of Persons with Mental Disorders
As reviewed in Lesson1
Background of DSM-IV Category, clinical literature
has tended to pathologize religiosity in persons with
mental disorders. One example is the assertion by Albert Ellis,
that: "The less religious [patients] are, the more
emotionally healthy they will tend to be" ( p. 637).
One study examined 44 psychiatric patients suffering
from depression, anxiety disorders, and personality
disorders to see if religious involvement was linked
with neurotic behavior. Forty-five psychologically
healthy subjects served as a comparison group. Results
show that patients who had little or no religious
commitment were just as likely to have depression,
anxiety or other personality disorders as patients
with higher levels of religious commitment. Being
highly religious was not a risk factor for psychopathology,
as has been often taught in mental health training
S, Waelty U Psychopathology
and religious commitment--a controlled study.
The recent (2001) Handbook
of Religion and Health reviewed over 1600 studies, and found that across
mental and physical disorders, religion is overwhelmingly associated with positive
outcomes. There is evidence that religious practices speed recovery in mental
disorders. For example, a recent study found that psychiatric patients who
regularly attend church and pray recover more quickly than their nonreligious
Religion and spirituality in the lives of people
with serious mental illness.
Therefore, therapy should consider the spiritual resources and needs of persons
Sudies have also found that hospitalized psychiatric
patients are as religious as the general population,
and they turn more to religion during crises.In
religious needs and resources of psychiatric inpatients,
Fitchett et al., 1997 found that 88% of the psychiatric
patients reported three or more current religious
needs. Psychiatric patients had lower spiritual
well-being scores and were less likely to have talked
with their clergy. The study concluded that religion
is important for psychiatric patients, and they
may need assistance to find resources to address
their religious needs.
One example of how religious beliefs can negatively
affect health outcome is the belief that sin leads
to one's illness. Of 52 psychiatric inpatients, 23%
believed that sin-related factors, such as sinful
thoughts or acts, cause illness. Such beliefs are
associated with negative health outcomes.
W, Kroll J Psychiatric
patients' belief in general health factors and sin
as causes of illness. Am J Psychiatry 1990 Jan;147(1):112-3
At St. Elizabeth's Hospital in Washington, D.C.,
the Chaplain Program conducts a "Spiritual Needs
Assessment" on each inpatient, concluding with a
treatment plan that identifies religious/spiritual
needs and problems.The program defines the role
of pastoral intervention and recommended religious/spiritual
activities. (For a lesson on instruments and approaches
to assessing spirituality, see the course on Spirituality
and Recovery from Mental Disorders.)
Axis I Disorders
In the DSM-IV,
the diagnosis of Religious
or Spiritual Problem is an Axis I condition and can
be assigned along with a co-existing Axis I disorder.
The APA Task Force on Religion and
] reported: "The religious convictions
of patients can be used effectively in therapy. Religion
can be a usable support system for the patient even
when the therapist believes the patient's religious
system has no objective value."
Explicit and nonjudgmental attention to religious
concerns can add significantly to the quality and
effectiveness of clinical work. Indeed, struggles
of faith are embedded in the life course of many
patients in acute treatment. Religious and spiritual
problems can be associated with the full range of DSM-IV mental
disorders since the integrity of the individual is
challenged in all illnesses.
Alcohol and Drug Dependence and Abuse
Twelve Step programs such as Alcoholics Anonymous
dominate addiction treatment in mental health settings,
and religion/spirituality plays a central role. The
first of the 12 steps mentions "A power greater than
ourselves." The final step mentions a "spiritual
awakening." Five of the 12 steps make a specific
reference to God, and the phrase "as we understand
Him" appears twice. The founders of A.A. did not
ponder whether religious and spiritual factors are
important in recovery, but rather if it is possible
for alcoholics to recover without the help of a higher
power. Jung told Bill W., the co-founder of A.A.,
that "craving for alcohol was the equivalent, on
a low level, of the spiritual thirst of our being
for wholeness." Jung maintained that recovery from
addiction required a religious experience: "Inasmuch
as you attain to the numinous experience, you are
released from the curse of pathology." (See History
of Early A.A.'s Spiritual Roots.) Similarly,
some theorists and clinicians have approached addictions
as essentially spiritual crises, not mental disorders
The strong relationship between religious/spiritual
commitment (e.g., church attendence) and the avoidance
of alcohol and illicit drugs is well-established.
However, not much is known about the religious/spiritual
dimensions of addiciton treatment. Religious/spiritual
variables have been neglected in research. Such
variables include measures of perceived purpose
or meaning in life, changes in values and beliefs,
shifts in religious/spiritual practices, clients'
religious/spiritual value systems, acceptance of
particular treatment goals and strategies, and the
impact of religious/spiritually-oriented interventions
on treatment outcome. Miller recommended that these
variables be considered in research in order to
"improve our understanding of the addictive behaviors,
and our ability to prevent and treat these enduring
It is known that patients in alcohol treatment who
bcome involved with a religious community after
treatment have lower recidivism rates than those
who do not. (See Association
of spirituality and sobriety during a behavioral
spirituality intervention for Twelve Step (TS) recovery.)
In obsessive-compulsive disorder, some individuals present with what they consider
scrupulous devoutness, but upon further assessment, the use of religion is
a metaphor for the expression of compulsive requirements. Superficially,
religious rituals and obsessive-compulsive behaviors share some common features:
the prominent role of cleanliness and purity; the need for rituals to be
carried out in specific ways and numbers of times; and the fear of performing
the rituals incorrectly.
Greenberg and Witzum 
describe an individual whose concern with correctly
saying his prayers led him to spend nine hours a
day in prayer instead of the usual 40-90 minutes
of other ultra-orthodox Jews. Persons in this religious
community with obsessive-compulsive disorder became
so preocuppied with some detail or area of religious
practice that they ignored or violated other tenets
of their faith. In these individuals, scrupulous
devoutness involved the use of religion to express
compulsive needs. (However, the authors also concluded
that ultra-orthodox Jews were not at higher risk
for obsessive-compulsive disorder.) In such cases,
Greenberg and Witzum recommend meeting together with
the patient's religious leader present and that "During
assessment, the terms and symbols of the religion
of strictly religious patients should be used ...[to]
enable the patient to feel as comfortable as possible" (p.
557). When these religious factors warrant independent
clinical attention and are explicitly addressed in
treatment, Religious or Spiritual Problem should
be coded along with Obsessive-Compulsive Disorder.
Greenberg and Witzum have proposed the following
criteria for differentiating obsessive-compulsive
behaviors from religious practices:
1. Compulsive behavior goes beyond the letter
of the religious law.
2. Compulsive behavior is focused on one specific area and does not reflect
an overall concern for religious practice.
3. The choice of focus of obsessive-compulsive behavior is typical of the
disorder (e.g., cleanliness and checking, obsessive thoughts of blasphemy
toward God or fear of illness).
4. Many important dimensions of religious life are neglected.
Co-occurrence of a Religious and Spiritual Problems
with psychotic disorders occurs frequently, especially
in manic psychosis. One study of hospitalized bipolar
patients found religious delusions were present in
25% and their hallucinations were brief, usually
grandiose, usually religiou s. Goodwin and Jamison (Manic-Depressive
Illness) have also noted the prominence of religious
and spiritual concerns in persons with manic-depressive
illness.They suggest that there, "have been many
mystics who may well have suffered from manic-depressive
illness--for example, St. Theresa, St. Francis, St.
John" (p. 362). Mystical features can occur along
with a psychotic disorder. For such patients, Religious
or Spiritual Problem could be coded along with the
concomitant Axis I disorder.
There is cross-cultural support for
the overlap of psychosis and religious experiences.
Anthropologists have observed that,
highly similar mental and behavioral states may
be designated psychiatric disorders in some cultural
settings and religious experiences in others...Within
cultures that invest these unusual states with
meaning and provide the individual experiencing
them with institutional support, at least a proportion
of them may be contained and channeled into socially
valuable roles. (Prince 
In Ken Wilber's 
spectrum model of consciousness, psychosis is neither
prepersonal (infantile and regressive) nor transpersonal
(transcendent and absolute); it is depersonal--an
admixture of higher and lower elements:
[Psychosis] carries with it cascading fragments
of higher structures that have ruinously disintegrated" (p.
64). Thus, psychotic persons "often channel
profound spiritual insights. (p. 108)
But psychotic persons are incapable of differentiating
the transpersonal from the regressive prepersonal
at the time of the experience. Afterwards, while
in recovery, they are often able to sort thorough
their experiences and separate the wheat from the
chaff. Psychotherapy can salvage the valid religious/spiritual
dimensions of the experience. James Hillman has stated
that recovery means recovering the divine from within
the disorder, seeing that its contents are authentically
Transpersonal psychotherapy can be especially valuable
in the postpsychotic period because it promotes the
integration of the healthy parts of religious/spiritual
experiences in psychosis. (See Lesson 6.2 on Psychotherapy)
Jerome Stack, a Catholic Chaplain for 25 years
at Metropolitan State Hospital in Norwalk, California,
observed that many people with mental disorders
do have genuine religious experiences:
Many patients over the years have spoken to me of
their religious experiences and I have found their
stories to be quite genuine, quite believable. Their
experience of the divine, the spiritual, is healthy
and life-giving. Of course, discernment is important,
but it is important not to presume that certain kinds
of religious experience or behavior are simply "part
of the illness."
During manic episodes in particular, people have
experiences similar to those of the great mystics.
Clay, an advocate and consultant for the Portland
Coalition for the Psychiatrically Labeled, has written
about the significant role that religious experiences
played in her recovery. She had been hospitalized
for two years diagnosed with schizophrenia at the
Yale-affiliated Hartford Institute of Living (IOL).
While there, she had a powerful religious experience
which led her to attend religious services.
My recovery had nothing to do with the talk therapy,
the drugs, or the electroshock treatments I had
received; more likely, it happened in spite of
these things. My recovery did have something to
do with the devotional services I had been attending.
At the IOL I attended both Protestant and Catholic
services, and if Jewish or Buddhist services had
been available, I would have gone to them, too.
I was cured instantly--healed if you will--as a
direct result of a spiritual experience.
Many years later Clay went back to the IOL to review
her case records, and found herself described as
having "decompensated with grandiose delusions with
spiritual preoccupations." She complains that "Not
a single aspect of my spiritual experience at the
IOL was recognized as legitimate; neither the spiritual
difficulties nor the healing that occurred at the
Clay is not denying that she had a psychotic disorder
at the time, but makes the case that, in addition
to the disabling effects she experienced as part
of her illness, there was also a profound spiritual
component which was ignored. She describes how the
lack of sensitivity to the spiritual dimensions of
her experience on the part of mental health and religious
professionals was detrimental to her recovery. Nevertheless,
she has persevered in her belief that,
For me, becoming "mentally ill" was always a spiritual
crisis, and finding a spiritual model of recovery
was a question of life or death. Finally, I could
admit openly that my experiences were, and always
had been, a spiritual journey--not sick, shameful,
The Wounded Prophet by Sally Clay
Mental health programs can, through their structures
and culture, create environments that promote this
spiritual work. New
Recovery Center at Boston University is an example
of a program that has adopted a recovery model incorporating
a spiritual component. Curricular options include
such courses as "Connectedness: Some Skills
for Spiritual Health," "Hatha Yoga," and
a "Recovery Seminar." This guided exploration
of personal recovery is the center's flagship course.
People recovering from mental disorders have rich
opportunities for spiritual growth, along with challenges
to its expression and development. They will find
much-needed support for the task when they are guided
to clinically explore to explore their spiritual
For more information on integrating spirituality
into recovery, see the Spiritual Competency Resource Center course
& Recovery from Mental Disorders
1 Ellis, A. (1980). "Psychotherapy
and atheistic values: A response to A, E. Bergin's "Psychotherapy
and Religious Issues"." Journal of Consulting and
Clinical Psychology 48: 635-639.
2 American Psychiatric Association. (1990). "Guidelines
regarding possible conflict between psychiatrists' religious commitments
and psychiatric practice." American Journal of Psychiatry 147: 542.
4 Grof C (1993) Thirst
for wholeness: Attachment, addiction and the spiritual path. San Francisco:
oka & J. Morgan (Eds.), Death
and spirituality. Amityville, NY: Baywood.
4 Miller, W R (1990) Spirituality: The silent
dimension in addiction research. Drug and Alcohol Review 9:259-266.
5 Greenberg, D. and E. Witztum (1991). "Problems
in the treatment of religious patients." American Journal of Psychotherapy
6 Prince, R. H. 1992 Religious experience
and psychopathology: Cross-cultural perspectives. In J. F. Schumacher
(Ed.), Religion and mental health, (pp. 281-290). New York: Oxford
7 Wilber, K. (1993) The pre/trans fallacy.
In Walsh, R. Vaughan, F. (Eds.) Paths Beyond Ego. Los Angeles: Tarcher.
QUIZ EXERCISE 26:
Religious or Spiritual Problem cannot be assigned as an Axis I diagnosis along with an Axis I Disorder.
Record your answers for later insertion into the Quiz.
QUIZ EXERCISE 27:
Hearing voices when no one is present is ...
a) a sign of a spiritual emergency
b) a symptom of a mental disorder
c) potentially a or b
Record your answers for later insertion into the Quiz.