Spiritual and Religious Issues in Psychotherapy with Schizophrenia: Cultural Implications and Implementation

The topics of spirituality and psychotherapy have often been controversial in the literature on schizophrenia treatment. However, current research indicates many potential benefits of integrating issues of religion and spirituality into psychotherapy for individuals with schizophrenia. In this paper, implications are presented for incorporating spiritual and religious issues in psychotherapy for individuals with schizophrenia. A background on the integration of spirituality into the practice of psychotherapy is discussed. The literature on spiritually-oriented psychotherapy for schizophrenia is provided. Clinical implications are offered with specific attention to issues of religious delusions and cultural considerations. Lastly, steps for implementing spiritually-oriented psychotherapy for individuals with schizophrenia are delineated to assist providers in carrying out spiritually sensitive care.


Introduction
The topics of spirituality and psychotherapy have often been controversial in the literature on schizophrenia treatment [1,2].Some practitioners have argued that religion had no space in the OPEN ACCESS psychotherapy setting given a need to be grounded in science.However, current research indicates many potential benefits of integrating issues of religion and spirituality into psychotherapy for individuals with schizophrenia with regards to promoting motivation, wellbeing, resilience, and cultural aspects of one's identity [3,4].In this paper, implications are presented for incorporating spiritual and religious issues in psychotherapy for individuals with schizophrenia.To achieve this goal, a background on the integration of spirituality into the practice of psychotherapy is discussed.Next, the literature on spiritually-oriented psychotherapy for schizophrenia is provided.Clinical implications are offered with specific attention to issues of religious delusions and cultural considerations.Lastly, steps for implementing spirituallyoriented psychotherapy for individuals with schizophrenia are delineated to assist providers in carrying out spiritually sensitive care.

Spirituality and Psychotherapy
Inclusion of spirituality and religion in psychotherapy practice has been a relatively recent development [5].Professional and scientific psychology during the twentieth century intentionally excluded issues of religion or spirituality from psychotherapy [6].In the psychotherapy literature prior to the 1990s, issues of religion and spirituality would, most frequently, be indexed in relation to particular kinds of psychopathology such as religious delusions in schizophrenia [7].Moreover, the positive association between religious and spiritual issues and mental health was rarely mentioned.
Prominent scholars, such as Sigmund Freud, John Watson, and Albert Ellis expressed minimal interest in the study or practice of religion (see Plante, [6]; e.g., Ellis, [8]; Freud, [9]; Watson, [10]).In fact, Freud [9] referred to religion as an -obsessional neurosis‖ (p.43) and even systematically rejected the contention by C. G. Jung [11], that the capacity for religious feeling and imagery was as basic as sexuality.Despite further interest of major theorists, such as William James, Alfred Adler, and Gordon Allport, in the connection between spirituality and psychology, the field continued to distance itself from this topic (see Plante, [6] for review; e.g., Allport, [12]; James, [13,14]).These scholars purported that psychotherapy practice should be grounded in scientific theory and research.In addition, the constructs of spirituality and religion were not easily measurable and did not lend themselves adequately to such scientific rigor [6].
However, the past two decades have witnessed a sea of change in the scientific interest in religion and spirituality.Between the years 2000 and 2006, 8,193 articles addressing religion and spirituality from a variety of theoretical and empirical perspectives were published compared to 3,803 such articles published over the course of sixty years from 1900 to 1959 [15].Yet, little consensus has been reached about how to define religion and spirituality and how to distinguish one concept from the other [16][17][18].While one prominent set of researchers conceive of religion as the broader term, inclusive of spirituality [18][19][20], another group of scholars view spirituality as the broader of the two concepts, inclusive of religion [21,22].Moreover, a third group of authors view religion and spirituality as separate but overlapping constructs [23].In this paper, we adhere to the broader understanding that religion tends to be associated predominantly with institutional representation of the divine while spirituality tends to be identified primarily with individual experience of the transcendent [17].
Within the broader health perspective on religion and spirituality [23], there have been growing efforts to incorporate spiritual perspectives in the context of psychotherapy [24][25][26].The burgeoning interest in the health and mental health benefits associated with spirituality and religion may be attributed to several factors.
First, religion and spirituality have recently been established as important motivating forces in people's lives [27].The majority of the population in the world considers themselves as being significantly influenced by spirituality or religion [28].In fact, the majority of the general public in the United States identify as spiritual, if not religious.The 2008 American Religious Identification Survey [29] found that almost 80% of the population in the United States professed to a particular religious affiliation.This finding was further substantiated by a recent Gallup poll [30] where 80% of U. S. residents reported that religion was at least fairly important in their lives while 54% of the same described religion as being very important.
Second, a body of recent research has noted some positive impact of spirituality on wellbeing.Across a broad array of cultural settings and populations, religion and spirituality have often been found to be contributing factors to life satisfaction, sense of personal efficacy, successful coping, and self-esteem [31][32][33][34][35]. Religion and spirituality have been identified as important factors in mental health, including in the recovery from serious mental illnesses [36][37][38].
Third, advances in positive psychology [39,40] as grounded in humanistic and existential thinking shifted the focus from pathology to healthy communities.Positive psychology is focused on increasing the potential for life enjoyment and the promotion of resiliency in the face of problems or stressors experienced by a person [41].In essence, the lens of positive psychology moves away from mental illness being viewed as harmful and stigmatizing to tracking the positive aspects of mental illness.Interventions are targeted towards health promotion rather than the treatment and cure of pathological conditions.From the perspective of enhancement of wellbeing, positive psychology recognizes that spirituality, among other positive psychological characteristics, may grow out of experiences of having a mental illness [42].The field of positive psychology also encourages the scientific study of religious and spiritual development as a contributory factor to positive development in adulthood.For example, spirituality and religiousness are associated with higher-order cognitive functions, which involve meaning-making processes, moral judgment, and complex problem-solving skills [31].
Fourth, the emergence of the field of multicultural counseling, contextualized in rapidly shifting cultural trends, re-integrated religion and spirituality as central concepts in psychotherapy practice [43].The multicultural movement focused on awareness and sensitivity to cultural diversity, an important aspect of which is religious and spiritual practice [44].The movement brought to light that people vary widely on spiritual and religious dimensions in a pluralistic society.This body of research further illuminated that religious populations preferred spiritually integrated care over conventional psychological services [45].Simultaneously, the shifting cultural milieu in the United States in the 1960s and 1970s and large-scale shifts in immigration brought about increased awareness of diversity along with exposure to Eastern religion and philosophy.More recently, technological advances in the past two decades have contributed to increased globalization and fostered proliferation in the information exchange especially with regard to culture-specific values and contextual factors that contribute to mental health and well-being.
These factors not only explain recent scientific interest in understanding the positive impact of spirituality and religion on wellbeing, but also underline the value of addressing issues of spirituality in psychotherapy with some of the most challenging mental health conditions.In this paper, we attempt to address the implications of incorporating spiritual and religious issues specifically in the psychotherapy treatments of individuals with schizophrenia.

Schizophrenia and Psychotherapy
Multiple meta-analyses have demonstrated that a significant number of therapy approaches and interventions for the symptoms of schizophrenia have been effective [1,3].However, the practice of psychotherapy for individuals with schizophrenia has still been controversial in the literature due to questions of the effectiveness of psychotherapy for schizophrenia, especially in acute cases [1,2].In addition, the recovery and rehabilitation model of care for individuals with serious mental illnesses has often overlooked the resource of individual psychotherapy [4].This omission may be due to the peer support focus of the recovery movement given the history of injustices committed by professional providers [46].
There are a number of benefits of psychotherapy for schizophrenia.For one, psychotherapy can provide a space for people with schizophrenia to explore their goals to increase life satisfaction while living with mental illnesses [4].Some of these goals include lessening the impact of the illness on selfesteem and sense of self, enhancing adaptive coping strategies, and supporting preventative efforts to alter the course of the illness [3].In addition, psychotherapy can facilitate the construction of a fuller, richer personal narrative of recovery from the illness that is free from stigma [47].Psychotherapy can also include the technique of metacognition, i.e., reflecting on one's thinking, to encourage a flexible, dynamic thought process in the face of psychosis [4].
These positive outcomes have been acknowledged across several therapeutic orientations, including psychodynamic, supportive, and cognitive behavioral therapy (CBT) [48].Specifically, psychodynamic therapy has demonstrated benefits in focusing on interpersonal relationships, self-knowledge and exploration, as well as a focus on resolving conflicts [49].Supportive therapy has also been found to be efficacious when working with individuals with schizophrenia in providing reassurance, reflective listening, offering suggestions, and focusing on present symptoms [3].Cognitive behavioral approaches have offered benefits in social skills training and coping strategy development [3].Lastly, a branch of cognitive behavioral therapy, Acceptance and Commitment Therapy, uses techniques of mindfulness and meditation to take a non-judgmental attitude towards psychotic thoughts of not acting on the thoughts or believing them to be true [50].
More recently, there have been attempts to develop therapy approaches that specifically address spiritual issues.Spiritually augmented CBT (SACBT) was developed at the University of Sydney and is a 10-16 session approach used with individuals with mental illnesses to draw from the cognitive component of CBT to address the individual's belief system and enhance thoughts and feelings related to acceptance, hope, achieving meaning and purpose, as well as forgiveness [51].The behavioral component of SACBT utilizes exercises in prayer, rituals meditation, and relaxation.Spirituality groups for individuals with mental illness in inpatient and outpatient treatment centers have been also gaining popularity [52,53].For example, Kehoe [52] reported from her eighteen years of experience that spirituality-based group therapy provided an important venue for people with serious mental illness to explore issues related to religion and spirituality.Effectively guided by an open-minded and nonjudgmental therapist, the group fostered tolerance, acceptance of alternative viewpoints, and careful examination of belief systems.Kehoe noted that the group also provided necessary opportunities to apply spirituality and values to important life questions.

The Role of Spirituality in Psychotherapy for Schizophrenia
Spirituality has often been identified as a crucial resource for coping with schizophrenia [38,54].In particular, the recovery and rehabilitation movement has highlighted the integral role of spirituality for the holistic and overall functioning of individuals affected by the most disabling mental illnesses [55,56].The recovery model is an approach to mental illness that focuses on the process of living a satisfying life of wellbeing and autonomy, as opposed to the traditional treatment focus on symptom elimination [57].Recovery from serious mental illness has been presented as a spiritual process in itself and a journey of facing spiritual questions about relationships to God, reasons for the illness, and finding a place in the world [55].
According to several studies, a range of 30-90% of people have reported spirituality and religion to be one of the most important parts of recovery from mental illnesses [37].Many people with schizophrenia report an increase of faith after a psychotic episode and the use of religious coping and seeking spiritual guidance to deal with the symptoms of the illness [38,54,55].Many individuals have reported a benefit from knowing they can still have authentic connections to God despite a diagnosis of schizophrenia [55].Deegan [47] put forth the controversial notion that for many people in recovery from schizophrenia, psychotic thoughts may even help to access spirituality.
Religion and spirituality are uniquely personal processes that deserve novel attention to the individual story of each person with schizophrenia [58].People with schizophrenia may even define their experiences of religion and spirituality differently from one another [17].In addition, some research suggests that religiousness in individuals with schizophrenia is representative of the rest of the population, although religious coping may be different [55].For example, they may be less participatory in community spiritual events, most likely due to fear of ostracization [58].
There is a clear importance of integrating spirituality into recovery-oriented treatment models of care for people with schizophrenia [56].However, it is still underrepresented in the recovery literature and often neglected in clinical care [38,56].Many people with schizophrenia do not disclose their religious or spiritual beliefs to their providers partially out of fear of being labeled religiously delusional and hospitalized involuntarily [59].These findings suggest the potential benefit of spiritual supports in recovery-oriented therapy to facilitate the spiritual education, counseling, and practices of people with spiritual interests who have schizophrenia [56].Based on findings from these studies, it is evident that sensitivity to spiritual and religious issues in psychotherapy may hold many benefits to the individual in recovery from schizophrenia.

Outcomes of Spiritually-Oriented Psychotherapy with Schizophrenia
Benefits.Incorporating clients' spirituality into psychotherapy can enhance treatment outcomes for individuals in general and holds applications for individuals with schizophrenia [7,60].Spirituality contributes significantly to coping mechanisms and meaning-making systems when dealing with pain and suffering [61].Clients frequently hold a variety of spiritual beliefs and coping resources that range from private personal practices (such as prayer or meditation) to involvement in supportive religious communities.Religious and spiritual practices, such as acceptance and forgiveness, prayer, meditation, and worship, are areas of coping which, developed in the context of psychotherapy, can enhance the ways in which people deal with adversity, and people with schizophrenia in particular.
A number of positive outcomes have been identified specifically for individuals with schizophrenia surrounding their religious and spiritual beliefs, yielding implications for therapy [37,[62][63][64].Fallot [37] indicated that positive outcomes are generally associated with positive religious coping-the affirmative religious beliefs and practices for coping with schizophrenia.Conversely, negative outcomes are generally related to negative religious coping-disparaging religious beliefs and intrusive practices for coping with schizophrenia.Positive religious coping has demonstrated improvement in mood and self-esteem.However, in cases of negative coping or religious strain, negative religious beliefs about the illness worsened self-esteem and anger at God for causing the illness.Therapists conducting spiritually oriented therapy with people with schizophrenia can bring an awareness of how positive or negative religious coping may be impacting the individual.
Several studies have delineated the benefits of positive religious coping for individuals with schizophrenia.In one study, individuals with schizophrenia who use positive religious coping had fewer hospitalizations and less symptom severity [65].Other individuals with mental illnesses have reported higher levels of wellbeing and fewer symptoms [66].Spiritual and religious practices were associated with lesser likelihood of smoking, potentially due to exposure to church doctrines and sense of fulfillment offered by spiritual practices with reinforcement for good behavior without substance use [67].Religious involvement was negatively correlated with substance misuse, and may prevent development of alcoholism via religious doctrine, while offering a protective role for some [63].In addition, reports of positive religious resources and commitments have been associated with lower rates of suicidality [58,64].Faith may be helpful to a sense of self, sometimes arising during delusions by increasing a sense of relaxation, optimism, resilience, social supports, hope, positive identity, increased sense of insight, and medication adherence [54].These outcomes suggest the potential benefits of integrating spiritual and religious content into therapy with people with schizophrenia.
Risks.For others, spiritual and religious beliefs and practices may be less helpful when they lead to negative religious coping.In several studies of individuals with schizophrenia, a small portion reported religious beliefs and values to contribute to medication non-adherence, increased suicide attempts, and increased substance abuse [58,62,63].While generally in the minority, there are a number of individuals with schizophrenia who may engage in negative coping associated with religious beliefs, values, and practices.Therefore, it is essential that psychotherapists maintain an awareness of the potentially harmful outcomes for religiosity among individuals with schizophrenia.
Fallot [37] described the potential risks of integrating issues of religion and spirituality into therapy for individuals with schizophrenia.Fallot indicated that some spiritual leaders warn therapists of the segmented approach of mental health providers in addressing issues of religion and spirituality.These leaders have voiced concern that therapists frame religious practices in terms of mental health benefits as opposed to focusing on a connection to and alignment with a spiritual journey that may have positive byproducts.
Weighing risks and benefits.Fallot [38] provides a helpful guide to dealing with these potential risks and benefits for individuals with schizophrenia in therapy interventions.For one, there may be benefits associated with inclusion with some religious communities being inclusive and welcome of individuals with schizophrenia, leading to a sense of acceptance and support.However, other religious and spiritual communities may be rejecting of individuals with schizophrenia or have expectations to express a heterosexual identity, discourage psychiatric medication and traditional medical supports, or make financial contributions to the religious organization.Secondly, individuals with schizophrenia may feel empowered as someone who is valued by the divine within their religious involvement.Or, they may feel devalued within a religion if they are seen as someone who is being punished with schizophrenia for past sins.Third, religion may offer coping strategies for expression and relief including prayer, meditation, and other behavioral rituals that may add structure or self-expression to the day.In contrast, the expected religious rituals may contribute to a sense of rigidity and compulsivity that is overly constrictive.Fourth, religion may offer a sense of autonomy through liberation from a strict reliance on traditional psychiatric care.In contrast, some religious beliefs may place too much emphasis on external control without internal responsibility or capability in altering one's life circumstances.Lastly, religion may offer hope or despair as it can boost energy and calmness, hope, enthusiasm, joy, motivation, through meditative practices of prayer and connection.In contrast, it may also lead to increased feelings of despair by emphasizing sin, guilt, or encountering hopeless obstacles to reaching salvation.Practitioners can carefully consider the risks and benefits associated with religious involvement for individuals with schizophrenia as these issues arise in therapy [38].

Religious Delusions and Schizophrenia
Conducting psychotherapy with individuals with schizophrenia may necessitate awareness of the role of religious delusions in psychosis.The literature in mental illness and religiosity has often focused on the association of demonic, satanic delusions with violent behaviors [64].While important to address, overfocusing on this topic often reinforces negative stereotypes of religious beliefs for individuals with schizophrenia.In addition, these types of delusions occur in a minority of individuals with schizophrenia who have religious beliefs, and are generally not acted on [54].
However, the topic of religious delusions is an important one.In fact, poorer treatment outcomes have been reported for individuals who report religious based delusions, potentially due to associated stigma [38].A religious delusion is an unusual, fixed belief or preoccupation of a religious nature outside the cultural norm that impairs functioning [54].Religious delusions may include supernatural, apocalyptical, or persecutory beliefs, in addition to beliefs of a special connection to, or identity as a God or another religious figure [54,64].Therapists should differentiate mystical, spiritual, or transcendental experience from a delusion to avoid pathologizing spiritual experiences that are culturally congruent [64].Therapists can differentiate between a transcendental spiritual experience from a psychotic delusion in that the former is typically followed by a return to reality, and is often considered acceptable within the individual's religion [64].Psychotherapists are encouraged to avoid confronting religious delusions [54].Instead, therapists can support the individual to recover from the acute distress of the delusion and draw from positive religious resources [38].
Rudalevicienel and colleagues [68] have indicated that religious based delusions may take on a cultural pattern within different groups.In their study of apocalyptic delusions, they found these types of delusions to be cross-cultural regardless of religious background.Religious delusions were particularly frequent in Catholic individuals with schizophrenia.In another study by the same authors, the sociocultural factors of gender, marital status, and education level revealed differences in religious based delusions [69].In this study, it was found that men were more likely to describe themselves as Gods while women identified as Saints [69].In this study, married individuals had fewer apocalyptic delusions, and lower levels of education were more predictive of religious based delusions [69].It is important for clinicians to be mindful of sociocultural factors in presentation [69] and be able to adapt interventions around issues of religion and spirituality in a culturally sensitive manner [70].
Religious differences may also occur in the context of religious delusions among individuals with schizophrenia.Another study indicated that highly religious Christian participants were more likely to hold the belief that demons were responsible for mental illness [64].However, for individuals without religious identification or faith, apocalyptic and religious-based delusions were less frequent.Persecutory or grandiose delusions are believed to be more common in Christian and Western faiths, although one does not have to be religious to develop a religious delusion [64].In addition, terrorist activities within an individual's country of residence or origin may also influence religious delusions, with an increase being evidenced following the attacks on the World Trade Center towers of September 11, 2011 in NYC [71].This phenomenon further reinforces the need for therapists to understand the unique sociocultural factors that impact beliefs of individuals with schizophrenia.

Cultural Considerations for Spiritually-Oriented Psychotherapy with Schizophrenia
Variations in spiritual and religious practices occur across ethnic and racial groups for individuals with schizophrenia.In fact, adapting mental health interventions to include the religious and spiritual practices and beliefs of a particular cultural group is considered a culturally competent approach to therapy [38,70].Some general considerations for issues that may arise when conducting spiritually-oriented psychotherapy with schizophrenia will be presented here for several ethnic groups.These considerations are not meant to be a comprehensive list of all cultural groups or religious practices, but some general cultural considerations for several groups.In addition, a focus on groups predominant to North America is chosen here due to the scope of the paper.Moreover, given the large degree of variation within each ethnic group, it is important to understand that each member of these groups may not always fit these guidelines.However, it can be helpful for a culturally sensitive therapist to be mindful of the potential cultural differences among individuals with schizophrenia regarding religious and spiritual practices.It is also important to note that many of the following cultural traditions in spiritual and religious practices may be modified by the process of immigration and acculturation.
Religious practices of African descent.While individuals of African descent are a heterogeneous group with very diverse spiritual and religious practices, there are many shared cultural values among African Americans in particular due to the history of oppression.These common spiritual values include seeking liberation from injustice, and African perspectives of seeing spirituality within all parts of life [72].Some spiritual and religious practices among African Americans in particular may include the use of prayer, the Bible, church attendance, religious singing, and the church community as coping strategies for dealing with mental health problems in schizophrenia [70].The church has been not only a site of religious observance but also a place of education, sanctuary for escaping slavery, economic resources, and political activism, which allows the church to be a valuable resource with multiple community purposes [72].In addition, therapists can consider the involvement of a spiritual healer or religious leader, which is often used in the treatment of schizophrenia in many African and Caribbean traditions [72,73].
Asian religious practices.While the Asian continent is comprised of a diverse array of religions and religious practices, some of the most commonly practiced religions are outlined in this section.Hannah and Green [74] presented guidelines for clinicians working with Asian clients of diverse Hindu, Buddhist, and Islamic backgrounds that have implications for psychotherapy with individuals with schizophrenia.Hinduism and Buddhism involve meditation practices that can be incorporated into therapy to reduce anxiety and distress that often accompanies psychotic symptoms.For example, the Svetasvatara Upanishad meditation in Hindu practices or the walking meditation and mindfulness exercises in Buddhist meditation may be integrated into therapy to reduce the anxiety, impulsivity, and distress often associated with psychotic symptoms.These authors suggested that in the case of Islamic religions, spiritual values of benevolence, personal development, and forgiveness can promote positive religious coping in therapy for individuals with schizophrenia.In addition, Islamic mysticism, namely, Sufism, provides more detailed psychological perspectives on mental health which foster growth through the use of dance, music, meditation, and prayer, and may also hold utility in mental health treatment for individuals with schizophrenia (see Pryor, [75]).
Latin American religious practices.Cervantes [76] suggested guidelines for culturally sensitive clinicians to integrate issues of religion and spirituality into work with individuals of Latin American descent.These guidelines provide useful considerations for therapists working with Latino individuals with schizophrenia.Given the wide range of diversity in Spanish speaking groups, there may be significant variation in religious and spiritual practices.Cervantes recounted the history of indigenous Latin American groups whose religious and spiritual practices were eradicated by colonizers and replaced with European traditions that mixed indigenous practices with Christian and Catholic religions.Therefore, many Latino clients may observe Christianity, Catholicism, indigenous religions, or some combination.The indigenous contribution to religious practices of Latino individuals may be presented in worship of deities and shrines, devotional offerings, prayer, and pilgrimages.Mestizo spirituality among Mexican groups in particular may reflect religious values in diversity and connectedness to the social and physical environment.Cervantes emphasized that integration of Latino spirituality and religious practices is essential for effective psychotherapy.For therapists working with individuals with schizophrenia of Latin American descent, sensitivity to these religious and spiritual practices and beliefs can enhance a culturally congruent source of support.
Native American religious practices.Similarly, there is a large degree of diversity across tribal groups within Native American cultures [77].Many Native American groups do not segment spirituality from the rest of daily life, but rather provide a spiritual infusion throughout daily life and culture.Some tribal groups initially viewed psychotic-like states as having a spiritual value to the culture.However, the influence of Western values has led many Native American groups to come to see mental illness as more stigmatizing [78].In addition, European colonization also brought Christianity to many Native American groups [77].Sensitivity to the different spiritual philosophy and potential Western influences on religion are important considerations for the therapist working with an individual with schizophrenia of Native American descent.
Culturally sensitive psychotherapy with individuals with schizophrenia may mean aligning oneself with the individual's religious or spiritual identity to work towards a desired goal, behavior, attitude, or emotional state [38,70].Clinicians should also exercise caution and care about religious countertransference [70], including awareness of bias towards the client's religion due to their own religious or spiritual practices, or perhaps skepticism towards religion and spirituality altogether.These cultural considerations for the religious backgrounds of different ethnic groups can guide therapists working with a diverse population of individuals with schizophrenia to be mindful of the unique history and traditions of the individual's religious culture of origin.

Implementation of Spiritually-Oriented Psychotherapy for Schizophrenia
The process of spiritually sensitive psychotherapy with individuals with schizophrenia can be conceptualized as involving several phases.These steps include training, inquiry, assessment, and implementation.Therapists may not follow a strictly linear and progressive process through these steps.These steps of the intervention process can be used as a flexible framework for integrating issues of spirituality into psychotherapy for individuals with schizophrenia.
Training.The training phase for the spiritually thoughtful therapist may involve personal development of the psychotherapist around religion and spirituality in therapy.This preparation can occur in didactic training, education, and self-exploration of spiritual and religious issues.Therapists can develop selfawareness and familiarity with the religious and cultural beliefs of the cultures of the individuals they serve [38].Didactic training may include in-service and continued education workshops in spirituality and religious issues for therapy with people with schizophrenia [37].Therapists can develop understanding of the risks/benefits and positive/negative coping that can occur around religious and spiritual issues in psychotherapy for people with schizophrenia.Self-exploration may involve developing awareness of one's own beliefs and comfort level towards religious issues in therapy [79].In addition, therapists should assess whether they have the ability to respect the spiritual and religious beliefs of clients with schizophrenia and refrain from proselytizing one's own religious beliefs [64].Familiarizing oneself with the policy and attitudes towards religion and spirituality within the institution in which one is working [79] is equally important in this phase.
Inquiry.As previously stated, a large portion of individuals with schizophrenia feel spirituality is vital to their lives, but only a minority raise the issue with their providers [79].Clinicians can actively inquire about the role of spirituality in their lives at a given time, and identify how spirituality might facilitate or interfere with recovery [38].Therapists can use empathic questioning and listening, exploring the motives and meanings of spirituality and religion for the client with schizophrenia and communicate a -respectful openness‖ [37].Therapists can engage individuals in a collaborative process to ask about when and how individuals would like religion and spirituality to be included in their life [37].Therapists can work with the individual to identify the spiritual and religious goals and activities that would be supportive of recovery, relevant resources, and the structure for addressing spiritual and religious goals in therapy sessions [37].Therapists can also ask about prayer or meditation in more depth given that there are large variations in what this practice means to people, with ranges in the content of the prayer, who they are praying to, the frequency, and expectations of the outcome of the prayer [38].
Clinicians should take care to avoid pathologizing religious beliefs as psychosis, given that intense religious beliefs are not necessarily a sign of pathology [38,55].It is important to avoid misdiagnosis during the assessment process due to religious and spiritual practices.In fact, understanding and expressing a mental health problem like schizophrenia in spiritual terms can be powerful way of reframing mental illness, and many people may even use a spiritual framework for understanding their illness [36].
Assessment.Clinicians may choose from preexisting models of assessment [37] to assist with this process.For example, therapists can use the HOPE questionnaire, which examines dimensions of hope (H), organized religion (O), personal spiritual practices (P), and the effects on medical care (E) [80].Clinicians can take a spiritual history, examining changes in faith and levels of commitment, core religious and spiritual beliefs, religious activities and rituals, level of connection to religious/spiritual communities, and the relation of spiritual life to goals of wellbeing [38].
Russinova and Cash [17] have also created a checklist of descriptors of the dimensions of and attitudes towards religion and spirituality among individuals with schizophrenia that might be used as a checklist for providers in the assessment process.These descriptors encompass two dimensions in the lay person's conceptual understanding religion and spirituality: (a) a core characteristics dimension which includes descriptors of the nature of each of these two concepts; and (b) a functional characteristics dimension which includes descriptors of the impact of religion and spirituality on a given person.Often, these descriptors contrast the understanding of religion and spirituality based on conceptual continuums.For example, prominent continuums that distinguish between the core characteristics of religion and spirituality are the ones juxtaposing the organized, communal, extrinsic, prescriptive and ritualistic nature of religion to the informal, personal, intrinsic, exploratory, and continuous nature of spirituality, respectively [17].Understanding the personal meaning attributed to religion and spirituality and the person's perceived level of religiosity and spirituality is important not only from the point of view of enhancing the therapeutic alliance and identifying most appropriate spiritual resources but also because there is emerging evidence about an association between the person's spiritual and religious beliefs and their perceptions of power in the therapeutic relationship.Both clinical observations and research findings suggest that religious persons with serious mental illness tend to attribute more power to their providers and expect treatment options to be prescribed to them, while non-religious individuals tend to seek partnerships with mental health providers who are open to their input as well as to the exploration of new treatment possibilities [17].
Implementation.The implementation of spiritual and religious perspectives in psychotherapy involves formulation and understanding of the individual's spiritual goals and making connections to appropriate resources in therapy.Implementation of religious or spiritual goals in therapy could occur in the context of individual therapy, group modalities, peer and professionally-led interventions, or in a religious setting [38].A spiritually sensitive therapist may present a framework of recovery as a spiritual journey, and integrate some spiritual or religious practices into the session, with consideration for modeling one's own spirituality if appropriate [55].These spiritual or religious practices may be psychoeducational or have a more traditional religious focus [37].Depending on the specific religious doctrine at hand, activities may include prayer, meditation, scripture or devotional readings, religious services at church, radio, or TV, singing in religious group, talking to religious leader, peers, or providers [81].Spiritual and religious resource access may require providing concrete support in accessing or linking with the appropriate religious referral, or including religious leaders as part of the implementation.A therapist may consider making referrals to religious organizations or groups, clergy, religious leaders, or other facilitators of religious processes, exercising caution to insure that the referral is likely to be helpful and not harmful [36,37].

Conclusions
The topics of spirituality, psychotherapy, and schizophrenia have often been controversial in the literature.Researchers and psychotherapists have historically raised doubts as to the appropriateness of the use of spiritual and religious resources in psychotherapy, and have even questioned the practice of psychotherapy for schizophrenia altogether.However, a significant body of literature reflected in this article suggests that psychotherapy, and therapy with a spiritual and religious focus, can hold many benefits for people with schizophrenia.Practicing therapy with sensitivity to aspects of religious, spiritual, and cultural diversity among individuals with schizophrenia can further enhance this process.Different strategies relevant to the phases of psychotherapy treatment, such as training, assessing, planning, and implementing can be considered for integrating issues of spirituality and religion into therapy in a flexible but thorough manner.Inclusion of spiritual and religious issues in psychotherapy for individuals with schizophrenia offers valuable opportunities to provide spiritual support in the individual's journey of recovery.