I found out that he was in one of the monasteries, where we found ourselves on a pilgrimage trip, I asked to be called, but he came out... a completely different person - forgive me, I will say rude words - but we have already seen dull facial expression, absent look. The matter ended in such a way that he was sent home from this monastery to his relatives.
A doctor once told me that one day a priest came to a ward for elderly patients and gave communion to everyone who was there. Suddenly she sees her grandmother sitting in the corner and crying. The doctor approached her: “What’s wrong with you?” - asks. - “The priest doesn’t want to give me communion.” She goes to the priest, and the priest: “Yes, I just gave her communion, five minutes ago!” These patients have no memory for current events. These are late-life dementias.
The following conditions usually concern young people - this is, first of all, pathological confidence in one’s own ugliness: ugliness of the figure, moral, and intellectual abilities. Often such patients, often girls, restrict themselves in food in order to lose weight and bring themselves to the point where they begin to have hormonal disorders - hair falls out, menstruation disappears. With successful treatment, the situation can be corrected. We had one patient who suffered from this condition since she was 18 years old. She came to us at the age of 30. We treated her with psychotropic drugs and then sent her to an endocrinologist. She recovered. These conditions are also called anorexia.
Finally, it is necessary to mention previously uncharacteristic episodes of asocial and antisocial behavior. Desire disorders, theft, vagrancy, drug addiction, alcoholism, sexual perversions. Sometimes, in some cases, depression is hidden under this, doctors begin to treat depression in such a patient, and suddenly his craving for drinking goes away. Or, for example, a child runs away from school, and this is also one of the manifestations in this case of childhood depression. This condition also requires attention. Intimidating those who run away from lessons, threatening them, beating them - as parents sometimes do - is not the solution. Father Vladimir Vorobyov told how a boy in their parish constantly stole. “What have I done with him,” said Father Vladimir. “I tried to persuade him and reassure him, once I even put him in front of everyone in the temple so that he would confess his sin of theft in front of everyone.” But all this does not help - we need medicine.
The next condition, also related to childhood, is a lag in intellectual development, which leads to disruption of adaptation, normal social behavior, untimely development of self-care skills, motor skills, inappropriate behavior in kindergarten, at school, and academic failure. This ranges from mild forms of mental retardation to severe forms of mental retardation. These conditions also require the help of a doctor, medication, and various psychological activities with these children. When they are trained, unlike older people, the results are still quite good: they begin to speak, and they are somehow able to adapt. Usually they are then granted disability, but in most cases such people can take care of themselves.
Another point that requires discussion is the so-called psychomotor agitation, which can be of different nature - when there are hallucinations, delusions, and some kind of depressive state. The patient is observed to be violent. Here you also need the help of a doctor.
The last one is about involuntary hospitalization. Since not everyone here is psychiatrists, and the publication is addressed to a wide range of readers, I wanted to dwell on this a little. It is often said that psychiatrists immediately grab their patients, turn them into vegetables, etc. There is a law on psychiatric care and guarantees of the rights of citizens when providing it. Forced hospitalization is possible only if the person’s mental state poses a threat to himself, that is, he tried to commit suicide, he was pulled out of the loop, he is alive, a special psychiatric team must be called and treated; or he poses a threat to others - he runs after someone with an ax or a knife, etc. I had such a patient with severe delusions of attitude, he was convinced that everyone around him wanted to kill him. When he had to go out to the store to buy cigarettes, he took an ax with him. If someone had approached him in the wrong way, he would have used this ax. This is the second reason for forced hospitalization - a threat to others. The third reason is that if the patient is not hospitalized, his disease will progress: these are, first of all, elderly dementia patients who have no relatives. If they are left like this, then after a while they will no longer be able to serve themselves, and this condition will lead to death. There are certain rules, I will not list them: a commission must meet for an examination, then again after a certain time the hospitalized person is examined, etc., then a representative of the court comes, and all this is discussed.
I will conclude by commenting on some of the points made in previous reports. Father Vladimir Vorobyov noted that in churches, mentally ill people seek help and support for themselves - they get a job, for example, as cleaners. At the moment, neither churches nor monasteries are equipped to accept mentally ill people and be full-fledged rehabilitation centers. It's none of their business. We need special rehabilitation centers with qualified personnel, as well as specially trained priests. Separately, there is the issue of drug supply, etc. Otherwise, all this could result in tragedy. Have the candlesticks been wiped down and all the problems have been solved? – this is the creation of a certain illusory appearance of something that requires a different professionally responsible approach.
Regarding whether we are mistaken in optimism when ordaining those who have experienced certain episodes of mental disorders, as Father Pavel Khondzinsky spoke about, I can cite the following case. When we first organized our religious department, Father John (Krestyankin) sent us from the Pskov-Pechersky Monastery a young man who had previously been in a psychiatric hospital for several months and underwent quite serious treatment there - insulin therapy, etc. However, Father John, a highly respected man with extensive experience and the gift of reasoning, believed that this problem could be solved. And even more so in relation to fairly mild erased states. The fate of each person must be decided individually.
We also treat priests of different hierarchical levels in our center, and they continue to carry out their ministry. So you shouldn’t be afraid of the disease itself or, especially, of turning to psychiatrists. It’s just important to constantly be in contact with your doctor and maintain this connection.
Recorded by Olga Orlova
Photo: Alexander Erofeev
Godless thoughts
What characteristics can a believer have a disease associated with the appearance of obsessive thoughts that begin to dominate a person against his will?
This is the so-called obsessive disorder, or obsessions (neurotic spectrum diseases) (see help), among which the so-called contrast obsessions stand out. They are accompanied by involuntary, unwanted, irresistible thoughts in a person, which are completely unacceptable and unnatural for him. For example, an obsessive thought arises to push someone under a train on the subway, a mother has the thought of taking a knife and inflicting a wound on her child. And among believers, blasphemous thoughts arise: blasphemy against the Holy Spirit, church sacraments, the thought of desecrating an icon, etc.
In my practice, there was a case when one of my patients, let’s call him Sergei, came to the priest and said that blasphemous thoughts often appeared in his head, blasphemy against the Holy Spirit (an insult to one of the hypostases of the Holy Trinity). The priest replied that everything would be forgiven to the person except blasphemy against the Holy Spirit, and he could not accept confession from this unfortunate man. Hearing this, the young man came home and decided to commit suicide (but, thank God, the attempt was unsuccessful). Sergei was a believer, but he compared his state of mind to hell on earth. Therefore, at that moment it no longer mattered to him where he would experience hell in this life or after death.
How could the priest help here?
The priest needed to accept his confession, but at the same time tell Sergei that these were not his thoughts, that they were a manifestation of the disease. And the main thing in such a situation is not to fight them, but to ignore them. You need to distance yourself from them, try to switch to something else. Explaining that the more neutral a person is towards obsessive thoughts, the less and less often they will appear in his mind. And that their appearance in a person is in no way a manifestation of his impiety, is not a sin. And it is never implemented at the level of specific actions. Such thoughts are more likely to reflect a high level of anxiety or extremely rigid moral attitudes, a desire to be a “perfect believer.” And, given that Sergei was in a psychiatric hospital several times, advise him to see a psychiatrist.
We have talked so far about the conditions when mental health care is available. What if a priest serves at the “ends of the earth” and faces one of the problems discussed, but in an acute phase? What should he do if the situation is really ripe?
The abbot of the Transfiguration Solovetsky Monastery, Bishop Porfiry, once told me a case when one of the workers in their monastery experienced an exacerbation of a mental disorder. They called a plane, the person was evacuated to the hospital, where they provided all the necessary assistance. Therefore, even if the situation is already at an acute stage, then in our country, always and everywhere, in any region, even if it is an island in the White Sea, psychiatric help is still available, because there is an air ambulance for this.
