incorporating individual spiritual beliefs in treatment of inpatient mental health consumers

PURPOSE. To promote incorporation of spiritual

beliefs into inpatient crisis psychiatric care.

SOURCES. Published literature, Web resources.

CONCLUSIONS. Individual spiritual resources

appear helpful to the consumer in times of crisis.

Further identification of ways to apply

spirituality, as well as professional standards, is

still needed.

Search terms: Hospitalization and spirituality,

psychiatry and spirituality, spirituality

114 Perspectives in Psychiatric Care Vol. 40, No. 3, July-September, 2004

Darlene McLaughlin, MS, APRN, BC, is a Psychiatric NursePractitioner, Personal Enrichment Through Mental HealthServices, Park, FL, and in private practice with Hector Corzo,MD, Pinellas Park, FL.

It did not seem prudent to allow Mary to repeat theRosary prayer over and over while rubbing her beads.After all, she was in an acute psychotic state, which in-cluded bizarre religious delusions. Wouldn�t allowingthis continuous behavior be adding to her delusionalprocesses? This sort of question plagues the novice aswell as the expert mental health practitioner when itcomes to spirituality and individualized care. Spiritual-ity has been defined as �the dimension of a person thatseeks to find meaning in his or her life. It is also thequality that supports connection to and relationshipwith the sacred, as well as with each other� (GeorgeWashington Institute [GWISH], 2002). Many inpatientmental health centers offer little consideration of thespiritual needs of their consumers. Spiritual belief issuesare rarely addressed after the initial intake informationis obtained.

Spirituality infers a sense of well-being. Incorporatingits use with inpatient mental health consumers wouldseem beneficial. For many reasons, this concept haseluded mental health professionals, presumably becauseof the scientific nature of medicine vs. the artistic designof individual spirituality. Science considers truths thatcan be proved true�for example, thorough tests of uni-versality, as in the double-blind study. Truths in spiritu-ality transcend empirical testing and are as individual asDNA. Practitioners must learn to combine both the sci-ence of medicine and art of spirituality to optimize pa-tient outcomes. The benefits of incorporating individualspiritual beliefs and practices in the treatment of inpa-tient mental health consumers are paramount, consider-ing the impact our thought processes and individual be-liefs have on all our decisions. Incorporation of a positivestrength is indeed prudent. This article looks at currenttrends, professional training, and useful practice sugges-tions to help mental health practitioners work with inpa-

Incorporating Individual Spiritual Beliefs inTreatment of Inpatient Mental Health Consumers

Darlene McLaughlin, MS, APRN, BC

tient clients who desire to incorporate their personalspiritual beliefs into treatment.

The Current Reality

In crisis psychiatry, individual spiritual needs areoften overlooked, yet spiritual beliefs are where mostgain their reserve personal strength in times of crisis.D�Souza (2002) completed a study on mental health con-sumers and found that 67% felt their spirituality helpedthem cope with psychiatric issues. Recent research (Lar-son, 2002) found that those reporting a religious re-sponse to the question �How do you cope with stress?�were likely to have a significantly shorter length of hos-pital stay than those with any other response. Those re-quiring inpatient mental health care are certainly in needof all available personal resources, and spirituality is oneimportant consideration.

This available resource is often not addressed in theinitial evaluation. Generally, once hospitalized, a pa-tient is evaluated by the practitioner, and an appropri-ate DSM-IV (APA, 1994) diagnosis is assigned depend-ing on the presentation symptomology, circumstancesof admission, and history. An evidenced-based ap-proach determines which medication and/or short-term cognitive therapy approach is deemed necessaryto correct the acute stressor(s). The treatment plan oftenoverlooks a very important factor�spiritual well-being.

Risk for spiritual distress is a NANDA-approved diag-nosis (NANDA, 2003). It is defined as �At risk for an al-tered sense of harmonious connectedness with all of lifeand the universe in which dimensions that transcendand empower the self may be disrupted� (p. 179). Somerisk factors identified include physical and mental stress,illness, losses, poor relationships, substance abuse, andpoor self-esteem. NANDA�s definition would indicatemost hospitalized patients are at risk for some degree ofspiritual distress. The Joint Commission on Accreditationof Healthcare Organizations (JCAHO, 2001) states that a�spiritual assessment should, at a minimum, determinethe patient�s denomination, beliefs, and what spiritualpractices are important to the patient.� JCAHO also of-

Perspectives in Psychiatric Care Vol. 40, No. 3, July-September, 2004 115

fers questions that could be directed to the patient orhis/her family: for example, �Who or what provides thepatient with strength or hope?� The answer to this ques-tion, if posed, could facilitate a more individualizedtreatment plan.

There is increasing evidence (Baetz, Larson, Mar-coux, Bowen, & Griffin, 2002) that spirituality/spiri-tual practices enhance one�s mental health in areassuch as feelings of depression, length of inpatientstays, satisfaction with life, and substance abuse.Koenig, Larson, and Weaver (1998) found, in a sampleof 455 older patients, that those who attended churchat least once a week were less likely in the previousyear to have been hospitalized. The researchers alsoconcluded that older adults who attend religious ser-vices at least once per week were hospitalized on theaverage of 11 days per year compared with 25 daysper year for the unaffiliated.

Spiritual beliefs are where most gain their

reserve personal strength in times of crisis.

Spirituality also appears to be beneficial with men-tal health consumers with substance abuse issues.Carter (1998) studied the importance of spiritual prac-tices in relation to recovery from substance abuse.Two cohorts were compared, one with alcoholics withmore than 1 year of sobriety and one with less than 1year of sobriety. A questionnaire based on the valuesstressed in 12-step recovery programs assessed spiri-tual beliefs and practices. This study concluded thatindividuals with more spiritual practices had fewerrelapses and longer-term sobriety. It should be notedthat embracing spiritual beliefs alone was not enough.Participation in spiritual practices was shown to en-hance recovery and offer early interventions that mayhelp prevent relapse.

Incorporating Individual Spiritual Beliefs in Treatment of Inpatient Mental HealthConsumers

Empirical Evidence

Recently, original research examined levels of spiritu-ality and religiousness among psychiatric inpatients(Baetz et al., 2002). Results showed religious commit-ment had a significant impact on reducing depressionand hospital use, and an increase in life satisfaction. Cor-relations significantly lent themselves to a decrease inpathological behaviors and an increase in life satisfactionamong those who utilized spiritual and religious re-sources routinely.

The importance of including spiritual issues intomedicine, and specifically psychiatry, has been the focusof many studies. D�Souza (2002) sought to determine howmental health consumers viewed their spirituality andhow important it is in their treatment. A significant num-ber of participants indicated that spirituality is important;82% believing their therapists should have knowledge re-garding their beliefs. In addition, 69% felt their spiritualbeliefs should be addressed in developing a treatmentplan. These results provide strong evidence that mentalhealth consumers have a desire for and would likely bene-fit from inclusion of spirituality in their care.

To fully address issues related to

spirituality, healthcare practitioners must

take a more open approach to care.

A recent survey research of more than 400 inpatientsparticipating at a Los Angeles county mental health facil-ity had similar results. Tepper, Rogers, Coleman, andMaloney (2001) reported that more than 80% of respon-dents used religious beliefs or activities daily in order tocope. The findings also showed that increased religiousactivity appears to be associated with reduced psychi-atric symptoms. It has become evident that utilization of


patients� innermost resource, their spiritual beliefs, pro-motes positive patient outcomes, including decreasedlength of stay and overall patient satisfaction (Tepper etal.). Benor, a medical doctor and consultant for WholisticHealing Research, specializing in spiritual psychother-apy, believes strongly that individualized treatmentmust match the therapy to the needs and personality ofeach person, couple, and family (Benor, 2000). He de-scribes current therapy practices as a vicious circle, oftenfocusing primarily on traumas, pains, and fears. He be-lieves that by discerning the positive aspects of an indi-vidual�s life from the negative, one can begin to discardthe negative, focus on the positive, and find �joy andpeace in your life� (p. 2).

To fully address issues related to spirituality, health-care practitioners must take a more open approach tocare. Considering the consumer�s individual wishes ineach treatment decision is imperative. Greasley, Chiu,and Gartland (2000) completed a study on mental healthconsumers and nurses to help clarify the concept of spiri-tuality in mental health nursing. The results revealedsome variations on how the groups viewed spiritualneeds in relation to personal well-being. The nurses indi-cated self-fulfillment and an opportunity to be produc-tive as important factors, whereas the consumers placedmore importance on inner peace, emotional well-being,and hope. These differences may be a contributing factoras to why spiritual needs are often not addressed. Inorder to effectively care for mental health consumers, ef-fort must be made to incorporate spiritual beliefs andpractices into their care, since the research shows theyprovide comfort and support during a crisis.

Educational Strategies for Incorporating SpiritualityInto Care

Staff and practitioner training is one way to aid in thepromotion of individual spiritual treatment planning.The Medical University of South Carolina (MUSC) offersstudents a curriculum that includes a comprehensive�Spirituality and Medicine� program. The course outlinerecognizes the need for increased spiritual awareness,

citing �The clinician�s ability to discern a patient�s spiri-tual values, personal meanings and vital connections,and to respect and enhance these spiritual dimensions inthe care of the patient, may vastly increase therapeuticbenefit� (MUSC, 2002, p. 2). MUSC�s core curriculum in-volves spirituality training during medical schoolthrough various classes and workshops. One class listsobjectives that include integration of an awareness of theimportance of a patient�s beliefs, values, religion, andspiritual practices in the actual care of patients.

The George Washington Institute for Spirituality andHealth (2002) proposes specific changes in health care thatbegin with practitioners and their outlook toward spiri-tual-based care. One goal listed for training included rec-ognizing and accepting the individual�s role with not onlyphysical, emotional, and social areas, but also the spiritualaspects of their patients� lives (GWISH). This organizationalso suggests that clinicians address spiritual beliefs aspart of routine history. A collaboration with clergy andother spiritual providers also was recommended. GWISHalso gives note to the importance of clinicians being intouch with their own spirituality, as to better understandhow it plays a role in their patients� lives.

Coyle (2001), director of psychiatry residency trainingat East Tennessee State University, stated that a large per-centage of the population is expectant of a spiritual com-ponent to their treatment. Questions no longer focus onwhether people are interested in spirituality-based carebut on how to meet the need that clearly exists. When apractitioner participates in patients� examinations of theirlife purpose, as is often done in inpatient crisis psychiatry,they may be helping to infuse a sense of importance, self-worth, and inner value, hence a sense of spirituality. Per-sonal insight, acceptance, and satisfaction will lead theconsumer to a more positive outlook, which will invari-ably increase the likelihood of a positive treatment out-come. Spirituality appears integrated with life crises.

Application

Promotion of patients� health must begin with the �dono harm� approach. Safety and common sense should


guide all decisions regarding the allowances of personalspiritual practices. Overt religious delusions that may in-volve potential harm to the patient or another should bediscouraged through reality orientation as warranted. Be-nign religious practices (e.g., continuous prayer) that ap-pear to offer relief and/or comfort should be promoted.Each case should be evaluated individually as eventscommence for safety and promotion of patients� positiveoutcome. Practitioners should ask questions regardingspiritual history to facilitate patients� individualized care.GWISH (2002) identifies itself as a �leading organizationon educational and clinical issues related to spiritualityand health.� The director of this institute, Christina M.Puchalski, developed a spiritual history tool called FICA(Table 1), an acronym designed to help practitionersstructure questions when taking a spiritual history. TheHOPE approach (Anandarajah & Hight, 2001) is anotherexample of a spiritual assessment tool developed to helppractitioners take a spiritual history (Table 2).

Direct therapy-related interventions should be cogni-tive in nature and focus on positive, future, and goal-ori-ented directions. This helps remove the negative correla-tive from past experiences and refocuses from currentstressor of decompensation to helping promote hope forthe future. For example, an involuntarily admitted pa-tient who recently lost custody of his or her children

Table 1. FICA

F is for questions of faith. Some examples of questions to askwould include the following: Do you consider yourself aspiritual person? What gives your life meaning?

I represents the importance of this resource in the client�slife. Assessment questions might include, how often doyou attend worship services? Do your beliefs largely influence your decisions with regards to your medicalpractices.

C is for community. Are you actively involved with a churchcommunity, and do you use this as a support?

A is for the practitioner to address these concerns with thepatient, such as to ask, how would you like me to addressthese issues in your health care?

Incorporating Individual Spiritual Beliefs in Treatment of Inpatient Mental HealthConsumers


ing reality orientation, would be initiated. Will this pro-mote the best likely outcome for Mary? In Mary�s case,spiritual history information had been obtained and thetreatment team was aware of her strong Catholic beliefsystem.

Being aware of her spiritual orientation, the staff ob-tained a more positive response when they opted not toremove the stimulus as it appeared to offer some com-fort; instead, they sat with her and encouraged her to dodeep-breathing techniques between prayers. After sev-eral prompts, Mary started to breathe deeply in betweenprayers. Within 3 to 5 minutes she began to relax andgive up a pathological focus on her behavior. After stabi-lization and discharge, Mary was questioned as to howshe felt the situation had been handled; she expressed ahigh degree of satisfaction with the staff�s interventions.Specifically, she said that if the staff had chosen to re-move the beads, she believed it would only have rein-forced her delusions of evil spirits and served to de-crease her trust in the staff for disregarding her beliefs.Mary also noted the creative way the staff engaged herin relaxation behaviors. During this inpatient stay,Mary�s time needed for stabilization of her symptomswas decreased by 2 days from her previous stays, takingonly 4 days compared with her average stay of 6 days.

In another example, a woman came to the hospitalwishing to pray and fast because voices instructed her todo so. The treatment team decided to allow this as longas she drank water. After 1 week, she was �cured� andappeared quite normal. One year later, she reappearedwith a similar scenario. Again she recovered without in-cident and without medication intervention. Her behav-ior was quite normal throughout the rest of the year, andthe staff questioned her diagnosis. Did she have a mentalillness or was she just experiencing some form of spiri-tual distress?

Conclusion

Psychiatry has evolved enormously in the last 50years. The invention of psychotropic medicines and theadvancements in therapeutic techniques have had a

would likely be devastated by such a personal loss andbe inclined to focus on this, only worsening the patient�scondition. The practitioner�s focus at this stage is to helpthe patient bring his/her loss into perspective throughimmediate grief counseling and, dependent on the his-tory or severity, antidepressant agents may be indicated.This would be a time one might want to access spiritualresources and should be encouraged to do so. Followingthe initial grief period, the practitioner would help thepatient shift focus to things he/she could do now and inthe future. Directing the focus to goal-oriented behaviorspromotes drive and satisfaction. Individual practitionerpractices vary greatly, dependent on their choice of ther-apy styles, and each must seek his/her own ways to in-corporate spirituality into practice. By doing this, practi-tioners can help patients identify strengths, beliefs, andpractices that are essential to health and well-being.

Case Studies

Mary sat on the inpatient unit, rocking back and forth,rubbing her beads while continuously repeating theRosary prayer. She was in an acute psychotic state,which included overt religious delusions that she wassent to the inpatient facility to �thwart off evil spirits.�Should the staff take away Mary�s beads and engage herin reality orientation? or should they allow her to con-tinue, and just monitor? Today�s practice standardsprobably would recommend removal of what appearedto be the stimulus and/or aggravator�in this case, herbeads. Engagement in therapeutic conversation, includ-

Table 2. HOPE

H addresses spiritual resources such as hope, without directfocus on religion or spirituality.

O represents importance of organized religion in their lives;the spiritual door is open.

P represents inquiry with regards to personal practices.E is to remind the practitioner to work with the patient to

discuss end-of-life issues, such as living wills.

significant positive impact on mental health care.Much remains to be done to continuously improve thequality of treatment available to inpatient mentalhealth consumers. Additional studies are needed to ex-amine the impact of various religious practices andtheir effects on consumers� care and outcomes. Furtheroutcome studies that indicate a reduction in treatmentcost would certainly make spirituality more popular inthe private sector. Practitioners are obligated to contin-uously work toward optimizing care available, withthe consumers� spiritual needs being considered. Whilewe await formal standards for spirituality to be identi-fied for each discipline of practice, we can begin to af-fect patients individually by allowing the safe use ofindividual spiritual resources when to do so would notinfringe on another.

Author contact: [email protected], with a copy tothe Editor: [email protected]

References

Anandarajah, G., & Hight, E. (2001). Spirituality and medical practice:Using the HOPE questions as a practical tool for spiritual assess-ment. American Family Physician. Retrieved October 20, 2002, fromwww.aafp.org/afp/20010101/81.html

American Psychiatric Association. (1994). Diagnostic and statistical man-ual of mental disorders (4th ed.). Washington, DC: Author.

Baetz, M., Larson, D., Marcoux, G., Bowen, R., & Griffin, R. (2002).Canadian psychiatric inpatient religious commitment: An associa-tion with mental health. Canadian Journal of Psychiatry, 47, 159�166.

Benor, D. (2000). You deserve individualized treatment. Retrieved October6, 2002, from www.wholistichealingresearch.com/consultations/clinicalconsult.htm

Carter, T.M. (1998). The effects of spiritual practices on recovery fromsubstance abuse. Journal of Psychiatric and Mental Health Nursing, 5,409�413.

Coyle, B.R. (2001). Twelve myths of religion and psychiatry: Lessonsfor training psychiatrists in spiritually sensitive treatments. MentalHealth, Religion and Culture, 4, 149�174.

D�Souza, R. (2002). Do patients expect psychiatrists to be interested inspiritual issues?. Australasian Psychiatry, 10(1), 44�47.


George Washington Institute for Spirituality and Health. (2002).GWISH vision. Retrieved November 24, 2002, from www.gwish.org/id64_m.htm

Greasley, P., Chiu, L.F., & Gartland, M. (2000). The concept of spiritualcare in mental health nursing. Journal of Advanced Nursing, 33,629�637.

Joint Commission on Accreditation of Healthcare Organizations. (2001,July 31). Does the Joint Commission specify what needs to be included in aspiritual assessment?. Retrieved September 5, 2003, from www.jcaho.org/accredited+organizations/hospitals/standards/hospital+faqs/provision+of+care/assessment/spiritual+assessment.htm

Koenig, H., Larson, D., & Weaver, A. (1998). Research on religion andserious mental illness. New Directions for Mental Health Services,80(4), 81�95.

Larson, S. (2002). Religious coping may reduce hospital stays for psy-chiatric patients. International Center for the Integration of Health andSpirituality. Retrieved November 24, 2002, from www.nihr.org/pro-grams/researchreports/web/november02.cfm

Medical University of South Carolina. (2002). Integrated spirituality andmedicine curriculum at MUSC. Retrieved October 9, 2002, fromwww.musc.edu/dfm/spirituality.htm

NANDA International. (2003). NANDA Nursing diagnoses: Definitions &classification 2003�2004. Philadelphia: Author.

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