Spirituality in the recovery from persistent mental disorders.

Mental health systems in this country are undergoing a quiet revolution. Former patients and other advocates are working with mental health providers and government agencies to incorporate spirituality into mental healthcare. While the significance of spirituality in substance abuse treatment has been acknowledged for many years due to widespread recognition of the therapeutic value of 12-step programs, this is a new development in the treatment of serious mental disorders such as bipolar disorder and schizophrenia. The incorporation of spirituality into treatment is part of the recovery model which has become widely accepted in the US and around the world. In 1999, the Surgeon General, in a landmark report on mental health, urged that all mental health systems adopt the recovery model. (1)

What distinguishes the recovery model from prior approaches in the mental health field is the perspective that people can fully recover from even the most severe forms of mental disorders. Services and research are being reoriented toward recovery from severe or long-term mental illnesses. (2) This creates an orientation of hope rather than the "kiss of death" that diagnoses like schizophrenia once held. One hundred years ago, Emil Kraepelin identified the disorder now known as schizophrenia as dementia praecox, a chronic, unremitting, gradually deteriorating condition, having a progressive downhill course with an end state of dementia and incompetence. (3) However, researchers have established that people diagnosed with schizophrenia and other serious mental disorders are capable of regaining significant roles in society and of running their own lives. There is strong evidence that most persons, even with long-term and disabling forms of schizophrenia, do "recover," that is, enjoy lengthy periods of time free of psychotic symptoms and partake of community life as independent citizens. (4) Daniel Fisher, a former patient, now a psychiatrist and internationally renowned advocate for the recovery model, maintains that

"Believing you can recover is vital to recovery from mental illness. Recovery involves self-assessment and personal growth from a prior baseline, regardless of where that baseline was. Growth may take the overt form of skill development and resocialization, but it is essentially a spiritual revaluing of oneself, a gradually developed respect for one's own worth as a human being. Often when people are healing from an episode of mental disorder, their hopeful beliefs about the future are intertwined with their spiritual lives, including praying, reading sacred texts, attending devotional services, and following a spiritual practice." (5)

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Recovery versus Medical Model

The medical model tends to define recovery in negative terms (eg, symptoms and complaints that need to be eliminated, disorders that need to be cured or removed). Mark Ragins observed that focusing on recovery does not discount the seriousness of the conditions (6):

"For severe mental illness it may seem almost dishonest to talk about recovery. After all, the conditions are likely to persist, in at least some form, indefinitely.... The way out of this dilemma is by realizing that, whereas the illness is the object of curative treatment efforts, it is the persons themselves who are the objects of recovery efforts."

Drawing on the 12-step approach to recovery from addictions, Ragins outlines an alternative to the medical model approach that he helped to develop for individuals at Village Integrated Services Agency (6):

1. Accepting having a chronic, incurable disorder, that is a permanent part of them, without guilt or shame, without fault or blame;

2. Avoiding complications of the condition (eg, by staying sober);

3. Participating in an ongoing support system both as a recipient and a provider;

4. Changing many aspects of their lives including emotions, interpersonal relationships, and spirituality both to accommodate their disorder and grow through overcoming it.

In the recovery model, healthcare professionals act as coaches helping to design a rehabilitation plan which supports the patient's efforts to achieve a series of functional goals. Their relationship often focuses on motivating and focusing the patient's own efforts to help themselves. What is important, particularly during the initial stages of interaction, is that professionals afford dignity and respect to those in their care. Respecting and supporting a patient's spiritual journey, as described later in this article, is often an important component of their recovery. In the words of one recovery center, "Recovery has so much to do with quality of life. And that may not necessarily mean going back to work or going back to school. It may mean developing friendships, belonging to a church, having a healthy body and a healthy mind." (7)

History of the Consumer Movement

The increasing adoption of the recovery model has evolved from the growing movement throughout the United States and the world of people calling themselves consumers, survivors, or ex-patients who have been diagnosed with mental disorders and are working together with mental health professionals to make changes in the mental health system and in society. The consumer movement grew out of the idea that individuals who have experienced similar problems, life situations, or crises can effectively provide support to one another. According Sally Clay, one of the leaders of this movement,

"The Consumer/Survivor Communities began 25 [now 45] years ago with the anti-psychiatry movement. In the 1980s, ex-mental patients began to organize drop-in centers, artistic endeavors, and businesses. Now hundreds of such groups are flourishing throughout the country. Our conferences (many sponsored by NIMH) have been attended by thousands of people. More and more, consumers participate in the rest of the mental health system as members of policymaking boards and agencies." (8)

Case Examples

Frederick Frese, PhD is a vocal example of the recovery model. Forty years ago, he was locked up in an Ohio psychiatric hospital, dazed and delusional, with paranoid schizophrenia:

"In March of 1966, I was a young Marine Corps security officer. I was responsible for guarding atomic weapons at a large naval air base and had just been selected for promotion to the rank of Captain. One day, during a particularly stressful period, I made a "discovery" that certain high-ranking American officials had been hypnotized by our Communist enemies and were attempting to compromise this country's nuclear capabilities. Shortly after deciding to reveal my discovery, I found myself locked away in the seclusion room of the base's psychiatric ward, diagnosed with schizophrenia." (9)

During the following ten years he was involuntarily hospitalized at a variety of psychiatric facilities around the country. Twelve years later, he had become the chief psychologist for the very mental hospital system that had confined him. Despite 10 hospitalizations, he married, had four children and earned a master's degree and doctorate. He is currently a prominent advocate for the recovery model.

In The Day the Voices Stopped, Ken Steele reports that staying medication compliant, having a therapist, having good friends and family, and working with the consumer movement were paramount in his recovery from mental illness. Ken's recovery began when he and his doctor discovered a medicine that softened the voices, and he was able to reconnect with his family, his faith, and to begin working for Fountain House. (10)

Recovery from Mental Disorder as a Spiritual Journey

Recovery from a mental disorder is experienced by many people as part of their spiritual journey. This was eloquently expressed by Jay Mahler, Program Director of the Mental Health Division of Contra Costa County:

"The whole medical vocabulary puts us in the role of a 'labeled' diagnosed victim.... But as they go through trial and error to control your symptoms, it doesn't take a genius to realize they haven't got the answers. No clue about cures! And oh boy, those side effects! I don't say medications can't help, or that treatments won't have value.

But, what I do say is that my being aware that I'm on a spiritual journey empowers me to deal with the big, human 'spiritual' questions, like: 'Why is this happening to me? Will I ever be the same again? Is there a place for me in this world? Can my experience of life be made livable? If I can't be cured can I be recovering, even somewhat? Has my God abandoned me?' We who have it have to wonder whether what remains constitutes a life worth living. That's my spiritual journey, that wondering. That's my search." (11)

Sally Clay, who was hospitalized at the Hartford Institute of Living with schizophrenia, writes: "My recovery had nothing to do with the talk therapy, the drugs, or the electroshock treatments I had received; more likely, it happened in spite of these things. My recovery did have something to do with the devotional services I had been attending.... I was cured instantly--healed if you will--as a direct result of a spiritual experience." (8)

Mental Disorder and Genuine Spiritual Experience

Many years later Clay went back to the Institute of Living to review her case records and found herself described as having "decompensated with grandiose delusions with spiritual preoccupations." (8) She complains that her spiritual experience, neither its difficulties nor its healing, was "recognized as legitimate." Clay makes the case that, in addition to the disabling effects she experienced as part of her illness, there was also a profound spiritual component that was ignored. She describes how the lack of sensitivity to the spiritual dimensions of her experience on the part of mental health and religious professionals was detrimental to her recovery. Clay considers her mental illness to have been a "spiritual crisis" for which "finding a spiritual model of recovery was a question of life or death.... My experiences were, and always had been, a spiritual journey--not sick, shameful, or evil." (12)

Pat Deegan also makes the point that psychosis can be a genuine route to spirituality:

"Distress, even the distress associated with psychosis, can be hallowed ground upon which one can meet God and receive spiritual teaching. When we set aside neurobiological reductionism, then it is conceivable that during the passage that is madness, during that passage of tomb becoming womb, those of us who are diagnosed can have authentic encounters with God. These spiritual teachings can help to guide and encourage the healing process that is recovery." (13)

Studies have shown that religious content occurs in 22 to 39% of psychotic symptoms. (14,15) One study of hospitalized bipolar patients found that religious delusions were present in 25% and over half of the hallucinations were brief, grandiose, and usually religious. (16) Goodwin and Jamison suggest that there "have been many mystics who may well have suffered from manic-depressive illness--for example, St. Theresa, St. Francis, St. John." (16) During manic episodes in particular, people have experiences similar to those of the great mystics. (17)

Jerome Stack, a Catholic Chaplain at Metropolitan State Hospital in Norwalk, California for 25 years, has observed that many people with psychotic disorders do have genuine religious experiences:

"Many patients over the years have spoken to me of their religious experience and I have found their stories to be quite genuine, quite believable. Their experience of the divine, the spiritual, is healthy and life giving. Of course, discernment is important, but it is important not to presume that certain kinds of religious experience or behavior are simply 'part of the illness." (18)

Psychotic experiences which have religious/spiritual content can be explored to find sources of strength, hope and belief that can provide spiritual support.

Research on Spirituality and Recovery from Mental Illness

A number of studies show that spirituality plays an important role in the recovery process for many. Fallot analyzed the key religious and spiritual themes in recovery narratives drawn from spiritual discussion groups, trauma recovery groups and other clinical groups at Community Connections, a mental health facility for people diagnosed with severe mental illness. (19,20) He found that although organized religion had been experienced as stigmatising and rejecting on some occasions, on the whole a personal, spiritual experience of a relationship with God helped build hope, a sense of divine support and love, the courage to change and to accept what cannot be changed, connection with faith communities, and supported calming practices such as prayer, meditation, religious ritual, religious reading, and listening to religious music.

The authors found three key themes. First, spirituality played a positive role in coping with stressful situations, and helped adherents to avoid drug use and negative activities. Second, church attendance and a belief in a higher power provided social and emotional support. Third, spirituality enhanced the sense of being whole. Sullivan conducted a qualitative study (21) involving 40 participants which sought to uncover factors associated with the successful adjustment of former and current consumers of mental health services. In it, 48% of participants found that spiritual beliefs and practices were identified as essential.

Jacobson (2001) applied the technique of dimensional analysis to 30 recovery narratives. (22) She identified a spiritual or philosophical crisis as destroying and then recreating the self:

"The crisis is an altered state of being. 'Mental illness' is the label society gives to these crises, but such designations don't represent reality. Standard interventions by the system--especially medication--hinder the individual's ability to seek and find the truth that can end the ordeal. Other people can be helpful only to the extent that they themselves have been through similar experiences or are willing to acknowledge the ineffable nature of the crisis. The greatest help comes when individuals are able to connect with some source of enlightenment; a community of practicing Buddhists, the Bible, treatises of philosophy or physics. Recovery is about enduring and coming out the other side. Coming back to life, in a recreated and enlightened self, the individual discovers new 'wisdom and compassion'. Those who have recovered, then, are obligated to demonstrate this wisdom and to practice compassion by reaching out to others who are in the midst of their own crises." (22)

Several studies document that patients with serious mental disorders use religion to cope with their illness, (23) and that the intensity of religious beliefs is not associated with psychopathology. (24) In many cases, religious practices (such as worship and prayer) appear to protect against severity of psychiatric symptoms and hospitalization, and enhance life satisfaction and speed recovery in mental disorders. (25)

However, many patients have been found to hold dysfunctional beliefs about their disorder. One study of 52 psychiatric inpatients found that 23% believed that sin-related factors, such as sinful thoughts or acts, were related to the development of their illness. (26) This is clearly a guilt-inducing belief for which there is no evidence, and one that the vast majority of religious professionals would challenge.

Studies have found that psychiatric patients are as religious as the general population and they turn more to religion during such crises. (27) In a study of the religious needs and resources of psychiatric inpatients, Fitchett et al found that 88% of the psychiatric patients reported three or more current religious needs. Psychiatric patients had lower spiritual well-being scores and were less likely to have talked with their clergy. They concluded that religion is important for the psychiatric patients, but they may need assistance to find resources to address their religious needs.

Many patients make use of religious and spiritual practices during their recovery. Among a sample of 157 patients, 86% of whom were on psychotropic medications, 50% reported using religious/spiritual reading, 31% meditation, and 20% yoga. (28) Another study of 74 patients with acute psychotic symptoms followed up every 6 months for 2 years found that 30.2% of these patients reported an increase in religious faith after the onset of the illness, and 61.2% reported they used religion to cope with their illness and to get better. (29) Eighty-three per cent of psychiatric patients in a different study felt that spiritual beliefs had a positive impact on their illness through the comfort it provided, and the feelings of being cared for and not being alone it engendered. (30)

Providing Spiritual Support

For many people, having a relationship with a higher power is the foundation of their psychological well-being. Providing spiritual support involves supporting the patient's sense of connection to a higher power that actively supports, protects, guides, teaches, helps, and heals. Some researchers have suggested that the subjective experience of spiritual support may form the core of the spirituality-health connection. (31) There is evidence that indicates that persons with mental disorders utilize their spiritual resources to improve functioning, reduce isolation, and facilitate healing; nonetheless, "mental health professions have a long history of ignoring and pathologizing religion." (25)

Spirituality is an important coping mechanism because individuals seek meaning when experiencing severe illnesses. Therefore promoting religious and spiritual beliefs and practices is appropriate with patients who are open to accepting that approach. Studies consistently show that at least two-thirds of people are open to such discussions with their physicians. For example, 66% of hospitalized pulmonary patients said they would "welcome religious questions in medical history"; 16% of patients, however, said they would "not welcome religious questions." The healthcare professional needs to be sensitive to the patient's religious values in any interventions incorporating spirituality. (32) In most cases, healthcare professionals can provide spiritual support to people coping with mental disorders by devoting some time to exploring spiritual issues and asking questions to discover a patient's deeper meaning in life. Healthcare professionals can initiate support of a patient's spirituality-health connection through a spiritual assessment such as the FICA interview, (33) now taught at over two-thirds of medical schools, which includes four questions and can be administered in 3 to 5 minutes.

In 2003, Randal, Simpson, and Laidlaw conducted a study (34) to assess whether a recovery-focused, multimodal therapy can improve the symptoms and functioning of treatment-resistant psychotic patients. Their treatment included medication, supportive therapy, focus on recovery, spirituality, and cognitive-behavioral therapy, as well as psycho-education and affective regulation. Although the sample size was small (9 patients), they found a significant improvement in the overall positive and negative symptoms. Of special note is the spiritual focus of the treatment.

Spiritual support can include:

* Educating the patient about recovery as a spiritual journey with a potentially positive outcome;

* Encouraging the patient's involvement with a spiritual path or religious community that is consistent with their experiences and values;

* Encouraging the patient to seek support and guidance from credible and appropriate religious or spiritual leaders;

* Encouraging the patient to engage in religious and spiritual practices consistent with their beliefs (eg, prayer, meditation, reading spiritual books, acts of worship, ritual, forgiveness and service). At times, this might include engaging in a practice together with the patient such as meditation, silence, or prayer;

* Modeling one's own spirituality (when appropriate), including a sense of purpose and meaning, along with hope and faith in something transcendent.

Conclusion

People recovering from mental disorders have rich opportunities for spiritual growth, along with challenges to its expression and development. They will find much-needed support for the task when they are clinically guided to explore their spiritual lives. Thus directed, they can begin to create a positive health-promoting outcome for their spiritual journey in recovery.

References

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The reward of patience is patience.
--Saint Augustine

David Lukoff, PhD

From the Spiritual Competency Resource Center, Peta Luma, CA.

Reprint requests to David Lukoff, PhD, Spiritual Competency Resource Center, 1035 B Street, Peta Luma, CA. Email: [e-mail]