Magical Thinking and Mystical Experience: An Exploration of Delusional Disorder in Schizophrenic Patients

Abstract

Background:

Delusions are common positive symptoms in schizophrenic patients. Individuals with delusional disorders have different experiences in memory and beliefs. Exploring patients’ delusional beliefs is crucial to ascertaining appropriate psychotherapy programs. A few studies have explored the meanings of delusions for delusional patients. This study explores how schizophrenic patients lived experiences about their delusional beliefs.

Materials and Methods:

The study was carried out at a psychiatric hospital in Indonesia in 2021. The participants included 30 adult schizophrenic patients who had delusional life experiences and were able to communicate. Open-ended questions and probes were applied during in-depth interviews. We interviewed family members as well to improve the rigor of the research. Interpretative Phenomenological Analysis was used in this study.

Results:

The patients’ clinical history revealed the experiences of failure and loss. Two main themes shaping their delusional experiences included demonic forces and magical powers.

Conclusions:

Patients with delusions had similar themes, but each had a different specific experience. The findings suggest that each patient may require a unique cognitive therapy based on their experience.

Introduction

Mental disorders are increasing worldwide, significantly impacting human health and quality of life. Psychological disturbances such as schizophrenia impact 20 million people worldwide[1]; in Indonesia, which has a prevalence of mental disorders, approximately 400,000 people—that is, 1.7 per 1,000 populations—suffer from schizophrenia.[2] Existing studies have identified several different mental illnesses diagnoses but did not indicate the prevalence of mental illnesses. They showed that even mild mental health problems could impact the quality of life and physical health.[3,4,5] Schizophrenia is a mental disorder that leads to failure in adapting to reality and impacts all aspects of human life, including personal, familial, social, educational, and occupational functioning.[1] Schizophrenic disorders have signs and symptoms related to fundamental and characteristic distortions of thinking, perception, and inappropriate affect. Reality and intellectual awareness are sometimes present, but usually, a certain cognitive impairment develops over time. Positive symptoms include delusions, hallucinations, and speech disorders[6,7]—delusions are one of the most significant positive symptoms of schizophrenia. The World Health Organization (WHO) concluded after a study of 811 schizophrenic patients that 52% of them showed signs and symptoms of persecutory delusions, 50% showed reference delusions, and 49% had other delusions.[8] According to the DSM-V, the prevalence of delusional disorder is approximately 0.02% in schizophrenic patients.[9,10] Delusions are cognitive disorders that are difficult to recover from but whose relapse can be controlled.[11] A few studies have argued that delusions arise when the cognitive mechanisms associated with the interpretation of environmental events related to perception are abnormal. These signs and symptoms appear in certain types of delusions.[12,13] A few studies have concluded that each individual who experiences delusions expresses delusional ideas differently, which is related to individual and cultural perceptions. The findings include the feelings of meeting invisible beings, being controlled by God, and believing that everyone is jealous of them.[13,14] Delusions appear in individuals with schizophrenia where the patient has experienced pressure or severe stressors in life.[15] Patients with delusional experiences usually have had life experiences that impact the balance between self-ideal and reality.[7] Observations conducted in a mental hospital in February 2021 on five delusional patients identified that they had different expressions of experience, although the type of delusion was the same—for example, persecutory delusions. Therefore, it is significant to explore patients’ experiences in relation to their delusional ideas. Previous studies have identified many types of delusions in schizophrenic patients; however, they focused on types of delusions. A few studies have explored delusional ideas and explored patients’ feelings when delusions occur.

The nurse–client relationship is the key factor throughout the nursing process. The assessment is one of crucial actions to determine a nursing implementation including on delusional patients. Therefore, it is significant to explore patients’ experiences in relation to their delusional ideas. Psychotherapy is an action that psychiatric nurses must apply. Appropriate assessments, such as those on beliefs related to delusions idea, make the psychiatric nurses carry out this role.[7] The findings may be used as a guide to take appropriate nursing implementations, such as cognitive therapy.

Material and Methods

The study was qualitative and conducted for 6 months, from July to December 2021, at a psychiatric hospital in central Java, Indonesia. It was an Interpretative Phenomenological Analysis (IPA) approach that involved 30 participants to explore the experiences of schizophrenia patients with delusions using purposive sampling. There was an emergency room, two acute rooms, and seven nonacute wards that comprised psycho-geriatric, pediatric, and adolescent wards; we utilized the four adult wards in this study, which collected five to seven participants in each nonacute ward in inpatient care with the following characteristics: adult, suffering from schizophrenia with delusional disorder followed the criteria for the Diagnostic and Statistical Manual of Mental Disorder DSM-5-TR™ with code (F22)^a,c 104,[7] stay on days 3 to 7 in nonacute wards of hospitalization days and able to communicate. This is because the patients who were admitted to the nonacute ward had undergone 1 week of treatment in the acute ward and were declared able to move to the nonacute ward if they had coherent communication. We used two interview guidelines comprising semistructured and open-ended questions—the former included 10 items; the latter had five trigger questions. We conducted interviews using a participatory observation approach. The researcher joined the nursing care morning shift. Interviews were conducted at any time, especially when the patient’s condition was relaxed and willing to express feelings, during breaks in the family visiting room and group activity therapy room in the inpatient ward. Each question was followed by a probe to explore the issue. The questions explored how the patients discussed the content and their feelings toward the delusion. In addition to interview guidelines, researchers used recorders and notes to record events related to attitudes and behaviors of the patients during the interview. The in-depth interview process uses special therapeutic communication techniques for patients with mental disorders. Therapeutic communication, prompts, and probes can be identified in the following example: Can you remember what you do when you believe two tigers guard you? Prompts: Could you tell me more about the tigers’ appearance? Probed: What do you imply when you say that the tigers exist? If the patient decides to stop during the interview and leave the reviewer, we will make a new contract the next day until we get the necessary data. We used the Braun and Clarke analysis to identify themes and applied the IPA to analyze exploratory patient experiences. Data analysis was performed during the research, involving the patient’s family and nursing staff in the inpatient ward to validate and verify the findings. In the initial stage, before searching for the themes, we organized the data, which comprised transcribing the data, listening to the recordings, and completing them with field notes made during the interview, including the body language of the respondents. Next, we repeatedly read the verbatim transcript and identified words, sentences, and paragraphs that were significant; we discarded words that were considered insignificant. To interpret the theme, we relied on the strategies of thematic statements, including a reading approach, while reading the data, the researcher back to the literature to compare with the participants’ information. This interpretational analysis focuses on what the experienced delusions imply to the patient.

Ethical considerations

Ethical clearance was approved by the Moewardi Hospital ethics committee of Surakarta Indonesia, with the number 986/X/HREC/2021. The researcher explained the purpose of the study and assured the data secrecy and anonymity of participants. Next, verbal informed consent was received from patients, and written informed consent from their families.

Results

Each participant underwent two to three interviews. We analyzed data from 75 interviews with 30 patients with diagnosed delusion disorders. Interviews were also conducted for all participant families when they visited patients. There were 21 male and 9 female patients. There were 26 patients with undifferentiated schizophrenia, and four had been diagnosed with paranoia schizophrenia. To obtain accurate data related to life experiences before illness, researchers conducted direct interviews with patients, examined medical records, and conducted interviews with family members. Table 1 presents the characteristics of the participants.

Table 1.

Demographic characteristics of the participants (n=30)

Patient demographics	Frequency (%)
Age
• 35-45	23 (76.67%)
• 46-60	7 (23.33%)
Gender
• Male	21 (70.00%)
• Female	9 (30.00%)
Education
• Junior high school	13 (43.33%)
• Senior high school	17 (56.67%)
Job
• Unemployed	14 (46.66%)
• Laborer	16 (53.34%)
Medical diagnosis
• Paranoia schizophrenia	4 (13.33%)
• Undifferentiated schizophrenia	26 (86.67%)
Duration of diagnosis
• <5 years	7 (23.33%)
• >5 years	23 (76.67%)

Participants’ average age was 26–30 years; the most recent education was high school (24 subjects), and the majority of them had private jobs (29 subjects). The maximum hospitalization duration was 9 days, and the average diagnosis duration was 6 years.

All participants experienced delusions with different causative factors, which included social factors, economic factors, environmental conflicts, and psychological factors. Four etiologies concluded from this study are shown in Table 2.

Table 2.

Causes of mental disorders (n=30)

Precipitating factor	Frequency
Job loss	7 (23.33%)
Divorce	11 (36.66%)
Bankruptcy	8 (26.68%)
Pressure from boss	4 (13.33%)

Table 2 describes that the majority of respondents who had the precipitating factor were divorced (36.66%), followed by seven participants with job loss (23.33%), and eight with bankruptcy (26.68%). In the case of four respondents (13.33%) who experienced pressure from superiors at work triggered their mental disorder.

The subjects were classified as mystical experience (N = 8), magical experience (N = 5), and other delusions (N = 17). This study explored the implications of the delusions for the patients. There were several significant issues within each brief extract. Interestingly, 13 patients experienced magic and mystical states delusions. In general, their statements included terms like power, a supernatural force that can defeat others, spirits, magic, and invisible beings. Table 3 presents the most significant statements of respondents.

Table 3.

Identifying thematic approaches

Participants’ quotes	Subthemes	Themes
This strength is due to the presence of a white tiger guarding me. (P1)	Protected by powerful spirit tiger	Spirits or demonic forces
I am guarded by a tall grandfather in a white robe; none can fight me, and all evil, magic will bounce off my body. (P2)	Protected by powerful spirit giant
I possess powers and an attractive light given by my ancestors; therefore, everyone is captivated and bows down to me. (P6)	Protected by ancestral spirits
Ancestors always take care of their descendants. My ancestors have a lot of power, which they have passed down to me. (P7)	Protected by ancestral spirits
I have a ring that can connect me with the invisible being; this ring was given to me by God. (P10)	Apotheosis to God
I met spirits and invited them to chat; I also saw demons and devils around me. (P12)	Spirits, Demons
I am sure that I am in the unseen realm—I see those who are invisible, and the dead. (P13)	Spirits, meeting the dead
I have a wand like Harry Potter’s; with that stick, I become powerful. (P3)	magic stick, powerful body	Magical powers
I have authority over other because of my supernatural powers; everyone obeys me. (P4)	strong, powerful body
I possess supernatural powers. The last magic I performed was extremely powerful, because of which many people follow and respect me. (P5)	supernatural powers, black magic
I feel someone is performing witchcraft on me, because they are jealous of me, but that ricochets off my body because I am more powerful than them. (P8)	black magic, powerful body
I can disappear and reappear elsewhere. No one can touch me. (P9)	powerful body
I was appointed as the last prophet because I have advantages and superpowers. (P11)	super power

Table 3 illustrates that patients who experience magical delusions generally believe that they possess a power that makes them superior to others. Owing to these strengths and superiority, they believe that everyone will abide by them. Their statements included significant linguistic clues that lead to the subtheme of a powerful body, strong, magic stick, supernatural powers, black magic, and superpower within the main theme of magical Power. Furthermore, most of them with mystical delusions believed they possessed powers provided by subthemes protected by powerful spirit tigers, ancestral spirits, spirits of the dead, apotheosis to God, demons, and meeting the dead. These subthemes lead to the primary theme of spirits or demonic forces.

Other extracts described their feelings related to delusions. Thinking of themselves as magical or mystical beings illustrates the intensity of the feelings involved. Based on the observations, most patients felt happy about their delusional experience; however, in the nurse’s analysis, it is anxiety. As a participant stated, “Do you know, I was guarded by two white tigers on my right and left so that my eyes could see translucent”.(P1)

On the next occasion, the patient also expressed to the nurse what he was thinking as follows: “My eyes are all white, yes. there was no black. This was due to the presence of a white tiger guarding me. I see things that others cannot. My strength is also because of my being guarded by two enormous white tigers on my right and left. The two tigers always protect me and give me strength. Yes, I am happy to be guarded by a tiger. no one dares to be with me”. (P1)

Some patients claimed to have magical thoughts about their delusions, and some of their statements were as follows: “I am guarded by a white-robed grandfather; he is tall and big, strong, and powerful, and none can, therefore, fight me. All evil and magic will be blown off my body. My body is surrounded by light and smoke, like a white mist. Many people send magic to me, but the magic is reverted to the sender. I am proud of my power”. (P2)

“I can disappear and reappear in another place. Yes, it is nice to have such power. it is a high-level dominion that can be attained with various rituals and sacrifices. Currently, I am here; later, I can appear in other places—for example, a church, or at home. I can appear anywhere, and return here; nothing can injure me”. (P9)

“Yes, I feel happy about the ring. I have a magic ring that can connect me with something invisible, such as a spirit—especially a deity. I wear this ring every time I pray, or if I intend to talk to the creator because this ring was given to me by God. Therefore, whatever I want, I will receive from God using this ring. I can dominate and control anything; I am powerful.” (P10)

Discussion

This study found that in the patient’s medical history, they experienced loss and grieving. In general, they experience divorce, an unfaithful spouse, job loss, and bankruptcy. Loss and grief can cause anxiety and low self-esteem; precipitating factors such as feelings of hopelessness, social pressure, and feelings of uselessness can result in mental disorders.[7,16] Despair is a cognitive distortion of cognitive developmental disabilities and makes individuals feel inadequate, useless, worthless, and helpless.[17] On the other hand, a study identified that psychological problems, such as hopelessness, can be related to beliefs.[18] Furthermore, this coping mechanism for low self-esteem can reveal itself in individuals in the form of a desire to possess the strength to overcome weaknesses that are subconsciously suppressed.[17,19] In this study, subjects created such thoughts in their subconscious that made them feel possessed and protected by superior powers.

Furthermore, based on the data analysis, we identified the main theme of spirits or demonic forces, associated with the subtheme of ancestral spirits, spirits of the dead, and assisted by God. Another theme was magical power, with the subthemes of powerful body and black magic. In this study, most of the participants with magical thinking and mystical experience were schizophrenic patients with delusion. It is argued that two conditions associated with mystical and magical thinking are Obsessive-Compulsive Disorder (OCD) and schizophrenia, which have positive symptoms of delusions and hallucinations.[7,20,21] Magical thoughts were found in undifferentiated schizophrenia patients who had persecutory delusions experience.[7,20,21] In contrast, several studies have suggested that magical and mystical thinking occurs in individuals with a specific psychosis that is different from schizophrenia.[22,23] Several studies have concluded that magical and mystical thoughts are influenced by the cultural background of the individual. Individuals usually follow meaningful religious and cultural practices that connect them to their community; however, the individual thinking would seem to defy logic, where individuals behave in certain odd ways.[24,25] Mystical and Magical thinking shows a series of beliefs that two actually unrelated experiences in the world are mutually connected and influential.[26,27] This study identified that the subjects felt safe and comfortable with their beliefs that they possessed supernatural strength and were guarded by higher forces—this response is a coping strategy for their weaknesses.[17] It can be seen that their triggering factors included experiences of failure and loss, which made them feel disappointed and weak. Commonly, when people have feelings like communication with God, they are buried in the subconscious mind; in patients with mental illness counteracted by their fantasies as strong people who can emerge as victors against all odds, and appear as signs and symptoms of mental disorders in the form of magical and mystical symptoms.[17,28,29] The magical and mystical characters are likely to be influenced by their history of growth and development and their cultural background.[24,25] For example, all participants in this study have a background in Javanese culture—a culture practiced in Indonesia. In general, the Javanese have a belief called “Kejawen,” in which they worship and combine God with other elements of magic and mysticism as a cultural and tradition, no matter what their religion—Islam, Christianity, Buddhism, and so on. Endresen identified that Albanians have a tend to sacralize ancestry and construct a higher racial soul that is related to the cultural context and tradition.[30] The main limitation of this study was related to the difficulty to interview of the patients because of must use specific therapeutic communication techniques on each patient and the lack of enough time.

Conclusion

This study identified that participants had magical thinking and mystical experiences. The main themes included spirits or demonic forces and magical powers. A significant limitation of this method is participant communication; therefore, data were repeatedly verified and validated. Future studies are recommended to address these limitations and improve the rigor of the research. A subsequent study may explore psychosocial therapy based on the patient problem in this study.

Conflicts of interest

Nothing to declare.

Funding Statement

Institute, Muhammadiyah University of Surakarta, Indonesia