Aging & Mental Health 2001; 5(4): 366–370

ORIGINAL ARTICLE

Spiritual healing in elderly psychiatric patients: a case-control study

in an Egyptian psychiatric hospital

E. SALIB & S. YOUAKIM

Hollins Park Hospital,Warrington, UK

Abstract
In some cultures, mental illness and its treatment may be closely linked to beliefs relating to sin, suffering, and separation
from the divine, or even possession by evil. The aim of this study was to explore whether there was an association
between receiving spiritual healing and the occurrence of schizophrenic relapses in a sample of elderly Egyptian patients.
The method used was a case-control study, comparing patients with an ICD 10 diagnosis of schizophrenia who received
spiritual healing and those without spiritual healing, in terms of the occurrence of relapses during a specified period.
Patients who received spiritual healing relapsed more frequently than those who did not (adjusted OR 3.5 p < 0.05).
Relapse was also associated with age and certain methods of healing. The risk of relapse was independent of gender,
duration of illness and type of religion. The study found spiritual healing to be positively associated with relapse of
schizophrenia in a sample of elderly Egyptian patients. It is however difficult to ascertain that the relapse actually started
after the process of spiritual healing and not before it. The study findings may suggest that religious history, at least in
some cases, should be taken into consideration when planning future management.

Introduction In spiritual healing, the setting may be a church, a

Beliefs about mental illness and its treatment may be
closely tied to religious beliefs about sin and suffering
and views that mental illness may result from some
kind of separation from the divine, or even possession,
by evil (Lowenthal & Goldblatt, 1993). Campion &
Bhugra (1994) found that 75% of their psychiatric
patients had consulted religious healers about
possession and stated that similar findings have been
reported from other parts of India. Teja et al., (1970)
and Verma et al., (1970) reported that possession
syndromes were seen in women, and were largely
hysterical in origin. Spilka et al., (1985) stressed that
mystical experiences are more likely to be reported by
intrinsically religious people because they value them
and have an attributional framework which enables
them to interpret them as meaningful. Lowenthal
(1995) discussed parallels between some mystical and
religious ecstatic states and some psychopathological
states such as schizophrenia. Parker & Brown (1982)
grouped prayer with problem solving behaviours as a
coping strategy. The perceived effectiveness of prayer
was related to the extent to which it was actually used
in coping with crises, and they included prayer as one
of many possible strategies for coping with negative
events and feelings (Parker & Brown, 1986).
temple, a shrine, a tomb, the home of a religious
healer, or a sacred place of pilgrimage. In many Arab
countries, the families of people with severe mental
problems (frequently blamed on the “evil eye”,
sorcery or possession by jinns) often turn first to
forms of ritual healing. These may include visits to
the tombs of famous sheikhs, consultations with a
respected sheikh or master (Al-Asyad), the use of
amulets containing holy verses, and purification
rituals, which involve drinking or washing in water
that has been washed off Koranic verses, written on a
plate. The setting and the rituals of spiritual healing
are both crucial parts of the healing process.
Spiritual healing however is not identical to
“curing”, especially in the case of severe psychosis,
or physical disability. Individuals, and their families
may feel that they have been “healed”, even though
they have not yet been “cured” in conventional
psychiatric or medical terms. People who attend
spiritual healers may be less likely to accept
conventional medical views of their illness. It may be
useful, therefore if psychiatric patients’ religious
history, at least in some cases, can be taken into
consideration when making a clinical diagnosis,
treating and planning future management of these
cases.

Correspondence to: Emad Salib, 18 Broughton Close, Grappenhall Heys, Appleton, Warrington WA4 3DR, UK

Received for publication 28th June 2000. Accepted 12th February 2001.

ISSN 1360–7863 print/ISSN 1364–6915 online/01/040366–05 © Taylor & Francis Ltd

DOI: 10.1080/13607860120080323

The aim of this study was to explore whether or not
there was a link between the occurrence of
schizophrenic relapses and receiving spiritual healing
in a sample of Egyptian patients.
Methods
The study sample of 40 elderly schizophrenic patients
was drawn from the Register of Behman Hospital—an
established private psychiatric hospital on the outskirts
of Cairo, Egypt. The hospital accepts referrals from
various counties in Egypt as well as some Arab
countries and is renowned for its high standards of
care and record keeping, and is also recognized by the
Royal College of Psychiatrists for professional
training.
Selection of subjects
In this case-control study, 20 schizophrenic patients
(cases) who were known from their previous history to
have received spiritual healing prior to the study and
were confirmed to receive some form of spiritual
healing after the follow up point in January 1996 were
compared to 20 controls—schizophrenic patients who
were not known to have received any form spiritual
healing prior to or after the follow up point in January
1996. For each group the occurrence of relapses
during an 18-month period was documented (Figure
1). All subjects, cases and controls, were schizophrenic
patients over the age of 60, on the Behman Hospital
Register, who required readmission after a period of
remission. All patients selected in the study had been
receiving maintenance antipsychotic medication prior
to readmission. Cases and controls were matched for
age, sex, and duration of illness. In this study a relapse
was included when a patient developed an acute
episode of schizophrenia that required hospital
admission following a stable remission period for
cases and controls. The clinical diagnosis of
schizophrenic disorder satisfied the ICD 10 criteria.
Cases included all patients aged 60 and above, who
reported any form of religious healing, regardless of
its nature, method or religious affiliation of patients.
Spiritual healing included: excessive use of prayers;
reading verses of the Koran or the Bible as a form of
counselling based on religious relevance (for at least
an hour a day); excessive attendance at Mosques or
Churches for solitary or group meditations (more
than 5 times a week); attending sessions that included
the use of witchcraft or related methods (ever) and
attending rituals including exorcism and Zar
processions (ever). Cases were excluded if:
· Relapse was due to stopping medication.
· Physical illness or organic brain disease prior and
related to relapse.
· Religious delusions occurred prior to relapse.
Spiritual healing in elderly psychiatric patients 367
Data collection
Information about cases and controls were extracted
from case notes by a qualified psychiatrist, using a
standard format. Data was collected on all patients
prospectively to confirm whether or not they were
reported to have used any form of spiritual healing
before readmission following an acute relapse during
an 18-month period starting from January 1996
(Figure 1). Details about spiritual healing in the study
were restricted because of various constraints,
including attitudes of patients and relatives towards
expressing their religious beliefs at the time of
admission to hospital.
There was a large diversity in types of religion,
and the nature of spiritual healing itself. In almost all
cases spiritual healing was carried out through
reading verses from the Koran or the Bible i.e. some
form of psychotherapy based on religious relevance.
For homogeneity of data collection in the report,
extremes of religious healing such as Zar and
spiritual possession were included under exorcism.
Information included: socio-demographic variables,
illness history including age of onset, duration of
condition and length of last remission. A detailed
account of religious beliefs and their use of spiritual
healing prior to relapse was also collected. The
reliability of the data collection questionnaire was
tested prior to its formal use by comparing
information collected by two independent doctors
and was shown to be reliable (Kappa = 0.6, P <
0.05).
Statistical analysis
In view of the small number of cases and skewed
distribution for most variables, logistic regression was
used to assess the association between relapse and
spiritual healing as a well as other variables,
simultaneously controlling for potential confounders.
From the logistic regression equation, probability of a
binary outcome:
Log odds (OR) Schizophrenic relapse
= Constant + B 1X1 +
B2X2 + ... BnXn
where X is the variable to be explored and B is its
regression coefficient. The odds ratio were computed
as exp (B), where B is the regression coefficient for
the variable of interest, adjusted for age, sex, duration
of illness, education, marital state, length of remission
prior to relapse and depth of religious beliefs.
Statistical analysis was carried out using SPSS
(version 5).
Results
Of the total sample of 40, 67% were male, 65%
married, 25% single, and 10% widowed. The mean
368 E. Salib & S.Youakim
FIG. 1. Selection of study sample.
age was 61 (SD 10) with a minimum of 60 and a
maximum of 72 years. There was no significant
difference between mean age of male and female
patients in cases and controls (P > 0.05). Mean
duration of illness for the entire study population was
21 years (SD 8) with a minimum < one year and a
maximum of 40 years.
The duration of illness did not differ significantly
between patients who used spiritual healing and
those who did not (p > 0.05). Four patients had no
medication (drug holidays) prior to the relapse,
while 40% received phenothiazines, 20%
butyrophenones, 21% thioxanthines, and 13%
received atypical antipsychotics. There were no
significant differences in antipsychotic use between
cases and controls.
Table 1 summarises the characteristics of the cases
and the controls. Four patients (10%) reported to
have no religious beliefs compared to 73% who
reported moderate religious beliefs (belief and
occasional practice i.e. attendance to religious places
or events at least once a month) and 23% who were
said to harbour deep religious beliefs (belief and
regular practice i.e. attendance to religious places or
events at least once a week). There were no significant
differences between cases and controls in the reported
depth of religious beliefs (p > 0.05).
Of the 20 cases who reported to have received
some form of spiritual healing while in remission
prior to hospital admission or other active
psychiatric intervention, 50% received spiritual
healing in the form of prayers, reading verses of the
Koran or the Bible as a form of counselling based
on religious relevance, 90% attended Mosques or
Churches to an excessive degree, 75% attended for
solitary or individual meditations, and 25%
attended sessions that included the use of witchcraft
or related methods including exorcism and Zar
processions.
Seventeen patients (85%) of those who reported
receiving any form of spiritual healing relapsed
compared to 12 (60%) of those who did not receive
similar spiritual support ( c 2 3.8, p < 0.05). Table 2
shows the odds ratio of relapse after controlling for all
other variables and potential confounders in the study.
The risk of relapse appeared higher at 4.3 (p = 0.01)
in cases that reported use of Zar, exorcism, and related
methods. Depth of religious belief did not appear to
have a statistically significant association with the
probability of relapsing (p > 0.05).
 Spiritual healing in elderly psychiatric patients 369

TABLE 1. Characteristics of the study groups

Cases Controls
Spiritual healing No spiritual healing

Sex:
Male 14 (70%) 13 (65%)
Mean age 61 (SD 10) 62 (SD 10)
60–71 60–72
Mean duration of illness 24 years 20 years
Marital status:
Married 12 (60%) 14 (70%)
Clinical relapse:
Yes 17 (85%) 12 (60%)
No 3 (15%) 8 (40%)
Religious beliefs:
None 0 2 (10%)
Moderate 15 (75%) 14 (70%)
Deep 5 (25%) 4 (20%)
Methods of religious healing:
Prayers 10 (50%)
Solitary meditation 8 (40%)
Excessive attendance 18 (90%)
Zar & exorcism 5 (25%)

TABLE 2. Relapse in a sample of elderly Egyptian schizophrenic patients

Variables B S.E. Sig. Exp (B)

(Odds ratio OR)

Duration of illness - 0.21 0.12 0.8 1.02

Sex (male) 2.23 1.88 0.2 1.33
Religious beliefs
No beliefs (R) 1
Moderate beliefs 0.66 0.77 1.2
Deep beliefs 1.6 1.00 1.4
Spiritual healing
No (R) 1
Yes 7.56 3.62 0.03 3.5
Method of healing
Prayers (R) 1
Solitary meditation 3.76 2.52 0.07 1.6
Use of Zar & exorcism 8.86 4.35 0.01 4.3

R: reference category

Discussion the study findings, probably resulting in differential

There were a number of limitations to the study
methodology. The retrospective nature of the study and
having to rely on case notes which were, in some
cases, incomplete with missing variables may have led
to information bias. Also having insufficient details
about religious healing, methods, frequency of use and
number of healers, may have led to some degree of
misclassification of cases and controls, though this was
likely to have been a random rather than a differential
one, thus affecting cases as well as controls. The study
sample size was rather modest and may suggest that
some of the negative findings may have been the result
of a Type II error. The small sample size is likely to
reduce the power of the study and limit its inferential
value. The varied quality in the documented religious
history and the presence of two main religions in
Egypt—Islam and Christianity—could have affected
misclassification of cases and controls.
The relapse rate was unexpectedly high for both
groups, especially when all subjects were receiving
neuroleptic treatment. The study found that a positive
association might exist between having received some
form of spiritual healing and the risk of developing an
acute relapse in elderly Egyptian schizophrenic patients.
However, holding a “religious belief ” as such and
independently of spiritual healing did not appear to
show a significant risk of relapse. The adjusted relative
risk estimate (OR) at 3.5 meant that cases who
received spiritual healing were three times more likely
to relapse compared to those patients who did not. The
association appears to occur independently but was
more pronounced in certain methods of healing such as
Zar, witchcraft, and exorcism. In some cases, it is rather
difficult to ascertain that relapse actually occurred after
the process of spiritual healing and not before it i.e. the
370 E. Salib & S.Youakim
patient may have gone to seek religious intervention as
a result of being unwell and not that the spiritual
healing process precipitated the relapse. Also it is
possible that some of the behaviours that appeared to
be a form of spiritual healing, such as solitary
meditation and excessive praying, might have been
symptoms of more severe psychosis.
The two main experiences that may occur during
spiritual healing process and could explain, at least
partly, the observed association are: [1] mystical and
contemplative states which involve a feeling of
communion with the divine and [2] ecstatic states with
psychomotor over-activity, and heightened feelings of
excitement as seen in Zar processions. Ecstasies include
possessions and trances, glossolalia and feelings of
being moved by the spirit. Both states involve the
rejection feelings of alienation and disappointment in
interpersonal relationships, and the construction of a
more gratifying reality. In schizophrenia, there is a
breakdown in the way the patient thinks of the
boundary between himself and the outside world so that
he can no longer accurately discriminate between the
two. Crossing the line between the ego experience of
“self ” and failure to identify inner experiences could
possibly be explained by “thought dwelling” whether
initiated by the person’s will or induced by spiritual
healing. It is possible that repetitive thinking and
preoccupation leads a predisposed person e.g. a
schizophrenic patient in remission, into a vicious circle
of thoughts at the end of which he becomes trapped,
thus triggering off psychotic experiences. It is therefore
possible to argue that in some cases and under certain
conditions, mystical experiences may precipitate
psychopathological states in some schizophrenic
patients.
A major problem in studies dealing with
schizophrenia is that they often make the assumption
that schizophrenia is a homogenous syndrome.
However, this is unlikely to be the case as
schizophrenia includes a variety of heterogeneous
subgroups that differ genetically, biochemically and
psychopathologically. Therefore findings of one study
may not be expected to apply in all cases. Future
studies, from different countries, are necessary to
support or reject our findings.
The study found that spiritual healing was positively
associated with relapse of schizophrenia in elderly
Egyptian patients. The association appeared to be
independent of type of religion and depth of religious
belief, but could be modified by age and method of
healing. The possibility that some of the behaviours
which appeared to be a form of spiritual healing could
have been symptoms of more severe psychosis seems
to suggest that, at least in some cases, the association
may have been an effect rather than a cause of relapse.
It is suggested that for some, patients’ religious history
should be taken into consideration when planning
future management.
Acknowledgements
The authors are most grateful to Dr Naser Laza,
Director of Behman Hospital and Drs Wagdi Salib
and Sherif Atalla, consultant psychiatrists, for their
invaluable help and support of the second author in
the process of collecting and validating the study data.
References
CAMPION , J. & BHURGA, D. (1994). Religions healing in south
India. Paper presented at World Association of Social
Psychiatry Meeting (June 1994), Hamburg.
LOWENTHAL, K. & GOLDBLATT , V. (1993). Family size and
depressive symptoms in orthodox Jewish women.
Journal of Psychiatric Research, 27, 3–10.
LOWENTHAL, K. (1995). Mental health and religion.
London: Chapman & Hall.
PARKER , G.B. & BROWN , L.B. (1982). Coping behaviours
that mediate between life events and depression.
Archives of General Psychiatry, 39,1386–1391.
PARKER , G.B. & BROWN , L.B. (1986). Coping behaviours
as predictors of the course of clinical depression.
Archives of General Psychiatry, 43, 561–565.
SPILKA , B., H OOD, R.W. & G ORSUCH, R.L. (1985). The
psychology of religion: an empirical approach. Prentice Hall,
Englewood Cliffs, NJ.
TEJA, J.S., KHANNA, B.C. & SUBRAHMANYAM , T.S. (1970).
Possession states in Indian patients. Indian Journal of
Psychiatry, 12, 71–87.
VERMA , L.P., SRIVASTVA , D.K. & SAHAY , R.N. (1970).
Possession syndrome. Indian Journal of Psychiatry, 12,
58–70.