There are many challenges facing the care of persons with mental illness. Most people who have been diagnosed face stigma from multiple directions, such as society, friends, family and health care practitioners and face obstacles to the best course of treatment depending on the philosophies of their healthcare provider. Historically, the medical model approach in Western culture continues to attempt to address only the physiological aspects of mental illness without taking into account the individual’s needs. Once the most overt physical manifestations of the illness are considered controlled with medication, it was left up to the patient to continue taking their medication as prescribed. However, medications for these symptoms are not improving cognitive or overall functioning (Chung, 2010). Chung (2010) continues to state that the belief that these medications could provide a “cure” combined with the humanistic movement to rescue patients from mental hospitals, has only resulted in decreased physical health, poverty, vagrancy and increased contact with the judicial system of those diagnosed with mental illness. This resulted in an increased demand for community involvement. Mental health professionals were forced to become more creative in treatment modalities. Along the lines of a more humanistic proposition, overall well being began to be addressed. In an attempt at a more holistic approach, more facets of the individual were being investigated to help address an illness that affects all areas of lifestyle, including physical health, vocation, social circles, and basic living skills. Spirituality and religion, once deemed incompatible with science, began to be looked upon as a tool to assist clients in the recovery process (Blanch, 2007).
An important factor when addressing spirituality and religion is to review the definitions of each. According to Brennan and Heiser (2004) religiousness is typically the ritualistic behavior of an inner spiritual life, while spirituality can exist in absence of religious affiliation. Hodge (2004) defines spirituality as an individual’s existential relationship with God (or other perceived transcendence), whereas religion is defined as an institutionalized set of beliefs and practices that have been developed in a community by people who share similar experiences of transcendent experiences. Kaye and Raghavan (2002) idealize spirituality as a broad concept that includes religion as a subset, viewing religion as a code of conduct including rituals and values. To better understand the subtle differences between spirituality and religion would be to relate spirituality as culture and religion as a subculture. For example, a person can identify themselves as Hispanic and identify with Hispanic culture as well as choose to be in an exclusively Hispanic gang, a subculture, or choose not to be a part of a distinct group (opting out of a subculture). Finally, Martsolf and Mickey (1998) view spirituality as having five features: “meaning, connecting, transcendence, value and becoming” To be spiritual has many meanings and no distinct definition and is all inclusive, whereas one may choose to utilize that spirituality in a specific group of like minded people, such as through the Christian church.
Religious Perspectives on Mental Illness
Oftentimes religion is the first contact with a person with mental illness (Stanford, 2007). The person seeks counsel with their religious counselor and depending on that initial contact is dependent upon the type of help they will seek. Due to this inclination, it is imperative for a religious leader to be educated on mental illness with the freedom to translate within their personal religious doctrine. Reciprocally, so should a mental health professional be aware of the religious or spiritual beliefs of the client and feel comfortable discussing interpretations of mental health symptoms through the lens of the client’s beliefs (Miller, 1990). Working as an integrated team can increase the likelihood of positive outcomes to recovery.
The Christian faith is based on the Bible, a religious text that includes the Old Testament and the New Testament. The Old Testament includes a creation story and a genealogy of important figures that had a direct contact with God. The New Testament includes the story of Jesus, believed to be the son of God sent to assist the world in salvation, and his disciples, who outline the tenants of Christianity after the death of Jesus. The divine is a trinity including God, his son Jesus, and a Holy Spirit, that resides internally within all living things. The religion also believes in a dichotomy of good and evil, where evil is portrayed as a fallen soldier of God known as the Devil. The rituals of Christians include prayer, church attendance, studying and following the values taught in scripture, and being active in a Christian community (Hartog & Gow, 2005)
Historically speaking, Christianity and psychology have not always had a mutually respectful relationship. Christianity previously believed that mental illness was a sign of demonic possession, a separation from God, or the result of sin (Hartog & Gow, 2005). However, as more of the population begins to have a basic understanding of psychology and more individuals come in contact with persons with mental health diagnoses, the focus becomes not on the cause of such a disease, but more towards how the Christian faith can assist those afflicted, although Hartog and Gow (2005) found that a third of Christians in their study still report demonic activity as an underlying cause.
Sanford (2007) sought to survey the experiences of those persons with mental illness with the Christian church. His findings were consistent with Hartog and Gow (2005). While the majority of those surveyed had positive interactions of acceptance and support within the Christian community, approximately 30% were told that the mental illness was directly correlated with a personal sin, denied that they were properly diagnosed with the mental illness, or told that they should not continue the prescribed medication, with the most prevalent reaction being abandonment or isolation from the church. As a result of these interactions, 27.3% said their faith was weakened or that they no longer identified themselves as Christians. Alarmingly, this study revealed that women more than men were most likely to experience a negative interaction.
It is important to remember that the majority gleams hope, stability, and support from the Christian faith (Stanford, 2007). These qualities are highly desirable for continued recovery from mental illness. Another important aspect to recovery within the Christian faith is the family support and guidance that is provided by the pastor and Christian community.
Hindu is considered the “world’s oldest religion” although it is better classified as a life philosophy rather than a religion. Its various texts were originally written in Sanskrit and are called Vedas. Vishnu, also known as Shiva, is the male aspect god and Shakti is the female aspect of god. There are multiple other icons that are deemed lower than Shiva and Shakti, but just as important (Parrinder, 1971, p. 192). Hindus believe in karma, or reincarnation, and dharma, a conglomerate of universal order, divine law and spiritual duty (Wig, 1999). The underlying belief is of interconnectedness within the universe, that all people and things are related and therefore, Shiva and Shakti reside within the individual and not separate from the person (Wig, 1999). Hindus believe that there is no right and wrong way of worshipping the divine and are therefore very tolerant and accepting of different spiritual views. The rituals performed in Hinduism include meditation, chanting, shrines and icon worship, yoga and reading of the Vedas.
Hindu has long been practicing a bio-social-spiritual model to all areas of health. Mental health can be described as a wheel with a central axis and three spokes. The center is called Dharma (righteousness, virtue and religious duty), the spokes are considered Kama (biological), Artha (social) and Miksha (spiritual) (Campion & Bhurgra, 1998). In the Hindu religion, illness arises out of the imbalance between these aspects. An individual is deemed weakened if their actions stress the relationships with their community and within their community due to the Hindu beliefs that all are interconnected (Navsaria & Peterson, 2007).
Many of the practices believed to restore balance include puja rituals, such as worship and devotional offerings to god, fasting, and meditating to positive and strengthening messages (Navsaria & Peterson, 2007). In a study conducted by Campion and Bhhurga (1998), where the religious treatment of those persons considered mentally ill in Southern India was recorded, the religious leaders asserted that religious treatment was not necessarily the most effective method to certain illnesses. If the wrong therapy was used, it could complicate the effects of the illness within the person. However, some of the treatments observed were residential stays at the temples, daily prayers and meditations to a religious shrines dedicated to the healing of specific psychiatric illnesses, drums and music, and in some cases considered severe, the patient was chained to the walls in order to increase their focus on recovery (Campion & Bhurgra, 1998).
From a Hindu perspective of interrelatedness, family is seen as a primary source for strength and support for the person with mental illness (Campion & Bhurgra, 1998). For Hindu men, mental illness is seen as sorrowful, whereas for Hindu women it is perceived as shameful or negative omen for the whole family unit because the women mirror the integrity of the family (Navsaria & Peterson, 2007). These beliefs affect the rate in which women are diagnosed as mentally ill, as well as the prevalence of sought treatment.
Islam is a worldwide religious movement founded my Mohammed, a prophet, with most of its followers residing in Pakistan, Bangladesh, and India. They believe in one divine Creator named Allah, and follow the religious text called the Qur’aan (Parrinder, 1971, p. 462). It is believed that God sent Mohammed, the last of all prophets, in an attempt to once again rectify man to the guidance of a Divine Creator. It is through Mohammed that an angel of God brought the scriptures that make up the Qur’aan. The ritualistic practices of Islam include daily prayers facing Mecca, reciting of the Qur’aan, fasting, and the paying of alms.
Individuals in the Islamic faith are believed to be the interaction of four parts: Aql (mind), Jism (body), nafs (self), and Ruh (soul/spirit).Harmony between these sections is necessary in order to obtain health, both physically and mentally. The cause of mental illness is seen as imbalance of these parts due to demonic possession by jinn (evil), a result of witchcraft or as a natural manifestation (Ally & Laher, 2008). According to Ally and Laher (2008), treatment of mental illness is on the part of the Baba (a Holy man). The Baba performs a type of exorcism where the Qur’aan is consistently read to the patient as well as blown on them and written on paper to be kept with the patient at all times. Daily prayer and remembrance of the Almighty are also considered effective treatments. These are believed to restore the belief of the individual, considered the essential element to healing.
Practical Applications of Spirituality and Religion to Psychiatric Rehabilitation
A survey conducted by Bussema (2007), found the majority of people in a psychiatric rehabilitation program believed that their faith played a significant role in their recovery. The meaning these patients put on their spirituality is that it helped them to cope with difficult times, gave them a sense of usefulness, allowed them to feel a part of (as in fellowship), gave them peace and comfort, and provided them with a sense of purpose. This parallels the recovery goal of possessing a more positive worldview that situations will work out for the good, therefore increasing quality of life and integration into their community (Bellamy,et al., 2007)
To begin a therapeutic relationship with a person with mental illness it is imperative that the perspective of the client be acknowledged and understood by the mental health practitioner. Assessing for spiritual views, as well as being open to religious discussion, can help establish rapport and trust with the client (Lloyd & O'Connor, 2007). It may also lend to increased participation in peer-supported group therapy.
Wong-McDonald (2007) reviewed the use of spiritual groups in the rehabilitation process. The spiritual group she studied was an optional part of a community mental health center. It was an ongoing program that allowed the client control of when and how often they would attend. The main purpose of the group was to allow the open discussion of spirituality as it related to recovery of mental illness. The topics discussed in this group were spiritual concepts (i.e. self-worth, peace, love, faith), forgiveness (as related to rebuilding previously damaged relationships), spiritual writings and encouraging support from within the group.
It was found that of the 20 participants that attended this group for a minimum of three months atleast half of the time, 100% completed their 6 month treatment goals. This was compared to a control group of 28 community mental health center clients who chose not to attend the spiritual group. Only 16 of those individuals completed their treatment goals.
The Clinical Research Evaluation Facility of the Nathan Cline Institute for Psychiatric Research offered a more structured group treatment approach to address spirituality (Revheim & Greenberg, 2007). In their study, Revheim and Greenberg (2007) described a group led by 3 leaders, one each from a psychology perspective, a religious perspective and a rehabilitation perspective. The format addressed cognitive deficiencies as well as restricted social skills while exploring nondemoninational religious and spiritual themes. Activities and excerises included reading from the Book of Psalms, reciting prayers, writing original prayers and reading spiritual stories in order to facilitate spirituality as a coping mechanism.
These examples of spiritual group support utilized a more Judeo-Christian perspective, as the majority of the members identified with that faith, however, the format of these groups could be utilized with most religions. Using readings of scripture and prayers original to a religion can be integrated into group or individual therapy. As with most religions reviewed, both habits are already extensively used by indigenous leaders. Uplifting music is used as a religious practice in Christianity and Hinduism. Reserving time to read religious stories and reflect on the underlying message can be used by the client to relate and apply to their individual experiences.
Treatment methods from religion can also be integrated into a recovery community. Yoga, a spiritual practice in Hindu, may to help strengthen the mind-body connection and assist in teaching a client to relax during difficult times. Meditation, practiced in Hindu, Islam, and Christianity, is a way in which to feel connected to the Divine and may ease feelings of loneliness or despair while strengthening the resolve of the client to remain focused on recovery. To apply these in a treatment setting could easily be done by setting aside time and space for 30 minute sessions, led by a CD or DVD. The experience and perceived benefits of these practices could be further reviewed with the therapist in individual or group sessions.
Many barriers are faced by persons diagnosed with mental illness including disruptions in biological, psychological and social aspects of life. Spirituality and religion can provide a a source of strength and guidance that parallel with values of the recovery paradigm. Understanding different religious perspectives can not only help the therapist to understand the perspective of the client, but can also influence holistic treatment applications used to aid the client in their recovery goal. However, spirituality and religious views are not just limited to treatment of a mental illness, but spiritual values have also been applied to vocational rehabilitation. In order to provide a more holistic approach to psychiatric rehabilitation, addressing spirituality and religious views integrates the entire view of an individual.