ABSTRACT
A multidisciplinary guideline on religion, spirituality (R/S), and psychiatry aims to address: (1) organising R/S consultation in mental health care, (2) categorising research findings, and (3) professionalism and education with respect to R/S. Contents are derived from brainstorm sessions with key participants in the field of R/S and psychiatry in the Netherlands, and from the position statements on R/S and psychiatry in the UK and by the World Psychiatric Association. The following chapters are proposed: (1) ethical and existential themes and R/S, (2) R/S in stages of mental health care practice, (3) R/S counselling, (4) collaboration, and (5) relationship to other guidelines. The core themes need verification by specialists in the field, nurses, therapists, counsellors, patient-practitioners, and psychiatrists. The author recommends to approach R/S in an easy way, to listen to matters of personal meaning, and to leave the task to others in case of a lack of affinity.
Introduction
Guidelines in mental health care aim to assist clinicians and therapists in taking rational decisions, either evidence based, or best-practice-based. Guidelines offer concise information, a clinical frame of reference, as well as boundaries. Moreover, as guidelines need regular actualisations over time, clinicians have recent information at their disposal. Guidelines may therefore be regarded as valuable and efficient tools, a safeguard for the patient and the professional, and a point of departure, to motivate when and why to make a diversion.
Guidelines may also imply an ethical evocation for the matters they address. When a new guideline is initiated, it implies a communication about certain professional values and competences, including aspects such as interdisciplinary collaboration, societal needs, and cultural values. The recent position statements on religion, spirituality, and psychiatry by the Royal College of Psychiatrists in the UK (Cook, Citation2013) and by the World Psychiatric Association (WPA; Moreira-Almeida, Sharma, Janse van Rensburg, Verhagen, & Cook, Citation2016) may stimulate mental health professionals to articulate the themes of religiousness and spirituality (R/S) within their contemporary, national or cultural contexts of mental health care. Multidisciplinary guidelines on R/S and psychiatry could guide or reflect the process of acknowledgement of the relevance including sensitivity on R/S in psychiatry. As Verhagen (Citation2017) points out, this will need dialogue. A guideline on religion, spirituality, meaning in life, and other closely related and overlapping themes will not escape critical questions from colleagues who are aware of the risk of boundary transgressions. The philosophy of life and affinity with existential questions among the professionals is likely to be very heterogeneous: either religious (with a myriad of variations), spiritual (with a myriad of connections), agnostic, atheistic, or humanistic. Especially in the secularising and pluralistic western European societies, patterns of convictions, experiences, and values may conflict among professionals. Therefore, these patterns deserve mutual exploration, dialogue, avoidance of unnecessarily extreme positions and, at best, consensus. The current contribution aims to describe a number of principles that may be helpful to develop a multidisciplinary guideline “religiousness, spirituality (R/S), meaning, and mental health care”, in short: “R/S and psychiatry”.
With respect to terminology, Verhagen and Cook (Citation2010) adopt the definition of spirituality by Van Ness (Citation1992): “Spirituality is a quest for attaining an optimal relationship between what one truly is and everything that is – it concerns how the self as a whole relates to the cosmos as a whole” (p. 274). Furthermore, from the perspective of care, the term “religion” is regarded as implying too much of a macrosociological construct, laden with conceivably opposing values, such as about intolerance, moral scrupulousness, doctrinal convictions, and lack of dialogue. The term “religiousness”, however, pertains to the individual, behavioural, and attitudinal perspective towards religion. Religiousness is in fact the core aspect of religion that has so far been operationalised in empirical studies, such as with measures on importance of religion, religious involvement, private behaviour such as prayer and meditation and attitudes towards religious coping.
Towards a multidisciplinary guideline on religiousness/spirituality and psychiatry
Mental suffering confronts the patient with existential questions. Religiousness and spirituality (R/S) aim to offer a perspective of hope, relief, coping, or meaning in life. Traditionally, this has been acknowledged by many mental health care institutions: The field of mental health care harbours a long tradition of healthcare chaplaincy and spiritual counselling (SC). Due to secularisation and the contemporary emphasis on individual meaning-making instead of more collective and traditional venues to meaning, the profession of spiritual counselling/spiritual caregiving/chaplaincy is subject to change. Furthermore, the role of R/S in psychiatry has received increasing attention from social scientists and epidemiologists in the past decades, leading to an “epidemiology of R/S” (Koenig, King, & Benner Carson, Citation2012). Although several scholars theorised about the psychology of religion over the past hundred years, a body of empirical, quantitative knowledge has emerged as well. How should we integrate the new research insights into clinical practice? What further research initiatives are necessary for further integration?
On the one hand, some research insights about R/S and psychiatry, such as stimulated by meta-analyses of the numerous existing studies, may carry a more or less global validity. On the other hand, cultural differences are likely to be very important in addressing of R/S in mental health care practices in different countries around the world.
For example, the history of the Netherlands is characterised by tensions between Protestantism and Roman Catholicism. These tensions have largely been resolved, but the country is subject to an ongoing process of secularisation, replacing a religious world view for a more spiritual, individualistic life view. About 15–20% of the Dutch population can be rated as Atheist (De Hart, Citation2014) and 15% as Agnostic (knowing that they will not know whether God exists). Moreover, another 20% do not belief in God, but confess to belief in “something like a higher power”, which has even led to the predicate “somethingism” (in Dutch: “ietsisme”; De Hart, Citation2011). Further integration of research insights on R/S in mental health care practice in the Netherlands requires that the terms “religiousness” and “spirituality” should at least be introduced as “meaning in life” or “meaning-making”. Verhagen (Citation2017) addresses how the formulation of a worldwide position statement on R/S and psychiatry can be qualified as a considerable achievement. The position statement may therefore serve as an example to accomplish a national consensus on matters of formulations and terminology.
The emphasis on multidisciplinarity may raise the question why it would be insufficient focusing on either psychiatrists, as is done in the British Position Statement (Cook, Citation2013), or on spiritual counsellors (SCs), who obtain a professional profile of competencies in the Netherlands (VGVZ, Citation2005). Both in clinical and outpatient care settings, however, the psychiatrist has far less time to discuss and find opportunity to address R/S. In clinical settings, nurses are far better equipped for this purpose. In outpatient settings, psychologists may also be able to find their venues to address R/S. Although spiritual counsellors are available to explore the individual needs with respect to R/S, they only reach a minority of patients: in the Netherlands, this pertains by and large to clinical settings only. For outpatient mental health care, the availability of SC expertise has not yet been anticipated to from a financial perspective. In addition, there is the gradual development in the Netherlands of including the new profession of patient-practitioners in mental health care, adding the perspective of recovery, meaning, and participation within the treatment teams. Verhagen (Citation2017) states that psychiatric care involves a multidisciplinary multilevel model of care. This is an invitation to elaborate themes on R/S and psychiatry in a format that not only allows for a multidisciplinary approach, but considers multidisciplinarity as point of departure.
The central assumption of the current exploration is that a multidisciplinary guideline on R/S and psychiatry at least will “categorise the research findings” in a meaningful way. Furthermore, such a guideline will actualise the research agenda, both from an international and national perspective. Multidisciplinary guidelines receive updates every few years. This enables a process of tuning in between mental health care practice and the fruits of research initiatives. The contents of a possible multidisciplinary guideline on R/S and psychiatry are derived from several sources: brainstorm sessions with key participants in the field of R/S and psychiatry, the position statements on R/S and psychiatry of the Royal College of Psychiatrists in the UK (Cook, Citation2013) the proposal for a consensus or position statement by the section on religion, spirituality, and psychiatry of the WPA (Verhagen & Cook, Citation2010), and the final version of this WPA Position Statement (Moreira-Almeida et al., Citation2016).
An outline of a guideline
The following areas of particular attention are proposed: (1) principles with respect to R/S, (2) R/S in mental health care practice, (3) R/S counselling, (4) collaboration, (5) the relationship to other guidelines. As advocated by Verhagen (Citation2017), the domain of personal recovery, receives a central position.
1. Principles with respect to R/S
Before focusing on R/S in the subsequent phases of care, diagnosis, treatment, and recovery, several core principles should be addressed. From a moral point of view, it cannot be clear enough that mental health care professionals should refrain from influencing their patients in their religious or spiritual beliefs. When examining R/S, clinicians and therapists are aware of the four key ethical values in medicine: respecting the patient’s autonomy, the duty to do good (beneficence), no harm (non-maleficence) and justice with respect to distribution of care and similarity of treatment (Beauchamp & Childress, Citation2013).
Another priority is constituted by the awareness of countertransference issues with respect to R/S. Countertransference can manifest itself with respect to R/S in at least three ways: a tendency to “confess” (too much dedicated towards R/S), to oppose (too much dedicated to another point of view, such as an atheist conviction), or to avoid R/S entirely, ignoring the subject as a possible relevant area of life (Kerssemakers, Citation1989).
Other points of departure pertain to the specific existential crises during episodes of mental illness. Yalom (Citation1980) identified four core areas of existential questions: isolation, loss of freedom, death, and lack of meaning. Which of these themes would raise the most demanding questions in psychiatric episodes may not as yet be ascertained. Several factors affect the existential impact of the disorder, such as the type of disorder, its stage of treatment, the immediate cultural environment, and tasks connected with the specific phase of life.
2. R/S in stages of mental health care practice
The different phases of mental health care offer radically different themes. The diagnostic phase may reveal how R/S may present itself in ways that are distorted by the psychopathological process. For example, in psychotic states, delusions of grandeur, persecution, or nihilism may manifest themselves with religious or spiritual convictions. In times of severe depression or post traumatic stress disorder, religious or spiritual alienation may dominate the subjective experience. A timely documenting of these symptoms with religious contents may facilitate the evaluation of R/S during treatment and recovery. From the patient-recovery perspective, this phase can be denoted as the phase of being “overwhelmed” (Spaniol, Wewiorski, Gagne, & Anthony, Citation2002).
In the treatment phase, either acute, or after careful screening procedures, R/S can be explored with respect to their relevance in personal life (R/S salience), their possible resources of hope and coping, as well as the possible pitfalls they offer, such as R/S distress or problematic expectations of the religious community. Here, the patient’s “struggling” phase comes to the fore (Spaniol et al., Citation2002).
Introducing the possible role of R/S in the treatment, just by exploring and verifying the relevance could be an investment in the therapeutic alliance, but it may also raise feelings of reservation in the patient. Why would the therapists talk about this area of life? Some patients may fear that clinicians consider the patients R/S as expression of psychopathology (Ouwehand, Wong, Boeije, & Braam, Citation2014), or at least as an irrational area of life. A related aspect is how the patient would estimate the R/S of the professional. Therefore, matters of timing and tactfulness may determine whether the exploration of R/S will add to the treatment alliance and to a better understanding of the patient. The competency of professionalism will be at stake here as well. Education about R/S in psychiatry can be counted as a condition for a professional approach. Realising one’s personal affinity with R/S may be even a more important condition: if a professional lacks any affinity with R/S, other colleagues could be involved in the task.
Next, in the stage of rehabilitation, matters of meaning in life and restoring one’s sense of identity may often relate to R/S. The relevant patient-recovery phase is “living with” the psychiatric disability. Whether clinicians have much to offer here is uncertain, and other professionals may make the difference, social psychiatric nurses, therapists, the spiritual counsellor, and the patient-practitioner. Finally, the patient faces the last recovery phase: “living beyond” the psychiatric disability. Knowledge from this phase may be highly relevant for the individual patient, for relapse prevention, and for other patients, as venues (such as recovery narratives) to know how to restore one’s themes on R/S and meaning in life.
3. R/S counselling
In the Netherlands, spiritual counselling belongs to the care facilities of clinical, inpatient mental health care. Most SCs have their roots in a religious tradition, such as Protestantism, Catholicism or Islam, or in the humanistic tradition. Furthermore, there are a few centres for special groups of interest, such as Jewish patients or the more strictly (Pietist/Orthodox/Evangelical) reformed protestants. Within the mental health care departments and institutions, the SCs offer their assistance for consultation for patients and staff. Traditionally, they embody a “refuge position”, with as few as possible ties to the treatment team as to protect confidentiality to the highest standards.
SCs, educated as theologians, humanistic counsellors, or a having followed a special master study in SC, are equipped with expertise in meaning-making and meaning in life and specialised for the target group of psychiatric patients. In general, the SC organises weekly services in the institution and is available for religious rituals. In addition, an important emphasis is on restoring the sense of identity by focusing on the biographic narrative of life, including the impact of the episode of mental illness, treatment consequences, and the interaction in relationships and the wider social surroundings.
Staff-members can consult the SC for further understanding of the role of R/S in the psychopathology, treatment, recovery, or other important themes. This may lead to collaboration. Furthermore, the SC also offers expertise in chairing moral deliberations in the institution.
The role of the SC in outpatient care has not sufficiently been demarcated. Some patients appreciate follow-up contacts. Others may need guidance in finding a regular connection with a religious group. Consultation by professionals working in outpatient teams occurs, but, so far, without a frame of insurance indemnities.
4. Collaboration
Internal collaboration within the institution or mental health care circuitry represents the most classic way of collaboration. The clinician, therapist, and treatment team will have different options to cooperate with the SC, depending on the type of disorder and the phase of treatment. When fitting the tasks with respect to R/S, the issue of timing is at stake. Identifying R/S needs can be done during the early treatment phase and even during emergency situations, whereas exploring R/S and referring to a SC deserve later attention.
Collaboration may imply the sharing of tasks, such as consulting the SC when there is an indication to explore R/S with the patient but when the clinician or therapist may not feel sufficiently equipped, or may lack affinity with R/S. Another example is the counselling of the meaning-making dimension of the patient’s narrative identity. However, defining collaboration models should not ignore situations that are counterproductive. It may therefore be better to anticipate the acknowledgement of opposing views. For example, in the context of involuntary treatment some patients invoke religious themes (principles, delusions, or both) as reasons for refusal of collaboration. This type of situation may require that the tasks to respect R/S and to confront the patient are divided, without disqualifying the share of the treatment team and the SC and vice versa. Another complex situation is in the treatment of patients with a borderline personality organisation. The therapist and the SC may elaborate on different themes, and without sufficient contact, the defense mechanism of splitting may find its free course.
Another facet of collaboration pertains to the domain of further recovery. Apart from the SC, the specialty of the patient-practitioner may take its share, e.g., in the restoration of meaning in life and the task of managing stigmatisation.
Ways of external collaboration pertain to the need of mental health care consultation and possible ways of mental health referral by clergy members, religious leaders, and pastoral workers. In general, clergy members have been shown to have a reasonable competency of recognising severe psychopathology (Noort, Braam, van Gool, & Beekman, Citation2012). Another venue is to involve clergy members during treatment in a systemic approach, or to use their authority in certain situations of decision-making. Finally, the SC may bridge the need for R/S counselling in outpatient care for a limited period. The SC will however also appeal to clergy members and individual spiritual coaches, first to normalise this area of life, and second because of restricted financial means.
5. Relationship to other guidelines
The Dutch, national psychiatrist profile (“Profielschets psychiater”) and the CANMEDs competency specifications for psychiatry contains several notions about the relevance of the patient’s religion, addressing religious diversity, also within treatment teams (Nederlandse Vereniging voor Psychiatrie, Citation2009). A second national document is the Guideline on Assessment and Treatment of Suicidal Behavior (van Hemert et al., Citation2012). With respect to philosophy of life, this guideline advices to inquire about the patient’s active involvement in a religious community, as a possible protective factor against suicide.
In another field of medicine, palliative medicine, spiritual care has achieved a clear position in the assessment, including spiritual distress or religious struggle, and the treatment and collaboration with the SC (Puchalski et al., Citation2009). There exists a Guideline Spiritual Care in Palliative Care (Leget et al., Citation2010). Main themes in this guideline include existential questions about suffering and the imminence of the end of life, spiritual crises, such as about meaninglessness and religious struggle, and a possible role in spiritual counselling for all care providers. The guideline considers undergoing existential struggle as an important step in finding a new psychological and spiritual balance. Spiritual struggle is therefore not an issue that should be suppressed and avoided. As noted earlier, the type of existential crises during or after psychiatric episodes may vary, and will also include other existential themes than those related to death and dying: isolation, meaninglessness, and loss of freedom are all at stake in psychiatric illness.
Guidelines from other countries and international statements may help to complete the agenda of the suggested multidisciplinary guideline on R/S and psychiatry. The RCPsych Recommendations on R/S offers an excellent example how to address the important issue of respecting ethical and professional boundaries (Cook, Citation2013). The Position Statement of the WPA Section on Religion, Spirituality and Psychiatry may help to legitimise the need of properly describing the essential elements on R/S for mental health care professionals (Moreira-Almeida et al., Citation2016).
Network, implementation, and education
The subject of R/S is by and large not the privilege of psychiatrists. Other disciplines, such as the nurses, SCs, therapists and patient-practitioners, will often find a more profound engagement. Therefore, representatives of several professional networks are needed to compose a multidisciplinary guideline. Furthermore, interest groups on R/S and mental health will have their tasks. In the Netherlands, there are several interest groups, more or less corresponding to the initial societal segregation of religious traditions. Fortunately, the boards of these interest groups increasingly collaborate in organising symposia and publishing research, case-reports and discussions (as has lead to the current paper). In 2016, their collaboration has led to an organising forum in the Netherlands, known as the Federation of Meaning and Mental Health. Finally, informal correspondence with representatives of patient organisations indicates that these organisations would strongly support professional initiatives with respect to R/S, meaning-making and addressing existential questions in mental health care. The opinion of patient organisations may be decisive in finding support for a multidisciplinary guideline. Future steps for a multidisciplinary guideline include the verification of the core themes with specialists in the field: physicians, therapists, spiritual counsellors, patient-practitioners, and patients.
A guideline on R/S and psychiatry is likely to facilitate education for the variety of professions. Furthermore, education sessions may serve as a soundboard for its contents. In the recently developed Dutch national course for psychiatric trainees, philosophy, ethics, and R/S are included in one joined programme. The guiding principle in this course is the awareness of the patient as a person, as well as the person behind the role of the professional (Glas, Citation2012).
Conclusion
Without position statements or guidelines, R/S runs the risk of remaining largely unaddressed in mental health care. With respect to value discussions, there is a rich tradition of thought. For mental health care practice, substantial empirical evidence justifies (at least) attention for R/S. Little research is available on the level of SC practice and collaboration. A guideline may help to identify for which advices and steps sufficient evidence is available, as well as to actualise the research agenda in a meaningful way. The issue of R/S and psychiatry counts numerous theoretically conceptual challenges. Guidelines, however, should not reflect complexity, but aim to get an overview and good points of departure. Both conciseness of the guideline and offering no affront to sceptics are requirements.
A positive message of the guideline could be that R/S and existential questions constitute a normal element in life: better to adopt an easy (E), inviting attitude than to act over-seriously. From an ethical point of view, discussion of the tenacity of certain themes (such as the contents of religious and spiritual beliefs) is a bridge too far (Cook, Citation2013). The main virtue therefore is: listening (L), and hence showing professional and personal presence. The main question pertains to the meaning (M) of R/S, the search for meaning in general, and, that professionals recognise that meaning in life is “normal”. Also Verhagen (Citation2017) clearly advices integrating a meaning-centred approach in applying the biopsychosocial model in daily practice. When a professional feels that there is a need for further consideration or guidance of R/S with the patient but he or she lacks the affinity or type of alliance, the main escape is asking others (O) for consultation or dividing tasks. The acronym of these four advices is “ELMO” (), reminding of Jim Henson’s charming, but not oversophisticated muppet character featuring in “Sesame Street”.
Table 1. Proposed, concise set of basic principles to include religiousness and spirituality in multidisciplinary psychiatric practice.
A guideline on R/S and psychiatry should not submerge mental health care practice into a lake of idealism or unrealistic debate or enthusiasm. It should however, for some patients, help to contribute to the professional sensitivity for meaning in life as a clinically relevant aspect of mental disorder and recovery.
Acknowledgements
This paper has been presented at the XVI World Congress of Psychiatry, Session “Consensus and Position Statements on Psychiatry, Religion and Spirituality”, September 16, 2014, Madrid, Spain. The current paper is the result of a brainstorm meeting by members of the Federation of Meaning and Mental Health (http://www.fzgg.nl), a Dutch platform with participation of KSGV (Prof. Dr. M. van Uden), CvPPP (B. Gooyer, MSc), the Dutch Foundation of Religion and Psychiatry (Dr. P. J. Verhagen, MD), Dimence Mental Health Care (Prof. Dr. G. Glas, MD), and KICG (Dr. H.J. Schaap – Jonker, PhD).
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