What is spirituality, and what does it have to do with psychiatry? These are good questions but not easily answered; they evoke a lot of debate. Some people think that spirituality is indefinable. Some psychiatrists are worried that any attempt to address spiritual concerns within clinical practice might blur the boundaries of good professional practice. Patients often see things differently. They find it difficult to separate spirituality from mental health and wellbeing but are worried that mental health professionals do not understand their spirituality and that the medical consultation is not a safe space within which to discuss it.
Mental health professionals are in fact more likely to be atheist or agnostic than their patients and so there are very real reasons to be concerned about the communication barriers created by the so-called “religiosity gap” between clinician and patient. There are also very real concerns about the potential for the clinical role to be abused by proselytising, or that the psychiatrist might end up venturing beyond the boundaries of their expertise and training. How can these concerns be effectively addressed?
The Spirituality and Psychiatry Special Interest Group (SPSIG) at the Royal College of Psychiatrists (RCPsych) was set up in 1999 by its founding chair, Andrew Powell. It brings together psychiatrists who want to explore these questions and concerns and who need a safe place themselves, within which to discuss the ways in which their own spirituality relates to clinical practice. The first edition of Spirituality and Psychiatry, edited by Chris Cook, Andrew Powell and Andrew Sims (all of whom have been chairs of SPSIG), was published by RCPsych Publications on the tenth anniversary of the founding of SPSIG in 2009. The book was a project conceived by the executive committee of SPSIG in an attempt to address some of the controversies, drawing on the experience of SPSIG members. It was hoped that it would provide a kind of textbook, or clinical handbook, to guide trainees and others in addressing spirituality as a “fourth dimension” of care, alongside the accepted three dimensional biopsychosocial model of mental healthcare.
It was soon recognised by the authors and editors of the first edition of Spirituality and Psychiatry that it could not be a textbook in the usual sense. Within psychiatry there are diverse perspectives on spirituality and religion, not only because of the diversity of spiritual and religious experience of clinicians and patients, but also because of the diversity of the subspecialities within psychiatry. In some areas – such as addiction psychiatry – the place of spirituality has been well recognised and researched. In others it has been almost entirely neglected. Overall, the field of spirituality and psychiatry was seen as being at a very early stage of development, not so much because of the evidence base (which even then was impressively large) but more because of the lack of consensus as to how such matters should best be addressed in clinical practice.
Happily, for all its limitations, the first edition of Spirituality and Psychiatry was a success. It sold well and was positively reviewed. To the extent that it contributed to the ongoing debate and controversy within psychiatry, this was a good thing. Constructive and critical debate was, and is, exactly what is needed. Another book, Spirituality and Narrative in Psychiatric Practice, also from RCPsych Publications, and edited by the same team, was released in 2016. This went some way to filling some of the gaps left by Spirituality and Psychiatry, but even so, it was apparent well before the tenth anniversary of publication that Spirituality and Psychiatry was in want of significant revision and expansion. Thus, the need for a second edition was recognised and the editors, together with colleagues at Cambridge University Press, began thinking about what this might look like.
Spirituality and Psychiatry needed updating; the research evidence based had expanded exponentially since the first edition was written. Gaps needed filling, notably in relation to common mental disorders but also in respect of subspecialities (forensic psychiatry) and the emergence of spiritually integrated treatment approaches (mindfulness, compassion focussed therapy, religiously integrated cognitive-behavioural therapy, and forgiveness therapy). There was need for greater author diversity; a new chapter was added on the patient perspective, disciplinary representation expanded, and more contributions from outside the UK included. Some chapters were completely rewritten by new authors and others extensively revised by the original contributors. A glossary has been added to provide an introduction to the often-contested terminology employed within the field and also in order to address some of the topics not covered in major chapters within the book. Overall, the second edition is almost twice as long as the first.
For me, as lead editor, the process of creating a second edition was both challenging and exciting. I was very grateful to have Andrew Powell in support, always ready with wise thoughts about how to respond to chapter authors and difficult editorial decisions around content or style. I thoroughly enjoyed engaging with the virtual community of authors who contributed to the book, many of whom went above and beyond all that was asked of them. I also found myself challenged by questions from outside my usual areas of professional and academic experience, revisiting my own understanding of the nature of spiritual and religious experience and its relation to psychiatric practice. Inevitably, I find myself as my own worst critic, aware of things that still have not been addressed in the book (e.g. eating disorders and personality disorders) and wishing that we had done some things differently. However, on behalf of the family of authors that have laboured over this volume, I also feel very proud.
Whilst Spirituality and Psychiatry does seek to be evidence based, it does not attempt to duplicate other textbooks that review the scientific literature. Rather, it seeks to draw on that literature in interdisciplinary engagement and, more importantly, in conversation with the wisdom of clinicians and patients, hard won through lived experience. It struggles with some of the existential questions that the interface between spirituality and psychiatry presents. It does not pretend that there are easy answers, and it recognises mystery, diversity, and difference as things to be cherished not eliminated.
Title: Spirituality and Psychiatry
Authors: Christopher C. H. Cook and Andrew Powell