The International Journal of Psychosocial Rehabilitation
Positive effects of spirituality in facilitating
recovery for people with severe mental illness




Dr. Daniel Young
Assistant Professor

Department of Social Work
Hong Kong Baptist University


 


Citation:
Young D.  (2015)  Positive effects of spirituality in facilitatingrecovery for people with severe
mental illness.
 International Journal of Psychosocial Rehabilitation. Vol 19(1) 5-12  


Abstract
This study aims at exploring positive impacts of spirituality on helping people with severe mental illness to overcome loss and despair in recovery. In-depth semi-structured interviews were conducted with six Chinese people having severe mental illness who relied on spirituality to facilitate their recovery. Five themes of spirituality are identified helping individuals to overcome profound loss and despair in recovery, including: positive meaning towards mental illness; hope for recovery; forgiveness; social support, and spiritual coping. Spirituality is found to have positive effects on mental health recovery. Benefits of spiritual interventions, e.g. forgiveness therapy, on mental health recovery worthwhile further study.

KEYWORDS. Spirituality, Recovery, Mental Illness


Introduction:
Many people hold a pessimistic view of the progressive deteriorating course of people with severe mental illness, leading the individual towards increasing impairment in functioning (Calabrese & Corrigan, 2005). On the contrary, research evidences have shown that more than 50% of people with severe mental illness can achieve mental health recovery (Harrison et al, 2001; Warner, 2004; Calabrese & Corrigan, 2005). Recovery has been adopted as an important element of mental health policy in many western countries (Ramon, Healy & Renouf, 2007). 
 
In general, literature has defined and focused recovery as outcome or process. By defining recovery as outcome, researchers tend to focus on symptoms alleviation and return to pre-morbid level of functioning. Rodgers and colleagues (2007) have summarized four specific operational definitions of recovery, and all definitions include the criterion of symptoms remission or stabilization as well as improved functioning which has been defined in a variety ways. However, many researchers have pointed out that from the perspective of consumers, recovery is not understood as end product or result, rather recovery is viewed as a unique personal process or as a way of life (Anthony, 1993; Davidson et al., 2005). This study adopts the approach of Anthony, focuses on recovery process, and defines recovery as a way of living a satisfying, hopeful, and contributing life even with the limitations caused by mental illness.
 
Difficulties in overcoming profound loss during the journey of recovery
Those researchers regarding recovery as a process have developed knowledge of the stages of mental health recovery based on the personal recovery experiences of people with mental illness (Young and Ensing, 1999; Spaniol, Wewiorski, Gagne, & Anthony, 2002; Ralph, 2005; Andersen, Caputi and Oades, 2006). For example, Andersen et al. (2006) developed a five-stage model of recovery: moratorium, awareness, preparation, rebuilding, and growth. Similarly, Ralph (2005) developed a six-stage model of recovery: despair; awakening; gaining insight; action plan; determination to be well; and well-being. Interestingly, Ralph (2005) included religiosity and spirituality in her six stage recovery model, suggesting that the recovery journey was also a spiritual journey. At the initial stage of recovery, people with mental illness lost meaning in life. At subsequent stages, people with mental illness: recognize that the pain of staying is greater than the pain of changing; seek help from a higher power and search for the meaning of life; find spiritual satisfaction; believe that they can recover and identify meaning in life; and finally develop a sense of well-being and show compassion for others.
 
All the theoretical models of the stages of recovery have identified that an initial stage of profound loss and despair immediately follows having a diagnosis of psychiatric disorder, particularly when people with mental illness hold negative expectations of a lifetime of disability arising from an incurable mental illness (Young and Ensing, 1999; Ralph, 2005; Andersen et al, 2006). Overcoming and moving away from the initial stage of recovery of loss and despair is found to be one the most difficult task for many consumers (Young & Ensing, 1999), and many consumers get stuck in the initial stage of recovery for years before they move on recovery journey (Smith, 2000). One important follow up question is: how can people with severe mental illness overcome profound loss and despair at the stage of profound loss? Some writers attempt to explore the positive impact of spirituality on facilitating consumers to regain hope, overcome loss and despair on their recovery journey.
 
Positive impacts of spirituality on recovery journey

A variety of definition of spirituality has been emerged within mental health professionals, 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 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, spirituality is defined as people’s search for the God, and is regarded as a subjective and personal experience with God (Hadiz, 2011).
 
Recent years have been a growing emphasis on the importance of spirituality in recovery from mental illness (Fallot, 2007). Many people with severe mental illness see spirituality as important to them (Bellamy, Jarrett, Mowbray, MacFartane, Mowbray, & Holter, 2007); and reported that spiritual lives played a significant role in their recovery and quality of life (Bussema & Bussema. 2007; Young, 2010). Koenig (2009), in a recent systematic review of research literature, has reported that spirituality can reduce symptoms for people with schizophrenia, depression and anxiety; and lower the rate of suicide. Koenig (2009)’s findings are supported by other research reviews (Plante & Sharma, 2001; Swinton & Kettles, 2001). While acknowledging the importance of spirituality on recovery among writers, few research work have been done to explore the underlining mechanism of positive impacts of spirituality on mental health recovery.
 
This study thus tries to explore this issue, and attempts to identify how spirituality help consumer to overcome profound loss and despair at the initial stage of recovery.
 
Research Design
in this study. The goal was to select subjects who were able to provide valuable information on how religiosity influences their mental health recovery. The subject selection criteria included: having a diagnosis of mental illness; having been admittedWhen analyzing the influence of spirituality on health, it has been proposed that the influence of spirituality largely operates through an individual’s meaning systems (Park, 2007). So, in this study, an interpretive qualitative research method (Fossey et al., 2002) was adopted so as to understand better, from the perspective of the research participants, how spirituality influences recovery in people with severe mental illness. Moreover, a multiple case study with a purposive sampling research design was adopted  to mental hospital at least once; being mentally stable; receiving community based rehabilitation services and attending a spiritual group provided by a local non-government agency in Hong Kong.

In depth semi-structure interviews were conducted with each subjects by the author.  Each subject was interviewed for one to two times to share their personal account of their mental health recovery journeypirituality could facilitate their mental health journey. Each interview lasted for about 2 hours. The content of these semi-structure interviews were audio-taped with the consent of participants. The recordings were transcribed in verbatim, and the transcripts of the semi-structured interviews were coded, categorized, and analyzed. Participants were asked questions such as: “Have you gone through profound loss during your mental health recovery journey?” “Could you describe your experiences of loss, and your feelings at that time?’’  “Could you describe how spirituality can help you to overcome this profound sense of loss?’’  Data collection was started and completed in 2009.
 
Research Results
Among six research subjects, five were female and one was male. Their age ranged from 23 to 44 years old, with a mean age of 36.3 years. Four suffered from schizophrenia (Case A, C, E, & F), one suffered from bipolar mood disorder (Case D), and one suffered from depression (Case B). Four of them were single, while two had divorced. Three lived with their family, while another three lived at halfway house. Although all of them had difficulties in seeking open employment, five were receiving supported employment service and one was working a part-time job at open job market. All of them reported to be Christian. All, except one, had attended church worship weekly, and attended fellowship organized by a rehabilitation agency biweekly. Although one participant did not attend church worship regularly, she attended fellowship organized by the rehabilitation agency regularly.  All participants reported to have pray almost daily. All of them reported that spirituality were important to them as well as their mental health recovery. Their recovery journey were non-linear. All of them had relapsed at least one. Their number of hospitalization ranged from one to eight, with a mean 3.5.  At the time of semi-structure interview, according to the five stage recovery model of Andersen et al (2006), all participants had gone through the first three stage of recovery, i.e. moratorium, awareness, and preparation, and were situating at the rebuilding stage.
 
All participants suffered from profound sense of loss
After the onset of mental illness and / or subsequent relapse, all participants reported suffering from profound loss, including: divorced and broken families (case B and E); termination of degree studies and broken career dreams (Case A and C); unresolved grief towards the death of relatives (Case F); persistent work instability and long term unemployment (Case A, C and D); and hopelessness and suicidal attempts (case B and E). When recalling that period of life, all participants (Case A, B, C, D, E, and F) said that they suffered from a profound sense of loss such as: beloved family members, friends, living place, job, and income; and felt useless, worthless, lonely, helpless, and hopeless.
 
Spiritual elements in facilitating mental health recovery
At the time of interview, all participants had already moved away from the stage of hopeless and despair. According to their personal account, five themes of spirituality were identified having positive effects in facilitating recovery for people with severe mental illness, and could help participants to overcome hopelessness and despair. These themes were: providing positive meaning towards the onset and relapse of mental illness; inducing hope for recovery from mental illness; forgiving those who hurt them during the relapse of mental illness; offering social support, and using spiritual coping skills to reduce symptoms.  These spiritual elements are explained below.
 
Providing positive meaning towards the onset and relapse of mental illness
Four participants (Case B, D, E and F) perceived that having mental illness were sufferings for their lives, but more important, their religious belief had provided positive meanings on these sufferings so that they could have the strength to live with and overcome these sufferings.
 
The personal account of Case F gave a typical example of it: “Having mental illness is certainly a suffering for me. Initially, I didn’t know how to react, how to live….Now, I view this experience as a blessing from God… Through these sufferings, you can learn how to rely on God” (Case F).

While sharing similar views, other cases added that “Divorce is a suffering for me…I believe that it is good training for me provided by God so that I can learn to rely on God….After my divorce, I pray more frequently and attend worship regularly” (Case B); and that: “These sufferings make me stronger…I believe that I have learnt to suffer for God” (Case E).
 
Inducing hope for recovery from mental illness
Four participants (Case A, B, D and F) perceived that their spiritual faith could help them overcome despair and hopelessness as they could rely on the transcendent God to lead and protect their future lives. Some participants could base on their reliance on God in the past to build up hope in their recovery journey and future lives.
The personal account of Case B gave a typical example of this: “I don’t need to worry about my future as I rely on God. God always helps me, and He has just helped me to find a job a few days ago. So I believe that my God will help me in my life… God will lead me on the way ahead” (Case B).
Others shared almost the same view, and one case added: “I don’t worry that my mental illness is a terminal illness. I don’t fear it, but I fear becoming hopeless. Having a Christian belief, I understand that my God will help me and save me” (Case F).
 
 Forgiving those who have hurt them during the onset or  relapse of mental illness
Three participants (Case B, C and D) shared that their experience on forgiveness. In the past, they attributed their onset or relapse of mental illness to others, which  led them angry, hate and poor mental health. These participants reported that spirituality helped them to forgive others, which led to better health and could facilitate them to move away from initial stage of recovery and move forwards in their recovery journey.

The personal account of Case B gave a typical example of this: “Just after my divorce, I hated my ex-husband as I felt that he had abandoned me because of my mental illness and left me a broken family!...Then I learnt to forgive him and start a new life…Now, my life becomes easier. I still have frequent contact with my lovely daughter; and I spend more time praying and attending church worship as well as visiting friends, etc. Thank God for leading me to a new and better life! Now, I have forgiven my husband, and I am starting to enjoy my new life” (Case B).

Similarly, Case D shared that she had forgiven her ex-boss who fired her and led her to mental illness, while Case C shared that he had forgiven his ex-classmate who sexually harassed him leading to delusion. Both cases shared that hating others made their mood even worse, and after learning to forgive, their moods become better.
 
Using spiritual coping skills to reduce psychiatric symptoms
All six participants reported that they use spiritual coping skills, in addition to psychiatric medication, to cope with daily stress such as work stress (Case A, C, D & E), living arrangements (Case D, E & F), family conflicts (Case B & D), and interpersonal conflicts with others (Case C & F).

The personal account of Case E gave a typical example of it: “I worry about many things and sleep badly. I only sleep four to five hours per night…Then I started to pray before I sleep. It really helps and I can sleep better! My mental health then becomes better!”

Three cases added that they used religious coping to cope with psychiatric symptoms such as audio hallucination (Case F), depression (Case E) and anxiety (Case C).
Case C shared that: “I always have audio-hallucination, i.e. a boy’s voice talking to me. I realize that this voice is in fact an hallucination… When this hallucination comes, I pray to God to help me face it. Then I feel better after praying and have peace in my heart”. Case E also shared that: “Whenever I am unhappy, I pray and sing hymns for about an hour. Then I feel better”. Case C shared a similar experience: “I am always anxious when meeting with strangers. Then I start (praying) and my anxiety is reduced”.
 
Offering social  support
Three participants (Case B, E, & F) appreciated the social support from church pastors, ministers and leaders who gave them emotional support, advice and accompanied them when they were in crisis.

The personal account of Case B gave a typical example: “My pastor and church members are concerned about me and support me...When they know that I am unhappy, they will visit me, give me delicious soup, comfort me and pray for me”.

Also, three participants (Case A, C & F) appreciated the support from fellowship members who gave them emotional support, advice and became their friends.
Case F gives a typical example: “I have gained mutual support from other Christian residents of this halfway house. I and other Christian residents sing hymns and pray together. Also they are concerned about me. When I encounter any difficulty, they will give me advice and pray for me”.
 
Conclusion
In this study, spirituality was found to have positive effects in facilitating recovery for people with severe mental illness. Overcoming and moving away from the initial stage of recovery of loss and despair is found to be one the most difficult task for many consumers (Young & Ensing, 1999), and many consumers get stuck in the initial stage of recovery for years before they move on recovery journey (Smith, 2000). Many writers found that finding hope is one important element in facilitating consumer to overcome despair and progress to next stage of recovery (Young & Ensing, 1999; Ridgway, 2001; Turner-Crowson & Wallcraft, 2002; Davidson et al., 2005). However, few studies have explored effective interventions in facilitating consumer to gain hope and move away from stage of loss and despair. Based on personal account of recovery journey, all participants in this study were found to rely on spirituality to overcome despair and hopelessness and made significant progress in their mental health recovery journey. In particular, five themes of spirituality have been identified which can help consumers to overcome hopelessness and despair. These themes are: providing positive meaning towards the onset and relapse of mental illness; inducing hope for recovery from mental illness; forgiving those who have hurt them during the relapse of mental illness; offering social support, and using spiritual coping skills to reduce symptoms.
 
As spirituality is found to have positive effects in mental health recovery, it is suggested that spiritual interventions should be adopted by mental health professional in facilitating mental health recovery for consumers. Based on the above five spiritual elements found in relation to mental health recovery, spiritual interventions can be developed for promoting mental health recovery for consumer. For example, spiritual group can be used to facilitate the use of appropriate spiritual coping, and to strengthen social support for consumers. Also during individual counseling, individual’s spirituality can be used to provide a positive meaning towards the onset of mental illness and related negative impacts on individual’s lives for consumers.
 
Interestingly, this study has identified forgiveness as an important spiritual element in facilitating mental health recovery. Forgiveness can help individual to facilitate grief what has been lost and develop a positive perspective on these losses (Turner-Crown & Wallcraft, 2002).  This finding has clinical implication of suggesting the use of forgiveness therapy (Enright & Fitzgibbons, 2000) to facilitate individual’s recovery. In fact, research evidences have already shown that forgiveness therapy is effective in reducing depression and anxiety (Reed & Enright, 2006). In future, more research study can be done in exploring positive benefits of forgiveness therapy in mental health recovery.
 
There has been movement to bring spirituality into general clinical practice and intervention,  but 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, McCorkle, Schell, & Kidder, 2003; Fallot, 2007; Koenig, 2009; 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, Ho, & Chow, 2002; Prest & Robinson, 2006).  In addition, spiritually-oriented therapeutic interventions for people with severe mental illness have also been documented (Koenig, 2005; Walsh, 2013)
 
Although spirituality has been identified by several writers as an important element for mental health recovery (Bussema & Bussema, 2007; Fallot, 2007; Young & Ensing, 1999; Davidson et al., 2005), little research work has been done in evaluating the effectiveness of spiritual interventions on mental health recovery. So more research work need to be done in this area to develop and verify various spiritual interventions in facilitating mental health recovery for consumers, and in particular, helping consumer to move away from the initial stage of loss and despair.
 
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. Also this is a cross-sectional study which has limitations in establishing the prospective causal effects of spirituality on mental health recovery. In future, a prospective longitudinal study with a larger sample size is needed in this area.
 



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