By Deborah Ann Forstner, MA, BCC
When people are in acute phases of mental illness, they may feel cut off from God. They might experience an inability to pray, even if this is a practice that has helped them in the past. They may experience spiritual delusions or feel compulsively unforgivable. They may be unable to find a sense of hope. To address these concerns, a spiritual assessment process, developed by two physicians, was implemented on a trial basis at a Community Support Program (CSP) in St. Cloud, MN. The project focused on the CSP's Mental Health Practitioners using the interview tool with clients who are living with mental illness.
I requested feedback from the practitioners and the program director regarding their experiences with the spiritual assessment process, and also in regard to its potential for continuing use when working with clients through their challenges beyond this study. I proposed that a conversation around spirituality would help clients/patients uncover their spiritual resources, and that there would be much we could learn from each other. My claim was that spiritual assessment would make outreach and ministry to those living with mental illness more holistic and effective.
There are many areas of stigma faced by people with mental illness related to spirituality. Some might believe that experiencing mental illness is a sign of weakness or character flaws, rather than an illness. Others may agree with the medical community that it is a brain disorder/chemical illness, but believe one should just wait until medication or other physical treatment becomes effective rather than entering into spiritual dialogue when a person is experiencing symptoms. Some in community settings (such as psychotherapy clinics or hospitals) may feel it is inappropriate to bring up spirituality due to the separation of church and state. And finally, some ministers may be uncomfortable with people experiencing mental health illness, due to a lack of knowledge or a desire to not interfere with other aspects of treatment.
At the same time, it has been demonstrated that there have been people with mental illness who, by unpacking their spiritual experiences and concerns, have made contributions to both themselves and the church. A significant example of this can be found in the life of Anton Boisen, founder of the Clinical Pastoral Education movement. Mr. Boisen viewed times of mental illness and religious crises as similar. Addressing problems psychiatrically and pastorally can lead to a turning point in the mentally ill person's life. Mr. Boisen lived this concept first hand, as he experienced psychotic episodes with a diagnosis of schizophrenia. Reflections upon his experiences resulted in Mr. Boisen becoming a leader in religion and mental health.
There sometimes does seem to be a fine line drawn between what can be a beautiful spiritual insight, and what can be delusional and destructive to a person's ability to function. While seeing visions and hearing voices are often associated today with schizophrenia, a saint and doctor of the Catholic Church who experienced visions and inner voices was Teresa of Avila (1515-1582). At around age 39, Teresa's visions and experiences began, and they were a source of embarrassment, confusion, and shame for her. Indeed, the Oxford Dictionary of Saints notes, “she was helped by both Dominican and Jesuit directors, but unfortunately her visions and other experiences became known through indiscretion and led to much misunderstanding, ridicule, and even persecution.” Some thought her visions were from the devil, but others believed that they were a gift from God.
St. Therese of Lisieux, at one point in her autobiography, translated to English by Ronald Knox in 1958, describes herself as “a mass of scruples” (125). She shared that she would tell her many worries to her sister Marie, and noted that “even my confessor didn't know I suffered from this distressing complaint, because I only mentioned to him the sins Marie had told me I might confess; you'd have thought I hadn't a scruple in the world, when in reality I was as bad as I could be” (120). In Therese's spiritual journey, she comes to free herself from scruples through the concepts of her “Little Way,” through which she proclaimed her vocation to be love and she learned to find joy in doing small acts of kindness. Rather than the trap of being a frightened and compulsive child, her lived spirituality, which she documented in her writing, moved to a deep knowledge of God's deep, tender mercy. Teaching people with obsessive compulsive disorder and excessive scrupulosity about “The Little Way,” through the example of St. Therese's life and writing, could be a helpful pastoral intervention.
In “When Saints Sing the Blues,” author Brenda Poinsett agrees that depression is a medical condition, but adds that “to define depression as strictly a chemical or medical problem ignores the fact that we are more than physical creatures. We are also spiritual, mental, emotional, and social creatures. Depression can enter our lives in any one of these areas, fan out, and affect other areas” (15).
By exploring the spiritual area, focus can be given to what gives life meaning, and a person's beliefs can be illuminated. Community support programs, such as Catholic social service agencies, hospital programs, and outreach through parish communities, can help a person in the process of lighting his or her way through spiritual conversations.
Through a review of literature, I found the HOPE spiritual assessment, which was published in American Family Physician (Jan. 1, 2001). Authors Anandarajah and Hight state that spiritual assessment is important for a variety of reasons, citing studies that suggest “positive correlation between a patient's spirituality or religious commitment and health outcomes” noting that “patients would like physicians to consider these factors in their medical care” (81). While Doctors Anandarajah and Hight state that there are many possible frameworks for both informal and formal spiritual assessment, they developed the HOPE questions as a tool for teaching medical students and physicians how to incorporate spiritually related questions into their patient interviews.
While they note the questions have not been studied for validity through research, they view their approach as an opportunity to explore, in an open-ended way, inner spiritual resources, concerns, and support systems. The HOPE assessment is the framework that I chose to use, with slight adaptation for focus upon people living with mental illness, in a pilot project associated with this study. A copy of the adapted HOPE spiritual assessment can be found in Appendix A. The basic flow of the questions is around the HOPE mnemonic, as follows:
H - Sources of hope, meaning, comfort, connection
O - Organized religion
P – Personal spirituality and practices
E – Effects on care
Catholic Charities for the Diocese of St. Cloud, MN, has a program called Hope Community Support Program. Hope's client outreach is for people diagnosed with serious and persistent mental illness. There are a variety of ways in which clients access Hope's services, including drop-in visits to the center during its open hours, scheduled appointments at the center, and home visits by the practitioners. Group therapeutic support and recreational opportunities are also offered.
The services of Catholic Charities and Hope Community Support Program are open to people of all faith traditions, and to those not affiliated with any religious faith. Sue Hanks, director of Hope, shared at a meeting in February 2011 that there were no specific spiritual assessment processes in place for clients at that time. With Ms. Hanks’ support of a vision for holistic treatment of clients, she scheduled time for me to present the HOPE spiritual assessment tool with her staff. She told the staff that as employees of Catholic Charities, they were in unique positions of not needing to discuss spirituality or religion with clients, but that this was an avenue open to explore. She encouraged the mental health practitioners to consider trying the HOPE assessment tool with clients –both with those they thought would be open to it, and with those they might guess would not be. Either way, the feedback obtained from trying to open up the conversation would be helpful toward a better understanding of their clients, and for the purposes of this study.
In March 2011, I presented to staff at Hope Community Support Center. I began talking about the rationale and importance of discussions about spirituality for people with mental illness. I referred to the work of Sister Nancy Kehoe (2009) and her spirituality and values groups that were held in a setting similar to Hope. We went through the content of the HOPE questions, encouraging staff members to use their clinical skills to modify the wording or to flow along with their clients' responses. One staff member who leads a weekly group asked if this was something that could be used in that setting. I highly encouraged that idea. This group leader shared her observation that when members of the group say something about spirituality/religion, they often look to the leader as if they are wondering, “Is that OK?” Therefore, she said she welcomed the idea of trying out the tool. Another worker asked if they could tell clients that this is for research, since the topic and process would be so different from anything discussed before. The agency director replied that use of the tool would be akin to staff members attending workshops and deciding to use information provided there with clients. I noted that if the research project was mentioned to clients, they would need to be assured of their total confidentiality, and that the focus of the research was the usefulness of the process rather than data about the clients' beliefs.
In April 2011, I again attended a HOPE staff meeting. The first activity was for staff to complete an anonymous written survey (see Appendix B for that survey and results). Data from 12 mental health practitioners was available. The responses show that nine practitioners responded that they used the spiritual assessment tool. Of the two who said “no” and the one who did not check “yes” or “no,” their comments were that it had either been used informally, in a modified form, or resulted in the practitioner being motivated to talk to clients about spirituality without using the format. I viewed this as total participation, since my perspective on the spiritual assessment process was that it could and should flow in a conversational, informal style; the questions could be modified; and the main goal was for people to have an opportunity to be questioned and listened to in regard to their spirituality. One suggestion was to make the items less open-ended, as a worker noted that it allowed clients to go on and on. I took this as a positive indicator regarding the importance of the topic. If clients would give long responses to the HOPE questions, there seems to be a confirmed need to explore spirituality in conversation with another. Overall, 10 of 12 respondents replied that they thought spiritual assessment/structured conversation should be part of the services offered through Hope Community Support Program, and two were undecided.
After the anonymous survey, the group held an open discussion of questions I presented to them in a handout. Several positive comments were given in response to their experience with the questions of the HOPE spiritual assessment. One worker stated that she was surprised at how much of a response she received, adding that spirituality was an area she had not asked about before. Another worker found approximately one-half of her clients seemed interested and open, and the other half did not. She cited privacy as a reason some did not feel comfortable sharing. In the Depression/Bipolar Support Group, the co-leaders found that members were open and wanted to talk about the topic. In just presenting the first question, it seemed that the dynamics of the group brought out answers and discussion. One worker noted that the clients with whom he used the tool seemed to want to talk about the effects on care first, including the impact their mental illness had upon their access to attending church and practicing their spirituality, with issues such as lack of transportation and human support. After discussing those concerns, they were comfortable with addressing questions that were listed earlier on the assessment tool.
It is the hope of this author that use of spiritual assessment/ dialogue by chaplains and others who minister to people with mental illness might be enhanced through the guidance of utilizing the HOPE format.
Deborah Ann Forstner is a school psychologist who works for District 742 Schools in St. Cloud, MN. She received a master’s degree in pastoral ministry from St. John's School of Theology in Collegeville, MN, in May 2011. This research was completed as part of the requirements for that degree. Ms. Forstner said she is indebted to Hope Community Support Program in the Diocese of St. Cloud and to Dr. Jeff Kaster, her faculty advisor, for their support and guidance.
Anandarajah G., & Hight. E. (2001). Spirituality and medical practice: Using the HOPE questions as a practical tool for spiritual assessment.
American Family Physician 63 (1), 81-88.
Kehoe, N.C. (2009). Wrestling with our angels: Faith, mental illness, and the journey to wholeness. San Francisco, CA: Jossey-Bass.
Knox, R. (trans. 1958). Autobiography of St. Therese of Lisieux. New York: P.J. Kenedy and Sons.
Oxford Dictionary of Saints http://www.answers.com/topic/teresa-of-avila (accessed 3/10/2011).
Poinsett, B. (2006). When saints sing the blues: Understanding depression through the lives of Job, Naomi, Paul, and others. Grand Rapids, MI: Baker Books.
Submitted by Gene Hausmann, D.Min. on January 9 2012 at 12:11 pm: