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“A Light in the

Darkness:

Spirituality in

those living with

Acute, Chronic,

and Persistent

Mental Illness”

Presented by: Rev. Michael C.

Sibley, M.Div., BCC

Disclosures and Professional

Biases

Objectives Of This Presentation:

– Part 1: A brief history of the treatment of mental illness and factors contributing

to its evolution.

– Part 2: The role of spiritual care within the context of present day psychiatry.

– Part 3: Spiritual and behavioral assessment of psychiatric patients from the

Chaplain’s vantage point.

– Part 4: Theological themes in psychiatric care.

– Part 5: Practical aspects of offering pastoral support to individuals living with

mental illness.

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Part 1

– A brief history of the treatment of mental illness and factors contributing to its

evolution.

The Beginnings of Psychiatry…

– The origins of Psychiatry and Psychology find themselves to go as far back as

ancient humankind in what is referred to as “Paleo-medicine.” (Schneck, 3).

– Paleo-Medicine moves forward with the adding of ritual and the religious

dynamic in “primitive medicine.” (Schneck, 3).

– Primitive humans, as it seems did not make distinctions between physical and

mental illnesses. (Schneck, 3).

– Ritual and the treatment of illnesses largely relied on the cultural and religious

ideas of various tribes and people groups as part of the meaning making

process and attempts to affect change. (Schneck, 6).

The Beginnings of Psychiatry…

– Often, mental illness was thought to fall upon one who broke certain societal

taboos…i.e. incest, etc. (Schneck, 6).

– In primitive peoples such as the Siberian Eskimos, the people of Polynesia and

Melanesia, and some Native American tribes equate the mental illness as the

loss of the soul and as an attempt to cure the malady, a medicine man or

Shaman type figure must “retrieve” the soul and return it to the body of his

patient. (Schneck, 6).

– The attribution of demonic possession as causing mental illness is a concept

that surfaces anthropologically throughout history in cultures far earlier than

those mentioned in the Bible. (Schneck, 6-7).

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The Beginnings of Psychiatry…

– Exorcism, which today is typically associated in our culture with the Roman

Catholic Church and a handful of Protestant denominations has in the eyes of

some the standing of being one of the oldest types of “psychotherapy.”

(Schneck, 7).

The Beginnings of Psychiatry…

– In Egyptian culture, there existed incantations and manual rites to treat those

exhibiting the symptoms of mental illness. (Schneck, 10-11).

– In Mesopotamian culture, there was a system of dream interpretation and

divination that was well developed and used to diagnose and treat by

attempting to discover the “sins” that had been committed by the individual

suffering. (Schneck, 10-11).

– The Hebrew culture had a degree of hostility toward those exhibiting psychotic

and/or neurotic symptoms. The meaning behind the behaviors was typically

attributed to spirits and/or negative influences. (Schneck, 10-11).

The Beginnings of Psychiatry…

– Early medicine in India also found itself using spells, incantations and other actions similar to exorcism, confession, and a high importance placed on the idea of the “sins” of the individual. (Schneck, 10-11).

– Demonic possession played a significant role in ancient Chinese beliefs as well. (Schneck, 10-11).

– The running theme that is present in these archaic and primitive ideas on mental illness is

two fold:

– 1.) The individual was not behaving in a way that was congruent with social mores of the given culture and people were trying to make some meaning of the behaviors.

– 2.) The behaviors were typically blamed on the individual suffering often attributed to some perceived “sin” or “taboo” that the individual had committed or broken. This attitude led to the trend of the mentally ill being ostracized from mainline society. This is a theme that is pervasive and continues today.

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Asylums and Early Psychiatric

Treatment in America…

– Prior to the 18th century, there were little to no formal services available to

those living with mental illness.

– Typically they ended up in almshouses, jails, or on the street.

– In what was to become America, after the 50 year sustained efforts of the

Quakers, The Pennsylvania Hospital was opened in 1751. (Baxter, 1).

Asylums and Early Psychiatric

Treatment in America…

– Early psychiatric treatment was abysmal. Patients were often kept in a state of

squalor.

– The so-called treatments were often violent and abusive toward those suffering

with mental illness, and largely due to ignorance, a high degree of superstition

remained attached to mental illness further contributing to the stigma.

Dorothea Dix

– Born in 1802 to alcoholic parents and the daughter to a Methodist Minister,

Dorothea Dix in known historically as one of the greatest advocates for those

persons living within mental institutions.

– “I proceed Gentleman, briefly to call your attention to the present state of

insane persons confined within this commonwealth, in cages, stalls, pens!

Chained, naked, beaten with rods, and lashed into obedience.”

– Dorothea Dix brought attention to the needs of those institutionalized who

were largely out of sight and out of mind of the general public. (Baxter, 29).

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The Advent of Psychotropic

Medication- The Game Changer

– In 1950, chlorpromazine, also known as Thorazine was discovered.

– Still used today, it is classified as a low-potency typical antipsychotic.

– For the first time in history, there was a medication to address psychotic

features in patients leading to a major shift in psychiatric care.

– Now, there are dozens of psychiatric medications on the market with the 10

most prescribed being: alprazolam, sertraline, citalopram, fluoxetine,

lorazepam, trazadone, escitalopram, duloxetine, bupropion XL, and venlafaxine

XR.

De-institutionalization

– In 1955, the Joint Commission on Mental Health and Health was authorized to investigate problems related to the mentally Ill.

– President John F. Kennedy had a special interest in mental health as his sister, Rosemary, had been the recipient of a lobotomy at the age of 23.

– In 1962, 112 recommendations were published by the Panel on Mental Retardation.

– The de-institutionalization movement started slowly, but gained traction as it adopted similar philosophies to the civil rights movement.

– During the 1960’s many patients were moved from long term facilities to community based care facilities.

– The goal of de-institutionalization was to create a situation in which those living with a mental illness could live in the least restrictive environment possible with their respective conditions. (https://www.thebalance.com/deinstitutionalization-3306067)

Part 2

– The role of spiritual care within the context of present day psychiatry.

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Advocacy

– The first advocates for mental health in America were the Quakers.

– Dorothea Dix was the daughter of a Methodist Minister.

– Prior to the creation of the career fields of social work and the involvement of

medicine in the treatment of mental illness, clergy and the church were often

involved in taking care of or advocating for individuals living with mental illness.

Origins of Pastoral/Spiritual

Care

In 1924 Anton Boisen started the first clinical training program for ministers at

Worcester State Hospital in Massachusetts.

Boisen himself had several major schizophrenic breaks in his lifetime.

His work served as the foundation for the Clinical Pastoral Movement.

In a manner of speaking, the Clinical Pastoral Movement was born in a psychiatric

hospital.

The Integration of the Behavioral

and the Theological

Spiritual Care lives at the razor’s edge between the Theological and the

Psychological. Theology is concerned with human kind’s relationship with their

idea of a higher power, i.e. God. The understanding of this relationship occurs

within the context of a psychological process.

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Psychological Process or

Something Else?

Spirituality and Religion are understood through psychological process. However,

to limit them simply to psychological processes is the take away the power of

mystery and the sense in which the divine works in a person’s life.

Spirituality and Religion are interpreted by way of our psychological process, but is

not limited by structure of personality or science.

Spirituality and Religion: What’s

the Difference?

There is a distinction between religion and spirituality. Contrary to popular belief,

they are not one and the same. This is particularly important to understand in the

psychiatric context.

Spirituality Defined

“Spirituality is a globally acknowledged concept. It involves belief and obedience

to an all powerful force, usually called God, who controls the universe and the

destiny of man. It involves the ways in which people fulfill what they hold to be

the purpose of their lives, a search for the meaning of life and a sense of

connectedness to the universe. The universality of spirituality extends across

creed and culture. At the same time, spirituality is very much personal and unique

to each person. It is a sacred realm of human experience. Spirituality produces in

man qualities such as love, honesty, patience, tolerance, compassion, a sense of

detachment, faith, and hope.” (Verghese, 2008.)

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Religion Defined

Religion is best understood as the lens through which we view our sense of

spirituality. It consists of dogma, teachings and tradition that makes up a system of

symbols and a framework or context in which one’s spirituality can be effectively

interpreted and applied.

Religion as Resource

Religion offers positive coping resources to patient including, but not limited to:

Self Regulation

Attachment and Connectedness

Emotional Comfort

Meaning

Spirituality

(Pargament, Lomax, 2013.)

Benefits of Religious Involvement

“In the majority of studies, religious involvement is correlated with well-being,

happiness, and life satisfaction; home and optimism; purpose and meaning in life;

higher self esteem; adaptation to bereavement; greater social support and less

loneliness; lower rates of depression and faster recovery from depression; lower

rates of suicide and fewer positive attitudes toward suicide; less anxiety; less

psychosis and few psychotic tendencies; lower rates of alcohol and drug use or

abuse; less delinquency and criminal activity; and greater marital stability and

satisfaction.” (Koenig, 2001.)

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Spiritual Patients and Religious

Patients

An individual can be spiritual without being religious and they can be religious

without being spiritual.

Consequentially, many of the patients that present with religious delusions have a

significant disconnect between their sense of spirituality and their sense of

religiosity.

Individuals with a healthy sense of spirituality have a congruence between their

sense of spirituality and their religiosity.

To better understand this connection it is important to understand the distinction

between a person’s “God Image” and their “God Concept” which we will discuss in

the next part of the presentation.

Part 3

– Spiritual and behavioral assessment of psychiatric patients from the Chaplain’s

vantage of point.

Assessment of Psychiatric Patients-

A Chaplain’s Perspective

– The first question to ask when evaluating a psychiatric patient is whether or not

their illness is one involving a psychotic disorder or a personality disorder.

– Sometimes, the two are co-occurring.

– It is also important to recognize potential environmental and biological factors

and their interplay in the individual’s pathology and effect upon their treatment

process.

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Psychotic Patients

– Psychotic patients experience the world very different from those around them.

They are “disconnected” and are often found living with firmly fixed ideas and

delusion. Some psychotic patients exhibit hyper-religiosity or religious delusion.

A psychotic patient cannot be “talked out” of a delusion. The role of

medication is to clear the patient up to the degree that the psychotic nature of

the individual’s illness becomes manageable and other forms of therapeutic

intervention can be effectively employed.

Psychotic Disorders

– Psychotic disorders can best be described as an illness that causes an individual

to “lose touch with reality.”

– Examples would include Schizophrenia and some types of Bi-Polar Disorder.

Schizophrenia-DSM V Diagnostic

Criteria

– A. Two (or more) of the following, each present for a significant portion of the

time during a 1-month period (or less if successfully treated). At least one of

these must be (1), (2), or (3):

– 1. Delusions

– 2. Hallucinations

– 3. Disorganized speech (e.g., frequent derailment or incoherence)

– 4. Grossly disorganized or catatonic behavior

– 5. Negative symptoms (i.e., diminished emotional expression or a volition).

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Bi-Polar Disorder- DSM V

Diagnostic Criteria

For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a

manic episode. The manic episode may have been preceded by and may be followed by hypo-manic or major depressive episodes.

Manic Episode-

A. A distinct period of abnormally and persistently elevated expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary.)

B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a

significant degree and represent a noticeable change rom usual behavior:

Bi-Polar Disorder-Symptoms

Continued

– 1. Inflated sense of self esteem or grandiosity.

– Decreased need for sleep (e.g. feels rested after only 3 hours of sleep).

– More talkative than usual or pressure to keep talking.

– Flight of ideas or subjective experience that thoughts are racing.

– Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as

reported or observed.

– Increase in goal-directed activity (either socially, at work or school, or sexually) or

psychomotor agitation (i.e., purposeless non-goal-directed activity).

– Excessive involvement in activities that have a high potential for painful consequences (e.g.,

engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments.)

Bi-Polar Disorder- Symptoms

Continued

– C. The mood disturbance is sufficiently sever to cause marked impairment in

social or occupational functioning or to necessitate hospitalization to prevent

harm to self or others, or there are psychotic features.

– D. The episode is not attributable to the physiological effects of a substance

(e.g., a drug of abuse, a medication, or other treatment) or to another medical

condition.

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Pastoral Care and Counseling

Dynamics with Psychotic Disorders

– An individual experiencing psychosis can not be “talked out” of their delusions

or the symptoms manifestations that they are experiencing. That is what

medicine is for…

– The capacity for rationality does not exist as it applies to the psychotic features

of their illness.

– Delusions represent a break from reality and typically take on one of three

characteristics: Grandiosity, Persecutory, or a mixture of the two.

Grandiosity

– Grandiosity manifests in an inflated sense of self. Often a person with grandiose

delusions will believe themselves to have some great life call or task.

– This individual may believe themselves to be someone of great importance such

as a prophet, politician, historical figure, or Batman.

– As with other delusions, it is important not to re-inforce the literal content of

the delusion as this can exacerbate symptoms and prolong the treatment

process.

Persecutory Delusions

– These individual feel as though someone or something were “out to get them.”

– Their behavior can often be secretive and very self protective, sometimes

ending in violence if the person becomes too fearful.

– Paranoia can generally be read in body language and in a patient’s limited

interest in participating in a visit.

– Efforts should be made to be aware of the paranoid nature of the patient and to

be as “un-threatening” as possible.

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Mixed Features In Delusion

– Patients with mixed features typically exhibit symptoms of both Grandiosity and

Paranoia.

– The symptoms may co-exist, or the individual may vacillate between the two

symptom types depending upon the day, the interaction, or the setting.

How Do I Know If It Is a

Delusion?

– Sometimes delusional material is obvious. Other times, it does not surface until

later in the conversation. For some individuals, the material of their delusion

does not deviate too greatly from some mainline religious doctrines.

– It has been my experience that while you cannot talk a person out of a delusion,

it is possible to reflect with them in the context of their delusion without

encouraging the delusion. Said another way, we can reflect on the emotional

content without commenting on the literal content.

– Delusions typically have a disconnected quality to them and while a person may

be able to reflect on them to a degree, this is often very limited and eventually

becomes a circular discussion with the individual repeating the content.

How Do I Know If It Is A

Delusion?

– Occasionally, when exploring a delusion, an individual may either shut down or

become angry. In these cases, often the elusion is some type of protection

mechanism for the individual.

– It is important to remember that while we can see that the delusion is not real,

the mentally ill individual is unable to make that distinction leaving him/her in a

position of being greatly affected emotionally by the delusion. It is important to

care for the emotions of the individuals and it is equally important not to offer

care in a manner that feeds the delusion.

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Religious Preoccupation

– Religious preoccupation is a preoccupation with religious subjects that are not

within the expected beliefs for an individual’s background, including culture,

education, and know experiences of religion. (Lieberman, 199).

– Indicators of religious pre-occupation would be a sense of disconnection and

the sense of dis-empowerment for the individual expressing religiously

preoccupied symptoms.

Development Through the Stages

of Faith

– Typically with the onset of psychiatric symptoms, there is a halt in development

through the stages of faith.

– Many of those living with mental illness remain in Fowler’s second stage of

faith- The Mythic/Literal Stage of faith characterized by concrete and literal

thinking. (Fowler, 150-151).

– Faith development can continue if the individual seeks and maintains

treatment.

Why Are the Majority of Delusions

and Preoccupations Driven By Fear?

– Roughly 50-80% of all inpatient psychiatric patients have a history of physical,

sexual, and/or emotional abuse.

– That number moves up to 70% as it applies to women being treated in an

inpatient psychiatric setting. (https://www.nasmhpd.org/content/prevalence-

abuse-histories-mental-health-system)

– Trauma changes the way the brain works.

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The Brain’s Response to Trauma

– Trauma, and in particular, childhood abuse is linked to later psychopathology.

– There is a strong case that case that early stress may lead to ongoing

dysregulation of the hypothalamic-pituitary-adrenal axis in relation to stress

response predisposing an individual to psychiatric vulnerability later in life.

(McCrory, 151).

– Trauma elicits both a psychophysiological response and a psychological

response. (McFarland, 4).

The Brain’s response to Trauma

– “In PTSD there is an exaggerated amygdala response which underpins the

excessive acquisition of fear associations and the expression of fear responses.

A corresponding deficit of frontal cortical functioning plays a central role in

mediating extinction. There is also a deficit in the appreciation of the context of

safety, which is related to hippocampal function.” (McFarland, 5).

Adaptive Functioning

– In a manner of speaking, the brain adapts and evolves to create functioning

conditions conducive to the survival of the individual as they endure

threatening situations.

– In the moment, these changes possible save the individuals life and contribute

to their survival, but long term, the changes become maladaptive and

disruptive to life as the individual maintains a heightened sense of danger and

stress on a consistent basis that is grounded in their physiological response

rather than the reality of a given situation.

– This response is present in individuals living with psychotic disorders as well as

those living with non-psychotic disorders.

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Non-Psychotic Disorders

– Non-Psychotic disorders are mental disorders in which a person does not lose

touch with reality. This group would include psychiatric illnesses such as

Borderline Personality Disorder, Anti-Social Personality Disorder, Generalized

Anxiety Disorder, Major Depressive Disorder, and other personality based

disorders.

– The following disorders to be described are the most common in an inpatient

psychiatric care environment.

Borderline Personality Disorder

– Borderline Personality Disorder is characterized by the following in the DSM 5:

– Poorly developed or unstable self-image, instability in goals, compromised ability to recognize the feelings and needs of others, intense, unstable, and conflicted close

relationships, emotional lability, anxiousness, separation insecurity, depressivity, impulsivity, risk taking, and hostility.

– These individuals are particularly sensitive to rejection or perceived rejection. Do to their poorly developed or absent sense of self, they tend to develop maladaptive coping related to attention seeking behavior in an attempt to get their emotional needs met. An individual living with Borderline Personality disorder will tend to

have a very external locus of control.

Anti-Social Personality Disorder

Anti-social personality disorder is characterized by the following in the DSM 5:

Ego-centrism, lack of empathy, incapacity for intimacy, exploitation as a primary

means of relating to others, use of dominance or intimidation to control others,

manipulativeness, deceitfulness, callousness, hostility, irresponsibility, impulsivity,

and risk taking.

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Generalized Anxiety Disorder-

DSM 5 Criteria

– A. Excessive anxiety and worry (apprehension expectation), occurring more days than not for at least 6 months, about a number of

events or activities (such as work or school performance.)

– B. The individual finds it difficult to control the worry.

– C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having

been present for more days than not for the past 6 months):

– Restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbances.

– D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other

important areas of functioning.

– E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another

medical condition (e.g. hyperthyroidism).

– F. The disturbance is not better explained by another medical disorder.

Major Depressive Disorder- DSM

5 Criteria

– A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a

change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

– Depressed mood, diminished interest or pleasure in activities, significant weight loss or weight gain without effort, insomnia or hypersomnia nearly every day, psychomotor agitation, fatigue or loss of energy nearly every day,

feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think or concentrate, recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide.

– B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important

areas of functioning.

– C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

– D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

– E. There has never been a manic episode or a hypomanic episode.

Adjustment Disorder- DSM 5

Criteria

– A. Development of clinically significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor (s). Symptoms must develop within three months after the onset of the stressor (s).

– B. These symptoms or behaviors are clinically significant as evidence by either of the following:

– 1. Marked distress that is in excess of what would be expected from exposure to the stressor.

– 2. Significant impairment in social, occupational, or academic functions.

– C. the stress-related disturbance does not meet the criteria for another disorder.

– D. The symptoms do not represent bereavement.

– E. Once the stress (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months.

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Environment versus Biology

– Generally, the causes of mental disorders fall under the categories of environmental and biological. This

distinction can be helpful when assessing a patient. However, in some cases, being able to separate the environmental from the biological is not an easy task such as in the following example:

– A young girl was born to biological parents that were methamphetamine users. The child was born addicted to Methamphetamine and suffered brain malformations as a result of her mother’s drug use. Because of her social

situation and the inability of her biological parents to care for her she was placed in a foster home. Through the course of her childhood, she was moved from foster home to foster home. She grew up to be a relatively smart child, but part of her developmental struggles were related to being unable to read body language or understand

non-verbal communication. She has ADHD and developed a Conduct Disorder as she entered her teen years. While she was relatively intelligent, she struggled with her ADHD and focus and her Conduct Disorder and inability to read non-verbal communication caused her to have limited friends/social relationships. As she struggled

socially, her behavior worsened and she spiraled into negative coping to deal with the pain of rejection and of “not fitting in.” This young woman grew into adulthood developing substance abuse issues as well as Antisocial Personality Disorder. She had multiple psychiatric hospitalizations as a result of behaviors that were disruptive in

the community. On occasion, she would threaten to harm herself and/or others. In this case, the environmental and the biological factors are almost too intertwined to separate.

– What pieces can we deal with from the vantage point of pastoral care?

How Does an Individual Relate to

Something Larger Than Themselves?

“The God of the symbols and signs I call the concept of God; the expression image

of God I use to refer to the God of the inner experience of the believer.”… “it is the

believer’s inner experience of his God that gives rise to the signs and symbols and

gives individual meaning to signs and symbols already existing.” (Rizzuto, Accessed

2015.) )

God Image

A persons image of their higher power happens during the course of human

development. As children, the first major attachment is the caregiver of the

child/parents.

The child’s level of self differentiation is relatively low and their need and sense of

attachment is high. The natural inclination of the child is to conceptualize the

parent as a sort of “God figure.”

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God Image Continued

For better or for worse, qualities of the parents and the child’s interactions with

them will serve as grounds not only for self image development, but also the

development of an image of a higher power.

A child’s type and level of attachment to the parent will also impact their sense of

seeking out a relationship with their higher power as well as serving as an indicator

as to the degree that they themselves will attach to their higher power.

God Image Influences

Some studies utilizing Bowlby’s Attachment Theory have found gender differences

in how individuals develop their image of God.

“Concepts of God as Loving, Controlling, and Distant were self-referenced in

women but were not so in men. In men, Loving God was predicted primarily by

attachment to mother, Controlling God was referenced to attachment to both

parents, and Distant God was related to a combination of viewing self as distant

and experiencing parental attachment difficulties, primarily with father.” (Reinert,

Edwards, 2014.)

God Concept

An individual’s God concept in contrast to one’s God image is very conscious and is

largely cognitive and learned information. Oftentimes this information is

unintegrated and when a person is sharing how they see God, there are obvious

incongruences between what is spoken and what is practiced.

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Implications

If the God Image is indeed tied to one’s self concept and/or a projection of

parental references then to affect healing in the area of one’s God Image can have

a systemic effect leading to improvement of one’s self concept as well.

Said another way, by working on the emotional, the individual’s God Image is

affected and by working on one’s God Image, an individual’s sense of self and

internal emotional state can experience improvement.

In the Psychiatric Hospital…

Nearly all recovery programs such as the 12 step programs utilize the idea of a

higher power that assists one on the journey of healing.

If a person’s sense of a higher power is negative or abusive, how will they be able

to draw upon that higher power to facilitate coping, healing, and wholeness?

Sometimes the work of offering pastoral support focuses on the facilitation of

healing in such a way that a person can recover or salvage some usable version or

image of a higher power.

What are the Individuals Stressors

and/or Sources of Spiritual Distress?

Religious Delusions (Sometimes religious delusions don’t appear to cause spiritual

distress, but they do serve as a pathological religious expression due to the

disconnect that they cause.)

Scrupulosity – Excessive Guilt

Frustrations Related to Recovery

Sense of Personal Worthlessness/Loss of Value

Existential Questions and Crisis

Relationship Difficulties with Others/Loved Ones

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Assisting Psychiatric Patients with

Recognizing and Utilizing their Spiritual

Resources

– When working to assist an individual living with mental illness to recognize and

utilize their spiritual resources toward healing and recovery, it is important to

determine whether or not spiritual resources presented in the visit are healthy

or pathological in nature.

Healthy Faith Versus Religious

Pathology

A Healthy Faith is… Religious Pathology Symptoms…

Empowering Disempowering

Connecting Disconnecting

A Healthy Positive Choice Compulsive Participation

Energy Giving Energy Stealing

Invites Questions Discourages Questions

Promotes Creativity Limits Creativity

Teaches Healthy Spiritual Practices Teaches unhealthy practices or none at all

Helps to Resolve Anger and Anxiety Masks Anger and Anxiety

Allows for the Full Range of Human Emotion Limits a Person’s Emotional Range/Capacity

Freeing Imprisoning

Connection and Empowerment

– Connection-

– To Higher Power (as the person understand their higher power)

– To others

– To self

– Empowerment-

– Being personally empowered by the above connections

– Eventually having some capacity to empower others through the above connections

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Part 4

– Theological Themes in psychiatric care.

Theological Themes in Spiritual Care to

Those Living With Mental Illness

– Identity- “Who am I?

– Power- What do I have power over and what has power over me?

– Blessing versus Curse

– Genesis 25:19-34 and Genesis 27

Identity

– “What we call our sense of identity is our sense that our truest, strongest,

deepest self persists over time in spite of change. It is the sense of self

sameness that is deeper than any difference, a true self on which all of

ourselves converge.” – Judith Viorst

– “Our identity is formed in the act of bringing together the several facets of life;

the physical, the relational, the material, and the mental. Each contribute

unless we champion one at the expense of the others…we accept being and

becoming as essential to our identity. Yet, that identity is not complete unless in

brings in all facts of our personhood.” – Myron Madden

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Identity

– Who am I?- Self Conceptualization

– Who do they say I am?- Social Conceptualization

– What I do. - External

– Who I am. – Internal

– A genuine sense of identity is a source of power.

Power

– What is power?

– Oxford Dictionary defines power as:

– 1. The ability to do something or act in a particular way, especially as a faculty

or quality.

– 2. The capacity or ability to direct or influence the behavior of others or the

course of events.

– Locus of Control-

– Does life happen to me? Or Do I have an active role in the unfolding of my life?

Abandonment and Rejection

– The perception of giving and taking of power and it’s relationship with how one

sees their locus of control.

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Blessing versus Curse

– Blessing- “Giving the gift of power.”

– Curse- “To be robbed of that power.”

– To Bless is to feed identity.

– To Curse is to rob from identity.

Theological Themes of Those Working with

Individuals Living With Mental Illness

(Pastoral Responses)

– Sin and Evil-

– Enablement versus Empowerment

– Acceptance and Grace

Sin and Evil

– Sin as a distortion of feeling

– Sin as betrayal of trust

– Sin as a lack of care

– Sin as a lack of consent to vulnerability (Engel, 153-161).

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Enablement versus

Empowerment

– Enablement is to act in such a way that allows for an individual or system to

continue it’s current trajectory without pushing for growth or positive change.

– Empowerment is sometimes difficult and painful. It is focused on growth and

positive change.

– This conflict between enablement and empowerment is as the very core of all

psychiatric work and is a fluid concept changing from case to case and individual

to individual.

Acceptance and Grace (Justice

and Mercy)

– To many dealing with psychiatric issues, particularly religious preoccupations

from a fear driven perspective, there is a need for acceptance and grace.

– Acceptance and Grace must also be weighed in light of the question of

empowerment versus enablement.

Part 5

– Practical aspects of offering pastoral support to individuals living with mental

illness.

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Care to Psychiatric Patients in a

Medical/Surgical Environment

– Psychotic Patients- Active listening can be helpful as can empathic reflection based

upon the patient’s feelings. Be careful to not reinforce the delusion. Remember,

the delusion may not be real, but the feelings the individual has are! Be graceful to

yourself. Do not go into a pastoral encounter with a psychiatric patient expecting to

cure them or otherwise work miracles…that is what medicine is for…

– It is also important to ensure personal safety with psychotic individuals. Avoid being

within arms or legs reach with the patient. If you are engaging with a patient in a

room, ensure that the patient does not block your egress route. If you stand in front

of a patient, be aware of the individual’s body language and stand at a 45 degree

angle to the patient as this makes you a smaller target if the patient chooses to

attack you. Think safety!

Care to Psychiatric Patients in a

Medical

– Non-Psychotic Patient- Many functional people in society have non-psychotic disorders. While hospitalized, things

such as medication change, environmental change, and physical stressors can exacerbate the individual’s situation.

– Some things that can indicate that you may be dealing with someone with a personality disorder/non-psychotic disorder:

– Dependency (excessive neediness).

– The individual can only weight things as good or bad, but cannot see “grey.”

– The individual may intentionally try to offend you in the visit or otherwise try to get you to “go away.”

– The individual may make visit termination difficult, even experiencing visit termination as a form of “rejection.”

– Self harm evidence or a past history of self harm may indicate the presence of a personality disorder.

Triangles and Staff Splitting

– In working with psychiatric patients, it is extraordinarily important to recognize

and avoid triangulation and other staff splitting techniques.

– In his book, Games People Play, Eric Berne discusses a game entitled: “Let’s you

and him fight.” This game effectively describes the most common form of staff

splitting.

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Power Dynamic and Power

Struggles

– Psychiatric patients in an inpatient setting typically experience a great sense of

having things taken from them.

– Couple this with a lack of self awareness of staff related to transference and

counter-transference issues and the person storm is set for potential power

struggles.

– Eric Berne, again offers an effective model mapping out and unpacking power

struggles through his work with “ego states.”

– Power struggles and other relational problems are almost always caused by

“crossed transactions” coupled with a high level of emotionality.

Ego States

Personal Boundaries

– Boundaries are the most important quality that one must have when working

with psychiatric patients.

– Without effective boundaries, a clinician will burnout and not last in the field.

– The challenge is to maintain boundaries, balance a genuine care for those

entrusted into one’s care, while continuously trying to avoid apathy.

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One Final Note…

– It is better to seek to understand than it is to seek to destroy, subjugate, or judge.

– An individual living with mental illness may push your buttons, they may test your

boundaries, and test every fiber of your patience, but at the end of the day, they are

a deeply hurting and troubled individual.

– Remember, if you are accosted, attacked, verbally abused, or subject to negative

behaviors that it is the person’s illness engaging you and not the person themselves.

This idea can sometimes help with rational detachment.

– The tendency will be to give up or even project our own shadows upon those we

serve. Through seeming failures and defeat, apathy can surface if we allow it, but

we must remember the humanity of the individuals that we serve.

Questions, Comments, and

Discussion

Resources

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Thank You For Your

Participation!

“May you be encouraged and blessed as you continue forward with whatever your

task may be in this life, and as you reach out to others and they reach out to you,

may your hearts be filled with joy and satisfaction.”