Religion and Spirituality in Psychiatry

76 Philippe Huguelet and Sylvia Mohrclergy. A thorough assessment should make itpossible to disentangle a “true” spiritual crisisfrom the expression of delusional thoughts.Finding the answers to the following questionscan help in this process: Is the patient experiencinga relapse? Is he or she in a moment ofhis or her life suggesting the possibility of sucha spiritual crisis? Things can be even trickierconsidering the fact that patients may be experiencingsymptoms and a period of spiritualcrisis as well. Generally, clinicians should assessand treat – if possible – such a situation beforereferring the patient to a chaplain or a spiritualleader. In this latter case, the clinician shoulddiscuss the patient’s medical context with himor her (with the patient’s consent).Identity building is also an issue of importance.Indeed, patients with psychosis often haveproblems related to identity, at least partly dueto the consequences of their disorder. Even ifmost of the therapeutic work with these patientsis now behavioral-cognitive based, there is agrowing trend to emphasize psychodynamicissues again.(30) In general, a psychodynamicapproach may be helpful in resolving conflictsand identifying recovery goals. As mentionedin Chapter 12 on self-identity, both the individualand social aspects of religion/spiritualitymay be key components of identity. Dependingon the time available and the skills and the orientationof clinicians, it should be possible tointegrate these aspects into individualized treatmentplans. Working on identity is not an easyprocess. The first step is to engage the patientin a narration of their story, making it possibleto reappraise certain elements of their identity,including the spiritual/religious components.Further steps may be envisaged, but a thoroughknowledge of the psychodynamic field isrequired at this point.Another issue pertaining – at least partly –to psychodynamics is the quest for meaning,not in a religious perspective, but in the senseof understanding one’s current reactions andemotions. In the field of religion, patients couldbegin to understand why they invest God as apaternal figure, in the light of the relationshipwith their parents. Different studies suggesthigher levels of insecure attachment in patientswith psychosis as compared to controls.(55)Based on research investigating attachmentstyles and spiritual coping in patients with psychosis,we identified a relationship betweenpatients’ compensation strategies in the processof constructing affective security and spiritualbeliefs. The first analyses suggest that patientsreproduce interpersonal parental experiencesthat are associated with a compensatory copingstrategy in the context of a relationship to aspiritual figure.(56)As mentioned below, all these interventionsshould be brought together with a common goalin mind: recovery. In particular, individualizedtreatment should help to provide culturally sensitivetreatments, emphasize consumer choice,and address barriers to access.18. IMPLICATIONS FOR GROUPTHERAPYRehabilitation is often implemented to progresstoward recovery. However, patients have reportedthat the services they received were least helpfulin achieving goals in spiritual and religiousdomains.(57) Nevertheless, moving beyondindividual treatment, group activities have beendeveloped in some places, mostly in the UnitedStates. A group format has some advantages overindividual treatment in terms of costs but also interms of the opportunities for interaction amongpatients.Some groups are less rigidly organized and/or psychodynamically oriented; others aremore structured, based on behavioral-cognitiveprinciples. Kehoe (58, 59) has been a pioneer inthe field, having run such a group for decades.This activity consists in weekly sessions involvingten to twelve patients for two to three yearsin general. The groups aim to foster tolerance,self-awareness, and nonpathological therapeuticexploration of a value system. Each new memberis asked to describe his or her religious/spiritualquest. Then, through interactions with peers,patients are given an opportunity to consider