The International Journal of Psychosocial Rehabilitation

Positive effects of Spirituality on Quality of life for
People with Severe Mental Illness



Dr. Young, K.W., PhD, RSW
Social work Department
Baptist University
of Hong Kong


Citation:
Young KW (2012).Positive effects of Spirituality on Quality of life for People with Severe
Mental Illness.  
International Journal of Psychosocial Rehabilitation. Vol 16(2) 62-77

Correspondence
Dr. Young, K.W.
Social work
Department
Baptist University
of Hong Kong
1/F, Blk 1 Low-rise Building,
Renfrew Road,
Kowloon
Tong, Kowloon, Hong Kong
E-mail: danielyoungkw@yahoo.com.hk

 


Abstract
Recently, various bio-psycho-social factors have been identified in relation to quality of life for people with mental illness, but the role of spiritual factor on it has been relatively neglected. This study aims at exploring the positive effect of spirituality on quality of life for people with severe mental illness. 103 Chinese people with severe mental illness who are Christian and have received service from two community-based psychiatric rehabilitation projects in Hong Kong are included in this study. Respondent’s quality of life is measured by Chinese World Health Organization Quality of Life Instrument, while respondents’ spirituality is assessed by Chinese Daily Spiritual Experience Scale.  Daily spiritual experience is found moderately and positively related to individual’s overall quality of life (r=.433, p=.000) and all quality of life sub-domains. Also daily spiritual experience can predict individual’s overall quality of life and explain 18.7% variance of it. As spirituality has positive effects on quality of life for people with severe mental illness, mental health professionals should further explore effective spiritual interventions in enhancing quality of life for our service users. 
Keywords:. Spirituality, Quality of Life, Mental Illness


Introduction
In mental health service, interest in quality of life is stimulated by de-institutionalization movement. In the past few decades, people with severe mental illness are consistently found to have a lower quality of life than the general population without mental illness in n Western and Chinese societies (e.g. Baker, Jordey, & Intaglia, 1992; Chan & Yu,  2004; Evans, 2007; Langeland, Wahl, Kristoffersen, Nortvedt, & Hanestad, 2007; Murphy & Murphy, 2006; Ritsner & Gibel, 2007). Also, the quality of life of people with severe mental illness is found lower than people with common mental disorders (Evans, 2007). Moreover, their lower level of quality of life is found to remain relatively stable throughout the course of mental illness (Ritsner & Gibel, 2007).

Recently, researchers have tried to identify those factors leading to better quality of life for people with severe mental illness. However, many research studies have focused on the negative impact of psychiatric symptoms on individual’s quality of life (Eack, NewHill, Anderson, Rotondi, 2007). These research studies consistently report that quality of life are negatively affected by current psychiatric symptoms, especially symptoms of depression and anxiety, experienced by people with severe mental illness (Chan, Ungvari, Shek, & Leung, 2003; Hansson, 2006; Langeland et al., 2007; Norholm & Bech, 2006; Middlelboe, 1997; Norman, Malla, McLean, Voruganti, Cortese, McIntosh,  Cheng, Rickwoord, 2000; Sullivan, Wells, & Leake, 1992; UK700 Group, 1999).

Other researchers have tried to identify psycho-social factors influencing quality of life for people with mental illness. Quality of life is found related to: social functioning (Norman et al, 2000; Sullivan, 1992; Timko, Nguyen, Williford, & Moss, 1993); negative life events (Chan et al, 2003); emotional distress (Ritsner & Gibel, 2007); coping style (Caron, Lecomte, Stip, & Renaud, 2005); perceived freedom (Young, 2004); perception of mastery (Rosenfield, 1992; Askerson, 2000; Hsiung. Pan, Liu, Chen, Peng & Chung, 2010); self-esteem (Murphy, & Murphy, 2006);  self-efficacy (Ritsner & Gibel, 2007); stigma and discrimination (Chan & YU, 2004).  Moreover, objective life conditions in living environment, family relationships, social relationships, vocational status, safety, leisure and financial, etc are related to quality of life (Evans, 2007; Lehman et al., 1982). In addition, better family interaction (Sullican et al, 1992); having a competitive job (Priebe, Warner, Hubschmid, & Eckle, 1998; Ritsner & Gibel, 2007);  social support (Carton et al., 2005; Eack, 2007; Young, 2006); social integration (Middelboe, 1997); and fewer unmet needs (UK700 group, 1999; Eack et al., 2007) are all related to quality of life.

While above studies focus on exploring the bio-psycho-social factors influencing quality of life, few studies explore the role of spirituality in enhancing quality of life for people with severe mental illness.

Spirituality
For many years, spirituality and religion have been considered by some mental health professionals to be strong contributors to mental illness, and thus any positive role that spirituality and religion might play in the treatment of severe mental illness receive little attention by researchers (Koenig, Larson, & Weaver, 1998). Systematic reviews of research literature have consistently reported that spiritual and religious involvement contribute to desirable mental outcomes, such as: reducing symptoms for people with schizophrenia, depression and anxiety disorder; and lowering the rate of suicide and substance abuse (Koenig, McCullough, & Larson, 2001; Plante & Sharma, 2001; Swinton & Kettles, 2001). About two thirds of people with severe mental illness see spirituality as important to them (Bellamy, Jarrett, Mowbray, MacFartane, Mowbray, & Holter, 2007) and have positive impacts on their illness (Coursey & Lindgern, 1995). The majority of people with severe mental illness reported that they used spiritual and religious coping methods to cope with daily difficulties (Tepper, Rogers, Coleman & Malony, 2001); and these coping methods have been shown to have positive effects for them (Plante & Sherma, 2001; Tepper et a., 2001).

Research findings also have shown that spirituality and religion can enhance individuals’ quality of life by positively contributing to greater life satisfaction, happiness, positive affect, morale, and hope (Koenig et al., 2001; Levin, 2001; Plante & Sharma, 2001; Swinton & Kettles, 2001; Thoresen, Harris, & Oman, 2001). In particular, life satisfaction are positively related to  religious belief (Koenig et al., 2001) and church attendance (Thoresen et al., 2001). However, most of these research findings come primarily from studies of healthy, community-dwelling persons, persons who are elderly, persons with medical illness, or various ethnic groups (Koenig et al., 1998; Plante & Sharma, 2001).  Little research has been done on the effects of spirituality on quality of life for people with severe mental illness (Corrigan, Mcrkle, Schell, & Kidder, 2003; Koenig et al., 1998).

Recently, two large-scale surveys have been done in this area. In a survey of 1,824 people with mental illness living in the community and involved in Consumer Operated Service Project in the United States, Corrigan and colleagues (2003) showed that self-reported spirituality and religiousness were related to individual’s subjective well-being. Similarly, in another survey of 1,835 people with mental illness involved in clubhouse and consumer drop-in centers in the United States, Bellamy and colleagues (2007) reported that spirituality was related to overall quality of life. Although these two studies contribute to our understanding of the role of spirituality in the lives of persons with mental illness, they have methodological constraints that limit generalization of research results. For example, in the study done by Bellamy et al., spirituality was measured by a single question: “Is spirituality important to you?” which assesses importance versus other aspects of spiritual involvement. In the study done by Corrigan et al., the focus was on subjective well-being rather than quality of life, which is a different variable both conceptually and operationally (Orley, Saxena, & Herrman, 1998). It is, therefore, important to provide clear conceptualizations and measurement of spirituality and further clarify what type of spiritual involvement is associated with what kind of mental health variables under what conditions and for whom (Thoresen et al., 2001).

This study attempts to explore the positive effects of spirituality on quality of life for people with severe mental illness.

Definition Issues
Defining Spirituality
It is now commonly accepted among researchers that spirituality is conceptually different from religion and that spirituality is regarded as a broader concept than religion. For example, Canda  defined spirituality as the “person’s search for a sense of meaning and morally fulfilling relationships between oneself, other people, the encompassing universe, and the ontological ground for existence” (Canda, 1990, p.13), which is distinguished from religion: “Religion involves the pertaining of spirituality beliefs and practices into social institutions, with community support and traditions maintained over time” (Canda, 1997, p.173). However, within mental health professionals, a variety of definition of spirituality has been emerged, and there is no commonly accepted definition of spirituality (Burke, 2006). A recent literature review on spirituality has found that the lack of agreement among researchers and scholars about the definition and concept of spirituality may reflect the cross cultural, cross religious and plurality in health care disciplines (McCarroll, O’Connor, & Meakes, 2005), as well as a diverse conceptual construct on spirituality (Parament & Zinnbauer, 2005). In this study, the conceptual framework  of Parament & Zinnbauer  (2005)  on spirituality is adopted here and spirituality defined as people’s search for the Transcendent (God, the Divine).

Defining Quality of Life
Similar to spirituality, there has been a lack of consensus and universal definitions among researchers regarding the concept of “quality of life” (Skevington, Lofty, & O’Connell, 2004). In this study, the World Health Organization’s (WHO) concept of quality of life is used as it is based on a large scale international and transcultural study and has been shown applicable to Chinese culture and societies (Skevington et al.,  2004).  WHO defines quality of life as “individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad-ranging concept affected in a complex way by the persons’ physical health, psychological state, level of independence, social relationships and their relationships to salient features of their environment” (Skevington et al., 2004, p. 299). 

Research Method
Research Design and Data Collection
The study sample was drawn from a population of mental health service users who had contacted with two community-based psychiatric rehabilitation projects in Hong Kong; and have Christen spirituality. The first project provided spiritual group and fellowship for people with mental illness and Christian belief. The first project consisted of about 220 members, although each spiritual group consists of about 15 members. Each group organized various educational talk, pray, sharing, mutual support, volunteer services, recreational activities for their group members. The other project was an integrated rehabilitation centre providing vocational training and halfway house for people with severe mental illness. This second project involved about 220 mental heath users. The agencies of these two projects had allowed the researcher to conduct this research study, and were willing to provide assistance in the research process. To be eligible to participate in the current study, service users had to be assessed by project mental health professionals as being mentally stable and having Christian belief. Service users meeting these criteria were then contacted individually and invited to participate in the study by project mental health professionals who explained the aims of the study and the purpose of data collection. This process resulted in a studied sample of 103 respondents who indicated interest in the study and gave their written consent to participate in this research. 74 subjects come from the first project and is named spiritual group, while 29 subjects come from the second project and is named church group in this research project.

Participants completed self-administered questionnaires designed to assess spirituality and quality of life (described below). Also, participants provided their basic demographic information, including: sex, age, marital status, education level, employment status, financial status, religious affiliation and church / fellowship attendance in a separate sheet designed by the researcher. Information on participants’ medical background, including mental health diagnosis, number of psychiatric hospitalizations, and period of mental illness, was collected mainly by participants’ self-report. If necessary, project mental health professionals would provide this information for participants on their request and consensus. Data collection began in March, 2009 and was completed in August, 2009.

Measuring Instruments
Measurement of Spirituality
Chinese Daily Spiritual Experience Scale (DSES). The spirituality of respondents was measured by the Daily Spiritual Experience Scale (Underwood & Teresi, 2002).  DSES is used to measure “a person’s perception of the transcendent in daily life and his or her interaction with or involvement of the transcendent in life” (Underwood & Teresi, p.23). It consists of 16 items. The first 15 items are scored using a modified Likert scale, with 6 represents many times a day and 1 represents never or almost never. The 16th item has four responses with a modified Likert scale, with 4 represents as close as possible and 1 represents not close at all.  Scores are summed over items such that higher scores indicate higher level of spirituality. The possible range of the DSE is 16 to 94. The reliability and validity of DSES have been tested to be satisfactory (Underwood & Teresi, 2002). The reliability and validity of the Chinese version of DSES has been tested to be satisfactory, too (Ng, Fong, Tsui, Au-Yeung, Law, 2009). In this study, the reliability of this scale is also found to be high, and the Cronbach’s alpha (a) of the DSES is 0.93. 
      
Chinese WHO Quality of Life Instrument (WHOQOL-BREF). As a measure of quality of life, the WHOQOL-BREF has been reported as demonstrating satisfactory estimates of reliability and validity, having cross-cultural sensitivity (Skevington et al., 2004), and suitable for use with people with mental illness (Orley et al., 1998). In the current study, the Chinese version of the WHOQOL-BREF was used to measure the quality of life of respondents, which also has been reported as demonstrating adequate validity and reliability (Leung, Tay, Chu, & Ng, 2003). This 28-item Chinese version of the WHOQOL-BREF assesses four domains (physical health, psychological, social relationships, and environmental).  Two items of the 28 items can be analyzed separately: one item asks about respondents’ overall perception of their quality of life and one item asks about overall perception of health. The response set for each item ranges from 1 to 5, with 1 representing “very dissatisfactory” and 5 representing “very satisfactory.” The overall quality of life and overall perception of health score of WHOQOL range from, 1 to 5 with 5 indicates better overall quality of life. The score of WHOQOL domains are calculated by multiplying the means of all items score included in each domain by a factor of 4 and accordingly, the possible scores for each domain range from 4 to 20, with  higher scores indicate higher levels of quality of life. In the current study, reliability estimates based on Cronbach’s alpha is high for the total WHOQOL-BREF scale (α = .93). Also, reliability estimates for Physical Health Domain subscale (α = .74); Psychological Domain subscale (α = .87); Social Domain subscale (α = .70), and Environmental Domain subscale (α = .80) are all satisfactory.


Research Results
Characteristics of Research Sample
The whole study sample consisted of 103. The basic demographic characteristics are summarized in Table 1.
Table 1. Basic Demographic and clinical characteristics of the sample

 

Spiritual Group

 

Church

Group

 

Total

 

 

N

%

N

%

N

%

Total number of participants

74

100

29

100

103

100

Sex

 

 

 

 

 

 

  Male

28

37.8

11

39.3

39

38.2

  Female

46

62.2

17

60.7

63

61.8

Age (Mean yrs)

42.01

 

45.23

 

42.86

 

         (S.D., Range)

(8.88,

24-61)

(10.88,

23-61)

(9.49,

23-61)

Marital Status

 

 

 

 

 

 

  Single, divorced, separated or widowed

53

71.6

24

82.8

77

74.8

  Married

21

28.4

5

17.2

26

25.2

Educational level

 

 

 

 

 

 

  None

1

1.4

1

3.4

2

1.9

  Primary

3

4.1

5

17.2

8

7.8

  Secondary

55

74.3

19

65.5

74

71.8

  Tertiary

15

20.3

4

13.8

19

18.4

Work status

 

 

 

 

 

 

  Unemployed

36

48.6

6

20.7

42

40.8

  Attending vocational training

3

4.1

21

72.4

24

23.3

  Having a part-time or full time job

35

47.3

2

6.9

27

35.9

Financial status

 

 

 

 

 

 

  Relying on governmental financial  assistance

37

50.0

27

93.1

64

64.2

Diagnosis

 

 

 

 

 

 

  Schizophrenia

47

63.5

18

69.2

65

65.0

  Mood Disorder

24

32.4

7

26.9

31

31.0

  Others psychosis

3

4.1

1

3.8

4

4.0

Duration of mental illness (Mean yrs)

15.86

-

23.64

-

17.70

-

                                           (S.D., Range)

(6.96,

2-29)

(11.05,

4-42)

(17.70,

3-42)

Number of Hospitalization (Mean)

3.03

-

4.38

-

3.36

-

                                            (S.D., Range)

(3.03,

0-15)

(3.59,

0-12)

(3.21,

0-15)

The study sample was predominant female, single, schizophrenia, and with a mean age of 43 years. Over two thirds had reached secondary school level. Only one third had full-time or part-time competitive job and most of them had to rely on governmental financial assistance to support their lives.
The two studied groups did not show significant difference in their age, sex, education, marital status and diagnosis, but had significant difference work status (Pearson Chi-Square=55.65, p=000) source of income (Pearson Chi-Square=16.45, p=000), and duration of illness (ANOVA F=15.522, p=.000). The spiritual group had a higher proportion of having part-time or full-time job, and relied on salary to support their life. Also this group had relative shorter period of mental illness. The church group had longer duration of mental illness, having higher proportion of receiving vocational training and most of them relied on governmental financial assistance to support their life. 

Quality of Life
The data of quality of life of the studied groups are shown in Table 2. The spiritual group and church group did not differ in overall quality of life and all quality of life sub-domains.

In general, the whole sample regarded their overall quality of life as average, with a mean score of 3.46 (SD = 0.83, ranging from 1.00 to 5.00), and about half (52.5%, n = 53) were satisfied or very satisfied with their overall quality of life. Similarly, they regarded their overall heath as average, with a mean score of 3.02 (SD = 1.06, ranging from 1.00 to 5.00), and less than half (42.7%, n = 44) were satisfied or very satisfied with their overall health. Also, this sample regarded all quality of life domains as average, and the mean score of these quality of life domains ranged from 12.91 to 13.13. Relatively, respondents were most satisfied with their physical domain; and were least satisfied with their social domain.


 Spirituality
All studied subjects were Christian. The studied group and church group differed in their attendance in religious activity (Pearson Chi Square=21.43, p=.000), and the spiritual group attended religious activity more frequently. The majority of the spiritual group (77.0%) attended religious activity at least once weekly. About one third (31.0%) of the church group attended religious activity at least once weekly, while another one third (37.9%) attended religious activity at least once monthly.

The studied group and church group did not differ in their daily spiritual experience (DSE) (Table 2). In general, the study sample regarded their spirituality as above average, and respondents reported a mean total DSE score of 60.89 (SD = 13.77, ranging from 29 to 94).
Spirituality in relation to Quality of Life 

Pearson correlation analyses were conducted using SPSS for Windows to test the relationships between spirituality and quality of life for the whole studied sample, i.e. 103 respondents. Results are shown in Table 3. Individual’s total DSES score was found moderately and positively related to individual’s overall quality of life score  (Pearson Correlation=.433, p=.000). In addition, individual’s total DSES score was moderately and positively related to physical domain (Pearson Correlation=.398, p=.000), psychological domain (Pearson Correlation=.459, p=.000), social domain (Pearson Correlation=.364, p=.000), and environment domain (Pearson Correlation=.256,  p=.000).




Table 2 Quality of Life and Spirituality of the study sample

 

 

Spiritual

Group

Church

Group

Total Sample

N

ANOVA

F value

sig. (2-tailed)

Overall QoL

Mean

3.41

3.55

3.46

101

.544

.463

 

S.D.

.85

.78

.83

 

 

 

 

Range

1.00-5.00

2.00-5.00

1.00-5.00

 

 

 

Overall Health

Mean

3.07

2.90

3.02

103

.543

.463

 

S.D.

1.00

1.21

1.06

 

 

 

 

Range

1.00-5.00

1.00-5.00

1.00-5.00

 

 

 

QoL Physical Domain

Mean

13.18

12.96

13.13

103

.160

.690

 

S.D.

2.34

2.50

2.37

 

 

 

 

Range

6.86-18.29

8.00-20.00

6.86-20.00

 

 

 

QoL Psychological Domain

Mean

12.96

12.99

12.97

103

.002

.964

 

S.D.

2.81

2.95

2.84

 

 

 

 

Range

5.50-18.50

7.00-20.00

5.50-20.00

 

 

 

QoL Social Domain

Mean

12.72

13.38

12.91

103

.911

.342

 

S.D.

3.04

3.47

3.15

 

 

 

 

Range

4.00-20.00

8.00-20.00

4.00-20.00)

 

 

 

QoL Environmental Domain

Mean

12.93

13.49

13.09

103

1.072

.303

 

S.D.

2.37

2.72

2.47

 

 

 

 

Range

6.50-17.50

6.50-20.00

6.50-20.00

 

 

 

Spirituality  DSES

Mean

60.80

61.14

60.89

103

.013

.911

 

S.D.

13.40

14.93

13.77

 

 

 

 

Range

29.00-94.00

37.00-94.00

29.00-94.00

 

 

 

* p< 0.5,  **p< .01

 

Further analyses were conducted to explore the possible correlation between demographic or medical variables with individual’s quality of life. Results are shown in Table 3. Religious activity attendance is found unrelated to overall quality of life. Also, all, except one, demographic and medical variables such as age, sex, marital status, educational status, medical diagnosis, number of hospitalization, and duration of mental illness were found unrelated to overall quality of life. Work status was found related to overall quality of life; and those who had part-time or full time competitive job had better overall quality of life than those who were unemployed and retired.

Hierarchical regression analysis is performed with data of 103 respondents by using SPSS for Windows. Overall quality of life is entered into the regression equation as the dependent variable. Variables, which are related to overall quality of life, are selected for regression analysis. At the first level of regression analysis, daily

spirituality experience is entered into the equation. Then at the second level of regression analysis, various quality of life domains, including: physical,  psychological, social, and environmental quality of life, are then entered into the equation.  The regression analysis is then done step by step for the above variables. The results are shown in Table 4. Daily spiritual experience alone can explain 18.7% of variance in overall quality of life, while physical,  psychological, social, and environmental quality of life altogether can explain 27.0 % of variance in  overall quality of life.

Table 3. Correlation among Quality of Life, Spirituality and other variables

Item

Test

 

Overall QoL

DSE

N

Value

(r / F)

sig. (2-tailed)

N

Value

(r / F)

sig. (2-tailed)

QoL (Physical Health Domain)

Pearson Correlation

101

.587

(.000)**

101

.398

(.000)**

 

 

 

 

 

 

 

 

QoL (Psychological

Pearson Correlation

101

.584

(.000)**

103

.459

(.000)**

Domain)

 

 

 

 

 

 

 

QoL (Social Relations Domain)

Pearson Correlation

101

.574

(.000)**

103

.364

(.000)**

 

 

 

 

 

 

 

 

QoL (Environmental

Pearson Correlation

101

.534

(.000)**

103

.256

(.009)**

Domain)

 

 

 

 

 

 

 

Daily Spiritual Experience

Pearson Correlation

101

.433

(.000)**

103

1.00

--

 (DSES)

 

 

 

 

 

 

 

Religious Activity Attendance (RAA)

 

Pearson Correlation

101

.039

(.699)

103

.210

(.034)*

Setting

ANOVA

 

101

.544

(.463)

103

.013

(.911)

Age

Pearson Correlation

101

-.005

(.961)

103

-.013

(.902)

Sex

ANOVA

 

101

.018

(.893)

103

.664

(.417)

Education

ANOVA

 

101

.407

(.748)

103

.224

(.880)

Marital Status

ANOVA

 

101

.100

(.753)

103

.040

(.852)

Work status

ANOVA

 

101

3.943

(.011)*

103

.015

(.998)

Financial status

ANOVA

 

101

3.714

(.057)

103

1.550

(.216)

Diagnosis

ANOVA

 

101

.357

(.701)

103

2.340

(.102)

No. of Hospitalization

Pearson Correlation

101

.096

(.353)

103

.037

(.715)

Period of mental illness (yrs)

Pearson Correlation

101

.089

(.401)

103

-.034

(.746)

 () indicates significance (2-tailed) ;      * p< 0.5,  **p< .01

 Table 4 Hierarchical regression analysis (Overall QoL as dependent variable)

Dependent variable

Model

Predictors

Standardized Coefficients

(Beta)

F

df

Sig.

R2

Std. Error of the Estimate

Overall Qol

1

(Constant)

 

22.829

99

.000

.187

.7528

 

DSES

.433

 

 

 

 

 

Overall Qol

2

(Constant)

 

16.018

95

.000

.457

.6280

 

DSES

.188

 

 

 

 

 

 

Physical  QoL

.200

 

 

 

 

 

 

 

Psychological QoL

.084

 

 

 

 

 

 

Social QoL

.216

 

 

 

 

 

 

Environmental QoL

.161

 

 

 

 

 

 

Discussion
The current findings suggest that spirituality is beneficial to people with severe mental illness.  Specifically, daily spiritual experience is found positively related to and predicting overall quality of life for people with severe mental illness. These findings are consistent with other research studies that show positive effects of spirituality on quality of life for persons with mental illness (Bellamy et al., 2007; Corrigan et al., 2003).

Attachment theory, originally introduced by Bowlby, has been adopted and modified by Kirkpatrick to explain the ways of spirituality in enhancing individual’s general well being (Kirkpatrick, 1995). According to the attachment theory, the Transcendent or God can become an important attachment figure for people. People will turn to the God for comfort and security during stressful circumstances as if a child asks for the protection from his parents during stressful circumstances. People who experience a secure connection with God would experience greater strength, confidence, and comfort. Researcher evidences tend to support this attachment theory by showing that general community residents who report a close connection to God experience a number of health-related benefits, including less depression, less loneliness, greater relational maturity, greater psychosocial competence, and better psychosocial adjustment when facing with life stress (Hill & Pargament, 2008). This research finding supports this attachment theory by showing that individual’s closeness to the Transcendent, as reflected by the DSES, is positively correlated with overall quality of life and various quality of life domains for people with severe mental illness.

In addition, the attachment theory suggests that the effects of individual’s closeness to God is greater than that of individual’s attendance of religious activity (Hill & Pargament, 2008). This research finding support this result by showing that individual’s closeness to the Transcendent, as reflected by the DSES is moderately positively related to and predicts overall quality of life. On the other hand, religious activity attendance is found not related to quality of life.

On the other hand, most demographic and medical variables measured in this study, including: age, sex, marital status, educational status, medical diagnosis, number of hospitalization, duration of mental illness are found unrelated to overall quality of life. These findings are also consistent with other previous research reports, which have found that these demographic and medical variables are unrelated, or at most weakly related, to overall quality of life (Ritsner & Gibel, 2007; Young, 2004).

Although there has been movement to bring spirituality into general clinical practice and intervention,  the role of spirituality in the lives of people with severe mental illness have been relatively neglected by mental health professionals (Huguelet, Nohr, & Borras, 2006). As spirituality has shown to be beneficial for people with severe mental illness, mental health professionals should adopt holistic treatment strategies that integrate spiritual factor into assessment and intervention, as advocated by many other writers (e.g. Corrigan et al., 2003; Fallot, 1998; Koenig et al., 2001; Plante & Sharma, 2001; Swinton & Kettles, 2001). Such treatment approaches, including the bio-psycho-social- spiritual model and the Body-Mind-Spirit model, have been advocated by many mental health professionals for assessment and interventions (e.g. Chan et al., 2002; Prest & Robinson, 2006).  In addition, spiritually-oriented therapeutic interventions for people with severe mental illness have also been documented (e.g. Koenig, 2005). For example, Koenig (2005) has reviewed several models and research studies on spiritually-based group therapy for people with severe mental illness and found that these groups yielded positive results. Moreover, a number of religious and spiritual activities are thought to encourage more frequent daily spiritual experience (Underwood & Teresi, 2002), and these activities can then promote individual’s closeness with the Transcendent and quality of life. In future, mental health professionals need to further explore various effective spiritual interventions in enhancing quality of life for our service users.

Several limitations of this study should be acknowledged. The study sample is non-randomized and has small size, which may limit the generalization of the research result. In fact, this sample is predominated with Christian affiliation, requiring caution in interpreting results. Also this is a cross-sectional study which has limitations in establishing the prospective causal effects of spirituality on quality of life. In future, a prospective longitudinal study with a larger sample size is needed in this area.  

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