People first, science second

It has been suggested that religion and spirituality is psychiatry’s ‘last taboo’, and that the spiritual beliefs of service users are frequently ‘pathologised’ by mental health practitioners (see the Mental Health Foundation report from 2007, Keeping the Faith, tinyurl.com/l7qxbrz). Isabel Clarke, a clinical psychologist with a special interest in spirituality, recalls (tinyurl.com/nfe6znb) offering spirituality awareness training for staff and how it was an extremely difficult subject for some to discuss, as difficult as issues of sex and sexuality once was: ‘…staff were frequently at a loss when faced with the religious and spiritual preoccupations of the people they were working with.’

Whilst this could be considered an extreme response and aversion to spirituality, the sentiments shared resonate quite strongly with me. Whilst working as an assistant psychologist on an inpatient ward, I was asked to facilitate a spirituality group and was astonished by the number of professional and personal issues it raised. I will briefly explore this issue and how the experience of facilitating the group led to fundamental changes in how I work and interact with service users.

My experience and ambivalence about the group
The spirituality group, ‘My Journey’, was offered at Phoenix Ward, a rehabilitation unit for 18 individuals at Springfield University Hospital, London. The ward specialises in offering care and treatment to individuals who have significant mental health difficulties and have found it difficult to live independently or in less supported accommodation. In recent years a spirituality group has been offered on the ward many times, and along with the chaplain I became a group facilitator in 2010.

I was very ambivalent about becoming involved in the group as I was more familiar with offering sessions that were highly structured, psycho-educational in nature and with a ‘proven’ evidence base, such as cognitive behaviour therapy. At the outset I was particularly concerned about the value of this intervention and in particular whether it was endorsed by research evidence.

I was also concerned about some of the very difficult, personal and spiritual topics that we would talk about in group. I felt unable to prepare myself adequately to respond and support group members, especially when discussing such a diverse, ‘unscientific’ topic in a ‘manual-free’ environment. I lacked confidence in my own clinical skills and was perhaps drawn to offering structured sessions that provided me with a sense of order and confidence in the material discussed; a sense of legitimacy and authorisation for the interventions.

I also considered whether discussing spirituality might be difficult or unhelpful for some service users. Harold Koenig has found (tinyurl.com/6wbm6du) that approximately one third of people who are experiencing psychosis either describe or are pre-occupied with ‘religious delusions’. Others have found that people with schizophrenia who were engaging in very excessive religious practice, such as spiritual healing, were more likely to experience further episodes of psychosis (see tinyurl.com/krk4xv8). Therefore, it is perhaps understandable that many practitioners, including myself, are hesitant about discussing spirituality.

I was also very aware that, despite having worked in mental health services for over 10 years I had not been involved with or even aware of spirituality groups being offered on inpatient units. I carried out a literature review of the topic and struggled to find many research articles. I had also hoped to uncover a ‘manualised’ approach that I could confidently use as a guide. Whilst this was all quite disappointing, my reading nonetheless proved extremely useful in other ways because a theme that I repeatedly encountered in my reading was that spirituality is an area that is ‘religiously’ overlooked by services.

I was also pleased to discover that some authors had indeed reviewed spirituality groups offered on mental health units. For example, Russell Phillips from Bowling Green State University facilitated a semi-structured group, and each week they proposed a specific topic (e.g. forgiveness, hope) (see tinyurl.com/myunhhw). They asked group members for informal feedback and found that the group was highly valued and that participants wanted it continue. And Nancy Kehoe, a psychologist who has 30 years’ experience of running spirituality groups, says that such a group ‘provides valuable therapeutic experiences in tolerance, acceptance of other’s views, and thoughtful examination of belief systems, as well as opportunities to apply spirituality and values to life questions’ (see tinyurl.com/oz3gwju).

The descriptions of these two groups gave me the final push I needed, despite my reservations, to commit to running the group spirituality group at Phoenix.

My journey
My initial ambivalence about facilitating the group melted away very quickly when we got started. I soon found being involved with the group extremely rewarding. The whole atmosphere in the group was completely different to any other group that I had experienced. From the moment we invited people to attend the group it felt different. Each week everyone was warmly invited to attend the group, as you might invite someone to attend a social event. It was a personal and genuine invitation for people to spend time together. In practice, whilst the facilitators always had some ideas and topics in mind, the group was largely directed by group members and the topics which they wanted to bring. However, if topics or items were introduced by the facilitators, the emphasis remained on the personal interpretation and meaning for group members. We encouraged an environment where people could share honest and critical opinions.

Over the course of two years we discussed many different topics, such as religious festivals, religious texts and stories, spiritual journeys and suffering – no two sessions were ever alike. This was a group about acceptance, people being themselves and being present with one another. The chaplain was particularly good at encouraging group members to share their own beliefs, and I could see that his curiosity and genuine interest meant a great deal to service users. To emphasise the importance of each contribution we started the ‘Phoenix Book of Wisdom’; a book where participants could share and record their own ideas.

The atmosphere within the spirituality group might be described as ‘non-directive’, an approach that has infused many psychological theories, such as recovery approaches and person-centred therapy. I was already familiar with the work of the American counselling psychologist Carl Rogers from the 1940s, and I feel that the atmosphere within our group promoted the three ‘core conditions’ of this approach – unconditional positive regard, empathy and congruence. I also found that I was continually drawing on different psychological theories and therapeutic approaches, such as motivational interviewing, psychodynamic theories, mindfulness and guided discovery. Whilst in the past I would have used theory in a more mechanical and rigid manner, in this group I was still drawing on my knowledge and skills but was doing so in a more sympathetic, responsive and creative manner. I have since learned that this approach also has a name: an ‘integrative’ approach.

However, I am still left wondering whether a tension remains within me about how to work with people: the one side drawn to offering pure, therapy from one theoretical viewpoint and the other feeling more confident about responding more creatively using an integrative approach. Whilst reflecting on this I found it useful to consider the comments of Isabel Clarke in her book Madness, Mystery and the Survival of God, as she recommends that there are two ways of thinking about the self: the ‘functional office represents the rational, either-or logic, way of knowing. The mysterious room with no clear limits corresponds to the relational and emotional, way of knowing that is based on experience.’

I suspect that when I became involved with the spirituality group I worked solely within the ‘functional office’. The group encouraged me to consider the ‘mysterious room’ and to experience for myself this way of being with people. The experience has also led to me reflecting on the mindful atmosphere within the group. Mindfulness practitioners often refer to the two modes of ‘being’ and ‘doing’. Often we are in the ‘doing’ mode and lose contact with the here and now or the ‘being’ mode. I feel that the very directive work which had been my preferred approach was akin to the ‘doing’ mode whilst the group made room for ‘being’ with service users.

Evaluation
It was rewarding to see people ‘come alive’ when they were in the group, the pride reflected in their faces when they themselves and their views were warmly accepted. When we asked people what the group meant to them, they tended to say it offered a sense community, that their contribution was respected, and that we were not trying to change them. They were thankful for the compassion and interesting discussions. Of course, this was an optional group, and we therefore only met with people who had a genuine wish to engage with us. And we could not demonstrate that this group made a difference for service users in terms of their symptoms, prognosis and length of stay in hospital. But we nevertheless felt that it had made a difference in terms of how people felt about themselves and that it had strengthened our therapeutic relationship with many service users.

Despite the apparent success of this group and the format used, it is also important to recognise that it was offered in a context where service users were offered many different interventions. Our group was facilitated alongside more directive interventions, assisting individuals to alleviate symptoms of their mental health problems and work towards their goals. However, this group seemed to offer a therapeutic counterbalance to interventions that place more emphasis on the need for change.

I look back at my experience in this group with great affection. I was inspired by many aspects of the experience; but mainly, the sensitivity of the chaplain, group members’ enthusiasm and the respectful and welcoming atmosphere fostered. I am also more inclined towards being in the moment, present and mindful with service users. Whilst I will continue delivering more ‘recognised’ and evidence-based treatments, I feel nonetheless that my experience of this group has made me a better practitioner.