Spiritually significant hallucinations: a patient-centred approach to tackle epistemic injustice.

SUMMARY: This article uses three fictitious case vignettes to raise questions and educate on how clinicians can appropriately approach patients experiencing spiritually significant hallucinations. Religious hallucinations are common but are not pathognomonic of mental illness. They are often intimate experiences for the patient that raise complex questions about psychopathology for clinicians. When assessing a patient with religious hallucinations it is important that clinicians hold at the centre that person's personal experience and create a safe space in which they are listened to and epistemic injustices are avoided. Involvement of chaplaincy services is important not just to support the patient but also to ensure that as clinicians we seek support in understanding the religious nature of these experiences.

Psychiatrists' attitudes to professional boundaries concerning spirituality and religion: mixed-methods study.

AIMS AND METHOD: Calls for the integration of spirituality into psychiatric practice have raised concerns about boundary violations. We sought to develop a method to capture psychiatrists' attitudes to professional boundaries and spirituality, explore consensus and understand what factors are considered. Case vignettes were developed, tested and refined. Three vignettes were presented to 80 mental health professionals (53% said they were psychiatrists; 39% did not identify their professional status). Participants recorded their reactions to the vignettes. Four researchers categorised these as identifying boundary violations or not and analysed the factors considered. RESULTS: In 90% of cases, at least three of the four researchers agreed on classification (boundary violation; possible boundary violation; no boundary violation). Participants' opinion about boundary violations was heterogeneous. There was consensus that psychiatrists should not proselytise in clinical settings. Reasoning emphasised pragmatic concerns. Few participants mentioned their religious beliefs. Equivocation was common. CLINICAL IMPLICATIONS: Mental health professionals seem unsure about professional boundaries concerning religion and spirituality in psychiatric practice.

Hearing spiritually significant voices: A phenomenological survey and taxonomy.

Whereas previous research in the medical humanities has tended to neglect theology and religious studies, these disciplines sometimes have a very important contribution to make. The hearing of spiritually significant voices provides a case in point. The context, content and identity of these voices, all of which have typically not been seen as important in the assessment of auditory-verbal hallucinations (AVHs) within psychiatry, are key to understanding their spiritual significance. A taxonomy of spiritually significant voices is proposed, which takes into account frequency, context, affect and identity of the voice. In a predominantly Christian sample of 58 people who reported having heard spiritually significant voices, most began in adult life and were infrequent experiences. Almost 90% reported that the voice was divine in identity and approximately one-third were heard in the context of prayer. The phenomenological characteristics of these voices were different from those in previous studies of voice hearing (AVHs). Most comprised a single voice; half were auditory; and a quarter were more thought-like (the rest being a mixture). Only half were characterful, and one-third included commands or prompts. The voices were experienced positively and as meaningful. The survey has implications for both clinical and pastoral work. The phenomenology of spiritually significant voices may be confused with that of psychopathology, thus potentially leading to misdiagnosis of normal religious experiences. The finding of meaning in content and context may be important in voice hearing more widely, and especially in coping with negative or distressing voices.

Psychiatrists, spirituality and religion.

The consensus within psychiatry is that patients' religion/spirituality are legitimate topics in assessment and treatment. Religion/spirituality can help people cope with mental illness, but their use as therapeutic tools is controversial. Despite the publication of position statements by national and international psychiatric organisations, there is no clarity over therapeutic boundaries.Declaration of interestR.P. and R.H. are atheists. C.C.H.C. is an ordained Anglican and a past Chair of the Royal College of Psychiatrists Spirituality and Psychiatry Special Interest Group. He writes here in a personal capacity.

Measuring mental health in the clinical setting: what is important to service users? The Mini-Service user Recovery Evaluation scale (Mini-SeRvE).

BACKGROUND: Since 2001, a policy of positive mental health recovery has been promoted in the UK, with service user involvement. This has not been easy to implement in the clinical setting. AIMS: To develop and validate a brief self-report, service user-designed, outcome measure (Mini-SeRvE), for clinical use, including spiritual and religious issues. METHODS: From the previously developed Service user Recovery Evaluation scale (SeRvE), 15 questions were selected for Mini-SeRvE which was self-completed by 207 people; 100 service users and, for comparison, 107 staff. Results were analysed using SPSS software (SPSS Inc., Chicago, IL). RESULTS: Mini-SeRvE is reliable, Cronbach's alpha 0.852. Correlation with another recovery scale, Mental Health Recovery Measure, was high, r = 0.819. Three reliable subscales emerged; existential well-being (EWB), mental ill-being (MIB) and religious well-being (RWB). Scores of the EWB and MIB subscales were higher for staff, consistent with higher mental well-being. Religious well-being scores were higher in service users, who also rated religion as more important to them. CONCLUSIONS: Mini-SeRvE is a valid measure of service user recovery. The importance of religion/spiritual belief for our users is highlighted, this being reflected in the subject matter of Mini-SeRvE. Mini-SeRvE assessments could show individual priorities, evaluate therapy and aid clinical decision-making.

God put a thought into my mind: the charismatic Christian experience of receiving communications from God.

The agentive aspects of communicative religious experiences remain somewhat neglected in the social sciences literature. There is a need for phenomenological descriptions of these experiences and the ways in which they differ from culturally defined psychopathological states. In this semi-structured interview study, eight congregants attending an evangelical church in London were asked to describe their experiences of God communicating with them. Communications from God were related to current events rather than to the prediction of future events. These communications were received as thoughts and do not generally reveal metaphysical insights, but rather they relate to the mundane world. They provided direction, consolation and empowerment in the lives of those receiving them. Individuals recounted that on occasion God sometimes speaks audibly, or accompanied by supernatural phenomena, but in the vast majority of cases, the way God speaks is through thoughts or impressions. In all instances, agency is maintained, individuals can choose to obey the thoughts/voices or not. The findings are discussed in relation to externalisation of agency and the phenomenon of thought insertion in schizophrenia.

Religious psychopathology: The prevalence of religious content of delusions and hallucinations in mental disorder.

BACKGROUND: Religious themes are commonly encountered in delusions and hallucinations associated with major mental disorders, and the form and content of presentation are significant in relation to both diagnosis and management. AIMS: This study aimed to establish what is known about the frequency of occurrence of religious delusions (RD) and religious hallucinations (RH) and their inter-relationship. METHODS: A review was undertaken of the quantitative empirical English literature on RD and RH. RESULTS: A total of 55 relevant publications were identified. The lack of critical criteria for defining and classifying RD and RH makes comparisons between studies difficult, but prevalence clearly varies with time and place, and probably also according to personal religiosity. In particular, little is known about the content and frequency of RH and the relationship between RH and RD. CONCLUSION: Clearer research criteria are needed to facilitate future study of RD and RH, and more research is needed on the relationship between RD and RH.

Suicide and religion.

Much of the evidence that religion provides a protective factor against completed suicide comes from cross-sectional studies. This issue of the Journal includes a report of a new prospective study. An understanding of the relationship between spirituality, religion and suicide is important in assessing and caring for those at risk.

Religion, spirituality, and mental health: current controversies and future directions.

Although studies examining religion, spirituality, and mental health generally indicate positive associations, there is a need for more sophisticated methodology, greater discrimination between different cultures and traditions, more focus on situated experiences of individuals belonging to particular traditions, and, in particular, greater integration of theological contributions to this area. We suggest priorities for future research based on these considerations.

Pathway to accommodate patients' spiritual needs.

Many service users would like their spiritual needs to be taken into account during treatment and doing so has been shown to have positive benefits. However, this rarely happens in practice. Barriers to healthcare professionals providing spiritual care include embarrassment, lack of awareness and training, fear and lack of time. This article describes the development of a spirituality care pathway as part of a wider organisational initiative to offer spiritual support in mental health services. The process highlighted the importance of developing awareness and ownership of the need for spiritual care in all service areas and among service users. A range of spiritual interventions were identified and a process of monitoring and review introduced. The approach was appreciated by service users and staff, and was developed within existing professional and management processes.

Praying with a patient constitutes a breach of professional boundaries in psychiatric practice.

The extent to which religion and spirituality are integrated into routine psychiatric practice has been a source of increasing controversy over recent years. While taking a patient's spiritual needs into account when planning their care may be less contentious, disclosure to the patient by the psychiatrist of their own religious beliefs or consulting clergy in the context of treatment are seen by some as potentially harmful and in breach of General Medical Council guidance. Here, Professor Rob Poole and Professor Christopher Cook debate whether praying with a patient constitutes a breach of professional boundaries in psychiatric practice.

Wernicke's encephalopathy revisited. Translation of the case history section of the original manuscript by Carl Wernicke 'Lehrbuch der Gehirnkrankheiten fur Aerzte and Studirende' (1881) with a commentary.

AIMS: A translation into English of the case history section of Carl Wernicke's original manuscript of 1881, with a discussion on its relevance for clinicians today. METHODS: A copy of Carl Wernicke's original German text was obtained by one of the authors (CCHC) and translated into English from the old German by a professional translator. RESULTS: The translation was subsequently agreed by native German speaking referees, and minor changes made. CONCLUSIONS: The authors studied the translation in detail and concluded that Wernicke's description had stood the test of time. The diagnosis of Wernicke's Encephalopathy remains a clinical one.

Wernicke's encephalopathy: 'Plus ça change, plus c'est la même chose'.

AIMS: To develop clinical guidelines to identify individuals who misuse alcohol and are at risk of developing Wernicke's Encephalopathy (WE). METHOD: Non-systematic literature review of studies which includes a careful clinical record of the development of signs and symptoms of thiamine deficiency and in which the diagnosis of WE has been confirmed at autopsy. RESULTS: The review of the clinical findings in cases of WE, diagnosed at autopsy, shows a consistent pattern of signs and symptoms. The pattern appears to be similar regardless of whether the thiamine deficiency is related to nutritional problems alone or associated with alcohol misuse. CONCLUSIONS: The assessment of the degree of thiamine deficiency and the diagnosis of WE remain a clinical evaluation, and guidelines are suggested to help the clinician. Since neurotoxicity due to the metabolism of excessive alcohol in patients with chronic and severe alcohol dependence may be an important factor in determining long-term outcome of treatment, this must form part of the overall evaluation.