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DSM-IV Religious and Spiritual Problems

LESSON 4 Co-Occurrence with Mental Disorders

Spiritual Issues of Persons with Mental DisordersCo-Diagnosis with Axis I Disorders

Spiritual Issues 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[1], 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 programs.

Feifer S, Waelty U Psychopathology and religious commitment--a controlled study. Psychopathology 1995;28(2):70-7).

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 counterparts.
See Religious practices speed recovery in mental illness
Religious Coping May Reduce Hospital Stays for Psychiatric Patients
Therefore, therapy should consider the spiritual resources and needs of persons in recovery.

Sudies have also found that hospitalized psychiatric patients are as religious as the general population, and they turn more to religion during crises.In The 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.

Sheehan 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.)

Co-Diagnosis with 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 Psychiatry [2] 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 [3].

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 problems [4]." 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 ICIHS Research Summaries.)

Obsessive-Compulsive Disorder
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 [5] 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.

Psychotic Disorders
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 [6]

In Ken Wilber's [7] 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 religious.

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.

Sally 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 end."

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, or evil.
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 lives.

For more information on integrating spirituality into recovery, see the Spiritual Competency Resource Center course

Spirituality & 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: HarperCollins.
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 45(4): 554-565.
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 University Press.
7 Wilber, K. (1993) The pre/trans fallacy. In Walsh, R. Vaughan, F. (Eds.) Paths Beyond Ego. Los Angeles: Tarcher.


Religiosity of Patients

Psychiatric patients are

a) more religious than the general public b) less religious than the general public c) as religious as the general public

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Religious or Spiritual Problem cannot be assigned as an Axis I diagnosis along with an Axis I Disorder.


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