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Build your staff's spiritual competency

September 01, 2010

In the July/August 2010 issue of Behavioral Healthcare, we began a conversation about the important role of spirituality in the recovery process. With the help of co-author Rev. Laura Mancuso, a psychiatric rehabilitation counselor and interfaith minister, we discussed factors that help and hinder the use of spirituality in the recovery process and traced its 20-plus year emergence as a wellness and recovery resource. In so doing, we sought to show that attending to the body, mind, and spirit of service recipients is not a new or fleeting fad, but an integral part of high-quality mental healthcare that consumers and family members have long sought.

Healthcare's spiritual history

One could easily call this “the return” of spirituality to mental healthcare, as the two were united long before they were at odds. Christina Puchalski, MD, founder of the George Washington University Institute on Spirituality and Health (, notes that there was a powerful relationship between spirituality and healthcare in this country until the 19th century. Before then, most healthcare services were provided by religious organizations who emphasized altruism, service, compassion, and the relief of suffering. Puchalski maintains that healthcare's drive for “quick fixes” and cures caused us to lose sight of the need for compassion, as well as the need to address spiritual and existential distress with the same urgency and focus as we do for physical pain. And, as we seek evidence-based practices, we must recognize that science can take us only so far. “Healing involves an appreciation of mystery,” she asserts, since science alone has not eliminated suffering.1

If they started out together, what led to the current divide between mental health and spirituality? Sigmund Freud famously viewed religious belief as an infantile, neurotic illusion. And, the remarkable scientific achievements of the last century have led Americans in particular to see science as a potential solution to all of our problems. Psychiatry and psychology, already considered “softer” sciences than their medical counterparts, joined in shunning the mystical in favor of the measurable, and instructed trainees to avoid discussing spirituality or religion altogether.

A model for reintegration

In her recent book, Wrestling With Our Inner Angels, Roman Catholic nun and clinical psychologist Nancy Kehoe describes how she instinctively downplayed her role as a member of the Sacred Heart religious order when she started working as a clinical instructor in psychology at Harvard Medical School. She heeded the admonition of Hungarian psychiatrist Thomas Szasz that theists were automatically suspect within the mental health field: “If you talk to God, you are praying; if God talks to you, you have schizophrenia.”2

When she finally gathered the courage to propose the formation of a group focused on religious and spiritual beliefs in a day treatment program, her idea was met with stunned silence, followed by a series of objections from fellow staff: Some participants might try to convert others; religious delusions might be affirmed; staff might be asked to explain their own religious views; program funding could be threatened; and more. But with the help of a determined program director, the group was eventually approved.

From the beginning, Dr. Kehoe required participants to “respect every other member and be able to tolerate differences in beliefs.” As the group's leader, she never inquired about participants’ psychiatric diagnoses, considering them irrelevant, noting, “Perhaps unconsciously, this came from my own experience of being stereotyped as a nun.” 3

Dr. Kehoe went on to lead spiritual beliefs and values groups at several other locations for 27 years, and the initial fears never came to fruition. She says, “With a track record of 3,224 group sessions, I can attest to the fact that no client has ever become more delusional because of the group, no client has tried to convert others in the community, and no client has resisted working with a therapist of a different belief. Clients with different religious beliefs have not split the community. These 27 years have uncovered a rich inner terrain, one that had been hidden from mental health providers but has been a source of strength and resilience for the clients.”3

That's an impressive body of experience that attests to the value of spirituality in mental health services, and how Dr. Kehoe succeeded in this delicate area is almost as important as what she did. First, she approached the topic with humility, an open mind, and an open heart. Second, she moved slowly and thoughtfully when introducing a new spirituality activity into a mental health program. Last, she set clear guidelines about respect and tolerance for diversity by all involved.

If you're interested in this approach, there's no reason to start from scratch. As we researched this topic, we discovered pockets of innovation in community-based and publicly-funded programs across the country. Some of these programs have done wonderful work for decades with little fanfare and perhaps prefer it that way, given the controversial nature of spirituality within the mental health system. We hope that starting the conversation with you, right here, will motivate you to share lessons learned or find out why spirituality is excluded from the wellness and recovery resources offered at your organization.

Initiating a recovery-focused spirituality program

If you find yourself at the beginning stages of exploration, here are some places to start:

Designate a space for contemplation. If outdoors, create a pleasing environment with comfortable places to sit close to nature. Consider adding a permanent or removable labyrinth if space allows. For indoor spaces, equip the room with supplies to soothe each of the senses: soft lighting and inviting colors; cozy places to sit or recline; relaxing music; pure essential oils for aromatherapy; candles; and materials for making art or journal writing.

Focus on the body-mind-spirit wellness of staff. Ask them how they take care of their own well-being and what nourishes their spirit. We've learned the hard way that we cannot transform our programs and systems in spite of our staff-rather, we need to engage them first, listening to and validating their experiences, while also clearly articulating our organizational values and strategic direction.

Consider objections to including spirituality in programming. Use a problem-solving approach by asking questions like, “How might we overcome that issue?” “What would help?” and “If you were receiving services here, what would you like to see happen?”

Learn about the cultural, spiritual, and religious characteristics of the people you serve, or desire to serve. Ask to be introduced to respected spiritual leaders in the local community. Bring a gift and do more listening than talking. Find out how they approach mental health issues and how you may support them in what they do. Look for areas in which your resources can complement theirs. For example, we know that people tend to turn to their faith communities for help with emerging mental health problems before looking to professionals for help. So how can your program establish itself as the go-to resource for individuals or families whose needs exceed the level of support provided there?

Promote diversity. Expose service providers and recipients to authentic sharing by individuals from diverse cultural, religious, and spiritual backgrounds. In doing so, keep in mind that no one person can speak for an entire group-for example, no single Christian can represent the views of all Christians.

Remember that spiritual strength comes in all shapes and sizes. Many people are deeply comforted by time spent in nature, for example, even if “God-talk” is meaningless to them. Include presentations by individuals who are atheist, humanist, and/or secular.

Make a list of dos and don'ts. Develop an organizational policy on the ethics of including spirituality in programming, and communicate it clearly to your staff.

Encourage self-exploration. As with other aspects of cultural competency, express the expectation to employees that we all need to become aware of our own sensitivities and biases regarding spirituality and religion.

Create an organizational culture in which it's safe and customary for staff to inquire about the wishes, preferences, and experiences of those they serve regarding spirituality and religion. Provide examples of neutral and helpful questions from established spiritual assessment instruments-such as the Pargament Meaning Scale or the FICA Spiritual History Tool-to help them open a dialogue.4,5

Include spirituality as a topic for self-help groups. This can enable individuals to share daily spiritual practices that have been helpful during troubled times. Include resources from diverse cultural, religious, and spiritual perspectives. Offer the opportunity for people to write a spiritual autobiography or draw a spiritual life map.6,7

It is the recovery vision and its focus on people's meaning and purpose that can help bridge the divide that some still believe exists between spirituality and mental health. When our field of practice and research turns from an almost singular focus on pathology and symptoms toward an emphasis on recovery, resilience, and health, our field of interest will expand and spirituality can assume its rightful place as a source of healing and growth.

Lori Ashcraft, PhD, directs the Recovery Opportunity Center at Recovery Innovations, Inc. in Phoenix. She is also a member of Behavioral Healthcare's editorial board. William A. Anthony, PhD, is director of the Center for Psychiatric Rehabilitation at Boston University. Rev. Laura L. Mancuso, MS, CRC, serves the mental health community in California as an interfaith chaplain, and was director of the California Mental Health and Spirituality Initiative from 2008-2010.


  1. Puchalski C. Presentation to Santa Barbara Cottage Hospital Psychiatric Grand Rounds. Santa Barbara, California :January 13, 2010.
  2. Szasz TS. The Second Sin. Garden City, NY:Anchor/Doubleday, 1973.
  3. Kehoe N. Wrestling With Our Inner Angels: Faith, Mental Illness and the Journey to Wholeness. San Francisco:Jossey-Bass, 2009.
  4. Pargament KI. Multidimensional measurements of religiousness/spirituality: Use in Health Research. Kalamazoo, MI:Fetzer Institute, 1999.
  5. FICA Spiritual History Tool. The George Washington Institute on Spirituality and Health.
  6. Wakefield D. The Story of Your Life: Writing a Spiritual Autobiography. Boston:Beacon Press, 1990.
  7. Hodge DR. Spiritual life maps: A Client-centered pictorial instrument for spiritual assessment, planning, and intervention. Social Work 2005; 50:77-87.

Behavioral Healthcare 2010 September;30(8):10-13

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