Spirituality and Mental Health: A Very Preliminary Overview
Abstract and Introduction
Purpose of review: Demand for the spiritual dimension to be taken account of in the diagnosis, treatment and care of people with mental ill-health has come strongly from users, carers and professionals.
Recent findings: Research in the US over the past 10 years has shown a clear correlation between affiliation to a religious group and better outcomes in terms of mental and physical health, and even longevity. In the UK, however, the evidence from research is much less clear, and needs a more focused approach to really elucidate what helps people stay mentally healthy and recover from mental ill-health.
Summary: Spirituality is now a key issue as individuals, communities and mental health services struggle to combine technical efficacy and business efficiency, but remain human, so as to nurture service users, carers and staff. This is set in a postmodern world, scarred by the trauma of 9/11 and its aftermaths, and in the context of a global consumerism, which has resulted in individuals being increasingly atomized and isolated. A consumerist society means that those classed as 'deficient consumers', especially those whose ill-health and/or poverty excludes them from the marketplace, are seen as outsiders and a dangerous class.
Today, it is widely recognized that the religious wars in Europe in the 17th century brought organized religion as a force for good into disrepute. The Enlightenment promised a new and improved approach to the ascent of human knowledge and societal interaction, but that has had its drawbacks as well, as rationality has sometimes slid into a form of: all that matters is what you can measure! Michel Foucault's critique of the birth and growth of the mental health system demonstrates how classification and measurement can squeeze out humanity. This debate is current, as surveys of user satisfaction by the inspection bodies in the UK, such as the Healthcare Commission and the Commission for Social Care Inspection, invariably discover that people desire technically competent services but also, crucially, to be treated as individuals, with courtesy, dignity and respect, and with a regard to their cultural identity. Professor Kamlesh Patel, in launching the National Census of In-patients in Mental Health Hospitals in England and Wales, posed the crucial question:
If you don't know who I am, how are you going to provide a package of care for me to deliver something? When you do not know how important my religion is to me, what language I speak, where I am coming from, how are you going to help me cope with my mental illness?
The recent survey by the National Health Service Confederation expressed concern that the culture in the National Health Service was such that it was not conducive to creating an ethos where human beings, at their most creative, could minister to the needs of patients.
The US and Australasia began to engage with issues around spirituality and religious faith earlier than in the UK. This was apparently because professionals leaving medical schools and universities educating social workers and nurses, among others, found themselves working with people who wished to discuss issues around the spiritual dimension of their lives and the existential challenges they faced that had not been covered in professional courses.
When John Swinton from Aberdeen University published his seminal work Spirituality in Mental Healthcare, he subtitled it: 'Rediscovering a forgotten dimension'. Other works have followed, most notably in the general field of medicine, e.g. Medicine of the Person, and again, in mental health, the forthcoming book by Coyte et al., which, as its title suggests, Spirituality, Values and Mental Health: Jewels for the Journey, is a compilation of the academic and the personal. Chapters on research, values, organizational efficacy and leadership, etc., are interspersed with personal reflections. Indeed, a number of the main chapters by professionals, such as Andrew Powell (a psychiatrist who was the first Chair of the Royal College's Special Interest Group in Spirituality and Psychiatry), have a personal perspective to them.
Spirituality and Religion
Not everyone welcomes the word 'spirituality'. For some, it is too diffuse, even misleading. The former Bishop of Durham, David Jenkins, described spirituality as 'a weasel word', perhaps because it allows people to access certain concepts and experiences that have previously been the province of 'religion'.
What is clear from etymology is that the word and concept of 'spirit' is very prevalent amongst all the philosophies and religions, and, whilst almost certainly, of a longer provenance, came into great prominence during an age which Karen Armstrong describes as 'the great transformation'. There is a helpful explanation of the Jewish concept of 'spirit' (ru'ach) in the Jewish contribution to the Staffordshire University Monograph of the Nurturing Heart and Spirit Symposium and also in Ray Anderson's book on spiritual care-giving. Judaism refers to the spirit as not only life, but invigorated life; in Islam, ruh is seen as the very breath from God that embodies the potential moral and positive characteristics that we hold.
For many people who use mental health services, or who describe themselves as survivors, spirituality is what is deepest within them; what makes them 'tick'; their motivating force. As one service user in the Croydon Mind DVD Hard to Believe (2005; https://www.mindincroydon.org.uk/videos.asp) describes it: 'My spirituality is an anchor to my soul', and perhaps in a postmodern world, and what Zygmunt Bauman terms 'liquid modernity', where the familiar lighthouses and landfalls are no longer present, this is particularly pertinent. People have to discover, make and re-make their own identity.[12,13]
Spirituality relates to that dimension of ourselves as human beings which erects frameworks of meaning that provide a motivating force to our lives. Spirituality is associated with the pilgrimage of life; connection with other people and the natural world; a sense of the sacred; and a reaching out to something beyond ourselves. The stress on hope and creativity has many resonances with the Recovery Movement, referred to below.
Religion encompasses many aspects within the concept of spirituality, usually in the context of belief in a transcendent being or beings, and with a meta-narrative which seeks to explain the origins of the world and those living in it; and the questions which face human beings around life, suffering, death and re-awakening in this world or another.
Religion can provide a worldview which is acted out in narrative, doctrine, symbols, rites, rituals, sacraments and gatherings, and the promotion of ties of mutual obligation. It creates a structure which can be a framework for meaning or a restricting and restrictive straightjacket.
Again, just as religion encapsulates many aspects of spirituality, so secular societies, or what I call 'communities of meaning', can have many of the ascriptions of religion. Human societies which provide support and significance, within a structural frame, may well provide the essence of a secular faith community. Research studies demonstrate that membership of a faith community produces increased benefits in terms of physical and mental health and longevity.[5,15] Robert Putnam, the doyen of social capital, has moved from a study on the decline of American community, Bowling Alone, which has a chapter on religion, to a work which will focus entirely on religion as an ingredient in social cohesion. Social capital, in effect, has its own political debate within the subject. Of course, social groupings will have their exclusionary elements. Forming a group which creates solidarity for some will almost inevitably mean exclusion for others, but what is lacking for many people now is a sense of community in which to place a hope for mental well being. Chief Rabbi, Jonathan Sacks, sums up what community, including faith communities, can mean, in the graphic phrase: 'A community is where they know your name and when they miss you when you're not there. Community is society with a human face'. What is not at all clear, is how far the benefits of religion are to do with the belief in a transcendent deity and how much it is connected to community solidarity. Staffordshire University has recently begun to arrange a series of symposia on multifaith perspectives (including Humanism) to mental health issues. Many faiths, perhaps specifically in the Abrahamic ones of Judaism, Christianity and Islam, speak of a surrendering to the will of the Divine, in a way which is not much in tune with modern individualism, but can bring much comfort. For those experiencing extreme mental distress, the Muslim Zikr, or remembrance of God, or a Christian identification with Christ suffering on the cross, can be most helpful. At times we need to lay the burden of living on others, at a corporeal or spiritual level, to gain some respite. As one service user put it (p. 113):
When I'm in a phase that I'm able to believe that there is a God who gives meaning to that universe, then I have hope. But there have been spells when I haven't been able to believe that, and that has been absolutely terrifying. That's been falling into the abyss.
The trenchant criticisms of religion, by such as Richard Dawkins, and, at a less polemical level, the evolutionist explanation of religious sentiment by Daniel Dennett, has tended to bring a more individual focus to the spiritual dimension.
The most severe critics of organized religion recognize that human beings cannot live by bread alone. David Hay, in his extensive research in Nottingham, speaks of an increasing awareness of, and interest in, spiritual matters, at a time when belief in mainstream religion declines (note, however, this needs to be said with reservations because, as some mainstream organized religion declines, there is a growth of Muslim, Sikh and Hindu communities in the UK; a rapid expansion of Pentecostal-style Christianity; and the influx of Polish workers has re-invigorated many Roman Catholic parishes). Hay, a zoologist and Christian, who combines his Christian faith with a strong sense of evolutionary progress, has a very profound respect for those he has interviewed in depth, and highlights the complexity of belief as people move in and out of belief systems for perfectly genuine reasons. The more pluralistic a society, the more likely it is that people will move between belief systems as they become exposed to them. As the evolution of the human mind and spirit progresses it is, perhaps, not unusual to find that people's sense of a greater synergy between people and events is heightened.
Neuroscience and quantum physics move into the equation, with the quantum physicist Dana Zohar and psychiatrist Ian Marshall, speaking of spiritual intelligence, and recent research by Beauregard and Paquette carrying out a fascinating study of the spiritual experiences of Carmelite nuns, which suggests that mystical experiences are mediated by several brain regions and systems, but also that these are different regions than those activated by the recall of human emotional encounters.
If individual spirituality seems more attractive in an age of individualism than organized religion, then there is a cautionary note from commentators such as Carrette and King arguing that spirituality is in danger of becoming another consumerist product of global capitalism, increasing the atomization of human beings and being an easy escape clause from social responsibility. Recent research for the Joseph Rowntree Foundation by Dorling et al. has shown rising levels of inequality in Britain, echoing trends in the US, and this appears to be having a de-stabilizing effect on people's mental well being, as aspirations are stretched further and further in front of people, as though the finishing tape in a race was constantly moved ahead of the runners. Mirroring this is the concern raised by the British Medical Association about the rising levels of depression and self-harm amongst children.
The Mental Health Foundation, a London-based UK-wide mental health charity, produced a review of the literature on the impact of spirituality on mental health in 2006. During research service users were asked to describe the role spiritual and religious beliefs and activity had in their lives, and a number of themes emerged, including the importance of guidance, a sense of purpose, comfort, grounding, the allowance of expression of personal pain, and the development of inner love and compassion for others. Service users regarded these as positive in terms of their mental health. In the context of depression, the research quotes Hodges as considering four dimensions of spirituality: meaning of life, intrinsic values, belief in transcendence and spiritual community. Hodges proposes that each of these has a part to play in the incidences and intensity of depression. It is interesting that Lewis Wolpert, in his book: Malignant Sadness: the Anatomy of Depression, describes depression as 'soul loss'. This is an interesting use of words and concepts, as Wolpert, a prominent scientist, describes himself in the book as a 'hard-line materialist'.
Recent research in England shows a much more complex picture than appertains in the US. The research by Michael King et al. points out that whilst much of the research in the US relates to 'Judeo-Christian concepts of religion in white, North American populations', the EMPIRIC (Ethnic Minority Psychiatric Illness Rates in the Community) study looked at six ethnic populations: Irish, Black Caribbean, Indian, Pakistani, Bangladeshi and White. The results, as one might expect from such a survey, are complex; the findings showed no difference in the prevalence of common mental disorders in people who were religious and those who were not. Perhaps, strangely, people with a spiritual view, but without religious practice, had a greater likelihood of common mental disorders than people with a religious view and those with no set belief system.
A study of this type almost certainly calls for more detailed research into the complexities of a society that is showing considerable tensions within different religious groupings and cross-fertilization between belief systems. The increased occurrence of common mental disorders amongst those reporting a spiritual orientation, but the absence of a religious framework, may be that those who are more sensitive to others and to societal pressures, in a society with few social supports, may find themselves to be particularly vulnerable.
The Mental Health Foundation literature search also argues for more detailed research, going into greater depth on specific issues and experiences.
In the UK, the Royal College of Psychiatrists have now had a special interest group running for several years (https://www.rcpsych.ac.uk/college/specialinterestgroups
/spirituality.aspx). This is now the fastest growing special interest group in the College and a publication will be issued in 2008 encapsulating the work of the Group.
Nursing has seen work by Professor John Swinton, Linda Ross and Wilf McSherry. Social work, sadly, lags behind, probably due to its suspicion of institutional religion, which has some justification. New proponents are coming on to the scene, such as Professor Bernard Moss and Professor Margaret Holloway.
If spirituality is our motivating force as human beings, then it must be connected with a whole range of other concepts and experiences. The work by Professor Bill Fulford and Kim Woodbridge has brought values centre-stage in areas of law, policy and practice.
Many commentators were taken by surprise that the British Government began to be interested in the concept of 'happiness'. The imperative behind this is clearly that, in a 'knowledge economy', mental well being and stability is essential, as is creativity; and in a complex multicultural society (however you view 'multiculturalism') social stability and cohesion is, again, of vital importance. Professor Richard Layard, an economist from the London School of Economics, raised all these issues in his book Happiness: Lessons from a New Science. Of course, happiness is very much linked in with issues around expectations, as epidemiologist Michael Marmot pointed out in his book Status Syndrome. Darrin McMahon, in his magisterial overview of The Pursuit of Happiness, points out that happiness is a relatively recent development. Historians of the Greco-Roman world, in fact, point to the fact that the concept of individualism does not appear in the earliest Greek poetry, but develops as the growth of the life of the polis proceeds. Now we often find this strange in the West, but Okasha raises similar issues around the ideal of family and the ideal of the individual. McMahon (p. 15), in fact, raises the question as to whether, perhaps, 'the search for happiness' might 'entail its own undoing? Does not our modern commandment to be happy produce its own forms of discontent?'. Robert Lane, again, looks at how happiness can be ephemeral if the life of the spirit is stultified. Material wealth has a limited benefit over a certain level of income and this is also confirmed by Jonathan Haidt's evaluation of The Happiness Hypothesis, where he considers the lessons both of ancient wisdom and modern psychological research. The Recovery Movement in mental health services also has a considerable stress on spiritual aspect, and in the executive summary of the recent position paper produced by Care Services Improvement Partnership, The Royal College of Psychiatrists and the Social Care Institute for Excellence (p. vi), the statement is made that the recovery approach is based 'on the core belief that adopting recovery as a guiding purpose for mental health services favours hope and creativity over disillusionment and defeat'. There are, of course, many moral imperatives for placing service users in charge of their own destiny, but one other driver may in fact be cost! Coming up with expensive treatment programmes which do not meet an individual's needs, aspirations or life conditions may not only be ineffective, but may be an expensive waste of money!
Perhaps one of the lessons of the work on spirituality is, in fact, to sit down with an individual and ask them what makes them 'tick', what drives them, in what direction do they see their life quest proceeding and to start where they are - it is not a bad place to start!
One final thought: in the UK, we have often divided the personal and the intellectual, something that Socrates, Plato and Aristotle would have thought quite absurd, and so would Moses, Jesus, Mohammed, Buddha and other initiators of the world faiths. One of the most enlightening aspects of Sir Michael Marmot's book on status syndrome is that, as a Professor of Epidemiology and Public Health and Director of the International Centre for Health and Society, he tells us, early in his book, that while he started his training as a doctor fascinated with the sciences of biochemistry and physiology, when he met patients at a clinic in London he discovered that 'real people … have problems with their lives as well as their bodily organs'. He realized and he informs the reader that, however good technical medicine is, it has no real value without an engagement with the whole person and the family, community and society, in which they live. Nobody wishes to live in a society, or to work in a service that has no spark, no spirit, no ru'ach, no invigorated life. If we cannot re-discover our humanity, then we might as well hand everything over to the machines - they are probably that bit more efficient at being machines than we are.
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