Spirituality and narrative in psychiatric practice: stories of mind and soul

Psychedelic Policy Quagmire presents a strong case for the notion that psychedelics have transcended seemingly outdated legal, academic, cultural and spiritual paradigms. Although by the editors’ own admission this volume is by no means definitive, it will undoubtedly prove to be a lightning rod in the academic community. With its focus on research and policy that maximise the benefits of the use of psychedelics, reduce the potential dangers of misuse and remove impediments to achieving these ends, it is inevitable that this book will be a catalyst for lively and robust debate. Recommended to academics and researchers in various fields, including psychology, psychiatry, anthropology and the arts, this work should challenge many long-held assumptions about these fascinating substances.

There is one more general introductory chapter, one more starter, before we reach the main course: Andrew Powell on 'Helping patients tell their story: narratives of body, mind and soul'. His aim, once again, like that of the whole book, is, 'To show how, across a wide range of clinical objectives, paying attention to narrative is important both for diagnosis and for treatment'. In addition, he writes, 'Transcending the limitations of the mundane life, soul wisdom brings a deeper understanding to the human predicament'. Calling for authenticity, Powell calls the narrative 'an act of co-creation' between people meeting on the basis of equality as human beings. Boldly, he states a major problem, that 'mental health services provide little by way of spiritually informed care'. 'Consequently', he adds, 'There is no way of knowing how often a transient psychotic episode might otherwise have become the turning point on a new path of meaning and purpose had the narrative only been explored in a different way.' In this same section he asserts vigorously that, 'Conflict, loss and soul-searching are implicated in most mental breakdowns. Body, mind and soul, whose interweaving remains the greatest conundrum in psychiatry, have to be taken together if the psychiatrist is to help the patient recover from breakdown to wholeness of being'. The remaining authors offer examples of good practice and show in different circumstances how this may be achieved, together with some of the pitfalls.
In chapter 5, authors James Lomax and Kenneth Pargament are more hopeful, writing, 'Practitioners are just beginning to attend to the spiritual dimension of patients' lives'. With the help of two extended clinical narratives ('Sylvia' and 'Arnold'), which give a good idea of what it might have been like to sit in the therapist's chair in their company, they focus on a range of 'religious and spiritual struggles' often associated with poor mental and physical health (with the divine, with the demonic, moral, interpersonal and doubt-related struggles, and struggles of ultimate meaning), also with a number of effective methods of 'spiritual coping'.
For my taste, Frederic Craigie's chapter, 'Stories of joy and sorrow: spirituality and affective disorder', was a favourite (along with chapters 8, 10 and 11). It began with an engaging story, followed by a brief review of the relevant literature, then some 'approaches and examples of narrative-based, spiritually informed clinical care'. The stories mentioned included those of resilience, presence, connectedness, forgiveness, hope and joy. One patient, for example, went away from treatment 'just feeling loved'. Another, remembering little of what the psychiatrist actually said, felt better because, 'She really seemed to believe in me'. Recurring and helpful themes in treatment were those of 'purpose' (living faithful to deeply important personal values) and of 'transcendence' (letting go of unchangeable outer and inner experiences), complementary elements of change and healing. Craigie suggests that simply 'inviting people to talk about the things they really care about' may be all that is needed, both to provide direction and to bring energy into the consulting room, thus enabling change to happen. What we care deeply about, in other words, is what we also hold sacred. This is a very rich chapter.
In contrast, I found Chris Williams's chapter, 'Stories of fear: spirituality and anxiety disorders', disappointing, not for what it included, but for what it left out. 'This chapter,' Williams writes, 'describes how CBT [cognitive behavioural therapy] can be used to make sense of some very different personal responses to a mental health crisis'; and so it does, using the narrative examples of 'Farah' (a Muslim), 'Daniel' (an Orthodox Jew), and 'Helen' (a Christian). We are told that spiritual/faith aspects of a person's problems 'can readily be incorporated into CBT because they can be construed in terms of three key elements of beliefs, behaviour and relationships'. But where is there any recognition by the therapist of the whole authentic being and life journey of the patient? Where is any reference to mindfulness, (originally adapted by Jon Kabat-Zinn and colleagues in Massachusetts from Buddhist meditation techniques) that is so frequently and usefully an adjunct of CBT? Not in this chapter, I'm afraid.
My appetite returned again soon, however, with Gwen Adshead's chapter, 'Stories of transgression: narrative therapy with offenders'. Mentioning 'the patients I work with' (perpetrators of homicide and child abuse, who have given her permission to use their anonymous stories), she writes with remarkable coherence and exemplary compassion, not only for her patients and colleagues, but also for her readers, taking considerable pains to elucidate her highly complex, troubled and troubling field of interest. I liked, for example, her clarifying distinction between 'resisters' (who avoid responsibility for their destructive thoughts and actions) and 'desisters' (who 'desist' from further criminality by accepting a narrative emphasizing a sense that their previous offending did not represent their real nature, the true self they now sought to become). This is a fascinating chapter.
'Even the darkest times can herald transformation.' This is the theme of chapter 9, 'Narratives of transformation and psychosis' written by Isobel Clarke with the help of three people involved in developing and running, or in close sympathy with, the Spiritual Crisis Network. Katie Mottram, Satyin (Jim) Taylor and Hilary Pegg tell their own brave stories of major breakdowns involving psychiatric services, with diagnoses including schizophrenia and bipolar disorder. 'All three … regard their experiences as ultimately narratives of transformation rather than narratives of illness,' writes Clarke, who makes sense of these experiences in terms of research into 'schizotypy', which here means 'ease of access to "non-ordinary experiencing"'. The chapter includes several suggestions for professionals assisting the transformative journey of people with psychosis in routine mental health care. In summary, she advises us to: (a) respect the experience with an open mind; (b) recognize the feeling as real, even when the story is suspect; (c) consider what might best motivate the person to rejoin the rest of us in the shared world of everyday reality; (d) see the person as on a journey, perhaps into darkness and confusion, from which they have the potential to emerge stronger.
These points carry over well into the following chapter by Jo Barber, 'My story: a spiritual narrative', which is another courageous and ultimately hopeful personal account of prolonged, at times highly debilitating mental illness. By her own admission it is the story of a shy, obsessively studying teenager, terrified of failure, a confused, guilt-ridden, lonely and struggling student, later a mute, motionless patient on a psychiatric ward, a mental health service-user for 30 years, who is now a published researcher responsible for the Handbook of Spiritual Care in Mental Illness, and 'a person coping independently, doing voluntary work, feeling fulfilled and happy for the first time in life'. It is well and straightforwardly-written, without pathos or drama, encouraging and instructive. It is satisfying, for example, to read, Many people have helped me on this journey. My consultant provided acceptance, understanding, encouragement, crucial support and insight. The chaplain has helped me sort out what I really believe and why. And there have been other people, psychiatric nurses, a psychologist, people I have met through my work and, more recently, people from the church.
It is satisfying, but it reminds us too of our spiritually supportive duties as mental health professionals. Listen as Barber concludes her story: 'Telling your spiritual narrative is often therapeutic in itself and I believe that this opportunity should be available for all as part of routine spiritual care'.
If there is a dessert course to this gala dinner of a book, it is surely here in another of my favourites, Beaumont Stevenson's chapter, 'God's story revealed in the human story'. Stevenson gives us a personal account of his developing faith to explain what 'spirituality' means to him, following this with 'Spiritual narratives in a mental health community' from his time as an Anglican chaplain in a psychiatric hospital. The stories are both serious and light-hearted. A patient feeling unworthy during a communion service accepts a Polo mint from her neighbour instead of a wafer from the priest, but the following weekto general applausetakes the wafer. Stevenson elaborates on the ways in which spiritual narratives heal, by means of metaphor and symbol, by promoting 'living in the eternal now', by 'writing a new story', 'reframing the delusional', 'transforming the I-it into an I-Thou' (some kind of healing relationship with the divine), and, 'finding a place for suffering'. The stories of a patient claiming to be Jesus confronted with a chaplain saying he is Moses, and of his moving encounter with a patient in conversation with a lamp post, are priceless. Stevenson's gentle, humble and wise words reveal the value of humour, kindness and simplicity. Although understated, it is clear that in his case these spiritual attributes are grounded in faith.
The chapter by the usually clear and reliable Jeremy Holmes, 'Meaning without believing: attachment theory, mentalisation and the spiritual dimension of analytical psychotherapy', could hardly be more different and was, for me, a second disappointment. There are some good bits, but the chapter as a whole comes across finally as too chewy and indigestible, perhaps best left on the side of the plate. Calling himself an 'agnostic atheist', Holmes takes on the theologian (and former Archbishop) Rowan Williams in what seems like an attempt to validate a kind of secular spirituality. Even after two careful readings, I failed to follow the argument precisely, but he does agree that the therapist's task is to help counter 'trauma, loss, hate, envy and destructiveness', acknowledging that most major religions helpfully foster love, awe, forgiveness, compassion and gratitude, and are therefore on the same side. The somewhat technical languages of 'attachment theory' and 'mentalisation' are recruited by Holmes, in an attempted fit with the more poetic and metaphorical languages of both Christianity and Buddhism, to argue for 'a spiritual dimension to psychological health', which 'manifests itself in the inner narratives that emerge in successful psychotherapy'. Bravo! By comparison, chapter 13 by John Wattis and Steven Curran, 'Stories of living with loss: spirituality and ageing', is far less convoluted. The issues regarding older patients are similar to those discussed elsewhere in the book, the emphasis being on the multiplicity of losses the ageing face and their shorter remaining time-span, plus the question, 'What do they think will happen to them after death?' The stories of 'Jean', 'Maureen', 'Janet', 'David' and 'Ibrahim' read well and are usefully illustrative of the spiritual aspects. The story of 'Margaret' and 'George', a couple in their 70s coping with George's dementia, serves the added purpose of demonstrating how intimately affected a person may be by loss sustained by the other, while also focusing on specific issues relating to dementia. The authors tell us hopefully that, 'Most old people cope with remarkable resilience, often based on a lifelong narrative of successfully coping with change and loss'. They remind us of the value of mental health professionals working together, and doing so 'in a spiritually competent way' in what is 'an essentially spiritual task'.
As mentioned, the final chapter by the editors, 'Beginnings and endings', includes a general summary and a few useful final comments, for example that 'listening takes time', which may be in short supply in an increasingly pressurized and closely governed health service. 'Many psychiatrists', we are also warned, 'will be sceptical of the views expressed in places throughout the book'. I agree, but this is no bad thing. Some chapters are so well-written as to engage meaningfully those with doubts, and if not persuade them, then at least encourage them to think these important issues through once more from a broader and more generous perspective.
The editors also remind us in this final chapter to listen for what people leave out of their narratives as well as what they include, and this encourages me to mention one complete omission: there is no mention of the spirituality of children and adolescents, an important topic that would surely merit a chapter of its own. I have already said that I would have liked to see more too about the narrative and place of 'mindfulness' in the lives of patients and professionals. And in this context, I would have liked to read more about the vocational spiritual path of those drawn to serve people with mental health problems and how their work offers them opportunities to grow wiser and more compassionate in the helping of others through adversity, how it may form, in other words, a major part of their own spiritual narrative and journey.
The final omission to mention, rather a missed opportunity, concerns something implicit in the book but made explicit only briefly, towards the end of Lomax and Pargament's thoughtful chapter (5). This concerns 'the steps needed for this nascent area of practice to advance', including particularly: more knowledge (different types of research), more training, and more narratives of the kind found throughout this book. These three linked facets all deserve considerable emphasis. Despite these few quibbles, I earnestly applaud all the authors and editors, who are to be thanked and congratulated for a magnificent slice of real life at the sharp endwhere it truly hurts, but where it can also be healed. It is usually better to read a book by Thomas Merton (of which there are over fifty) than a book about him. However, this is a remarkable piece of scholarship, filling an important gap in the bigger picture of Thomas Merton's life and spiritual struggle. At first sight, it is solely for specialists, for people with a strong interest in the life and work of this acclaimed 20th century monk, poet and spiritual writer; but other readers of this review might equally benefit, for Merton's story is also, in some senses, universal. From this specific example, we can learn something valuable about ourselves and each other as spiritual beings.

Notes on contributor
Donald Grayston tells us early on that the 'Noonday Demon' of the title refers to Psalm 91:6, 'The destruction that wastes at noonday'. Recognized by contemplatives of old as a kind of spiritual restlessness or defensive apathy, well known to the original 'desert fathers' and early theologians like Ponticus Evagrius and John Cassian of the third and fourth centuries, this demon of 'temptation to leave one's cell' goes also by the Latin name 'acedia'. Cassian is quoted as writing, 'It is akin to sadness', with attacks 'at regular and set intervals' (around midday), and: