IS SPIRITUALITY ESSENTIAL FOR RECOVERY?

If spirituality supports resiliency, then it's definitely part of our business by Lori Ashcraft, PhD, William A. Anthony, PhD, and Rev. Laura L. Mancuso, MS, CRC
Issue Date: July-August 2010 Citation: Behavioral Healthcare 2010 July-August;30(7):7-8 Available online at http://www.behavioral.net/ Click on Archives, then July/August 2010

Get ready to squirm in your seats because we need to have a talk with you about spirituality. Spirituality is a topic we behavioral health types have shied away from: Professionals are taught to avoid it in their practices, and organizations have concerns about the separation of church and state. Many of the people who use our services, however, tell us that some form of spirituality plays a key role in their recovery process. So, since we're all trying to create opportunities for people to recover, we'd better get over ourselves and figure out how to talk to people about this. We've asked Rev. Laura Mancuso, a psychiatric rehabilitation counselor and interfaith minister, to help us discover ways of including spirituality in program planning and initiate conversations with people that will help them develop spiritual competence. Laura worked in the public mental health field at the local, state, and national levels for 15 years before her own journey of health challenges and personal losses culminated in a calling to become ordained. As an interfaith minister, she strives to honor all faith traditions, as well as the beliefs and life philosophies of those who do not adhere to any religion. Laura observes that “spirituality is highly personal, very central to a person's inner life, and oftentimes inseparable from one's cultural identity. It seems to me that if mental health programs can figure out how to respect and support the spirituality of the people we serve and the people we employ, we will have figured 1 out how to respect and support their very essence as human beings. That's why spirituality should be included in programs that intend to be holistic, culturally competent, and recovery-oriented.”

Laura observes that “spirituality is highly personal, very central to a person's inner life, and oftentimes inseparable from one's cultural identity. It seems to me that if mental health programs can figure out how to respect and support the spirituality of the people we serve and the people we employ, we will have figured out how to respect and support their very essence as human beings. That's why spirituality should be included in programs that intend to be holistic, culturally competent, and recovery-oriented.” The Joint Commission's Standards and Elements of Performance require healthcare organizations-including accredited behavioral health organizations-to assess how a person's spiritual outlook may affect his or her care, treatment, and services. The February 2005 issue of the Joint Commission's newsletter, The Source, states: “Spirituality can be defined as a complex and multidimensional part of the human experience-our inner belief system. It helps individuals search for the meaning and purpose of life, and it helps them experience hope, love, inner peace, comfort, and support.”1 Aren't those things we could all use more of? Then why is it so hard for mental health programs to “go there”? There are many reasons. Although it's now shifting (see “Milestones in the recognition of spirituality in mental health wellness and recovery” below and at http://www.behavioral.net/moretools1007), professional training programs warned students for decades not to discuss religion or spirituality with clients, as it was thought to foster delusions. Publiclyfunded programs must be careful not to promote religion, or to favor one religion over another. Incidents of discrimination and violence on the basis of religious beliefs create more fear. The drive to improve the credibility of our interventions through scientific evidence causes us to turn away from concepts and processes that are more difficult to measure. Given these challenges, the most common response is to avoid the topic altogether. The challenge before us is to wade into these murky waters with our eyes and hearts open, meet myths and misconceptions with facts, and listen to what service recipients have told us over and over: Spirituality is often a valuable resource in the recovery journey. Here are a few things to avoid while wading in:     Avoid proselytizing. Exploring one's spirituality is a very personal experience. Each of us needs to discover our own way of relating to spiritual issues. Programs should not favor one religion over another. Service eligibility should not be conditional on expressions of faith or participation in religious ritual. Humanists, agnostics, atheists, and other secularists should not be excluded - directly, indirectly, or even subtly.

These are basic premises of welcoming spirituality at non-discriminatory workplaces and service sites. Following these core practices still leaves a whole lot of room for dialogue about spirituality. Now that we know what not to do, what can we do to help people develop spiritual strength that supports their recovery journey? One approach is to talk about spirituality as one of the three parts of our basic makeup: body, mind, and

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spirit. Most of us know how to take care of our bodies, and in our business, we talk a lot about how to manage our minds. Since we've largely avoided conversations about spirit, we haven't given people much support to develop competencies in this area. Next month we will wade deeper into this subject and explore more approaches to supporting this important aspect of recovery. In the meantime, here are some ideas that can create an opening for a supportive, recovery-based conversation about developing spiritual competencies:  A good place to start is just listening to what people have to say about spiritual issues. As simple as this may sound, it's a step many of us haven't yet taken since we have not been open to having this conversation. We can ask how people understand the words “spirituality” and “religion,” and if they view them as distinct. Listen deeply to what they say. We can ask what gives their lives purpose and meaning. For example, the following questions were developed for use by physicians: “What do you hold on to during difficult times?” “What sustains you and keeps you going?” “What aspects of your spirituality or spiritual practices do you find most helpful to you personally?” “Is there anything I can do to help you access the resources that usually help you?”2 If people express interest in gaining spiritual competencies, we can describe some practices that many others have found helpful, such as: prayer, meditation, contemplation, reading inspirational books, journal writing, spending time in nature, taking part in religious services, or volunteering services to others. We can show interest in and provide support for their spiritual findings and encourage them to stay with practices that support their recovery, and to let go of those that don't.

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Spirituality is different from religion. It has less to do with organized approaches and is more individualized. But since there is a strong connection between the two, let's look at what the national polls reliably indicate about religion. They say that religion is an important facet in the lives of the vast majority of Americans. In 2009, Newsweek stated that polls since 1992 have consistently found 85 percent of Americans say religion is “very important” or “fairly important” in their lives.3 Research also indicates that faith, religion, and spirituality play important roles in coping with stress, trauma, and illness.4,5 Why would we assume that people with psychiatric conditions are any different? Anything that can support the resiliency of the people we serve should definitely be our business. We must move beyond our ambivalence about including spirituality in mental health programs if we intend to provide holistic, culturally competent, and recovery-oriented services.

Lori Ashcraft, PhD, directs the Recovery Opportunity Center at Recovery Innovations, Inc. in Phoenix. She is also a member of Behavioral Healthcare's editorial board. William A. Anthony, PhD, is director of the Center for Psychiatric Rehabilitation at Boston University. Rev. Laura L. Mancuso, MS, CRC, serves the mental health community in California as an interfaith chaplain, and was director of the California Mental Health and Spirituality Initiative from 2008-2010.
Citation: Behavioral Healthcare 2010 July-August;30(7):7-8

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References
1. The Joint Commission. The Source, February 2005, 3(2), p.7. 2. Anandarajah, Gowri and Hight, Ellen. “Spirituality and Medical Practice: Using the H.O.P.E. as a Practical Tool for Spiritual Assessment.” American Family Physician, 63(1), January 2001, pp. 8189. Available at: http://www.aafp.org/afp/2001/0101/p81.html. 3. Stone, Daniel. “One Nation Under God?” Newsweek, September 20, 2009. Available at: http://www.newsweek.com/id/192915. 4. Lukoff, David. “Spirituality in the Recovery from Persistent Mental Disorders.” Southern Medical Journal, 100(6), June 2007. Available at: http://www.smajournalonline.com. 5. Peteet, John “Selected Annotated Bibliography on Spirituality and Mental Health.” Southern Medical Journal, 100(6), June 2007. Available at: http://www.smajournalonline.com.

More tools for transformation: Spirituality and recovery from mental illness
In the July/August issue of Behavioral Healthcare, columnists Lori Ashcraft and William Anthony, with coauthor Rev. Laura Mancuso, suggest integrating spirituality into treatment to promote recovery from mental illness. Spirituality has been known to strengthen recovery for many individuals with mental illness for years, but it has also been widely ignored by professionals in the field. However, the tides are changing on spirituality and recovery, and the evolution of spirituality as a vital component of recovery from mental illness is documented in the following timeline: • 1988 – Pathways to Promise (www.pathways2promise.org) is founded in St Louis, Mo. by 14 faith groups and mental health organizations to provide resources and technical assistance to faith communities in reaching out to those with mental illnesses and their families. • 1991 – David Lukoff, PhD, Francis Lu, MD, and Robert Turner, MD, submit a proposal for a new diagnosis, “Psychoreligious or Psychospiritual Problem,” to the American Psychiatric Association’s Task Force developing the DSM-IV, in order to improve the manual’s cultural sensitivity. The proposal is endorsed by the APA’s Committee on Religion and Psychiatry and the NIMH Workgroup on Culture and Diagnosis. • 1994 - Religious or Spiritual Problem V Code V62.89 (Other Conditions That May Be a Focus of Clinical Attention) is added to DSM-IV: “Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of other spiritual values which may not necessarily be related to an organized church or religious institution.” • 1994 – Essay by Sally Clay entitled “The Wounded Prophet” (http://www.sallyclay.net/Z.text/Prophet.html) describes the role of spirituality in her recovery. • 1997 – Issue of The Journal of the California Alliance for the Mentally Ill, edited by Dan Weisburd, is devoted to spirituality.

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• 1998 - Roger D. Fallot edits “Spirituality and Religion in Recovery from Mental Illness,” New Directions for Mental Health Services, Number 80, Winter 1998 (Jossey-Bass). • 1998 - NAMI Faith-Net is founded in California by Dr. Gunnar Christiansen for outreach to religious organizations, then later expanded nationally (www.nami.org/faithnet). • 1999 – The First National Summit of Mental Health Consumers and Survivors in Portland, Ore. by the National Mental Health Consumer Self-Help Clearinghouse. Working session cofacilitated by Jay Mahler and by Andrea Schmook results in a consensus that the four values most important to recovery are: hope, responsibility, spirituality, and empowerment (http://www.mhselfhelp.org/pubs/view.php?publication_id=121). • 2001 – “Culture, Race, & Ethnicity Supplement” to the Surgeon General’s Report on Mental Health identifies spirituality and religion as key protective/resiliency factors in racial and ethnic minority communities (http://mentalhealth.samhsa.gov/cre/). • 2001 – Mental Health Ministries is founded by Rev. Susan Gregg-Schroeder to provide educational resources to help erase the stigma of mental illness in faith communities and develop caring congregations for persons living with a mental illness and their families (www.mentalhealthministries.net). • 2002 – Pathways to Recovery: A Strengths Recovery Self-Help Workbook by Priscilla Ridgway et al explores eight key components of recovery including spirituality (http://www.socwel.ku.edu/projects/SEG/pathways.html). • 2002 – Federal Center for Mental Health Services convenes a dialogue between mental health consumers and members of faith-based organizations resulting in a report entitled “Building Bridges: Mental Health Consumers and Members of Faith-Based and Community Organizations in Dialogue” (http://mentalhealth.samhsa.gov/publications/allpubs/SMA04-3868/default.asp). • 2005 – American Psychiatric Association Assembly and Board of Trustees approves a Position Statement on “Use of the Concept of Recovery” which states that “the APA endorses and strongly affirms the application of the concept of recovery ... best results come when patients feel that treatment decisions are made in ways that suit their cultural, spiritual, and personal ideals.” (www.psychiatry.org, Position Statement #200504) • 2005 – Caring Congregations Curriculum developed by Rev. Barbara Meyers, a Unitarian Universalist minister in recovery, to educate congregations about how to be more intentionally supportive of people with mental disorders and their families (http://www.mpuuc.org/mentalhealth). • 2007 - Spring 2007 issue of the Psychiatric Rehabilitation Journal co-edited by Zlatka Russinova & Andrea Blanch, devoted to spirituality and recovery, describes spirituality as a “new frontier for recovery-oriented mental health systems.” • 2008 – Establishment of the California Mental Health & Spirituality Initiative with voluntary financial contributions from 53 of the 59 county behavioral health authorities. One year later, two statewide conferences on Mental Health & Spirituality are attended by over 1,100 people (www.mhspirit.org).

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• 2009 - Spirituality is identified as a key domain for quality of life in the revision of the USPRA Core Principles & Values for Psychiatric Rehabilitation (http://www.uspra.org/files/public/USPRA_CORE_PRINCIPLES2009.pdf). • 2009 – SAMHSA holds a Listening Session on the role of “Religion & Spirituality in TraumaInformed Mental Health Care” in Annapolis, Md. (http://mentalhealth.samhsa.gov/nctic) • 2009 – NAMI STAR (Support, Technical Assistance and Resource) Center conducts a workshop on “Multicultural Competence, Intense Spiritual Experiences, and Mental Health” in Walnut Creek, Calif. The STAR Center is funded by SAMHSA to assist consumer-operated and consumer-helper programs in meeting the needs of under-served populations (www.consumerstar.org). • 2010 – The SAMHSA 10x10 Wellness Campaign to increase life expectancy of persons with mental health problems by 10 years over the next 10 years identifies spirituality as one of eight dimensions of wellness (www.10x10.samhsa.gov).

Compiled by Lori A. Ashcraft, PhD, William A. Anthony, PhD, and Rev. Laura Mancuso, MS, CRC
Citation: Behavioral Healthcare 2010 July-August; 30(7):7-8

BUILD YOUR STAFF’S SPIRITUAL COMPETENCY Help staff reunite “the mystical and the measurable” in themselves and in consumers by Lori Ashcraft, PhD, William A. Anthony, PhD, and Rev. Laura L. Mancuso, MS, CRC
Issue Date: September 2010 Citation: Behavioral Healthcare 2010 September; 30(8):10-13 Available online at http://www.behavioral.net/ Click on Archives, then September 2010

In the July/August 2010 issue of Behavioral Healthcare, we began a conversation about the important role of spirituality in the recovery process. With the help of co-author Rev. Laura Mancuso, a psychiatric rehabilitation counselor and interfaith minister, we discussed factors that help and hinder the use of spirituality in the recovery process and traced its 20-plus year emergence as a wellness and recovery resource. In so doing, we sought to show that attending to the body, mind, and spirit of service recipients is not a new or fleeting fad, but an integral part of high-quality mental healthcare that consumers and family members have long sought.

Healthcare’s spiritual history
One could easily call this “the return” of spirituality to mental healthcare, as the two were united long before they were at odds. Christina Puchalski, MD, founder of the George Washington University Institute on

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Spirituality and Health (www.gwish.org), notes that there was a powerful relationship between spirituality and healthcare in this country until the 19th century. Before then, most healthcare services were provided by religious organizations who emphasized altruism, service, compassion, and the relief of suffering. Puchalski maintains that healthcare's drive for “quick fixes” and cures caused us to lose sight of the need for compassion, as well as the need to address spiritual and existential distress with the same urgency and focus as we do for physical pain. And, as we seek evidence-based practices, we must recognize that science can take us only so far. “Healing involves an appreciation of mystery,” she asserts, since science alone has not eliminated suffering.i If they started out together, what led to the current divide between mental health and spirituality? Sigmund Freud famously viewed religious belief as an infantile, neurotic illusion. And, the remarkable scientific achievements of the last century have led Americans in particular to see science as a potential solution to all of our problems. Psychiatry and psychology, already considered “softer” sciences than their medical counterparts, joined in shunning the mystical in favor of the measurable, and instructed trainees to avoid discussing spirituality or religion altogether.

A model for reintegration
In her recent book, Wrestling With Our Inner Angels, Roman Catholic nun and clinical psychologist Nancy Kehoe describes how she instinctively downplayed her role as a member of the Sacred Heart religious order when she started working as a clinical instructor in psychology at Harvard Medical School. She heeded the admonition of Hungarian psychiatrist Thomas Szasz that theists were automatically suspect within the mental health field: “If you talk to God, you are praying; if God talks to you, you have schizophrenia.ii When she finally gathered the courage to propose the formation of a group focused on religious and spiritual beliefs in a day treatment program, her idea was met with stunned silence, followed by a series of objections from fellow staff: Some participants might try to convert others; religious delusions might be affirmed; staff might be asked to explain their own religious views; program funding could be threatened; and more. But with the help of a determined program director, the group was eventually approved. From the beginning, Dr. Kehoe required participants to “respect every other member and be able to tolerate differences in beliefs.” As the group's leader, she never inquired about participants’ psychiatric diagnoses, considering them irrelevant, noting, “Perhaps unconsciously, this came from my own experience of being stereotyped as a nun.iii Dr. Kehoe went on to lead spiritual beliefs and values groups at several other locations for 27 years, and the initial fears never came to fruition. She says, “With a track record of 3,224 group sessions, I can attest to the fact that no client has ever become more delusional because of the group, no client has tried to convert others in the community, and no client has resisted working with a therapist of a different belief. Clients with different religious beliefs have not split the community. These 27 years have uncovered a rich inner terrain, one that had been hidden from mental health providers but has been a source of strength and resilience for the clients.iii That's an impressive body of experience that attests to the value of spirituality in mental health services, and how Dr. Kehoe succeeded in this delicate area is almost as important as what she did. First, she approached the topic with humility, an open mind, and an open heart. Second, she moved slowly and thoughtfully when introducing a new spirituality activity into a mental health program. Last, she set clear guidelines about respect and tolerance for diversity by all involved. If you're interested in this approach, there's no reason to start from scratch. As we researched this topic, we discovered pockets of innovation in community-based and publicly-funded programs across the country. Some of these programs have done wonderful work for decades with little fanfare and perhaps prefer it that way,

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given the controversial nature of spirituality within the mental health system. We hope that starting the conversation with you, right here, will motivate you to share lessons learned or find out why spirituality is excluded from the wellness and recovery resources offered at your organization.

Initiating a recovery-focused spirituality program
If you find yourself at the beginning stages of exploration, here are some places to start: Designate a space for contemplation. If outdoors, create a pleasing environment with comfortable places to sit close to nature. Consider adding a permanent or removable labyrinth if space allows. For indoor spaces, equip the room with supplies to soothe each of the senses: soft lighting and inviting colors; cozy places to sit or recline; relaxing music; pure essential oils for aromatherapy; candles; and materials for making art or journal writing. Focus on the body-mind-spirit wellness of staff. Ask them how they take care of their own well-being and what nourishes their spirit. We've learned the hard way that we cannot transform our programs and systems in spite of our staff-rather, we need to engage them first, listening to and validating their experiences, while also clearly articulating our organizational values and strategic direction. Consider objections to including spirituality in programming. Use a problem-solving approach by asking questions like, “How might we overcome that issue?” “What would help?” and “If you were receiving services here, what would you like to see happen?” Learn about the cultural, spiritual, and religious characteristics of the people you serve, or desire to serve. Ask to be introduced to respected spiritual leaders in the local community. Bring a gift and do more listening than talking. Find out how they approach mental health issues and how you may support them in what they do. Look for areas in which your resources can complement theirs. For example, we know that people tend to turn to their faith communities for help with emerging mental health problems before looking to professionals for help. So how can your program establish itself as the go-to resource for individuals or families whose needs exceed the level of support provided there? Promote diversity. Expose service providers and recipients to authentic sharing by individuals from diverse cultural, religious, and spiritual backgrounds. In doing so, keep in mind that no one person can speak for an entire group-for example, no single Christian can represent the views of all Christians. Remember that spiritual strength comes in all shapes and sizes. Many people are deeply comforted by time spent in nature, for example, even if “God-talk” is meaningless to them. Include presentations by individuals who are atheist, humanist, and/or secular. Make a list of dos and don'ts. Develop an organizational policy on the ethics of including spirituality in programming, and communicate it clearly to your staff. Encourage self-exploration. As with other aspects of cultural competency, express the expectation to employees that we all need to become aware of our own sensitivities and biases regarding spirituality and religion. Create an organizational culture in which it's safe and customary for staff to inquire about the wishes, preferences, and experiences of those they serve regarding spirituality and religion. Provide examples of neutral and helpful questions from established spiritual assessment instruments-such as the Pargament Meaning Scale or the FICA Spiritual History Tool-to help them open a dialogue.iv v

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Include spirituality as a topic for self-help groups. This can enable individuals to share daily spiritual practices that have been helpful during troubled times. Include resources from diverse cultural, religious, and spiritual perspectives. Offer the opportunity for people to write a spiritual autobiography or draw a spiritual life map.vi vii It is the recovery vision and its focus on people's meaning and purpose that can help bridge the divide that some still believe exists between spirituality and mental health. When our field of practice and research turns from an almost singular focus on pathology and symptoms toward an emphasis on recovery, resilience, and health, our field of interest will expand and spirituality can assume its rightful place as a source of healing and growth.

Lori Ashcraft, PhD, directs the Recovery Opportunity Center at Recovery Innovations, Inc. in Phoenix. She is also a member of Behavioral Healthcare's editorial board. William A. Anthony, PhD, is director of the Center for Psychiatric Rehabilitation at Boston University. Rev. Laura L. Mancuso, MS, CRC, serves the mental health community in California as an interfaith chaplain, and was director of the California Mental Health and Spirituality Initiative from 2008-2010.
Citation: Behavioral Healthcare 2010 September; 30(8):10-13

References
Puchalski C. Presentation to Santa Barbara Cottage Hospital Psychiatric Grand Rounds. Santa Barbara, California : January 13, 2010. ii Szasz TS. The Second Sin. Garden City, NY: Anchor/Doubleday, 1973. iii Kehoe N. Wrestling With Our Inner Angels: Faith, Mental Illness and the Journey to Wholeness. San Francisco: Jossey-Bass, 2009. iv Pargament KI. Multidimensional measurements of religiousness/spirituality: Use in Health Research. Kalamazoo, MI: Fetzer Institute, 1999. v FICA Spiritual History Tool. The George Washington Institute on Spirituality and Health. http://www.gwumc.edu/gwish/clinical/fica.cfm vi Wakefield D. The Story of Your Life: Writing a Spiritual Autobiography. Boston: Beacon Press, 1990. vii Hodge DR. Spiritual life maps: A Client-centered pictorial instrument for spiritual assessment, planning, and intervention. Social Work 2005; 50:77-87.
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