National Training Forum Christchurch, 2006 Jim Geekie ADHB

1. National Training ForumChristchurch, 2006Jim Geekie ADHB Spirituality and Psychosis NTF 2006

2. Overview • Act 1 • My personal position – spirituality & psychosis • My personal “ten commandments” of mental health work • Act 2 • Psychosis and spirituality (literature) • Reflections on psychosis/spirituality • Act 3 • Spirituality and psychosis in the client’s story • Clinical implications and considerations • ( NB: Not focussing on cultural issues) NTF 2006

3. Where I’m coming from: Psychosis/Spirituality • “Spirituality” and “psychosis” are different ‘explanatory models’ for out-of-the-ordinary experiences NTF 2006

4. My personal“ten commandments” • Working in mental health – ethical and conceptual matters are as important as empirical/scientific • (Bentall 1992; proposal to classify happiness as psychiatric disorder) NTF 2006

5. My personal“ten commandments” • We work with ‘consciousness’ • There is something in the nature of consciousness which makes it in ineffable (can’t be fully described or appreciated) • “Both psychology and psychiatry suffer from the lack of a satisfactory theoretical framework for investigation and explanation of consciousness” (Fenwick, 2001) NTF 2006

6. My personal“ten commandments” • Schizophrenia is just a construct • (but then again, construct is also ‘just a construct’) • “If we wanted to be candid today in our talk about schizophrenia, we would admit to this: Little is known about what causes schizophrenia.” Robert Whitaker, 2002 NTF 2006

7. My personal“ten commandments” • The nature of knowledge: • There is no such thing as objectivity; all knowledge is from a position, whatever position • Personal knowledge is logically prior to and underpins ‘impersonal’ knowledge • (The from/to nature of knowledge, Polyani, 1958) NTF 2006

8. My personal“ten commandments” • “Authoring” one’s own experience is an ethical right, and a personal responsibility • Of considerable importance for FEP clients NTF 2006

9. My personal“ten commandments” • ‘In a moral world, no one but the person in question has the status, the authority, under normal conditions, to decide what his experience means to him.’ • Shotter (1981) NTF 2006

10. My personal“ten commandments” • Clinical work exposes us to ‘the pink-underbelly’ of society and of Being • We have a responsibility to provide testament to this • giving voice to subjugated knowledge • (Foucoult, 1980) NTF 2006

11. Psychosis/Spirituality: Literature review • Definitions and notions of ‘spirituality’ • Spirituality and health • Spirituality and psychosis/psychiatry • The Spirituality-psychosis paradox • Spiritual emergence/emergency • Assessing spirituality NTF 2006

12. Definitions and notions of ‘spirituality’ • William James (1902) • “a sensation of union”. • Connection with cosmos, humanity, nature and with Divine Energy. • Also – ineffable and with a sense of revelation of knowledge. NTF 2006

13. Definitions and notions of ‘spirituality’ • Spiritual is the experience of relationship with a transcendental force or being • Object of one’s ultimate concern • Paul Tillich ; 1956 NTF 2006

14. Definitions and notions of ‘spirituality’ • “an unbounded apprehension of the whole, glimpsed during peak experiences and creativity, but plunged into full mystical experience, in some drug induced states, and psychosis” • (unconstrued experiencing of reality) • Clarke (2000): NTF 2006

15. Definitions and notions of ‘spirituality’ • “Spirituality relates to the way in which people understand and live their lives in view of their sense of ultimate meaning and value. It includes the need to find satisfactory answers to ultimate questions about the meaning of life, illness and death”. Swinton (2005) NTF 2006

16. Spirituality and general health • Health benefits include: • Extended life expectancy. • USA meta-analysis attending church once a week associated with increased life span – 7 years for whites, 14 for blacks • Larson, Larson and Keonig (2001) • Lower blood pressure. • Lower rates of death from coronary artery disease. • Reduction in myocardial infarction. • Increased success in heart transplants. • Reduced serum cholesterol levels. • Swinton 2005 NTF 2006

17. Spirituality and health • Health benefits include: • Reduced levels of pain in cancer sufferers • Reduced mortality among those who attend church and worship services. • Increased longevity among the elderly. • Protection against depression and anxiety. • Reduced mortality after cardiac surgery Swinton 2005 NTF 2006

18. Spirituality and mental health • Some evidence suggests religious belief and practice good for mental health (see Dein, 2004) • Larson, Larson and Keonig (2001): • reduced risk of depression and maybe faster recovery. • Less risk of suicide (x4) • Less risk of substance use NTF 2006

19. Spirituality and health • Negatives: • Rigid religious families with ‘harsh parenting practices’ associated with potential clinical problems • individual psychopathology linked with families use ‘spiritual’ notions to support enmeshment, rigidity, and emotional harshness • Mental health patients: 1 in 4 believed that sinful thoughts or acts may have contributed to the development of their illness • Larson, Larson and Koenig (2001) NTF 2006

20. Conclusion…? • Religious or spiritual beliefs are good for your health NTF 2006

21. Spirituality and psychosis: clinical relationship • Heery (1993) • in-depth interviews with 9 voice hearers • seeing the experience as indicating ‘fragmented parts of self’, in the spiritual realm = common framework for making sense of voices NTF 2006

22. Spirituality and psychosis: clinical relationship • Jones, Guy, and Ormrod (2003) • Small scale qualitative study (n=20) • voice-hearers’ understandings of experience • 3 broad frameworks: biological; psychological; spiritual • spiritual framework associated with less distress NTF 2006

23. Spirituality and psychosis: clinical relationship • Jones, Guy, and Ormrod (2003) • “understanding the range of beliefs that voice hearers hold about their voices should therefore be of great importance to researchers and clinicians” • treatment options need to reflect these differences in beliefs. NTF 2006

24. Spirituality and psychosis: clinical relationship • Romme and Escher (1989) • voice hearers’ explanatory model influences impact of voices and associated distress • spiritual understandings associated with less distress NTF 2006

25. Spirituality and psychosis: clinical relationship • Warner, (1985) • Better outcomes for schizophrenia in developing countries • these societies also place greater emphasis on spiritual/religious realm • considers possibility that this is significant. NTF 2006

26. Conclusion…? • Some evidence to suggest that religious and spiritual beliefs are good for your mental health NTF 2006

27. Spirituality and mental health:what mechanism? • Enhances coping by offering hope, value, meaning and purpose • Provides systems of meaning and existential coherence • Facilitates social integration & support – participation and provide links to caring communities. • Relationship with Divine Other provides support • Swinton, 2005 NTF 2006

28. Spirituality and psychiatry* • Kung (1986): • religion is ‘psychiatry’s last taboo’ • “Psychiatrists have too often concentrated exclusively upon the mental, and ignored, to the extent of denying its possibility, a spiritual dimension” • Sims (1994, p444) NTF 2006

29. Spirituality and psychiatry • “Religion and spirituality have always had an influence on the form and especially the content of mental illness, yet in mainstream psychiatry the tendency has been for them to be pathologised, ignored, or relegated to an uneasy borderland, with uneasy labels such as ‘existential’ or ‘cultural’“ • (Turbot, 1996) NTF 2006

30. Spirituality and psychiatry* • “we live in an age of spiritual illiteracy (both within and outside psychiatry)” • Randal and Argyle (2005) NTF 2006

31. Spirituality and psychiatry; the ‘religiosity gap’ • General public and clients tend to be more religious than mental health workers. • (Dein, 2004; Hay (1987) NTF 2006

32. Spirituality and psychiatry; the ‘religiosity gap’ • UK Mental Health Foundation: • User-led project (Somerset) • spiritual and religious needs of users of MHS. • Many users highlighted importance of spirituality • Commonly unhappy with response of mental health workers – ignored or seen as sign of illness NTF 2006

33. Spirituality-Psychosis paradox • What is the relationship between ‘spirituality’ and ‘psychosis’? NTF 2006

34. Spirituality and psychosis; the spiritual-psychotic paradox • “Religious mysticism is only one half of mysticism. The other half has no accumulated traditions except which the text-books on insanity supply” • (paranoia as a ‘diabolical mysticism’) • William James, 1902. NTF 2006

35. Spirituality and psychosis; the spiritual-psychotic paradox • Greenberg et al (1992); • Comparison of mystic and psychotic states: • Both commonly involve hallucinations • psychotic mostly auditory, mystic visual • Speaking in tongues vs thought disorder • Delusions of grandeur more common in psychosis • Affective response – mystic =positive; psychotic = fear • Mystic transient and resolves; psychosis long lasting NTF 2006

36. Spirituality and psychosis; the spiritual-psychotic paradox • Jackson, 2001; qualitative and quantitative study, • Comparison of experiences labelled ‘psychotic’ and ‘spiritual’. • Many commonalities in phenomenology • emotional tone (negative more common in diagnosed group) • degree of conviction & insight (similar) • sense of control (similar) NTF 2006

37. Spirituality and psychosis; the spiritual-psychotic paradox • Jackson, 2001; qualitative and quantitative study, • Functioning: • short term impact = most difference between groups • ‘mystics’ – felt empowered and helped by their experience, • ‘psychotic’ - felt overwhelmed and isolated • this distinction lost over the longer term. NTF 2006

38. Spirituality and psychosis; the spiritual-psychotic paradox • Jackson (2001) ‘the spiritual-psychotic paradox’. • How is it that two categories of experience, defined in terms of their opposing pragmatic effects, are seen as reflecting one underlying process or pathway? NTF 2006

39. Spirituality and psychosis; the spiritual-psychotic paradox • Randal and Argyle (2005) • “the phenomenology of what might be interpreted as a ‘spiritual emergency’ by the person or by an informed clinician, can be identical to other psychoses” NTF 2006

40. Spiritual emergence/emergency • Grof and Grof (1989):‘spiritual development’ • normal process = ‘spiritual emergence’ • process of spiritual awakening • sense of deeper connection to other people, nature and the cosmos; • normal, can be subtle and gradual • Can be rapid and dramatic = emergency NTF 2006

41. Spiritual emergence/emergency • Spiritual emergency • profound psychological transformation • intense emotions; • visions, • unusual thoughts; • spiritual themes • Some argue that sometimes psychiatry misdiagnoses as mental illness NTF 2006

42. Differentiating ‘spiritual emergency’ & psychosis • Grof and Grof (1989): • person ‘owning’ this inner experience, differentiates from psychosis • person open to explore experience • no conceptual disturbance. NTF 2006

43. Differentiating ‘spiritual emergency’ & psychosis • Randal and Argyle (2005) – pragmatic approach • Spiritual emergency = helpful explanatory model • reduces risk unnecessary use anti-psychotic • suggest minor tranquilizer/hypnotic for sleep • provides a normalising, hopeful framework where client & clinician can work together NTF 2006

44. Spiritual emergency: ‘treatment’ (response) • Randal and Argyle (2005) • “Psychosis appropriately framed as ‘spiritual emergency’ can be seen as an opportunity for further personal growth” • person is supported in expressing content of inner world at their own pace and in time, psycho-spiritual roots of the problem can be addressed NTF 2006

45. Assessing spirituality: should we? • USA study (King, 1994) • >200 patients • 77% want doctors to consider spiritual needs • 37% would like to discuss these. • 48% wish that physician would pray with them. • 68% physicians hadn’t considered/discussed spiritual matters with patients NTF 2006

46. Assessing spirituality: how? • Zohar and Marshall, (2000); • Spiritual intelligence (SQ) • Fallot (1988b) assessment tool: • ‘beliefs and meaning’ • ‘experience and emotion’, • ‘rituals and practice’; • ‘community’, • ‘explicitness of religious language’ • ‘role in patient’s well-being’. NTF 2006

47. Assessing spirituality: how? • Eagger (2005) “HOPE assessment” • H: Hope • (sources of: meaning, comfort, strength, peace, love and connection) • O: Organised religion • P: Personal spirituality & practices • E: Effects on medical care NTF 2006

48. Assessing spirituality • Dr Larry Culliford and Rev Dr Stuart Johnson (2003) • A reliable way to broach the subjects of religion and spirituality is simply to ask, ‘What sustains and keeps you going in difficult times?’ NTF 2006

49. Psychosis and spirituality:the client’s story • “There is a great need to acknowledge, have respect for, and use in treatment, the patient’s own experience” • Sims (1994; p445) NTF 2006

50. Psychosis and spirituality:the client’s story • “Religion and spirituality are central to the self-understanding of many consumers” • sources of identity and meaning. • Fallot (1998) NTF 2006