Spiritual Meaning in Life and Values in Patients With Severe Mental Disorders.

Spirituality and meaning in life are key dimensions of recovery in psychiatric disorders. The aim of this study was to explore spiritual meaning in life in relation to values and mental health among 175 patients with schizophrenia, borderline personality disorder, bipolar disorder, and anorexia nervosa. For 26% of the patients, spirituality was essential in providing meaning in life. Depending on the diagnosis, considering spirituality as essential in life was associated with better social functioning; self-esteem; psychological and social quality of life; fewer negative symptoms; higher endorsement of values such as universalism, tradition (humility, devoutness), and benevolence (helpfulness); and a more meaningful perspective in life. These results highlight the importance of spirituality for recovery-oriented care.

Attachment and coping in psychosis in relation to spiritual figures.

BACKGROUND: Studies have found higher levels of insecure attachment in individuals with schizophrenia. Attachment theory provides a framework necessary for conceptualizing the development of interpersonal functioning. Some aspects of the attachment of the believer to his/her spiritual figure are similar to those between the child and his/her parents. The correspondence hypothesis suggests that early child-parent interactions correspond to a person's relation to a spiritual figure. The compensation hypothesis suggests that an insecure attachment history would lead to a strong religiousness/spirituality as a compensation for the lack of felt security. The aim of this study is to explore attachment models in psychosis vs. healthy controls, the relationships between attachment and psychopathology and the attachment processes related to spiritual figures. METHODS: Attachment models were measured in 30 patients with psychosis and 18 controls with the AAI (Adult Attachment interview) in relationship with psychopathology. Beliefs and practices related to a spiritual figure were investigated by qualitative and quantitative analyses. RESULTS: Patients with psychosis showed a high prevalence of insecure avoidant attachment. Spiritual entities functioned like attachment figures in two thirds of cases. Interviews revealed the transformation of internal working models within relation to a spiritual figure: a compensation process was found in 7 of the 32 subjects who showed a significant attachment to a spiritual figure. CONCLUSIONS: Attachment theory allows us to highlight one of the underlying dimensions of spiritual coping in patients with psychosis.

An exploration of sexual desire and sexual activities of women with psychosis.

Sexual disturbances in patients with severe mental disorders can be related to medication, to psychological issues such as self-stigma and anhedonia, but also to the social context. This research aims to gain knowledge of desire and sexual practices in women suffering from schizophrenia. Women outpatients suffering from schizophrenia were compared with healthy women. Contrary to previous research, women with schizophrenia featured dyadic and individual desire similar to women of comparable age. Yet, only half of women with psychosis had sexual practice, either alone or with a partner. They were less satisfied with their activity, both in terms of function and psychological issues such as sexual self-esteem. Keeping into account the fact that most clinicians avoid this topic, this finding underscores the stigmatization these women suffer from, which prevents the opportunity of a possible improvement in this important interpersonal domain.

Effectiveness of a brief group cognitive behavioral therapy for auditory verbal hallucinations: a 6-month follow-up study.

The current study investigated the effectiveness of a group cognitive behavioral therapy for auditory verbal hallucinations (AVHs), the Voices Group. This consists of seven specific sessions. Forty-one participants with schizophrenic or schizoaffective disorders completed a battery of questionnaires. The severity of psychiatric symptoms, beliefs about voices, quality of life, self-esteem, clinical global impression, and functioning were assessed at baseline, before and after intervention, and at the 6-month follow-up. After intervention, there was a statistically significant reduction in the severity of AVHs. This result remained stable at follow-up. The dropout rate was high. Some differences were found in subjective experience of AVHs between the patients who completed the intervention and those who dropped out. Altogether, these findings suggest that a brief intervention has some positive benefits in patients struggling with voices, which remain stable over time.

The wishes of outpatients with severe mental disorders to discuss spiritual and religious issues in their psychiatric care.

OBJECTIVE: In a previous multisite comparative study of spiritual and religious coping (S/R) among outpatients with schizophrenia; S/R were adaptive for 80% of patients; harmful for 13%; and marginal for 7%. This importance was underestimated by clinicians. We created an interfaith therapeutic group to address such topics. The aim of the study is to assess patients' wish to address S/R issues in their psychiatric care. METHOD: Psychiatrists asked consecutive outpatients about their wish; with who they shared S/R concerns; and their interest to enroll in the "Spiritual and Recovery Group". RESULTS: Among the 147 patients included less than half shared their spiritual concerns with other people. A quarter wished to address S/R issues in their care; 24/147 already shared those issues with a religious professional; half of them wished also to share them with their psychiatrist. Among the 21 patients who participated in an in-depth spiritual assessment 16 patients were directed to the S/R group and 5 patients were directed to groups addressing other therapeutic objectives. CONCLUSION: For one patient out of ten, S/R issues were of a clinical significance warranting integration into psychiatric treatment. This study shows that patients' views are in accordance with former research, putting forward psychiatrists' stance on this issue.

A thematic analysis of delusion with religious contents in schizophrenia: open, closed, and mixed dynamics.

The aim of the present study was to elicit how patients with delusions with religious contents conceptualized or experienced their spirituality and religiousness. Sixty-two patients with present or past religious delusions went through semistructured interviews, which were analyzed using the three coding steps described in the grounded theory. Three major themes were found in religious delusions: "spiritual identity," "meaning of illness," and "spiritual figures." One higher-order concept was found: "structure of beliefs." We identified dynamics that put these personal beliefs into a constant reconstruction through interaction with the world and others (i.e., open dynamics) and conversely structural dynamics that created a complete rupture with the surrounding world and others (i.e., closed structural dynamics); those dynamics may coexist. These analyses may help to identify psychological functions of delusions with religious content and, therefore, to better conceptualize interventions when dealing with it in psychotherapy.

Spirituality and religiousness as predictive factors of outcome in schizophrenia and schizo-affective disorders.

Spirituality and religiousness have been shown to be highly prevalent in patients with schizophrenia. This study assesses the predictive value of helpful vs. harmful use of religion to cope with schizophrenia or schizo-affective disorder at 3 years. From an initial cohort of 115 outpatients, 80% were reassessed for positive, negative and general symptoms, clinical global impression, social adaptation and quality of life. For patients with helpful religion at baseline, the importance of spirituality was predictive of fewer negative symptoms, better clinical global impression, social functioning and quality of life. The frequencies of religious practices in community and support from religious community had no effect on outcome. For patients with harmful religion at baseline, no relationships were elicited. This result may be due to sample size. Indeed, helpful spiritual/religious coping concerns 83% of patients, whereas harmful spiritual/religious coping concerns only 14% of patients. Our study shows that helpful use of spirituality is predictive of a better outcome. Spirituality may facilitate recovery by providing resources for coping with symptoms. In some cases, however, spirituality and religiousness are a source of suffering. Helpful vs. harmful spiritual/religious coping appears to be of clinical significance.

Evolution of spirituality and religiousness in chronic schizophrenia or schizo-affective disorders: a 3-years follow-up study.

PURPOSE: Spirituality and religiousness have been shown to be highly prevalent in patients with schizophrenia. Religion can help instil a positive sense of self, decrease the impact of symptoms and provide social contacts. Religion may also be a source of suffering. In this context, this research explores whether religion remains stable over time. METHODS: From an initial cohort of 115 out-patients, 80% completed the 3-years follow-up assessment. In order to study the evolution over time, a hierarchical cluster analysis using average linkage was performed on factorial scores at baseline and follow-up and their differences. A sensitivity analysis was secondarily performed to check if the outcome was influenced by other factors such as changes in mental states using mixed models. RESULTS: Religion was stable over time for 63% patients; positive changes occurred for 20% (i.e., significant increase of religion as a resource or a transformation of negative religion to a positive one) and negative changes for 17% (i.e., decrease of religion as a resource or a transformation of positive religion to a negative one). Change in spirituality and/or religiousness was not associated with social or clinical status, but with reduced subjective quality of life and self-esteem; even after controlling for the influence of age, gender, quality of life and clinical factors at baseline. CONCLUSIONS: In this context of patients with chronic schizophrenia, religion appeared to be labile. Qualitative analyses showed that those changes expressed the struggles of patients and suggest that religious issues need to be discussed in clinical settings.

The relationship between addiction and religion and its possible implication for care.

Spirituality is a topic of increasing interest to clinicians and researchers interested in addiction because its perceived role in the promotion of meaningfulness in the recovery from addiction. Our review of the literature evaluates different domains relative to the relation between addiction, religion, and psychiatric treatment. Spirituality as a protective or precipitating factor for substance use and as a key component of recovery will be debated. Illustrations of its potential and limitations as a component of treatment will be presented. Types of investigation and integration of this dimension in an eventual therapeutic process strictly respecting the needs and specificities of each one will be discussed.

Religion and spirituality: how clinicians in quebec and geneva cope with the issue when faced with patients suffering from chronic psychosis.

Spirituality and religion have been found to be important in the lives of many people suffering from severe mental disorders, but it has been claimed that clinicians "neglect" their patients' religious issues. In Geneva, Switzerland and Trois-Rivières, Quebec, 221 outpatients and their 57 clinicians were selected for an assessment of religion and spirituality. A majority of the patients reported that religion was an important aspect of their lives. Many clinicians were unaware of their patients' religious involvement, even if they reported feeling comfortable with the issue. Both areas displayed strikingly similar results, which supports their generalization.

Influence of spirituality and religiousness on substance misuse in patients with schizophrenia or schizo-affective disorder.

Substance misuse represents a major issue in the treatment of schizophrenia patients. Spirituality and religiousness have been shown to reduce substance misuse and to foster recovery among substance misusers in the general population. One hundred and fifteen stabilized outpatients with schizophrenia (mean age 39; 70% male) were selected in 2004 for an interview about religious coping. Religious involvement was significantly inversely correlated to substance use and abuse. A content analysis showed that religion may play a protective role toward substance misuse in 14% of the total sample, especially for patients who had stopped substance misuse (42%). It played a negative role in 3% of cases. Religion may play a role in the recovery of schizophrenia patients with substance misuse comorbidity.

Influence of spirituality and religiousness on smoking among patients with schizophrenia or schizo-affective disorder in Switzerland.

BACKGROUND: The rates of cigarette smoking among patients with schizophrenia are two to four times the rates observed in the community. Spirituality and religiousness have been shown to be associated with lower smoking rates in the general population. AIMS: This study assessed the role of religion in cigarette smoking among patients with schizophrenia or schizo-affective disorder. METHODS: Some 115 stabilized outpatients from Geneva's public psychiatric facilities were included. Interviews were conducted to investigate spiritual and religious beliefs, religious practices and religious coping. Cigarette smoking was assessed through interviews and medical records. RESULTS: Some 58% of patients were smokers. Two-thirds of the total sample considered spirituality as very important or essential in their every day life. Religiosity was negatively associated with tobacco use: there were more current smokers without religious affiliation than non-smokers (p < 0.05). For non-smokers, the support of their faith community was significantly more important and they reported more frequent group religious practices than smokers ( p < 0.05). This relation persisted after controlling for demographic confounders (gender, age, ethnicity, education, civil status). CONCLUSION: In patients with schizophrenia, religion and spirituality seem to be related to smoking behaviour. Similar results were previously found in the general population. These results underscore the need for a systematic exploration of religious issues in the care of smokers with schizophrenia.

Effect of religion on suicide attempts in outpatients with schizophrenia or schizo-affective disorders compared with inpatients with non-psychotic disorders.

Little is known of the relations between psychosis, religion and suicide. One hundred and fifteen outpatients with schizophrenia or schizo-affective disorder and 30 inpatients without psychotic symptoms were studied using a semi-structured interview assessing religiousness/spirituality. Their past suicide attempts were examined. Additionally, they were asked about the role (protective or incentive) of religion in their decision to commit suicide. Forty-three percent of the patients with psychosis had previously attempted suicide. Religiousness was not associated with the rate of patients who attempted suicide. Twenty-five percent of all subjects acknowledged a protective role of religion, mostly through ethical condemnation of suicide and religious coping. One out of ten patients reported an incentive role of religion, not only due to negatively connotated issues but also to the hope for something better after death. There were no differences between groups (i.e. psychotic vs. non-psychotic patients). Religion may play a specific role in the decisions patients make about suicide, both in psychotic and non-psychotic patients. This role may be protective, a finding particularly important for patients with psychosis who are known to be at high risk of severe suicide attempts. Interventions aiming to lower the number of suicide attempts in patients with schizophrenia should take these data into account.

[Income and expenses of patients with chronic psychosis]. / Revenus et dépenses des patients souffrant de psychose chronique.

Knowledge about the income of patients with chronic psychotic disorder and how they use the money may help to provide appropriate clinical and social assistance. Fifty-seven outpatients with schizophrenia treated in Geneva, Switzerland, were studied. Mean income was 3866 Swiss francs (4209 for those with the Swiss disability fund). Only a minority of patients live on meager resources with insufficient comfort. A 4 weeks follow-up showed that patients disposed of a mean of 400 Swiss francs discretionary money. Twenty eight percent of this money was used for leisure activities. This psychiatric and social system allows stabilized patients with psychosis to get what they need in terms of financial support and housing. However, patients should be helped to use their discretionary money in ways more prone to help recovery.

Toward an integration of spirituality and religiousness into the psychosocial dimension of schizophrenia.

OBJECTIVE: Spirituality and religiousness have been shown to be highly prevalent among patients with schizophrenia. However, clinicians are rarely aware of the importance of religion and understand little of the value or difficulties it presents to treatment. This study aimed to assess the role of religion as a mediating variable in the process of coping with psychotic illness. METHOD: Semistructured interviews about religious coping were conducted with a sample of 115 outpatients with psychotic illness. RESULTS: For some patients, religion instilled hope, purpose, and meaning in their lives (71%), whereas for others, it induced spiritual despair (14%). Patients also reported that religion lessened (54%) or increased (10%) psychotic and general symptoms. Religion was also reported to increase social integration (28%) or social isolation (3%). It may reduce (33%) or increase (10%) the risk of suicide attempts, reduce (14%) or increase (3%) substance use, and foster adherence to (16%) or be in opposition to (15%) psychiatric treatment. CONCLUSIONS: Our results highlight the clinical significance of religion in the care of patients with schizophrenia. Religion is neither a strictly personal matter nor a strictly cultural one. Spirituality should be integrated into the psychosocial dimension of care. Our results suggest that the complexity of the relationship between religion and illness requires a highly sensitive approach to each unique story.

Spirituality and religious practices among outpatients with schizophrenia and their clinicians.

OBJECTIVES: Religious issues may be neglected by clinicians who are treating psychotic patients, even when religion constitutes an important means of coping. This study examined the spirituality and religious practices of outpatients with schizophrenia compared with their clinicians. Clinicians' knowledge of patients' religious involvement and spirituality was investigated. METHODS: The study sample included 100 patients of public psychiatric outpatient facilities in Geneva, Switzerland, with a diagnosis of nonaffective psychosis. Audiotaped interviews were conducted with use of a semistructured interview about spirituality and religious coping. The patients' clinicians (N=34) were asked about their own beliefs and religious activities as well as their patients' religious and clinical characteristics. RESULTS: Sixteen patients (16 percent) had positive psychotic symptoms reflecting aspects of their religious beliefs. A majority of the patients reported that religion was an important aspect of their lives, but only 36 percent of them had raised this issue with their clinicians. Fewer clinicians were religiously involved, and, in half the cases, their perceptions of patients' religious involvement were inaccurate. A few patients considered religious practice to be incompatible with treatment, and clinicians were seldom aware of such a conflict. CONCLUSIONS: Religion is an important issue for patients with schizophrenia, and it is often not related to the content of their delusions. Clinicians were commonly not aware of their patients' religious involvement, even if they reported feeling comfortable with such an issue.

Values as determinant of meaning among patients with psychiatric disorders in the perspective of recovery.

Recovery is a personal process of growth that involves hope, self-identity, meaning in life and responsibility. Determinants of meaning have not been explored among populations of patients with persistent psychiatric conditions. However, an evidence-based approach aiming at assessing such determinants should provide some insight into the psychotherapeutic aspects of recovery. We tested a model hypothesizing that some symptoms and social parameters of patients are related to values, and secondarily to meaning in life, and in turn that meaning is associated with various parameters, such as depressiveness and self-esteem. We assessed 176 patients with schizophrenia, anorexia, borderline personality disorder and bipolar disorder. Overall, our hypotheses proved correct: firstly, characteristics such as depression, hopelessness, self-esteem and the number of relationships influenced values; secondly, the presence and an enactment of values were associated with meaning, and thirdly, meaning was associated with some symptoms and social characteristics. This model was confirmed in the four psychiatric populations under study. These results support the relevance of addressing values and meaning in the recovery-oriented care of patients with persistent psychiatric disorders, in addition to other psychosocial interventions which are more systematically considered in this area.

Stages of change in smokers with schizophrenia or schizoaffective disorder and in the general population.

This study compared smoking behavior and motivation to quit smoking, assessed with a "stages of change" questionnaire, in outpatients with schizophrenia or schizoaffective disorder and in a representative sample of the general population. We conducted a mail survey in a representative sample of the general population of Geneva, Switzerland, in 1996 (n = 742); and a survey of 151 patients with schizophrenia (84%) or schizoaffective disorder (16%) who attended a Geneva ambulatory psychiatric clinic in 2000. There were more smokers (70% vs. 28%, p < 0.001) in patients with schizophrenia or schizoaffective disorder than in the general population, and fewer ex-smokers (15% vs. 52%, p < 0.001). Patients with schizophrenia or schizoaffective disorder smoked more than smokers in the general population (22 vs. 16 cigarettes per day, p < 0.001). Among current smokers, the distribution of stages of change was similar in patients with schizophrenia or schizoaffective disorder (precontemplation 79%, contemplation 18%, preparation 3%) and in the general population sample (74%, 22%, and 4%, p = 0.6). In both samples, similar proportions of smokers had made an attempt to quit in the previous year (27% vs. 22%, p = 0.3). These results suggest that a substantial minority of smokers with schizophrenia or schizoaffective disorder are motivated to quit smoking, try to quit, and succeed in quitting.

The relationship between schizophrenia and religion and its implications for care.

This paper focuses on the relationships between schizophrenia and religion, on the basis of a review of literature and the data of an ongoing study about religiousness and spiritual coping conducted among outpatients with chronic schizophrenia. Religion (including both spirituality and religiousness) is salient in the lives of many people suffering from schizophrenia. However, psychiatric research rarely addresses religious issues. Religious beliefs and religious delusions lie on a continuum and vary across cultures. In Switzerland for example, the belief in demons as the cause of mental health problems is a common phenomenon in Christians with high saliency of religiousness. Religion has an impact, not always positive, on the comorbidity of substance abuse and suicidal attempts in schizophrenia. In many patients' life stories, religion plays a central role in the processes of reconstructing a sense of self and recovery. However religion may become part of the problem as well as part of the recovery. Some patients are helped by their faith community, uplifted by spiritual activities, comforted and strengthened by their beliefs. Other patients are rejected by their faith community, burdened by spiritual activities, disappointed and demoralized by their beliefs. Religion is relevant for the treatment of people with schizophrenia in that it may help to reduce pathology, to enhance coping and to foster recovery. In the treatment of these patients, it appears useful to tolerate diversity, to respect others beliefs, to ban proselytism and to have a good knowledge of one's own spiritual identity.