Positive effects of spirituality in facilitating
recovery for people with severe mental illness
Dr. Daniel Young
Department of Social Work
Hong Kong Baptist University
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
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
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 &
In general, literature has defined and
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.
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
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,
with mental illness: recognize that the pain of staying is greater than
pain of changing; seek help from a higher power and search for the
life; find spiritual satisfaction; believe that they can recover and
meaning in life; and finally develop a sense of well-being and show
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,
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
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.
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.
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
the influence of spirituality largely operates through an individual’s
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
research participants, how spirituality influences recovery in people
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
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
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.
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
the time of interview, all participants had already moved away from the stage
of hopeless and despair. According to their personal
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
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
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
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”.
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.
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.
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.
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)
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.
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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