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From Luke’s Journal Nov 2024 | Vol.29 No.3 | Mental Health II

This work was presented in part at the NCFI Congress, Malaga, Spain 2024
(After reading this article and completing the activities you can gain 1 hour of CPD)

Introduction

This work was developed to assist nurses and other healthcare professionals to address the spiritual care needs of people with mental illness: Building courage and resilience through wise communication.

This presentation is the fruit of collaboration between the Hunter Mental Health Network (who are Christian Practitioners) during two Saline Process^TM Tasters delivered in Newcastle in 2023.  The Tasters were attended by almost 30 people from many areas of healthcare.  Attendees included a mental health registered nurse, a psychiatrist, psychologists and counsellors as well as an occupational therapist and members of the church. One attendee was a non-Christian carer and active participant.

The standard set of 20 slides approved by IHS Global  for a Saline Process^TM Taster (SPT) were presented within the context of  a workshop in which attendees were invited to discuss the content of the slides and participate in 4 activities.

Worksheets were prepared and approved by the Nurse’s Christian Fellowship International (NCFI) Saline Process^TM Coordinator.  The fruit of these SPT workshops was the knowledge that the area of disability and mental health requires particular attention to the language and approach used when assessing the spiritual health of people with mental health issues.

In principle, what I will be illustrating here is the application of wise communication by drawing from the corpus that the Bible provides, using the ethical principles of permission, sensitivity and respect when dealing with vulnerable and underserved populations.^1-3

Background

Much experience and research has gone into developing an understanding of the complexity of interaction on a spiritual level with people who are affected by mental health issues.^4,5

My personal experience (2005 to 2023) with a person who was living with an acquired disability caused by mental illness (Type 1 bipolar disorder) has led me to study and evolve as a nurse educator and linguist, and resulted in the compilation of a case study. 

This person (here I will call CS) was followed up for a period of six years. CS demonstrated courage as they became interested in the Saline Process^TM(IHS Global)³ in 2018. New skills gave me insight into the ethics of supporting clients, as well as my own mental health^4,5, resulting in the development of my own resilience and awareness.

Activity 1:  What is your context? 

Think of a person whom you treat or support, to whom you can apply the language of wise communication.

Clients in Australia may present with a National Disability Insurance Scheme (NDIS) referral which could relate, for example, to bipolar disorder, schizophrenia, a history of trauma, substance abuse. Case facts could also include that they are homeless, unable to attend to psychosocial needs or have a diagnosis of psychosis, with auditory hallucinations and perceptual difficulties (delusions).

Table 1. Facsimile of template used for discussion in the 2023 SPT Workshops

*Client’s journey	Case facts	Related activity	Discussion focus
Patient with anxiety presents to a mental health clinic, referred by GP. Are they reactive? Establish boundaries Emotional regulation required	Draw from an authentic case (remains anonymous).	Supportive action in taking a spiritual history; building a support network. Eg,Apply national Guidelines; develop a sense of reassurance, do not be judgemental; build trust	Type of mental health issue; be cautious; requires experience; Delicate. Consult the literature.

*Client, patient, resident or friend could be used throughout this article. For ease of reading, client will be used throughout.

Activity 2:  Timeline your case study

Indicate the weeks/months/years of ongoing spiritual care.

Table 2. Case Study Timeline:

2018	Introduced CS to the Saline ProcessTM with permission, by answering CS’s questions
2019	Discussed teaching and training activities with CS (intense that year!)
2020	CS Commenced Zoom prayer meetings with HealthServe Australia
2021	Implementation of holistic person-centred care.  Application of active listening
2022	CS developed prayerful networks.  Answered open-ended questions about Biblical topics
2023	Continued to pray in the name of Jesus.  CS passed on to eternity

Activity 3: What key words and phrases apply to your context?

When thinking about the client with mental health issues to whom you have been able to apply the human right of spiritual care, which words or phrases from the list (Table 3) could be used appropriately in the context of your case study? (Remember  to maintain confidentiality).

Table 3. Key Words and Phrases

ACCOUNTABLE	DYSREGULATION	REACTIVE
ACQUIRED DISABILITY	EMOTIONAL	RECOVERY ORIENTED
ANGER	ETHICS	RESILIENT
ANXIETY	HOPELESSNESS	SUPPORTIVE ACTIONS
ASSESSMENT	HOSTILITY	UNDERSERVED
COURAGE	MISTRUST	UNDERVALUED
DISCONNECTION	PERSONAL RESPONSIBILITY	VULNERABLE

Activity 4:  In your experience what is essential:

1. To obtain before you assess a client?
2. To demonstrate towards your client?
3. In your treatment of them?
4. What emotions can be observed ?
5. What is the most difficult spiritual barrier to overcome?

**Some suggested answers can be found at the end of this article, compare them to your own.

Spiritual history taking as a supportive action

Taking a spiritual history could involve discussing the client’s upbringing and education (and if/when these were disrupted).  It could also include past trauma as well as past and current treatment.  Ask open-ended questions in order to build trust and rapport.^6,7 Discern if their spiritual life is natural or esoteric, new age, non-existent, hocus pocus or a more established religion or faith.

Supportive actions include effective implementation of the recovery approach as well as strategies and narrative threads,⁸ e.g. talking about nature could lead to a discussion on the Fibonacci sequence, spirituality and the attributes of God as per https://christianperspective.net

Spiritual Assessment Tools

These assessment tools are useful in both acute and long term care settings. They gather and evaluate relevant data pertinent to the client’s situation and bio-psycho-social-spiritual and religious health.  The most effective questions to use are open-ended and encourage the client to speak freely in a safe environment. Spiritual assessment is not just the domain of chaplains. Doctors and nurses can integrate spiritual history-taking within the context of holistic person-centred care. 

Table  4. Spiritual Assessment Tools

FACT	The facts, feelings, family/ friends, and faith9
FICA	Faith and Belief; Importance; Community of Faith; Address in Care10
HOPE	Sources of Hope; Organized Religion; Personal Spirituality and Practices; Effects on Medical Care and End-of-Life Issues.11
Open – Invite	Open the Door to Conversation; Invite Discussion of Spiritual Needs.5

Quotes from the spiritual assessment of persons with mental health issues.³

Emotional barriers in these vulnerable people could involve anger, fear, anxiety, hostility and frustration. These emotions often cause dysregulation. The client may not want to press on with the idea as they may already feel overwhelmed and may look at these emotions in a negative light. There could be mistrust and disconnection with low self esteem (“Why should Jesus care about me?”).  They could also be embarrassed or lonely (“Jesus can’t give me connection”), or angry (“If He cares, why doesn’t He help me?”). The client may have suffered trauma; negative health, faith, relationship or life experiences; as well as past injustices (“Pain is causing all my problems!”).

Identifying and overcoming intellectual barriers may be affected by a client’s low cognitive ability¹,  and meeting these challenges would only come after establishing emotional safety.  Often a client in crisis is worried primarily about ‘survival’ and meeting basic needs. They may lack self-identity (what it is to be human), who they are in relation to others; or have difficulty identifying their boundaries as a person. There are also cultural considerations.

After overcoming emotional and intellectual barriers, clients then enter the end stages of change. Volitional choices come into focus as they decide whether to accept and commit to treatment or therapy in line with their values and desires. This needs to be conducted in a safe environment.

The ethics of spiritual care^7,8

Ethical behaviour or responsibility is doing the right thing for the client.  Ignoring responsibilities makes clients suffer.  Healthcare workers can be held accountable for these behaviours.  Examples of unethical behaviour include fraud and neglect, including neglecting to address spiritual care if the client requests and consents to it.  An in depth course with training on the ethics of and tools for spiritual history-taking by Christian healthcare workers is available via The Saline Process^TM Witness Training.¹²

Table 5. Principles of nursing ethics, spirituality and the Bible

Moral Principles7	Bible references
Beneficence	The Good Samaritan (Luke 10:25-37)
Non-maleficence	First, do no harm (Luke 10:29-37)
Autonomy	Free to do what is right (I Cor 6:12)
Justice	Jesus said “And will not God bring about justice for his chosen ones?”(Luke 18:7-8)

Table 6. Biblical verses to allay anxiety (NLT)

The Lord nurses them when they are sick and restores them to health. Psalm 41:3

For God has not given us a spirit of fear, but of power, love and self-discipline (and of a sound mind. www.christianity.com) 2 Timothy 1:7

Don’t worry about anything; instead, pray about everything. Philippians4:6

Seek first the Kingdom of God above all else, and live righteously, and He will give you everything you need. Matthew 5:33

Conclusion

More studies on the language of wise communication for the support and care of people with mental health issues are required.  This population can be fearful and guarded. There is still a lot of shame and stigma. Nurses and other healthcare workers are often ill-prepared to address client issues and need to be better equipped to overcome the barriers and challenges.  Nurses can ethically address mental health communications but need to be educated to do so.^6,7

Doctors need to support nurses by providing consistency of assessments and documentation of required psychosocial interventions and health promotion.¹¹ One of the main advantages of nurse-led mental health treatment is the ability to provide a holistic and person-centred approach to care.¹³ However, nurses themselves encounter psychological distress and burnout (a major health issue facing healthcare staff over recent years) and require support from employers, policy makers and management to ensure their mental health is maintained.¹⁴

**Suggested answers for Activity 4

1. Consent/permission.
2. Sensitivity and respect
3. Safety
4. Anger, frustration, irritation, judgement, fear
5. Emotional dysregulation

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