MEDITATION vs MEDICATION

The Importance of Spirituality in the Treatment of Mental Illness

A description of spirituality's links with health and especially with psychiatry

Introduction
Our days at medical school are filled with seminars, workshops and wellmeaning pep talks that aim to make us good doctors. We’re told repeatedly to empathise with our patients, to understand the context of their illness and view them as ‘whole persons’, not medical labels. We’re instructed on the importance of taking a social history, and we’re encouraged to attend multidisciplinary team meetings. Usually, however, it’s not long before our meticulous social histories degenerate into a brief enquiry about alcohol and tobacco consumption (usually vague and wildly inaccurate), and the MDT meeting is seen as nothing more but a chance for a nap while the histology slides are shown. This article aims to challenge our view that talk about ‘whole persons’, spirituality, and other difficult (some may say vague) subjects should be constrained to communication skills sessions. It is concerned with the need for us to recognise our patients’ spirituality, enabling us to view illness as a multifaceted entity that requires more than a merely biomedical approach to treatment, and although it addresses spirituality in the context of psychiatry, its themes are relevant to all medical specialties.

What is Spirituality?
Spirituality, notoriously hard to define, can be characterised in many ways. Some writers take a philosophical point of view:
‘The word Spirit is taken from the Latin ‘spiritus’, meaning ‘breath’. An analogy would be human respiration, by which oxygen is taken in to sustain and maintain the existence of the person. The Spirit provides a similar sustaining and maintaining role on a more ontological level.’ (Swinton, 2001)
More pragmatically, others have stated that religious feelings are due to increased blood flow in the frontal lobe (Fenwick, 2003). For the purposes of this article, it is important to realise that there is a distinction between ‘spirituality’ and ‘religion’. One view is that ‘spirituality is the wellspring within and religion the edifice to cover it’ (Mental Health Foundation, 2000). Put less tritely, most people have a concept of their place in the universe and the purpose of their life (‘spirituality’), and some express this through the rituals and systematised beliefs known as religion. Asking about someone’s spirituality is more than finding out whether they would call themselves Muslim or Christian.

The Effect of Spirituality on Health
Spirituality isn’t just a relevant concern in psychiatric practice; it has also been widely studied in other areas of medicine. Some of these studies serve to challenge our sceptical views about the relevance of this topic. The literature in this area covers many aspects of spirituality; to look at it is beyond the scope of this article, so only a couple of examples will be quoted (Townsend et al., 2002).One of the first pieces of research – now a classic — was conducted by Byrd in 1988. The research looked at the effect of randomised intercessory prayer on patients’ recovery in ITU, and found that those receiving prayer had a significantly lower severity score based on the hospital criteria (use of antibiotics, pulmonary oedema etc.). These data suggest that intercessory prayer to the Judeo- Christian God has a beneficial therapeutic effect in patients admitted to a CCU.The Byrd study looks at the effects of other peoples’ prayers on health, but there is also plenty of work on individuals’ own spiritual beliefs and practices, and the impact this has on health. One such study looks at the effect of Chinese Taoist cognitive psychotherapy (CTCP) on generalised anxiety disorder (GAD) in a Chinese population, compared to benzodiazepines (BZ). CTCP combines elements of cognitive therapy and Taoist philosophy, which is a widely held belief system in urban China. At entry to the study, patients were evaluated and randomised to one of three groups: CTCP only, BZ only, or both. They were assessed one and six months later. Results indicated that although BZ offer immediate, short-term relief from anxiety, CTCP gave the patients a slower but more enduring effect, causing reduced type A behaviour, improved coping style and decreased neuroticism. The combination of BZ and CTCP lead to both immediate and long-term improvement (Zhang et al., 2002).A similar piece of work looks at the effect of incorporating socio-cultural and religious aspects into the management of anxiety in Muslim patients of Malay origin. Those patients who had strong religious beliefs and received religiouscultural psychotherapy had a much faster response to treatment than those receiving standard psychotherapy (Razali et al., 2002).Subsequent researchers have looked at the effect of religious behaviour on health: for example, Koenig et al. (1999) looked at a population of nearly four thousand 65 year old people over a sixyear period and found that those who go to church at least once a week are more likely to be alive after six years.

Psychiatry and Spirituality
Psychiatry has had a troubled relationship with faith, religion and spirituality (Sims, 2003). There has even been open hostility between the two areas — in the 1930s Freud stated that belief in a single god is delusional. For a long time, each group viewed the other with suspicion, psychiatrists believing that religion equates to neuroticism and the Church conceptualising the symptoms of mental illness as ‘sin’. As recently as 1994, psychiatrists were adding religious and spiritual problems to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), saying "This category can be used when the focus of clinical attention is a religious or spiritual problem. 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 organised church or religious institution."
Later in history, psychiatrists who had a personal faith grew bolder in discussing the links between these beliefs and their work. As one psychiatrist says:
“My own understanding of theology, which I come to from Christianity, is the absolute centrality of relationship in the whole of creation. As the fostering of healthy relationships is also fundamental to psychiatry, one might have thought that the two, religious faith and psychiatry, would work together.”
Increasing confidence within this small minority of practitioners culminated in the establishment of a Royal College of Psychiatrists Special Interest Group (SIG) in the area of Spirituality at the start of the millennium. The SIG aims to enable professionals to integrate the areas of spirituality and clinical practise, providing an integrative approach to mental health care.

Practical Aspects of Spirituality in Psychiatric Care
The studies quoted above, and the interest of the Royal College’s SIG, seem to indicate that spirituality does have some effect on peoples’ health. Does this mean we should be prescribing meditation, attendance at religious services or prayer to our patients? It is instructive to distinguish cure of symptoms from healing of people. The words "heal" and "whole" have common roots. Healing entails restoration of psychobiological integrity, with the implication of personal growth and a sense of renewal.Maybe part of the reason why doctors (and students) have been reluctant to address patients’ spirituality is because it’s a subject we feel we know little about. We’re used to being the bearers of knowledge and information; spirituality is an area where we are all floundering out of our depth. Whilst we may maintain that we don’t want to ask about spirituality in case it is too upsetting for the patient, maybe the truth is that it’s too disturbing for us.Yet addressing the part a person’s spiritual beliefs may play in their illness or their recovery need not be so traumatic (to either party!). The Care Plan Approach (CPA), used to assess patients with mental illness and plan and review their treatment, can be a good place to start. As it already involves many different professionals, patients can be encouraged to speak openly about their spiritual beliefs and even be asked if they would like to choose somebody to help the team understand their beliefs and spiritual needs, like an appropriate religious leader in the community. It is helpful if the mental health team represents the culture of the society in which it is based.Doctors don’t need to provide all aspects of care: just as occupational therapists assess and aid patients in the activities of daily living, religious leaders in the community can aid patients’ spiritual needs. There are already areas where medical practice and charitable, often religious, organisations work together; addiction services, work with carers, counselling, family and couple therapy, and community projects like drop-ins and befriending.Psychiatry, religion and spirituality should be complementary to one another, answering different kinds of questions and forming a meaningful partnership: allies, rather than friends or foes.

Spiritual Care for All Patients
We must be aware of our own spirituality and identity – how we see the world and our place in it – and conscious that we should not impose this on the people we speak to. Then asking a patient about their spirituality need not be something we avoid from fear we’ll say the wrong thing – a simple question like ‘What makes life meaningful for you?’ or ‘Do you have a faith which helps you at a time like this, or are you undecided?’ can be all that is needed to make someone feel like they’re being listened to. This can make all the difference to a person’s impression of the care they’re receiving:
‘I’m tired of being talked about, treated as a statistic, pushed to the margins of human conversation. I want someone who will have time for me, someone who listen to me, someone who has not already judged who I am or what I have to offer. I am waiting to be taken seriously.’
As doctors, we should be aiming to discern what is important to our patients – after all, how can we treat what we do not understand? Illness is more complex than the pathophysiological processes we diligently memorise, and whether your future lies in psychiatry or surgery, you will certainly meet people whose illness is made up of more than their presenting symptom.

This article has drawn on material from seminars and discussions and the ‘Mind and Spirit Conference’ (February 2004) organised by the Eastern division of the National Institute for Mental Health in England
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