Psychyatra

ABSTRACT
Spirituality and psychotherapy are two different entities that are always talked about in the field of mental health. Spirituality cannot be totally separated from religion. For the purpose of our paper we consider spirituality as Essence of religion. It is about an individual's inner life, ideals, attitudes, thoughts, feelings and prayers towards the Divine, and about how he or she expresses these in daily way of life. It is a very subjective experience and it might happen even within the context of religion. If this is the case, therapist might have a difficult time in handling clients coming from different religious backgrounds. So we thought of focusing if spirituality could be used in psychotherapy and whether the spirituality of the client and that of the therapist conflict. If it conflicts how does the therapist handle it? Whether the therapist has the right to introduce spirituality even without the consent of the client? We thought of interviewing psychotherapists and clinical psychologists in order to gain more insights into it.

KEY WORDS
Spirituality, Psychotherapy, Religiosity, Mental health.

INTRODUCTION
The World Health Organization defines mental health as "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.
Traditionally, mental health problems were handled by the Shamans or the faith healers with medical knowledge. Mental health patients used to get cured at the place of worship. Later on psychology and psychiatry and other such disciplines emerged and professionally trained people like psychiatrists and psychologists started handling the problems with mental health and they took over. Freud viewed religion as an illusion and, and connected it with pathology such as obsessive compulsive behavior. This view encouraged many therapists to avoid the topic altogether. Yet recent statistics shows that about ¾th of the population of USA who are suffering from mental health problems are less likely to go such professionals. Instead they go to the traditional healers. While this is a statistics from a developed country, for the developing countries, the number would even more increase. Even in this 21st century,if people are still going for the traditional healers, then there should be some scope for the integration of spirituality and psychotherapy. We often do not think about this possibility because of the bio medical model that we are following and when the spiritual dimension is missing from mental health, a good chance is lost to connect with the person as a whole.
"Psychotherapy is the art, science, and practice of studying the nature of consciousness and of what may reduce or facilitate it." - James Bugental, (1978). In order to seek integration between spirituality and psychotherapy, it is necessary to differentiate between Religiosity and spirituality. Both these terms are interrelated Religiosity means the participation in particular beliefs, rituals and activities of traditional religion. Spirituality is more basic than religiosity. It is the essence of the religion. It is a subjective experience that exists both within and outside of traditional religious systems. Spirituality relates to the way in which people understand and live their lives in a view of their sense of ultimate meaning and value. So spirituality exists in all the patients. For those who follow any particular religion, spirituality happens within the religion while for others it happens outside.

It is seen that about 80- 90% of the population believes in a higher power. This belief may reflect in their perception of the cause of the illness. The main reason why mental health professionals are not using spirituality is that it opens up patients to powerful ideologies that may be dangerous. Because any powerful belief system has the potential for good and bad. Usually it is concluded without sufficient evidence that spirituality is bad for the patient. The spiritual side of a person should be considered as an important dimension in the therapeutic process.
Over the years, however, there have been attempts by therapists such as Carl Jung and others to integrate spirituality and psychotherapy. Many therapists now are beginning to consider the healing opportunities available when incorporating a more holistic view of mind, body, and spirit. Even the American Psychiatric Association (APA) has begun to consider the role of religion and spirituality in psychiatry. For example, the Diagnostic and Statistical Manual of Mental Disorders (DSMIV) (APA, 1994) includes a category, "religious and spiritual problems," which, while it focuses on problems, separates spiritual issues from psychological problems for the first time. At present among different approaches, only the transpersonal approach uses spiritual dimension directly in psychotherapy.


PROBLEM
• Can spirituality be used in psychotherapy?
• If so, under what circumstances it could be used?
• Do the therapists face any problems while using spirituality?
• Is there enough training for the use of spirituality?
• Is spirituality relevant in psychotherapy?

REASONS
Personally we believe that belief in a supreme being is necessary in coping with the world. Moreover, the moment we get out of the curriculum, most of us forget about the science and scientific things and retreat into the traditional beliefs. So when someone close to us have a mental problem, the immediate thought that comes into our mind is the traditional healers, may it be a priest, monk or someone of that kind. Only if they are not able to cure the person, we think about the professionals such as a psychologist or a psychiatrist. Also when we become therapists, it would be helpful for us if we know whether to use spirituality and what would be the consequences.
REVIEW OF LITERATURE
There are several studies indicating that people who are religiously or spiritually affiliated are 40% less likely to have depression. Also if they get into Depression, it is found that they recover faster. It is found that for every 10- point increase in the intrinsic religion score, there was 70% increase I the remission from Depression. When psychotherapy is religiously oriented, it had better improvement after treatment. Studies have found that adults who are above the age of 50 and have never participated in religious activities are at 4 times higher risk for committing suicide. And the religious or spiritual commitments are found to be having reduced risk for substance abuse and suicide. Another study found that chance for alcohol dependency is 60% greater when there is no religious affiliation. Also those who participated in a spiritually oriented therapy for alcohol abuse were found most likely to be abstinent after the treatment. In a study conducted by D’ Souza to find out the applications of spirituality augmented CBT, they found that is significantly beneficial in extinguishing hopelessness and despair and to reduce relapse.
In an article titled Spirituality and Mental Health- Synergic, antagonistic or the missing Dimension, Avdesh Sharma points out the benefits of using spirituality in mental health. The integration increases the positivity of the person about self and healing. It also creates a connection with the Higher Power to draw the power to heal.
In a survey conducted in Australia, 68.7% of the clients suggested that they want the therapist to be aware of their spiritual needs and beliefs. To do the therapy with the spiritual or religious clients, the therapist would be more self-aware to enhance their work (Bartoli 2007). According to Wiggins (2008) the awareness of themselves like their own ideas and beliefs as well as the biases about the religion or the spirituality would help the therapist to avoid imposing their own values on their clients. He explored a solution for therapists are that to write a spiritual autobiography.
In the beginning of the twentieth century, the spirituality has not a significant role in psychotherapy. It has overcome these issues in the last twenty years. There are number of researches focused on this issue and this is an emerging issue in psychology. The APA has formulated the role of religion and spirituality in psychiatry. These give a new chance or a new shift in the field through the integration of spirituality in psychology. Nicholas (1994) talks that now a day’s patients are seeking for not only for reducing psychological issues but also to compensate for the lack of reliable and humane guideposts that are available in society as a whole. In these scenario the psychologists should support the client who are emptiness and hopeless in nature. Kaurusu(1999) emphasis that therapist who are giving a traditional kind of therapy gives only a transitory relief and he would not be provide any techniques for the wider development rather than pathology.
Clinicians are using spiritually oriented therapy to reduce the various psychological problems. Coelho, Canter, Ernst (2007) reported the significance of the integrated interventions on the prevention of depression for patients with three or more episodes of depression. There are recent studies on the implications of spiritual oriented treatments and this would help in reducing drug use or addictive behaviors, (Avants, Beital, Margolin(2005) and intervention for sexual abuse victims (Murray, Swank, Paragment, 2005). These interventions are mainly likely to help spiritually oriented people to an extent and this can be used by the therapists who are not necessarily religious in nature. The researched interventions that are effectively used in psychotherapy are prayer, teaching spiritual or religious concepts, mindfulness etc.
Religion is considered to be institutionalized spirituality (Abraham V). Spirituality provides or initiates humane qualities like love, honesty, patience, tolerance etc. Spirituality has a prominent role in everyone’s live as though they are aware or not. To treat the person spiritually means treat the whole person in the therapy session, few of the therapists address the spiritual beliefs in their daily practices (Shafranske, 1996). A meta analysis study conducted by Walker, Gorush,Siang-Yang in 2004 reported that therapists sees spirituality as important and there are psychologists who work with the integrated therapy, this study gives the outcome that there is a positive relationship between participating in spiritual beliefs and the use of spirituality in counselling.
Spiritual clients give importance to their own spiritual part of their life. According to Gallop and Lindsey 90% of people in United States prayed and they do their daily rituals without any fail. What they says that the therapist might be remiss if they neglect the spiritual aspect during therapy because these people considers that spiritual values have the ability to shape and influence their own lives.
Spirituality is considered to be vital for growth and it is essential for dealing with life’s problems (Lukoff, Turner, Lu, 1992, Sperry, 2001). The psychotherapy and spiritual dimension can be incorporated by identifying the relationship between these two concepts. The personal experience of clients, personal and professional responses by psychotherapists, the business setting, and the increasing tolerance for spiritual issues are the four aspects that can affect the relationship between spirituality and psychotherapy. The spirituality oriented patients seeks the treatment in which they eagerly wanted to discuss the spiritual issues and concerns, particularly spiritual experiences are considered to be appropriate (Westfield, 2001).
FINDINGS
Ms. Shobana Managoli, a well known clinical psychologist, who has been working in this field for 22 years spoke about the use of spirituality in psychotherapy. Psychotherapy works on to forget the event or situation which is a threat to the client. Psychotherapy teaches the client to let go the event or incidence which causes distress to the client. The patient has to learn from the incidence and then follow up the learning which she or he has been learned from the therapist. In spirituality, the spiritual healer teaches the client to forgive the incidence. It gives emphasis on the forgiveness. Then the client has been carried up to the acceptance of the sin. The client should be aware of the sin and should admit the right to be punished.
According to her, if the therapist uses the psychotherapy only, it is not effective for the holistic development of the individual. In the psychotherapy, forgiveness is not taking place; instead forgetting has a major role in the psychotherapy. But the anger or distress remains in the client. Anger could not be completely resolved by the therapist.
In the case of spiritual healer, forgiving has a major role, where forgetting the threatening situation is not taking place. If images of the event still persist in the client, it would arise the feelings of anger. Here the spiritually oriented psychotherapy works. In this case psychotherapy teaches the client to forget and spirituality focuses on the forgiveness aspect. These together works towards the development of the individual in various dimensions.
Comparison with the biomedical model
The medical model works in a specific way in which illness, health and fitness are taken care of. The patient comes to the doctor with some kind of illness and he/she wants to be cured. This is the first stage. Then the doctor provides with medications and takes the patient to the second stage that is health. Now the patient is healthy and has to move into the third stage of fitness. Here the doctor provides some tips to maintain fitness such as exercise or meditation etc. therapist with a certain kind of distress and a desire to be cured the illness.
In spiritually oriented psychotherapy the holistic development of the individual works through three steps: the illness_ eustress_ empowerment. The patient meets the therapist with a distress and the cure of the distress should be done with supportive psychotherapies till the person attains the eustress. Here the learning process works and for that, the therapist might be using different types of therapies like behavioral, psychoanalytic, cognitive behavioral therapy etc. The next and the final step is to empower the client with the help of spirituality. Through this the client maintains the fitness and promotes what he has been done with the previous sessions. Through the role of spirituality the self exploration of the client gets activated and it promotes a well being in the individual.
So in her therapy she uses spirituality towards the end. She strongly believes that nothing should be done that would hurt the religious beliefs of the client and the family. For her, she has not faced any problems as such in using spirituality. For her, if a client comes with a belief of an unforgiving and punishing god, she would still work on the aspect of forgiveness because for them it would reduce the degree of punishment.
According to Ms.Shobha, the therapist can use spirituality only after the self –exploration of the therapists themselves. The therapist should be aware of what is going on his or her mind. Self-exploration is the fundamental qualification of using spirituality in the therapy and it is attained only after long years of experience. Through experiences the therapist would acquire a balanced state of mind. Spirituality can be introduced to the therapy if the client is inclined to the spiritual orientation and when the therapists themselves have a very clear idea about their spiritual path. There is no appropriate training available for spiritually oriented psychotherapy model. According to her the spiritually oriented therapy is beneficial and it is worthful in nature.
Dr. S.C, is a clinical psychologist practicing in Kerala. According to him spirituality is the faith in the Supreme Being and it is very closely connected to psychology. Because it provides us with a better physical and mental health. For him it is always good to have spirituality for everyone. As the famous sayings suggests you become what you think. Faith is also a kind of thinking. This could be the reason why people get cured during the worships. Because the patient has a faith in God and he or she believes that God has cured him that is enough for the patient. If you believe that god has created you with a purpose and whatever happens in your life has got a purpose, this belief itself can make lot of difference in your life as per the above quote. Spirituality is also very useful in adjusting the problems of life. According to him an atheist would not be able to cope with the life as a believer does. Spirituality is also self-promoting and it is very helpful for a healthy mind.
Dr. S.C talked to us about the famous story of Jim, a child who was severely injured and was hopeless according to the medical science. But he recovered significantly within 16 days. When the boy asked about this miracle said that he heard the voice of God telling him that “Jim, God is here”. So the belief is that God is with him helped him to recover from the dead bed. So according to him, faith heals. Studies conducted among the soldiers suggest that soldiers who have faith took only half the time to get cured when compared to others. Studies also suggest that nuns and the priests have higher life span because of the spiritual element in their life.
Suggestion is the base for the psychological treatment. Similarly faith can also act as a suggestion. It can also trigger the neurotransmitter actions. According to him psychologist should be a spiritual person. This can improve the treatment effectiveness.
Dr S.C uses spirituality in his therapy only when the client is convinced or inclined to the spiritual dimension. For an atheist he would not use the spiritual element because he believes that the patient is there for not a conflict but for help. The aspect of forgiveness and prayer can only be brought into the patients notice through the spiritual dimension. So he explains to the patient about the scientific side of forgiveness and the importance of faith. For example, if we do not forgive someone, it would create hostile feelings in you which in turn cause excessive adrenaline in the body. This increases tension, depression and other biological changes and can cause health of mind and body. So the base for all these problems is the unforgiving mind. Still the if the patient is not convinced he uses pure biological techniques to reduce the harm. If a client comes to him with the concept of an unforgiving God, he uses the same strategy of explanation. He believes that people with moderate education would understand the scientific side of spirituality and would cooperate with the therapy.
In his practice he does not face much conflict because of the application of spirituality. Clients from different religious background do not cause a problem in using spirituality because spirituality is different from religiosity. For him, the training for the use of spirituality is necessary and he is highly optimistic about the integration of spirituality and psychotherapy.
We interviewed some other Clinical Psychologists also. Mr. G, who is a working in Kerala, said that he himself is an atheist and does not believe in using spirituality in his practice. At the same time, another Clinical Psychologist JP from Mangalore stressed on the importance of spirituality in therapy and is using it as well. He does not face any conflict in dealing with the clients from different religious background because he believes that spirituality and religion are different.
OUR OWN POSITION
For most of us important things in our life can only be experienced and cannot physically hold. Spirituality is also the same. Just because spirituality is not directly subjected to science, we cannot reject its significance. More over there are plenty of researches that have proved the significance of spirituality in health in general, especially mental health. But most clinicians feel that they are not well equipped to use spirituality in their practice. This is mainly because the mechanistic view of patients as only a material body. This view is no longer satisfactory. Patients and the therapist have begun to realize the importance of spirituality in the therapy. The therapist should consider the therapy as a healing process rather than just a business. They should look into the whole person rather than just a patient. They should treat all the dimensions of the patient, including spiritual healing. For example, if a patient comes to the therapist who just had a break up with his girl friend, and the person is suffering from depression because of this, the therapist can actually bring in the spiritual element here provided the patient is firm in his spirituality. Suppose the client is a Christian, according to Christianity, your life partner is pre-determined and ultimately you will end up marrying that person. If the therapist can focus on this aspect, it would actually speed up the healing process better than any other methods. Through our readings and findings we came to a conclusion that self- exploration and experience is highly necessary for the use of spirituality in psychotherapy.
CONCLUSION
Psychotherapy should take all the dimensions in a person’s life into consideration and should not be restricted only to the biomedical model. The goal of both psychotherapy and spiritual practice is often thought to be the relief of suffering. But not all the psychotherapists can do the role of a spiritual guide and vice versa. Yet psychotherapy and spirituality also have a great deal in common. In particular, many of the processes that contribute to psychological health and well-being contribute to spiritual growth as well.
Before some years, spirituality was just a marginalized issue in psychotherapy. Now it has moved to the forefront and there are several schools offering the integration between spirituality and psychotherapy. Now the clinicians are well aware of the importance of the importance of spirituality in mental health. But most clinicians feel that they are not well equipped to use spirituality in their practice. A therapist cannot just use spirituality in psychotherapy after attending a workshop on the topic. It needs thorough knowledge of the history and the present of religion, spirituality and mental health. The therapist should know how to answer the patient’s questions regarding spirituality and psychology. Ethics should be given importance throughout the training. The therapist should keep in mind that they should not impose their values and beliefs on to the clients. Many of them do it even without understanding that they are doing it. Another important point is that the therapists should have a thorough understanding of their belief system. Because many of the clients who come to the therapy would not have a very clear idea about their belief system. This might lead to therapist imposing their own beliefs on to the clients. Different approaches of psychotherapy have different views of religion and spirituality. So it is necessary for the therapist to know the different perspectives and not just one view. Also, there are diversity among spiritual trends. It might happen within the religion as well as outside of it. The therapist should be aware of the major trends emerging. If the therapy incorporates the belief system of the person in an appropriate way , it would be helpful for the client and the family to cope with the distress. This aspect improves the quality of life for the patients.













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