Spiritual understandings of psychosis: the perspectives of spiritual care staff

Figures & data

Table 1. Interview questions and topic guides.

Topic	Questions
Participant’s experiences of providing spiritual consultancy within a mental health framework	Could you give me a brief description of how you got involved in spiritual work? Could you describe what usually happens in chaplain services, in your own words? What do you do as a [faith leader]? How do you feel when you are guiding someone on spiritual concerns? (emotionally, physically, mentally) What do you think about experiences that are difficult to explain in other kinds of ways, such as in science? If you had to describe what spirituality means to you, what words/images come to mind?
Participants views on psychosis and current psychosis interventions	What does the term “psychosis” mean to you? What do you think about the current way people with psychosis receive treatment? How have your experiences been in helping to manage people that have these experiences? What do you think is most important for recovery in psychosis?
After the participant has read each case vignette	How would you describe, in your own words, what is happening with this person? How would you explain the causes of this? How would you decide what to do with this person to help them through these difficulties? How would you offer your support? What do you know about experiences similar to this? What do you think the professionals in this case should do now?

Table 2. Inclusion and exclusion criteria.

Inclusion Criteria	Exclusion criteria	Rationale
Faith leaders, spiritual practitioners, chaplains	Spiritual/faith practitioners and chaplains in training	The study aimed to find participants that have already had experiences and perspectives working with psychosis.
Over the age of 18	Under the age of 18	The study aimed to recruit people employed as spiritual care staff (i.e., will be working age).
Based in the UK	Not based in the UK	The study was interested in exploring working with psychosis in a UK mental health service.
Access to the internet	No access to the internet	Data collection was conducted entirely online.
Fluent in English	Requires an interpreter	Due to the limitations of research sponsorship for this study, there were no resources available to support the recruitment of an individual who did not speak fluent English.
Voluntary participation	Practitioners that charged fees for spiritual/faith/religious consultancy	The study did not provide monetary or otherwise benefits for participating.

Table 3. The steps taken to carry out an IPA analysis.

IPA Steps	Rationale (in accordance with Smith, Flowers, & Larkin, 2009)	An example: “Wilma”
Reading and re-reading	Each transcript to be read several times to begin the process of understanding participant narratives	Interview was re-read throughout the transcribing process. Once completed, it was continuously re-read over several days to immerse the researcher into the data.
Initial noting	Each transcript to be explored in-depth: the semantic content, language, contents, and concepts used	The author generated a three-column table: “Interpreted themes,” “Original Transcript,” and “Exploratory comments.” Under “Exploratory comments” the researcher explored the content, language, metaphors, and concepts used in transcript “Wilma,” as well as her own reflections.
Developing emerging themes	To begin generating interpreted themes for each transcription that reflect individual participant narratives and the researcher’s interpretations	Using the same three-column table, under “Interpreted themes” the author wrote down the interpreted themes of “Wilma” line-by-line, which was also guided by the notations made under “Exploratory comments.”
Searching for connections across emergent themes	To generate interpreted themes across transcriptions that reflect both individual and collective participant narratives, as well as the researcher’s interpretations	“Interpreted themes” of each transcript were compared and explored both to gain an overall descriptive summary of participants’ narratives, as well as to make interpretations of participants experiences, narratives and reflections.
Identifying quotes to illustrate themes	To make clear connections between each theme and participant.	Quotes from transcripts were printed out and physically charted until we reached clear interpreted themes with distinct voices

Table 4. Quality indicators as guided by Nizza, Farr, and Smith (2021)..

Quality Indicators	Rationale (as provided by Nizza, Farr, & Smith, 2021)	How this was applied to this study
Constructing a compelling and unfolding narrative	Findings should convey a “narrative” that is not only coherent to the analysis but expresses the hermeneutic circle that links to how the researcher understood the findings as a whole.	Each quote was used to contribute to the narrative of the overall findings. Analytic commentary by the researcher about these quotes were aimed to not only add to data richness, but be interconnected, accessible, and easy to follow.
Developing a vigorous experiential and/or existential account	The quality of the analysis is increased depending on the depth and insight it can offer, which is the primary of aim of phenomenological inquiry in exploring lived experiences.	Data was explored in-depth: what “psychosis” means to participants, how participants work with it, where experiences differ and/or complement the other, and how the findings generate reflective activity by participants.
Close analytic reading of participant’s words	IPA follows Heidegger’s (1962) hermeneutic phenomenology, which considers phenomenological enquiry as inherently interpretive. This makes IPA a double hermeneutic challenge: participants make their own interpretations and meanings of their world, and the researcher interprets their interpretations (Smith & Osborn, 2008).	Ensured steps in Table 8 were followed so data could be grounded in its trustworthiness, used a reflective diary, and reviewed the quality, rigor, transparency, and trustworthiness of the researcher’s findings with both her supervisor and a qualitative analysis support group.
Attending to convergence and divergence	IPA aims for an idiographic analysis where each case is examined on an individual and detailed level. Therefore, small purposeful samples are valued.	The sample used was accessed purposefully to ensure participants were able to engage fully with the interview and case vignettes as part of illuminating their experiential world and associated sense-making. Each case was compared to identify similarities and differences with particular attention paid to nuanced interconnections between and across experiences.

Table 5. Case vignettes that were presented to participants.

Name	Vignettes
Hannah (Vignette A)	Hannah is a 31-year-old woman who works as an Accountant part-time. For the last 2 weeks she has not been coming into work. A few months ago, she was talking to her husband about seeing faces and shadows on the walls and hearing someone whisper her name. She once tried to record it on her phone but found she could not and told her husband she was afraid of “going mad.” Hannah told her husband she did not know what this was and felt afraid. Since quitting her job, Hannah has grown more aloof and detached, often avoiding talking to her family. Her husband stated that she can also suddenly become argumentative and aggressive for no apparent reason. Sometimes her husband hears her talking to herself when nobody is around. She has also been refusing to eat and has explained that she suspects the neighbors are poisoning her food. When speaking with Hannah, she says that she thinks someone – possibly the neighbors – has “cursed” her and she is now being “tormented” by evil spirits. Hannah does not feel much hope about her future and believes she must have done something wrong in order for her neighbors to have cursed her. She has had some suicidal thoughts but has never tried to harm herself. Hannah is attending spiritual care as she would like help to remove the curse.
Nadeen (Vignette B)	Nadeen is a 25-year-old teacher who was very close to her father before he passed away from a terminal illness with a life expectancy of just a few short months. Before her father passed, he told her that they would remain in contact after death. According to Nadeen’s husband, she went through a complicated mourning period when her father died, as she first was completely devastated before becoming more cheerful and more interested in returning back to work about 6 months later. Curious about the dramatic shift, her husband began observing her around the house and noticed that she was talking to herself in their bedroom at least once a day for an hour each time. When he asked who she was talking to, she told him that her father likes to visit her once a day to see how she is doing. Aside from that, he has not noticed any deterioration in her mental health or her personality worthy of note, but he has asked her to visit a service to talk about this. She told him that talking to her father makes her happy and keeps her life normal and balanced. They both disagree about the source of this experience and it is causing frequent arguments between them. Nadeen has attended spiritual care as she wants her husband to understand that she finds the visits from her father’s spirit comforting, and she is happy that these continue for as long as her father wishes to visit.
Jimmy(Vignette C)	Jimmy is a 28-year-old Master’s student who was diagnosed with schizoaffective disorder when he was 25 years old after hearing voices that told him he was evil and was going to suffer, as well as believing that he is being used as a vessel by a demon to purge the world of evil. Terrified, Jimmy joined a spiritual/religious support group and spent most of his savings with the religious group in an effort to manage the unpleasant experiences. However, Jimmy’s thoughts grew worse, so he eventually sought psychiatric support, following which he was he was diagnosed and started on treatment for psychosis. Since then, Jimmy has stopped believing in any higher power and said he feels bittersweet about the entire experience and diagnosis. He now feels he can attribute all of these experiences to the diagnosis and can orient himself better to reality. However, his medication needs to be changed and Jimmy is worried that the voices may return to try to convince him that they are “real.” Jimmy is visiting spiritual care to see if they can offer any help with these worries and stop him “slipping back.”

Table 6. Summary table of themes.

Theme	Subtheme	Participants contributing
7.1 Spirituality transcends and connects the individual	We are one entity, and things are intertwined Science as a part of spirituality The negative aspects of spiritual experiences	Jason, Wilma Kareem Mick, Nadiyah, Jason
7.2 Locating “psychosis” within a wider context beyond an individual	The importance of understanding the potential harm of psychosis Psychosis can sometimes be a mental health issue (but other times not)	Wilma, Jason, Jerrod, Nadiyah, Kareem Wilma, Jason
7.3 Chaplaincy as a holistic and bespoke approach to recovery from psychosis	Providing a holistic care package Using religious and non-religious activities as a part of tailored spiritual care Working with the views that people bring Chaplaincy work is “not a magic wand” Challenges in implementing chaplaincy work within services that emphasize a medical framework	Kareem, Jerrod Mick, Nadiyah, Jason, Kareem, Jerrod Wilma, Jerrod, Nadiyah, Mick, Jason Mick, Jerrod, Wilma, Kareem, Jason Mick, Jerrod, Jason

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