Institute of Mental Health 8, Nov 06 (Photo credit: Wikipedia)

The boundary between religious belief and mental illness can sometimes be fuzzy. It is common for persons suffering from some forms of mental illness to have religious content in their delusions or obsessions, and this can be a complicating factor in effective diagnosis and treatment. Still, beliefs which may seem quite unusual to most of us are almost never sufficient for a psychiatric diagnosis.

Sam grew up in a small town in the Midwest and was raised in the same fundamentalist Protestant denomination of most of his neighbors. Faith was an important part of his life, not because he was particularly devout but because it was the context in which he grew up. His childhood was fairly ordinary, but he was never what his parents would consider a typical child. Sam was always much quieter and more introspective than his brother. He struggled in school, had difficulty making friends, and was never the athlete his father sought.

Sam was 14 when his father died, and this affected him greatly. Within two years, he would drop out of high school and take a job at a gas station near his home to help support his family. Sam's brother, 3 years his elder, had graduated from high school and received a scholarship to attend a state college, leaving Sam and his mother behind.

Sam had some mechanical aptitude and was soon able to secure a better paying job as an auto mechanic. He was living on his own by 19, as his relationship with his mother became increasingly distant. Some would later say that Sam's mother had experienced a series of "nervous breakdowns." Sam spent much of his time reading a Christian bible and watching TV.

Over the next few years, Sam became increasingly quiet and withdrawn. He had civil relationships with his co-workers, but he rarely accepted their offers to go out for a beer after work. He attended church regularly, but even there, he seemed more distant. His pastor reached out to him a few times, but Sam struck him as little more than socially awkward. There was something off about him.

Nobody knows exactly what sent Sam over the edge. It was such a gradual process that there was no way to identify any one trigger. It might have been his mother's failing health, although he rarely saw her by this point. It might have been the alcohol, for he had been drinking more lately. In any case, Sam's functioning began a gradual process of deterioration. He became increasingly obsessed with his bible, continued to retreat inward, and grew careless at work. His appearance became increasingly disheveled, and his hygiene suffered.

After a loud argument with his pastor, Sam was asked not to return to church. This argument, prompted by Sam's conviction that humanity was failing to follow the law laid down in Leviticus, ended with him accusing his pastor of being "a fake" and "an agent of Satan." This would be the beginning of Sam's legal troubles.

Sam became convinced that his god considered mixed fiber clothing sinful. He had seen the hate-mongers on TV condemning homosexuality but could not understand why they ignored the rest of Leviticus. He started harassing shoppers of the largest clothing store in town, eventually entering the store and damaging racks of mixed fiber clothing. He was arrested dozens of times, convicted often, and given antipsychotic medication which he refused to take. The local mental health system was ill-equipped to handle Sam, and he continued to slip through the cracks.

There are people like Sam in every community. They often bounce in and out of the legal and mental health systems, neither of which are particularly well-equipped to deal with them. Their mental illness does not always have religious overtones, but when it does, this can make friends and family members less likely to seek mental health treatment. Some may see them as mentally ill; others may think that they are just being good fundamentalists.

When mental health professionals look at Sam's case, it is the functional impairment that stands out rather than the content of what he believed. Generally speaking, beliefs that do not lead to significant distress or impairment in functioning are not considered sufficient for psychiatric diagnosis. In Sam's case, the impaired functioning was readily apparent.