Spirituality and Mental Illness in Old Age Susan Mary Benbow and David Jolley

CONTEXT: SPIRITUALITY, FAITH AND RELIGION

Spirituality is an important concept and often regarded as intrinsic to mental health: the Health Education Authority includes it within its definition of mental health: ‘the emotional and spiritual resilience which enables us to enjoy life and to survive pain, disappointment and sadness. It is a positive sense of well-being and an underlying belief in our own, and others’, dignity and worth’¹.

Nevertheless spirituality is difficult to pin down, and its differentiation from (and relation to) religious faith is a matter of debate. The Church of England Archbishops’ Council with the National Institute for Mental Health in England (NIMHE)² has defined it as: ‘A quality that goes beyond religious affiliation: that strives for inspiration, reverence, awe, meaning and purpose, even in those who do not believe in God’. Thus spirituality can be independent of religious faith, or, as Paul Wilson³ writes, ‘Spirituality is the searching for the meaning of life. Religion is one way of conducting the search’. Much of the literature relates health to religious belief and practice rather than spirituality as such and only now are we beginning to tease out how spirituality and faith interact.

As a concept, spirituality is sometimes criticized as free-floating and nebulous, although it has gained acceptability and respectability in Western societies, where adherence to faith or religion is sometimes regarded with suspicion, or as primitive, old-fashioned or outdated. On a global level there is massive commitment to religious faiths^4,5. Numbers of adherents to Islam continue to grow, and though there has been a decline in active belief and church going within the nominally Christian countries of the West, the number of Christians worldwide is sustained or growing⁶. Population movements mean that most countries are now home to communities of many faiths. Thus an understanding of the research evidence concerning the relationships between spirituality, religion and health is essential for health care practitioners. In addition, it is important to be aware of the influence of spiritual and religious beliefs on the perception and interpretation of symptoms by patients and their families. Beliefs will also modify views on the acceptability or appropriateness of interventions intended to be therapeutic.

Health is often divided into six dimensions: physical, mental, emotional, social, environmental and spiritual⁷. The first five are accepted routinely as significant in the understanding, aetiology and management of health/illness. Spirituality is the dimension that has been neglected in Western professional health care theory, research and practice during the twentieth century, with health care staff taking little account of patients’ perspectives regarding their experience of health/illness. Recent years have seen a return to interest in alternative views of life and a corresponding increase in study and research in this area. At a basic biological level, George et al.⁸ demonstrated an association between spiritual beliefs and enhanced immunity, while, within the realms of clinical psychiatry and behaviour, Strawbridge et al.⁹ found that strong spiritual beliefs were associated with a reduced risk of suicide. The Royal College of Psychiatrists has established a Special Interest Group on spirituality¹⁰. The evidence is such that the National Institute for Health and Clinical Excellence’s (NICE) guidance on the supportive and palliative care of adults with cancer¹¹ recommends provision of spiritual support services, and the NIMHE Guiding Statement on Recovery¹² includes consideration of spirituality as intrinsic to holistic treatment.

Why should strong spiritual beliefs be associated with better health outcomes? Could it simply relate to the social support provided by membership of a faith community? Is it possible that interest in spirituality/membership of a faith community is independently linked with better health? Or are there specific aspects of a faith (such as prayer or worship) that carry additional advantages to health? Is it the case that, as Andrew Sims writes, ‘one of the best kept secrets of modern epidemiological medicine is the effect that religious belief and practice have upon outcome from both physical and mental disorders’?¹³

Chronic illness (whether physical or mental) is likely to be an area where the relationship between spirituality and health assumes particular importance. How does spirituality impact on long-term illness and coping? What effect does long-term illness itself have on spirituality and faith? How does chronic illness affect membership of a faith community? What of the families and carers of those living with long-term physical and/or mental illness? As yet we cannot answer these questions, but there is evidence which hints at possible answers. The evidence divides into qualitative (often personal accounts of living with a chronic illness, e.g. Robert Davis’s account of changes in his faith and understanding while living with Alzheimer’s disease¹⁴) and quantitative. Researchers are exploring this area, measuring associations using instruments such as Hill and Hood’s Measures of Religiosity¹⁵, which records 126 different measures of religion, faith, belief and spirituality, and the Royal Free Interviews for Religious and Spiritual Beliefs^16,17.

DEMENTIA AND SPIRITUALITY

Katsuno¹⁸ studied 23 people with mild dementia attending a day centre in the United States, using both qualitative and quantitative measures, and found a positive correlation between strength of spirituality and quality of life. Religion was reported to be important in the everyday lives of 19 of the group. One main theme, ‘Faith in God’, and six related categories were identified: beliefs, support from God, sense of meaning in life, private activities, public activities, and changes arising from dementia. Katsuno argues from her sample that it is an individual’s intrinsic religiosity, rather than the social support they receive from a faith community, which influences their quality of life. We used the Royal Free Interview for Religious and Spiritual Beliefs: self-report version¹⁹ in a memory clinic population in the West Midlands²⁰ to start to explore the following issues:

How are spirituality and faith affected by dementia?
How are spirituality and faith affected by caring for someone with dementia?
How do religious communities view dementia and respond to its presence within their membership?
How is the experience of dementia modified for patient and carer by their spirituality and faith?
Are there opportunities for strengthening spirituality and faith and/or improving life for patients and carers in this situation?

A group of people attending a memory clinic in the West Midlands and their carers completed the Royal Free questionnaire and in additional semi-structured interviews were carried out with patients, carers and local faith leaders. The patients were mainly women living with Alzheimer’s disease and they described themselves predominantly as Christian. They scored a mean of 24 on the Mini-Mental State Examination²¹. Our main conclusions were as follows: patients with dementia are interested in, and able to talk about, issues of faith and spirituality; the spectrum of their beliefs is similar to that of their main carers; the strength of their beliefs is at least as strong as their carers; and satisfaction with life and carer stress (as measured by the General Health Questionnaire²²) appear to be independent of strength of spiritual belief in this population. Both patients and carers ranked the personal components of spirituality most highly: for carers, coping came highest (‘do you believe in a spiritual power which helps you cope with events which occur in your life?’), and for patients’ strength of belief (‘how strongly do you hold to your spiritual/religious view of life?’). Both patients and carers considered practices associated with their beliefs to be very important.

What of people with more advanced dementia? Some formulations argue that as dementia progresses and erodes the individual’s abilities, memory traces and emotional repertoire, their spiritual identity is lost to a primitive chaotic biological base. Others say that if you know the person well, their spirit remains available for contact, and, indeed, that their spirituality becomes more evident and precious^23,24. Meeting spiritual needs is certainly accepted as part of supportive and palliative care in dementia as in other terminal conditions¹¹ and is anticipated in residential care, which pre-dates death for many people^25,26. Lawrence²⁷ argues that ‘spiritual matters remain pervasively in the background’ as dementia progresses and that staff need to employ non-verbal methods and devote time to connecting with the spiritual needs of people with dementia. Families and carers who have sustained intense involvement through this final stage will take time to adjust to the transition to life without their relative after the latter’s death. Their experience of communication may continue and the mode, manner and completeness of resolution will be influenced by their established beliefs^28,29.

DEPRESSIVE DISORDERS, PSYCHOSIS AND SPIRITUALITY

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