Journal of Religion, Disability & Health

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A Significance of Sacramental Ministry Among

Individuals with Severe and Persistent Mental
Illness

Mary Q. Browne

To cite this article: Mary Q. Browne (2009) A Significance of Sacramental Ministry Among
Individuals with Severe and Persistent Mental Illness, Journal of Religion, Disability & Health,
13:3-4, 260-273, DOI: 10.1080/15228960902931863

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Journal of Religion, Disability & Health, 13:260–273, 2009
Copyright © Taylor & Francis Group, LLC
ISSN: 1522-8967 print / 1522-9122 online
DOI: 10.1080/15228960902931863

A Significance of Sacramental Ministry

Among Individuals with Severe and Persistent
Mental Illness

MARY Q. BROWNE

People with serious mental illness have identified spirituality as an

important component in recovery. A positive relationship between
religious beliefs and spiritual practices, such as worship, hymn
singing, scripture reading and prayer and sustained recovery has
been identified. Little research has been conducted as to the im-
portance of participation in sacramental ministry. Sacramental
ministry is broadly defined as a tangible element combined with a
word from God. Using a structured interview format, an investiga-
tion into the ways in which sacramental ministry might function
in the lives of those who live with a severe and persistent mental
illness demonstrates that the concrete elements of bread, wine and
oil, as offered during Holy Communion or prayer and anointing
does contribute to recovery for those with severe mental disorders.

KEYWORDS sacrament, mental illness, spirituality, recovery,

theology

There are many treatments available for those who are diagnosed with a se-
rious mental illness. The goal of treatment is recovery. For many people with
mental illness, religious beliefs and spiritual practices play an instrumental
role in the recovery process. The Church makes use of a number of rituals,
such as worship, hymn singing, scripture reading and prayer. These rituals
have been identified as important components for many who are recover-
ing from serious mental disorders. However, not much research has been
conducted as to the importance of participation in sacramental ministry.
Sacramental ministry could broadly be defined as a tangible element
combined with a word from God. Using this broad definition, this article
will seek to answer the question, “In what ways does sacramental ministry

Address correspondence to Mary Q. Browne. E-mail: mqbrowne@gmail.com

260
 Significance of Sacramental Ministry 261

function in the lives of those who live with a severe and persistent mental
illness?” More specifically, in what ways does participation in Holy Commu-
nion or prayer and anointing contribute to recovery for those with severe
mental disorders?

DEFINITIONS AND LITERATURE REVIEW

Mental Illness/Mental Disorders
According to the National Institute of Mental Health (NIMH) (2008), approx-
imately 26.2% of Americans age 18 years and older, about one in four adults,
will be diagnosed with a mental disorder in a given year. When applied to
the 2004 United States Census, this figure translates to 57.7 million people.
However, a smaller proportion, approximately 6%, or one in 17, are consid-
ered seriously or persistently mentally ill. Additionally, many people suffer
from more than one mental disorder at a given time, and nearly half (45%)
of those with any mental disorder meet criteria for two or more disorders
(NIMH, 2008).
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)
(American Psychiatric Association [APA], 2000) of the American Psychiatric
Association is the standard used for symptom identification, classification
and diagnosis for mental illnesses. The definition of mental disorder is:

a clinically significant behavioral or psychological syndrome or pattern

that occurs in an individual and that is associated with present distress
(e.g., painful symptom) or disability (i.e., impairment in one or more
important areas of functioning) or with a significantly increased risk of
suffering death, pain, disability, or an important loss of freedom (APA,
p. xxxi).

Not all mental illnesses are severe and persistent (SPMI), only those that
cause significant functional disability in daily life, or those that continue to
reoccur over time and also lead to a loss in ability to function.
The DSM-IV-TR identifies a number of difficult symptoms in people who
develop an SPMI, such as schizophrenia and schizoaffective disorder. These
symptoms include unusual or bizarre thoughts or perceptions, delusions,
thought disorders, a loss or decrease in the ability to express emotions,
maintain attention, concentrate, and/or to find pleasure in daily life. People
who develop a mood disorder, such as major depression or bipolar disorder
may also develop symptoms of psychosis and exhibit these same symptoms
in addition to the symptoms of their mood disorder.
Due to the severity of these symptoms, participation in daily life is often
limited, but with appropriate treatment, recovery is possible. Longitudinal
262 M. Q. Browne

studies indicate that partial and full recovery does occur and may be sus-
tained over time (DeSisto et al., 1999).

Spirituality
Within the field of social work, spirituality has been defined as “the human
quest for personal meaning and mutually fulfilling relationships among peo-
ple, the nonhuman environment, and for some, God” (Canda, 1998, p. 243).
Spirituality refers to the inner feelings and experiences of the immediacy of
a higher power. It is by its very nature eclectic and inclusive. Spirituality
has to do with connectedness to something outside of oneself—spirituality
transcends the individual. It is also an interesting phenomenon in that one’s
sense of being spiritually connected occurs within the individual; it is in-
terpersonal (Bullis, 1996). Spirituality as an internal phenomenon addresses
such issues as the search for a sense of meaning and purpose in one’s life,
one’s beliefs about the functioning of the universe, and a personal moral
code. It is often seen as the human need to create order, connectedness,
and meaning in a chaotic existence, much like an inherent need to achieve
fulfillment. This set of personal beliefs derived from the individual’s percep-
tion of self and his or her relationship to both the natural world and some
metaphysical realm can include an individual experience with or without a
structured belief system (Pellebon & Anderson, 1999).
These definitions imply that spirituality is inherently relational. Spiritu-
ality is a relationship with God, or whatever is held to be the Ultimate that
fosters a sense of meaning, purpose, and mission in life. In turn, this rela-
tionship produces fruit (such as altruism, love, and forgiveness) that has a
discernible effect on an individual’s relationship to self, nature, others, and
the Ultimate (Hodge, 2001, p. 204).

Religion
Religion refers to the outward form of belief including rituals, dogmas and
creeds, and denominational identity (Bullis, 1996). Religion is seen as flowing
“. . . from spirituality and expresses an internal subjective reality, corporately,
in particular institutionalized forms, ritual beliefs, and practices” (Hodge,
2001, p. 204). Religion is “an integrated belief system that provides principles
of behavior, purposes of existence, meaning of death, and an expression
of reverence for a supernatural being (or beings)” that is structured and
typically has a group following. Religion is usually subsumed within the
term spirituality (Pellebon & Anderson, 1999).

Lutheran Theology
A Lutheran theological understanding of spirituality originates in an under-
standing of the work of the Holy Spirit. In the Small Catechism (1529), Martin
 Significance of Sacramental Ministry 263

Luther’s explanation of the third article of the Creed “On Being Made Holy”
concerning the work of the Holy Spirit reads,

I believe that by my own understanding or strength I cannot believe

in Jesus Christ my LORD or come to him, but instead the Holy Spirit
has called me through the gospel, enlightened me with his gifts, made
me holy and kept me in the true faith, just as he calls, gathers together,
enlightens and makes holy the whole Christian church on earth and keeps
it with Jesus in the one communion, true faith. Daily in this Christian
church the Holy Spirit abundantly forgives all sins—mine and those of
all believers (Luther, p. 355–356)

A Lutheran understanding of spirituality is both universal and specific.

The Spirit’s activity is unlimited. God is present in all of creation, and not
just in one particular expression of faith or in only one type of church.
Additionally, the Spirit’s activity is specific, personal. It is by the power of the
Holy Spirit that faith comes to an individual, and this happens most notably
at baptism, when the Sprit comes as a gift to believers. The Spirit continues
to be present among believers in other personal, tangible ways: speaking
and hearing the word as it comes in the forms of reading and proclamation
of the gospel, bearing witness, and gathering believers together.

The Eucharist: A Brief Summary

One tangible way that the Holy Spirit is present with believers is in the
sacrament of the Eucharist. Within the Christian tradition, a sacrament has
been defined as “an outward sign instituted by God to convey an inward or
spiritual grace” (McKim, 1996, p. 245). An outward sign is something that is
concrete; an earthly element that serves as a physical sign of God’s presence
among us. There are two sacraments recognized by the Protestant churches:
Baptism and the Eucharist, or the Lord’s Supper. The outward sign in baptism
is water; in the Lord’s Supper it is bread and wine.
The elements of bread and wine are considered sacramental in the
Eucharist because they are tangible elements connected to the covenant
promise of Jesus Christ when he says, “In the same way, after the supper he
took the cup, saying, ‘This cup is the new covenant in my blood, which is
poured out for you,’” (Luke 22:20) and in 1 Corinthians 11:24–11:25:

And when he had given thanks, he broke it [bread] and said, ‘This is my
body that is for you. Do this in remembrance of me.’ In the same way
he took the cup also, after supper, saying, ‘This cup is the new covenant
in my blood. Do this, as often as you drink it, in remembrance of me’.

In the Christian celebration of the Eucharist, it is believed that we receive

God’s grace; that God comes to us in and through the physical elements of
bread and wine.
264 M. Q. Browne

According to Baptism, Eucharist and Ministry (World Council of

Churches, 1982), the Eucharist is received by the Church as a gift from
Christ, in remembrance of the meals that Jesus shared during his earthly
ministry to proclaim and enact the nearness of the Kingdom of God. There
are many meanings attached to this celebration: thanksgiving to the Father;
anamnesis or memorial of Christ; invocation of the Holy Spirit; communion
of the faithful; meal of the kingdom.
Although there has been debate over the centuries as to how Christ
might come to us in the Eucharist, it is enough to recognize that there is
something important to the Church and to its members about participating
in this sacrament. A theological understanding of the work of the Holy Spirit
helps to highlight the spiritual connection that is made between the believer
and God.
Although not recognized by the Protestant churches as a sacrament,
prayer and anointing with oil serves a sacramental function. Oil is an out-
ward sign, a tangible symbol that is connected through words of prayer
and blessing with God. Anointing oil is often scented with frankincense and
myrrh, making the smell of this oil distinctive, special. In the Scriptures Christ
does not command that anointing be done; it is not an official sacrament in
Protestant traditions. However, an association is made between the oil and
prayer and the presence of the Spirit that takes on sacramental significance.
People with serious and persistent mental illness often have difficulty
with normal means of understanding the world around them. It could be
argued that for these people being able to participate in the Lord’s Supper
or other tangible acts can allow them to find communion with all who
participate with them in receiving a physical sign of God’s love, grace and
presence among them. Participation in the Eucharist is an event that can be
profoundly important in achieving and maintaining recovery.

Recovery

The cornerstone definition of recovery in mental health that is in current

usage is a deeply personal, unique process of changing one’s attitudes,
values, feelings, goals, skills and/or roles. It is a way of living a satisfying,
hopeful, and contributing life even with limitations caused by the illness.
Recovery involves the development of new meaning and purpose in
one’s life as one grows beyond the catastrophic effects of mental illness
(Anthony, 1993).

Two main views of recovery exist in the literature. One is based on a

rehabilitation model that views mental illness as a primary, permanent im-
pairment similar to a spinal cord injury resulting in paralysis. With supports,
the impairment may be managed, and some functioning may be regained,
 Significance of Sacramental Ministry 265

but the ‘illness’ will never disappear; cure is not possible. This view leads to
labeling and marginalization (Fisher, 2008).
The empowerment model views full recovery as a possibility; this model
is not merely a regaining of functioning while still remaining mentally ill.
Recovery is possible through a combination of social supports and the self-
management skills needed to take control of the major decisions affecting
one (Fisher, 2008).
Viewing recovery in terms of an ongoing and highly personalized ex-
perience, rather than a biomedical disease, is a new and somewhat radical
concept in the mental health field. Treatment and recovery are not the same;
recovery exists on a continuum of improved health and functioning; there
are multiple pathways to and varieties of recovery experience; the self is
important in this process, as is transformation; spirituality is a potentially im-
portant but often ill-understood ingredient of the recovery process requiring
a transcendence of stigma and development of new ways of talking about
mental illness (White, Boyle, & Loveland, 2004).

LITERATURE REVIEW
For many who have been diagnosed with a serious and persistent mental
illness, spirituality is an important component in the recovery process. A
review of research studies that have been undertaken to address the role
of religion or spirituality in the lives of those individuals with this diagnosis
reveal a generally positive association between the two (Baetz et al., 2002;
Fallot, 1998; Gordon, 2002; Hawkins, Siang-Yang, & Turk, 1999; Hodge,
2004; Koenig & Larson, 2001; Koenig, McCullough & Larson, 2001; Larson
& Larson, 2003; Lindgren & Coursey, 1995; McFadden, 2006; Mc Laughlin,
2004; Moller, 1999; Noordsy et al., 2002; Phillips, Lakin & Pargament, 2002;
Reger & Rogers, 2002; Sullivan, 1993, 1998; Thompson, 2002).
Fallot (1998) reports that the role of religion and spirituality is central to
self-understanding and recovery, and often functions as a significant source
of strength in facilitating recovery from mental illness. Baetz et al. (2002), in
a sample of consecutively admitted Canadian inpatients, found that higher
levels of attendance at worship services were associated with lower levels
of depression, lower levels of current and lifetime alcohol abuse, and higher
levels of life satisfaction. They conclude that the length of stay in a psychiatric
unit was significantly shorter for patients who attended worship services or
used religious thoughts and activities as the most important strategy in coping
with their illness than for those who do not.
Religious communities can provide a deep sense of affirmation, comfort
and belonging in the lives of those who are chronically mentally ill. Spir-
itual practices, such as prayer and meditation, scripture reading, listening
to worship music, and participating in religious rituals, such as taking the
266 M. Q. Browne

sacraments, are often important factors that support recovery from mental
illness (Fallot, 1998).

BACKGROUND ON POPULATION UNDER STUDY

People interviewed were part of an inpatient psychiatric facility. Most of the

residents are people with serious and persistent mental illness. Most of the
residents have had more than one inpatient hospital stay. Most also have
more than one psychiatric diagnosis.
On admission during their Spiritual Assessment, 60% of the patients
identified themselves as Protestant; 32% were Roman Catholic, and 8% were
Jewish, Muslim or other. Of the Protestant patients, 33% were female and
67% were male; 41% were Caucasian; and 59% were African American.
The Department of Spiritual Supports Services provides a number of
opportunities for patients to develop their spirituality and participate in re-
ligious practices. Weekly prayer and meditation groups, Bible studies and
worship services, as well as one-on-one pastoral counseling are available.
Within the Protestant chaplaincy program, a service of Holy Communion
is held monthly, as is a Service of Wholeness and Healing. The remaining
worship services are Service of the Word. A Roman Catholic Mass is held
weekly.
The average attendance at the weekly Protestant worship during the
period of this study was 20 people, which is 39% of the general population,
and 24% of the Protestant population. Of these attendees, most were male,
and 50% were African American. This “congregation” represents a cross-
section of the general hospital population, and is generally congruent with
those of the general population.
For this study, it was decided to interview six patients that would rep-
resent this population. Five males and one female were chosen. The female
was Caucasian while three of the males were Caucasian and two were African
American.

METHOD AND SAMPLE

Definition of the Instrument
The aim of this article is to discover in what ways sacramental ministry might
function in the lives of those who live with a severe and persistent mental
illness. In an attempt to answer this overriding question, an open-ended
questionnaire was designed by this writer in consultation with Dr. Nelson
T. Strobert, Professor of Christian Education and Director of Multicultural
Programs at the Lutheran Seminary at Gettysburg (PA), titled “Spirituality and
Sacramental Practices Structured Interview” (Appendix A). This questionnaire
 Significance of Sacramental Ministry 267

seeks to find answers as to the reasons for attending worship, images that
come to mind related to Holy Communion and anointing; how one feels after
leaving worship on these particular days; and the types of spiritual practices
that are engaged in throughout the week.

Sample Characteristics
Patients were contacted on an individual basis to discuss their interest in
participating in this study. They were told that I was writing an article for
one of my seminary classes and that I had a few questions to ask them
about worship. I informed them that confidentiality would be maintained
and that their names would not be used in this article. Verbal permission
was obtained prior to beginning the interview. All patients that I asked to
participate agreed to do so.
The patients chosen for this study are all middle-aged. They have been
hospitalized multiple times throughout their adult lives. The average length
of time for this admission was 2 years. Two were diagnosed with major
depression, two with chronic paranoid schizophrenia, and two with bipolar
disorder. All have a history of substance abuse. Half have attempted suicide.
The denominational identity of this sample is as follows: two Epis-
copalian, one Roman Catholic, one Presbyterian Church of America, one
Pentecostal, and one non-denominational. All attend worship on a regularly
basis, and most attend weekly. Five have been members of the Chapel choir,
and all have participated in other spiritually focused groups.

Limitations
One of the limitations of this study is that it is not randomized. This writer
chose the patients interviewed because they are the most consistent in at-
tending worship and other spiritually focused groups. They are among the
most articulate and stabilized within this setting. An additional limitation is
that, due to the qualitative/descriptive nature of this study, the results may
not be generalizable to other populations. A further limitation is that all of
the patients interviewed are middle-aged, having dealt with their illnesses
for the entirely of their adult lives and having come to some understanding
of how to manage their illnesses. Some have had long periods of stability
and have lived and worked in the community prior to this admission. This
is not representative of the general hospital population.

RESULTS

All of the patients interviewed expressed that participating in Holy Com-

munion and Wholeness and Healing positively relates to their spirituality.
268 M. Q. Browne

When asked what brings them to Holy Communion, the responses indicated
a sense of feeling more connected to their faith, affirmed or renewed in
their faith, and united to others. There was a sense that something special
was taking place, that God was there in this symbol, that communion is the
bread of life that links us to the Body. One patient felt that sharing in Holy
Communion connects all of us with past tradition.
Words or thoughts that come to mind in relation to Holy Commu-
nion include, “cleansing of mind, body and spirit,” a sense of decrease in
barriers—people coming together. It was commented that waiting in line to
receive the bread and wine is like coming closer and closer to the Lord.
Also expressed was a sense of joining with the last days of Jesus in the
Upper Room; a good feeling of connection. God is present in the bread and
the wine, in the special prayers, in the mystery of this holy sacrament. And
participation in this sacrament affirms.
On leaving worship following receipt of Holy Communion, patients
expressed a feeling of well-being, connection and forgiveness. They feel
“real well,” “good,” “honored to be included.” In relation to these positive
feelings of regeneration and fulfillment, one patient stated, “I don’t know
why I feel like I do, but I do.”
When asked what brings them to the Service of Healing and Wholeness,
one patient stated that he liked to “receive the touch of glory when the cross
is put on my head.” All like the smell of the oil. For most, this service
is perceived as more special to them than Holy Communion. It is a more
individual sign that God loves them. It renews their faith and fulfills their
deeper needs.
Words or thoughts that come to mind when hearing the term anointing
include: intimate, warm, an individual singling out. There is a sense that God
is coming to them, touching their heads, and for them, that is amazing. One
patient again expressed that this oil connects us to the past; that in this and
in the elements of bread and wine, God is reaching out from the past to the
present. It was also expressed that this is a symbol of forgiveness, a gift.
On leaving worship following anointing, patients stated that they felt
“blessed,” “hopeful,” “loved,” “unified,” “good,” “relaxed,” “rejuvenated,” and
that their guilt was calmed.
When asked what they might do in between worship services to main-
tain their spiritual connection; what types of spiritual practices they engage
in, 50% indicated that prayer and Bible reading were regular disciplines.
Others talk with the chaplains about spiritual issues, listen to Christian mu-
sic, read other devotional literature, or watch religious programming on
television.
Additional comments included, “We live beneath our privilege if we go
without Christ.” One patient expressed a fear that his soul was becoming ill
in addition to his mind. Another expressed that it is hard to concentrate and
make connections, “If things get too deep, it’s easy to get lost.”
 Significance of Sacramental Ministry 269

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

The results of this study confirm that participation in spiritual practices, and
inclusion in a religious community does provide a deep sense of affirmation,
comfort and belonging in the lives of those who are chronically mentally ill.
The patients interviewed for this study expressed a meaningful connection
to God, their faith, and to one another when they received the sacrament of
Holy Communion and prayer with anointing. All had the sense that some-
thing important and different was happening when bread, wine, or oil was
offered in addition to Scripture reading, proclamation, prayer or singing.
In answer to the question, “In what ways does sacramental ministry
function in the lives of those who live with a severe and persistent mental
illness?” based on this study, one response might be that sacramental ministry
makes God’s presence real for those who live with a severe and persistent
mental illness. One patient commented that it is hard to follow along with
just words. Sometimes, when trying to filter through delusions and/or hallu-
cinations, words get lost. But with a concrete element, bread, wine, or oil, a
connection is made. They are recognizable and mean something that words
alone are not able to convey. God is present; Christ is present; the Holy
Spirit is sensed in the smell of the oil, in the touch of the chaplain’s hand,
in the eating of the bread and the wine. In this moment, a connection is
made to all who have come before in the faith, and to all who are present
in the room. This connection enabled the patients in this study to leave the
worship space with a renewed sense of their relationship with God.
The meanings patients attached to the Lord’s Supper in this study were
consistent with those of Baptism, Eucharist, and Ministry (1982). These
patients expressed a sense of gratitude to God for the gift. They expressed
an understanding of sharing with past tradition, in this memorial of Christ
and of joining in communion with other believers. The Holy Spirit was felt
to be present. This is for them, a meal of the kingdom.
Noteworthy is that prayer and anointing with oil was viewed as even
more meaningful due to the personal nature of this event for them. Patients
expressed that they were grateful for the opportunity to offer their individual
concerns to God through the touch and prayers of another. They carried the
importance of this act out of worship more tangibly because they had the
cross in fragrant oil on their foreheads as a reminder. Perhaps for people
with serious and persistent mental illness who are accustomed to being
stigmatized or marginalized, this is indeed a more powerful sign of God’s
loving presence with them.
Effective recovery from mental illness includes spirituality, and based
on the results of this study, it is recommended that spiritual and religious
supports consistently be offered to people with serious and persistent men-
tal illness. As there is a shift in mental health provision from inpatient to
outpatient care, it is increasingly the responsibility of community churches
270 M. Q. Browne

to understand and provide for the spiritual and religious needs of those
with serious and persistent mental illness and to include this population
in worship and other church-related programs. Clergy and congregational
education might be one way to help accomplish this goal.
It is not, however, only people with serious and persistent mental ill-
ness who have difficulty in focusing on and understanding words alone.
There are many in our congregations who struggle with less severe mental
disorders or with mental retardation that may also benefit from an increased
understanding and awareness of their mental and emotional needs so that
they might better be able to participate in and benefit from worship. The
Spirit works though means and through human interaction. Congregations
might work towards creative worship opportunities for all that incorporate
concrete, physical elements with the word of God. One congregation that
I know of is beginning a special worship service for those with autism that
includes body movement and sign language. This is one example of what
can be accomplished to enable God to be present for all.
One recommendation for further study would be to repeat this or a sim-
ilar interview process with other psychiatric inpatient and outpatient popula-
tions. It may also be of benefit for research to be conducted in congregational
settings to begin to determine the types of programming that might be of-
fered, both for members and leaders.

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APPENDIX A

Spirituality and Sacramental Practices Structured Interview

Name: Date:

Let’s talk about some of the different ways that we do worship here at
Mayview and what these mean to you. First we’ll talk about Holy Commu-
nion:

1. What brings you to worship on the first Sunday of the month, when we
celebrate Holy Communion? How is that different than a regular worship
service for you?
2. What words or thoughts come to mind when you hear “Holy Commu-
nion?” Any related feelings?
3. How do you feel after worship, when you leave after receiving Holy
Communion?

Now let’s talk about the Service of Healing and Wholeness that we have on
the third Sunday of the month:

4. What brings you to worship on the Sundays that we offer individual prayer
and anointing?
 Significance of Sacramental Ministry 273

5. What words to thoughts come to mind when we say anointing? Any feel-
ings?
6. How do you feel after leaving worship on these Sundays?
7. What do you do in between worship services? What types of spiritual prac-
tices help you?
Additional comments or questions asked by participant: