Experiences of spirituality of in- and out-patients in mental health facilities: A thematic synthesis of qualitative studies

Figures & data

Table 1. Eligibility criteria.

Inclusion criteria	Exclusion criteria
Research articles including spiritual experiences and descriptions from the first-person perspective Hospitalized patients or patients that have experienced hospitalization (with mental health issues)	Educational context Students’ experiences/perceptions on spirituality Descriptions from the perspectives of nurses/mental health staff/ chaplains/psychotherapists/theologists
Articles exploring individual needs related to spirituality or meaning making/meaning in life Articles describing/exploring inpatients’ experiences related to beliefs/belief systems or religious experiences	Spirituality from the view of relatives/next of kin Spirituality from a leader/management perspective Children/family context
Published between January 2019 and October 2022	Published before January 2019 Not English language

Table

S (Sample)		P I (Phenomenon of interest) (Intervention)		D (Design)		E (Evaluation)		R (Research)
Psychiatric hospitals		Spirituality		Interviews		Recovery		Qualitative research
OR		OR		OR		OR		OR
Psychiatric units	AND	Spiritual perspectives	AND		AND	Well-being	AND	Phenomenology
OR		OR				OR		OR
Psychiatric patients		Spiritual experiences				Spiritual well-being		Hermeneutic Phenomenology
OR		OR
Psychiatric illness		Existential
OR		OR
Schizophrenia		Meaning-making
OR		OR
Psychotic disorder		Meaning structure
OR
Affective disorders

Table

TITLE-ABS-KEY (spiritual*) OR TITLE-ABS-KEY (“Religious Belief*”) OR TITLE-ABS-KEY (existential*) TITLE-ABS-KEY (mystic*) OR TITLE-ABS-KEY (ascetic*) OR TITLE-ABS-KEY (belief*) OR TITLE-ABS-KEY (“religious experien*”) OR TITLE-ABS-KEY (faith) OR TITLE-ABS-KEY (“Faith Healing”) OR TITLE-ABS-KEY (transcenden*) OR TITLE-ABS-KEY (“self-transformation*”) OR TITLE-ABS-KEY (“self transformation”) OR TITLE-ABS-KEY (“belief system*”) AND TITLE-ABS-KEY (“Affective Disorder*”) OR TITLE-ABS-KEY (schizophrenia) OR TITLE-ABS-KEY (psychosis) OR TITLE-ABS-KEY (“Psychiatric Patient*”) OR TITLE-ABS-KEY (“Bipolar Disorder*”) OR TITLE-ABS-KEY (anxiety AND disorder*) OR TITLE-ABS-KEY (personality AND disorder*) OR TITLE-ABS-KEY (mental AND disorder*) OR TITLE-ABS-KEY (“major depression*”) OR TITLE-ABS-KEY (“trauma disorder*”) OR TITLE-ABS-KEY (“stressor related disorder*”) OR TITLE-ABS-KEY (hospitali?ed AND patient*) OR TITLE-ABS-KEY (inpatient) AND NOT TITLE-ABS-KEY (“cancer patient*”) AND (LIMIT-TO (DOCTYPE , “ar”)) AND (LIMIT-TO (PUBYEAR , 2022) OR LIMIT-TO (PUBYEAR , 2021) OR LIMIT-TO (PUBYEAR , 2020) OR LIMIT-TO (PUBYEAR , 2019)) AND (LIMIT-TO (LANGUAGE , “English”))

Figure 1. PRISMA 2020 flowchart: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 2. Overview of included primary studies.

First author, year and country	Aim & research question	Study design	Sample/population	Instrument	Main findings	CASP (H, M, L)
1. van Nieuw Amerongen-Meeuse, Schaap-Jonker, Hennipman-Herweijer, Anbeek, and Braam (2019) Netherlands	The aim of this study was to find out how patients in clinical multidisciplinary mental health care want religion/spirituality to be addressed in their care.	Qualitative inductive content analysis	35 patients in two mental health clinics, one secular and one Christian mental health clinic	35 semi- structured interviews	Four categories; 1) Individual religious/spiritual conversations between patients and care team members (mainly nurses), 2) A familiar religious/spiritual environment, 3) A special religious/spiritual program, 4) contact with their religious/spiritual network. Patients varied in their presentation of religious/spiritual care needs from (a) explicit, mostly in the Christian clinic, to (b) implicit, predominantly in the secular clinic, or showed (C) hidden religious/spiritual care needs. A non-acute stage of the illness and religious/spiritual affinity of the mental health professionals were classified as possible conditions for addressing religious/spiritual.	High
2. Lee, M. (2021), Ohio	The aim of the study was to explore the recovery process	A qualitative study with a grounded theory approach	19 patients diagnosed with schizophrenia, bipolar disorder or major depression	In-depth interviews	The lived experiences of recovery highlighted both 1) internal and 2) external factors. 1) Internal recovery processes included a perspective change in how participants viewed themselves and their symptoms, cognitive changes, emotional processes, and spirituality and faith. 2) External recovery processes included the support received from others, such as professional treatment and social support as well as giving back by taking on social roles, social giving, and finding a meaningful external focus	High
3. Damsgaard, J. B., (2021), Denmark	The aim of the study was to explore perceptions and challenging issues related to living with depression, allowing the researchers to get a deeper understanding of existential and social aspects	A phenomenological-hermeneutic design, based on Ricoeur’s theory of interpretation	5 outpatients	Observations and semi-structured interviews	The interviewees were lonely at home as well as at the hospital. This caused experiences of sheer isolation with feelings of sadness enhancing desperation concerning what to do with themselves. This could even cause physical feelings of pain. In different ways, the interviewees expressed how being with other people filled their lives with relationships and closeness. Health care professionals were focused on applying structure into clients’ everyday life, shadowing the person’s individuality, strengths, and resources. The prioritizations between clients and health care professionals were not always in concordance. The interviewees experienced recurrent situations where their authority and individuality were ignored or felt to be non-existent.	Medium
4. Koslander, T., (2021), Sweden, Norway & Switzerland	Aims to describe lived experiences of spirituality from the perspective of adults who have been in inpatient psychiatric care, and to interpret these experiences from an understanding of health as dialectical	A phenomenological-hermeneutic approach to analysis	11 outpatients	Narrative interviews	Three themes emerged: 1) perceiving the presence of something extra- mundane, 2) making sense of reality and 3) struggling for acceptance. The comprehensive understanding highlights spiritual experiences as going beyond religion, even though religious experiences appear as part of them. These experiences can indeed be a resource contributing to experiences of hope, connectedness, meaning and coherence in life. They can also give rise to doubt, anxiety and feelings of loneliness and hopelessness. Rather than understanding spiritual experiences as being good or bad, we could approach spirituality as something that is always present in alternate and related forms.	High
5. Ibrahim, N. (2022), Egypt	The aim was to explore mental health recovery	A phenomenological research design using inductive thematic analysis	17 outpatients	Semi-structured qualitative interviews	Participants predominately reported personal and functional definitions of mental health recovery. Posttraumatic growth was the strongest theme comprising relation to others, spirituality, new possibilities, identity & strengths, and appreciation of life. Themes of acceptance and forgiveness, functional and clinical recovery, and finding hope were also identified.	High
6. Jordan, G., (2019), Canada	To investigate aspects of positive change among persons receiving early intervention services for psychosis	Mixed method Quantitative, cross sectional survey design, using descriptive statistics and the qualitative component was carried out using a qualitative descriptive approach	Ninety-four participants (quantitative study) 12 (qualitative study), thematic analysis	Cross-sectional survey and semi- structured interviews	Quantitative results indicated that most participants reported a moderate amount of posttraumatic growth. A greater appreciation of life was the most commonly endorsed domain, whereas spiritual growth was the least commonly endorsed domain. The qualitative results revealed that in addition to suffering, participants experienced positive changes, such as improved health and personality, and a stronger sense of self; stronger, more balanced religiosity and spirituality; improved relationships with others; and improved lifestyles, goals, and expectations for the future.	Medium
7. Jordan, G., (2020), Canada	Identify predictors and perceived facilitators of positive change and posttraumatic growth	Mixed method study: Quantitative and qualitative studies	94 (quantitative study) 12 (qualitative study)	The quantitative study: Measures of posttraumatic growth and predictors of posttraumatic growth. The qualitative component involved in-depth interviews	Quantitative results revealed that being hospitalized for psychosis, spiritual coping, positive reframing, and subjective recovery were significant predictors of posttraumatic growth. Qualitative findings revealed that positive change was perceived to be facilitated by the psychosis itself; receiving mental health services; drawing on personal and social resources and strategies; healing and recovering; a meaning-making and knowledge gaining process; and normative development	High
8. Jones, S., (2019), Australia	Explore spirituality among people who have a lived experience of severe mental illness from Australia	Qualitative	Sixteen individuals with a severe mental illness	Interviews	Participants reported physical, sexual, social, occupational, and emotional harms from grandiose delusions. All patients described the grandiose belief as highly meaningful: it provided a sense of purpose, belonging, or self-identity, or it made sense of unusual or difficult events. The meaning from the belief was not synonymous with extreme superiority or arrogance. The meaning obtained appeared to be a key driver of the persistence of the beliefs. Other maintenance factors were subjectively anomalous experiences (e.g., voices), symptoms of mania, fantasy elaboration, reasoning biases, and immersive behaviors. Participants described insufficient opportunities to talk about their grandiose beliefs and related experiences and were generally positive about the possibility of a psychological therapy.	Medium
9. Chan, Lau, and Wong (2020)Malaysia USA	This study examined young adults’ experiences of recovery from depression from a subjective stance.	Qualitative transcendental phenomenological design	9 Malaysian young adults	In-depth semi structured interviews	6 interconnected emerging themes addressing personal healing contributors were revealed: 1) supportive relationships, 2) medication, 3) attending counselling, 4) religion and spirituality, 5) care for others, 6) employment. Each major theme was supported by three subthemes	High

Analysis and synthesis.

Table 3. The thematic synthesis (Thomas & Harden, 2008): development of analytical themes.

Examples of codes	Descriptive themes	Analytical themes
I get comfort from praying. I feel lifted. Religion gives me wisdom. Receiving strengths from a higher power. Security you can rely on. I feel connected to God. Everything will fall onto God`s shoulders. Give my sadness over to the Lord. God is living amongst us.	Spirituality as guidance and support	1) Longing for connection
Ignored individuality. Extreme loneliness. Emptiness. Not having an I. A feeling of not belonging. Being a diagnosis. Afflicted by a dark force.	Spiritual isolation	2) The need for vital relationships
Praying with a nurse. Read the Bible. Yoga and meditation are helpful. Go for a walk, get fresh air. Listening to the birds. Do artwork. I love nature. Play soft music.	Spirituality as calming resources
Seeing psychosis as a positive spiritual experience. Doing good for others. Focusing on the good and lovely. Having a purpose. Find something to live for. Helping others. Doing charity. Relationships with others.	Meaning making	3) Searching for a new meaning

van Nieuw Amerongen-Meeuse, J. C., Schaap-Jonker, H., Hennipman-Herweijer, C., Anbeek, C., & Braam, A. W. (2019). Patients’ Needs of Religion/Spirituality Integration in Two Mental Health Clinics in the Netherlands. Needs of Religion/Spirituality Integration in Two Mental Health Clinics in the Netherlands: Issues in Mental Health Nursing, 40(1), 41–49. doi:10.1080/01612840.2018.1475522

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Lee, M. Y., Eads, R., Yates, N., & Liu, C. (2021). Lived Experiences of a Sustained Mental Health Recovery Process Without Ongoing Medication Use [Article]. Community Mental Health Journal, 57(3), 540–551. doi:10.1007/s10597-020-00680-x

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Damsgaard, J. B., Overgaard, C. L., & Birkelund, R. (2021). Personal recovery and depression, taking existential and social aspects into account: A struggle with institutional structures, loneliness and identity. The International Journal of Social Psychiatry, 67(1), 7–14. doi:10.1177/0020764020938812

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Koslander, T., Rönning, S., Magnusson, S., & Wiklund Gustin, L. (2021). A ‘near-life experience’: Lived experiences of spirituality from the perspective of people who have been subject to inpatient psychiatric care [Article]. Scandinavian Journal of Caring Sciences, 35(2), 512–520. doi:10.1111/scs.12863

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Ibrahim, N., Ng, F., Selim, A., Ghallab, E., Ali, A., & Slade, M. (2022). Posttraumatic growth and recovery among a sample of Egyptian mental health service users: A phenomenological study. BMC Psychiatry, 22(1), 255. doi:10.1186/s12888-022-03919-x

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Jordan, G., Malla, A., & Iyer, S. N. (2019). “It’s Brought Me a Lot Closer to Who I Am”: A Mixed Methods Study of Posttraumatic Growth and Positive Change Following a First Episode of Psychosis. Frontiers in Psychiatry, 10, 480. doi:10.3389/fpsyt.2019.00480

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Jordan, G., Malla, A., & Iyer, S. N. (2020). Perceived facilitators and predictors of positive change and posttraumatic growth following a first episode of psychosis: A mixed methods study using a convergent design. BMC Psychiatry, 20(1), 289. doi:10.1186/s12888-020-02693-y

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Jones, S., Sutton, K., & Isaacs, A. (2019). Concepts, Practices and Advantages of Spirituality Among People with a Chronic Mental Illness in Melbourne. Journal of Religion & Health, 58(1), 343–355. doi:10.1007/s10943-018-0673-4

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Chan, S. L., Lau, P. L., & Wong, Y. J. (2020). ‘I am Still Able to Contribute to Someone Less Fortunate’: A Phenomenological Analysis of Young Adults’ Process of Personal Healing from Major Depression [Article]. International Journal for the Advancement of Counselling, 42(1), 97–111. doi:10.1007/s10447-019-09387-5

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Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology, 8(1), 1–10. doi:10.1186/1471-2288-8-45

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