Original Research

Development of a Christian Pastoral care and counselling model to support recovery of schizophrenia patients in Maluku

Monike Hukubun, Yohanes Parihala, Fandro A. Tasijawa

Received: 29 Sept. 2025; Accepted: 24 Nov. 2025; Published: 31 Jan. 2026

Copyright: © 2026. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

The development of the Christian Pastoral Care and Counselling (CPCC) approach aims to support the recovery process of schizophrenia patients, who have not been appropriately handled by the church. A lack of understanding of schizophrenia has led church ministers and congregations in Maluku to consistently identify schizophrenia patients as possessed by evil spirits or ancestral spirits, affected by witchcraft, experiencing original sin, or breaking traditional vows. Consequently, the recovery approach used by pastors is to perform exorcisms, which include prayer, covering schizophrenic patients with priestly robes, or striking them with the Bible. Through descriptive qualitative research using a Focus Group Discussion (FGD) approach and analysed using Clarke & Braun’s six stages, this study proposes a holistic pastoral counselling approach to support the recovery of schizophrenia patients. This pastoral counselling approach is expected to improve the spiritual well-being of schizophrenia patients, reduce anxiety, enable self-management and help them find meaning in life despite their symptoms. The development of this model not only focuses on pastoral-spiritual interventions but also collaborates with medical, psychological, social and cultural approaches to provide holistic support for schizophrenia patients.

Contribution: This article contributes to the growing body of holistic pastoral theology studies, caring for and assisting with the recovery processes of patients with schizophrenia. The holistic pastoral theology approach is also interdisciplinary, encompassing the involvement of other disciplines, such as health and psychosocial-cultural studies.

Keywords: model of Christian Pastoral counselling; schizophrenia; patient; Pastor; Maluku.

Introduction

Mental health remains an issue that has not received sufficient attention. However, the number of people with mental disorders keeps growing. According to data from the Basic Health Research (RISKESDAS) by the Indonesian Ministry of Health from 2013 to 2018, mental health conditions – including emotional mental disorders and psychosis or schizophrenia – in Maluku increased by 1 305 292 people (Kementerian Kesehatan RI 2018). RISKEDAS data show that in Maluku, emotional mental disorders rose by 5%, from 2013 to 11.5% (11 908) in 2018, and patients with psychosis increased from 1.7% in 2013 to 3.9% (4598 people) in 2018 (Kementerian Kesehatan RI 2018). PIS PK screening data from Maluku Province revealed that only 16.49% of individuals with severe mental disorders or schizophrenia received treatment and were not neglected, meaning that 83.51% of patients with mental disorders did not receive mental health services.

The government has pursued mental health services, including early case detection, medication monitoring, home visits, mentoring and counselling (Tasijawa et al. 2021). Several interventions, including regular home visits, health education, psychotherapy, fostering interests and talents through workshops, and spiritual interventions, have been explored. Within the context of mental healthcare, spirituality has become a growing focus of research, particularly in relation to religious beliefs (Heffernan et al. 2016).

Several studies of Islamic and Christian spirituality have been conducted in patients with schizophrenia (Callaghan 2015; Myers, Meeker & Odeng 2024). International research shows that Christian spirituality plays a significant role in the recovery process of schizophrenia patients (Lambdin 2016; Pennybaker et al. 2016).

One intervention that pastors can provide is pastoral care and counselling (Fritz 2024; Sutherland 2018). The importance of pastoral care lies in its ability to meet spiritual, emotional and mental needs, thereby fostering a sense of belonging and support within the congregation. Individuals who receive pastoral care will deepen their faith, hope and understanding of religious teachings. Pastoral counselling fosters personal growth, recovery and change by guiding and supporting individuals in overcoming obstacles and cultivating a sense of meaning and purpose in their lives (Albers, Meller & Thurber 2019). Pastoral care and counselling are concepts that align with the recovery process for schizophrenia.

Pastoral care and counselling have many advantages but there are challenges that pastors face. One challenge is addressing the diverse needs and concerns of congregants, ranging from spiritual crises and marital problems to mental health issues (Dias, Talaway & Hukubun 2020; Turalely & Hukubun 2023). Therefore, pastors must possess broad skills and a deep understanding of human nature, ethical dilemma management, cultural sensitivity and psychological concepts (Ayhuan, Souisa & Hukubun 2021).

These challenges can be addressed through collaboration with other professionals. This interdisciplinary approach offers comprehensive and holistic support, addressing patients’ spiritual needs and connecting them with relevant resources and expertise. This intervention has the advantage of being implemented within the context of church ministry within the Maluku Protestant Church to enhance the recovery of schizophrenia patients in the community and in mental hospitals. In Maluku Province, where Christian culture and spirituality play a significant role in community life, a pastoral and counselling-based approach could be an alternative intervention to support the mental health of schizophrenia patients.

Maluku has a culture deeply rooted in Christian values (Hukubun & Apituley 2023). Church communities are often the primary source of social and emotional support for individuals experiencing life difficulties, including those with mental disorders (Hukubun 2023; Imuly & Hukubun 2019). However, understanding of schizophrenia from a theological and pastoral perspective remains limited. Some communities tend to associate schizophrenia with negative spiritual aspects, such as spirit disturbance or curses, thus exacerbating the stigma surrounding patients. Therefore, developing pastoral care and counselling models tailored to local contexts can significantly contribute to improving the quality of mental health services.

Research methods and design

This study used a qualitative approach focused on fieldwork (Creswell 2014) and conducted Focus Group Discussions (FGDs) with 20 pastors from the Maluku Protestant Church across five districts or cities in Maluku Province. Specifically to describe the characteristics of the participants, a limited quantitative approach was used, only showing the presentation of experiences as a pastor treating schizophrenia patients (See Table 1).

This study was conducted by three principal researchers: two senior pastors, both associate professors, and one psychiatric nurse, also an assistant professor. The main moderator was a senior pastor who is also an associate professor, and two co-moderators, a pastor and a psychiatric nurse, who facilitated the discussion and documented the non-verbal dynamics in the FGD.

A multivariate sampling strategy was used to recruit pastors from five districts or cities in Maluku Province. The goal was to capture diversity based on age, length of service with the congregation, location of pastors (urban versus rural), length of service to schizophrenia patients and gender. This variation allowed for the identification of different patterns of pastoral experience. Recruitment was conducted between July and August 2025.

Twenty pastors from five regions with experience serving patients with schizophrenia were recruited. The recruitment process was facilitated by the Maluku Protestant Church Synod and Classis to ensure trust and impartiality. Inclusion criteria required participants to have at least 1 month of experience serving people with mental illness, reside in Maluku, and be willing to participate in the FGDs. All participants received a plain language information sheet and provided written informed consent.

Confidentiality and voluntary participation were top priorities throughout the recruitment process.

Focus group discussions were held between July and August 2025 at several different locations. Each session lasted 120–140 min. At the beginning of the session, ground rules were established, emphasising mutual respect, confidentiality and equal opportunity to speak without interrupting. The facilitator actively managed the group dynamics to encourage broad participation from all members. With participants’ consent, all sessions were audio-recorded and transcribed verbatim into Indonesian by a trained transcriber. The transcripts were then verified against the recordings and field notes of the co-moderator. For reporting purposes, key quotes were bilingually translated into English, and some sections were back-translated to maintain conceptual accuracy before analysis.

The data in this study were analysed using an inductive thematic analysis approach as described by Squires (2023). The analysis process involved six stages: (1) Identifying the data by the team through repeated reading of the transcripts; (2) Creating codes to capture key statements; (3) Grouping codes into interrelated themes; (4) Reviewing and refining themes; (5) Identifying and naming informative themes; and (6) Compiling a final report.

Trustworthiness

In this study, trustworthiness is an essential indicator of the quality of the findings. There are four main dimensions applied: (1) Credibility, which emphasises data accuracy; these data are guaranteed through participants’ confirmation, clarification and validation by qualitative experts. (2) Transferability, namely the extent to which the results of this study can be applied to similar contexts, is maintained through detailed descriptions of participant characteristics, sampling strategies and research contexts. (3) Dependability, which relates to data consistency, is maintained through (4) Confirmability, which emphasises the objectivity of the findings; this is achieved by matching participant statements with the results of data analysis. These four dimensions together strengthen the validity and credibility of the research results, ensuring that the results of this study can be scientifically accounted for.

Ethical considerations

This study has received ethical approval from the University Ethics Committee, Indonesian Christian University, Maluku, on 30 September 2025. All participants have also signed informed consent. This study also maintains participant anonymity, using pseudonyms instead of participant names with P1–P20 in five groups in five districts or cities in Maluku (Ambon City, Central Maluku Regency, Buru Regency, Southeast Maluku Regency, Tanimbar Islands Regency). Therefore, coding uses FGD, then the name of the region, and participants to facilitate the findings, for example, FGD – Maluku Tengah, P1, to describe the perspective of participant 1 in the Central Maluku region.

Results and discussion

In FGDs, participants’ characteristics are crucial in determining the quality of the information provided. All participants were pastors from five different regions of the Maluku Protestant Church, with characteristics shown in Table 1.

In Table 1, of the 100 participants, the majority were male (59), with 61 participants serving in rural areas and 39 in urban areas. A total of 86 pastors had experience serving schizophrenia patients, with a duration of more than 6 months. The majority of participating pastors were aged 41–50 years. Ninety-nine participants held a bachelor’s degree in theology, and one held a master’s degree in theology. All of these data indicate that the participants had sufficient experience conveying important information about pastoral care for schizophrenia patients.

Thematic analysis results

The data compilation in Table 2 shows that six main themes emerged from the FGDs with participants. These six themes are: Schizophrenia and Spirit Possession or Takanal; Schizophrenia and Culture; Schizophrenia and Sin; Schizophrenia, Magic, and Mysticism; Schizophrenia and the Problem of Church Ministry; and Prayer and Accompaniment Service. These themes were then scientifically discussed to gain a deeper understanding of schizophrenia from a Christian pastoral counselling perspective.

Schizophrenia and spirit possession or Takanal

Mental health phenomena are often influenced by how society interprets a person’s symptoms. In the Maluku context, which has a strong religious tradition, mental disorders such as schizophrenia are often not understood as medical problems, but rather as a form of possession or spirit possession, or, in local terms, takanal. This creates a significant gap between psychiatric-based clinical understanding and belief-based cultural understanding. Research on pastors shows that the meanings of schizophrenia and possession or spirit possession are intertwined. In their ministry experiences, church members and pastors often interpret schizophrenia symptoms, such as hallucinations, aggressive behaviour or bizarre behaviour, as signs of possession or evil spirit possession.

Cultural differences in understanding psychotic symptoms have given rise to the perspective that spiritual experiences, such as trance, can mimic or even mask the clinical manifestations of schizophrenia. Historically, the definition and classification of schizophrenia have evolved from Kraepelin to Bleuler (Lieberman et al. 2020). This suggests that cultural context cannot be ignored in assessing the clinical characteristics of patients experiencing trance-like experiences (He & Petrakis 2025; Rosmarin et al. 2022). This historical approach demonstrates how pastors and congregations interpret psychotic symptoms – hallucinations, delusions and dissociation – as spiritual phenomena that can ultimately influence a person’s identity.

Recent research on schizophrenia confirms that, despite standardised diagnostic criteria, schizophrenia remains a broad clinical syndrome that must be understood through the subjective experiences of patients (American Psychiatric Association 2022; World Health Organization 2022). Therefore, differences in spiritual experiences, cultural experiences and dissociative phenomena need to be considered in the diagnostic evaluation process (Fathi Azar et al. 2025). The interpretation of symptoms such as hallucinations and delusions cannot be separated from the cultural, historical and theoretical frameworks that frame the concept of ‘psychotic’ itself (Subandi et al. 2023).

The phenomenon of possession in various cultures often presents as a subjective experience that is often misinterpreted as psychotic symptoms, even though it has a distinct clinical pattern. One example is the case of ifufunyane in the Xhosa community of South Africa, which is culturally understood as a trance state but exhibits symptoms similar to psychosis (Niehaus et al. 2005). This trance experience represents a unique cultural and psychiatric phenomenon, where ifufunyane is perceived as a state of possession caused by witchcraft or the displeasure of ancestral spirits. This state is characterised by altered consciousness, speaking in an unusual voice or language (glossolalia), mental confusion and unpredictable behaviour. In the Xhosa community, ifufunyane is considered a form of spiritual disturbance, not a psychiatric disorder. In contrast, from a Western psychiatric perspective, its symptoms are similar to schizophrenia or dissociative disorders, involving auditory hallucinations, delusions and psychomotor agitation.

The case report by Niehaus et al. (2005) shows how a 23-year-old Xhosa man experiencing these symptoms was diagnosed with schizophrenia by psychiatrists, despite his and his family’s belief that he was being punished by his ancestors for not observing certain traditional rituals. The clinicians then chose a collaborative approach, negotiating a shared explanatory model that respected the patient’s cultural beliefs while affirming the importance of medical treatment with antipsychotics. This approach proved effective, as the patient maintained adherence to therapy and remained stable for nearly two decades, despite occasional hallucinations. This story demonstrates the importance of sensitive and empathetic cross-cultural understanding in psychiatric practice, particularly when dealing with patients with strong spiritual backgrounds.

Similarly, other studies emphasise that cultural and spiritual contexts need to be taken seriously when assessing dissociative symptoms, as possession experiences can complicate the clinical picture of schizophrenia (Tschoeke et al. 2014). Possession phenomena can manifest as religious delusions, identity fragmentation, or trance-like dissociative experiences, but do not always meet the criteria for a primary mental disorder. In fact, religious delusions in schizophrenia can sometimes manifest as a form of symbolic possession. Some studies view this as a variation of the psychotic phenotype that interacts with the dynamics of religious and dissociative experiences (Denend et al. 2022; Dvoinin et al. 2025; Pastwa-Wojciechowska, Grzegorzewska & Wojciechowska 2021). Therefore, a comprehensive evaluation encompassing clinical symptoms, trauma history and cultural context is key to understanding the content, meaning and motivation behind these delusions. Therefore, both in the case of ifufunyane and similar phenomena in other cultures, integrating biomedical approaches and cultural understanding is essential for successful diagnosis and therapy in mental health. The attribution of mental disorders to possession has significant practical implications, particularly regarding help-seeking and utilisation of health services. Studies in Ethiopia show that the majority of people attribute mental illness to supernatural causes (Birkie & Anbesaw 2021). This influences their preference for recovery processes that rely more on community mechanisms, while reinforcing the stigma that hinders engagement with medical services (Birkie & Anbesaw 2021). These findings align with the Maluku context, particularly on Buru Island, Tanimbar Islands Regency (Saumlaki), Southeast Maluku Regency (Elat) and Masohi Regency, where the phenomenon of takanal is viewed as a spiritual reality.

However, from a psychiatric perspective, takanal can reflect psychotic symptoms. The primary challenge lies in accurately differentiating between the two to avoid misdiagnosis and treatment delays.

In our field research in the Maluku region, we also found that the public’s perception of schizophrenia as a phenomenon of possession, evil spirit possession or black magic is influenced by several dominant factors.

Firstly, the Maluku people are generally indigenous, still bound by traditional customs. In these traditions, the connection with ancestral spirits or cosmic spirits remains very strong (Salampessy, Hukubun & Hetharia 2025). The community typically views the phenomenon of people suffering from schizophrenia as a sign of the entrance of evil cosmic spirits, or ancestral spirits, because the person is committing a violation (FGD – Maluku Tengah, P1). Secondly, the Maluku people are generally also very pietistic in their religious beliefs.

Religious teachings are absorbed as taken for granted, and of course, they influence the practices of everyday life (FGD – Maluku Tengah, P3, P5). In interviews, the pastors expressed their perspective that the practice of exorcism is one of the main stories in the testimony and ministry of Jesus as reported in the Bible. This means that evil spirits exist and always possess believers (FGD – Maluku Tengah, P1, P3, P5). That’s why the pastoral approach to handling symptoms of possession also involves praying, wrapping the person with a priest’s robe, or slapping them with holy books (the Bible) (FGD – Maluku Tengah, P7, P9). Thirdly, community members and religious leaders realise and admit that they don’t yet have a basic understanding of schizophrenia. For them, hearing the term schizophrenia is the first time the word has ever crossed their ears (FGD – Maluku Tengah, P11, P15).

Theologically, the Bible, particularly the Gospels, tells stories of Jesus’ exorcisms. One such story is about Jesus healing a man suffering from schizophrenia in Gerasa (Mt 8:24–34; Mk 5:1–20; Lk 8:26–39).

The Greco-Roman community of the first century of the Common Era referred to him as possessed by an evil spirit. This was associated with anarchic behaviour (beating himself with stones), screaming and living in tombs. The community chained him, but he managed to break all the chains. Jesus then healed the man in Gerasa, as an expression of liberating and healing love. This is the basis of pastoral theology that motivates the church to compassionately care for people with mental disorders through pastoral care and counselling to support the recovery process of schizophrenia patients.

However, this narrative of sin has negative implications. Patients are often subjected to a double stigma: they are not only considered mentally ill but also judged to be sinful or unrighteous before God (Imuly & Hukubun 2019). As a result, social support is weakened as families feel shame and congregations are reluctant to engage with patients. In the Christian tradition, sin is understood as a violation of God’s will that carries both spiritual and worldly consequences. However, congregational interpretations often frame sin within the framework of direct punishment so that mental suffering is perceived as a result of God’s wrath. For example, a congregation member believes that her child is mentally ill because of the sin of a parent who had an affair (FGD – Buru, P15), or a mother suffers from mental illness because she neglected her parents (FGD – Kepulauan Tanimbar, P14) or a woman experiences mental illness every October because her parents committed the sin of murder, committed by her father in October (FGD – Maluku Tenggara, P16).

From a pastoral theology perspective, this understanding is problematic because it gives rise to a theology of blame – a theology that blames the patient or their family (Pakpahan 2017). Yet, the essence of the Gospel is grace that restores, not punishment that exacerbates suffering. A number of pastoral theologians emphasise that Christian ministry should present a loving God who is present in human suffering, not simply passing judgement (Low 2005; Swinton 2001). In this context, it is relevant to present the Duan Lolat approach. The Lolat (love) dimension demands that the church accept the patient as a brother worthy of unconditional love, while the Duan [professional responsibility] dimension encourages the church to go not only beyond simply assigning meaning to sin but also referring the patient to appropriate medical therapy. Similarly, the Ain Ni Ain approach in the culture of the Kei Islands encourages the community to share compassion and responsibility in accompanying the patient in the process of medical care and treatment for the recovery of schizophrenic patients. This is an implementation of cultural values that align with the Christian faith’s values in God in Christ, who is full of love and compassion for the suffering of His creation, for the sake of holistic recovery and salvation (Parihala 2024).

Schizophrenia as a consequence of lecturers emerged strongly in this study through participant narratives describing personal experiences serving schizophrenic patients and their families. Several participants explicitly stated that mental illness in the congregation occurred because of moral-spiritual issues, such as disobedience to God or offences against ancestors. This belief system influenced initial help-seeking patterns, with most families opting for a religious or cultural approach before seeking medical help. This finding suggests that moral perspectives on illness are embedded in the cultural and theological frameworks of local communities. These findings align with existing literature highlighting the relationship between moral or religious attributions to mental illness and stigma and delays in seeking treatment. Studies conducted by Belayneh et al. (2019) and Digwamaje and Tadi (2024) also show that internalised stigma, particularly that rooted in moral or religious beliefs, can worsen depression, increase psychotic symptoms and decrease treatment adherence. Thus, these fieldwork findings strengthen global evidence that moral stigma acts as a psychological and social barrier to the recovery process of patients with schizophrenia.

However, there are also contextual differences from existing literature. While previous research focused on moral stigma experienced individually, this study demonstrates the existence of collective or family-based moral stigma, where mental illness is seen as a reflection of family sin or divine punishment inflicted on all household members. This collective moral pattern is shaped by local theology and traditional cosmology, which are rarely discussed in international literature. Thus, the difference lies not in the direction of the findings but rather in the cultural mechanisms that maintain and transmit this moral stigma.

Schizophrenia and cultural violation

In Maluku society, schizophrenia is not solely understood as a medical phenomenon but is closely linked to customs and violations of cultural rules. This perspective demonstrates how culture, spirituality and social structures shape the interpretive framework for mental illness. The view that schizophrenia is caused by ‘customary errors’ or ‘unfinished customs’ is not simply a local myth, but rather part of the community’s way of giving meaning to mental suffering. Academically, this aligns with the concept of culture-bound syndromes (CBS), conditions in which the clinical expression of mental illness is strongly influenced by local cultural constructs and social structures (Teodoro & Afonso 2020; Volkan 2021).

From a medical anthropological perspective, customs function as systems of meaning that help communities explain phenomena that cannot be fully understood through modern medical approaches. Interviews with priests in Maluku revealed the belief that mental illness results from violations of customary rules or from families holding unresolved ‘customary debts’. For example, some priests stated that mental illness results from parents’ misconduct in accordance with customary law (FGD – Buru, P5; FGD – Maluku Tenggara, P10, P11), while others asserted that the cause is related to customary violations (FGD – Buru, P8; FGD – Maluku Tenggara, P17). Several stories of how schizophrenics are treated in Masohi Regency indicate that customary violations, for example, involve promises to bring dowry money to the ancestral home, promises to carry family vows to the village, and promises to introduce the wife or husband to members of the traditional family in the town. These violations often result in family members or individuals who fail to fulfil their promises often experiencing symptoms of schizophrenia, or, in the traditional community, being possessed and possessed (FGD – Maluku Tengah, P6, P4). From an anthropological perspective, this kind of explanation has a social function: it maintains adherence to customary norms while providing a framework for communities to understand mental suffering as something that ‘makes sense’ within their cultural cosmology (Drake 2015). In other words, schizophrenia is positioned not only as a biological condition but also as a ‘warning’ or ‘moral consequence’ of collective transgression.

Theologically, the interpretation of schizophrenia as a violation of customary law is often conflated with the concept of sin. In pastoral practice, pastors are often asked to offer prayers of reparation, referred to as ‘breaking customary bonds’ or ‘forgiving ancestral sins’. This suggests that in congregational theology, violation of customary law is viewed as akin to spiritual sin: something that requires purification and reconciliation with God and ancestors. However, this theological approach presents a pastoral challenge. On the one hand, prayers of reparation provide spiritual strength for families and patients but on the other hand, positioning schizophrenia as a result of ‘customary sin’ risks reinforcing stigma and guilt in patients.

Therefore, culturally sensitive pastoral theology needs to move in a more holistic direction: not only emphasising the aspect of sin or violation but also presenting God as the source of love and healing. This principle aligns with the cultural concept of Duan Lolat in the Tanimbar Islands, which emphasises both love [Lolat] and professional responsibility [Duan] (FGD – Kepulauan Tanimbar, P3, P5, P10).

From a clinical perspective, the interpretation of schizophrenia as a violation of customary law has a significant impact on the help-seeking pathway. Many families take their patients to traditional healers or traditional rituals before going to a mental hospital. For example, there are cases where families invoke ‘ancestors’ or ‘mawe-mawe people’ to heal their sick family members, but this fails, leading them to seek the services of a priest and be referred to a mental hospital (FGD – Buru, P5; FGD – Maluku Tenggara, P16). This phenomenon creates a dangerous delay in treatment. International research confirms that the longer the period of untreated psychosis (DUP), the worse the prognosis for schizophrenia patients (Sun et al. 2025).

Thus, belief in customary law violations is not only a cultural issue but also a clinical factor influencing the quality of recovery for schizophrenia patients (Cechnicki et al. 2014). Connecting these three perspectives, custom plays a dual role. From an anthropological perspective, it maintains social cohesion; from a theological perspective, it provides a moral and spiritual framework and from a clinical perspective, it has the potential to become an obstacle to recovery if not integrated with a medical approach.

Schizophrenia and sin

In the context of Maluku society, the meaning of schizophrenia is often inseparable from moral and spiritual categories. In addition to being associated with customary violations, interviews with priests show that mental disorders are often interpreted as the result of sin, both personal and inherited from the family (FGD – Maluku Tenggara, P.16; FGD – Buru, P8, P14, P16). Several cases indicate the belief that people with mental disorders (ODGJ) suffer because of their parents’ mistakes, infidelity, domestic violence or unresolved customary violations. This understanding gives rise to terms such as inherited curses, ancestral sins or divine punishment. These beliefs demonstrate that mental disorders are not viewed solely as medical illnesses, but also as spiritual phenomena closely linked to humans’ relationship with God and their community. That is why, in all cases of schizophrenia treatment, people prefer to take patients with schizophrenia to pastors or ministers in the congregation rather than taking them to the hospital. A pastor in Masohi told the story of a man who suffered from complications and nerve constriction for years, only left to lie in his room wearing black clothes (symbol of traditional clothing and service) because the family believed that the man’s suffering was because of having committed sins against God and ancestors. When the pastor offered the family financial assistance from the congregation to take the man to the hospital, the family maintained their opinion that it was better to take the man to the church for forgiveness of sins than to take him to the hospital. Finally, they agreed to have a doctor come to the family’s home. After being diagnosed with complications of the disease, which caused suffering, the family still maintained their position that it was only because of sin (FGD – Masohi, P6).

Theologically, the interpretation of schizophrenia as sin reflects a long tradition in which suffering is understood as an ethical and moral consequence. However, the biblical perspective itself rejects the linear relationship between suffering and sin. John 9:3, for example, asserts that the suffering of a man born blind is not because of personal sin or the sin of his parents, but rather so that the work of God may be revealed (Parihala 2019). Jesus’ statement is His critical response to the disciples’ question about the fact that the man they encountered was born blind. The disciples’ question in John 9:2: Who sinned, the man (the blind man) or his parents, that he was born blind? This question reflects the common societal perspective in the first century of the Common Era, which posits that a person’s suffering, misfortune and disability are forms of God’s punishment for personal sin and/or the sin of one’s parents (inherited sin) (Parihala 2021). Jesus’ answer in verse 3 is both a critique and a transformation of perspective, stating that there is no direct link between suffering and sin. Unfortunately, this understanding has not yet fully taken root in the community, so schizophrenia is still often viewed as a ‘curse of sin’. Field data indicate that the practice of praying for the termination of generational sin is carried out to prevent the ‘curse’ from being passed on to children. This phenomenon confirms that sin is not only understood as a moral fault but also as a transgenerational entity believed to be capable of causing mental suffering.

This is in line with the global literature, which shows similar phenomena. For example, Niehaus’s (Niehaus et al. 2004) study of amafufunyana in the Xhosa community confirmed that mental disorders are often interpreted as manifestations of evil spirits or family curses, despite clinical overlap with the category of schizophrenia. Thus, the meaning of sin in the context of schizophrenia can be understood as a product of the interaction between local beliefs, customs and clinical experience. From a medical anthropological perspective, sin is understood not only as a religious category but also as a social mechanism that maintains moral order within a community. According to participant-informant statements, there is a belief that mental disorders arise from sinful acts, such as infidelity, neglecting parents or domestic violence (FGD – Kepulauan Tanimbar, P14; FGD – Buru, P15; FGD – Maluku Tenggara, P16). Within this framework, sin functions as an aetiological narrative – a story that helps the community to explain why someone suffers. By positioning mental illness as a result of sin, the community simultaneously reinforces the moral norm that violations of social and religious ethics will have consequences.

The results of this study demonstrate that sin and schizophrenia are twofold. On the one hand, the sin narrative provides the community with an ethical and moral framework for understanding suffering. However, on the other hand, it creates stigma that worsens the patient’s condition. Therefore, the church needs to develop a theology of compassion based on culturally sensitive love. Sin should not be reduced to the sole cause of schizophrenia but rather placed within a broader framework: schizophrenia as a disease with biological, psychosocial and spiritual aspects. In this way, the sin narrative ceases to be a stigma but becomes an opportunity to emphasise God’s healing grace. The Kai-Wait approach can strengthen this by emphasising family solidarity. Rather than ostracising the patient for being ‘sinful’, the family is encouraged to accept the patient as a valued member of the family. Emotional and relational support have been shown to play a significant role in the patient’s clinical recovery.

Schizophrenia, black magic and mysticism

The experience of schizophrenia across cultures demonstrates a close link between psychotic symptoms and societal beliefs in supernatural powers. The presence of occult concepts such as black magic, jinn or supernatural powers often influences how patients interpret psychotic symptoms, how families respond and how the community evaluates treatment. These interpretations do not necessarily indicate that the symptoms are not biologically real; rather, they demonstrate that psychotic experiences exist at the intersection of biology, psychology and culture (Caqueo-Urízar et al. 2015; Cheng 2017).

Cross-cultural literature suggests that patients often interpret hallucinations and delusions as the result of spirits, jinns or black magic practices (Cheng 2017; Kirmayer 2018). The relationship between magical beliefs and schizophrenia has been consistently documented across cultures, for example, in Nigeria, Bangladesh and the United Kingdom (Cheng 2017; Gureje, Ojagbemi & Esan 2023; Mullick et al. 2013). This is in line with findings in Buru Regency, Tanimbar Islands Regency, and Southeast Maluku Regency, where mental disorders are believed to originate from demonic powers or black magic. This reinforces the argument that the meaning of psychotic symptoms cannot be reduced to purely biological explanations but must be understood within the patient’s cultural horizon.

Several studies have also shown a relationship between magical ideas, belief in the supernatural and religious practices in shaping the experiences of schizophrenic patients (Darban et al. 2023; Gupta et al. 2021; Pratiwi et al. 2025). The case study of ‘Jinn possession’ demonstrates the importance of considering the patient’s cultural narrative in understanding symptoms and behaviour, without denying the clinical reality of psychosis (Cheng 2017). In the Bangladeshi context, surveys have shown that beliefs in Jinn and magic dominate perceptions of psychotic symptoms (Mullick et al. 2013). Research in the UK has also shown that Jinn possession and occult practices influence the expression of psychological distress and require careful clinical assessment (Cheng 2017). Overall, the literature suggests that beliefs in supernatural powers are often part of how patients interpret psychotic experiences.

Several studies have shown that patients with schizophrenia often display a form of ‘magical thinking’ associated with psychotic symptoms. Globally, research on magical thinking suggests that magical ideas can coexist with psychotic symptoms without necessarily indicating the severity of the illness (Eckblad & Chapman 1983; García-Montes et al. 2014). Magical thinking has been studied as an indicator of schizotypy and can appear in patients with schizophrenia and requires a contextual reading that distinguishes between culture, personal beliefs and clinical pathology (Eckblad & Chapman 1983). Therefore, an approach is needed that appreciates patients’ magical narratives as part of their cultural identity, rather than accusing them solely of delusional symptoms without considering the local cultural context. This is consistent with findings in Maluku, where mysticism is not viewed as mere delusion, but rather as part of a spiritual reality acknowledged by the community. However, problems arise when these cultural beliefs lead families to shackle or rely solely on shamans, thus hindering access to medical treatment. Clinical literature emphasises that this delay in access worsens the prognosis (Sandbu et al. 2025), as seen in cases in Buru and Ambon City, where schizophrenic patients only improved after undergoing treatment in a psychiatric hospital.

Therefore, the phenomenon of ‘schizophrenia and black magic or mysticism’ requires a harmonious approach between biomedical studies, cultural understanding and spirituality. The presence of supernatural elements in the narrative of psychotic symptoms should not be treated as an obstacle to treatment, but rather as an opportunity to develop a more humane, contextual and inclusive care model.

Schizophrenia and ministry problems

One of the serious problems that emerged was the violent behaviour experienced by pastors when serving people with schizophrenia. Violence appeared in various forms according to the research narrative, such as (first) Beatings and physical resistance: A pastor was beaten when trying to reprimand a person with mental disorders who was destroying the pastor’s house (FGD – Buru, P1). Meanwhile, in Kabupaten Kepulauan Tanimbar, a pastor was kicked from behind by a schizophrenic patient (FGD – Kepulauan Tanimbar, P10). (second) Aggressive behaviour during prayer: The pastor was spat on while praying for the patient (FGD – Kepulauan Tanimbar, P11), and (third) the pastor prayed with his eyes open for fear of being beaten (FGD – Kepulauan Tanimbar, P11; FGD – Malra, P9). Threatening actions: In one case, a patient attempted to tear off the pastor’s robe during prayer under the pulpit, as the pastor’s robe was the only thing he feared (FGD – Kepulauan Tanimbar, P9). Other anarchic behaviour (fourth): The pastor felt disturbed because the patient kept approaching and asking to sleep in the pastor’s house (FGD – Buru, P7, P16).

This situation creates fear, causing some pastors to be reluctant or avoid direct service to schizophrenic patients. These data show that Christian service is not only about faith readiness but also related to the physical safety and psychological health of pastors as ministers. Pastoral literature emphasises that spiritual counsellors need to be equipped with therapeutic communication skills, crisis management and collaboration with healthcare workers so that the service does not cause new wounds for both ministers and patients (Herman & Senjaya 2024).

Another challenge in pastoral care for schizophrenics is the economic hardship caused by poverty. Maluku remains the fourth poorest province in Indonesia. Almost all schizophrenics come from poor families (Hursepuny & Chongloi 2025). Therefore, when advised to take a family member to the hospital for medical treatment, they are often refused. Furthermore, in areas remote from hospitals and medical services, isolation is a significant problem.

Pastoral care model – Counselling for schizophrenia patients

The pastoral care and counselling model, which incorporates prayer and pastoral counselling for patients with schizophrenia, is based on three interconnected dimensions: pastoral theology, practical counselling and collaboration with mental health services.

In the holistic theological-pastoral dimension, pastors start from the belief that every schizophrenic patient remains a dignified and beloved creation of God. The principles of Kai-Wait (Buru), Duan Lolat (Tanimbar Islands) and Ain Ni Ain (Southeast Maluku) form the basis of a culture that emphasises compassion and acceptance without stigma – that people with mental disorders are not strangers or enemies, but rather brothers and sisters and children who must be loved and embraced. The suffering of people with mental disorders is part of the suffering of the community, and therefore, providing support and services to people with mental disorders is also a shared responsibility within the community. Within this framework, prayer and liturgical services (worship) are not only aimed at seeking healing but also serve as symbols of acceptance, strengthening and reintegration of patients into the congregation as a community. Pastors pray not to replace the role of medicine, but to strengthen faith, bring hope, and foster a sense of security for patients and their families.

The practical, humanistic dimension of counselling provides a tangible bridge between spirituality and the patient’s psychosocial needs. The chaplain acts as a compassionate friend and empathetic listener, helping the patient interpret psychotic symptoms or delusions within a spiritual framework that provides meaning without denying medical reality. Counselling is also directed at the family, as stigma, shame and the tendency to restrict often arise from within the immediate environment. Through pastoral counselling, the family is equipped to see the patient as a valuable individual, reduce blame, and are encouraged to build supportive communication patterns. Prayer is an integral part of counselling, strengthening the family while reminding them that recovery is a long process that requires patience, faith and disciplined care.

In collaboration with mental health services, chaplains act as facilitators and liaisons. In cases of severe or recurrent symptoms, chaplains not only go beyond prayer or counselling but also encourage and accompany families to seek referrals to mental hospitals or other health professionals. This collaboration involves encouraging patient adherence to medical treatment, supporting their involvement in non-pharmacological therapies (such as group activity therapy, music therapy or social skills training), and integrating spiritual values so that patients feel their medical treatment aligns with their faith. At the same time, chaplains communicate with traditional leaders and congregations to avoid clashes between cultural, religious and medical understandings.

These three dimensions combine to create a complete service ecosystem: prayer and theology provide a spiritual foundation, pastoral counselling provides a compassionate, humanistic dialogue, and mental health collaboration ensures that patients receive appropriate clinical care. Thus, recovery for schizophrenia patients occurs not only in the medical aspect but also in relational, spiritual and social dimensions. This model emphasises that pastors, along with families, congregations and healthcare professionals, can work together as partners in the recovery process, so that patients are no longer isolated but instead accepted, supported and restored in God’s love and within a community of solidarity.

Conclusion: Pastoral counselling management of schizophrenia

We conclude this study with a proposal for pastoral counselling management in the treatment of schizophrenia. We classify this proposal into basic principles and stages of counselling patients with schizophrenia. We base our proposals on three pillars: pastoral theology, psychosociocultural and public health perspectives.

Acknowledgements

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Monike Hukubun: Conceptualisation, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualisation, Writing – original draft. Yohanes Parihala: Conceptualisation, Data curation, Formal analysis, Investigation, Methodology, Resources, Software, Supervision, Validation, Writing – original draft, Writing – review & editing. Fandro A. Tasijawa: Conceptualisation, Data curation. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication, and take responsibility for the integrity of its findings.

This research received a grant from the Ministry of Higher Education, Science and Technology of the Republic of Indonesia (Kemendiktisaintek RI) for the development of higher education research that has an impact on society (grant number: 0419/C3/DT 0500/2025).

The authors declare that all data that support this research article and its findings are available in the article and its references.

The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

References