Looking back, Jenny thinks that her symptoms began when she was only 12 years old, but receiving a diagnosis of obsessional compulsive disorder was still a shock when it came in her early twenties. I first met her not in my work as a psychiatrist but in my role as an honorary NHS chaplain, by which time she was training to be a chef. Her obsessional thoughts about sharp knives and contamination of food had begun to cause problems for her at work. She had distressing mental images of harm that she might cause herself or others. A GP (primary care physician) had referred her for psychiatric assessment.

Jenny was preoccupied with fears of death. When babysitting as a teenager she had had worries that the infant she was caring for would stop breathing, and so would be constantly checking that the child was still okay. If she knew someone was going to die, she reasoned, she would want to tell them that she loved them. Extrapolating from this, in a form of thought-action fusion (TAF) (Shafran and Rachman, Reference Shafran and Rachman2004), she worried that if she did tell her family or boyfriend that she loved them then they might actually die. This, in turn, made it difficult for her to tell them that she loved them.

A consultant psychiatrist diagnosed obsessive-compulsive disorder (OCD), started Jenny on citalopram, and referred her for psychotherapy. The therapist began a programme of exposure and response prevention. She made good progress on treatment, but still struggled to manage aspects of her condition which, she felt, neither the GP nor the psychiatrist had fully understood.

Jenny is a Christian, a member of the congregation of her local parish church where charismatic spirituality involves expressive acts such as raising hands in praise to God when singing contemporary worship songs. Biblical teaching in the church emphasises spontaneity in prayer and obedience to the Holy Spirit. Jenny found herself distracted during church worship by intrusive thoughts about whether or not it was the Holy Spirit that was prompting her to raise her hands. She didn’t want to be disobedient to God, or to miss out on opportunities to draw close to him, but how could she know if this was God or not?

At night, Jenny experienced ‘promptings’ to get out of bed and pray, so that she was losing sleep and getting increasingly tired during the day. She feared that – if she did not pray as she should – she might not be forgiven for wrong things she had done during the past day, or that she might die in her sleep and go to hell. She feared that if she had not prayed for her loved ones, bad things might happen to them, or they might die. She feared not being thankful to God for all the good things in her life. This had been made worse by a minister in the church who used to ask, ‘What would you have tomorrow if you only had what you thanked God for today?’ She also felt anxiety if she missed her prayers before bedtime, which consequently made these devotions an obligation rather than a joy and further enhanced her tiredness. There was thus a lot of fear and anxiety, and it revolved mainly around Jenny’s Christian spirituality.

A Sunday sermon in church, just after Christmas, had focussed on the story of the ‘slaughter of the innocents’ (Matthew 2:16–18), a rather gruesome biblical story in which King Herod murdered thousands of innocent children. This left Jenny with particularly distressing and intrusive mental images of murdered children. She became angry with God that he would allow all of this to happen to her and frustrated that her illness was affecting all the areas of her life that were most important to her. In her conversation with me, she voiced the question: ‘Is nothing sacred?’ She was finding it difficult to disentangle her faith from her illness.

Jenny had told her psychiatrist about these concerns but, although he seemed to understand at one level, he clearly didn’t appreciate why the spiritual aspects of her illness were so important to her. The psychotherapist had been a little more understanding and had incorporated some of the religious compulsions into her programme of exposure and response prevention. However, Jenny found that medical professionals generally didn’t seem to understand her faith, or the particular distress that she experienced because of the way that her illness was disrupting her spiritual life and causing her to question everything. She was even more worried about what folks at church would think about her illness. The failure of medical professionals to understand the importance of Jenny’s faith led to omission of significant aspects of her illness from treatment planning. The lack of understanding of members of her faith community in relation to mental health issues left her not knowing where to go with the important, and very valid, spiritual and theological questions that she had about what she was experiencing.

In our conversations together, Jenny and I were able to explore illness in the context of faith and faith in the context of illness, so that she was able to find a way of integrating the different areas of her life with her Christian worldview. Illness in the context of faith was hard to accept. Why would God allow this to happen? Looking back, Jenny realises that – as a result of her illness – her faith had become very rule-bound and obligational. As she put it, she had lost sight of the grace of God. Faith in the context of illness was more complicated than she felt it should be. Now, however, as she enters into a phase of recovery where she is able to get back to work and enjoy life again, she is able to be more discerning about inner ‘promptings’ and where they come from, spiritually speaking. This has made faith a bit more complex but has also deepened her awareness of the importance and nature of her relationship with God. She has learnt to be more discerning about the inner promptings that she experiences, and to distinguish more easily between what she believes is the voice of the Holy Spirit and what is more obviously obsessional. Her faith and her self-awareness have deepened as a result, all of which has enhanced and promoted her recovery from her mental health condition.

Reflecting with Jenny

Reflecting on Jenny’s illness, I’m sure that all psychiatrists will easily identify the features of an obsessive-compulsive disorder. The recurring, intrusive thoughts and mental images that she experienced are a very typical example of the psychopathology of this condition, although, actually, intrusive thoughts are experienced by almost everyone in the wider population in a sub-clinical, and less distressing, form (Clark et al., Reference Clark, Abramowitz, Alcolado, Alonso, Belloch, Bouvard, Coles, Doron, Fernández-Álvarez, Garcia-Soriano, Ghisi, Gomez, Inozu, Moulding, Radomsky, Shams, Sica, Simos and Wong2014). The themes of concern around sharp objects and food contamination are common ones. Compulsive checking is similarly characteristic, albeit this was a less distressing feature of the illness as far as Jenny was concerned. I don’t think that the diagnosis was in much doubt, and the treatment prescribed was reassuringly and rapidly effective. An observant psychiatrist, as indeed her clinician was, would have noticed that the spiritual ‘promptings’ also had an obsessional character. However, reflecting on this aspect of her illness, as merely another instance of psychopathology, risks an important omission that could have been avoided by reflecting with Jenny on her spiritual experience.

The phenomenology of Jenny’s story is both an account of an illness and an account of a spiritual experience (or series of experiences) in the context of Christian faith. It is understandable, although not necessarily excusable, that mental health professionals should focus more on the illness than on the spiritual experiences. A person-centred account might more readily identify spiritual concerns as the primary feature of the story, in support of which psychiatry has something important to offer by way of a diagnosis that supports a treatment plan which, in turn, leads to relief of distress. However, the treatment plan is inadequate if it leaves the salient area of the patient’s concerns unaddressed. How is Jenny to make sense of the confusion she experiences in relation to distinguishing between promptings of the Holy Spirit and obsessional anxieties due to her illness? The spiritual aspects of Jenny’s illness were not a peripheral matter, and they were not adequately addressed by clinicians who, at best, treated them as part of the illness or, at worst, ignored them. Equally, members of her local church did not know how to help her with her illness and, such was the stigma, she did not feel able to talk to most of them about it.

Reflecting with Jenny, and seeing things from her perspective, the phenomenology of spiritual experience and that of psychopathology were all mixed up with each other. This was a central concern, raising questions about how to deal with an illness in the context of faith, and how to address spiritual concerns in the context of an illness. Just dealing with the illness was, at best, addressing only half of the problem, and the less important half at that. We might speculate that, in the mind of her psychiatrist, faith was not his problem, or else was only peripheral. Actually, that is a kind of mix-up too – mixing up a personal pragmatic atheismFootnote ¹ with a professional role as clinician and thereby failing to see things from Jenny’s spiritual perspective. Similarly, we might speculate that folks at church would view Jenny’s illness as a failure of her faith in some way, perhaps as something that wouldn’t have happened if she had had more faith, or – even worse – not an illness at all but a failure to be obedient to the promptings of the Holy Spirit. Again, this seems to be a mix-up on their part, a mixing up of illness and faith in such a way as to obscure almost completely the role of the former in giving rise to her distress.

These mix-ups, or entanglements, of spirituality and mental illness also betray stigma and prejudice on the part of those concerned. Clinicians, whether they consciously mean to or not, easily convey a largely subliminal message that they don’t want to talk about spirituality (which, in their minds, may be only a part of the illness anyway), and members of a faith community easily convey a similarly implicit message that faithful Christians (or Muslims, or Jews, or others) shouldn’t experience mental illness. This leaves the patient – the person – at the centre of all of this in a position of not being properly understood by anyone and being stigmatised by everyone. It is a lonely place to be.

Entanglements

Entanglement has become a focus of interest in a range of different literatures in recent years, from physics to sociology (Fitzgerald and Callard, Reference Fitzgerald, Callard, Whitehead, Woods, Atkinson, Macnaughton and Richards2016). In the critical medical humanities, it has raised important questions about the ways in which different disciplines and professions engage with each other as they seek to understand, and treat, the human condition. This is not a question of trying to disentangle complex phenomena; it is rather an active seeking out of entanglement as a better way of understanding things:

My contention in this book is that spirituality and religion are inherently entangled with psychiatry. Boundaries and differences do matter, as will be discussed later in the book, but these are things that are necessarily created, and should not be seen as things that have to be overcome in order to achieve an integrative perspective (Fitzgerald and Callard, Reference Fitzgerald, Callard, Whitehead, Woods, Atkinson, Macnaughton and Richards2016, p.41). Rather, spirituality and religion exist in a fluid, relational and dynamic entanglement with psychiatry which offers scope for a different way of seeing things than the one that currently fuels the oppositional boundary disputes that will be discussed in Chapter 8.

Just as academic and professional disciplines are entangled, so are people. In anthropology, a distinction is made between the ‘dividual’ and the individual self. Whereas the individual self, so highly prized in individualistic Western society, is understood as a discrete entity, the dividual self is both more fragmented and more integrated:

If the concept is related to self (rather than person), the dividual self ‘according to modern psychiatry’ shows signs of severe psychopathology (Spiro, Reference Spiro1993, p.109). However, the concept arguably relates more to the person, rather than the self, and as such is less concerned with psychology or psychiatry and more with sociology and anthropology. In any case the distinction between the dividual and the individual, arising originally from comparisons of Western and non-Western concepts of self/person, has been increasingly recognised as representing contrasting modes of personhood that all human beings inhabit. It is less concerned with distinctions between people, Western and non-Western, and more with different ways of seeing ourselves in the world.

In A Secular Age, Charles Taylor (Reference Taylor2007) contrasts what he calls the ‘porous’ self of an enchanted premodern world and the ‘buffered’ self of the modern disenchanted world. The buffered self experiences a much stronger sense of the boundary between the self and the world (including others), whereas the porous self has more permeable boundaries and sees greater connectedness both with other human beings and with a wider order of material and spiritual things. As Karl Smith (Reference Smith2012) has pointed out, the porous self and the dividual self share some significant things in common, albeit the distinctions in relation to the former have been based more on changes in worldview associated with European history, and the latter more upon cross-cultural comparisons. Smith suggests that the human subject is inherently porous and that this is actually a good thing:

Whilst I accept Smith’s point completely in the context of his argument, Taylor’s articulation of the concept of porosity clearly does include an openness to a spiritual world, as well as to a social and natural one. The porous self, in many ways like the dividual self, is radically entangled with a wider natural, sociocultural and spiritual order. The buffered self, so characteristic of our secular age, seeks to deny this, but is that a good thing to do?

Spirituality

So much metaphorical ink has been spilt in an attempt to ‘define’ spirituality that it easily completely obscures the key issues in relation to psychiatry. Spirituality is an inherently complex and contested concept which eludes simple definition. It is virtually impossible to distinguish from psychological outcome variables in research, so that Harold Koenig (one of the leading scientific researchers in this field today) has argued that, in terms of research methodology, it is better to study religion or religiosity (Koenig, Reference Koenig2008a). However, as Koenig acknowledges, spirituality is still a useful term in clinical practice. It allows a more inclusive conversation than does, for example, the concept of religion. To this end, some years ago now, I proposed the following definition, which has subsequently been used in the position statement on spirituality and psychiatry adopted by the Royal College of Psychiatrists (RCPsych):

This definition is not perfect; it is prolix, and some significant work has been done by others over the last two decades in terms of further clarifying the different components of the concept which might be important in clinical practice (e.g., De Brito Sena et al., Reference De Brito Sena, Damiano, Lucchetti and Peres2021). However, it is inclusive of those who are spiritual but not religious (SBNR) as well as those who adopt religious forms of spiritualty, which was one of the original objectives in developing it. It incorporates some of the key concerns – relationality, transcendence, meaning – without requiring subscription to any of the more divisive stances in debates over theology, religion or tradition. It was intended to open up a constructive conversation, rather than promote defensive arguments, and I think that it has helped towards this end. However, like all definitions of spirituality, it indirectly implies that scientists might study it as a ‘thing’ that is amenable to objective investigation, and this is somewhat in contradiction to its highly subjective nature. If it is truly concerned with transcendence, this may simply not be possible in any meaningful way, given that science is concerned with the immanent order of things. If it is possible at all, then it will involve studying proxy variables (such as meaning and purpose in life, or religious identity) which will always move the conversation to a slightly different field of meaning than that of ‘spirituality’.

Perhaps it is important here, in passing, to note some of the things that spirituality is not. It is not a proxy for religion (which will be discussed later), albeit there is a significant overlap and connection between the two topics. For some people, spirituality and religion are almost opposites; for others, they are almost co-terminous. It is not a shorthand for some kind of dualism of supernatural and material domains, even if some people do see it in exactly this way. By the same token, it does not mean ‘belief in God’. In many ways, it is easier to say what spirituality is not than to say what it is.

The concept of spirituality is inherently problematic. For example, I know that some of my colleagues see it as unhelpful in relation to boundary issues (which I will discuss further in Chapter 8). However, that does not necessarily mean that we should dispense with it; rather – I believe – we should engage with it in a critical and thoughtful way. My major concern here is the way in which it is seen as an optional extra, rather than as a core concern of the biopsychosocial model which has been so central to psychiatry for the last several decades. Ironically, it is many of those who share my concerns with the importance of spirituality with whom I differ here. A common trope has been to propose the expansion of the biopsychosocial model to become a biopsychosocial-spiritual model (e.g., Kuhn, Reference Kuhn1988; McKee and Chappel, Reference McKee and Chappel1992; Galbadage et al., Reference Galbadage, Peterson, Wang, Wang and Gunasekera2020). This fundamentally fails to take into account the entanglement of spirituality with the biopsychosocial domains and simply makes it easier to say that the latter are the responsibility of health professionals, whilst the former is the responsibility of clergy, chaplains and spiritual care professionals.

Spirituality is radically, and inextricably, entangled with the biopsychosocial concerns of psychiatry. Starting with the biology, George Vaillant (Reference Vaillant2013), for example, has suggested that what we ‘really’ mean by spirituality is a constellation of eight emotions – ‘awe, love/attachment, trust/faith, compassion, gratitude, forgiveness, joy and hope’ (p.590) – that have historically been neglected by psychiatry. Spirituality is, he believes, ‘not about ideas, sacred texts and theology’ (p.590) but, rather, ‘all about emotion and social connection’ (p.590) which, in turn, he observes, are dependent on the limbic system rather than the cortex. ‘[R]eligion arises from cognitive culture; spirituality arises from limbic biology’ (p.592). To take a rather different example, transliminality, a rather broad concept, thought by Thalbourne and Maltby (Reference Thalbourne and Maltby2008) to be associated with mystical and paranormal experiences (amongst other things), is said to be associated with temporal lobe lability. Yet another example may be found in the attentional concerns of spirituality (discussed in Chapter 7), which relate to biologically based specialisation of the different modes of attention made possible by circuits in the left and right hemispheres of the brain. Indeed, however spirituality might be interpreted, there has to be some biological basis for it in neuroscience unless, of course, one adopts a completely dualistic model of anthropology with all its concomitant Cartesian problems.

Spirituality is further entangled, as Koenig (Reference Koenig2008a) has cogently observed, with human psychology; so much so that it is virtually impossible to operationalise it in empirical research in non-psychological terms. Measures of spiritual well-being typically include such things as ‘optimism, forgiveness, gratitude, meaning and purpose in life, peacefulness, harmony, and general wellbeing’ (Koenig, Reference Koenig2008a, p.349), all of which are also aspects of mental health, and primarily psychological variables. Ralph Piedmont (Reference Piedmont1999) has proposed that spirituality, understood as a motivational domain of ‘spiritual transcendence’, actually represents a sixth factor of personality, alongside those included in the now well-established five-factor model. None of this should be surprising. Spirituality may be centrally concerned with transcendence, but transcendence is a concept with which people engage in cognitive and emotional ways. Even if spiritual experiences are sometimes ineffable, they are still psychologically mediated and they have cognitive and affective concomitants. Even theological virtues such as hope are inextricably entangled with psychological states of well-being (Espedal, Reference Espedal2021).

Finally, and equally unsurprisingly, spirituality is concerned with social and cultural dimensions of well-being. Whilst spirituality is often portrayed as subjective, and individually orientated, in contrast to the social structures of religion, it is also usually defined as relational. It is centrally concerned with relationships with self, with others, and with some wider or transcendent reality, variously defined (e.g., Cook, Reference Cook2004). Spiritualities that are religious in a traditional sense even more obviously include a social and cultural dimension in that religion (as discussed later) necessarily involves shared systems of symbolism, ritual and meaning.

None of these biopsychosocial entanglements, however, completely captures what spirituality is all about, and it cannot satisfactorily be reduced to any of them. In a similar way, much can be said about experiences of falling in love, as they affect us socially, emotionally and physiologically, but none of these scientific accounts adequately conveys the human experience in all its fullness. Spirituality is elusive, but it is more adequately conveyed by disciplines historically considered to be the humanities than it is by those considered to be sciences. Often experienced as ineffable, it can sometimes be more effectively portrayed in art than in words. Even within the disciplines of theology and the (academic) study of spirituality, it is often better portrayed as apophatic, in terms of unknowing or not knowing, than it is in terms of what can positively be said. It evokes a heartfelt search for whatever is held to be most deeply important and desirable, and yet it always hints at something more, something not entirely within the human grasp.

A patient-centred approach to Jenny’s distress reveals that spirituality was deeply important to her, both in terms of her wider enjoyment of life and in terms of understanding the nature of her distress. A corresponding treatment plan was needed to address the biological, psychological and social dimensions of this spirituality. Because spirituality was not understood as integrally entangled with all of these dimensions of well-being, the treatment plan that was offered failed to address some of her central concerns. Because the professional vision of recovery was conceived of in reductively biopsychosocial terms, it failed to grasp a vision of ‘something more’. It failed to convey empathy for the things that were most important to Jenny; it failed to appreciate the things that she loved; it failed to keep spirituality in mind.

Religion

No less metaphorical ink has been spilt in attempts to define the concept of religion than in attempts to define spirituality. Ultimately, religion is a concept whose ‘meaning is unstable and contested, and … cannot be defined so as to specify anything uniquely’ (Taves, Reference Taves and Orsi2011, p.58), but precise conceptual definitions are not necessarily what is needed in relation to research or clinical practice in psychiatry.

Amongst the many definitions of religion that have been proposed, that offered by Clifford Geertz has been amongst the most influential: ‘(1) a system of symbols which acts to (2) establish powerful, pervasive, and long-lasting moods and motivations in men by (3) formulating conceptions of a general order of existence and (4) clothing these conceptions with such an aura of factuality that (5) the moods and motivations seem uniquely realistic’ (Geertz, Reference Geertz and Geertz1993, p.90). It might be argued that this definition is too broad, and it may draw in things that we would not normally consider religious. It may also not say enough (at least directly) about some things that are really important to many religious people. However, it does draw attention to some of the concerns that are important in relation to psychiatry. Religion is concerned with symbols that evoke affective and motivational change and provide existential meaning. There were important symbols within the phenomenology and narrative of Jenny’s story, notably her reference to the sacred, that provide clues to the way in which her illness and faith were entangled. Her Christian faith offered an important resource for positive religious coping – in terms of emotional regulation and the search for existential meaning – which was almost completely neglected by her clinicians.

In her ‘building blocks’ approach to religion, Ann Taves (Reference Taves and Orsi2011) looks at the ways in which religion involves a setting apart of ‘special things’. The special things that provide the building blocks that Taves identifies within this framework include anomalous experiences of agency, anomalous places, objects, experiences and events (without agency), and ideal things. Amongst the ideal things (we might better, here, call them ‘themes’) identified by Taves that make a significant appearance, implicitly or explicitly, in Jenny’s psychopathology are: transcendence, reality, truth, good, evil, purity and perfection. The setting for these ideal things was in some special/spiritual places and events, including worship in church and liminal places between life and death, arising as a result of TAF, in relation to those whom she loved, or for whom she had responsibility. The central concern for Jenny, however, was with anomalous experiences of agency, that is, the inner ‘promptings’ which she experienced as being from God and yet which, because of her illness, she doubted and questioned. In a very real sense, Jenny’s illness struck to the heart of her identity and experience as a Christian. As she succinctly and rhetorically summarised in her own words, ‘Is nothing sacred?’

Like spirituality, religion is deeply entangled with the biopsychosocial matrix that is the central concern of psychiatry (see, for example, Argyle, Reference Argyle2002; Rim et al., Reference Rim, Ojeda, Svob, Kayser, Drews, Kim, Tenke, Skipper and Weissman2019).

The Person-Centred Holistic Model of Psychiatry

The RCPsych Silver Guide (2022), which sets out to help new trainees (and their trainers) navigate professional formation in psychiatry, offers a list of foundational concepts which underpin good professional practice. The vision of psychiatry that it presents includes an understanding of the patient as a whole person, ‘body, mind and spirit’, and ‘a model of the person which draws on the social sciences, neurosciences and the humanities’ (p.6). It urges its readers to take into account the ‘impact of culture, religion and social systems on individuals’ and encourages them to adopt ‘a compassionate clinical approach, based on both values and evidence’. It highlights the importance of ‘a holistic person-centred care approach for patients, taking into account physical, psychological and spiritual needs’ (p.6).

This holistic approach to psychiatry is inspiring, but how is it to be realised? Few psychiatrists have a grounding in the humanities, and postgraduate training in psychiatry usually offers very little on spirituality or religion (and nothing on theology) to complement a highly scientific curriculum in which the biopsychosocial aspects of psychiatry are otherwise addressed in depth. Candidates for the membership examination of the RCPsych might be forgiven for thinking that, in reality, the biological, psychological and social elements of the whole person are important, but spirituality is not.

The Silver Guide is, of course, not the whole story. The spiritual needs of patients do appear in the RCPsych curriculum documents, albeit alongside a heavy weighting towards an understanding of the biopsychosocial that omits discussion of spirituality. The College has a helpful position statement, Recommendations on Spirituality and Religion for Psychiatrists, in which guidance is provided for assessment, clinical practice, training and collaborative working (Royal College of Psychiatrists, 2013). Spiritual and religious concerns are integral to the recovery approach, which is now central to psychiatric practice (Leamy et al., Reference Leamy, Bird, Le Boutillier, Williams and Slade2011), and are further affirmed in a report of the Person-Centred Training and Curriculum (PCTC) Scoping Group (2018). A number of other College publications address the topic, including, notably, Spirituality and Psychiatry (Cook and Powell, Reference Cook and Powell2022). However, there have also been sometimes heated debates around such things as professional boundaries, such that many trainees (not to mention consultants) feel uncertain about how to address spirituality/religion in actual clinical practice (Cook, Reference Cook and Cook2013a). The Spirituality and Psychiatry Special Interest Group (SPSIG) at the RCPsych has, for over 25 years, offered continuing professional development for psychiatrists on spirituality/religion, including day conferences and webinars, as well as an online CPD module (RCPsych, 2024). As will be discussed further in Chapter 8, psychiatrists in other countries around the world have pursued a similar agenda in relation to research, teaching and clinical practice, nationally and internationally.

Outside the circles of groups such as the SPSIG of the RCPsych, or the Caucus on Religion and Spirituality of the American Psychiatric Association, it is not clear how many psychiatrists see spirituality/religion as central to their daily work. Awareness of the importance of these issues is undoubtedly much greater than it was over a quarter of a century ago, when SPSIG was founded, and attendance at webinars and training events (such as those offered by SPSIG) suggests that there is a widespread interest in the topic. This book is offered partly in response to that demand but also with the intention of provoking greater interest and debate amongst those psychiatrists who remain to be convinced of the importance of the topic for their daily work. For these, and for other interested readers, what are the currently available options for integrating spirituality/religion more fully into clinical practice and research in psychiatry?

From Biopsychosocial Model to Patient-Centred Care

The simplest way in which to envisage change is to acknowledge that the biopsychosocial model, on its own, does not go far enough. Spirituality therefore needs to be added as a fourth dimension, so as to create a biopsychosocial-spiritual model (Kuhn, Reference Kuhn1988). This certainly gives visibility to the topic (or, at least, it would if widely adopted) but it also suggests that spirituality is an ‘add-on’ and therefore, potentially, something that can be neglected wherever psychiatrists see the biological, psychological and sociocultural aspects of well-being as their primary concern. Even more importantly, as discussed earlier, it fails to recognise that spirituality is in fact an inextricably entangled concern of the three biopsychosocial domains. It is simply not possible to employ the biopsychosocial model properly without addressing the spiritual within the biological, the psychological and the social, even though this is in fact exactly what many psychiatrists try to do every day.

Another approach would be to recognise that spiritual/religious concerns are already identified as important elements within, for example, the recovery approach, transcultural psychiatry and patient-centred care, and that nothing new is needed so much as to ensure that it is not neglected within teaching, research and practice in these areas. The need, then, is to improve quality and practice of care according to existing models, rather than to see the need for anything new. As with the earlier comments on the biopsychosocial model, there is much to commend this approach, except for the invisibility of spirituality/religion within it. The danger is that it is not prioritised unless or until it is explicitly mentioned. Given that many patients are already hesitant to mention the topic, there is every likelihood that it will not be mentioned and that it will constantly be forgotten.

Taking a more radical line, others have suggested that what is really needed is a complete ‘paradigm shift’. This is well illustrated by one of the founding members of SPSIG, Larry Culliford (Reference Culliford2011b), in his book The Psychology of Spirituality. The idea of paradigm shift was introduced in the natural sciences by Thomas Kuhn in the 1960s but has since been applied in many other contexts. As summarised by Culliford: ‘A paradigm shift involves a major conceptual change in both theory and practice. It is necessarily a development or extension of what has gone before’ (Culliford, Reference Culliford2011b, p.91). Culliford sees such a shift taking place in relation to spirituality in Western society: ‘Western culture is undergoing a significant paradigm shift – from a materialist view, based on the assumptions of dualism, rationalism, positivism and empiricism, towards a naturalistic understanding that acknowledges the significance of such things as personal stories, emotions and experiences that cannot be explained purely in terms of science’ (Culliford, Reference Culliford2002, p.250). More particularly, he sees this shift taking place within psychiatry and the allied disciplines: ‘The psycho-spiritual paradigm involves recognition that spirituality involves a universal yet deeply personal and essentially subjective dimension of human experience, about which it can be hard to communicate in words’ (Culliford, Reference Culliford2011a, p.46). I largely agree with Culliford, but I’m not seeing a recognition of the need for such a paradigm shift amongst the majority of my professional colleagues. There is also a problem with positing the universality of spirituality. Some people consistently identify as neither spiritual nor religious. Whilst I may have conversations with them, as colleagues and patients, about such things as meaning in life, relationships and perhaps even some kinds of transcendence, yet they do not identify any of this as ‘spiritual’ and I cannot impose this label on them. Much though I’d like to see this paradigm shift, if it ever occurs, I don’t think it will be in my lifetime. Having said this, I think that it is also possible to argue that, in many ways, it has already taken place, even if only in a limited way.

Transcultural psychiatry, for example, has had a vision of the ‘common humanity’ at the heart of professional practice, albeit the place of spirituality and religion within this is variously construed and not entirely free from its own forms of reductionism (Antic, Reference Antic2021). The diagnostic category ‘Religious or Spiritual Problem’, introduced into DSM since its fourth revision (Baccetto, Reference Baccetto2023), does now give a significant space within which the spiritual dimensions of distress may be discussed in psychiatry without necessarily diagnosing pathology. Spirituality and religion find their way into most conceptualisations of the recovery approach and, most importantly of all in my view, patient-centred (or person-centred) care is now firmly established as foundational to the good professional practice of clinical psychiatry. Putting the patient at the centre of psychiatry, rather than the science, is arguably the best way of all to ensure that spirituality takes its rightful place at the heart of psychiatry. However, we cannot leave matters there because this still does not ensure that spirituality is given proper attention in practice, at least not in the secular Western world.

A Secular Age

Charles Taylor (Reference Taylor2007) has drawn attention to how secularity has a way of viewing things (an ‘imaginary’ in his terminology) which is closed to transcendence. Secular societies adopt an immanent frame of reference. This ‘immanent frame’ includes, notably, an understanding of the ‘buffered self’, living in a social environment in which instrumental rationality is prized, and in which time is ‘pervasively secular’ (Taylor, Reference Taylor2007, p.542). To take just the first of these features of the immanent frame, the buffered, or bounded, self contrasts with the porous self of premodern society. As discussed earlier, this buffered self can more easily disengage from the surrounding world and is understood as less vulnerable to the influence of spiritual forces, whether good or evil. The buffered self faces a very different existential plight than does the porous self. It can step back from, and reflect on, the world around. Meaning and purpose are to be found within. The cost of this is the loss of an intimate connection with the world around us and with a transcendent order (something that Taylor goes on to discuss as a ‘malaise of immanence’).

The buffered self, according to Taylor, occupies a constructed social environment within which ‘closed world structures’ (CWSs) make transcendence a problematic topic. Taylor defines CWSs as ‘ways of restricting our grasp of things which are not recognised as such’ (Taylor, Reference Taylor2007, p.551). In particular, they are closed to transcendence and, further, they make this constructed way of looking at things seem natural, as though it is just how things are (rather than being a constructed worldview). Science, based on a materialist view of the world, is taken to be capable of explaining things, whilst religion is understood as mythology (in a bad sense of the word, not as meaningful and true): ‘So religion emanates from a childish lack of courage. We need to stand up like men and face reality’ (Taylor, Reference Taylor2007, p.561). The unbeliever, in contrast, is taken to be mature and courageous, and to have a (humanistic) grasp of reality as it ‘really’ is.

Taylor’s understanding of secularity will be discussed further in Chapter 8 but, for now, the important thing to observe is that – if Taylor is correct – we cannot assume that patient-centred care will give adequate attention to spirituality in clinical practice in a secular health service. Patients are likely to find spirituality and religion difficult to talk about, perhaps even more so than other sensitive topics such as sex or death, and clinicians are likely to focus on the immanent concerns which were the preoccupation of their professional training. The boundary between the secular and the spiritual/religious, a fundamental feature of a health service in a secular society, makes spirituality a problematic topic for conversation. Even in the theoretically ‘safe’ space of the clinical consultation, patients can be afraid of censure because of the CWSs that – they fear – make transcendent topics off limits and subject to censure.

The perceived conflict between science and religion, to which Taylor alludes, will be further discussed in Chapter 4, but the way in which spirituality is excluded from clinical practice in psychiatry when, as I am arguing, it should be seen as central to it owes much to the unhelpful ways in which much of the popular debate has been conducted. Viewing theology or religion as incompatible with science in some way, rather than as complementary or in dialogue, easily leads to a perception that they cannot be discussed with scientists (including, here, clinicians as ‘applied scientists’) without fear of contradiction or dismissal. A more critical analysis of the relationship between science and theology in psychiatry is therefore needed and will be explored further in Chapter 4.

Faith Communities

This book looks at the entanglement of spirituality and psychiatry from the perspective of psychiatry. There are other perspectives, notably the perspectives of faith communities who struggle with the equal and opposite problem presented by the tangle. How may psychiatry, and mental health, be understood through the eye of faith? This is a real problem for some, given that psychiatry and spirituality/faith share many common concerns in relation to the human condition and the relief of suffering and distress. However, they share these concerns from very different standpoints, the one built largely upon a medical scientific foundation, with a focussed programme of the relief of sickness and suffering, and the other built upon a theological and philosophical foundation, with a broader quest for meaning, redemption and human flourishing. There is therefore plenty of scope for misunderstanding and suspicion.

There is a wide range of answers to this question of how psychiatry may be viewed from the perspective of religious faith, not only because there are many different religions but also because, within each faith tradition, there are a variety of different possible ways of engaging with the problem. Some adopt a very oppositional stance, emphasising boundaries between their faith community and a wider, spiritually dangerous world. Some adopt a much more integrative position. The former are much less likely to engage with secular health services and there may be significant reluctance to seek help from mental health professionals. For the latter there may be much less of a problem with engagement and access, but much more of a problem with questions around the impact of illness on faith and how to understand faith in relation to illness. This was very much the situation in which Jenny found herself in the story with which this chapter opened.

In order to try to improve mutual understanding, and remove unnecessary barriers, the American Psychiatric Association (in partnership with a number of other convening organisations) has established the Mental Health and Faith Community Partnership, to foster collaboration between psychiatrists and clergy (American Psychiatric Association, n.d.). This partnership promotes mutual education – of clergy about psychiatry, and of psychiatrists about spirituality and faith. In the current absence of anything similar in the UK and elsewhere, local collaborations between NHS mental health services and faith communities are all the more important.

Psychiatry

This is a book about psychiatry, but what exactly is psychiatry? At one level, the answer is quite simple. Psychiatry is a speciality within the wider field of medicine. Psychiatrists train to be doctors first and then specialise in what sometimes used to be called psychological medicine. However, psychological medicine – psychiatry – is not quite like other medical specialties. Take, for example, Nancy Andreasen’s definition: ‘Psychiatry is the medical specialty that studies and treats a variety of disorders that affect the mind—mental illnesses. Because our minds create our humanity and our sense of self, our specialty cares for illnesses that affect the core of our existence’ (Andreasen, Reference Andreasen1997, p.592).

This ‘core of our existence’ is what used to be called the soul. Etymologically, from the Greek, the word ‘psychiatry’ refers to a physician, or healer (iatros), of the soul, or mind (psyche). Ordained ministry in many parts of the Christian Church is also referred to as a ‘cure of souls’ and so, on an etymological basis, vocations to priesthood and psychiatry might be understood as much the same thing. In fact, we all know that in practice they are not, and problems occur when doctors, priests or patients begin to confuse the two. Andrew Sims, past president of the RCPsych and a strong advocate of the importance of addressing spirituality in psychiatry, suggested that, even though someone may tell much the same story, their reasons for telling it to a psychiatrist rather than a priest (or vice versa) are very different: ‘The account is told to the psychiatrist with the hope that relief of psychic pain and distress will follow; it is told to the priest because the individual wants to make use of the priest’s moral position and stance in relationship with God’ (Sims, Reference Sims1988, p.161). In Sims’ understanding, the ‘basis for a psychiatrist’s knowledge of his patient is phenomenological; that is he uses his [or her] capacity for empathy as a delicate instrument to reveal the patient’s own subjective experience’ (Sims, Reference Sims1988, p.161).

This empathic, phenomenological starting point for the work of the psychiatrist is just the beginning. Psychiatry draws upon a wide range of other disciplines, including, notably, the neurosciences, in order to understand the causes of a patient’s distress. For some, it is this scientific basis for psychiatry that is fundamental, such that Samuel Guze, in a lecture at the Institute of Psychiatry in 1988, was able to assert that ‘there is no such thing as a psychiatry that is too biological’ (Guze, Reference Guze1989, p.315). To be fair, by the end of the lecture he deftly weaves in an acknowledgement of the importance of psychotherapy, which he sees as in no way contradictory to his fundamental, biological premise. However, many would disagree completely with the biological emphasis and would argue that psychiatry has become much too biological over recent decades. For example, it has been suggested that ‘Defining psychiatry as applied neuroscience valorizes the brain but urges on us a discipline that is both mindless and uncultured’ (Kirmayer and Gold, Reference Kirmayer, Gold, Choudhury and Slaby2011, p.308).

Others, finding the current ‘technological paradigm’ of psychiatry wanting, have argued that ‘we need a radical shift in our understanding of what is at the heart (and perhaps soul) of mental health practice’ (Bracken et al., Reference Bracken, Thomas, Timimi, Asen, Behr, Beuster, Bhunnoo, Browne, Chhina, Double, Downer, Evans, Fernando, Garland, Hopkins, Huws, Johnson, Martindale, Middleton, Moldavsky, Moncrieff, Mullins, Nelki, Pizzo, Rodger, Smyth, Summerfield, Wallace and Yeomans2012, p.432). Despite the language, they do not appear to be looking for a paradigm shift, of the kind discussed earlier, so much as a broadening of existing horizons: ‘We are not seeking to replace one paradigm with another. A post-technological psychiatry will not abandon the tools of empirical science or reject medical and psychotherapeutic techniques but will start to position the ethical and hermeneutic aspects of our work as primary, thereby highlighting the importance of examining values, relationships, politics and the ethical basis of care and caring’ (p.432). Kirmayer and Crafa (Reference Kirmayer and Crafa2014, p.1), similarly concerned about the over-emphasis on neuroscience, argue that what is needed is ‘A multilevel, ecosocial approach to biobehavioral systems.’ In such an approach, they argue, ‘the coherence of the paradigm can come from its personal and social meaning rather than its reducibility to a discrete neural circuit’. Again, this is not a paradigm shift, more a combining of paradigms.

Concerns about reductionism and an over-emphasis on neuroscience are, as these examples show, now leading to a much broader vision of the grounds upon which psychiatry is built. This includes recognition of the importance of the humanities. For example, in an editorial in Acta Psychiatrica Scandinavica, some two decades ago, Tom Bolwig wrote: ‘The humanities and arts are appropriate areas of study in interdisciplinary medicine, because within each patient, the physical, the psychological, emotional and spiritual are all inextricably linked’ (Bolwig, Reference Bolwig2006, p.381). Psychiatry is an art as well as a science (Chur-Hansen and Parker, Reference Chur-Hansen and Parker2005), and it concerns people understood in the full context of the human situation: ‘At root, the neurobiological project in psychiatry finds its limit in the simple and often repeated fact: mental disorders are problems of persons, not of brains. Mental disorders are not problems of brains in labs, but of human beings in time, space, culture, and history’ (Rose and Abi-Rached, Reference Rose and Abi-Rached2013, p.140).

This broader view of things, which is essentially the basis for patient-centred care in psychiatry, is now gaining much more traction. However, spirituality and religion, as important aspects of ‘culture and history’ and the humanities more widely, not to mention the ‘sense of self’ of the vast majority of people worldwide, still repeatedly get forgotten. Even in Tom Bolwig’s excellent editorial, from which I quoted just now, religion and theology are not mentioned at all, and spirituality is only mentioned in the passage that I quoted. Stephen Pattison has suggested that religion and theology are amongst the ‘absent friends’ of the medical humanities (Pattison, Reference Pattison2007). This is gradually changing, with critical exploration of the part that these absent friends play in the medical and health humanities (Slominski et al., Reference Slominski, Powell and Cook2026) and in psychiatry (Cook and Powell, Reference Cook and Powell2022) increasingly acknowledged, but still as uncertain friends, rather than as loved members of the family. This book is therefore as much about the lost soul of psychiatry as it is about the souls of patients.

Tangles

Psychopathology is entangled with spiritual experience. Spirituality and religion are entangled with the very nature of psychiatry, and they are entangled with the biopsychosocial matrix of human life. Psychiatric training, at least in the RCPsych, but also in other national and international psychiatric associations, now promotes a person-centred holistic model of psychiatry and many patients (the vast majority worldwide) find spirituality and/or religion to be a core concern of life. The secular age in which we live, at least in the Western world, seeks to disentangle all of this, to relegate spirituality and religion to a private domain, to promote a pragmatic atheism in public life which makes it difficult or impossible to talk about spirituality and religion, and to build a barrier between the secular and the spiritual/religious domains of life. This same barrier intrudes upon the lives of people who belong to faith communities so as to make it more difficult for them to engage with mental health services. When they do engage, like Jenny, they face significant problems in trying to integrate their understanding of their faith and their illness in meaningful and health-promoting ways. Psychiatry, in its core concerns, has a vocation to help Jenny and others, not by disentangling, or even by a differential diagnosis between psychopathology and ‘healthy’ religious experience, but by recognising that a holistic and patient-centred model of practice is concerned with treatment of the psyche – mind and soul – in all its complex entanglements. The core concerns of psychiatry need to be much more closely aligned with the core concerns of patients, both immanent and transcendent. In order to do this, it needs to be more (not less) reflective on the core concerns of psychiatrists. Spirituality, entangled as it is with the biopsychosocial matrix within which psychiatry operates, offers a vision of something better, something more, which – although sometimes articulated only with difficulty – is at the heart of what patients are looking for when they enter treatment.