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The first thing to say about this book is that it is not a book that one sits down and reads from cover to cover. It is a book to dip into or to use as a resource when looking at the whole area of spirituality and mental health. The aim of the book is to try and delineate psychiatric disorders from spirituality. As the editors write in their introduction, "As the commentaries to the chapters make clear, the challenge of incorporating religious and spiritual considerations into an increasingly evidence-based DSM is an iterative process...A DSM that more fully incorporates these ideas could help clinicians recognize their importance to the ways that patients understand and approach their emotional difficulties... finally it could locate the diagnostic categories of contemporary Western psychiatry within a larger historical, philosophical, and cultural context" (p.xix)
And, already, the introduction points to one of the difficulties inherent in contemporary psychiatry. Namely its Positivist agenda-which defines terms like "Evidence based practice" in strictly "scientific" rationalist terms. One of the discussions I often have with my student nurses is why the Pope is not in a psychiatric hospital. They point out that he hears the voice of God talking to him; believes that when he speaks, God is speaking through him. That as a consequence of this he is possessed of an infallible authority and his words have supernatural weight. Despite being a German he believes himself to be in a direct line of decent from a Jewish fisherman some 200 years ago. And far from being a detained patient in a psychiatric unit, he leads a church of some 1.16 billion individuals. Similarities between these ideas and those of many a delusional patient in hospital are often pointed out by these students This leads to some interesting discussions about "meaning"; about who makes "the rules "and who sets the "evidence". (It soon becomes apparent that something more than simple diagnostic categories are involved in making judgments about somebody's mental health.)
This problem of diagnosis is explored most fully in the final section of this book. (This seems an odd place for it, considering the centrality of the concepts discussed.) This is the chapter by Fulford and Sadler on "Mapping the Logical Geography of Delusion and Spiritual Experience". And subtitled "A Linguistic-Analytic Research Agenda Covering Problems, Methods, and Outputs". Despite a less than "sexy" title this paper goes to the heart of the material discussed throughout the book. "Psychiatry, as a discipline within scientific medicine, is at best uneasy with the received authority and revealed truths of religion... one man's miracle is another man's medication, as it were, and the burden of deciding between them is carried, from the perspective of psychiatry at least, by psychopathology." (p.230) Or, to return to the earlier example, who makes the decision that the Pope is a divinely inspired , divinely appointed leader or a delusional psychotic? One solution for Fulford and Sadler is to invite philosophers into the consulting room along with the clinicians-and, presumably, the patient. Their task could be to engage in concept analysis. Who determines the meaning of concepts such as "delusions"; "psychosis"; "mental disorder"? This paper is not left hanging in a theoretical metaphysical universe, however. Fulford and Sandler offer an amended list of criteria for assessing whether or not a diagnosis of schizophrenia is valid. Thus DSM-IV-TR's opening statement that "... two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated)..." becomes "... two or more of the following, each present for a clinically significant portion of time..." (p.251author's italics").This small change, they argue, shifts the weight of evidence away from the purely descriptive to the clinically significant. (A small change but one which could have very important implications for clinical work.) And as a reminder that both contributors are clinicians as well they add "The judgment of individual practitioners, therefore, in the more complete view of the logical geography of delusion and spiritual experience, to be had from linguistic-analytic philosophical field work, is not an add-on to applying diagnostic criteria. It is of the essence." (p.250). This essay alone could be distributed as a one-off piece and it would be immensely useful in all branches of mental health work and training. (My students are most certainly going to be presented with the ideas, if not the paper itself.)
Having started this review with the final essay, it will be helpful to discuss the body of the book. It consists of ten main chapters which then comprise an extensive literature review of some aspect of spirituality and mental health. This literature review is then accompanied by two shorter commentaries taking further some aspect of the main chapter. Thus there are chapters on Spirituality and Depression; Schizophrenia and Other Psychotic Disorders; Substance Use Disorders and Spirituality. Also included are essays on Spirituality in Child and Adolescent Psychiatry and Religious and Spiritual Issues in Personality Disorders. One could use the book as "bran tub" and dip into any chapter to find an intriguing fact. Thus "In a study of female breast cancer patients from Croatia, high religiosity was associated with lower frequency of depression but not with the intensity of pain perception." (p.16). Or the studies that found that "In general, measures of participation in organized religion have been more strongly associated with an absence of depression than intrinsic religiosity or participation in a non-organized religion in older adults..." (p.14) Koenig offers some equally intriguing statistics from a trans-cultural perspective in his paper on "Schizophrenia and other Psychotic disorders". In the United States religious delusions are present in about 25% - 39% of patients with schizophrenia ... in Great Britain and Europe, about 21% - 24% of patients with schizophrenia have religious delusions, and in Japan the rate is 7% - 11%."(p.34). This "fact" of course, has to be interpreted in the context of Fulford and Sadler's paper.
One could draw out similar tit bits from the book but perhaps a better image is that of jig saw pieces. Taken at random they have no logical connection. Put together with the rest of the pieces and more sense emerges. And the "sense" seems to be that the relationship between spirituality and mental health is necessarily, ambiguous. For some, religious faith is helpful and nourishing. For others it is persecutory and damaging. (This seems to substantiate what object relations theory suggests about the nature of the inner world.)
Whilst by no means a bedside book nor a devotional tome, "Religious and Spiritual Issues..." is a valuable book for anyone interested in issues of spirituality and mental health ("mental health" as opposed to "mental illness").
© 2011 Terry Burridge
Terry Burridge is a Senior Lecturer in Mental Health Nursing at Buckinghamshire New University. He has spent most of his professional life as a psychiatric nurse and now spends considerable time and energy trying to inspire future psychiatric nurses to be the best kinds of nurses that they can be! He is very much influenced by psychoanalytic thinking and sees analytic theory as offering a valuable critique to many other areas of human activity. He can be contacted at Terry@dancingbears.co.uk