Dimensions of human experience

The spiritual dimension of human experience can be described as one of five interrelated dimensions. In Box 3 these are displayed as a hierarchy, suggesting (in bold) how the disciplines of general medicine, psychiatry and religion each relate principally, in an overlapping fashion, to the five dimensions.

In many cosmologies, the spiritual dimension is the most complex, subsuming and inhabiting the other four in a seamless and integrative fashion. It is the source of the remainder – of time, space and everything else – thus rendering the system circular and dynamic, a poetic and mandalic vision of wholeness. Paradoxically, by virtue of its unity and indivisibility, it is also the simplest dimension.

Spirituality with reference to a shifting paradigm

In support of the WHO report, Capra (1983), Ravindra (2000) and many other commentators (e.g. Reference LorimerLorimer, 1998) have suggested that Western culture is undergoing a significant paradigm shift – from a materialist view, based on the assumptions of dualism, rationalism, positivism and empiricism, towards a naturalistic understanding that acknowledges the significance of such things as personal stories, emotions and experiences that cannot be explained purely in terms of science.

People are moving away from self-centred individualism towards a recognition of the fundamental wholeness and interconnectedness of human beings, indeed the whole of time and creation (Reference FindlayFindlay, 2000; Reference PowellPowell, 2001).

According to Capra (1998), reductionist and mechanistic explanations are giving way to more holistic and ecological ways of interpreting the world. Chaos and complexity theories are already being considered within health care (Reference Plesk and GreenhalghPlesk & Greenhalgh, 2001). Consciousness studies (Reference LorimerLorimer, 1998, Reference Lorimer2001), including investigation of the healing effects of prayer (Reference DosseyDossey, 1993) as well as so-called ‘peak’ experiences (including past life, out-of-body and near-death experiences), also have relevance to psychiatry without yet being integrated within the discipline. These new ways of understanding human experience point positively towards the new paradigm and promote the concept of a non-material or spiritual dimension to life.

The distinction between healing and cure

The influence of the medical model, with its assumptions of cause and effect, specific aetiology, diagnosis and appropriate treatment, leads to an understanding of mental health as simply the absence of mental illness. According to Trent (1999) the assumption is that if people are not ill, they must by default be healthy. The new paradigm argues differently.

Swinton (2001: p. 57) says that ‘strategies and understandings that seek to cure mental health problems are obviously valid and should be encouraged. However, the reality for a significant number of people is that certain forms of mental illness are interminable’. Borrowing from medical anthropology, he notes that cure has to do with the eradication of disease. It is the anticipated outcome of attempts to take control of disordered biological and/or psychological processes.

Healing, derived from Saxon and high German words for ‘whole’, is more than ridding a person of particular symptoms or difficulties. It relates to that aspect of care that attends to the deep inner structures of meaning, value and purpose that form the infrastructure to all human experience. Swinton (2001: p. 57) calls healing ‘a deeply spiritual task that stretches beyond the boundaries of disease and cure’.

Tudor (1996) helpfully suggests understanding mental health in terms of two continua: a mental disorder/cure continuum and a mental health/healing continuum (Fig. 1).

Fig. 1

Health within illness, the two continua model (from Reference TudorTudor, 1996, with permission)

The former focuses on pathology and severity of illness in the conventional way, informed by the medical model. The latter focuses on issues such as degree of contentment, joy, inner peace and emotional equanimity as well as maturity, relationships, social functioning, degree of disability, sense of meaning and purpose (hence motivation) and so forth.

Mental health can, therefore, be defined in terms of the whole person and understood in terms of growth and personhood. In writing about this, Swinton (2001) echoes Fowler (1981) who, drawing on the works of Jean Piaget, Erik Erikson and Lawrence Kohlberg as well as his own extensive research, mapped out human psychological development as ‘a quest for meaning’ through six ‘stages of faith’. Mental health care can thus be viewed in terms of persons being provided with encouragement, adequate resources and a conducive environment to enable them to grow as unique individuals (Box 4).

This approach resonates well with attitudes already prevailing and promoted within rehabilitation psychiatry. Shepherd (1991), for example, writes:

Religion or spirituality?

This is an important question, because both health care practitioners and early researchers have tended to equate the two. According to Narayanasamy (1993) this results in ‘nurses identifying spiritual care as the exclusive realm of chaplains or religious agents’; furthermore, ‘many carers steer clear of spiritual material for fear they are unqualified, ill-equipped, or because they simply feel it is not part of their job description’. In a study quoted by Nolan & Crawford (1997), of 176 nurses, only 11% felt able to provide spiritual care for their patients. These authors, referring to the different dimensions of human experience, remark that all religions embrace spirituality, but religion is only one of a variety of ways of understanding or accessing it.

The WHO report (1998) referring to the facets proposed for the WHOQOL SRPB module (Box 2), suggests that the areas covered are common to people coming from many different cultures and holding different beliefs. It acknowledges that some people follow a particular religion, that others do not follow a particular religion but believe in a higher spiritual entity, and still others do not follow a religion or believe in a higher spiritual entity but do have strong personal beliefs that guide them in their day-to-day activities (such as scientific theory or a particular philosophical view). Each will look at the WHOQOL SRPB ideas and statements with their particular belief system in mind, and allowance has been made for this.

In a focus group study, Greasley et al (2001) asked the question, ‘Is there a difference between spiritual care needs and religious care needs?’ They reported the majority of study participants as seeing and emphasising the two as distinct, arguing that a person does not have to adhere to a particular set of religious beliefs or practices to have spiritual beliefs and needs of a more individual and personal nature. There was concern that, where spirituality is perceived to be synonymous with religious beliefs and practices, a patient's spiritual needs might not be addressed when he or she does not express any religious affiliation.

Conventional (empirical) research

Systematic reviews of the research literature have consistently reported that aspects of religious and spiritual involvement are associated with desirable health outcomes (Reference SwintonSwinton, 2001, p. 68). Spirituality has been positively correlated with symptom reduction in depression, anxiety, addictions, suicide prevention, anorexia and schizophrenia.

Acknowledging that the human spirit may not be measurable as an independent variable, King (see Reference GlasGlas, 2001) suggests, however, that even without knowledge of its content, the strength of a person's religious or spiritual belief can be measured. Perhaps more important, the impact or salience of a spiritual belief to life and its effect on behaviour is measurable using, for example, the Royal Free Interview for Religious and Spiritual Beliefs (Reference King, Speck and ThomasKing et al, 1995).

In spite of acknowledged problems, the authors of the authoritative Handbook of Religion and Health (Reference Koenig, McCullough and LarsonKoenig et al, 2001) have conducted a critical, systematic and comprehensive analysis of empirical research, examining the relationships between religion and a variety of mental and physical health conditions, covering more than 1200 studies and 400 research reviews. Careful to try to distinguish religion from spirituality, the authors have written general chapters on the positive and negative effects of these, as well as on the patient's subjective experience. There follow specific chapters on mental well-being, depression, suicide, anxiety disorders, schizophrenia and other psychoses, alcohol and drug use, delinquency, marital instability and personality, as well as on research methods, measurement tools and areas of research needing further study.

Koenig et al (2001) comment that, from a scientific perspective, the question of religion's effects on health is an important one that has yet to be fully answered. This is partly due, they say, to the main preponderance of studies being on subjects from the USA, Europe or Israel, and from traditional Christian or Jewish backgrounds, adding that research with Muslims, Hindus and Buddhists is relatively rare, difficult to access and hard to interpret. The authors conclude firmly, nevertheless:

Appropriately supportive of the empirical approach, they add that the fields of psychoneuroimmunology and psychosomatic medicine have shed light on the physiological mechanisms by which psychological, social and behavioural factors can affect health and well-being.

New paradigm research

According to Dixon-Woods & Fitzpatrick (2001), referring to recently published guidance from the NHS Centre for Reviews and Dissemination, increased recognition has now officially been given to diverse types of evidence that can, perhaps should, contribute to systematic reviews. Qualitative research has established a place for itself.

This is helpful and may be further evidence for the paradigm development in both science and health care. We are moving beyond positivism, which limits knowledge to observable facts, and empiricism, which regards nothing as true, save what is given by sense experience or by inductive reasoning from sense experience (Reference Honer and HuntHoner & Hunt, 1987), towards a ‘participant–observer’ type of approach (Reference LorimerLorimer, 1998) and constructivism – whereby observation is assumed to be value-laden, thus an interpretative process (Table 1).

Table 1

Contrasting traditions and new paradigms (personal communication, P. Fenwick, 2002)

Context	Traditional perspectives	New paradigm perspectives
Models	Reductionist, positivist, empiricist, dualistic, mechanistic	Participant—observer, constructivist, holistic, ecological
The nature of the world	Everything is composed of physical matter	The human world is emergent and non-local. Realities appear to be multiple and overlapping
World views	Objective: the outside is seen as the only reality	Simultaneously subjective and objective: inner and outer reality are experienced as interconnected and indivisible
Values	The world is seen as value-free, independent of the observer	The world is value-laden and has intrinsic meaning; interpretations necessarily reflect this
Causal relationships	Reality is causally based in time-linear fashion	Causes can arise outside the system, acting through non-local effects
The possibility of general laws	General laws generated are universally valid	“Laws” are based on assumptions (often hard to verify), and are limited to each unique and changing set of interdependent circumstances

In a study of spirituality and depression Swinton (2001: p. 99) has used the methodology of hermeneutic phenomenology, which asserts that the (phenomenological) facts of lived experience are always already meaningfully (hermeneutically) experienced.

Data were collected using unstructured, in-depth interviews on six subjects, who had each experienced depression for at least 2 years. Each interview was initiated with the question, ‘What is it that gives meaning to your life?’ Interview texts were entered into a software program designed to facilitate analysis. The 10-stage research process involved production of a rich description of the depression experience, with both independent and participant validation, and it was completed by the research product being fed back to the participants, their thoughts and comments being taken into consideration in the final account.

Swinton lists eight central themes of spiritual significance emerging from the data (Box 5). He describes the ways in which participants use their spirituality to restore meaning, purpose and hope to their lives under two headings: the healing power of understanding; and liturgy and worship. All participants were volunteers, committed to the Christian faith tradition and interested in spirituality. This is an acknowledged limitation of the study.

Caveats accepted, this innovative methodology successfully reveals and emphasises the relevance of spirituality in mental health care. The methodologies of the questionnaire studies of Narayanasamy (1993), Ross (1994) and McSherry (1998), the questionnaire-plus-interview study of Nathan (1997), the focus group study of Greasley et al (2001) and the narrative-based approach identified by Roberts (2000) point in a similar direction.

Professional attitudes, training and the benefit of ‘spiritual skills’

Many of the components of spiritual care listed in Box 4 are already aspects of good psychiatric practice. Similarly, many of the benefits listed in Box 6 represent hoped-for outcomes of competent clinical care. This seems to indicate that no major development in thinking or philosophy of care is required. However, Greasley et al (2001) report that a personal, trusting relationship between professional and patient is necessary in addressing patients' spiritual needs, which is not achieved frequently enough. Furthermore, all patients interviewed by Nathan (1997) perceived spiritual care as an area involving all care providers.

Giving and receiving

Professional and personal development in terms of spiritual attitudes, values and skills (Box 7) can be nurtured, for example by encouraging a language of spirituality in mental health care (Reference Nolan and CrawfordNolan & Crawford, 1997) or through architecture, providing quiet spaces that are conducive to contemplative activity.

Spiritual skills can be taught directly (Reference RossRoss, 1996; Reference EaggerEagger, 2001), as occurs beneficially already in education (Reference Erricker and ErrickerErricker & Erricker, 2001). Not least, they can be self-taught, both under guidance and from books (Box 8).

It is a principle of spiritual care that offering it benefits both parties, giver and receiver. In the medical profession, there is a high incidence of marital breakdown, drug dependency, alcoholism, depression and suicide. The data indicate that psychiatrists are especially vulnerable. Improved psychospiritual self-care by mental health professionals may help.

Nolan & Crawford (1997: p. 289) point out that those who seek to add a spiritual dimension to the care they provide must also be prepared to wrestle with their own spiritual needs. More optimistically, they add that time invested in learning about giving spiritual care can have a number of beneficial consequences for the individual, including spiritual growth, new insights, new interpretations of personal situations, a new vigour in professional practice and protection from burn-out.

Trust

The skills listed in Box 7 complement and support each other. They are useful, for example, by being among those that help professionals present themselves as honest and trustworthy and so rapidly establish lasting bonds with patients. Swinton (2001) suggests that, in the face of psychiatric illness, the quest for cure must continue, but the process of enabling healing is also a vital and immediate aspect of the daily task of caring. This bonding, and the trust that it fosters (faith in the doctor), is therefore important.

He adds that the aims and objectives of healers are to enable a person to find enough meaning in their present struggles to sustain them, even in the midst of the most unimaginable storms. He suggests that the spiritual carer has not simply to find the locus of pathology but also to discover the locus of meaning within a person's life, and in so doing, begin to explore ways in which the person's spirit can be revitalised. He draws a distinction between automatic, reflexive responses and personally intentional, meaningful actions, which are preferable. In promoting the latter, he says, it is for clinicians ‘to discern between the forms of spirituality that may be negatively affected by the person's mental health problems, and the more helpful and constructive responses of individuals to the longings of their spirits’(p. 18). In this way, the movement from reflexive existence to meaningful living can be initiated and followed through.

All this implies that mental health professionals have a duty themselves to achieve resilience, emotional stability and spiritually mature ways of living and coping. This will of necessity be a cooperative endeavour. Spirituality can be discussed with colleagues as well as with patients in non-religious, non-denominational terms; it is something to be shared rather than something potentially divisive. This discussion has already begun and is bearing fruit.