Spiritual Psychotherapy for Inpatient, Residential, and Intensive Treatment

Interest in spiritually integrated therapy has grown substantially over the past 2 decades. The clinical and scientific literature on spiritually integrated psychotherapy now includes randomized controlled trials (1–3), meta-analyses (4–9), review articles (10–14), clinical practice articles and chapters (15–17), and full-length practice texts (18–20). However, almost all clinical innovations in this area have been applied specifically and exclusively to outpatient care for individuals with mild-to-moderate mental distress. As a result, few clinical methods exist for the provision of spiritually integrated treatment to patients with acute psychiatric conditions.

Why is spirituality-integrated therapy relevant to patients receiving care for acute mental health conditions? First, it is relevant because many such individuals want to address the topic. A 2015 study found that 58.2% of patients presenting to an intensive outpatient day program (partial hospitalization treatment) reported “fairly,” “moderately,” or “very much” interest in spirituality as part of their care (21). Notably, neither demographic nor clinical factors predicted greater interest in spiritually integrated treatment, except that patients with depression reported a greater desire to speak about spiritual matters with their clinicians compared with patients with other disorders. Second, spirituality can be an important resource for patients with acute psychiatric conditions to draw upon during recovery (22). In particular, belief in God has been associated with better treatment outcomes during intensive treatment, such as greater reductions in depressive symptoms and self-harm and improvement in psychological well-being (23). Third, spiritual struggles are a known correlate of greater distress and intensity and frequency of suicidal ideation and behavior among patients with acute psychiatric conditions (e.g., 24). Therefore, from a public health perspective, this domain warrants clinical attention.

Barely a handful of clinician-led spiritually integrated interventions exist for individuals with severe mental disorders. In 2011, Harris and colleagues developed an 8-week intervention, called Building Spiritual Strength, for veterans exposed to trauma (25). With a structure for each session and topics such as prayer, forgiveness, and spiritual coping, this intervention was found to reduce symptoms of posttraumatic stress disorder. Weisman de Mamani et al. (26) created an optional treatment module involving spirituality to support individuals diagnosed with schizophrenia as well as their families. Around the same time, Huguelet and colleagues (1) created a structured spirituality assessment for individuals with psychotic disorders. However, all three of these approaches were implemented solely with outpatients, and none have been implemented in acute psychiatric settings, such as inpatient, residential, or intensive outpatient (partial hospital) settings. More recently, a Judeo-Christian self-help workbook was published for individuals receiving residential treatment for eating disorders (27), and a similar, but diagnostically broader, self-help workbook adapting Victor Frankl’s logotherapy was published for patients across various clinical settings (28). However, neither of these latter resources facilitate direct therapist intervention. Thus, we are unaware of any existing spiritually integrated clinician-led psychotherapy approaches that can be delivered to patients receiving acute psychiatric care.

Clinical protocols with spiritually integrated psychotherapy are needed to accommodate such patients. More specifically, there is a need for spiritually integrated treatments that clinicians can implement to serve patients of diverse demographic and spiritual or religious backgrounds, with various levels of acuity, across a spectrum of diagnostic profiles. Notably, many nonspiritual psychosocial treatment protocols have been successfully delivered within inpatient, residential, and intensive outpatient settings. Such treatments tend to use flexible, modular approaches, providing sufficient structure to support diverse patient needs while allowing clinicians to select specific topics and skills to focus on with individual patients. Protocols that provide adequate guidance while allowing flexibility are key in acute psychiatric settings, given the need for treatments to apply cross-diagnostically and at various levels of symptom acuity. Perhaps the best example of a structured, modular yet flexible psychotherapy approach is dialectical behavioral therapy (29), which is commonly used in acute psychiatric settings. Similarly, cognitive-behavioral therapy (CBT) is also used at multiple levels of psychiatric hospital care for patients with a broad spectrum of diagnoses (30).

This article presents a protocol for a flexible, group-based treatment, called spiritual psychotherapy for inpatient, residential, and intensive treatment (SPIRIT). This protocol integrates spirituality into the care of patients in acute psychiatric settings. We logged 1,468 unique patient visits to SPIRIT groups across 11 specialized clinical settings (see Table 1), including six inpatient units (for treatment of patients with mood and/or anxiety disorders, acute psychotic disorders, chronic psychotic disorders, substance use disorders, posttraumatic and dissociative disorders, and mood disorders of older adults), two residential units (one for patients with eating and feeding disorders and one for patients with substance use disorder and other co-occurring disorders), and two intensive outpatient (partial hospital) units (one mixed-gender unit for patients with various disorders and another unit specifically for women with posttraumatic and dissociative disorders). Our clinical protocol, survey instruments, and study methodology were approved by the Partners Healthcare Institutional Review Board in Boston.

Treatment Setting

The SPIRIT protocol was developed and disseminated within McLean Hospital, a freestanding psychiatric facility located in Belmont, Massachusetts, associated with Harvard Medical School. Similar to other psychiatric hospitals, McLean’s general treatment approach includes daily rounds, case management, medication management, neurotherapeutics, milieu therapy, and psychotherapy groups. Typically, doctoral-level clinicians (with medical and/or doctor of philosophy degrees) determine the course of treatment, and residents, fellows, nurses, and master’s-level clinicians implement treatment approaches across three levels of care: inpatient, residential, and intensive (partial hospital). Inpatients are of the highest acuity, commonly presenting with self-injurious behaviors or plans, and are therefore in need of the most intensive level of psychiatric intervention for stabilization. Inpatient treatment thus occurs on locked units with round-the-clock monitoring to ensure patient safety. In the current era of insurance-based managed care, typical lengths of stay for inpatient hospitalization range from 3 days to 2 weeks. Residential treatment is most appropriate for individuals who are not an acute danger to themselves or others but have serious and chronic mental disorders that take significant time to remit (e.g., severe eating or feeding disorders, severe obsessive-compulsive disorder, nonacute schizophrenia). In residential treatment, patients do not have 24/7 monitoring, but they do live at the treatment facility, where they engage in structured daily psychotherapy (individual and group) as well as staff-organized outings in the community. Length of stay for residential care ranges from 2 to 6 months but can extend to a year or longer. At McLean Hospital, intensive treatment is provided within a partial hospital program, which is often a “step-down” unit for patients discharged from an inpatient unit or a “step-up” unit for patients referred by community mental health clinicians (e.g., outpatient psychiatrists or therapists) as an attempt to prevent inpatient hospitalization. Intensive treatment occurs Monday through Friday, excluding holidays, from 9:00 a.m. to 3:00 p.m. (with a lunch break), after which patients return to their homes. In the intensive treatment, patients attend up to five group psychotherapy sessions per day and have family consultations and regular meetings with their individual therapist and pharmacology management. Intensive treatment typically spans 5–10 treatment days. SPIRIT was developed for use within all three levels of acute psychiatric care (inpatient, residential, and intensive).

Treatment Description

SPIRIT is based on a CBT framework and includes a psychoeducation component, as well as specific tools or skills drawing on spiritual concepts or beliefs (cognitions) and activities (behaviors) that patients can use to shape their emotional experience. Specifically, the goals of the group therapy are to help patients explore and understand relationships between their own spirituality or religion and their mental health or distress as well as the relevance of this domain to their treatment; identify spiritual or religious concepts they can use to bring about emotional change; and identify concrete activities to integrate spirituality or religion into their overall treatment plan. Given the nature of acute psychiatric settings, however, our approach does not include formal identification of cognitive biases or distortions, cognitive restructuring, behavioral scheduling, behavioral activation, exposure, or other common CBT techniques. (A full copy of the SPIRIT protocol, including all handouts, is included in the online supplement.)

SPIRIT sessions are delivered for groups of patients on a weekly basis at the three levels of care described above (inpatient, residential, and intensive). The protocol is not only flexible in content, as described below, but also in its format, to allow for implementation on various units. The therapy ranges from 30 to 55 minutes per session. On inpatient units, where patients have acute conditions and abbreviated attention spans, SPIRIT sessions range from 30 to 45 minutes. In residential and intensive units, each session ranges from 45 to 55 minutes. Furthermore, the group material is flexible and can be presented as a one-time stand-alone session or in recurring sequential sessions. Stand-alone groups are most common in inpatient and intensive treatment settings, where lengths of stay are measured in days and not weeks. On residential units, where patients have extended stays, SPIRIT is delivered as series of 4 or even 6—8 weeks. This adaptable approach provides clinicians with freedom to make adjustments based on patient needs. While it is theoretically possible to adapt SPIRIT to outpatient settings, we have yet to explore this option.

Each SPIRIT session can be divided into two parts: Part 1 begins with an ethical disclaimer to explain that the group is not intended as an opportunity to convert others to a particular belief and to highlight the importance of being respectful of others’ beliefs and practices. A discussion is then facilitated around the following question: How is your spirituality relevant to your mental health? This question has two aims: It facilitates functional assessment to help patients identify and understand how their spirituality or religion may be related to their symptoms (in both positive and negative ways), and it provides psychoeducation to help patients think about how spirituality or religion conceptually applies to their treatment. Typically, patients voice one or more of four responses: their spirituality or religion is beneficial to their mental health and provides solace, hope, and/or a sense of connection; their spirituality or religion is a source of struggle or pain and exacerbates their mental health concerns in some way, such as excessive guilt, relationship discord with spiritual themes, or anger toward God; their symptoms have spiritual or religious content, such as religious psychotic delusions, hyper-religious mania, or scrupulosity (religious obsessive-compulsive disorder); or their spirituality may not feel relevant to their mental health. After asking the above question, SPIRIT group leaders are encouraged to guide the discussion to identify common responses among attendees.

It must be emphasized that this focused group discussion is viewed as a clinical intervention to facilitate a functional analysis and psychoeducation and not simply an overture to include the topic of spirituality or religion into psychotherapy. To these latter ends, the clinicians are encouraged to redirect and refocus patients who give nonspecific responses to the question, “How is your spirituality relevant to your mental health?” For example, when patients respond by simply speaking about their spiritual or religious beliefs or their spiritual history in general, clinicians are encouraged to prompt them by asking, “How do you think that affects your mental health and treatment?” Depending on the session’s duration and the number of participants, approximately 50% of each SPIRIT meeting is dedicated to this discussion, and each patient is encouraged to share in a tangible way how spiritual life is a resource or a strain and/or how it shapes the presentation of their symptoms. In residential units, where SPIRIT consists of more than one session, clinicians typically engage only new patients in this discussion about how their spirituality is relevant to their mental health, although all patients are permitted to share responses to this question during the ensuing discussion.

Part 2 of the SPIRIT session provides patients with concrete direction on how to harness spiritual resources (cognitive and behavioral) in the context of their treatment. This part of the group is introduced with the following phrase: “Irrespective of how spirituality relates to your personal mental health, it can be helpful to draw upon spiritual resources in shaping our thoughts, behaviors, and feelings.” Subsequently, clinicians select from a collection of seven handouts (described below), each of which provides spiritually based cognitive and/or behavioral tools to shift patients’ emotional states. Handouts were adapted from a recent text on spirituality and CBT (18) and further developed in an iterative manner. Initially, working drafts of three handouts (Spiritual/Religious Beliefs and Reframes, Spiritual/Religious Coping in Treatment, and Spiritual/Religious Struggles) were implemented in one intensive treatment unit for patients with various disorders (i.e., mood and/or anxiety disorder, personality disorders, and psychotic disorders) and in one inpatient unit for high functioning patients with acute psychotic disorders. We then sought feedback from clinical staff about the handouts and made revisions based on comments received. Because two members of the clinical staff stated that several patients had requested inclusion of more traditional spiritual content, we developed the Meditating on the Psalms and Sacred Verses handouts. Subsequently, we implemented the SPIRIT protocol with five handouts across two residential units (one for patients with eating or feeding disorders and the other for patients with substance use with co-occurring disorders) and in five inpatient units (one for patients with mood and/or anxiety disorders, one for patients with substance use disorders, one for women with posttraumatic stress and/or dissociative disorders, one for older adults with mood disorders, and one for low functioning individuals with acute psychotic disorders). After 2 months of implementation, we held a series of semistructured focus group meetings with SPIRIT clinicians from all of these units and solicited further feedback and discussion. In addition to suggested edits to the handouts, which were incorporated, the clinicians identified a need for additional materials on the subjects of prayer and forgiveness, so we drafted the Power of Prayer and the Forgiveness handouts. Subsequently, clinicians on all of the units described above began conducting SPIRIT groups using all seven handouts, as described below.

Given the brief length of each SPIRIT meeting (30–55 minutes per session as described above) clinicians typically cover only 1–2 handouts in each session. It therefore must be understood from the outset that SPIRIT is simply an initial spiritually integrated psychotherapeutic intervention to help patients with acute conditions think about their symptoms in spiritual terms and consider spiritual resources they can use in their recovery. Furthermore, given the group nature of the protocol, it is typically not possible to attend to the spiritual needs of all patients in a single meeting. However, to provide maximal flexibility, clinicians can select which handouts to use with a given group, depending on what they think may be most appropriate for their treatment setting and the specific patients attending the group on a given day. Typically, on inpatient and intensive units, clinicians will use handout 1 (Spiritual/Religious Beliefs and Reframes) and/or handout 2 (Spiritual/Religious Coping in Treatment) as initial cognitive and behavioral tools. However, if a clinician determines that patients in a given group are experiencing spiritual distress, he or she can use handout 3 (Spiritual/Religious Struggles) to validate patients’ feelings. Similarly, if the themes of prayer or forgiveness emerge prominently during the first part of the SPIRIT group, clinicians can use handout 6 (The Power of Prayer) or Handout 7 (Forgiveness).

Clinicians should use careful judgment when selecting handouts. For example, Meditating on the Psalms is often well received by Judeo-Christian patients who wish to engage in traditional forms of spiritual activity, whereas the Sacred Verses handout is more appropriate for patients who do not identify with a Judeo-Christian religion or for those who have been wronged by religious communities. More broadly, it must be stressed that not all handouts and not all components of each handout will apply to all patients, and some may contain ideas or suggestions that may be viewed as unhelpful or even harmful, depending on individuals’ spiritual preferences. Clinicians should therefore preface their introduction of each handout by encouraging patients to simply identify one or two points that resonate with them and by validating that some aspects may not resonate with patients’ spiritual beliefs or experiences.

Handout 1: Spiritual/Religious Beliefs and Reframes

This handout utilizes a cognitive approach by presenting uplifting spiritual messages that patients can use to shift their thinking in positive ways. The handout contains a list of statements categorized into six spiritual themes: we are never alone; nothing is impossible; life is a test; we can only control the process, not the outcome; everything happens for a reason; and nothing is permanent. When using this handout, the clinician asks patients to read through the entire document, either aloud or silently to themselves, before beginning the discussion. Subsequently, the clinician engages patients in a discussion about the handout, trying to help patients identify which statements they can use to help themselves feel better and validating that some statements may not be helpful. Common leading questions for this discussion include: Do any of these statements resonate with you and why? Are there any that you dislike? How could you reframe those statements to be helpful? Throughout the discussion, the clinician should highlight that these spiritual or religious statements can be used as an aid in coping with distress. By the end of the session, the clinician should help patients identify at least one spiritual statement that they will try to implement into their treatment (e.g., as a coping statement).

Handout 2: Spiritual/Religious Coping in Treatment

This handout provides a form of spiritually integrated behavioral activation in that it encourages patients to engage in spiritual or religious activity as a means of shifting their mood states. The handout introduces a list of common spiritual activities that can be used to reduce emotional distress, including prayer, meditation on a spiritual statement, seeking religious support, reading religious texts, forgiving, performing good deeds, using religious framing, counting blessings, and finding meaning. When using this handout during a session, clinicians should start by having patients read through the list of spiritual and religious coping activities, either alone or together as a group. Clinicians then facilitate a discussion by asking questions such as the following: Which of these activities have you used in the past or currently? How do they impact your mood? Do they make you feel any better? Do you ever feel worse when you engage in these activities? Are there any activities on this list that you would be interested in doing? By the end of the discussion, clinicians should encourage patients to identify at least one spiritual or religious coping activity that they will use.

Handout 3: Spiritual/Religious Struggles

The Spiritual/Religious Struggles handout contains common spiritual struggles, divided into the three main categories identified in the extant literature: intrapersonal spiritual struggles, which reflect inner spiritual tension; interpersonal spiritual struggles, which involve person-to-person conflicts that carry spiritual themes; and divine spiritual struggles, which involve wrestling with matters of faith (31). Clinicians are encouraged to use this handout when patients raise spiritual struggles during part 1 of the meeting. It should be noted that this handout uses more advanced language than the other handouts, to provide a cognitive buffer and to prevent dysregulation or triggering of more severely distressed patients, who may lack core self-regulation skills. With that said, clinicians should be mindful of the high academic level of this handout, and they may need to explain difficult words, phrases, and concepts as appropriate for the abilities and emotional states of group members. The primary goal of this handout is not to solve struggles, rather simply to help patients to identify their struggles and provide an opportunity for them to explore their concerns. Clinicians are therefore discouraged from providing alternative viewpoints or challenging patients’ struggles, rather they should simply validate patients’ experiences and perspectives. This handout is viewed as having a behavioral rather than a cognitive framework, because the overarching goal is not to change patients’ thinking about struggles but for the patients to articulate their struggles and habituate to thinking about this emotionally charged subject.

Handout 4: Meditating on the Psalms

This handout provides a form of spiritually integrated behavioral activation and cognitive reframing, in that the Psalms are often recited meditatively or prayerfully (behavior) and also used as a way of changing one’s perspective (cognition). When selecting this handout for use with patients, clinicians should note that the Psalms originate from Judeo-Christian teachings. Clinicians should therefore consider the religious constitution of each group, including the presence of patients from non-Judeo-Christian faiths. Clinicians typically introduce this handout by instructing patients to read through the verses on their own. Subsequently, patients are encouraged to identify which verses, if any, carry uplifting messages or are otherwise relevant to them personally at their current stage of treatment. Patients are then encouraged to select one or more verses that resonate with them and that they can use regularly as a prayer or meditative coping statement.

Handout 5: Sacred Verses

The Sacred Verses handout is an interfaith version of Meditating on the Psalms. It contains a collection of passages from various faith traditions. Content is organized by theme across the following common spiritual concepts: faith, self-compassion, peace, courage, and hope. Just like the Psalms handout, the Sacred Verses handout provides a combination of behavioral activation and cognitive reframing. Clinicians should note that this handout is twice as long as the other handouts in the SPIRIT protocol, and they may need to adjust the length of the part 1 discussion. Typically, clinicians commence a discussion of this handout by asking patients to read sections to themselves, in order or by theme. Afterward, clinicians facilitate a discussion of patients’ reactions to the verses, culminating with each patient identifying one or more verses or themes they can use to connect with their faith and to help themselves feel better.

Handout 6: The Power of Prayer

This handout provides a combined cognitive and behavioral framework to validate common barriers and struggles related to prayer, to help patients think more broadly and openly about prayer, and to encourage use of prayer as a strategy to instill hope and spiritual connection. Clinicians follow the handout’s structure to facilitate a discussion, progressing from basic questions, such as “What do you pray for?” and “How do you pray?” to deeper and more emotion-relevant questions, such as “Do you use prayer to cope?” and “Do you struggle with prayer?” Throughout the discussion, clinicians should be careful to validate struggles and issues that patients raise and to encourage patients to further discuss such struggles with their individual psychotherapists after the SPIRIT session.

Handout 7: Forgiveness

This handout uses a behavioral structure, in that it encourages patients to assess their readiness for the spiritual quality of forgiveness and to take steps to forgive (themselves, others, and/or their higher power). The opening paragraph of the handout introduces the topic of forgiveness and acknowledges that it can be complex and challenging to let go of deeply held negative feelings. The clinician generally reads this entire handout to the patients (or solicits individual patients to read to the group). This reading out loud provides for a cohesive discussion format, which is helpful, given the sensitive nature of the topic. The clinician then asks the patients to self-assess where they are in the process of forgiveness for a specific previous hurt and what next step or steps they can take to move forward and let go. Patients are also encouraged to speak about forgiveness with their individual clinicians or therapists and others in their network (e.g., friends, family, clergy), given that this handout is often simply an introduction to the topic of forgiveness and not a complete intervention.

Treatment Implementation

Importantly, patients were not mandated to participate in SPIRIT sessions as a part of their care but rather attended voluntarily. Nevertheless, since February 2018, we have logged 1,468 unique patient visits to SPIRIT groups across 11 clinical units, at inpatient, residential, and intensive levels of care (Table 1). Patients participating in SPIRIT have included individuals with acute mood disorders, anxiety disorders, psychotic disorders, substance use disorders, posttraumatic disorders, dissociative disorders, eating and feeding disorders, and personality disorders. Interestingly, patients presenting for SPIRIT groups have been spiritually and religiously heterogeneous in that 28.5% (N=418) of patients have self-identified as Catholic, 15.2% (N=223) Protestant, 6.4% Jewish (N=94), and 0.4–2.1% Buddhist (N=31), Muslim (N=10), and Hindu (N=6). More than one in three patients (39.5%; N=580) reported no religious affiliation (“spiritual without religious affiliation” or “none”) (Table 2). These findings suggest that our approach can be implemented among religious and nonreligious patients alike.

The staff conducting SPIRIT groups at McLean Hospital have had varied educational and career backgrounds. At present, 22 McLean clinicians have provided SPIRIT groups throughout the hospital, ranging from pre-master’s-level mental health specialists (8) to master’s-level social workers (3), expressive arts therapists (5), nurses (1), chaplains (1), and doctoral-level psychologists (4). Clinicians have been spiritually and religiously diverse, with some reporting strong affiliation and regular practice and others reporting no spiritual or religious identity. The majority of the clinicians had minimal previous training or experience in spiritually integrated psychotherapy. Optional support and/or training offered to the clinicians included structured meetings to review the SPIRIT protocol and handouts; observation of other clinicians conducting SPIRIT groups; observation by other SPIRIT clinicians coupled with feedback; and consultation with the current authors regarding specific questions arising during implementation. Additionally, active and prospective SPIRIT clinicians are invited to a quarterly luncheon to foster dialogue, provide support, and broadly discuss how spirituality and religion are relevant to clinical mental health practice. Reflecting the flexible nature of the protocol, training support was provided in a flexible manner. Staff who felt comfortable with facilitating groups immediately were provided with less support, whereas staff who wished for greater supervision and training were provided with additional observation, feedback, and consultation.

To date, we have had no adverse clinical events from patients attending SPIRIT groups on any unit, nor have we received any reports of patients decompensating or experiencing significant clinical setbacks in the context of a SPIRIT group. We have learned several lessons, however, in providing SPIRIT to a large and diverse sample of patients with acute psychiatric conditions. Principally, there are several areas of complexity that can arise in implementing spiritually integrated treatment in psychiatric hospital settings that also should be considered when disseminating SPIRIT to other clinical settings. First, as with any spiritually integrated psychotherapy, it is ethically imperative that staff be committed to and capable of providing high standards of professional mental health care. McLean clinicians tend to be highly skilled, well trained, and abundantly supported in that they have access to on-site supervision, extensive consultation, nationally acclaimed professional development, and significant research resources, all of which promote clinical excellence. While this extent of support is not necessary to deliver SPIRIT or other spiritually integrated treatment, it was helpful in developing and circulating the clinical protocol across a large and diverse group of staff and patients within a relatively short time frame. To be clear, the specific training required for SPIRIT does not vastly differ from the general skills and support necessary to provide psychotherapy to patients with acute psychiatric conditions. However, without a fairly high level of competency in this area, the conduct of spiritually integrated psychotherapy is ill-advised.

Second, as emphasized throughout the SPIRIT protocol (see the online supplement), it is ethically imperative for clinicians to know and understand that spiritually integrated treatment is not a form of evangelism or a spiritual or religious change process; rather, it is a clinical approach to mental health change that draws upon the domain of spirituality. This distinction requires that clinicians espouse steadfast commitment to clinical care, without allowing their own religious sensitivities or beliefs to overshadow that primary charge. To these ends, discussions with patients in the provision of SPIRIT should focus on symptom reduction and functional improvements. Encouraging spiritual belief or activity is a means toward the goal of psychiatric improvement, not an end in itself. Our clinicians reported using all of the handout topics across all patient populations (e.g., patients with anxiety, mood, psychotic, substance use, dissociative, and eating and/or feeding disorders), levels of acuity (inpatient, residential, and intensive), and for groups of various sizes (e.g., 2–15 patients). This level of engagement underscores the importance of clinicians putting aside their own spiritual or religious beliefs, practices, preferences, and biases and focusing on patient needs. Clinicians who struggle with any of these issues should seek supervision and consultation.

Third, many patients present with spiritual symptoms, such as religious delusions, hyper-religious mania, or scrupulosity. Such patients often confuse their spirituality with their spiritual symptomatology, and it is important for clinicians to help such patients separate these distinct domains. To address this confusion in a group setting, however, requires clinical discretion and good judgment, and clinicians must consider patients’ levels of insight, mood lability, and emotional stability when considering how to approach such discussions in session. In the best-case scenario, clinicians can engage in reality testing and contrasting by articulating that for some individuals from religious or spiritual backgrounds, their symptoms co-opt aspects of their spiritual or religious lives. Furthermore, clinicians are encouraged to articulate that spirituality or religion is rarely a cause of such symptoms, although it may be a context for the development of spiritual symptoms. This message is important because it can prevent or alleviate spiritual struggles in which patients may blame their spirituality or religion for their distress.

Fourth, because of the nature of acute psychiatric settings, many patients express having significant spiritual struggles. Such concerns tend to be unnerving to clinicians, and many therapists are tempted to respond by voicing alternative viewpoints and refocusing patients on more positive and hopeful aspects of spiritual life. As stated above, the primary aim of SPIRIT is not to facilitate a greater sense of spirituality on the part of patients or to help them claim or reclaim aspects of spiritual life. Rather, the protocol seeks to help patients understand how spirituality may be relevant to their mental health in positive and negative ways and to find a path forward from that understanding. Thus, when patients describe spiritual symptoms, we encourage the clinicians simply to listen, validate, and encourage patients to speak freely about their concerns in the group setting. Acknowledgment and validation of spiritual struggles are part of the healing process for many patients, particularly because so few opportunities occur in mental health practice for patients to discuss spiritual matters in any format. From a CBT perspective, providing a safe forum to express spiritual struggles can facilitate creation of new learning patterns and inhibit maladaptive patterns of thought, behavior, and emotion pertaining to spiritual matters (18).

Fifth and finally, large psychiatric hospitals are dynamic, multifaceted organizations. While clinical units draw upon general support from hospital administration and clinical leadership, they tend to operate as silos, retaining their own subcultures, processes, and procedures. Additionally, individual clinicians within each unit tend to have their own stylistic approaches to psychotherapy, and they tend not to like micromanagement. For these reasons, SPIRIT’s flexible approach was part of its successful deployment at McLean, allowing us to “lead from behind” by leveraging clinicians’ interests without mandating changes to their general psychotherapeutic style. Training emphasized that the protocol and handouts were resources to help support the provision of spiritually integrated care and not mandates on how to do so. Similarly, all aspects of training were optional, including structured meetings to review the SPIRIT protocol, observation of other clinicians providing SPIRIT, receipt of direct observation and feedback, consultation with the protocol authors, and quarterly lunch meetings. Such minimal oversight would be unwise in settings that lack general professionalism or for staff who have spiritual biases that may interfere in the provision of this therapy. However, we believe our flexible training approach would be appropriate for the majority of academic psychiatry and medical centers around the globe.

Discussion

Since the dawn of psychotherapy, spirituality has remained largely on the sidelines of clinical theory, science, and practice. However, the literature has shown that this domain is relevant to mental health in both positive and negative ways (32), and the statistical majority of mental health patients desire spiritually integrated care (33). It is thus an ethical obligation to provide spiritually integrated psychotherapy to patients who want such treatments. In particular, patients in acute psychiatric distress should have access to such approaches as a resource to aide their recovery. As made clear by the American Psychological Association (34), there is ample evidence to support that spiritual and religious life are intrinsically linked to mental health. While the American Psychiatric Association has made no explicit statements about this domain (35), it clarifies that, for many patients, addressing the sacred amounts to “providing competent medical care with compassion and respect for human dignity and rights.” Further, the World Psychiatric Association (36) has been emphatic that person-centered approaches to spirituality and religion are “essential components” of psychiatry training, continuing education, and practice. To these ends, SPIRIT is an important clinical innovation that can help clinicians to uphold higher order values for our field by providing general clinical guidelines and materials for clinicians who wish to provide spiritually integrated treatment to patients with acute psychiatric conditions.

Providing spiritually integrated psychotherapy comes with its own ethical issues, however. For example, such treatments must be voluntary, provided only with informed consent, and conducted by competent clinicians who uphold high standards of professionalism (e.g., attending to boundary issues and multiple relationships) (37). It is also of concern that most clinicians do not receive adequate training in how to address spiritual matters in treatment (15, 18, 38), as academic programs do not currently require coursework or supervised practice in this area. While SPIRIT addresses some of these latter limitations by equipping clinicians with a broad set of cognitive-behavioral tools and handouts to use with patients, we caution against using SPIRIT materials in clinical settings that do not uphold high standards of professionalism or by clinicians who may be vulnerable to spiritual or religious bias. A one-size-fits-all approach is inappropriate for any psychotherapy and in particular for spiritually integrated treatments. As one example, more than a third of patients attending SPIRIT groups reported no religious affiliation, and this finding is consistent with previous data suggesting that desire for spiritually based treatments spans the gamut of spiritual diversity (21). Clinicians must therefore be careful to adhere to a patient-centered approach in providing SPIRIT or similar treatments, without typecasting patients on the basis of their stated religious affiliations or preferences.

To our knowledge, SPIRIT is the first available clinician-led protocol for spiritually integrated psychotherapy in acute psychiatric settings. It is also one of the first such approaches that is appropriate for diagnostically and spiritually heterogeneous patients in various levels of care. We have described the implementation of this protocol by a diverse group of clinicians for 1,468 unique patients presenting across inpatient, residential, and intensive care at a large academic psychiatry hospital, with no adverse events.

Our approach has several limitations, however. First, SPIRIT has not yet been tested for outpatient use, and the protocol would require some adaptation for that setting. Second, while SPIRIT is protocol-driven and provides resources for clinicians to effectively deliver spiritually integrated care to patients with complex conditions, it is neither scripted nor manualized. While this flexibility was viewed as essential to provide clinicians with the necessary latitude in implementing each session, SPIRIT inherently relies upon clinicians’ good judgment, general psychotherapy skill, and professionalism. The risk in this approach is that the burden of oversight is placed on general clinical supervisors, who may not be fully familiar with the details of the SPIRIT protocol. We believe this risk is relatively low compared with the alternative of encumbering the provision of spiritually integrated treatment to patients in need. A third significant limitation is that it is difficult to determine the degree to which SPIRIT is a key ingredient to successful recovery from psychiatric conditions, because participation in SPIRIT is by design voluntary and this therapy was only one component of a multi-pronged approach in an acute-care setting. While the number of participants in this study demonstrates interest in spiritually integrated treatment and offers reason to believe that SPIRIT enhances treatment, the irreducible complexity of hospital-based psychiatry makes it difficult to test this hypothesis empirically.

Conclusions

Despite the limitations, we have described the SPIRIT protocol as a clinical innovation to facilitate spiritually integrated treatment in various psychiatric settings and delineated guidelines for implementation. We have also showcased the feasibility of SPIRIT within a large and complex psychiatric center. To these ends, as the field moves toward greater value of holistic and patient-centered care, we hope that our approach may be used and/or adapted at other locales to facilitate broad-based integration of spirituality into the treatment of patients with acute mental health conditions.