Religion and Spirituality in Psychiatry

Religion/Spirituality and Psychosis 69functioning, are part of the concept of recovery.(26) Over the past few years, recovery has beenrecognizedas an organizing principle for the systemsof care for the mentally ill that can replacepaternalistic, illness-oriented services.(27)8. INDIVIDUAL TREATMENTAND COMMUNITY PROGRAMSSchizophrenia and other psychoses affect allareas of a patient’s life. Consequently, treatmentsshould comprehensively cover all affectedareas. This should include individual, supportive,and cognitive approaches, (28) but it mayalso involve psychodynamic therapy (29) (evenif it may be difficult to integrate both behavioralinterventions and more psychoanalyticallyoriented approaches).(30)A comprehensive treatment also involves avariety of actions, for example, aggressive communitytreatment, family and individual psychoeducation,supported employment, social skilltraining, and integrated treatment for substancemisuse.(21)Recovery-oriented services should take theseaspects into account to obtain a better understandingof the meaning of what patients areexperiencing, and this from the perspective oftheir personal histories.(31) Guidelines have beendeveloped to facilitate the development of servicesaccording to this paradigm.(27) Beyond thecomprehensive approach briefly described above,treatment features should include a variety ofservices that support consumer self-sufficiency,encourage the use of advanced directives, provideculturally sensitive treatments, emphasize consumerchoice, limit the use of coercive measures,and address barriers to access. This is the frameworkthat allows us to study, assess, and interveneon spiritual and religious issues when treatingpeople with psychosis.9. THE ROLE RELIGION/SPIRITUALITYWe have described why religion/ spiritualityshould be incorporated within a recovery- orientedapproach to patients with psychosis.But how can we integrate this part of treatment?This is not an easy question to address.Indeed, the answer depends on various factors,the main one being the cultural context in whichclinicians work. Ultimately, the choice to bemade will be whether the clinicians should dealwith an issue by themselves, or whether it shouldbe delegated to a trained religious professional.In fact, we must admit that research is stillneeded on this topic to fully address some crucialquestions. The first is to know what patientswant us to do. Do they want us to discuss religionwith them? If we hypothesize that the answer tothis first basic question is affirmative, others arisebeyond that. What can we do, what are the issues aclinician could broach with his or her patient? Asmentioned before, some issues certainly fall withinthe domain of the clinician; others, however, maybest be addressed by a specialist in religion – achaplain, pastoral counsellor, or other member ofthe clergy trained in mental health care.If research is lacking on these issues, commonsense may suggest some indirect answers, whichare described later in this chapter.10. ASSESSMENT OF RELIGION/SPIRITUALITYBefore considering factors related to the interactionbetween religion/spirituality and psychosisin terms of coping and treatment, webriefly describe how to assess these elementsin patients with psychosis. Although more generalaspects of the assessment of religion andspirituality are discussed in Chapter 16, weemphasize here aspects specific to patients withpsychosis. The main issue (and maybe the mostdifficult for clinicians) is that these patients mayexpress themselves in ways that make it difficultto disentangle normal elements from pathologicalones.However, types of religious coping in schizophreniaand how they may affect clinical outcomesand adherence to psychiatric treatmentmust be assessed. No validated questionnairesexist that survey religion and religious coping forpsychotic patients. Wulff (32) pointed out that