‘Why Does This Happen to Me?’ Religious and Spiritual Struggles among Psychiatric Inpatients in The Netherlands: A Narrative Analysis

Round 1

Reviewer 1 Report

  Religions

Reviewer Comments

Title: Why does this happen to me? Religious and spiritual struggles among psychiatric inpatients 3 in The Netherlands: a narrative analysis

MS #: religions-1919323

The purpose of this report was report was to examine the role of spiritual/religious (R/S) struggles in the experience of mental illness. Using a sample of 35 psychiatric patients, these authors examine these patients’ experiences of R/S struggles as part of their emotional difficulties. The authors note that issues with God and disturbances in their spirituality are co-incident with the psychiatric processes these individuals are experiencing. An important and timely paper; I am a strong advocate on the value and psychological significance of R/S struggles in the mental lives of people. While this study is mostly descriptive, it highlights the role of these dynamics in the psychological process, but does not provide a critical analysis of the role of these issues in treatment. A few comments.

1)      First, the fact that people who are experiencing significant emotional/characterological distress are having issues with spiritual and religious material is not, in and of itself, a very important finding. These individuals are experiencing significant conflict in their lives, with work, friends, family, intrapersonal issues, and overall emotional adjustment in life. To point out that they also experience distress with R/S issues just seems to round off the overall level and extent of the affective dysphoria these people are encountering. One issue that this paper overlooks, is a compelling rationale for why therapists in general need to attend to these issues. What is so special about R/S conflicts? How are they different, if at all, from the other conflicts these people are experiencing. Is there any thing unique or special about R/S issues that warrant a specific intervention? These are important questions that seem to go unanswered in this paper. Without a compelling reason for addressing these issues, most clinicians would not really be interested in directly engaging with them. Doing so, for many clinicians, would not be very productive and take the therapy towards issues that the therapist feels either is not as important as the points of distress, or not something the therapist themself would feel comfortable in addressing. Many therapists would tend to see R/S issues as mere extensions of the more general psychological issues that are driving more salient aspects of maladaptiveness. AS such, the authors need to do more in their literature review than just cite research that shows the prevalence of R/S issues in clinical work. Again, distressed people feel distress across their life space. I think the authors need to demonstrate that R/S issues are not necessarily just a facet of underlying emotional distress. Rather, that R/S issues have their own unique psychological significance. I would recommend reviewing this book by Sharon Mijares and Gurucharan Khalsa entitled, “The psychospiritual clinician’s handbook: Alternative methods for understanding and treating mental disorders” 2005 by Hayworth Press. This work does a great job in helping clinicians discern between the expression of R/S issues that are symptomatic of larger, underlying emotional problems, and R/S issues that are themselves issues that may be driving the emotional distress. This is an important work because it identifies R/S issues as representing a different source of emotional distress than that encountered with many other psychiatric problems.

2)      The point to be made in this paper, is that R/S issues need to be addressed by clinicians, not because they frequency appear alongside other disorders, but because disruptions in one’s sense of ultimate existential existence creates is own, unique source of emotional distress that is both profound and extensive in distorting patients’ sense of personhood. Simply put, underlying many psychological and characterological impairments is the personality dimension of Neuroticism. One’s tendency to experience negative affect can predispose one to develop emotional disorders. Those high on Neuroticism experience large amounts of negative affect, lowered self-esteem, impaired coping ability, and much more. It is not surprising that this dimension is such a broad, robust predictor of psychological disorders. However, research has begun to demonstrate that R/S issues represent an aspect of personality that is independent of Neuroticism that also is predictive of psychological distress and disorders. Because R/S issues address peoples’ ultimate sense of meaning, purpose, and worthiness, disruptions in these existential aspects of functioning carry profound implications for well-being and adjustment. I would recommend that the literature review include some of the following papers to help make this argument:

*Piedmont, R. L., Fox, J., & Toscano, M. E. (2020). Spiritual crisis as a unique predictor of emotional and characterological impairment in atheists and agnostics: Numinous motivations as universal psychological qualities. Religions. https://www.mdpi.com/2077-1444/11/11/551/pdf

*Fox, J., & Piedmont, R. L. (2020). Religious crisis as an independent causal predictor of psychological distress: Understanding the unique role of the numinous for intrapsychic functioning. Religions, 11. doi:10.3390/rel11070329

Piedmont, R. L., Hassinger, C. J., Rhorer, J., Sherman, M. F., Sherman, N. C., & Williams, J. E. G. (2007). The relations among spirituality and religiosity and Axis II functioning in two college samples. Research in the Social Scientific Study of Religion, 18, 53- 73.

These studies demonstrate that R/S issues are independent of the domains of the five-factor model of personality, particularly Neuroticism. Further, that aspects of R/S conflict provide an independent, additive effect of the experience of negative emotions and psychological dysphoria. These papers can help the authors outline the true psychological value of R/S dynamics and the unique, powerful influence they have on the mental lives of people. As such, therapy needs to address these issues because not doing so leaves current treatments inadequate in addressing the core drivers of the disorders. Without engaging with the existential issues represented by R/S conflicts, problems will continue to worsen and complicate functioning. Current practices in treatment do not have any systematic procedures for addressing ultimate existential issues in treatment. Given the preponderance of such issues in the clinical context, this needs to change.

Author Response

Thank you for your valuable feedback and very appropriate suggestions to extend the relevance of the current study by demonstrating the specific relevance of R/S issues. We have carefully read your feedback and the suggested articles. In addition we have examined a review concerning the interesting book you mentioned, but were not able to read the book within the 5 days that we had for the revision. However, we took your suggestions into account and made some adaptations, both in the introduction and discussion, in order to make the points you suggested. We hope it will meet your expectations.

Reviewer 2 Report

Thank you for the opportunity to review this article. I admit that the text is clear, very interesting and methodologically substantive in terms of the presented structure and procedure. The Authors present the results based on the narrative analysis of religious and spiritual struggles among psychiatric inpatients in the Netherlands. The text raised in me a few questions which are more intended to broaden those aspects of the text that seem important from a theoretical perspective (questions 1 and 4) and practical implications (questions 2 and 3).

1.       First, do your results confirm or relate to any empirical research conducted previously among psychiatric inpatients on religious struggles? I am thinking here, for example, of the research carried out by (to mention only few): Phillips III and Stein („God’s Will, God’s Punishment, or God’s Limitations?...”); Elliot and Reuter („Religion, spirituality, and mental illness among working professionals…”); Hefti („Integrating spirituality into mental health care…”).

2.       Second, based on your study, can you indicate any ways to normalize and reframe struggles as a time of patients’ personal growth?

3.       Is there a difference between the help mental health professionals and spiritual caregivers can offer with regard to patients’ religious struggle? Did you take i tinto account?

4.       Do you think of future perspectives that could be takien into account in next studies?

Below I present my doubts regarding the way of writing quotations, punctuation marks and grammar issues.

Lines 31-32: I am not sure whether it is necessary to repeat the name in parenthesis when mentioning the Author in the text. Perhaps it would be better: Pargament and colleagues (1998). I propose to review the text in this aspect. Another example, although not the only one, is in line 464.

Lines 46: It is: Gods actions. It should be: God’s actions.

Line 49: Is it necessary to repeat „combined”?

Line 68: after Pieper & van Uden should be date (not at the end).

Line 253: Is „the”necessary before „more”?

Line 255: It is: … autism. It should be: … autism].

Lines 277-278: I think that instead of „lead” should be „led”.

Line 298: Should not be? „The presence of ‘negative’ feelings?

Line 411: It is: Wilt et al.. 2020. It should be: Wilt et al. 2020

Line 487: It is: tabbo’s. I am not sure but I think that it should be: taboos. Please, verify this word.

Author Response

1. Thank you for these valuable suggestions of relating literature. We have tried to discuss our findings in relation to these articles now.
2. As a matter of fact, patients did not really mention their R/S struggles as ways of personal growth, but that could be because of the clinical stage in which the interviews took place (in the midst of their illness and R/S struggles so to say). Recently I (first author) have read interviews with mental health patients in a later stage (so after periods of clinical stay) and these patients were more able to reflect on their struggles as a way of spiritual growth. It would however be interesting to find out whether caregivers could be able to help patients think in this way (at least for the future). In line with the process of recovery it could be a way of rethinking, reframing indeed. We have now added a line about it. Concerning ‘normalizing’, this indeed is important and sustained by our study results. The example mentioned in the text is about ‘anger’ – to hear that this is common can help patients.
3. This is a good question. We think there is a difference yes, since spiritual caregivers are educated in these matters and more experienced and competent. However, the current study was focused at the role of other disciplines and shows that one step before the spiritual caregivers, these other mental health care professionals could play an important role in R/S care, because of their availability in clinical care and their knowledge of mental illness. We think the roles of mental health care professionals and spiritual caregivers could be complementary and have added some lines about this in the discussion.

4. Yes, we have mentioned some ideas in the implications and recommendations session, and have added an extra idea now. It could really be of high relevance to intervene on the presence of the R/S struggles.

Thank you also very much for the careful reading of the manuscript! We have tried to adapt the text according to your suggestions.

Reviewer 3 Report

Very interesting paper, especially useful for clinical practice

Author Response

Thank you for reviewing the article and expressing your interest! We indeed hope the fingings may help mental health professionals in their work.  

Reviewer 4 Report

A well written and interesting article on a subject of significance which may have relevance outside of the context being researched eg with acute physical illness, for example.  

I wonder if a note outlining the disciplines of the researchers might be added and perhaps further recommendations for practice.

Author Response

Thank you for reviewing the article and expressing your interest. We have added now some lines about our disciplines (line 111-113, it might be also possible to put this in a footnote) and also some extra recommendations about future research, interventions for practice and training for professionals. We hope this will meet your expectations.