A growing body of research attests to the importance of religious beliefs and spiritual practices in coping with life-threatening illnesses, depression, and anxiety, among other conditions. However, only a few studies have focused on religious beliefs and spiritual practices of chronic psychiatric patients (1,2,3,4). Koenig and associates (5) and Worthington and colleagues (6) have noted that for the most part the religious beliefs of this population have been ignored in treatment and research.
Among chronic psychiatric patients, religion has all too often been viewed as a symptom of mental illness, something pathological. But ignoring this area in treatment deprives patients with chronic psychiatric disabilities of the opportunity to reflect on the meaning of their suffering, to use their religious beliefs or spiritual practices as a means of coping with their illness, or to consider ways in which their beliefs might add to their suffering.
Eighteen years ago I consulted with a therapist in a day treatment program concerning a therapeutic impasse. The client, a staunch Lutheran, was trying to convert his Jewish therapist to Christianity. Neither conversion nor therapy was occurring. Although this conflict was related to the client's psychological issues, it raised the question of how to work with religious material in ways that did not simply pathologize it. After the consultation, a staff member at the day treatment facility noted that "many of the patients talk about religious things, but we generally ignore them because we don't know what to do with them."
My suggestion to have a group focused on religious issues was accepted by the staff. I believed that the group would be therapeutic rather than pathogenic. When the group first began, several questions were raised: Would the discussion of religious and spiritual material foster a person's delusional ideation? Would such discussion strengthen a person's defenses and be counterproductive to treatment? How would the patients tolerate diverse systems of beliefs? What difference, if any, would participation in such a group make?
In this paper, I describe the experience of 18 years of conducting group therapy focusing on religious issues with chronic psychiatric patients. Additional description of the group therapy appears elsewhere (7).
Introducing the group to patients and staff members
A group for chronically ill psychiatric patients focused on spiritual beliefs and values was started in 1981 in a day treatment program. It has been meeting once a week for 45 minutes for the past 18 years. The group is introduced to patients as a place where they can consider their religious beliefs and traditions, as well as questions, problems, and feelings about their beliefs. The group is described as an opportunity for members to explore ways in which their beliefs and practices help or hinder them in coping with mental illness.
Membership is voluntary, and participants in the day treatment program may choose to attend other scheduled groups. Over the years, the rate of attendance has been consistently high. On average, about a third of clients attending the day treatment program choose to participate in the group. Although those who join the group are asked to make a commitment, a client may leave the group at any time after consultation with his or her case administrator and a meeting with the group to explain the reason for leaving. The most common reason for leaving is that the person feels he or she needs another group more. A person may rejoin at any time. A few members have left because they found participation too stressful.
Typically, about ten to 12 clients attend a session, and a typical client attends the group for two to three years or longer, with participation ranging from four months to six years. The group is co-led by myself and one of the staff members. Group members know that I am a nun and a psychologist, but staff members' religious affiliation or tradition is generally not known.
At first, the idea of having such a group generated anxiety, fear, and doubt among staff members. It brought out the ambivalence that many mental health professionals have about religious issues, an ambivalence reflected in Gallup poll findings (8). In addition, Bergin and Jensen's work (9) has highlighted the marked difference between the religious beliefs and practices of the general population and those of the mental health professionals.
Staff training and instruction alleviated some concerns. However, the long-term success of the group has been the strongest factor in staff acceptance. Group rules contributing to its success are tolerance of diversity, respect of others' beliefs, and a ban on proselytizing. Another factor is that membership is open to all, regardless of religious background or diagnosis.
Over the years both men and women have participated in the group, and ages have ranged between 22 and 60 years. Group members have belonged to many religious traditions or spiritual paths, including Roman Catholic, Episcopal, Methodist, Lutheran, Muslim, Buddhist, Jewish, Christian fundamentalist, and Baptist. Some have been agnostics or atheists.
Each member is initially asked to describe his or her current religious tradition or spiritual quest, as well as how it may have changed over time. Beliefs, values, and spiritual concerns are not accepted unquestioningly. Patients are encouraged to be willing to consider questions, rather than to react with anger or with a Biblical quote. This approach helps the group understand how people are using their beliefs. Religion and spirituality are seen as areas to explore rather than "crutches" to be outgrown.
The following material from a group meeting exemplifies group interactions. The background for this discussion is that Mr. A interprets Scripture literally, which he recognizes as part of his illness. Ms. B, another group member, believes in a more pantheistic God, and she has a hard time accepting the idea of a personal God. After months of being a silent member of the group, Mr. C began to talk about his anger at God because he has a mental illness, and Mr. D also joined the discussion. Members of this particular group are Catholic, Jewish, Buddhist, and Protestant.
Mr. A: I can't use Scripture. It gets too confusing for me. There are too many contradictions, and it messes me up. I am just trying to pray, to relate to Jesus in my own way, like you say, Burt [Mr. C].
Mr. C: That is what I do. This is the only group I say this in, but I am finding Jesus in my heart and in my life, that I am content. And you know that I haven't always felt that way. I have been very angry at God. But I know that this is really helping me. I am not going around telling other people what they should believe but I know it's helping me. I don't think God wants us to be telling everyone about religion all the time or always talking Jesus, but to be good, to treat people right.
Mr. D: That's inspiring, Burt.
Mr. A: That's true, Burt. You don't tell people. You respect them.
Mr. C: I think each person has to find his own path—to be true to his own inner search.
Ms. B: It's about finding your own way.
Mr. A: You know, there's a minister around here who says that Jesus wants the spirit of the law, not the letter of the law, that you have to look at the big picture, that what Jesus was about was compassion, kindness, and service.
Group leader: Like the Buddha.
Although the content of this example focuses more on the Christian religion than the group often does, it reflects some of the initial concerns staff members expressed about the group. However, Mr. A's obsessiveness was not encouraged. Diversity was tolerated and valued, and no particular belief was imposed.
Years of experience have shown me and other staff members involved in the group that concerns about negative effects of the group were not borne out. No transcript of the group's interactions can capture the level of trust that has developed in the group over the years and the ability of the members to reflect continually on the meaning of their beliefs and to learn from each other. By focusing on the meaning of a person's beliefs, not on the value of a belief or judgments about a belief, religious content can be coherently dealt with in a heterogeneous group—therapeutically, not pathogenically. In the course of 18 years, no member has ever become delusional during the group.
A group focused on religious issues can provide even seriously mentally ill persons with an opportunity to explore issues usually scanted by mainstream mental health practice. Properly guided in nonjudgmental and nonproselytizing directions, such a group provides valuable therapeutic experiences in tolerance, acceptance of other's views, and thoughtful examination of belief systems, as well as opportunities to apply spirituality and values to life questions. Negative effects occur rarely and may be put to therapeutic use. Delusions are not exacerbated, and defenses are not strengthened. In fact, group interactions reveal that individuals are more than their mental illness and that a neglected aspect of mental life can be fostered as a strength to the benefit of the individual and the milieu.
Dr. Kehoe is instructor in psychology in the department of psychiatry at Cambridge Health Alliance and Harvard Medical School, 113 Belmont Street, Belmont, Massachusetts 02178 (e-mail, email@example.com).