SPIRITUALITY IN MENTAL ILLNESS
Many experts agree, and experience and research support, that our spiritual state influences health. Given that understanding, what role does spirituality play in treating mental illness? Does the Bible offer help in addressing mental illness? Christians who believe the Bible is God's Word, true and reliable words from God revealing his character, human nature, and solutions to our problems, would agree that the Bible can be a significant source of healing in mental illness. Biblical Framework Counseling (BFC) is an intervention based on belief that the Bible is adequate to treat the root causes of mental disorders that are not otherwise physiologically caused. Traditional pharmacological treatment is used with BFC counseling, but the purpose of pharmacotherapy is to manage symptoms while BFC works on underlying causes. Nurses may encounter patients seeking Christian approaches for mental illness and need to understand this approach and pharmacological treatment. First, how is spirituality thought to impact health, and more specifically, behavioral health?
SPIRITUALITY AND HEALTH
Spirituality is the aspect of an individual's life involving the spirit: nonphysical in essence yet considered just as important, if not more, than the physical aspects of a person. Spirituality encompasses beliefs, core values, faith systems, and practices by which an individual assigns meaning to life, and is believed to significantly impact sense of purpose, wholeness, and response to people and circumstances. An individual's belief, attachment, and relationship to God is an intrinsic religiosity source, evidenced by public practices (e.g., church attendance), private practices (e.g., prayer), religious commitment, religious experiences, and religious coping. These in turn impact life choices, decisions, and health behaviors, resulting in positive emotions of peace, existential well-being, happiness, hope, optimism, meaning, and purpose (Koenig, 2009).
Spirituality is a part of one of six key domains for quality-of-life assessment developed by the World Health Organization (Culliford, 2002). Spiritual assessment was established by the Joint Commission for Accreditation of Health Organizations (JCAHO) as an accreditation requirement, identifying at the least, any spiritual belief, denomination, and practices considered important to a patient (JCAHO, 2008). The expectation is to identify spiritual needs, determine the impact of spirituality on the healthcare provided, and respect the right to spiritual services. Accredited organizations are required to define their spiritual assessment content, scope, and assessor qualifications.
There is no established model for spiritual assessment or care. JCAHO offers examples of questions regarding personal beliefs on strength, hope, suffering, illness, and death; spiritual such as the use of prayer; or names of spiritual affiliations and leaders. The HOPE assessment tool encompasses questions on sources of Hope, Organized religion, Personal spiritual practices, and the Effect of spirituality on medical care and death (Anadarajah & Hight, 2001). The EBQT paradigm provides a guide to addressing spiritual care based on Evidence, Belief, Quality of care, and Time (Lawrence & Smith, 2004). Clinicians evaluate whether a strategy has supportive evidence of its value, will improve the quality of care, and can be implemented within the time frame of the clinical encounter. Level of compatibility or congruence between clinician and patient belief, and relevance of belief to therapy are evaluated.
SPIRITUALITY IN MENTAL HEALTH
The significance of spirituality to behavioral health is depicted in Andreasen's (1996) classic illustration of psychiatric care as "therapy with medications that mend biological processes in the body and therapy with psychotherapeutic techniques that mend psychosocial processes in the soul or mind" (p. 589). The American Psychological Association published Religion and the Clinical Practice of Psychology (Shafranske, 1996), legitimatizing religion as an important variable in mental health. "Religious or Spiritual Problem" was introduced into the American Psychiatric Association Diagnostic and Statistical Manual, Fourth Edition (Text Revision) (DSM-IV-TR) (2000), and the association has published guidelines for handling psychiatrist and patient religious and spiritual commitments in psychiatric practice (2006).
Spirituality and religion have been shown to have a positive impact on coping behaviors, well-being, self-esteem, self-care, depression, anxiety, substance abuse, and mediating mind–body mechanisms (Hugelet, Mohr, Borras, Gillieron, & Brandt, 2006; Koenig, 2005, 2009; Murray-Swank et al., 2006). Religion has been suggested to exert a "protective effect" on behavior among individuals with schizophrenia, depression, and comorbid substance abuse (Mohr & Huguelet, 2004), and associated with lower suicide rates (Koenig, 2009; Koenig, Larson, & Larson, 2001).
Healthcare systems have been criticized for emphasis on the provision of medical care (prescribing medications to eliminate or control undesirable symptoms) and less psychotherapy. On the other hand are widely accepted therapies such as the Recovery Model, an approach that incorporates spirituality as a key component (Lukoff, 2008). Individuals undergo a process of self-assessment, spiritual self-reevaluation, developing self-respect, and optimistic thoughts of achieving healing. Practices such as praying, reading scriptures, and attending devotional services are encouraged.
In spiritual assessment, a clinician may choose to observe and note a patient's spiritual beliefs and practices without encouraging, discouraging, or criticizing beliefs, especially where a greater level of spiritual care is beyond the defined scope of the healthcare organization, or where there is incongruence in patient–clinician belief. Sometimes the most appropriate strategy is to refer the patient to pastoral or some other form of spiritual care not directly provided by the clinician.
FAITH-BASED VERSUS MEDICAL-BASED CARE
What happens when the main treatment modality is a framework of spiritual practices, and healthcare (medical) referral is considered the supportive adjunct? What level of care may be needed and expected for a health professional to provide? These are important questions as patients pursue settings they believe have less association with stigma, hope for a possibility of recovery, and care that is consistent with the significance of faith in their lives.
Among Christians, choices for psychiatric care may be based on
1. psychological counseling or psychotherapy alone or in combination with pharmacotherapy or medical care (e.g., cognitive therapy, interpersonal therapy)
2. medical care with psychotherapy that incorporates faith-based counseling/practices (e.g., Christian counseling, integration counseling)
3. medical care with faith-based counseling/practices that exclude psychotherapy (e.g., nouthetic counseling, BFC).
Among these options, BFC establishes a model for counseling based on the Bible and congruently applied to DSM-IV-TR diagnostic criteria.
BIBLICAL FRAMEWORK COUNSELING
BFC is faith-based counseling based on belief of the Bible's sufficiency to address the root cause of mental disorders. However, BFC is not psychotherapy. Psychotherapy involves treatment by psychological techniques (insight, persuasion, reassurance, instruction) designed to encourage communication of conflicts and insight into problems, with the goal being relief of symptoms, changes in behavior, and personality growth (Good & Beitman, 2006). BFC involves treatment by spiritual means, with the Bible as a guide. Positive emotions related by research to spirituality and health (Koenig, 2009) are encompassed in the BFC model as peace, confidence, and drawing near to God. These come from adequately and consistently addressing human heart or conscience issues, and are outwardly expressed as loving attitudes toward God and others (Thomson, 2004). BFC ultimately is aimed at pursuing a quality of life that is encompassed in I Corinthians 13:4–7, resulting in a positive impact on mind–body mechanisms.
Key elements of BFC are (1) Material and Immaterial Man, (2) the Root Cause of Mental Disorders, and (3) the Role of Pharmacotherapy (Thomson, 2004). A template of the BFC framework can be found as supplemental digital content at http://links.lww.com/NCF-JCN/A3.
From a BFC perspective, man has an immaterial heart and a material brain and body. The term "heart" can refer to the soul or spirit, all representing man's nonphysical essence. The framework illustrates biblical teaching about the inner workings of the heart (immaterial being), picturing how people are responsible to God for some things in life and not responsible for others. Only thoughts, decisions, and behaviors outside the realm of responsible choice can be determined by the material body and brain. Physiological disease, chemical agents, physical imbalances and deficiencies, poisons, and other substances may affect the physical body and brain, but do not determine the choices of the heart to which one is accountable to God.
On the other hand, man's heart can generate physiological changes in the material brain and body. Indeed, researchers have demonstrated that immune, endocrine and cardiovascular function, and mental health are impacted by positive and negative emotions, life choices, health behaviors (Koenig, 2009), heart attitudes, and response to the conscience (Thomson, 2004). The BFC framework shows how one's conscience, in response to the loving and unloving choices for which a person is responsible, instinctively and instantaneously produces (1) knowledge and sense of peace or knowledge and a sense of guilt; (2) expectation of God's blessing and confidence or knowledge of deserved judgment and a fear of this judgment (apparently uncaused fear or anxiety); and (3) a call and urge to draw near to God and others or an urge to flee from one's sense of guilt and fear of judgment (apparently uncaused fleeing). These are all behaviors associated in biblical Scripture with right or wrong choices. When these expressions are identified among the defining features of a mental disorder as described in DSM-IV-TR, and are not clearly associated with any physiological etiology (e.g. general medical condition, chemical, pharmacological substance), such expressions are considered as physiological manifestations of the root cause in man's immaterial heart. A Christian is able through BFC to identify deep personal problems or defining features of a mental disorder and recognize these as effects of apparently uncaused fear or fleeing resulting from unloving attitudes not paid attention to, ignored, or justified in the heart (Thomson, 2004).
BFC stresses, among other things (a) the importance of walking in God's Spirit and agape love (1 Corinthians 13), (b) four basic kinds of human relationship found in Scripture, and (c) how to establish and maintain open loving relationships in all areas of life. The counselee discusses life relationships, circumstances, attitudes, and behaviors in response to these areas. The counselor observes for behaviors considered as lack of love for God and/or other people. Lack of love in a person's immaterial heart can lead to a sense of guilt, apparently uncaused fear (e.g., anxiety), or apparently uncaused fleeing (e.g., withdrawal), which could produce physiological effects (e.g., insomnia, paranoia). Scripture is used to bring attention to the need to confess wrongdoing and wrong attitudes, and count on God's forgiveness and empowerment to change attitudes and behavior. Bible reading, prayer, church attendance, and intentional acts of love toward God and others are homework given to the counselee to begin to experience peace, confidence, and drawing near to God. Behavioral changes are expected to ultimately manifest in improved psychiatric symptoms.
An individual grappling with a severe, persistent mental disorder with physiological symptoms for which medications have been prescribed is encouraged in BFC to continue pharmacotherapy (Thomson, 2004). However, in nonphysiologically caused illness, medications deal with symptoms, not the root cause. Medications can decrease physiological symptoms, providing help and time to deal with a root cause with minimal distraction. Once the root cause is consistently addressed and the physiological symptoms diminish, it is believed within the BFC paradigm that both prescriber and patient may recognize less need for medication and decrease dosage, until a time when they may consider it is no longer needed.
Evidence as to the benefit of BFC is based on anecdotal reports, not controlled studies. Nevertheless, existence in the literature of the benefit of faith and spiritual practices may provide a basis for consideration, warranting formal research to validate the BFC framework. Belief and quality of care are critical considerations in choosing BFC. Acceptance of only psychological principles and rejection of faith-based ones present significant incompatibility with the BFC belief system. Healthcare clinicians caring for an individual receiving BFC must consider compatibility of their personal and professional beliefs with the patient's spiritual beliefs, and how this impacts pharmacotherapy approach and outcome. BFC counselees are encouraged to seek medical care from a clinician who supports their goals in counseling.
It may not seem ethical for a clinician to provide or refer to BFC due to concerns with "diagnosing" the root cause (i.e., the belief that there is an underlying spiritual problem). The clinician may be worried about possible medication nonadherence, or the perceived impact of excluding psychological services on health outcomes, as well as liability questions. However, BFC encourages counselees to continue medical care. This is especially significant where an individual expresses a desire to discontinue pharmacotherapy, because of the risk of relapse. Requests for medication discontinuation typically are patient initiated, not counselor initiated or persuaded; and the request is due to decreased medication tolerability rather than an apparent absence of psychiatric symptoms. A counselee's healthcare provider would have to decide if discontinuation is truly in his or her best interest. In first episode instances, where full remission has been achieved, pharmacotherapy discontinuation after remission can be possible. Where there has been a more severe, chronic course, and where full remission hasn't been achieved, relapse is more likely, and pharmacotherapy considerations become more challenging.
HOW PSYCHOPHARMACOLOGY WORKS
Neurotransmitters. Pharmacotherapy used in the treatment of mental disorders involves modulating the transmission of chemical messengers or neurotransmitters across the nervous system. Neurotransmitters relay or modulate information from one neuron (nerve cell) to another. Figure 1 illustrates the general activity of nerve impulse or signal transfer at the neuronal junction level, known as the synapse, via points of neurotransmitter synthesis, release, transport, receptor binding, reuptake, and destruction. These are the potential points for pharmacological activity.
The portion of a neuron before a synapse is presynaptic and after the synapse is postsynaptic. Neurotransmitters are synthesized, stored in the presynaptic vesicles, and released from the presynaptic terminal into the synaptic cleft, where they bind to and activate specific receptors in the membrane on the postsynaptic side of the synapse. The receptor binding and activation elicits specific physiological actions, depending on the neurotransmitter and the type of receptor activated. Neurotransmitters may be transported back to the presynaptic side where they can (a) bind to presynaptic autoreceptors that regulate further neurotransmitter synthesis and release, (b) experience reuptake back into the presynaptic terminal, or (c) be destroyed by deactivating enzymes.
Three common categories of neurotransmitters are amines, amino acids, and peptides. Neuronal transmission may form distinct neurotransmitters systems, where activation affects various regions or pathways across the brain. Dopamine, norepinephrine (noradrenaline), and serotonin are common amine neurotransmitters involved in the mechanism of mental disorders. Gamma-aminobutyric acid (GABA) and glutamate are examples from the amino acid category. Examples of amine neurotransmitters, their receptors, and system pathways are listed in Table 1.
Psychotropic Mechanisms of Action. Pharmacological agents that act at the receptors can have agonist and/or antagonist effects. An agonist binds to a receptor and triggers a response that is similar or mimics the kind of action that would be seen if a specific neurotransmitter activates that receptor. An antagonist also binds to a receptor, but does not elicit a neurotransmitter-like effect, thereby blocking the neurotransmitter's action at the receptor site. Psychotropic medications can utilize agonist or antagonist mechanisms of action at receptors, or points of neurotransmitter synthesis, release, reuptake, or destruction. The goal is to improve or restore adequate neurotransmission across brain pathways that manifest as disrupted or dysregulated in mental illnesses. Although all the mechanisms of psychotropic action are not fully understood, they do help provide symptom relief. Psychotropic pharmacological actions are applied with the goal of influencing thought, emotions, and behavior to an extent where an individual's capacity for the functions of everyday living become more feasible.
Pharmacological Agents. Common medications used in treatment of mental disorders are listed in Table 2. Antipsychotics are the agents of choice for treating schizophrenia, a disorder associated with abnormalities in dopamine and glutamate transmission (Laruelle, Frankle, Narendran, Kegele, & Abi-Dargham, 2005). The older, first-generation "typical" antipsychotics (also referred to as neuroleptics) are believed to antagonize dopamine (D2) receptors. The newer, second-generation "atypical" antipsychotics are believed to be more selective in dopamine (D2) blockade and produce serotonin (5HT2) receptor blockade. Antipsychotics produce a variety of side effects due to their actions on other neurotransmitter systems, such as hypotension, sedation, and weight gain.
Antidepressants are hypothesized to increase norepinephrine and serotonin transmission to improve mood. Serotonin-specific reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) inhibit the reuptake of serotonin by nerve cells; the older tricyclic antidepressants (TCAs) (e.g., amitriptyline [Elavil], imipramine [Tofranil]) inhibit reuptake of serotonin and/or norepinephrine, thereby enhancing transmission. The TCAs also block cholinergic receptors, producing effects such as constipation, dry mouth, and urinary retention. Monoamine oxidase (MAO) inhibitors like phenelzine (Nardil) inhibit MAO enzyme destruction or metabolism of serotonin, norepinephrine, and dopamine, thereby increasing their transmission.
Antianxiety agents include benzodiazepines (e.g., lorazepam [Ativan]), which modulate the transmission of GABA, the major inhibitory neurotransmittter in the brain.
Mood stabilizers or antimanics are believed to impact serotonin and norepinephrine reuptake. Lithium modulates reuptake of serotonin, norepinephrine, dopamine, and acetylcholine. Valproic acid (Valproate), an anticonvulsant agent with antimanic properties, increases GABA levels.
Pharmacological management in the treatment of mental disorders is geared at applying what is known of psychotropic mechanisms of action with dosage adjustment to optimize control of psychiatric symptoms, minimize unwanted side effects, and enhance an individual's quality of life. Some research indicates remission with pharmacotherapy is possible, though not easily achievable as remission and relapse may be complicated by several factors (Pintor, Torres, Navarro, Matrai, & Gastó, 2004; Rush et al., 2006).
From a medical perspective, pharmacotherapy is a core treatment strategy for mental disorders. From a BFC perspective, pharmacotherapy is an adjunct to the primary goal of addressing the root cause for the mental disorder. Pursuing spiritual maturity is balanced with symptomatic relief as a goal. BFC encourages physiological symptom relief but focuses on addressing spirituality, with pharmacotherapy as an adjunct that provides enough relief to avoid becoming a distraction. BFC counselors raise individual accountability for attitudes and actions they perceive might otherwise be excused as secondary to abnormal brain chemistry. Biblical principles are applied to effect behavior change. Healthcare clinician agreement with BFC viewpoints or collaboration between counselor and clinician is not required. It would be beneficial, however, if spiritual views are not antagonized if they do not present any clear patient risk (American Psychiatric Association, 2006).
Mental health clinicians can identify or rule out target symptoms that are psychiatric manifestations of medical conditions, substance abuse, medication side effects and drug interactions, or organic brain injury. Clinicians can facilitate care for BFC patients by recognizing how symptoms are categorized in BFC, for example, emotional tone of hallucinations as apparently uncaused (AU) fear, or tangentiality as (AU) fleeing.
Physicians, pharmacists, and nurses may collaboratively participate in medication therapy selection, provide counseling on proper medication use and adherence, monitor side effects, and assist with mechanisms to access free or discounted medications and services. Clinicians should explain medical aspects of patients' conditions and how medications help, encourage greater responsibility for caring for general health, and discuss ideas on hope for recovery and empowerment to change and grow from their experiences. Health professionals can communicate with BFC counselors as they provide healthcare, and consider symptom changes and the effect on medication dosage and selection changes. Psychiatric symptom management would involve balancing the need to address the root cause as a priority over comfort, yet with symptom control to preserve safety and functionality, and to prevent distraction and symptom relief from becoming the overwhelming focus. Open communication between patient, BFC counselor, and clinician is beneficial, facilitating trust and quality care access.
Spirituality is significant to individual well-being and mental health. Health professionals are encouraged to identify spiritual care needs and decide on strategies contributing to positive outcomes. Some individuals with mental disorders may choose faith-based counseling, with medical care as a supportive adjunct. BFC is based on belief of the Bible's sufficiency to address the root cause of mental disorders as defined in the DSM-IV-TR. Pharmacotherapy adherence is encouraged, with the expectation of symptom relief, not recovery. Education and consultation should be an important aspect of any care provided. Goals of pharmacotherapy should be reviewed regularly, taking into account perspectives of the patient, BFC counselor, and healthcare clinician to optimize treatment outcomes.
* American Association of Christian Counselors—http://www.aacc.net/resources/biblical-counseling-quick-reference-guide/
* Biblical Framework Counseling—http://www.biblicalframeworkcounseling.org
* National Alliance on Mental Illness (NAMI)—http://www.nami.org/
* National Institute of Mental Health—http://www.nimh.nih.gov
New Beginnings: A Case Study
EZ., a 58-year-old divorced mother of two children, was diagnosed with bipolar disorder many years ago. She was physically and sexually abused by two men in her family and then chose a husband who continued the cycle of abuse. E.Z. has been taking different medicine combinations for 10 years to manage her disorder; both of her children have been diagnosed with bipolar disorder and are taking medications. E.Z. entered into Biblical Framework Counseling (BFC) for her illness. A host of unloving attitudes toward God and others were identified through counseling. A plan was developed to guide E.Z. through recognizing, confessing, and turning away from unhealthy unloving attitudes; accepting forgiveness; and practicing expressions of love toward God and others.
During initial assessment, E.Z. was asked if she was being managed on medications or was being seen by a physician. She was encouraged to continue follow-up with her physician and pharmacist. Time in counseling was spent bearing the burden, seeking guidance from Scripture, and rejoicing over the victories she experienced after putting into practice the biblical principles she learned in the BFC sessions.
Over the course of the sessions, E.Z. began to "diagnose and treat" her own unloving attitudes, guilt, apparently uncaused fear and fleeing with skill, and continued to apply biblical principles to her daily life. She also tracked regularly in her journal the times and quality her attitudes and actions remained loving based on I Corinthians 13:4–7. As E.Z. improved, she asked if she should try to get off her medications; the counselor instructed her to discuss the matter with her physician. E.Z. and her physician agreed to attempt to wean her off the medications. E.Z. showed no sign of relapse over 90 days after medication discontinuation, or in subsequent interactions with the BFC counselor. No longer-term information about E.Z. was known to the counselor.
Table 3 illustrates the general application of BFC to E.Z.'s case. More information about E.Z.'s BFC treatment can be found as supplemental digital content at http://links.lww.com/NCF-JCN/A3.