use of sacred story in a psychiatry spirituality group

8/12/2019 Use of Sacred Story in a Psychiatry Spirituality Group

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The Use of Sacred Story in a PsychiatrySpirituality Group

Robert A. Kidd, M.Div.

Sr. Staff Chaplain, Spintual Care ? Education;

Virginia Maripolsky, M.S.W., R.N..

Nursing Director, Psychiatry Unit;

Patricia R Smith, M.A.

Sr. Staff Chaplain, Spintual Care f Education;

The Methodist Hospital

6565 Fannin Street

Houston, TX 77030

Describes the philosophy and methodology for using sacred stories from several

religious traditions with psychiatric patients. Notes how chaplains are integratedinto a psychiatric unit's interdisciplinary team. Details how sacred stories are

selected for use in a spirituality group, how patients are screened for participa

tion, and how the gro up is facilitated. Demonstrates the benefit and value pat ients

and staff derive from a spirituality group on a psychiatric unit.

T

hroughout human history, stories have called people into community. Humanity seems to have learned that stories can be medicine forthe soul, a medicine "similar to listening to the ocean or gazing at

sunrises. Stories flow where needed, acting like an antibiotic that finds thesource of infection and concentrates there."1

The Psychiatric Unit

The subject of this article, known simply as "The Spirituality Group," isheld on the Psychiatric Unit of The Methodist Hospital, a full service, 900bed private hospital located in the Texas Medical Center in Houston. Thehospital serves as the primary teaching facility for The Baylor College of

Medicine and draws patients from around the world.The hospital's 30 bed psychiatric unit admits only adults for both gen

eral psychiatric and chemical dependency diagnoses. Patient ages rangefrom 18 to 96 with an average age of 55 years. Though the average lengthof stay for inpatients is 10 days, stays vary depending on the complexity ofthe case. Patients in the partial hospitalization (out-patient) programattend most groups along with inpatients.

The Buddhist story cited below, "The Mustard Seed," is frequently

utilized in the Spirituality Group. This story suggests a foundational element of the unit's treatment philosophy: health is found not in isolation, butcommunity

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TheMustardSeed

The Buddha was walking on a dusty county road one day when he stopped at theedgeof a

river to splash cooling water on his face. When he finished washing, he looked up and saw

an old woman kneeling besidehim. Her clotheswere ragged and her face was worn. Her

armswere coveredwith sores.

'Oh, Master, " shewailed."I sufferso.Please help me. "

"What troublesyou?" the Buddha asked,looking at her with compassion in his eyes.

"Look at me! See my sad lot!" She touched her rags, and she pointed with skinny fingers to

herblisteredarms. "I ampoor,my clothes are torn, I am ill. Once I was prosperous, with a

farm and now I am old and have only a bowl of rice to eat. Won't you heal me and bring

back myriches?"

"You havedescribedlife as it is, " the Buddha answered. "We are all born to suffering. "

The old woman shook herhead,weeping. "No, no, I wonYlisten. I was not born to suffer."

The Buddha saw that she could not understand. "Verywell, I willhelpyou, " hesaid."You

must do as I say."

"Anything, anything!" shegasped."Then bring me a mustard seed."

She stared in astonishment. "Only a mustard seed?"

"Yes, but the seed must come from a house that has never known sorrow, trouble, or suffer

ing. I will take theseedand use it to banish all your misery. "

"I will do as you say. Thank you, Master, thank you!"

The old woman hobbledaway, her bare feet shuffling m the dust. She was on her way to find

a house without sorrow.

The Buddha continued down theroad.

Weekslater,he returned along the same road and came to the same place by theriver,and

therehe saw the old woman again. This time, she was scrubbingclothesm the river water

and spreading them on rocks to dry in the sun. While shewashed,she sang a tune.

"Greetings, " the Buddha said. "Have you found the mustard seed?"

"No,blessedOne. Every house I visited had far moretroubles than I have. "

"So,areyou still seeking theseedI sent for?"

"No,I'll do thatlater. Yousee, I have metsomanypeoplewhoareless fortunate than I, I have

to stop and help them. Right now, Tm washing clothes for a poor family with sick children. "

Gently,sheplaced a wetpieceof cloth on a rock.

The Buddha smiled.He said, "I see, then, that you no longer need the mustard seed. Help

ing othersis a great virtue. You are now on the road to becoming a Buddha yourself."

Repnnted by permission of Sibyl Publications, Ine 800 240-8566

As in the above story, the patients on the hospital's psychiatric unit arecalled on to move beyond preoccupation with their own illnesses and intoenhanced community with others. Such refocusing of attention is not seenas a way of neglecting or minimizing patients' problems, but rather as a wayof dealing with them both inter- and intra-personally. The SpiritualityGroup described in this paper has proved a viable element in accomplishing this team goal. Skillfully utilized, sacred stories help individuals moveout of isolation into community.


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is that for many patients, a satisfying, helpful spiritual life has predatedtheir psychiatric illness and thus is often part of their memory of wellness.Giving patients an opportunity to remember these helpful elements oftheir history enhances their sense of wholeness.

Third, several regulating agencies monitor the hospital's psychiatric services.The Joint Commission on Accreditation of Healthcare Organizations

(JGAHO) expects that psycho-social assessments of patients will includeinformation about their spirituality and that the resultant treatment planswill identify types of care and services which will meet those needs. 9 ThisSpirituality Group complies with JCAHO's standards for Patient Rights andPatient Education by insuring that these religious needs are assessed,addressed, and documented in the medical record.10Additionally, both theTexas Department of Health and the Texas Commission on Alcoholismand Drug Addiction recommend a holistic approach to mental healthwhich includes assessment of spirituality needs followed by attempts tomeet those needs.11

Inclusion of Chaplains on the Interdisciplinary TeamThe initiative for including chaplains in the psychiatric interdisciplinaryteam began with the Department of Spiritual Care and Education. Afterseveral meetings with the psychiatric medical director, nurse manager, clinical supervisor, and other team leaders, a plan was agreed upon for the regular offering of a Spirituality Group on the unit. This alone, however, didnot establish the chaplains as functional team members.

Strengthened relationships with nursing leadership has been the key tothe ultimate inclusion of chaplains as real, day-to-day players on the interdisciplinary team. Although the Department of Spiritual Care and Education had always been available to this unit, it was the growing, collgial,chaplain/nurse relationship which truly solidified the chaplains' presenceon the psychiatric care team.

Nursing standards also played a role in carving out a place for chaplain

cy services on the unit. Including a Spirituality Group on a psychiatric unithas allowed the hospital to be in compliance with American Nursing Associations' Standard IX for Interdisciplinary Collaboration.

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In The Methodist Hospital's psychiatric unit, the interdisciplinary teamconcept is a foundational care philosophy. Chaplains, then, cannot minister in isolation. For therapeutic and operational reasons, chaplains arecalled on to be radically interdependent with other psychiatric staff persons. This new alliance with Spiritual Care has fostered a revisiting of values, attitudes, prejudices, and perceptions by all members of the

psychiatric care team, chaplains included.


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What Stories are Sacred?Because The Methodist Hospital's patient base is international and its commitment is to ecumenical ministry, it was determined that sacred stories forthis group should be from a variety of religious traditions. As previouslymentioned, Houston, Texas becomes an international community by virtue

of business, educational , travel, and climate dynamics. This broad-basedapproach not only relieved fears that any hint of religious coercion wouldbe present but also insured that patients could feel as free as possible toexpress their spiritual inclinations in any way that seemed to fit themUsing a variety of traditions in story selection had the additional benefit ofincreasing the field of ideas which could be broached in a spiritual context

Yet this commitment to ecumenicity made the group leaders realize thaan agreement had to be reached on the definition of a sacred story. Notreally wanting to get into the task of deciding what was sacred and what was

not, the group leaders chose a pragmatic approach for discerning storiessacredness. Sacred stories are defined as narratives found in currently activreligious traditions which are utilized bypresent-day religious adherents to offeinspiration and instruction. This definition included but was not limited toBuddhist, Hasidic, Hindu, Native American, Muslim, and Judeo-Christiantraditions. It did, however, exclude illuminating stories such as Aesop'sFables, which might, in another setting, with another group of facilitatorsbe used with spiritual benefit.

Here, it can be argued, why not use those stories that most likely reflectstories most familiar to the members of the group? Why, indeed, would onepurposely introduce foreign and new materials to a group whose make-upis mostly of over-stressed patients? Our experience has given us two basicsupportive tenents to do so:

The Use of the OverfamiliarWe would argue that for the religiously resourced patient, familiar sto

ries are often too familiar to catch our attention. We have heard how thisstory comes out. Too often we have heard sermons and lessons about thatstory that just explain it away and leave us with some well-ascribed ethic weare to follow. Again, we are careful not to read too closely to ascribing to acode of conduct or convincing others of a point of view. In the Judea-Christian tradition, we trust that the Maker of the story continues to pursue thepresent listener with a call to wholeness as the nature of stories to healunfolds.

Many Images of God are Already PresentWhether we are conscious of it or not, we believe that images of God are

always present in the back of our minds. "Such imagistic symbols are partof the long-neglected language of the soul, part of our heart's accumulat


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von Hgel, the great turn-of-the-century spiritual director, called our ownpersonal attrait,or way of being attracted to God. Morris claims that out ofa great panoply of symbols, only some connect one's own deepest self tothe Divine.

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Why Use Sacred Stories as a Modality?Of all the options open to the group leaders, it seemed more therapeutically effective to engage patients around spiritual concerns if these issueswere presented a bit obliquely, even paradoxically. Stories seemed to dothis especially well. Historically, shamans, holy leaders, preachers, andteachers have used stories to offer comfort, guidance and counsel. Sacredstories offer rich and symbolic images to trigger memory and imaginationof both individuals and groups. Each symbolic image in sacred storiesstands as a container for numinous energies, packed away until triggered

into recall. Introducing images allows imagination to awaken. Like prayer,the use of the imagination allows us to hope in a new way. A kind of hoping has begun in stories of struggle and sacrifice and where the intervention of the Transcendent is sought. Often it is in the very presence ofhopelessness that hope becomes alive. Patients are quick to give a name totheir hopelessness, for it is often this very desperation that brought themto hospital admission.

Sacred stories help patients communicate and change. Stories' concreteimages give shape to the highly subjective and nuanced aspects of individuals' spirituality which may otherwise defy clear verbal expression. Issuessuch as forgiveness, courage, faith, hope, joy, purpose in life, and the meaning of community are intensely personal and can be hard to articulate.When the energies of the images in stories are released in story telling,hearers can recognize their own experience and where landmarks for themmight point toward change .

Finally, using sacred stories seemed the path of least resistance for discussing with psychiatric patients their spiritual issues. The use of spiritual

ity as a therapeutic modality in any medical/scientific setting frequentlyraises questions among many health care professionals and not a fewpatients. This is especially true in psychiatric settings. In consultation withthe interdisciplinary team, it was agreed that using sacred stories as a vehicle for spiritual discourse was relatively unlikely to exacerbate patients withspiritual concerns. The group leaders believed that if suggested throughstories, spiritual issues would be more likely broached at the patients' initiative, met with less resistance, and therefore be more freely dealt with.

Detailed MethodologyTh f h i d d fl i i d


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Selecting the StoriesThe day before each meeting, the group leaders confer about the fol

lowing day's story selection. Truly, there were times when the group leaders were unsure whether they chose the story, or the story chose themOccasionally, the real appropriateness of a story did not reveal itself untithe group process was well along. As experience with the groups increased

there was more intentionality about the types of stories utilized given theneeds of a particular group of patients. For example, the more highly functioning the group, the more metaphorical the story could be. Though iwas a vague criterion, intuition played an important role in story selectionas well.

As stated earlier, a commitment was made to the rest of the psychiatricteam to be inter-faith in approach. Members of the psychiatric team, (particularly those from less familiar religious traditions) were enlisted to shar

their sacred stories. Additionally, interested staff persons pointed out bookwhich often contained additional stories. All this heightened staff interesand ownership of the group.

Stories are selected by several criteria. First, a story must simply be interesting. It must have all the traditional elements of any good story: an exposition, a complication, a climax and a denouement. A selected story mushave sharply drawn figures which have a good chance of eliciting somehelpful emotional response from the patients. Finally, the story must bbrief, with no more than five hundred words.

Attempts were made to select stories which generally point toward issueof hope, strength, courage and enhanced relationships. These are, after althe key elements in the leaders' working definition of a helpful spiritualityCare is taken to avoid, as far as possible, stories which might exacerbatepatients. Nursing and medical staff were consulted about such stories whenin doubt.

In general, stories were avoided that were disturbingly violent and thosethat simply seemed bland. For example, the story of Abraham nearlyslaughtering his own son, or of Jeph tha sacrificing his daughter, were bothruled out. Also avoided were stories presenting only male championsInterestingly, as already pointed out, it seemed that the non-Christian stories worked better in this setting than Christian ones. Apparently, usingmore unfamiliar stories allowed everyone in the group (facilitators included) a larger measure of playfulness, objectivity and creativity in interpreting the sacred stories. New stories presented us with a cleaner slate to drawupon and set the stage for the element of surprise.

Crafting the Questions

After selecting the story for the day, work is done crafting questionwhich will be asked after the story is read. Consideration was given to the


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the meeting than thought necessary, ranking them according to theirpotential importance and impact. Then,as thegroup process unfolds, thefacilitators decidein themoment which questionsto ask andwhich toskip.This offers the facilitators more freedom and increases their ability tomatch questions to theneedsof the group.

Group questions tend to fall into two types: those which are closed

ended andserve mainly toassist patients inpaying attention to the detailsof the story itself; and questions which are more thought-provoking andopen-ended, designed tohelp patients grapple with the personal meaningthey find in thestories.

When theBuddhist story,"TheMustard Seed," isused (referenced earlier),thefollowingmay beasked: "With whomdid youmost identify in thestory? Have you ever seen a mustard seed before?" These closed-endedquestions focus the patients' attentionon thedetailsof thestory.

Leaders alsoask thought-provoking, open ended questions that illumi

nate patients' senseofmeaning andexistential states. Theseare questionslike, "Is there anything about this story that troubles you?" "What is thegood newsofthis storyforyou?"and, "Howdoes this story giveyouhope?"

The chaplains are very careful not to intentionally superimpose theirown meanings onto thestories. Becauseofthis, patients' interpretationsofthe storiescan bequite unexpectedandfresh.Thestoryof"Joshuaand theWall of Jericho"was aparticularly arresting example.To anumber of thatday's patients, Joshua came acrossas thevillain in this story, pulling down

the walls of people who'd really done nothing to provoke this behavior.That particular session unfolded intoadialogue about thefunction ofparticipants' personal walls: "Whatare they for? Whatdo they look like?Whodowe let in and who do wekeep out?"

The Muslim story, "Hajar and the Miraculous Well," is a story whereHajarand herbabyson areabandoned in thedesertand an angel miraculously provides them with life-sustaining water. This session featured conversations about dealing with betrayalandabandonment. It also producedconversations about maintaining faithin Godevenintimesofdesperation.

A very popular Native American story, "How the Coyote Got HisName,"15focusesonhow various animals soughtthehelpofthe Spirit Chiefto find anameandroleforthemselvesin theworld. Here, questions aroseabout Who/What each person's SpiritChief, orguiding life force, was.Thegroup also talked about favorite nicknamesand howthey represented partsof participants' personhood. Also, as an outgrowth of this story, participants talked about inherent personality traits which were somehow usefulin day-to-day community life.

Over time, two closing questions have been designed to help patientssummarize their reflections andassist them in thinking about life after discharge These questions are: "What is this story really about?" and "What


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models an acceptance of others which is foundational for good mental andspiritual health.

Screening Patients for ParticipationCare clearly needs to be taken in determining who should be actively

encouraged to attend the spirituality group and who might be adverselyaffected. The issue of screening patients for participation in the Spirituality Group is an interdisciplinary matter on the unit and takes place on manyfronts.

To accomplish this, a chaplain attends the Multi-disciplinary TreatmentConference each week to solicit feedback from other team membersregarding specific patients' Spirituality Group attendance. A chaplain alsoattends the weekly Community Meetings (which all patients and staffattend) to assess patients' interactions with others in a group setting. Thisobservation helps a great deal in judging their appropriateness for Spiritu

ality Group participation. Also, a chaplain attends occupational therapysessions three times a week and another co-facilitates one of the patients'twice-weekly focus groups. In the Occupational Therapy Clinic, patientsand chaplains get to know one another in a low stress environment. Suchface-to-face encounters not only assist the chaplains in screening for theSpirituality Group, but also help some patients feel more comfortable risking group attendance by virtue of their heightened familiarity with one ofthe group leaders.

Since patient attendance at all meetings is ultimately voluntary, inten

tional efforts are made to help patients self-screen as much as possible forthis group. During the calendar review portion of the Community Meetingon the day of the Spirituality Group, group facilitators provide the nameand faith tradition of the day's story. The Group's "commercial" goes something like this:

The spintuality group is at 3:15 this afternoon in Room 722. This is not a worship service,

not a prayer service and not a preaching service. No one will attempt to change what you

already believe. In this group we take a story from one of several religious traditions and we

reflect togetheron it to find what things give us strength and faith and hope. Today's storyis a Native American one called "Grandmother Spider Brings the Sun. "

It was learned that this procedure helps patients make informed decisions about Spirituality Group attendance. As this group has become oneof the standard scheduled groups, "word of mouth" by other patients hasbeen instrumental in increasing attendance.

On the day of the group, the chaplains meet with the psychiatric clinicalsupervisor and compare notes about who should attend the group. At thispoint, the chaplains and clinical supervisor also do some final strategizingaround specific patients' needs. Excluding those for whom the group iscontraindicated, all patients on the unit are invited to attend. Generally,


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Substance Abuse Related DiagnosesMood Disorders

Anxiety DisordersSomatoform Disorders

Sexual and Gender Identity DisordersEating Disorders

Sleep DisordersPersonality Disorders

Adjustment Disorders (usually found in the out-patient population)

Patients with the following diagnoses may benefit from spiritualitygroup, but will require close scrutiny:

Thought Disorders/Schizophrenia/ParanoiaBorderline Personality Disorder

Attention Deficit Disorder

However, persons with the following diagnoses are not allowed to attendthe Spirituality Group until their status changes:

Active psychotic episodeDementia

ManiaDissociative Disorder

Group ProcessThe group is scheduled weekly in the late afternoon, but well before dinner and is held on the Psychiatric Unit in a large, comfortable group roomwith a large marking board.

The Group process is relatively simple and attendance is voluntary.Chaplains explain the purpose of the group, remind the participants ofbehavioral ground-rules, facilitate introductions, tell the story and engagethe group in the reflective questions pertaining to the day's story.

If anyone leaves the group early for any reason, it is the responsibility ofone of the chaplains to check with that patient before leaving the unit toascertain why he or she left the group early. If consultation with the patientis needed, it is arranged at that point and documented.

Not infrequently, participants in the group will want to confess something. Confession in this context refers not only to admission of wrongdoing, but also the public statement of some core belief that has beenchallenged during a time of crisis and now, as a way of affirming its validity, needs to be spoken aloud before others. This is particularly common

among chemical dependency patients who need to continue processinghurts they have inflicted on themselves and others as well as affirm the


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group leaders feel creative. It is during this debriefing session that theunit's clinical supervisor sometimes gains new insights into the patients'spiritual lives while the information is still fresh.

After the group has concluded and after dealing with any individualpatient concerns, chaplains document the patients' participation in theirindividual medical charts. Documentation focuses on the level of the

patient's involvement in the group and any pertinent issues which were discussed. Naturally, care is taken to ensure confidentiality. Further, if apatient had a particularly powerful emotional experience or moment ofinsight, this would be shared with the nursing or physician staff.

Outcomes of the Spirituality GroupPatients report that the Spirituality Group is helpful for them because theyfeel some competence there. They are not directly taught anything. In

addition, it is an occasion in which staff and patients participate in a discussion on a more even footing as opposed to the more commonhelper/helpee paradigm.

Patient benefits of the Spirituality Group are summarized as follows:

The group provides a forum for spirituality to act as a healer.

It provides a place for exploration of beliefs, cultures and values in a non-threat

ening environment.

The stories give shape to highly subjective material that might otherwise defy ver

bal expression.

It offers an opportunity for patients to ask for individual spiritual guidance.

It facilitates emotional healing by providing patients an opportunity to be in

touch with their memories of wellness.

It gives patients an additional chance to participate in an interesting, informative,

and pleasant group experience.

Adding chaplains more intentionally to the psychiatric milieu has, of

course, changed the team's group dynamics. This inclusion has presentedthe challenge of accepting still more differences and perspectives of otherprofessionals which transfers to the acceptance of the differences of thepatient. As well, new modes of conflict resolution and problem solving havebeen incorporated into the team process now that the chaplains are a routine part of the mix. All of these qualities are necessary to establish a well-balanced team.

As with the patient benefits, team benefits can be summarized in the fol

lowing way:The new inclusion of the Spirituality Group and chaplains have helped the psy

hi i b h i i f h h i l


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Heightened at te nti on to spirituality issues me an s that th e tea m now focuses mo re

of its planning on values, beliefs and religious and cultural issues

Adding new team members and programs toth e pr es ent psychiatric milieu has

had an energizi ng effect on th e whole tea m

Stoneshave become, for the group leaders, a place where living souls go

to livingwaters that touch the heart and where the self can become clear

and strong again Th e Group's foundation was this "When at least one soul

remainswho can tell the story andthatsoul recounts the tale the greater

forces of love, mercy, generosity and strength are continuously called into

being in the world" 17*t

17Clanssa Pmkola Estes, TheGiftof Story A WiseTaleAboutWhat isEnough (NewYork, NY Bal

lenirne Books, 1993), 10

LoyolaCollegeinMaryland

JTciS OFci1 ^

tk Spiritual andPastofalCare

StodgyICA?!*/

LCliiiaiiii&f HUP)


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use of sacred story in a psychiatry spirituality group

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