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Religious and/or spiritual practices: Extending spiritual freedom to

people with schizophrenia

Sharon Smith, Melinda J. Suto

Key words Abstract

Agency Background. It continues to be a challenge to define and utilize spirituality in cli-
Phenomenology ent-centred occupational therapy practice. Dialogue about spirituality is especially
problematic for occupational therapists working with people with schizophrenia.
Purpose. To explore the meaning of religion and/or spirituality for people living with
a diagnosis of schizophrenia. Methods. Nine community-based individuals with
Mots clés schizophrenia engaged in interviews about the meaning of religion and/or spiritual-
Libre choix ity and demonstrated self-defined spiritual practices. Phenomenology, hermeneutic
Phénoménologie theory, and a symbolic interactionism framework provided methodological and an-
alytic guidance. Findings. Participants employed religious and/or spiritual practices
to cope with schizophrenia symptoms and make meaning of their lives. Individuals
used multiple systems of meaning to explain their experiences. Religious and/or spir-
itual agency, an individual’s sense of freedom to choose among the spiritual options,
renewed their sense of empowerment. Implications. Therapists can engage in spiri-
Sharon Smith, PhD, is the Coordinator tual negotiation with clients by using well-worded empowering questions toward a
of the Spirituality Project for Vancouver common goal of life enhancement.
Community Mental Health Services,
520 West 6th Avenue, Suite 200,
Vancouver, British Columbia, Canada, Abrégé
V5Z 4H5. At the time of this study Description. Il est toujours difficile de définir et d’utiliser la spiritualité dans la
Sharon Smith was a doctoral candidate pratique de l’ergothérapie centrée sur le client. Pour les ergothérapeutes travaillant
in the Rehabilitation Sciences gradu- auprès des personnes schizophrènes, le domaine de la spiritualité représente un
ate program at The University of British problème particulier. But. Explorer le sens attribué à la religion ou à la spiritualité
Columbia. Telephone: (604) 222-4167. chez les personnes vivant avec un diagnostic de schizophrénie. Méthodologie.
E-mail: Neuf personnes schizophrènes vivant dans la collectivité ont participé à des
entrevues portant sur le sens qu’elles attribuaient à la religion ou à la spiritualité
Melinda J. Suto, PhD, OT(C), is Assistant et sur leurs pratiques spirituelles. La phénoménologie, la théorie herméneutique
Professor, Department of Occupational et un cadre de référence sur l’interactionnisme symbolique ont fourni les bases
Science and Occupational Therapy, The méthodologiques et analytiques de l’étude. Résultats. Les participants avaient
University of British Columbia, T-325, recours à des pratiques religieuses ou spirituelles pour faire face aux symptômes de
2211 Wesbrook Mall, Vancouver, British la schizophrénie et donner un sens à leur vie. Ces personnes se sont servi de plusieurs
Columbia, Canada, V6T 2B5. systèmes de sens pour expliquer leurs expériences. Le libre choix religieux ou spirituel,
c’est-à-dire, le sentiment d’avoir la liberté individuelle de choisir parmi différentes
options spirituelles, a permis aux participants d’avoir à nouveau le sentiment de
pouvoir contrôler leur vie. Conséquences. Il est possible pour les ergothérapeutes
Citation: Smith, S., & Suto, M. J., (2012). de s’engager dans un dialogue sur la spiritualité avec leurs clients, en leur posant des
Religious and/or spiritual practices:
questions stimulantes et bien formulées pour atteindre un but commun, soit celui
Extending spiritual freedom to people
with schizophrenia. Canadian Journal of d’enrichir la vie de leurs clients.
Occupational Therapy, 79, 77-85.

doi: 10.2182/cjot.2012.79.2.3
hen Mr. P. enters the occupational therapist’s office, he reveals a newly
Submitted: 6 February, 2011; acquired limp. Puzzled, the occupational therapist asks him, “How was
Final acceptance: 18 February, 2012.
your week?” Mr. P., feeling safe to share in the context of this long-term
This research was supported by a Social therapeutic relationship, replies, “It’s been a wonderful week. I have spent more
Sciences and Humanities Research time with God.” The occupational therapist asks her usual probing question, “What
Council Doctoral Fellowship and a Canadian does that look like for you?” Mr. P. describes how recently he has realized that God
Institutes of Health Research Quality of Life requires him to pray nine hours a day, kneeling. She asks how his knees are taking
Training Grant. the strain. Mr. P. rolls up his pants legs to reveal bruised and swollen knees. The
This manuscript was initiated under the occupational therapist knows very little about this prayer ritual, yet she sees that Mr.
editorship of Dr. M. Finlayson and accepted P. is motivated by his spiritual practice. She is concerned about his unbalanced daily
under the associate editorship of J. Davis. routine and his physical pain, and she is at a loss.

© CAOT PUBLICATIONS ACE Canadian Journal of Occupational Therapy April 2012 79(2) 77
Smith & Suto

Incorporating spirituality into practice challenges occu- places for conversation about the interaction between their RS
pational therapists’ personal understanding of spirituality and practices and mental health.
the language they use to converse with clients about spiritual-
ity. Psychiatry’s historic skepticism about the value of religious Literature Review
and/or spiritual (RS) practices for people living with mental In the occupational therapy literature the broad concept of
illness adds to this challenge (Baetz & Toews, 2009). This has spirituality has been framed in terms of the profession’s core
led to clients of mental health professionals fearing that disclo- concept: occupation (McColl, 2003). Some theorists have
sure of their engagement in certain practices will contribute proposed stronger occupation-focused terms to replace
toward aspects of their mental health diagnosis (Huguelet et spirituality, such as occupational identity (Unruh, Versnel &
al., 2006). Mental health occupational therapists have diffi- Kerr, 2002) and intrinsicality (Hammell, 2001). However, the
culty establishing (1) if their clients utilize RS practices as a research suggests that the use of spiritual language for men-
resource for their recovery, (2) whether to facilitate dialogue tal health clients remains a priority as a resource for recovery
with their clients about their RS practices, and (3) if they dis- and is often connected to occupation through meaning (Clark,
agree with their clients’ choices about their RS practices, how 2005; Davidson, 2003; Wilding, May & Muir-Cochrane, 2005).
to negotiate these practices to work toward holistic wellness Occupational therapists have used the term “spiritual
whilst maintaining clients’ agency? occupation” (Kang, 2003) or “activities of spirit” (Christiansen,
Spirituality forms the core of the Canadian Model of 1997) to describe overtly RS practice. Some studies have advo-
Occupational Performance and Engagement (Polatajko, cated that therapists engage in clients’ explicit spiritual occupa-
Townsend, & Craik, 2007), and yet the struggle to name, tions, such as prayer (Farah & McColl, 2008) and accessibility to
frame, and utilize spirituality in occupational therapy prac- sacred places (Swedberg, 2001). When spirituality is linked to
tice remains problematic. Spirituality is conceptualized as the occupation through meaning, it also has the potential to take on
“essence of the person” (Polatajko, Davis, et al., 2007, p. 30), an implicit sense (Egan & Delaat, 1997). Therefore, seemingly
and although no consensus exists, many theorists believe that “ordinary” activities, such as gardening (Unruh, 1997) or writ-
spirituality offers a link to understanding personal meaning in ing (Kirsh & Welsh, 2003), when imbued with personal spiri-
the context of occupation (Baum & Christiansen, 2005; Egan tual meaning, may take on spiritual significance. Kang’s (2003)
& Swedersky, 2003). psycho-spiritual frame of reference proposed that an individ-
As a colloquial concept, spirituality is personally and com- ual’s engagement in occupation will be life-enhancing when
munally defined, based on the values, beliefs, experiences, and spiritual order exists, that is, harmony among the six dimen-
practices emerging from individuals’ cultures, families, and, for sions of becoming, meaning, being, centredness, connectedness,
some, their religious communities (Kroeker, 2003). Following and transcendence. McColl (2003) made more explicit and posi-
Zinnbauer et al. (1999) and Baetz and Toews (2009), we use the tive links among spirituality, occupation, and health that were
phrase religious and/or spiritual (RS) to refer to the everyday supported by more than a decade of research. She showed that
language of spirituality that is sometimes separate, overlapping, engagement in occupation opens a doorway to spirituality.
or synonymous with religion. This phrase, therefore, enhances The relationships among spirituality, occupation, and
the freedom of choice for occupational therapy clients in talk- health are complicated within mental health practice, and the
ing about their spirituality in their language of choice. research findings are contradictory. Some compelling research
We utilized a combination of the theory and methods has shown spirituality to be life-enhancing/sustaining, empow-
of phenomenology, symbolic interactionism, and hermeneu- ering, and a coping strategy for people with diagnoses such as
tics to research the concepts of spirituality and schizophrenia. schizophrenia (Huguelet et al., 2006; Jackson & Fulford, 2005;
Phenomenology is a research methodology that focuses on Koenig, 2009; Wilding et al., 2005). In contrast, other research
understanding the subjective, lived experience of individuals findings have shown spirituality to be counterproductive for
(Wilding & Whiteford, 2005). The addition of symbolic inter- people with psychosis, potentially causing unnecessary exis-
actionism expanded the study to look beyond the individuals’ tential turmoil (Fallot, 2008; Koenig, 2009; Mohr et al., 2006).
experience to their meaning-making within the surrounding The research literature creates a dilemma for occupa-
local, contextual discourse. Hermeneutics is a theory that pro- tional therapists working in mental health: whether to dia-
vides a conceptual framework for researchers to interpret writ- logue about spirituality and facilitate clients to engage in
ten and oral texts that include human experience and social spiritual practices?
conduct (Rennie, 2007). This methodological combination Survey research in Britain, Ireland, Canada, and the USA
was helpful to explore the present research question: What is has highlighted therapists’ fears of imposing their beliefs on
the meaning of RS for people living with a diagnosis of schizo- clients (Beagan & Kumas-Tan, 2005; Egan & Swedersky, 2003;
phrenia? In this study, spirituality was framed as a personal Engquist et al., 1997; Johnston & Mayers, 2005). These fears
construct, shaped by each individual’s worldview in context are further complicated for occupational therapists working
and possibly containing religious language (McSherry & Cash, in mental health with vulnerable persons. There is concern
2004). that discussion about sensitive or emotionally loaded topics
In this paper, we aim to (1) provide qualitative, experien- may place stress on individuals with mental illness, provoking
tial data that explore the utilization of RS practices by individ- symptoms and decreasing their sense of agency (freedom of
uals living with a diagnosis of schizophrenia and (2) show that choice) (McCann & Clark, 2005). Yet spiritual conversations
these individuals expressed a desire for safe, nonjudgmental between therapist and clients living with mental illness diag-

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noses, when conducted in a respectful and empowering man- Consistent with hermeneutic theory and phenomeno-
ner, may provide individuals living with schizophrenia with a logical approaches, two strategies, reflexivity (Hall & Call-
renewed sense of agency. ery, 2001) and bracketing (Giorgi & Giorgi, 2003), were used
Schizophrenia experiences have the potential to dimin- throughout the study to explicate the researchers’ assumptions
ish an individual’s sense of agency (Davidson, 2003) yet the and diminish their influence on the research process. A specific
human potential for agency remains (Jeannerod, 2009). The dialogical approach called triadic reflexivity was used to nego-
sense of loss of personal agency during an unusual experience, tiate respectful conflict as a means of deepening understand-
whether attributed to psychosis or a religious and/or spiritual ing (Klaassen et al., 2002). This strategy for three-way dialogue
causation (Dein, 2007), may be re-established if a person is involves ongoing honest conversation with a diverse research
given space to reflect on and name the experience according to team; dialogue with scholars who differ ideologically from the
his or her beliefs (Williams & Collins, 1999). Dialogues that researchers and their endeavors; and prolonged engagement
consider spiritual agency have the potential to give individuals with research participants.
a renewed sense of hope (Snyder et al., 1997). In this paper, we The research team acknowledged the strong critique by
develop the term “religious and/or spiritual agency” to refer to social constructionist scholars (Wilding & Whiteford, 2005)
an individual’s sense of freedom to choose among the spiritual of traditional bracketing, whereby researchers set aside past
options in the public discourse and the freedom to mobilize knowledge of the phenomenon being studied and adopted a
spiritual practices to meet an individual’s needs. naiveté, an uninformed curiosity (Giorgi & Giorgi, 2003). How-
To explore RS practice and RS agency, we present a ever, Pollio et al. (1997) reconceptualized bracketing as a way of
portion of research findings from a study that focused on acknowledging and negotiating researcher assumptions, that is,
the meaning and the process of meaning-making of RS for to “illuminate the researcher’s way of seeing” through a brack-
individuals living with a diagnosis of schizophrenia. Mean- eting interview (p. 48). Therefore, in this study, a researcher
ing in this sense depicted the language that participants used proficient at semi-structured interviewing but unfamiliar with
to speak about RS and the significance of RS to their lives as the project, interviewed the first author using the same inter-
individuals in recovery from schizophrenia. Through the use view guide intended for the participants. The interview tran-
of a variety of lenses, theoretical frameworks, and method- script was subsequently circulated among the research team for
ology, we were able to explore the experiential structures of the purpose of uncovering assumptions that could have unduly
RS; the language used to describe and make meaning of these influenced data collection and analysis.
experiences; and the discursive contexts in which the lan-
guage was acquired. Participants
Twenty-three individuals engaged in a prolonged recruitment
Methods process, beginning with a screening interview. Participants
A combination of a symbolic interactionism framework, her- were recruited by the first author from community mental
meneutic theory, and phenomenology guided this study. Sym- health teams in the metropolitan Vancouver area; the research
bolic interactionism has a specific focus on the individual as a team had no pre-existing relationships or clinical involvement
meaning-maker within the context of participation in every- with these participants. To engage in the research, participants
day life (Fine, 1993; Strauss, 1995). Symbolic interactionist were required to be 19 years or older, have their diagnosis of
theorists view persons’ identities as temporal and repeatedly schizophrenia confirmed by mental health professionals, have
reconstructed in interactive moments (Doubt, 1992). Dialogi- had more than one hospital admission for the condition but not
cal self-formation takes place: (1) in the context of social inter- within six months prior to the study, reside in the community,
actions with others, where individuals assume social roles to and clearly articulate their ideas about spirituality. In addition,
experiment with language and (2) in a self-reflective dialogue the 11 participants included in the study (see Table 1) offered
between the I (the subject, doer, initiator) and the me (the self diverse spiritual and/or non-spiritual viewpoints guided by
as object) (Doubt, 1992). One of the key reasons for select- McSherry and Cash’s (2004) continuum of individuals’ world-
ing symbolic interactionism as a framework for this study was views and spiritual language. At the close of the first phase, each
that it broadened the project’s focus beyond the microlayer of participant was plotted on this continuum to see if he or she rep-
a person’s consciousness to a larger understanding, shared by resented a different variation of spirituality from others in the
like-minded people within an historical, social, and political sample. A person who preferred not to use the term spirituality
context (Strauss, 1995). It is in this larger context and from was also included in the study for maximum variation.
the surrounding discourse that individuals form their unique
individualized RS language (Kroeker, 2003). Although social Data Collection
context was not the primary focus of this research project, Nine individuals met the inclusion criteria and provided
individuals’ experiences and expressions of spirituality occur informed consent as per the University of British Columbia
within the context of families, communities (religious or Behavioural Research Ethics Board. They participated as “co-
other), the economic system, and the mental health system. researchers” in all three phases of the research study over a
These interactions were appropriately considered while spe- period of four months. The term co-researcher emphasizes that
cifically focusing on the individual’s construction of meaning the individuals living with schizophrenia are experts of their
using hermeneutic theory and phenomenology. experiences and gives equal value to their contributions. The

Canadian Journal of Occupational Therapy April 2012 79(2) 79

Smith & Suto

extended length of engagement fostered trust between the first have gotta find that centre.
author and the co-researchers. The first phase comprised inter- Primary data: John in the midst of a distressing moment
views that explored participants’ experience of schizophrenia in the interview, while recounting an experience of psy-
and spirituality by asking questions about significant events in chosis and suicide attempt, uses the spiritual practice of
their lives. The second phase explicitly explored spiritual prac- centring.
tices. Co-researchers introduced the first author to a spiritual After an overall impression of each co-researcher’s expe-
practice, an object they associated with spirituality, someone who rience was diagrammed to form an experiential structure, that
shared their spirituality, and/or a place they considered spiritual. person was asked for feedback about this initial structure and
In the third phase of the data collection, ideas from previous to debrief about the research experience.
phases that required clarification were discussed in a personal- The interpretive analysis sought to draw parallels between
ized, structured interview. All interviews were conducted by the co-researchers and to construct core dimensions of the phe-
first author, tape-recorded, and transcribed verbatim. nomenon. The formation of the core dimensions was an
iterative process, occurring alongside the grouping of indi-
vidual co-researchers’ primary data to form exemplars of their
Data Analysis experience of spirituality. These experiences were then inter-
The data were analyzed using a descriptive approach (Giorgi
preted through three hermeneutical lenses: a neurobiological
& Giorgi, 2003) followed by an interpretive phenomenological
(informed by Andreasen, 2000), a cognitive-behavioural (Beck,
approach (Pollio et al., 1997). Utilizing the framework of sym-
1995), and a sociological lens (informed by Ratner, 2008). This
bolic interactionism also focused the analysis on the language
interpretive analysis enhanced the experiential descriptions
used by the co-researchers within their discursive context. The
and raised questions about the phenomenon of spirituality.
aim of the descriptive analysis was to construct the most com-
plete descriptive summary of each participant’s spirituality,
in context, from all the available data (interviews, letters, art, Findings
observations). The analytic stages were (1) reading and reread- The research team constructed five core dimensions of spiri-
ing the transcripts, (2) dividing data into meaning units, that tuality for the co-researchers in this study and demonstrated
is, a continuous thread of thought about the phenomenon, (3) their interrelationship in Figure 1. These core dimensions,
condensing the meaning units into primary data, and (4) form- though distinct, are interrelated through interactive meaning-
ing a descriptive or diagrammatic structure (Giorgi & Giorgi, making in the context of others and in self-reflective dialogue
2003). The following exemplifies stage 3, demonstrating how (with the “me”). The core dimensions can be defined as follows:
everyday expressions were rewritten to highlight psychologi- 1. RS practices are activities that nurture spirituality. These
cal meaning, making explicit the language and processes that practices held particular meaning for co-researchers as
were implied: they lived with the symptoms of schizophrenia. Some of
Meaning unit: (John Smith) I think I am OK now. I have these practices were explicit (e.g., meditation) and others
gotta find my centre. You have heard that expression? I were ordinary activities imbued with spiritual meaning

Table 1
Co-researcher Demographic Information

Co-researcher Phases Country or Diverse spiritual or Pseudonym Sex Age Length of illness
of study continent nonspiritual
of birth viewpointa

P1 3 Canada Existential, Quality of life, John Smith M 48 approx. 26 years

Mixed religions
P2 3 Canada Religious, Political Paul, the apostle M 59 40 years
P3 3 Europe Theistic, Mystical Suzie F 57 10-12 years
P4 1 South East Asia Religious F
P5 3 Canada Religious, Theistic, Mystical Gringo M 54 36 years
P6 1 Trinidad Language, Mixed religions F
P7 3 Canada Language, Emerald F 50 10 years
P8 3 Canada Existential, Mystical Shawna F 39 7 years
P9 3 Canada None Veronica F 47 19 years
P10 3 Canada Mystical, Religious Scott M 54 approx. 28 years
P11 3 Africa Theistic, Religious, and Cultural Bill M 40 14 years

McSherry & Cash, 2004.

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by applying RS principles (depicted as a shadow in Figure resent their spirituality to others. Each time they repre-
1). Participating in RS practices was also a means of vis- sented their spirituality, whether in actions or words, they
ibly validating their spirituality to others in the act of RS carefully negotiated (using RS agency) their spiritual dis-
role-taking. course, the expectations of the other, and the risk entailed
2. RS principles are belief/value statements that co-research- in becoming vulnerable. The RS role performance required
ers adopted from surrounding societal discourse. They the application of RS principles that defined necessary
utilized RS principles to reflect on their lives, particularly behaviour, and they participated in RS practices that pro-
as they framed their embodied experience of schizophre- vided credibility for the enactment of the RS role.
nia. The demonstration of RS principles through RS prac- Below we focus in more detail on RS practices (activities)
tices reinforced the co-researchers value/belief in the RS and RS agency (choice and empowerment) that have particu-
principles. The co-researchers valued their right to choose lar relevance for spirituality in occupational therapy practice.
(agency) principles and practices.
3. RS agency is the sense of freedom that co-researchers felt RS Practices: Doing to Nurture Spirituality
to choose among the spiritual options in the public dis- The co-researchers in this study, like others in the city, engaged
course (a broken circle in Figure 1). For people living with in RS practices alone (meditation, creative writing) and/or in
schizophrenia, this was empowering, a contrast from other the context of others (yoga class, communal praying). Most
social positions. The co-researchers’ RS agency was most of these practices are widely accepted, yet in their accounts,
vividly noted when they reflected on RS experiences that we discovered that these practices were specifically helpful for
“happened” to them. their unique needs as people with schizophrenia.
4. Psychotic-like RS experiences are experiences that the co- John Smith is curious, a searcher of spirituality. He takes
researchers did not deliberately seek out and when articu- every opportunity to learn about new spiritual ideas, particu-
lated to an “other” required an explanation. Because they larly ones that assist him to focus. John is a regular attendee
usually occurred outside of a defined RS practice, these of a [small spiritual community], where he was introduced to
experiences could be framed using either psychiatric or the spiritual practice of “centring.” Centring (alone or with oth-
more traditional spiritual discourse. The co-researchers ers) is a means for him to establish his emotional equilibrium,
did not ignore psychiatric discourse. Instead they mobi- managing extreme emotions secondary to his schizophrenia
lized various explanatory frameworks in order to think symptoms.
about their experiences and make meaning of them, alone John: [After emotional moment] I think I am OK now. I
and in the presence of others. have got to find my centre. You have heard that expres-
5. RS role-taking is a means for the co-researchers to rep- sion? I have got to find that centre. See that is what I
think the [spiritual communities] are offering is centring
. . . the centre is something that’s your equilibrium. You
are not too emotional about this or that . . . feeling cen-
tred, not too angry, not too melancholy.
John attends the services of this spiritual community,
which provides him with an opportunity to centre and connect
to the divine within. Centring also presents a challenge for John
as he lives with schizophrenia. There are times when he can-
not focus because of poor concentration, disordered thoughts,
and side-effects from the medication (specifically akathisia).
While the symptoms of schizophrenia present a challenge
to John’s engaging in the spiritual practice of centring, Bill’s
spiritual practice enhances his concentration. As a Jew, Bill’s
spiritual practice involves the ritual of attending a synagogue
every Friday night. Each week the Rabbis lead the members of
the synagogue through the same Hebrew prayer recitation. Bill
is a new convert and cannot understand Hebrew. Yet it is his
ability to follow the repetitive pattern of prayer that is helpful
for him. Bill says that when he is in prayer at the synagogue his
mental health is at its best. Judaism provides Bill with a week-
end prayer ritual that sustains his sense of respect and his hope
that he will be healed.
Bill: Well, the spirituality of Judaism is, when you see it
from afar it’s, it, it doesn’t mean anything, but when you
follow it . . . I feel different. Right. How they respect each
Figure 1: The five core dimensions of spirituality for (Later in the interview)
co-researchers with schizophrenia. Interviewer: What does the Torah say about mental illness?

Canadian Journal of Occupational Therapy April 2012 79(2) 81

Smith & Suto

Bill: It says we will be cured if we pray for that. mental processing of the co-researchers. At times they seemed
John and Bill articulated solitary and communal, cred- to settle on one explanation, while at other moments they were
ible spiritual practices as one way of overcoming neurobio- able to hold the tension between undecided competing expla-
logically defined symptoms associated with schizophrenia and nations. Suzie serves as a good example of this process.
secondary emotions. However, Scott’s story is different. Scott’s Suzie’s first experience of a psychotic-like RS vision was
participation in his chosen spiritual practice caused him con- when she was training in a convent to become a nun. Later
fusion about his experience of his later diagnosed symptoms she trained as a nurse. Suzie is an example of a person who
of schizophrenia. is knowledgeable about two systems of thought to inform her
Scott’s spiritual practice is from a less recognized source. understanding of her experience.
A little-known spiritual order helped Scott establish a belief Suzie: Just about when I was to graduate as a nun there
system to make sense of his place in the universe. Scott engages was incident. . . . Apparently I saw Devil. . . . Because I
in the practice of “translation” taught to him by this spiritual read a lot of religious books about miracles and situa-
order. Seeing himself as primarily spiritual enables Scott to tions like that, when the holy person had vision and saw
take control of his life and to trust his thoughts, feelings, and either God or Devil, and that was supposed to be miracle
choices. Scott interacts with spiritual principles through the . . . I was the only one in the room. And I wasn’t sure if
spiritual practice of translation, which enables him to ascribe that was a dream in the way—because it was late in the
individualized meaning to his experiences. evening, but I could describe with details how the Devil
Scott: I’d better explain what translation is. Translation looks like. And I told them in the meeting about that
starts with a premise that I am my whole, sound and per- and apparently they thought there was something wrong
fect. All is well with the world ‘coz God is on His throne with me. And I didn’t know at this time. I thought I had
. . . You start with . . . You write at the top: “In the Divine miracle happen to me. And they let me go out from the
order” . . . you start with the absolute . . . it goes from that convent after this episode. Now when I think backwards
to senses. “What do your senses claim to be a problem?” I think that was . . . showing one of my signs of my dis-
Scott began to experience psychotic-like visions while he ease, my schizophrenia.
was a member of this spiritual order. He, together with the RS agency, then, is the sense of freedom the co-research-
members of the order, interpreted his experiences as spiritual ers had to mobilize spiritual discourse to meet their unique
visions and failed to notice the symptoms of thought disorder needs and renew their sense of empowerment. At times spiri-
and functional deterioration. The practice of translation, using tual practices actually enlarged a sense of agency by providing
principles from this spiritual order, provided no avenue for a additional language for the co-researchers to draw on. When
neurobiological interpretation of Scott’s experience. Scott was interacting with other explanatory frames, the co-researchers
hospitalized in a catatonic state some months later. in the study showed a tremendous ability to dialogue between
diverse systems of meaning. This was particularly evident when
RS Agency: Freedom to Think in Spiritual using language to describe psychotic-like spiritual experiences.

The co-researchers were empowered by having the freedom Discussion
to choose their RS practices and beliefs. Gringo’s chosen RS Engagement in RS practices (e.g., centring) gave the co-
practice of Christian mentorship has given him the freedom to researchers in this study a way to find meaning, experience
participate in a healthy relationship. Gringo’s mentor (a mem- empowerment, and to cope with hard experiences in mental
ber of the same spiritual community) acts as a conduit of other health recovery. This aligns with the findings of Huguelet et al.
frameworks, often introducing biological and psychological (2006) and Mohr et al. (2006), in which 71% of their sample
ideas when Gringo has the tendency to fixate on a spiritual reported that RS practices instilled hope, purpose, and meaning
lens. Gringo’s mentor helps Gringo to mobilize alternative lan- in their lives (although 14% said it induced spiritual despair),
guage to describe experiences, enlarging his sense of agency by and RS practices increased social integration in 28% (worsened
expanding his horizonal options. social integration in 3%). In his review of spirituality in mental
Gringo’s mentor: That’s healthy for you [Gringo]. I’ve health, Koenig (2009) also highlights the difficulty of the use of
always said that to you; it’s healthy for you to try to dis- RS practices and principles in meaning-making when people
cern between the two [spiritual and psychological causes]. living with schizophrenia may be experiencing religious delu-
That some of it’s just baggage that you’ve been stuck with, sions. For these individuals, utilizing RS practices is more com-
that’s not your fault, it’s just there, it is what it is. I’ve got plex, even leading to distress. Similarly co-researchers in this
mine as well. And, and some is spiritual . . . spiritual war- study may be setting themselves up for existential turmoil, for
fare, but not all of it is doing battle with Satan, you know, example, Jewish prayer may not heal Bill, or Scott’s visions may
in the trenches. It’s not all that. advance dormant schizophrenia symptoms.
Gringo reflected with his mentor about possible ways In these instances, mental health professionals (as “other”)
to explain his most difficult experiences. Each co-researcher may choose not to engage in dialogue about spirituality with
sifted through the spiritual discourse to work out how to repre- individuals living with schizophrenia. However, it is because of
sent their various experiences, particularly the ones psychiatry the complexity described above that Koenig (2009) asserts that:
had labelled as psychosis. The data set attests to the complex Clinicians need to be aware of the religious and spiri-
tual activities of their patients, appreciate their value as a

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Smith & Suto

resource for healthy mental and social functioning, and their clients about their engagement in RS practices. One way
recognize when those beliefs are distorted, limiting, and to begin RS conversations is making use of the framework/
contribute to pathology rather than alleviate it. (p. 289) acronym HOPE, where H stands for sources of hope, mean-
Although we recognize that Koenig’s work is contextu- ing, comfort, strength, peace, love, connection; O for organ-
alized within a narrow definition of spirituality (as synony- ised religion; P for personal spirituality and practices; and E
mous with religion), this particular insight is valuable, though for effects on medical care (Anandarajah & Hight, as cited
complicated. Huguelet et al.’s (2011) most recent study is a in Edwards & Gilbert, 2007). Starting with a question, such
randomized controlled trial, in which a treatment group (out- as What are your sources of hope?, allows for client-centred
patients with psychosis) was assessed by their psychiatrist language that maintains the client’s sense of agency (in keep-
using semi-structured interviews on spiritual and religious ing with our findings) and validates his or her resources for
topics. Results revealed that after three months clinicians coping.
were less motivated to discuss spirituality with their patients The role of the occupational therapist may initially be
as they felt that some conversations were out of their scope to inquire about and validate his or her client’s RS practices,
of practice. However, Edwards and Gilbert (2007) argue that that is, enacting the “coach” enablement skill (Townsend et al.,
inviting clients to share their RS rituals and practices is essen- 2007). But occupational therapists also collaborate with clients
tial, if done in a way that meets the individual where he or she and facilitate their occupational decision-making processes.
is at. They explore ways that professionals can initiate these The same can be applied to an RS practice decision-making
conversations using a language of the heart, active listening, process. Wilding et al. (2005), Swinton (2001), and Kang
and sensitive validating responses. This approach would allow (2003) provide the principle that spirituality is life sustaining/
clients to use their personal RS language and to maintain their enhancing, which could be helpful in weighing up RS prac-
sense of agency. Yet neglecting RS conversations may be a tices. If, as the findings of this study show, clients living with
form of invalidation for clients (Tarko, 2003), many of whom schizophrenia are actively thinking through the benefits/costs
utilize RS practices as a means of coping, particularly in man- of their engagement in RS practices, therapists can ask appro-
aging the internal and external demands of stressful situations priate questions about life enhancement. These questions
(Davidson, 2003). could be framed to inquire about the client’s views regarding
Another reason mental health professionals may dis- the outcome of engagement in these practices and whether
engage from RS conversations is out of fear of the potential they see the practice as enhancing for the whole of their life.
psychological cost of engaging in RS practices for their cli- In addition, occupational therapists who engage in dialogue
ents. Professionals are trained to be aware of the moments about RS practices with their clients need to have a clear sense
of vulnerability of people living with a diagnosis of schizo- of their professional boundaries. While it might be their role
phrenia (McCann & Clark, 2005) and may assume too much to listen, validate, and facilitate decision-making, it is not the
responsibility as protectors of these individuals. However, the prerogative of occupational therapists to provide their clients
research findings of this study indicate that for these nine co- with spiritual care; that is, directly using RS practices as part of
researchers, engaging in RS practices was within their domain client intervention (Clark, 2005). This is in contrast to what is
of agency, and, as Huguelet et al.’s (2006) study showed, they proposed by Farah and McColl (2008).
may avoid professional control by selectively disclosing their Therapists have expressed concern about their inad-
spirituality to health care practitioners. These individuals may equate training in spirituality. Rather than having the unre-
choose instead to dialogue with others, such as a spiritual alistic expectation to know and be skilled in all RS practices,
mentor, about their mental health and spiritual experiences. occupational therapists could focus on collaborating with
One of the key features of mentors in this study was spiritual resources in the community. This would provide links
that they limited their control over the co-researchers, which to those who have expertise in a client’s specific RS practice.
facilitated a sense of RS agency. Davidson (2003) recognizes Occupational therapy education could focus on assessing cli-
the importance of a validating other in the process of recovery. ents’ specific RS practices in order to access appropriate com-
Mentors who validated the co-researchers’ ways of framing munity resources.
their experiences were also able to offer a bridge to neuro-
biological intervention, thus modelling the multiple framing
of experience. Gringo’s Christian mentor had also visited his
The co-researchers who participated in this phenomenologi-
mental health team to assist with a vocational decision, an cal study utilized RS practices as a resource for their mental
example of collaboration between spiritual groups and mental health recovery and sense of empowerment. Their choice of
health services. Engaging in this area may not be comfortable RS practices demonstrated a developed sense of agency. They
for mental health professionals, and further work is needed to imbued these practices with profound meaning and expressed
educate professionals regarding spiritual assessments, nego- their desire for validation from mental health professionals.
tiation of RS practices, and collaboration with RS groups and Yet individuals like Mr. P. require intervention from occupa-
mentors (Macmin & Foskett, 2004). tional therapists in facilitating their decision-making process.
This may include empowering individuals living with mental
Implications for Occupational Therapy health diagnoses to make life-enhancing decisions regarding
Occupational therapists, with their focus on occupation, have their engagement in spiritual practices and choice of explana-
the potential for the most direct access to conversations with tory frameworks for their experiences.

Canadian Journal of Occupational Therapy April 2012 79(2) 83

Smith & Suto

tional Therapy, 51, 173-180. doi: 10.5014/ajot.51.3.173

Key Messages Fallot, R. D. (2008). Spirituality and religion. In K. Mueser & D. Jeste
(Eds.), Clinical handbook of schizophrenia (pp. 592-603). New
• People living with a mental illness offer credible
York: Guilford Press.
insights into how RS practices may be used in a life-
Farah, J., & McColl, M. A. (2008). Exploring prayer as a spiritual
enhancing way.
modality. Canadian Journal of Occupational Therapy, 75, 5-13.
• Research designs that incorporate phenomenology, Fine, G. A. (1993). The sad demise, mysterious disappearance, and
hermeneutic theory, and symbolic interactionism can glorious triumph of symbolic interactionism. Annual Review of
help to illustrate how people construct meanings in Sociology, 19, 61-87. doi: 10.1146/
particular contexts and in relation to others. Giorgi, A., & Giorgi, B. M. (2003). The descriptive phenomenologi-
• Occupational therapists can use existing enablement cal psychological method. In P. M. Camic, J. E. Rhodes, & L.
skills to facilitate life-enhancing decisions related to Yardley (Eds.), Qualitative research in psychology: Expanding
clients’ spiritual practices and choice of explanatory perspectives in methodology and design (pp. 243-273). Washing-
frameworks of their experiences. ton, DC: American Psychological Association.
Hall, W., & Callery, P. (2001). Enhancing rigor of grounded theory:
Incorporating reflexivity and relationality. Qualitative Health
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Canadian Journal of Occupational Therapy April 2012 79(2) 85

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