Should we be making a differential diagnosis?
Christians have held many different views on how we should apply New Testament accounts of demon possession (or 'demonisation') to the construction of a contemporary understanding of spiritual and mental disease. Following the enlightenment, and particularly within more academic or scientific circles, it has been popular to 'demythologise' the Gospel stories of demon possession Anthropologists, psychotherapists, psychologists and psychiatrists see beliefs about demonology as being culturally or socially determined explanations for problems which can otherwise be fully explained in sociological, psychodynamic, psychological or psychiatric terms. However, many Christians (particularly in some charismatic circles) still believe that demons really do exist as actual spiritual entities, and that they can adversely affect or invade the lives of men and women today.
It is not possible here to provide a full coverage of this subject. The interested reader is encouraged to read Roy Clements' brief but excellent Cambridge Paper, 'Demons and the Mind', or else the book 'Demon Possession' by John Montgomery, which provides a multi-disciplinary, perspective on the subject. However, a particular aspect of this problem is of very practical relevance in medicine - and especially in psychiatry. Should we see demon possession (or 'demonisation') as being a differential diagnosis for certain kinds of mental disorder. or should we see it as being an alternative, perhaps redundant, explanation for such disorders? Alternatively, and this point has recently been argued particularly cogently by Roy Clements, should we see demonic influence as being a neglected aetiological factor within a multifactorial model for the aetiology of mental disorder?
Before giving consideration to the Gospel accounts of demonisation, it is interesting to reflect briefly on some of the general issues concerned here. For example, how did Jesus respond to the erroneous scientific views of His time? We have no account of Jesus ever trying to correct prevailing beliefs that the earth was flat. He does not seem to have engaged with Luke in a dialogue about the aetiology of any of the illnesses that He healed. Of course, His mission was not to interfere with the scientific accumulation of human knowledge about the world and the universe, but to win back those who were spiritually lost because of sin. We presume, therefore, that He shared our human limitations in terms of His understanding of other matters. To 'go along with' prevailing errors of a medical or scientific kind was not dishonesty, but rather a sharing of our human limitations.
When we consider Jesus' understanding of demons, however, it is really not satisfactory to suggest that He was limited by a lack of scientific knowledge. Demons, if they exist, are spiritual beings and Jesus came to bring spiritual truth. Surely, He would not accede to erroneous views regarding the influence of evil in human lives? Furthermore. the Gospels provide evidence that Jesus actually saw the casting out of demons as a part of His mission on earth (eg Lk 13: 32), and that He made it a part of the mission of His disciples (eg Lk 9: 1). We must, therefore, be very hesitant to accept any idea that Jesus was simply acceding to, or actively colluding with, a primitive misconstruction of the nature of mental illness. In any case, elsewhere, the Bible suggests that Hebrew culture did indeed have an understanding of mental illness as being separate and different from demonic activity or human evil (eg 1 Sa 21: 13).
If mental illness and demonisation are not simply different names for, or different models of understanding of. the same thing, then we are left then with two possibilities. Either they are unrelated phenomena, or else there is some kind of association between them. Of course, even if they are unrelated, they may stilt be confused with each other because of superficial similarities. If they are related, however, we need to understand the nature of the connection between them. Thus, we may be faced with a differential diagnostic problem. Either we need to distinguish which of these two entities we are dealing with, or else we need to identify which is the primary problem which led to the other as a secondary 'complication' . Alternatively, perhaps we may need to identify a third, independent, variable which gives rise to both demonisation and mental illness.
Demon possession: Biblical and Contemporary Presentations
In order to answer some of these questions, we need to turn to the New Testament accounts of demonisation. Jesus clearly cast evil spirits out of many people who He met (Mt 4:24, 8:16; Mk 1:32, 4:41). However, we are told about 6 cases in some detail:
The demon possessed Gerasene(s): Mt 8:28-34; Mk 5:2-20; Lk 8: 26-39
A demon possessed mute man: Mt 9:32-34; Lk 11:14-26
A demon possessed blind and mute man: Mt 12:22-28
The Canaanite or Syro-Phoenecian woman's daughter: Mt 15:22-28; Mk 7:25-30
An epileptic boy: Mt 17:15 -21; Mk 9:14-2 9; Lk 9:3 8-43
The man in the synagogue at Capernaum: Mk 1:21-28; Lk 4:33-36
From these accounts. we may see that there is a diversity in the presentation of demon possession. The demon possessed Gerasene showed enormous strength, cried out loudly, engaged in deliberate self-harm, and immediately recognised Jesus as the Son of God. Others were mute, or blind and mute, or epileptic. We must, therefore, be wary of imagining that there are invariable and characteristic signs or symptoms of demonisation. We must also, apparently, look out for demonic influence in the neurology clinic as well as in the psychiatric clinic. Clearly, differential diagnosis along traditional medical lines is going to be a very difficult if not futile exercise, even if we accept the Biblical accounts as providing a comprehensive picture of the different possible presentations. In fact, it would appear more reasonable to argue that the Biblical presentations are so diverse that they probably represent just a small proportion of the full spectrum of possibilities. It would seem, therefore, that the exercise of a spiritual gift (1 Cor 12: 10) would be likely to be more useful than the application of medical knowledge when a person is demon possessed, although a knowledge of psychiatric illness is undoubtedly of value in continuing the diagnosis of a psychiatric illness when one is present.
The relationship between demonisation and mental illness
Why, then, is psychiatry particularly thought of as being the area of medicine in which demon possession is most likely to be encountered? It is true that behavioural disturbance, and deliberate self harm, such as that presented by the Gerasene, might also accompany psychiatric disorder. In fact, the range of possible differential diagnoses in this case is probably quite wide. In the other Biblical cases, loss of sight or hearing, and epilepsy, could all have an hysterical basis rather than being due to a neurological diagnosis. Roy Clements has also suggested that the voices reported as those of demons might be the alter-egos of multiple personality disorder. (It is worth noting, though, that this is a contentious diagnosis, which is rarely made in the UK at the present time). However, there are no scriptural accounts of demonisation which sound particularly like schizophrenia as we see it today. Furthermore, there is every reason to believe that most prevalent psychiatric disorders may have more to do with environmental stress, psychological or biological vulnerability, and social deprivation rather than the influence of evil spirits.
In the lay mind, some accounts of demonisation (notably the Gerasene) do present a very convincing example of 'madness' . However, I believe that there is a danger that we look for demonisation amongst those who are psychiatrically ill for a variety of reasons which do not have a basis in their similarity with the description of demon possession as found in the Gospels. Psychiatric patients, especially those who are psychotic, behave, speak and think in ways that we find difficult to understand. We therefore struggle to find an explanation for their experiences, and if science does not have convincing answers, then we look elsewhere. Not only this, but we find the behaviour, speech and thought of these patients frightening, both because of what they might do to us or others, and because of the recognition that 'there but for the grace of God go I' .
As Christians in psychiatry, then, we have an important responsibility. We need to be informed of the findings and limits of psychiatric research, so that we can offer rational scientific explanations and treatments for psychiatric illness, where these exist. We need to bring healing to, and show love and care for, patients with stigmarising mental illnesses, just as Jesus showed compassion for those who were stigmatised by physical illness (eg Mt 8:1-4). However, we also need to recognise that not all human problems will be explicable by medical science. The New Testament tells us that Jesus has commissioned us to ' drive out demons' (Mk 16:17), and we must be ready to respond to this commission if and when we are called to do so.
Psychiatry, then, is not the only domain within which we need to be aware of demonic influence, and perhaps it is not even the most important such domain. Furthermore, we cannot expect to make a simple differential diagnosis according to certain signs or symptoms of demonisation. However, this does not exclude the need to consider other possible links between demonic activity and mental illness.
We recognise that psychiatric illnesses, and also a wide range of so-called 'somatic' disorders, are of a multifactorial aetiology involving psychological and social, as well as physical components. Why, then, should not spiritual factors also play a part? For example, if people can become depressed because they are bereaved, or because of physical illness, why should they not also become depressed because of demonic interference in their lives? Thus, we must keep in mind a truly holistic view of the human condition, which involves spiritual, as well as psychological, social and physical dimensions.
Psychiatrists are particularly familiar with assessing the physical and social, as well as the psychological, aspects of their patients lives. Like other doctors, they need to ensure that they do not neglect the spiritual dimension of life. However, I am not convinced that psychiatric clinics are particularly full of unrecognised demonic influence. Neither is the recognition of demonisation a question of medical differential diagnosis, although a psychiatric assessment may sometimes assist the non-medical minister to avoid attributing a primary psychological disturbance to demonic activity. Rather, I believe, that we may encounter demonic activity in all walks of life, just as Jesus did. If, and when, we have such an encounter, we can be confident in His authority over such matters - an authority which He has delegated to us.
Demon Possession and Mental Illness: Conclusions
Demon possession and mental illness, then, are not simply alternative diagnoses to be offered when a person presents with deliberate self harm or violent behaviour, although they may need to be distinguished in such circumstances, whether by spiritual discernment or the application of basic psychiatric knowledge. It would seem reasonable to argue that demon possession may be an aetiological factor in some cases of mental illness, but it may also be an aetiological factor in some non-psychiatric conditions, and in other cases it may be encountered in the absence of psychiatric or medical disorder. Furthermore, demon possession is essentially a spiritual problem, but mental illness is a multifactorial affair, in which spiritual, social, psychological and physical factors may all play an aetioIogical role. The relationship between these concepts is therefore complex. Differential diagnostic skills may have a part to play in offering help to those whose problems could be of demonic or medical/psychiatric origin. However, spiritual discernment is of at least equal, if not greater, importance in such matters.
Professor Chris Cook
Kent Institute of Medicine and Health Science
University of Kent at Canterbury
11 May 1997