Front Porch Essay #1

 Starting Points for Spiritually Sensitive Mental Health Practice and Assessment
  Edward R.Candy, Ph.D.

The word psychotherapy literally means "healing for the soul." The Greek root of "psycho" refers to breath, spirit, soul, and mind. Many languages note this connection between mind, breath, and spirit. Mental health is not just the absence of symptoms that relate back to mental disorders and maladies as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM). It is a dynamic condition of well being and well doing characterized by a sense of centeredness, clarity of perception and thinking, personal integrity, and relational responsibility. From a social work perspective, mental health practice should address the whole person in the context of his or her relationships and environmental setting. From the perspective of spiritually sensitive social work, mental health practice makes explicit this mind/spirit connection by honoring the whole person in environment with special attention to the way people work out a sense of meaning, purpose, and morally fulfilling relationships with oneself, other people, the world, and the ultimate ground of being, however one may understand it (for example, in theistic, atheistic, agnostic, animistic or other ways). In general, spiritually sensitive social work practice is not about imposing or restricting any particular religious beliefs or practices. However, it is about honoring the diverse religious and nonreligious ways that people find meaning, resilience, strength, resources, and creative transformation, even in times of joy and despair, crisis and stability, illness and ease.

In social work and related health and mental health professions, the past sixteen years has witnessed an incredible shift from major neglect of spirituality to a tremendous amount of research, educational and practice innovations, and publication on this subject (e.g. Canda, et al., 1999). In these fields, it is becoming common to define spirituality as having to do with people’s search for a sense of meaning, purpose, morality, and responsible relationship in the context of their understanding of ultimate reality or the divine (Canda and Smith, 2001). Religion refers to institutional patterns of beliefs, values, and behaviors concerned with spirituality and shared by a group with traditions developed over time (Canda and Furman, 1999). Thus, spirituality may be expressed through religion, but it need not be.

 Spirituality as a resource for people with mental distress and illness

In the United States, most people profess some type of religious belief and affiliation and consider them to be important for their daily life and well being. Everyone is working out a spiritual path, whether or not one uses words such as spirituality, religion, and faith. Especially for people who face crisis, distress, serious illness, and disability, issues of spirituality often come to the forefront. Although people may experience harmful effects from unsupportive or damaging behaviors in religious and nonreligious spiritual groups and beliefs, there are a tremendous amount of spiritual resources to support mental health and resilience. Given the prevalence of religious and nonreligious spiritual perspectives, the universal human quest for meaning, and the opportunities for strength and resilience in spirituality, it is crucial for mental health practitioners to attend to spirituality.

There are now hundreds of quantitative and qualitative empirical studies about links between religion, spirituality, and health. For example, quantitative (statistical) studies have shown that religious commitment and participation are commonly associated with positive results such as: lessening the likelihood of suicide and suicidal impulses; enhancing self-esteem; lessening the likelihood of illicit drug use; lessening the likelihood of alcohol abuse; lessening the likelihood of juvenile delinquency; increasing the likelihood of marital satisfaction and stability; lessening the likelihood and severity of depression; and decreasing the severity of psychological distress (Larson & Larson, 1994). In interviews with 40 adults who had severe mental illness, Sullivan (1992), learned that some people associated positive effects with social support experienced in religious communities; a sense of meaning and self-understanding, including dealing with a mental illness, gained from religious beliefs and spiritual perspective; positive feelings in response to prayer and worship; a sense of support and love from God or a Higher Spiritual Power; and spiritual perspective on ways to cope with and transcend a mental disability. These studies reinforce the importance of building on the strengths of people’s inner spiritual practices (such as meditation, prayer, inspirational reading, and dream reflection) and resources (such as sense of loving relationship with the divine, personal wisdom, and spiritual experiences) as well as their outer spiritual support systems, such as religious communities, culturally based wisdom traditions, religious leaders and traditional healers, spiritual mentors, and wise relatives and friends.

Assessment of spiritual resources in a mental health context

In order to tap spiritual resources, helpers first need to know what they are for the mental health service consumer. One simple way to begin is to ask the person during initial assessment whether spirituality, religion, or faith are important to her or him in any way; and if so, would the person like to include them in the helping process. Then the consumer can describe what they mean to him or her and give examples. This can easily be done in the context of a strengths assessment by including spirituality as one domain of life to consider. Any such question should be open-ended and should allow the person to indicate whether spirituality is relevant, what words are appropriate to describe this aspect of life, and what ways, if any, spirituality should be addressed. In keeping with the NASW Code of Ethics and the principle of client self-determination, no particular ideological or religious agenda should be imposed or insinuated. On the other hand, social workers and other mental health professionals should not restrict or denigrate any particular religious or non-religious spiritual perspectives of clients.

Sometimes mental health professionals are reluctant to address religious and spiritual issues because they are worried about exacerbating delusions or hallucinations with religious content. This raises another more complex assessment issue: How to distinguish between psychopathology and spiritual experiences that may appear strange or problematic? Transpersonal theory in psychology and social work provides some helpful distinctions (Canda and Smith, 2001; Nelson, 1994). Assessment can explore distinctions between common qualities of some mental disorders and spiritual experiences and crises that are sometimes mistaken for psychopathology, such as: symptoms generated by organic disease (e.g. a brain lesion) versus absence of organic pathology; chronic long term debilitation versus short term incapacitation; subjective sense of meaningless chaos versus meaningful life disruption and transformation; disability versus intensified ability; incoherent speech versus poetry, metaphor and paradox; religious delusions versus spiritual inspirations; ego inflation versus ego transcendence and genuine humility; involuntary dissociation versus spiritual trance; hallucinations versus mystical visions and insights. This is complicated because spiritual crises and experiences can intersect with mental illness symptoms, and, in a more human way of putting it, people with serious mental distress and mental illness (and all of us are some point) may find some of the strongest insights, strategies, and environmental supports for dealing with the challenges through spiritual experiences and support groups. Further, some people endure periods of intense spiritual suffering and mental distress as part of the spiritual journey.

The DSM-IV-TR offers some cautions and helps in this regard. DSM-IV introduced a V-Code, V62.89 Religious or Spiritual Problem, to be used when religious or spiritual issues are the focus of clinical attention but are not part of a mental disorder and may or may not be related to one (p. 741). Several sections of the DSM-IV-TR include cautions to complete diagnosis in the context of the person’s larger life context, culture, and religion, so that inappropriate ethnocentric or religiously biased judgments are not made. Further, Appendix B (Criteria Sets and Axes Provided for Further Study) includes Dissociative Trance Disorder, and Appendix I (Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes) includes guidelines for cross-cultural assessment, with many examples of religiously related types of distress or mental disorder. In general, the authors of successive editions of the DSM have been moving toward approaches to assessment that are more contextual, culturally aware, religiously informed, and based on international research.


There is a danger of drifting into a technocratic, expert-driven approach to studying, evaluating, and doing to’ the client while considering the implications of diagnosis and assessment. That is far from what spiritually sensitive practice is about. Canda and Furman (1999) provided a comprehensive framework for spiritually sensitive social work practice. It can be summarized by going back to the link between spirit, mind, and breath mentioned in the beginning of this essay. Mental health practice should literally be a conspiracy between client and worker. The roots of the word conspiracy mean "to breathe together" or "to be together in spirit." The helping process is most powerful and satisfying when worker and client join in rapport and empathy, breathe together, get centered together, and work creatively together to enlist the highest, deepest, and widest resources for resilience and recovery. When we engage these resources, we can enjoy well-being and health in a profound way even while we respond to the challenges of mental distress, illness, and disability.


American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: American Psychiatric Association.

Canda, E. R. & Furman, L. D. (1999). Spiritual diversity in social work practice: The heart of helping. New York: Free Press.

Canda, E. R., Nakashima, M, Burgess, V. & Russel, R. (1999). Spiritual diversity and social work: A comprehensive bibliography with annotations. Alexandria, VA: Council on Social Work Education.

Canda, E. R. & Smith, E. (Eds.) (2001). Transpersonal perspectives on spirituality in social work. Hazelton, PA: Haworth Press.

Larson, D. B. & Larson, S. S. (1994). The forgotten factor in physical and mental health: What does the research show? An independent study seminar. MD: National Institute for Healthcare Research.