Should Spirituality be Incorporated into the Treatment of People with Psychotic Disorders? a Systematic Review of the Literature

Background: Psychosis—a mental condition in which people experience some loss of contact with reality—is a substantial burden for persons with psychotic disorders (PPD), their families, and the larger society (Milner et al., 2020). Many PPD, especially those belonging to racial/ethnic minority groups, report that spirituality is a resource, helping them to cope with psychosis symptoms (Maura & Weisman de Mamani, 2017). Including spirituality in the treatment of psychosis is, however, controversial (Yamada et al., 2019. To determine the effect of incorporating spirituality into treatment, we conducted a systematic review of spiritually informed interventions with PPD.

Methods: 15 electronic databases were searched to identify randomized controlled trials (RCTs) that met the study inclusion criteria (e.g., used spiritually informed interventions, participants diagnosed with a PD, outcomes measured recovery from psychosis symptoms). The methodological rigor of the resulting studies was independently assessed by two coders using criteria developed by the American Psychological Association for assessing intervention quality (0=lowest rigor, 6=highest rigor). Cohen’s kappa was calculated to determine inter-rater reliability.

In addition to conducting a narrative review, effect sizes and 95% Confidence Intervals (CIs) were calculated to assess the effects of spiritually informed interventions on psychosis symptomatology using Comprehensive Meta-analysis software. To ensure statistical independence of the data, only one effect size value was computed from the primary measure of psychosis symptoms in each study. In cases where multiple subscales were used, but single total score was not reported for the primary measure, individual effect sizes were calculated for each subscale and then averaged together to achieve a single effect size. For studies that employed multiple follow-up points, the first follow-up point was used. Due to study heterogeneity, a random effects model was selected, a priori, to estimate a mean effect (Littell et al., 2008).

Results: The search procedures produced 4,317 studies, of which 7 met the eligibility criteria. The rigor of these studies ranged from 3 through to 6 (κ=0.91). A narrative review revealed the use of spiritually informed interventions was significantly associated with positive outcomes across all 7 studies. Quantitative analysis indicated the use of spiritually informed interventions was associated with lower levels of psychosis symptoms (Hedges’s g=1.06, 95% CI=0.46 to 1.66, p=0.001). A subsequent sensitivity analysis suggested the findings were relatively robust although the high I-squared value (I²=83.13) indicated the existence of considerable heterogeneity, underscoring the importance of treating the results of the quantitative analysis with caution.

Conclusions: The results suggest practitioners should consider incorporating client spirituality into treatment when working with PPD. This may be a particularly relevant issue for clients from disadvantaged groups. Large disparity exists in the utilization of mental health services. African Americans and Latinos, for example, may be less likely to receive services for mental health problems relative to European Americans. Yet, these are the very populations for whom spirituality as often a key factor in the recovery process. Accordingly, practitioners should conduct an assessment to determine clients’ preferences regarding the incorporation of spirituality into treatment to offer more effective care to racial/ethnic minorities.