Multidisciplinary perceptions and considerations for spiritual care and biblical framework counseling in mental health

Data Collection and Analysis

The study first utilized a literature review to gain qualitative, exploratory data. The review is summarized in Figure 2 as recommended by PRISMA, using 1) ProQuest Religion database, 2) PubMed/MEDLINE National Library of Medicine, with citation chasing to trace relevant author research, 3) Search by specific author or topics pertaining to spiritual care guidelines or medical education competencies. The literature was manually reviewed for the provision of R/S care and notable characteristics (Table 1) by the two research investigators (BP, VO), both health professionals of the Christian faith. VO is a mental health practitioner of the clinical pharmacist discipline with R/S care training, while BP is of the osteopathic medicine discipline.

Figure 2

Those articles that were reviewed identified various health disciplines providing R/S support for biblical clients, reports on efficacious R/S interventions, as well as any consensus practice guidelines on R/S in medical education. Articles excluded for instance, were those focused solely on substance misuse; focused solely on patients with religious delusions; religious support of schizophrenia in remission, defined as those not on current treatment or without breakthrough symptoms over several years; published work using religiosity solely to improve pharmacotherapy compliance rather than a means of treating the illness. R/S care articles with very limited religious subsets and restrictions that did not appear generalizable to Christianity were excluded. Review articles of published research were prioritized, while articles that highlighted or reiterated the data from the literature without the introduction of additional findings were excluded. Forty articles were approved for inclusion. One investigator served as the primary literature reviewer while another investigator served as a primary coder for repeated cycles of individual and joint review, discussion, identification of patterns and themes. The investigators also consulted with the institution medical library staff on the search strategy. The investigators utilized an iterative approach to devise a preliminary coding list of descriptive words, phrases, and concepts. The list was grouped into three categories of characteristics for theme development and revised with repeated investigator review and discussions.

The second part of the study utilized an online survey which was developed for participant review of a schizophrenia case as described by a Biblical Framework Counselor using an open-ended questionnaire for anonymous responses. The online informed consent included a brief definition of BFC and gave access to the survey. Inclusion criteria were individuals with training and experience within a professional discipline by which they may encounter individuals with mental health conditions. The survey involved questions regarding 1) willingness to provide professional care for BFC clients, 2) examples and extent of support to be provided, 3) opinions of BFC efficacy. Participant enrollment occurred by snowballing with distribution by the investigators of an online survey link via email to introduce the study and to click a tab for consent to participate. The data were collected in real time with the REDCap (Research Electronic Data Capture) application for secure storage, then exported into NVivo software for qualitative analysis. Survey responses were analyzed by inductive coding and thematic analysis, utilizing a stepwise procedure manually as described by Braun and Clarke (2006) and employing NVivo 12 software. In the first step of the analysis, data was reviewed to identify patterns. The second step grouped different responses with similar meanings. In NVivo, each participant response was assigned to a node or initial code and labeled with a descriptive phrase to summarize the meaning of the data assigned to it. When different responses had similar meanings, they were clustered by assigning them to the same node. In the third step, themes were sought in the data. The themes emerged through clustering initial codes that were related in the sense that the data assigned to them expressed different aspects of a larger, overarching idea. The fourth analysis step involved comparing the themes to the original data to verify patterns. The fifth step involved naming the themes (Table 2). The investigators also conferred with external qualitative research consultants on the NVivo-collected data to confirm content validity.

The case study reviewed by the survey participants was described to them as hypothetical and verbatim by a Biblical Framework Counselor supporting an individual referenced as MM (please see Appendix). The investigators manually reviewed the responses for findings consistent with the literature and survey goals, emergent concepts, as well as participant opinions in common and contrast with those of the biblical counselor. Findings from each study component (literature review, survey, case) were reviewed by the investigators to articulate key points for the final overall themes (Table 1, 2, 3).

A Biblical Framework for Mental Health Support

Biblical Framework Counseling (BFC) is one spiritual care intervention based on the belief that the Christian Bible is adequate to treat root causes of mental disorders not otherwise physiologically caused.¹² It takes the concepts of mental health and defines them in Biblical terms with application to mental disorders as defined by the DSM. Fig 1 gives a conceptual illustration of the Biblical Framework based on mankind’s “heart,” sometimes called the soul and spirit -one’s immaterial essence,^12,19-20 as differentiated from the material or physical body and brain. Thomson¹² identifies the immaterial heart as a major source of emotions, described as sensibilities, which urge or lead to thoughts, decisions, and actions, as well as the site of the conscience which distinguishes personal right and wrong thoughts, motives, decisions, and actions. Sensibilities are to be distinguished from general physical emotions or feelings from the brain or body. Additionally, the immaterial heart includes the mind (intellect) and will (volition); the will functions within the mind, while the sensibilities function within the will and conscience.¹² Thoughts, decisions, and behaviors outside the realm of man’s responsible choices are reportedly determined by material body and brain. They can also be affected by physiological disease, chemicals, physical imbalances, poisons, and other substances, but they do not determine responsible choices of the heart. Still, man’s heart choices can impact physiological changes on man’s material brain and body. Positive and negative emotions, health behaviors, life choices have reportedly been associated with changes, such as in cardiovascular, endocrine, immune function, and mental health;⁴ these are also impacted by heart attitudes and response to conscience.¹²

BFC is R/S treatment, not psychotherapy, and pursues a quality of life consistent with scripture (1 Corinthians 13:4-7), facilitating positive emotions and impact on mind-body mechanisms.¹² Emotions and cognitions (e.g., peace, existential well-being, happiness, hope, optimism, meaning, purpose) that have been positively associated with physical health outcomes and wellness⁴ are reflected in the biblical framework as peace, confidence, and drawing near to God, from consistently expressing loving attitudes to God and others, and addressing human heart or conscience issues.¹² Intentional “Active Love” has also been described in medical practice literature.²¹ Unloving choices for which one is responsible, instinctively, and instantaneously on the other hand result in a sense of knowledge and guilt, knowledge, and fear of deserved judgment (apparently uncaused fear or anxiety), and an urge to flee from one’s sense of guilt and fear of judgment (apparently uncaused fleeing),^5,12 behaviors all associated in biblical scripture with wrong choices.

Individuals for whom spirituality is significant may prefer faith-based strategies over medical or psychological ones. R/S may influence life choices, decisions, and health behaviors.^4,5,22 Many receive initial mental health support from faith leaders than psychiatrists.²³ Thus, health professionals may encounter individuals receiving or preferring R/S care, whether they are aware or not. During spiritual assessment, a clinician may observe and note patient R/S affiliations, beliefs, and practices without endorsing or dismissing them,⁵ or attempting to proselytize. A patient's beliefs and care preferences may be perceived to be beyond clinician or health facility scope of care policy, or there may be incongruence in patient-clinician R/S beliefs. Health providers may be comfortable encouraging client R/S beliefs and practices, engaging with them, such as offering prayer, or instead deciding on a complete hands-off approach with referral to a house of worship or R/S provider. Others may be concerned about BFC's exclusion over integration of psychotherapy. Decision-making could be controversial: How could one discern if a mental health condition is physiologically caused or not? The BFC provider's stance is to make a determination and provide care with the awareness that only God can fully discern an individual's heart.¹² Still, schizophrenia, the condition in the study case, is considered multi-faceted and stemming from environmental, physiological, and genetic components that cannot be easily teased apart. For these reasons as well as a limited awareness of BFC efficacy data beyond anecdotal oral case reports, some might feel reluctant to support the intervention. From a Biblical perspective, an individual with schizophrenia may demonstrate delusional symptoms illustrated by Nebuchadnezzar (Daniel 5:20-22) as expressions of what is described using the biblical framework (Figure 1) as “apparently uncaused fleeing”¹² or fearful hallucinations or anxiety as the biblical description of “fear when there is no one pursuing” (Prov. 28:1), often manifesting as a conscience-stimulated emotion of anxiety, which may be described as an inexplicable, disproportional, excessive emotion, disorganized thought, anger, hostility, catatonia, or consequent attempts to avoid judgement as in Genesis 3:10. Pharmacotherapy as a recovery approach is helpful (Prov 31:6-7), but not considered a treatment end-all.

With increasing public mental health and substance issues, as well as the launch in the US of the 988-crisis number, there are increasing support demands and awareness of the benefits of counseling. On the other hand, an individual choosing BFC may misunderstand health professional hesitancy to support their choice and feel that it infringes upon their position or religious freedom rights as per the US Constitution or even their right of autonomy. Yet the DSM-IV does underscore the importance of environmental factors in the etiology of schizophrenia,^12,24 which in the BFC paradigm would include man’s immaterial choices and reactions to their environment, alongside the physiological factors which may predispose them.¹²

Some health professionals would consider it unethical to rely solely on Christian Bible therapy to treat individuals competently. BFC providers typically encourage clients to continue to see their primary care physician and other health providers for medical treatment. Professionals who provide biblically based R/S care such as BFC and nouthetic counseling may be hesitant to collaborate with health providers that cannot support a patient’s preference for R/S care as primary treatment modality, monotherapy, or as an alternative to psychological interventions. Furthermore, while there is positive data in the literature regarding religiously modified CBT,^34,42,54 integration of biblical and psychological interventions is not always accepted or could be considered contradictory to a patient’s religious beliefs. Awareness and health literacy may facilitate better therapeutic alliance among health professionals and BFC clients. Some healthcare workers would seek the emergence of published research data. Others may lean towards this as a supplemental or integrated approach, not primary or monotherapy. One might argue that refusal to accept a patient’s biblical counseling could be characterized as an objection of conscience or personal ethics. Such ethical dilemmas could be handled with professional discretion with the intent of providing competent, individualized patient care and quality of life, accompanied by monitoring of the patient’s symptoms and responses. Examples of support described by the survey participants included health education, annual medical checkups, support group referrals such as National Alliance of the Mentally Ill (NAMI) or Mental Health of America (MHA). Others might feel strongly enough on the issue to completely “wash their hands” of the matter; patients may feel likewise, choosing not to integrate their R/S care with psychological approaches, to minimize pharmacotherapy and seek non-pharmacological treatment options where feasible. Some individuals in our resource-constrained communities expressed this during the course of our Africa Diaspora CEC work and had help-seeking preferences in trusted faith-based settings. Clinicians should be aware of patient religious activities and appreciate their value as to whether they positively/negatively impact their mental health conditions. There is also a greater tendency for health professionals to support integrated care, while a BFC perspective might lean towards monotherapy or parallel, concurrent care which excludes psychotherapy.

BFC and Health Professional Communication, Engagement, Ethics

The BFC provider in the case reported that MM had a long medical history of schizophrenia; they made no psychiatric diagnosis. The BFC provider, however, does diagnose spiritual problems.¹² The description and emphasis points are different for health professionals, as noted from survey participant comments. Some noted information that they considered important was absent; others questioned the diagnosis, either as an honest inquiry or reflecting bias and skepticism about BFC. MM’s case had prominent negative symptoms. Both DSM-4 and DSM-5 do have schizophrenia types with prominent negative symptoms.^24-25 An independent evaluation might be useful, while noting the patient’s medical and spiritual history.

Communication of the healthcare provider and BFC provider would involve key points both parties can understand through their respective lenses to exchange information mutually considered most pertinent. Collaborative practice entails multiple parties working together towards common goals. For example, physicians could refer MM to his BFC spiritual “therapist.” Introspection could decide on engaging with, recusal, or referral out of BFC clients. Interdisciplinary collaboration can be achieved without congruence in spiritual care beliefs or faith-tradition. Core ethical considerations include autonomy with the latitude to consent or decline treatment; beneficence and non-maleficence to do no harm; open-mindedness and validation of other provider perspectives.

Physician Hesitancy

Investigator (BP) noted a recurring theme in the literature of physician hesitancy, even discomfort broaching the subject of faith with their patients. This stance also emerged in some instances with the survey, even if the professional was Christian. Yet, from a positionality/reflexivity standpoint, they (BP) have had direct observational experiences such as with a psychiatry clerkship preceptor whom they considered to model best practices. The preceptor always asked patients if they are religious, if they practice, and if they have someone whom they'd like to call. It was the preceptor’s personal practice from their military experiences and religious values to consider religious communities as a good support resource; with only one patient in their entire career where the church publicly cast someone out due to mental illness. Investigator (VO) noted communities where patients had denied mental health concerns during clinic screenings, but when the physician and clinic staff made spirituality groups available for enrollment, they openly shared concerns in R/S group settings.²² They (VO) have also offered R/S options during comprehensive medication management services, which is well utilized in their mental health practice. Some studies have noted psychiatrists to be significantly less likely than patients to engage in religious affiliation, worship services or activities.^26-28 This could leave patients with access to fewer religious resources during psychiatric care, especially in the face of existing mental health worker shortages.

An interdisciplinary team approach, including BFC providers, could allow physicians to avoid delving into a patient’s faith, yet still address spiritual care needs if so desired. In resource-constrained communities which may have higher levels of mental health worker shortages, as well as populations experiencing medical system distrust, access to BFC as a mental health support could help to facilitate trusted access to care. An interdisciplinary approach could also allow for broader spirituality training and assessment of religious and spiritual factors impacting mental health. The BFC provider has more time to spend with the patient compared to some physician-patient encounters of about 10-20 minutes, a time constraint also contributing to R/S hesitancy. Smith and Suto,²⁹ found that clinicians lost motivation to discuss spirituality with their patients due to feelings that some conversations were outside of their scope of practice and training. This was voiced also in this study survey. Others avoided the topic, despite congruence in belief, to avoid offense. Clearer GME guidelines for skills development might be helpful.

Conscious Objection: Do physicians have a responsibility to incorporate religious forms of treatment?

As touched on earlier, physicians rely on conscious objection when deciding whether to perform procedures or apply treatments that may not coincide with their religious beliefs. The American Osteopathic Association (AOA) code of ethics states, “A physician-patient relationship must be founded on mutual trust, cooperation, and respect. The patient must have complete freedom to choose her/his physician. The physician must have complete freedom to choose patients whom she/he will serve, but should not refuse for reasons of discrimination, including, but not limited to, race, creed, color, sex, national origin, sexual orientation, gender identity, or disability. In emergencies, a physician should make her/his services available.” ³ The US 1964 Civil Rights Act 28 (Title VII) mentions religion.³⁰ Still, if a patient seeks or receives R/S services that are deemed antithetical to a healthcare provider’s personal beliefs or may be absent from their general professional practice guidelines, it may present an ethical dilemma in decision-making. With BFC patients, a personal determination for R/S care could be for conscious objection, collaborative engagement, or direct provision.

Patient Considerations for R/S Care and BFC

Patient location could be a barrier to care, where houses of worship could help. For example, individuals residing in homeless shelters or identifying as homeless may not have access to a quiet place for prayer/meditation. Our community assessment work in rural, resource-limited areas have demonstrated a strong and repeatedly expressed interest in R/S mental health support and nonpharmacological approaches as initial treatment, including EFT, osteopathic medicine manipulation (OMM), etc. despite resource opportunities for medication access, affordability, and education.^13,31 Some may have limited access to primary care physicians for BFC provider referrals. Houses of worship in the community that assist with social support, such as food banks, homeless shelters, or other benevolence, could be BFC referral, access, and communication points. Education and eliminating stigma in some church communities would be an important consideration.

Limitations

This study was sought to gain a greater understanding on R/S care that could be applied towards increasing access to mental health services in resource-constrained communities, which have particular interest in biblically based care such as BFC. Our literature review and survey reinforced key points from data collection until no new ideas emerged. There would still be benefit from the dissemination of a greater number of patient cases and anecdotal reports that include biblical counseling from health professionals across our targeted HIC and LMIC resource-constrained communities, which may allow for greater generalizability. BFC may be an unusual illustration of R/S care, as it is unfamiliar to many health professionals and has limited published literature. Yet, it is very useful to consider BFC for potential application in mental health since it identifies symptoms as classified by the DSM, perhaps to help bridge communication and understanding between health care and biblical counseling providers, and build capacity and confidence for biblical coaching or selecting spiritual care interventions (e.g., prayer) by health providers. The schizophrenia case presents a more challenging scenario than other mental disorders because of the severity of this condition. This could have negatively influenced some survey respondent opinions, compared to if a mild or moderate alternative condition had been selected. Yet, the literature did indicate potential benefits of R/S care in schizophrenia, such as religious coping, reduced hospitalizations, and lower suicide risk. Furthermore, the case could be said to introduce perhaps a “worst-case scenario” example of issues that arise for biblically based care where there is the belief of sufficiency of the intervention as monotherapy, or at the very least, an alternative to psychotherapy. This is important for our target populations among whom such beliefs do exist, and which are not necessarily compatible with those of their healthcare provider.

The concerns of schizophrenia symptom severity and relapse by some health professionals might have been a reason to include the articles identified in our literature search on the use of spirituality to solely increase pharmacotherapy adherence, even though that focus was not on schizophrenia treatment.

Practice guidelines were only searched for the medical profession, not all disciplines represented in the survey. Psychiatrists’ primary role in mental health services, as well as increased moves for behavioral health integration in primary care physician settings, made the focus on medical education guidelines apt for this research. The professionals included in our data collection can offer new ideas for broadening treatment teams alongside physician care. This work overall might pique the interest of interdisciplinary professionals, health services researchers, and interprofessional educators who could provide detailed case reports and series of BFC effectiveness among individuals, such as addictive, anxiety, depressive, sleep-wake, stressor-, and trauma-related disorders.