Spirituality and Religiosity in Mental Health Patients: A Major Roadblock in Healthcare
“Spirituality is a quest for the meaning in life.” It is something that connects you with something bigger than yourself (Verghese 2008,). Too much of a good thing, can turn something pleasant into unpleasant because you had too much of it – Shakespeare. Spirituality and Religiousness in mental illness have been of great importance since decades.
Some patients may unconsciously use religion to manipulate and control certain psychologically vulnerable issues as a part of their illness (Reeves, Beazley & Adams, 2011). Consequently, this proves to be a major challenge for Health care providers (HCPs) to differentiate the patient’s psychotic religious delusions from their spiritual experiences.
A study was conducted in United States, revealing that 60% of patients with schizophrenia had religious grandiose delusions believing themselves to be God, Prophet or as possessors of some super natural powers. About 30-50% of patients had diminished insight about their mental disorder (Evan, Miles & Bruce, 2016).
Cultural and value conflicts between the patient and his healthcare provider (HCP) are likely to occur under such circumstances. According to Mehraby (2009), one of the major predisposing factors to mental illness are the cultural and spiritual beliefs imposing adverse effects on a patient’s healing.
Spirituality in mental health has significantly been used as a measure of therapeutic healing. The other sides of the coin have always been neglected. Thus, the reason for choosing this topic is the enormous socio-cultural-spiritual beliefs about mental illness. In the western world, mental illness is considered as a possession by demons or evil spirit.
This even led them to get locked up, chained, beaten and isolated from the society. In Muslim culture, psychiatric illness is viewed as a holy message from God, or a religious awakening. Indian and Buddhist cultures believe mental illness as a punishment for their misdeeds in one’s previous life (Karma). Subsequently, this brings indignity and disgrace for the sufferers in the society (Mehraby, 2016).
Religious healers (Sufi) play a powerful role in the Pakistani society. Rather than going to HCPs, people often turn to Sufis. Families and societies portray respect and faith towards them. Sufi saints are effective healers who tend to withhold therapeutic treatment, for psychotic disorders irrespective of educational backgrounds. In Karachi, there are around 400 such practitioners.
Low stigma, low cost and easy access makes it a piece of cake. Consequently, it enforces a major effect on a client’s access to mental health services and care. Diseases like diabetes and hypertension were once considered as a stigma, but today awareness among people has eradicated such issues. On the other end, seeking help concerning mental disorders have always been unseen. As a result, people often attach physical or spiritual allusions to mental health (Gadit, 2009).
In my clinical rotation, I encountered a 32 years old female client with Bipolar Affective Disorder. While her mental state exam was being conducted, she said she was a Messiah appointed by God. She perceived herself to be spiritually uplifted, and said that she could hear voices revealing secret messages for her. She assured that the voices are real, and only a person with high powers of God can hear them.
The client forced me to promise not to share her religious information with anyone. However, I convinced her that information pertinent to her health will be shared with my faculty. The client had a history of self-mutilation. She also mentioned about her Religious Healer, “Mawlawi Sahib” who use to heal her in her serious conditions. She used to have regular visit to him. I found multiple challenges pertaining to her spiritual and mental health.
Due to social stigma attached, psychiatric services in hospitals have been poorly offered and utilized by the people in Pakistan. As a result of this, a lot of individuals with psychiatric disorders have reported no use of health services for their illness. Thereof, a vast gap exists between resources available and need for utilization of treatments.
In developed counties about 40%-70% patients don’t receive treatment for mental illnesses whereas in developing countries the gap is even more close to 90% (Afridi, 2016).
Integrating the mentioned case study, we can understand client’s spirituality and religiosity through 3H model presented by Anandarajah (2008). The model comprises of Head (cognitive), Heart (experiential) and Hand (Behavioral). The division of spiritual issues in this model, deals with the cognitive (head) aspect means cognitive appraisal of any situation.
That is to Divine Spirits. Similarly, the client had altered thought process with grandiose acts and religious delusions. She believed that she is a messiah of the God, and that she has a special relationship with God. The experiential (heart) part includes relationship with self and others in community. Steadily, the client believed that others won’t be able to understand her level of spirituality.
As a result, she isolated herself from the society. Finally, the behavioral (hand) concept deals with the outward expressions of spiritual beliefs. This includes maladaptive behavioral responses. Relating it to the case, th
e client was showing hostile, aggressive and paranoid behavior. Hence, the 3H model provides a tool for a HCP to evaluate spiritual issues in their clients.
The client’s firm beliefs were leading to her intense psychotic episodes. According to Freud in his book “The Future of illusions”, Spiritual beliefs in God and rigid religious practices are signs of narcissistic delusions and acts of obsessive neurotics, and that such religious orthodox can result in a destructive life, imposing threats to an individual’s mental health, as cited by Levin, 2010.
This gives us a sight that the client’s threats to health were in the form of self-mutilation, resistance to seek mental care and interpersonal relationship conflicts.
Reffering to the case study following recommendations are helpful at individual, community and institutional level. At individual level a nurse can use CARE framework i.e. Containment, Awareness, Resilience, and Engagement (McAllister & Walsh, 2003). In containment, the nurse provides a therapeutic environment for a client to interact. Development of therapeutic alliance is necessary to avoid cultural conflicts.
Once a trusting relationship is developed a nurse can aware the client and family about maladaptive behavioral responses due to spiritual issues and its consequences. In order to develop an insight, in resilience, the nurse helps the client to develop adaptive behavioral responses. Working on capabilities and inner strengths, the nurse finally engages into holistic care.
Awareness can be raised through the social media by targeting qualified groups like HCPs, conventional and traditional sectors and also by organizing family training programs in the community regarding spiritual beliefs and their impact on mental health. Training Religious Healers and involving Spiritual HCPs in exploring religious delusions may be of great help.
Initiating mental stigma projects and rehabilitation of psychiatric patients in the community will progress the nation as a whole.
The Government should provide career jobs for psychiatrists and improve service structures, especially in underprivileged areas. Mental health policies (2006), the five year plan (2005-10) and legislation (2001) do exist in Pakistan and should however, be revised, maintained and implemented, in compliance with international standards.
To conclude, spirituality is a search for the meaning in life. Over religiosity and spiritual believes can deteriorate an individual’s mental health. A major challenge for an HCP is to distinguish between the client’s psychotic religious delusions and spiritual experiences.
Hence, the application of a 3H model can help in overcoming such challenges. Finally, through application of the CARE framework, organizing awareness programs and implementing policies can help in reducing such issues.
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