#1. Review the vignette of Brett, and then provide a DSM-5 diagnosis (pages 87-122). Based on your cultural background/worldview, what is your perspective on the nature of psychotic disorders? #2. Bri

#1. Review the vignette of Brett, and then provide a DSM-5 diagnosis (pages 87-122). Based on your cultural background/worldview, what is your perspective on the nature of psychotic disorders?

Brett is a 19-year-old Caucasian male who is brought to counseling by his parents, Margaret and Henry. Margaret and Henry are extremely concerned about their son and are looking for answers regarding his unusual behaviors. Brett is a college sophomore attending a local university; to save money, he lives at his parent's house and commutes to school. During his freshman year, Brett appeared to be doing well, but over the summer he began to act very strangely. His parents

Report that Brett started to spend a lot of time in his rooms with the shades drawn. He refused to bathe for days at a time and stopped eating regularly. Additionally,

Margo and Henry heard Brett having conversations in his room when they knew that no one else was with him. One morning, Margo observed Brett sitting at the breakfast with a "blank" expression on his face while trying to pour milk into his shoes. In all, Henry believed that these odd behaviors have been occurring

For about 9 months. Margo and Henry are devout Pentecostal believers and report that they have raised Brett to attend church and to believe in God. They are worried because before the onset of Brett’s symptoms, he reported a

Disturbing incident. He took a World Religions class in which

A student performed a “show-and-tell” Ouija board ritual for a class project in which he described Occult religions. Brett was very upset by the event. They sought help from the pastors in their church with little relief. A friend referred them to you. They state that mental illness does not run in their family.

#2. Briefly review the biblical narrative in Mark 5: 1-20. How would you help a psychotic individual who presents to your treatment center and insists that the etiology of his disorder is spiritual in nature and not biochemical?

5 They went across the lake to the region of the Gerasenes.[a] 2 When Jesus got out of the boat, a man with an impure spirit came from the tombs to meet him. 3 This man lived in the tombs, and no one could bind him anymore, not even with a chain. 4 For he had often been chained hand and foot, but he tore the chains apart and broke the irons on his feet. No one was strong enough to subdue him. 5 Night and day among the tombs and in the hills he would cry out and cut himself with stones.

6 When he saw Jesus from a distance, he ran and fell on his knees in front of him. 7 He shouted at the top of his voice, “What do you want with me, Jesus, Son of the Most High God? In God’s name don’t torture me!” 8 For Jesus had said to him, “Come out of this man, you impure spirit!”

9 Then Jesus asked him, “What is your name?”

“My name is Legion,” he replied, “for we are many.” 10 And he begged Jesus again and again not to send them out of the area.

11 A large herd of pigs was feeding on the nearby hillside. 12 The demons begged Jesus, “Send us among the pigs; allow us to go into them.” 13 He gave them permission, and the impure spirits came out and went into the pigs. The herd, about two thousand in number, rushed down the steep bank into the lake and were drowned.

14 Those tending the pigs ran off and reported this in the town and countryside, and the people went out to see what had happened. 15 When they came to Jesus, they saw the man who had been possessed by the legion of demons, sitting there, dressed and in his right mind; and they were afraid. 16 Those who had seen it told the people what had happened to the demon-possessed man—and told about the pigs as well. 17 Then the people began to plead with Jesus to leave their region.

18 As Jesus was getting into the boat, the man who had been demon-possessed begged to go with him. 19 Jesus did not let him, but said, “Go home to your own people and tell them how much the Lord has done for you, and how he has had mercy on you.” 20 So the man went away and began to tell in the Decapolis[b] how much Jesus had done for him. And all the people were amazed.

#3 Review Mercer’s article and identify two or three recommendations/practices you find relevant in this source as pertaining to a clinician that considers treating Brett.

This paper outlines an unconventional treatment for mental illness, the exorcism or deliverance ritual used by Pentecostals and some other charismatic Christians. Deliverance beliefs and practices are based on the assumption that both mental and physical ills result from possession of the sufferer by demons, and are to be treated by the expulsion of those demons. Deliverance practitioners claim to treat schizophrenia, ADHD, and Reactive Attachment Disorder, and believe that these problems are related to sins either of the person in treatment or of an ancestor. Clinicians and counsellors dealing with clients who partially or completely espouse deliverance beliefs may need to understand their worldviews and to discuss their belief system before managing to engage them in conventional mental health treatments. Unusual ethical problems may also be met in the course of such work.

Religions contain within them the seeds of psychologies, in the form of statements about the nature of human beings and about their right or wrong conduct. These seedling psychologies include views of mental illness, its causes, and its treatment, and may emphasise either supernatural or natural causes for mental disturbance. In the Western world, mainstream Christian and Jewish groups generally consider natural factors as primary in mental illness and mental health interventions, in spite of their acknowledgement of the importance of spiritual or supernatural phenomena. Pentecostal believers, on the other hand, emphasise the role of the supernatural in both causation and healing of mental and physical disorders. These disorders are considered as due to demonic possession, and effective interventions are thought to require expulsion of the responsible demons by means of deliverance (exorcism). Some Pentecostals are said to reject medical and psychological treatment for mental illness, and to consider such treatment to have the potential for exacerbating the disorder, even in cases of serious depression or of schizophrenia (Harley, [23]), but others accept the use of secular treatments while at the same time requiring that interventions have some congruence with Pentecostal beliefs.

The present paper will address beliefs about mental illness and deliverance as they have been outlined by Pentecostal authors and by members of other groups who are committed to the deliverance concept (for example, some Roman Catholics and Anglicans of charismatic types). Although Pentecostalism lacks hierarchical organisation, tends to be highly congregational in nature, and has frequent schisms, a number of concepts about deliverance appear to be shared by most groups that would claim the Pentecostal category. Mental health professionals attempting to work with deliverance-believing clients, or to cooperate with deliverance ministers, need to understand the deliverance background in order to meet potential challenges in both practical and ethical realms.

The need for psychologists and counsellors to understand deliverance beliefs is underscored by the existence of an estimated 80,000,000 Pentecostals in the United States ("The new face of global Christianity", [42]) as well as by the rapid growth of this belief system in Latin America and Africa. Some older works suggest that there have been significantly higher six-month and lifetime rates of depression, anxiety, and other mental health disorders among Pentecostals than among mainline Protestants (Koenig, George, Meador, Blazer, & Dyck, [27]). Where this large population is concerned, deliverance beliefs and practices may have serious implications for treatment of mental health problems.

Among those sharing charismatic beliefs (not all of whom are Pentecostals), opinion varies about the need for psychological or psychiatric training, or other education, for those working with the mentally ill. Anglicans and Roman Catholics make deliverance the task of ordained clergy and expect them to consider psychological and psychiatric concepts before taking a supernatural approach. Pentecostals, however, who have little hierarchical organisation, may use psychological terms and concepts but do not consider them essential to the task of casting out demons, nor do they consider any form of ordination or training to be necessary. Any Christian (as defined by Pentecostals) is thought to be able to deliver a sufferer from demons and thus from mental illness, although individuals have differing abilities for this work. Mainstream mental health professionals working with believers of these types need to have sufficient understanding of deliverance principles to be able to tolerate these views, so different from most of their own perspectives, and to anticipate their influence.

The present paper will outline some of the historical background explanatory of the deliverance belief system, and will explore some aspects of deliverance-oriented mental health practice. Because many Pentecostals and related groups believe that treatment of mental health problems cannot be complete without deliverance, psychologists, psychiatrists, and counsellors can expect that their contributions to treatment will be in cooperation with a deliverer; this paper will include a discussion of the ethical problems that may result from this cooperation.

Historical background and evolution of Pentecostal beliefs

Pentecostalism is usually considered as an aspect of evangelicalism, a Protestant Christian movement that began in the 1700s with groups like the Methodists (Bebbington, [ 4]). Evangelical thinking stresses the need for conversion (being "born again"), the reliance on biblical authority, an emphasis on Jesus' death and resurrection as the primary factor in salvation, and the importance of actively spreading the gospel. Pentecostals share the belief in the critical nature of personal conversion and on the final authority of the Bible. However, in addition to a focus on Jesus' death, Pentecostals adhere to a pneumatological soteriology (Ngong, [35]), in which the works of the Holy Spirit are seen as central to salvation and to life events. These include such gifts of the Holy Spirit as casting out of demons and speaking in tongues.

As is well-known, traditions of exorcism date back to ancient times. Roman Catholic rituals for exorcism were formulated in the seventeenth century, as were those of the Church of England (Malia, [32]). However, the capacity for deliverance (the expulsion of demons), as a gift of the Holy Spirit, and one among several gifts said to have been received by the Apostles at the event celebrated as Pentecost or Whitsunday, was not an aspect of these rituals. Neither were the gifts, which included "speaking in tongues" as described in the New Testament, part of the periodic religious revivals experienced in North America in the eighteenth and nineteenth centuries. The Pentecostal practice of glossolalia apparently emerged in about 1830 as a practice of a British millennial Presbyterian group known as the Catholic Apostolic Church (Ellis, [16]). At about the same period, the Holiness Movement developed out of Wesleyan Methodism; this group stressed an experience of conversion in which the presence of the Holy Spirit was felt, and the experience of "signs and wonders" was expected (Poole, [37]). Pentecostalism proper, which is usually dated to a revival meeting in Los Angeles at the turn of the twentieth century, held that this experience was shown to be genuine only when the individual spoke in tongues. The gradual development of this belief in the influence of the Holy Spirit, and the symmetrical belief in the powers of demons, followed a folkloric pattern rather than emerging as an organised, hierarchical set of religious beliefs.

The practice of "pleading the Blood" for purposes of healing and deliverance, mentioned later in this paper, appears to have begun in a 1907 London prayer group headed by Catherine Price. An important Pentecostal figure, H.A. Maxwell Whyte, whose mother had been a follower of the prophetess Joanna Southcott, joined this group in 1939. By 1948, Maxwell Whyte was running a charismatic ministry in Toronto and using deliverance to treat arthritis and homosexuality, among other things. His 1959 book The power of the Blood described the use of pleading the Blood for the purpose of casting out spirits (Ellis, [16])

During the 1940s and 1950s, some Pentecostal groups, like the Assemblies of God, became more mainstream and marginalised the "gifts" that had been characteristic of the movement. From about 1960, however, there was an increasing influence of Pentecostal/Charismatic beliefs and practices among both Catholics and Protestants; a 1972 report of the Church of England discussed appropriate use of exorcism and suggested that some events resembling mental illness could be caused by demonic possession (Malia, [32]).

Other factors like the rise of "prosperity theology" (Roberts & Montgomery, [39]) and missionary efforts in Africa that brought in themes of African traditional religion also contributed to the developing syncretism that combined deliverance beliefs with psychological concepts (cf. Betty, [ 6]). An example of this syncretism is a paper in which Euteneuer [17] listed a number of risk factors for demon possession, but noted that persons who have been subjected to Satanic Ritual Abuse require the care of a therapist skilled in treatment of Dissociative Identity Disorder. Another example is the use of "Theophostic" (Bidwell, [ 8]), a treatment that expels demons in order to remove "lie-based thinking."

Because of their folkloric and syncretic nature, deliverance beliefs and practices are dynamic and show continuing influences from both religious and psychological or psychiatric sources. Pentecostals on the whole are little influenced by mainstream religious positions, and have been described as taking "an eschatological position that feared ecumenical contact" (World Council of Churches, [49]). However, Pentecostal groups' influence on each other is exemplified by the visits made to churches in the United States by Helen Ukpabio, the Nigerian "lady evangelist" and accuser of child witches (Ngong, [35]); advertising for her planned 2012 "marathon deliverance" at a church in Houston stated her expertise at helping those under attack by "mermaid spirits" ("Marathon deliverance," [33]).

Pentecostal beliefs and mental health

The estimated number of Pentecostals in the United States – equivalent to one out of four people – and the history of adverse effects from deliverance practices (discussed later in this paper) suggest that we need to examine the specifics of Pentecostal thinking about mental illness and its treatment. A better understanding of these points may be of help in understanding the attitudes of a large group towards conventional psychological approaches to the prevention and treatment of mental illness, and may thus contribute to related public health efforts as well as to the effectiveness of work by mental health professionals.

Although much Pentecostal teaching occurs in small, private groups, there has been sufficient agreement to support a number of publications about the nature of demonic possession and deliverance, and the positions advocated by these publications appear to be acceptable to many Pentecostals. The most popular of these is Pigs in the parlor: The practical guide to deliverance (Hammond & Hammond, [20]). The same authors have published A manual for children's deliverance (1996/2010). A similar guide is Deliverance for children and teens (Banks, [ 3]). These and a series of Internet sites are sources of information about Pentecostal approaches to both mental and physical illness. The following section will outline relevant Pentecostal beliefs as described in those sources. (However, it is quite possible that between the time of writing and the publication of this paper, further schisms will have created some differences in the thinking of Pentecostals, especially in the United States and Canada, where Pentecostal beliefs seem to be particularly volatile.)

Causes of mental illness

In the Pentecostal view, mental illnesses, including autism, bipolar disorder, depression, Reactive Attachment Disorder, and schizophrenia, all have their direct causes in the presence or "indwelling" of demons who have entered the victim's body. These demons, who are servants of Satan but not usually Satan himself, are spiritual in nature, but can operate through material bodies, and are thus parallel to the Holy Spirit, which can also enter a body and cause behaviours like speaking in tongues. Behaviours caused by spiritual entities show the presence of those entities; just as speaking in tongues indicates the presence of the Holy Spirit in the speaker, disturbed behaviours are indicators of the demonic presence.

The type of mental illness manifested by an individual depends on the type of demons influencing him. Hammond and Hammond [20] provide four pages of names for groupings of demons, including spirits of bitterness, rebellion, strife, control, nervousness, and paranoia. In each case of demonisation, there is considered to be one ruling spirit, or "strong man," and it is essential that this one be addressed, but also that every one of the subordinate demons be expelled as well.

Hammond and Hammond [20] devoted an entire chapter to demonic causes of schizophrenia, which they regarded as "split personality." Mrs. Hammond described being awakened from sleep by a revelation in which God described the nature of schizophrenia.

The Hammonds' description of schizophrenia is typical of Pentecostal thought in its selection of specific demons who cause a problem. In addition, it characteristically points to experiences or conditions that invite the entrance of specific demons. Mrs. Hammond continued her description of her revelation by discussing the indirect causes of schizophrenia:

Schizophrenia can be demonically inherited ... demons seek to perpetuate their like kind. It is easiest for them to do this in a family. For example, suppose the schizophrenia nature is in the mother. The demons will pick out one or more of her children to feed down through. The schizophrenic mother feels rejection ... She is the one who touches, handles, and fondles the infant. The rejection within herself creates problems in her relationships with the child. So, the child is opened for rejection by the mother's instability. I repeat, schizophrenia ALWAYS begins with rejection. (p. 144)

Read without the reference to demons, this view of mental illness may appear simplistic, but not completely unlike a conventional but strongly environmental approach to psychological disorders; however, understanding the claimed role of demons makes it clear that the Pentecostal system shares little with conventional, naturalistic approaches.

Mrs. Hammond's reference to rejection in early life and the entrance of a demon into the individual typifies the Pentecostal view that experiences and circumstances open "ports of entry" for demons, who are attracted by certain situations. In some cases demonisation follows the person's intentional participation in sinful actions; in others, the sins of related persons cause the attraction of demons to an individual; in still other situations, demons are attracted by events that are neither intentional nor sinful, but accidental. Demonisation is not always preventable even by the most committed Pentecostal. Of the circumstances thought to create mental illness by attracting demons, some, but not all, have been posited as potentially disturbing by conventional psychologists.

Adoption

Adopted children are considered very likely to be afflicted by demons. Although the child himself may never have experienced thoughts or behaviour that created vulnerability to demons, Pentecostals hold that the circumstances under which adoption is likely to occur attract demonic interest (Banks, [ 3]; Hammond & Hammond, [21]). These may include the death of a parent, after which spirits of abandonment and fear may make their entrance. More often, the child who is to be relinquished for adoption has already been exposed to demonic activity, produced when a conception occurred out of wedlock or in a spirit of lust.

The mother's consideration of abortion also invites demons to enter the child and the womb itself (although spiritual in nature, demons appear to experience some constraints of time and space and thus may preferentially affect certain body parts). According to Hammond and Hammond [21], "A spirit of death gains a legal right to a child yet in the womb if the mother and/or father attempt or even contemplate an abortion" (p. 86). In the opinion of Banks [ 3], the demonic dangers of abortion extend also to contraception by means of IUDs, foams, and contraceptive pills "that work by inducing an abortion" (p. 83).

Childhood trauma

Pentecostals consider demons to enter during traumatic events, and stress the possibility that this will happen during early life. The use of drugs in childbirth is questioned; apparently referring to Pitocin, Hammond and Hammond [21] state that when "the mother is given the drug patosium to induce labor, the drug passes through the placenta into the baby affecting the nervous system with adverse effects upon his emotions" (p. 86). Birth traumas are given special consideration, as they may have attracted "spirits of birthing trauma, oxygen deficiency, and death" (Hammond & Hammond, [21], p. 87) that remain with the afflicted person into adulthood, causing intellectual delays. Physical, emotional, and sexual abuse all attract demons that distort thought, emotion, and behaviour, as do other experiences of fear.

Sickness and death

Experiences of one's own illnesses or those of other people and of pets, or of deaths, are thought to invite demonic entry through grief, abandonment, loneliness, and insecurity. These spirits may remain with the affected person from childhood into adulthood, and bereavement even in adulthood may lead to similar demonisation.

Occult experiences

Association with any aspect of the occult is thought to attract demons. This includes stories or movies involving magic or witches, Ouija boards and tarot cards, having one's fortune told or palm read, and dressing in costumes for Halloween. All "New Age" practices are considered occult, and Pentecostal schisms may include references to schismatic practices as occult in nature (Ray, [38]).

Curses

According to Banks [ 3], a curse is "a demonic force brought to bear upon a person or family by the words, will or actions of another individual" (p. 84). The other person may create a curse by ill-wishing or by specific behaviours or words that are hostile to the cursed individual, the latter explanation of mental illness being congruent with the concern of mainstream psychology about experiences with hostile interactions.

Some curses are also considered to be generational in nature, so that an individual is demonically attacked because of actions or experiences of parents, grandparents, or more distant generations. Generational curses are likely to involve occult activities of the ancestor or prohibited sexual practices. Adopted children are particularly likely to suffer from generational curses, because they inherit from a "double lineage" (Banks, [ 3]) with evil spirits potentially coming to them from both adoptive and biological parents.

Results of demonic attack

What are the results of demonic possession? They may include an extensive list of physical and mental ills, including infertility, obesity, asthma, seizure disorders, ADHD, and schizophrenia. Alcoholism and drug use in adults, and disobedience or nightmares in children, are attributed to demonic activity. Deliverance, or expulsion of the demons, is expected to cure these and other conditions, and even Pentecostals who accept some medical intervention would deny the possibility of a complete cure without deliverance (Legako & Gribble, [29]).

Some African Pentecostals have in recent years emphasised the belief that children may be demon-possessed and as a result may be dangerous to others as well as suffering their own symptoms. These "child witches" are thought to be stubborn and resistant to schooling, and to plot with other children and with evil spirits to do harm to people and property. They can "drain" adults' happiness and prosperity and cause electronics to fail (Wilson, [47]). The "child witch" belief has not so far been a major part of Pentecostalism in the United States, but in 2012 a Houston church planned a "marathon deliverance" involving the Nigerian Pentecostal minister Helen Ukpabio, who is known as an accuser of "witch children" (Ngong, [35]). Her books and a film, The end of the wicked, have encouraged this type of belief. Whether Ukpabio has already influenced beliefs among US Pentecostals, or whether she will do so in the future, is not known.

Treatment of mental illness by deliverance

As would be the case for any conventional psychotherapy or counselling technique, deliverance techniques address mental illness, educational, and behaviour problems by both diagnosis and intervention.

Discernment

Diagnosis of demonic presences begins with reports of problems and with very general clues to the presence of demons. For example, demonic possession can be indicated by behaviours a person cannot control, by extreme mood changes, by cravings for power or the practice of manipulation, by persistent bad habits, and by a pattern of being victimised (Legako & Gribble, [29]). Some descriptions of demonic possession stress altered appearance of the victim's eyes, which may be red in colour or "almost black like shark's eyes" ("Warning signs of demonic ... ," [45]). Animals may appear frightened of the person, and there may be incontinence.

The diagnosis of which spirits are responsible for these or more specific problems involves the process of discernment. Discernment is one of the gifts of the Holy Spirit, Biblically described as having occurred at Pentecost.

Discerning of spirits is the supernatural ability given by the Holy Ghost to perceive the source of a spiritual manifestation and determine whether it is of God ... It implies the power of spiritual insight – the supernatural revelation of plans and purposes of the enemy and his forces (Boshart, [ 9]).

Discernment, which is most often an ability shown by women (Franklin, [19]), may proceed by way of a word of knowledge.

A word of knowledge is a definite conviction, impression, or knowing that comes to you in a similitude (a mental picture), a dream, through a vision or by a scripture that is quickened to you. It is supernatural insight or understanding of circumstances, situations, problems, or a body of facts by revelation; that is, without assistance by any human resource but solely by divine aid. Furthermore, the gift of the word of knowledge is the transcendental revelation of the divine will and plan of God. (Boshart, [10])

Discernment is also based on certain assumptions about the relationship between a problem and the responsible demon. According to Hammond and Hammond [20], groups of demons can be associated either with symptomatic moods or behaviours (e.g., anxiety, lying) or with past experiences (e.g., occult practices, cult membership, or membership in certain churches or societies). The discerning individual can use those connections to make decisions about specific demons involved. Some attribute specific demon-attracting events, like adoption, to specific diagnoses, such as Reactive Attachment Disorder.

Deliverance

Deliverance, also known as exorcism or expulsion of demons, is the primary mode of treatment for mental illnesses thought to be caused by demonic possession. It is possible for deliverance practices to include violent or dangerous actions, and this will be discussed later in this paper when deliverance will be considered as a potentially harmful intervention. In the present section, common deliverance methods will be described, with the understanding that specific techniques may vary from one deliverer or group to another.

Deliverance is often carried out with a group attending a scheduled church service. There is usually a deliverance team rather than a single deliverer, and the team is encouraged to include both men and women. Not only are women thought to be superior at discernment and men at deliverance, but it is thought desirable to have members of each sex so that a person who needs restraint will be held only be same-sex individuals. Vomiting, spitting, and thrashing are all part of the deliveree's behaviour, and sufficient team members are needed to manage these as well as to move from person to person as needed (Cuneo, [13]). Deliverance of a single individual may also be the work of a team, and it is possible that this is a more common approach when a child is to be delivered.

Organising the room and equipment

Suggestions for the conduct of deliverance include the choice of a room where others will not intrude, and one "so situated that others will not be disturbed or excited by sounds emitted" (Hammond & Hammond, [20], p. 117). A secretary is to be appointed and notes taken, to be provided to the deliveree and used in any follow-up proceedings. One deliverer (Wagner, [44]) advises the use of an informed consent document.

Pleading the Blood

An essential step in deliverance is to "plead the Blood" by spoken references to the powers of the blood of Jesus as a weapon of spiritual warfare, which may be as simple as stating "I plead the Blood," or may include phrases like "This child is covered with the precious blood of Jesus," coupled with references to the blood of the lamb at Passover (Hammond & Hammond, [21], p. 54). Pleading the Blood is a first step in casting out demons as well as for magical healing of burns and excessive bleeding (Ellis, [16]).

Investigating demons

The deliverance process begins with an anamnesis-like period, during which the deliveree is encouraged to remember events in childhood that might have attracted demons and permitted their entry. Once a demon has entered, it is not thought to leave until deliverance occurs, so early events continue to influence the adult. As Hammond and Hammond noted,

Current problems with the person usually have their roots in earlier life. For example, there may be tension and strife between a husband and wife. It could stem from a spirit of rebellion that entered the wife when she was a little girl and a spirit of resentment that entered the husband when he was only a small boy. These are the facts that the conference will bring to light. (1973/2010, p. 118; italics in original)

The procedure leads to the identification of specific demons that are causing problems.

The deliverance proper

The deliverance begins with a prayer, read verbatim by the deliverance team and candidate, citing the power of Jesus' blood, forgiving others, and renouncing sins. The deliverer then commands all evil spirits to unlink themselves from each other and forbids them to help or encourage one another. The spirits are to be "bound," and the ruling spirit of the hierarchy forbidden to do its managerial or administrative work. One of the deliverance team commands specific demons to go, while others sing or pray or speak in tongues.

The deliverance candidate is not to pray aloud or speak in tongues, because his mouth and breath need to be available for the exit of the evil spirits. At this point, he or she blows out forcefully several times or forces a few coughs. These actions, or yawning, are ways in which the demons may be expelled. According to Hammond and Hammond, breathing or coughing will usually be "enough to 'prime the pump' and the demons will begin to move out readily ... [or] the demons then begin to yawn themselves out" (1973/2010, p. 123).

Some deliverers emphasise the use of "eye contact" and treat mutual gaze as a mode of direct contact with the demon – presumably the "strong man" who manages a group of demons, as they are generally thought to be present in multiples. One deliverer has suggested,

Once you have established the distance you want to work at, then you can look directly into the eyes of the demonized person [The term 'demonized' is used to indicated that the person is possessed or attacked by demons. J.M.] The demon will not like the light of Jesus that you will have coming out of your eyes. The person may try to look away, but if at all possible try to have them maintain proper eye contact with you through most of the actual deliverance if they possibly can. ("Deliverance system for casting out demons on the inside of a person", [14])

Deliverance may require several hours or longer to accomplish, however. The candidate may ask for a drink of water or the use of the toilet, but the deliverance team needs to take care that this request was not made by the demon rather than the person. Hammond and Hammond suggest that alert deliverers will not be taken in, but will consider

How deeply has the person been taken over by the spirits? Are the eyes glazed or fixed? Is the voice that of the person? What does your own spirit say? [again, the issue is the existence of a word of knowledge that is of necessity true. J.M.]. (1973/2010, p. 98)

Similarly, demons may cause the deliverance candidate to become wildly active and dangerous to the deliverers:

[in one case] spirits had taken the man over and the two [deliverers] were down on the floor forcibly restraining his arms and legs. After awhile the man pleaded that they were hurting him and that he needed to rest for a few minutes. Not realizing that it was a demon speaking ... they released their holds. As soon as the legs were released the demon caused the man to kick, and [one of the deliverers] suffered three broken ribs. (Hammond & Hammond, [20], pp. 98–99)

Positioning of the deliverance candidate is an important part of the proceedings. This is because the expulsion of the demons, along with mucus and possibly vomit, through nose and mouth is more easily accomplished in certain postures.

One of the best positions is for the person to be seated in a straight chair and bent forward from the waist with forearms resting on the knees ... In a few cases the person may want to lie face down on the floor or get on his hands and knees. (Hammond & Hammond, [20], p. 99)

When a child is the deliveree, the situation is somewhat changed. Adult deliverance candidates have asked for help, and although they may show "demonic" resistance, they are on the whole cooperative. Children have usually not asked for deliverance, but are brought by parents who attribute child moods or behaviour to demonic possession. Deliverance of children begins with laying on of hands, which may be resisted by the child, who complains that it hurts or burns. These objections are treated as statements made by demons and thus further proof of demonic possession. An additional step is the testing of the child's will, which

must be brought into subjection by use of authority and of perseverance ... When you encounter a stubborn child, he will set his will against the ministry. He will not cooperate but will resist you. The child will not willingly sit on your lap or do anything you suggest ... [Demon spirits] may cause the child to struggle to get off your lap and struggle against your restraint of his flailing arms and legs. He may be screaming, kicking, clawing and biting. This is no time for faintheartedness. You are engaged in spiritual combat with a heap of flesh thrown in, and you must be committed to see the battle through to victory. (Hammond & Hammond, [21], p. 55)

Although deliverers may refer to words of knowledge received in the course of a deliverance, or may report that they are not conscious of the proceedings (Wagner, [44]), students of the "anthropology of Christianity" have reported that the ritual used appears repetitious and exterior-originated. Bialecki [ 7], who observed the deliverance practices of a California group, described the events as focused on the conventional and material. Bialecki commented that

there is a sense that the demonic presence has a crypto-physical aspect, with coughing and vomiting often taken as a sign that the demon has either exited, or is on its way out. Even some of the language used to control the demon has a mechanistic quality – the staccato recitation of the command to depart "in Jesus' name", rapidly repeated and paired with the repetitive punctuation of snapped fingers, seems to stress the magical aspect of language in its reliance upon the power of that name; it also implied a conception of repeated invocations of that name that seems divorced from any semantic meaning attached to it. (p. 696)

Factors that interfere with deliverance

Advocates of deliverance theology recognise that deliverance practices do not always cure physical and mental illnesses, even when deliverers claim the disorders as demon-caused. Factors present in the deliverance situation are blamed for the lack of efficacy. For example, a lack of forgiveness in the deliverance candidate will interfere with deliverance. Similarly, a person's deliverance will fail if he or she has been involved with occult matters or any religious cult (as defined by Pentecostals), without subsequently confessing this and asking God's forgiveness. Unconfessed connections with abortion have the same effect; for instance, a woman who had not confessed agreeing with a neighbour that the neighbour should terminate a fourth pregnancy could not be delivered from her demons. However, there is disagreement about whether or not an unconfessed adultery will prevent successful deliverance (Hammond & Hammond, [21], pp. 119–120).

Ethical concerns about deliverance as a mental health intervention

As far as deliverance practitioners are concerned, their techniques are not open to ethical criticism, as they are based on biblical authority and on words of knowledge and therefore right (although individual practitioners may make mistakes). In addition, they consider that complete healing is impossible without the expulsion of demons (Legako & Gribble, [29]). From the perspective of mental health professionals, however, the use of deliverance practices alone or in a syncretic mode raises a number of ethical questions.

A primary concern has to do with the ethical training of deliverance practitioners and their commitment to ethical principles emphasised by psychiatrists, clinical psychologists, and clinical social workers. The ethical principles and code of conduct developed by the American Psychological Association (APA, [ 1]) provide a useful standard of comparison between deliverance practitioners and mental health professionals.

Established ethical guidelines

The APA ethical guidelines require psychologists to consider the boundaries of their competence as determined by their training and experience before undertaking work. Because deliverance practitioners are committed to the idea that discernment (diagnosis) and deliverance (treatment) are gifts of the Holy Spirit, they are unconcerned with boundaries of competence. The APA guidelines also specifically state that psychologists' work should be based on established scientific and professional knowledge. Deliverance practitioners may have some background in these areas, but their perceived access to revealed truth is most important.

The APA ethical guidelines require the use of informed consent documentation as part of a contract between therapist and client. When children or other legally incompetent persons are to be treated, and informed consent is given by a guardian, the psychologist is nevertheless to explain the proceedings to the patient, seek his or her agreement, and consider his or her preferences and best interests. Deliverance practitioners may correctly assume that a member of a church who has seen deliverance events in the past and who presents himself for deliverance is implying informed consent, although some practitioners use a form of informed consent document that does not include any discussion of risks or alternative treatments (Wagner, [44]). Although deliverance practitioners working with children and adolescents may explain what they are going to do, minors are not asked for their agreement (refusal would be seen as an action of the indwelling demons, in any case) and may be forced to participate by means of physical restraint or physical punishment. The stress placed by most evangelicals and by Pentecostals on child obedience gives primary importance to parental wishes, and deliverance of children is generally done at parental behest.

The APA ethical guidelines emphasise the therapist's obligation to keep client information confidential. Deliverance practitioners have no specific training in confidentiality. In addition, because a deliverance "team" involves not only the deliverer but a woman (usually) adept at discernment and various helpers who may restrain or otherwise work with the deliverance candidate, any information revealed during the deliverance is likely already to have passed to a group who may not feel responsible for confidentiality. The fact that someone has sought deliverance is not kept private, but is instead a matter of congratulation and celebration within the congregation. The confession theme, discussed earlier in this paper, contradicts a requirement of confidentiality.

The APA ethical guidelines require psychologists to use assessment methods with established validity and reliability. Pentecostals claiming the gift of discernment believe that their assessments are the work of the Holy Spirit and therefore are by definition both valid and reliable without the need for empirical evidence.

Evidence-based treatment as an ethical issue

Although no professional organisation requires that practitioners use only evidence-based treatments, defined in the most stringent way, mental health organisations have been pressing the use of evidence-based treatments for almost two decades (see Chambless & Hollon, [12]). The ethical guidelines discussed earlier imply the importance of evidentiary foundations for treatment in their stress on the scientific basis of methods. In addition, the possibility that a treatment can be harmful (Lilienfeld, [30]), and thus in contradiction to the ethical principle of beneficence (APA, 2010), brings the evidence basis of an intervention into the ethical arena.

Can deliverance be considered in terms of questions of evidence-based treatment? The Pentecostal belief system makes this difficult. On the whole, deliverance ministers are committed to what Howick [25] has called the "pathophysiologic rationale"– the use of inference from supposed facts about underlying mechanisms of illness to reach conclusions about what treatments should work, rather than a concern with evidence of effectiveness. In addition to this problem, the Pentecostal tradition assumes periods of "backsliding" or decompensation that are a natural part of being "healed" or delivered (Belcher & Hall, [ 5], p. 69), so that effective treatment becomes difficult to define.

Although concerns with evidence would seem to be a somewhat contradictory approach, given the deliverance belief system, some important facts about deliverance may be revealed by stating the question in terms of levels of evidence (Mercer & Pignotti, [34]). Considering levels of evidence allows an analysis beyond the simple "evidence-based" versus "non-evidence-based" categorisation and can include both a "belief-based" category, in which no systematic evidence is considered, and a "potentially harmful" category (Lilienfeld, [30]; Mercer & Pignotti, [34]).

Consideration of the evidence basis for an intervention usually begins with an examination of its plausibility, in theory and in relation to conventional treatments. The theory of supernatural deliverance is generally implausible and incongruent with conventional beliefs about mental illness, although the two share certain assumptions like the stress on childhood events as causing emotional disturbance. Supernatural entities, of course, have no place in conventional understanding of mental health problems or their treatment, although clients' religious beliefs may be of importance for successful treatment.

A particular barrier to attempts to find parallels between deliverance beliefs and conventional, science-based views of mental illness is the fact that deliverance theory blurs the line between supernatural and natural processes. In scientific thought, supernatural and natural events are clearly differentiated, and the former is rejected as a possible explanation of any phenomenon. For deliverance believers, on the contrary, demons, which are supernatural spirits, may penetrate the body as a result of physical actions (e.g., masturbation) and through contact with bodily fluids like blood, semen, or saliva (DeRogatis, [15]; Wier & Carruth, [46]). The supernatural is seen not solely as a cause of unusual, occasional miraculous events, but as co-existing at all times with the physical world and both affected by and affecting that world. The resulting view of time and space relations cannot be made congruent with scientific perspectives on the universe.

Plausibility remains the primary focus for examination of deliverance methods, as little systematic information is available to test the efficacy of deliverance as a treatment for either mental or physical illness. A review by Bull [11] noted several published reports claiming successful use with clients who believed themselves to be under demonic attack; however, there appear to be no such reports of unsuccessful use.

Harmful outcomes of deliverance

There is considerable evidence that deliverance methods should be considered potentially harmful treatments (PHTs; Lilienfeld, [30]), and as such be placed at the extreme end of the continuum of levels of evidence, as far removed as possible from interventions classed as evidence-based. Even a cursory investigation of news stories about deliverance reveals deaths resulting from external and internal injuries, as well as from fasting. The list might begin in 1976 with the death from starvation and ill-treatment of Anneliese Michel, a young German woman with a seizure disorder who was exorcised according to the Roman Catholic rite (Hansen, [22]). A Korean woman in Los Angeles died in a deliverance proceeding in 1996 (Ryfle, [40]). Victoria Climbie, an eight-year-old Ivory Coast child, died at the hands of relations in London after being accused of being a child witch ("Timeline: Victoria Climbie", [43]), an event that was followed by an inquiry and report of the House of Commons (House of Commons Health Committee, [24]) on the failure of social services staff to recognise the child's history of injuries. This case, and related events, were later investigated in a British education research report (Stobart, [41]). In 2003, an autistic eight-year-old, Terrance Cottrell, died of suffocation during a deliverance service in the United States ("Autistic boy's death at church ... ", [ 2]). In 2008, a US toddler, Javon Thompson, was starved to death by a religious cult who called him a "demon" ("Police: 'Cult' starved ... ", [36]. Relatives were recently convicted of killing 15-year-old Kristy Bamu in a deliverance attempt in London ("Witchcraft murder ... ", [48]). Deliverance deaths and injuries in Africa, especially those involving child witch accusations and subsequent beating and burning (see LaFontaine, [28]), are difficult to assess, although claims have been made that thousands of children have been mistreated during deliverance efforts, as shown in the documentary Saving Africa's Witch Children. Information about examples of these events is readily available (see "Exorcism priest gets bail", [18]; "Little girl's exorcism hell in Humansdorp", [31]).

Adverse mental health effects of deliverance are more difficult to document and far less likely to appear in news reports than physical harm is. A review by Bull [11] focused on the use of deliverance or "therapeutic exorcism" for Dissociative Identity Disorder in Christian patients who identify the "alters" as demonic. Bull cited several reports of deleterious effects of deliverance, with unnamed problems said to have been reported by patients. Bull suggested, however, that negative outcomes could be the result of controlling or demeaning approaches that essentially victimised or re-victimised patients. He argued that problems resulted when the deliverance was performed by religious persons without psychological training, and that such methods should always be non-coercive, patient-initiated, and in compliance with informed consent procedures. Bull suggested that it would be appropriate for psychologists to tolerate or use deliverance measures in alliance with a patient's phenomenological experience of events as demon-caused. (Less plausibly, Bull also discussed the possibility that one of the "alters" has a trauma bond with a demon. This paper is, incidentally, used in an on line CEU program for social workers [www.onlineceucredit.com/cues-online/did-dissociative-identity-disorder/secDID26.html].)

Science and deliverance: Changing views?

Although Pentecostals at one time rejected conventional medical treatment, they now generally accept it when they think it appropriate. Some theologians have suggested that science has an appropriate role in Pentecostal thought, especially in the African version (Ngong, [35]). One commentator has declared that Pentecostals cannot afford to ignore scientific discourse (Yong, [50]). He suggested that avoidance of scientific thinking serves to marginalise Pentecostals in a world that is advancing by means of scientific discovery. In addition, Yong noted that scientific thought needs to be understood by Pentecostals so they can understand and argue for or against scientific assessments of their beliefs; for example, neuroscience may contribute to comprehension of visions and healings. It is also possible that understanding of scientific advances may fit well into the prosperity theology (belief that a purpose of religion is to obtain health and worldly success) characteristic of African Pentecostalism. For the time being, however, the Pentecostal use of science in deliverance treatment of mental illness is ostensive rather than genuine. The use of conventional diagnostic terms and the emphasis on early childhood events and trauma (see Kim & Ko, [26]) exemplify this use.

Conclusion

This paper has outlined beliefs and practices of deliverance, a faith-based form of mental health treatment that exists outside conventional psychotherapy. For psychologists or counsellors who are committed to the concept of evidence-based treatment (Chambless & Hollon, [12]), the theory and practice of deliverance raise important questions about effective professional mental health interventions as they may or may not be acceptable to the large Pentecostal population. Can deliverance believers be brought to greater acceptance of effective conventional practices, and can conventional mental health practitioners work effectively with such clients, or ethically co-operate with deliverance practitioners? No general answer to these questions can be given, but situational differences may provide some help in considering them.

One common problem of mental health practice with Pentecostals is that members of the group may prefer the brevity, simplicity, and familiarity of Pentecostal methods (in which the troubled person can respond to an "altar call" in the presence of friends and acquaintances) rather than the expenditure of time and psychological effort on therapeutic work in a strange setting (Belcher & Hall, [ 5]). A second issue is the belief that secular methods alone cannot provide adequate treatment. Third, it may be a general problem that secular methods lack the emotional immediacy of deliverance, and in particular are missing the factors that help the believer discern the desired presence and influence of the Holy Spirit during the intervention. In considering these issues, Belcher and Hall [ 5] suggested that chaplains or pastors working in mental health facilities may need to facilitate "healing" experiences for Pentecostals, a contribution that would be more difficult for private practitioners to access.

Whether deliverance believers can accept effective conventional mental health treatment may also depend on the attitudes of their home churches. As Harley ([23]) pointed out, some of these organisations have counselling centres, and the use of conventional treatments or referrals to conventional practitioners is an important factor in determining the views of church members. In addition, however, the experiences of deliverance-believing clients with conventional therapists will also determine whether they will continue in treatment or recommend it to others.

Conventional or "non-Christian" practitioners are not as likely to understand the deliverance belief system as "Christian psychologists". However, they may be able to work more effectively with clients who want what they call a "Christian" approach, if they have some sophistication about deliverance concepts and the metaphors they imply. It would not be disingenuous for a therapist to co-opt some deliverance concepts, for example, the deliverance emphasis on early childhood and on family issues, and to point out their significance within the deliverance framework, without accepting demon possession as other than a metaphor for emotional disturbance. Understanding the concerns Pentecostals feel about the influence of the occult or of ancestral behaviours might allow a conventional clinician to take a balanced view of problems reported by a client. Concerns about the "stubbornness" or disobedience of a child, while not to be lightly dismissed, may also need to be interpreted in the context of the fundamentalist fear that disobedient children will not achieve salvation in the afterlife. Handling these issues may be especially important when a clergyman is also counselling a psychologist's client, or when a practitioner wants to work in cooperation with a person who considers sin and demonic possession to be causes of mental illness.

Pentecostals and other fundamentalists are well aware that commitment to their beliefs is not universal, and accept the fact that even committed believers have periods of doubt. For a practitioner to acknowledge that he or she is not a believer, or is committed to a more conventional faith, may not necessarily end an attempt to treat a Pentecostal client. An important step in the treatment process may be for the therapist to inquire what the client thinks about psychological problems and their causes, and to demonstrate an understanding of Pentecostal perspectives on these points. A more complicated issue for the "non-Christian" therapist may be to consider the ethical problems inherent in possible co-operation with a deliverance practitioner whose views of informed consent and confidentiality are at odds with guidelines for mental health professionals; the answer to this problem may depend primarily on what is known about a specific deliverer, and no general answer may exist.