This course explores the recovery model, its origins in the consumer movement, and its connection with spirituality. Mental health systems in this country are undergoing a quiet revolution. Ex-patients and other advocates are working with mental health providers and government agencies to incorporate spirituality into mental health care. While the significance of spirituality in substance abuse treatment has been acknowledged for many years due to widespread acceptance of 12-step programs, this is a new development in the treatment of serious mental disorders such as bipolar disorder and schizophrenia.

Three dimensions of this new respect for the importance of spirituality will be addressed: (1) Many patients and their relatives experience recovery from an episode of mental disorder as part of their spiritual journey. (2) Patients with mental disorders have genuine religious experiences. (3) Patients with mental disorders benefit from spiritual support. The author of this online course is David Lukoff, Ph.D.

Learning Objectives
Upon completion of this course participants will be able to:

• Conduct a spiritual assessment.



• Develop treatment approaches sensitive to the spiritual issues and backgrounds of persons with mental disorders.



• Apply spiritual interventions into appropriate situations.



• Conduct searches on the Internet for the latest research and clinical articles on recovery.



• Describe and discuss the role of the consumer movement in the recovery model.



• Demonstrate mastery of the knowledge and Internet search skills required to achieve course objectives.

Recovery Model Overview
The mental health field in the United States is undergoing a quiet revolution. Former patients and other advocates are working with mental health providers and government agencies to incorporate spirituality into mental health care. While the significance of spirituality in substance abuse treatment has been acknowledged for many years due to widespread recognition of the therapeutic value of 12-step programs, this is a new development in the treatment of serious mental disorders such as bipolar disorder and schizophrenia. The incorporation of spirituality into recovery is one of four hallmarks of the recovery model that is becoming increasingly accepted as the reigning treatment approach in the mental health field.

A second perspective that distinguishes the recovery model from prior approaches is the assumption that people can fully recover from even the most severe forms of mental disorders. It creates an orientation of hope rather than the "kiss of death" that diagnoses like schizophrenia once held. One hundred years ago, Emil Kraepelin,MD, identified the disorder now known as schizophrenia. He described it as dementia praecox, a chronic, unremitting, gradually deteriorating condition, having a progressive downhill course with an end state of dementia and incompetence.

However, researchers in in the past two decades in Japan, Germany, Switzerland, Scotland, France and the USA have established that people diagnosed with schizophrenia and other serious mental disorders are capable of regaining significant roles in society and of running their own lives. In fact, most persons with serious mental disorders do recover. Robert P. Liberman, MD, Professor of Psychiatry at UCLA School of Medicine notes that there is strong evidence that persons, even with long-term and disabling forms of schizophrenia, can 'recover,' that is, enjoy lengthy periods of time free of psychotic symptoms and partake of community life as independent citizens. Daniel Fisher, MD, PhD, a former patient, now a psychiatrist, and internationally renowned advocate for the recovery model, maintains that "Believing you can recover is vital to recovery from mental illness." Recovery involves self-assessment and personal growth from a prior baseline, regardless of where that baseline was. Growth may take the overt form of skill development and resocialization, but it is essentially a spiritual revaluing of oneself, a gradually developed respect for one's own worth as a human being. Often, when people are healing from an episode of mental disorder, their hopeful beliefs about the future are intertwined with their spiritual lives, including praying, reading sacred texts, attending devotional services, and following a spiritual practice.

The belief that one can recover from mental disorder is well established as an important aspect factor affecting outcome. Daniel Fisher, MD, PhD, a former patient, now a psychiatrist who is one of the most vocal advocates of the recovery model, has noted that,

Although it is encouraging that Western medicine is beginning to acknowledge the central role of a positive belief in recovery in the area of physical disorder, it is disturbing that psychiatry does not see the wisdom of such an attitude for mental disorder. Even though the weight of personal testimony and epidemiological studies argues that most people are able to regain a productive role in society and recover from mental disorder, the mental health field in particular persists in a belief that mental disorder is a permanent condition.
Daniel Fisher,MD,PhD Believing you can recover is vital to recovery from mental disorder

People can recover from mental disorder by Daniel Fisher, MD, Ph.D. and Laurie Ahern.

Recovery versus Medical Model
The medical model tends to define recovery in negative terms (e.g., symptoms and complaints that need to be eliminated, disorders that need to be cured or removed).

EXERCISE: Read article
Recovery: Changing From A Medical Model To A Psychosocial Rehabilitation Model (click here) by Mark Raggins, M.D.

Mark Ragins, MD, observed that focusing on recovery does discount the seriousness of the conditions.

For severe mental illness it may seem almost dishonest to talk about recovery. After all, the conditions are likely to persist, in at least some form, indefinitely. How can someone recover from an incurable illness? The way out of this dilemma is by realizing that, whereas the illness is the object of curative treatment efforts, it is the persons themselves who are the objects of recovery efforts.

Drawing on the 12-step approach to recovery from addictions, Dr. Ragins outlines an alternative to the medical model approach.

• 1. Accepting having a chronic, incurable disorder, that is a permanent part of them, without guilt or shame, without fault or blame.
  
  
• 2. Avoiding complications of the condition (e.g. by staying sober).
  
  
• 3. Participating in an ongoing support system both as a recipient and a provider.
  
  
• 4. Changing many aspects of their lives including emotions, interpersonal relationships, and spirituality both to accommodate their disorder and grow through overcoming it.
  

This focus on self-directed treatment is the third distingquishing feature of the recovery model. Treatment professionals act as coaches helping to design a rehabilitation plan which supports the patients' efforts to achieve a series of functional goals. Their relationship often focuses on motivating and focusing the patient's own efforts to help themselves. What is important, particularly during the initial stages of interaction is that professionals afford dignity and respect to those in their care.

EXERCISE: Listen to Webcast
The Recovery Vision: New paradigm, new questions, new answers. (click here)

This webcast from Boston University's Center for Psychiatric Rehabilitation reviews the empirical knowledge underlying the vision of recovery.

Dr. Courtenay Harding, known for her groundbreaking research in the field of recovery, reviews the evidence for recovery and its implications.

Dr. William Anthony, one of the pioneers in the field of recovery-oriented rehabilitation, discusses how recovery research must change the paradigm of the field and the questions we ask.

Ms. Judi Chamberlin, an internationally known psychiatric survivor and advocate of individuals with a mental disorder label, discusses the implications of the emergence of the vision of recovery for the roles of consumers and non-consumers.

Dr. Marianne Farkas, researcher, staff developer, educator and consultant in recovery oriented psychiatric rehabilitation for over 20 years, addresses how the emergence of a new paradigm will pose challenges for the development of mental health and rehabilitation systems.

Example of a Recovery Oriented Clinical Program
New Recovery Center at Boston University is an example of a program that has adopted a recovery model. Their curricular options include such courses as Connectedness: Some Skills for Spiritual Health, Hatha Yoga, and Intro to the Internet. Matriculated students take at least two of these semester-long classes, as well as a Recovery Seminar --a guided exploration of personal recovery that is the center's flagship course.

Recovery has so much to do with quality of life. And that may not necessarily mean going back to work or going back to school. It may mean developing friendships, belonging to a church, having a healthy body and a healthy mind. I think we've gotten so secular in the way we provide services -- focusing on either work or school.


History of the Consumer Movement
There is a growing movement throughout the United States (and the world) of people calling themselves consumers, survivors, or ex-patients--who have been diagnosed with mental disorders and are working together to make change in the mental health system and in society. The consumer movement grew out of the idea that individuals who have experienced similar problems, life situations, or crises can effectively provide support to one another. According Sally Clay, one of the leaders of this movement,

The Consumer/Survivor Communities began 25 years ago with the anti-psychiatry movement. In the 1980's, ex-mental patients began to organize drop-in centers, artistic endeavors, and businesses. Now hundreds of such groups are flourishing throughout the country. Our conferences (many sponsored by NIMH) have been attended by thousands of people. More and more, consumers participate in the rest of the mental health system as members of policy-making boards and agencies.

When it began, there was an initial hostility toward the mental health system, but the consumer movement has evolved into a recovery model that encompasses everyone involved in caring for people with mental disorders.

From around the country, people who had been in treatment for schizophrenia and other forms of serious mental illness began coming out of the shadows and identifying ourselves. We were no longer willing to remain hiding, quietly suffering the ridicule and hostility that too often characterize people's reactions to serious mental illness. Slowly, we began to organize, forming local, state, and then national organizations for recovering persons and our allies. We advocated, trying to regain our rights as human beings. For the most part, the more articulate consumer-advocates felt that professionals, who so readily dismissed our point-of-view when we had been patients, were not to be trusted. Many of us felt we could make it "on our own." And why not? All of us had been diagnosed with having serious mental illnesses...About twelve years ago, however, some consumer-advocates began to suggest that many of us, particularly those who were most disabled, could not so easily make it "on our own."We suggested that most of us did indeed need other people: family members, friends, and often the help of experienced mental health professionals.
Frederick J. Frese

The importance of the consumer movement has been recognized and documented by mainstream mental health, such as in the Surgeon General's Report.

A history by the consumer organization--National Empowerment Center

Case Example and Advocate
Frederick Frese,PhD is a vocal example of the recovery model. Thirty years ago, he was locked up in an Ohio psychiatric hospital, dazed and delusional, with paranoid schizophrenia.

In March of 1966, I was a young Marine Corps security officer. I was responsible for guarding atomic weapons at a large Naval Air base and had just been selected for promotion to the rank of Captain. One day, during a particularly stressful period, I made a "discovery" that certain high-ranking American officials had been hypnotized by our Communist enemies and were attempting to compromise this country's nuclear capabilities. Shortly after deciding to reveal my discovery, I found myself locked away in the seclusion room of the base's psychiatric ward, diagnosed with schizophrenia. This was the beginning of my official life as a person with serious mental illness. After about six months I was released from the psychiatric ward at the U.S. Naval Hospital at Bethesda, Maryland, and from the Marine Corps. During the following ten years I was repeatedly re-hospitalized and released from a variety of psychiatric facilities around the country. Most of these hospitalizations were involuntary.

Twelve years later, he had become the chief psychologist for the very mental hospital system that had confined him. Along the way, despite 10 other hospitalizations, he married, had four children and earned a master's degree and doctorate. He is currently an active consumer advocate for the recovery model.

The full story of Frederick J. Frese, PhD

Stigma
The stigmatizing of people with mental disorders has persisted throughout history. It is manifested by bias, distrust, stereotyping, fear, embarrassment, anger, and/or avoidance. Stigma leads others to avoid living, socializing or working with, renting to, or employing people with mental disorders, especially severe disorders such as schizophrenia. It reduces a person's access to resources and opportunities (e.g., housing, jobs) and leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking, and wanting to pay for, care. In its most overt and egregious form, stigma results in outright discrimination and abuse. More tragically, it deprives people of their dignity and interferes with their full participation in society.

National Stigma Clearinghouse
This Clearinghouse tracks stigmatizing stereotypes of mental illness in the media and provides information about stigma to concerned activists. It focuses on inaccurate images of mental illness in news, advertising, and entertainment media but also include articles and news on stigma.

The Roots of Stigma
The Surgeon General's Report on Mental Health includes a section on stigmatization of people with mental disorder.

Online Support Resources
Mutual support is another foundation of the mental health consumer movement. Throughout the the world, consumers are creating self-help groups (also called support groups, peer-run services, consumer-run services, and alternative services).

National Mental Health Consumers' Self-help Clearinghouse
This consumer-run national center serves the mental health consumer movement. They help connect individuals to self-help and advocacy resources, and offer expertise to self-help groups and other peer-run services for mental health consumers. Self-help groups have proven to be effective on a number of levels:

• The act of joining together with others who have walked in your shoes enables individuals to recognize that they are not alone.
  
  
• Individuals in the mental health system often do not have the support of family and friends. Self-help groups can provide the support that may be missing from these other systems.
  
  
• Self-help groups offer a safe place for self-disclosure.
  
  
• Self-help groups encourage personal responsibility and control over one's own treatment. Because group members are actively helping others, they gain a sense of their own competence.
  
  
• In contrast to the professional/client relationship, members of self-help groups are equals.

The Clearinghouse has developed the Freedom Self-Advocacy Curriculum, a complete set of free online training materials for teaching consumers how to advocate for themselves.


Definitions of Spirituality and Religion
The Thesaurus of Psychological Index Terms , which is used to classify articles and books in the construction the PsycINFO database, defines spirituality as the

Degree of involvement or state of awareness or devotion to a higher being or life philosophy. Not always related to conventional religious beliefs. (p. 208)

It defines religiosity as the

Degree of one's religious involvement, devotion to religious beliefs, or adherence to religious observances...term is associated with religious organizations and religious personnel. (p. 184)

Thus a religion is a dogma, a set of beliefs about the spiritual and a set of practices which arise out of those beliefs. Spirituality is that realm of human experience which religion attempts to connect us to. Sometimes it succeeds and sometimes it fails. While spiritual is not a synonym for religious, a person who has internalized the beliefs and practices of a religion generally would be considered spiritual.

However, one can be "religious" without being "spiritual"--many members of religious institutions perform the necessary rituals and accept the creed (at least superficially), but their ethics, morals, and opportunities for day-to-day practice of their religion do not match their professed beliefs. (p.6)
Krippner, S. and Welch, P. (1993). Spiritual Dimensions of Healing. New York: Irvington.

Jerome Stack, a Catholic priest who has worked at Metropolitan State Psychiatric Hospital in California for 25 years concurs that Spirituality is Not the Same as Religion

Everyone has a spirituality, is that each of us must answer basic questions like 'Who am I?" or "What is the meaning of my existence?" or "Why am I suffering?" We are all spiritual, even if we don't belong to a faith group or have a spiritual practice. Spirituality is characterized by a freely undertaken, mature commitment to religious beliefs and practices...On the other hand, people can be "religious" without allowing the many resources of their religious tradition to touch their spirits in a significant way.

Theoretical Background
Spirituality plays a major role in the recovery movement, as we shall explore in lessons 4-7. However, the mental health field has a heritage of 100 years of ignoring and pathologizing spiritual experiences and religion. Freud promoted this view in several of his works, such as in Future of an Illusion wherein he pathologized religion as:

A system of wishful illusions together with a disavowal of reality, such as we find nowhere else...but in a state of blissful hallucinatory confusion.

Albert Ellis,PhD is the creator of Rational Emotive Therapy, the forerunner of cognitive modification approaches now widely used in cognitive-behavioral therapies. In a recent interview, Ellis stated:

"Spirit and soul is horseshit of the worst sort. Obviously there are no fairies, no Santa Clauses, no spirits. What there is, is human goals and purposes...But a lot of transcendentalists are utter screwballs."

From a recovery perspective that views spiritual awakening as central to the healing process, this could be called "Stinking Thinking!"

BF Skinner,PhD, the psychologist who pioneered understanding of behavior modification principles that are the other half of cognitive-behavioral therapies, did not publish a single word on the topic of spirituality. He approached humans as stimulus response boxes with varying behaviors that depend on environmental contingencies. Skinner's psychology gave no attention to inner experience, which does leave out a lot of what makes people human beings. However, Skinner's implicit views on religion can be gleaned from the novel he wrote about a Utopian community, Walden Two.

In this novel, one member describes religion as:

"an explanatory fiction, of a miracle-working mind...superstitious behavior perpetuated by an intermittent reinforcement schedule"

New Diagnostic Category: Religious or Spiritual Problem
As noted above, the mental health system has become much more open to recognizing the importance of spirituality in mental health and in recovery from mental disorders. One major step was the acceptance a new diagnostic category for Religious or Spiritual Problems into the Diagnostic and Statistical Manual-IV in 1994.

This category can be used when the focus of clinical attention is a religious or spiritual problem. Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of other spiritual values which may not necessarily be related to an organized church or religious institution. (p. 685)

The adoption of this new category as a nonpathological category (it is listed as a problem along with Bereavement) has also led to increased inclusion of religious and spiritual issues into the curriculum of psychiatry, nursing and mental health training in other disciplines.
History of the DSM-IV category Religious or Spiritual Problem (V62.89)

In some talks I have given, I have used this ancient Scandinavian fairytale as an allegory of how the mental health field and spirituality need to "get married" and get to know each other better:

A kingdom was falling into ruin, and an oracle was consulted who determined that the kingdom could only be saved if the beautiful princess marries a dragon. The reluctant princess is advised by a wise woman to wear 10 layers of wedding dresses and when they are alone on their wedding night to ask the dragon to shed a layer of his skin each time she sheds a dress. When in fact he does so ten times, the dragon stands revealed as a prince, and the couple and kingdom live happily ever after.

Some would say that mental health and spirituality are already married but need couples counseling to help them get along better! The development of this course, originating in presentations to consumers and staff at the San Francisco, Sonoma, and Contra Costa County Departments of Mental Health, is also an example of the increased receptivity and sensitivity to spirituality within mental health.


Mental Disorder as a Spiritual Journey

"Your life is a sacred journey. And it is about change, growth, discovery, movement, transformation, continuously expanding your vision of what is possible, stretching your soul, learning to see clearly and deeply, listening to your intuition, taking courageous challenges at every step along the way. You are on the path... exactly where you are meant to be right now."

Caroline Adams

Recovery from a mental disorder is experienced by many people as part of their spiritual journey. This was eloquently expressed by consumer advocate and Program Director of the Mental Health Division of Contra Costa County Jay Mahler. During a conversation with Dan Weisburd, editor of the CAMI Journal, Jay mentioned that he viewed his disorder as a spiritual journey. When Dan questioned how a devastating mental disorder could be a spiritual journey, Jay responded:

Regardless of what anyone else chooses to call it, that's what it's been for me. The whole medical vocabulary puts us in the role of a 'labeled' diagnosed victim. We are the ones whom they must skillfully attempt to fix, according to them. But as they go through trial and error, looking to see if anything they have to offer works at all to control your symptoms, it doesn't take a genius to realize they haven't got the answers. No clue about cures! And oh boy, those side effects! I don't say medications can't help, or that treatments won't have value.

But, what I do say is that my being aware that I'm on a spiritual journey empowers me to deal with the big, human 'spiritual' questions, like: "Dan! Why is this happening to me? Will I ever be the same again? Is there a place for me in this world? Can my experience of life be made livable? If I can't be cured can I be recovering. . . even somewhat? Has my God abandoned me?" Bottom line is, as victim of whatever it is, we who have it have to wonder whether what remains constitutes a life worth living. That's my spiritual journey, Dan, that wondering. That's my search. That's something I must do.

Case Examples
Sally Clay describes how her mental disorder was healed by her involvement with religious practices.

As another example, I will also use my own experience of a spiritual journey in recovery. Joseph Campbell once said if there was a sign in a hallway that said:
Lecture on God turn right. Meet God turn left
most people would go to the lecture. I was one of those who not only turned left to meet God but became God--or at least Buddha and Christ. This happened in 1971 when at the age of 23, I spent two months firmly convinced that I was a reincarnation of both Buddha and Christ. I spent many sleepless nights while holding conversations with the "spirits" of eminent thinkers in the social sciences and humanities. I had discussions with contemporary persons including R. D. Laing, Margaret Mead, and Bob Dylan, as well as individuals no longer living, such as Rousseau, Freud, and Jung. I also conversed with my past reincarnations as Buddha and Christ. Based on the wisdom they imparted to me, I compiled a collection of their teachings into a "Holy Book" that would unite all the peoples of the world. I began this sacred endeavor by making photocopies of the book and giving them to my family and friends.

For those two months, my episode met the diagnostic criteria for Acute Schizophrenic Reaction in the Diagnostic and Statistical Manual-II. In the current DSM-IV, that experience could be diagnosed as a Hallucinogen Induced Delusional Disorder or a Brief Psychotic Disorder. As has happened to others (Lukoff and Everest, 1985), I might have been diagnosed with some other psychotic disorder if I hadn't been supported by friends while going throught that episode. In 1974 in San Francisco, John Perry, MD, founded Diabysis treatment center that still serves as a model therapeutic environment for such crises. Diabysis created a homelike atmosphere where diagnostic labels were not used. Staff members were selected for their ability to be comfortable with the intensive inner processes of persons in psychotic states. In this healing environment, patients in such vulnerable states were able to follow their psyches while being protected from harm. Most episodes treated at Diabysis lasted 6-8 weeks.

I was fortunate during this period to be supported by friends who took me in for weeks at a time. They provided sanctuary for me and helped me to get grounded again in the everyday social world and consensual reality. Without their help, I might have been confined in a psychiatric hospital, diagnosed with a lifelong psychotic disorder, and "treated" with medication. Being supported by caring friends is one of the many experiences in my life for which I am deeply grateful.

However, for a long time after my delusional episode, I kept silent. No one had responded to me about my gift of the "Holy Book." I was intensely embarrassed about having believed myself to be such grandiose figures and distributing that book. For years I talked with absolutely no one about my experience--not my wife, my parents, nor even my therapist. Yet, like Jay Mahler, I also consider my psychotic episode to be the beginning of my spiritual journey.

Six years after this episode, I entered Jungian analysis and had a dream in which a large red book appeared. My analyst asked for my associations to the book. Memories of my "Holy Book" leaped into my consciousness. I had not discussed my episode with anyone in seven years, and my heart raced at the prospect of sharing my story with someone in my own profession. Recognizing therapy as a sacred place where one can safely tell secrets, I blurted out the details--about believing myself to be a reincarnation of Buddha and Christ whose mission was to save the world by writing the new "Bible." To show that I was now a sane member of the psychology profession, I described these as "grandiose delusions" and "visual hallucinations." At the end of my description, she said,

"Well, I don't think that's craziness. Sounds like something important was happening to you on a deep level."

She invited me to bring the book to the next session, and I got to tell my story for the first time.

At the time I assumed the identities of Buddha and Christ, I had very little knowledge about Buddhism or Christianity. In overcoming my own reluctance to discuss it, I discovered that the valid spiritual dimensions of my experience could be salvaged through psychotherapy. Jungian analyst John Perry, MD noted that,

"What remains...is an ideal model and a sense of direction which one can use to complete the transformation through his own purposeful methods."
Visionary Experience and Psychosis

I now view my own experience of having "been" Buddha and Christ as opening me to ideal models for my spiritual life. As James Hillman (1986) points out, "Recovery means recovering the divine from within the disorder, seeing that its contents are authentically religious (p. 10). I began my own process of "recovering the divine." I explored Buddhism, Christianity, and other forms of spirituality as I integrated this episode into my spiritual journey (see Lukoff, 1990 for a fuller account).

During the past 25 years in my clinical practice as a psychologist at UCLA-NPI, Camarillo State Hospital, and the San Francisco VA, I have often found myself face-to-face with individuals who have had delusions similar to mine. I believe that my ability to work effectively with those individuals has been aided by being given a rare opportunity to journey through the complete cycle and phenomenology of a naturally-resolving psychotic episode. Thus, beyond serving as a spiritual awakening, my journey held within it the archetypal gift of the Wounded Healer, providng me with the ability to connect more deeply with persons recovering from episodes of mental disorders.

Based on what I learned from my own psychotic episode, and through my work with other individuals who had similar episodes, integrating such experiences into a personal spiritual journey. It involves three phases:

• Phase 1: Telling one's Story
           
  
• Phase 2: Tracing its Symbolic/Spiritual Heritage
           
  
• Phase 3: Creating a New Personal Mythology

Telling One's Story
This is one of the key steps in integrating an episode of mental disorder into a spiritual journey. I have published several case studies and found that people in recovery from mental disorders are not asked to recount or reflect on their experiences. Yet based on my case studies and contact with people in recovery, telling one's story is the important first step in the three stages of integrating a mental disorder. It often helps to talk about and write out a full account of all one has experienced. I did this with patients at Camarillo State Hospital, UCLA, and the San Francisco VA, and found that even constructing a simple time line marked with ages and key events serves a therapeutic ordering function. Then the work of phases 2 and 3 can move toward integrating the experience.

Tracing its Symbolic/Spiritual Heritage
At least of half of people with diagnoses of disorders such as bipolar and schizophrenia have religious delusions and hallucinations. In the medical model, further exploration of such experiences would be unnecessary and could even exacerbate symptoms by reinforcing his/her "delusional system."

At the age of 23, I spent 2 months firmly convinced that I was a reincarnation of Buddha and Christ and was on a mission to write a new "Holy Book" that would unite all the peoples of the world. And I had been raised as a Jew! Jungian analyst John Beebe (1982) has noted that,

Minimally, the experience of psychotic illness is a call to the Symbolic Quest. Psychotic illness introduces the individual to themes, conflicts, and resolutions that may be pursued through the entire religious, spiritual, philosophical and artistic history of humanity. This is perhaps enough for an event to achieve. (p. 252)

After 7 years, when I did begin to reflect on my experiences, I approached them as symbolic experiences, I first asked: who were Buddha and Christ? I really had little knowledge of Christianity or Buddhism at the time I assumed their identity. Like others whom I have talked with who developed the grandiose delusion that they were god or the messiah, these stereotypical delusions of grandeur, inflation, and possibly inappropriate behavior were embarrassing to me later. Yet the treatment literature documents that there is much therapeutic value in addressing a person's religious delusions [6]. The valid religious/spiritual dimensions of the experience can be salvaged through psychotherapy. James Hillman (1986) maintains that,

Recovery means recovering the divine from within the disorder, seeing that its contents are authentically religious (p. 10).
Once I was back with both feet on the ground, these experiences gave me great cause to explore Christianity, Buddhism, and other forms of spirituality. In retrospect, I consider this period to be my spiritual awakening. In Seduction of Madness, Ed Podvoll, MD, observed that,
Many who have come through psychotic episodes describe them as the most fantastic time of their lives.

Much of my work in Jungian analysis consisted of learning how to explore the meaning of my personal symbols as they appeared in dreams and in my own episode. This search for meaning by exploring parallels in traditional myths and religious texts has also played a role in the integration of many of the ex-patients whom I have written about.

Myths in Mental Illness Case

Creating a New Personal Mythology
Stanley Krippner, PhD, co-author of The Mythic Path : Discovering the Guiding Stories of Your Past Creating-A Vision for Your Future defines a personal mythology as

"an individual's system of complementary and contradictory personal myths which shape our expectations, and guide our decisions."

Each of us has a personal mythology--beliefs about life that make up our view of the world, shape our expectations, and guide our decisions.

Personal myths address life's most important concerns and questions, including:

• 1. Identity (Who am I? Why am I here?)
  
  
• 2. Direction (Where am I going? How do I get there?)
  
  
• 3. Purpose (What am I doing here? Why am I going there? What does it all mean?)
  

Weaving a mental disorder into a life-affirming personal mythology is essential for recovery. Unfortunately, many beliefs that people develop around an episode of mental disorder are dysfunctional myths that emphasize pathological qualities. Since these are not attuned to the person's actual needs, capacities, or circumstances, such myths do not serves as constructive guides during recovery.

Experiences of nonconsensual reality, such as dreams and parapsychological events, as well as the non-ordinary experiences from mental disorders can play a significant role in shaping positive personal mythologies. All of these involve transcendence of ordinary life concerns and an experience with a "higher" or "deeper" reality. Awareness of being on a spiritual journey often becomes the foundation for a new personal mythology that is growth-enhancing and spiritually supportive.

My personal mythology evolved after discovering the works of Joseph Campbell a few years after my episode. Campbell identified three stages in the Hero’s Journey. First the Call, then Initiation, and finally the Return stage, which

"requires that the Hero shall now begin the labor of bringing the runes of wisdom, the Golden Fleece, or his sleeping princess, back into the kingdom of humanity, where the boon may redound to the renewing of the community, the nation, the planet, or the ten thousand words." (Campbell, 1949, p.193)
During psychosis, the mind is driven to reveal its deepest, most intimate workings, images, and structures. Whereas the myths are metaphors for journeys into the psyche, psychosis is a journey into the psyche. Stories of successful inner voyages of persons in recovery are boons that communicate the workings of the psyche at the most direct level. This is why madness is such an important theme in the arts. We have much to learn from such accounts. I have published several case studies illustrating the powerful dimensions for both the person on the inner journey and the reader.

My personal boon has involved publications and presentations targeted to increasing the awareness of mental health professionals about the important role of spirituality in recovery and in mental health in general. This work contributed to the addition of a new category to the DSM-IV entitled Religious or Spiritual Problem (V62.89) which I co-authored with Francis Lu, MD, and Robert Turner, MD.

Some clinicians have expressed the concern that having patients discuss their delusional experiences could exacerbate their symptoms by reinforcing them. I was involved in a study of a holistic health program conducted at state psychiatric hospital in which participants were encouraged to actively explore their psychotic symptoms. They participated in in groups such as "Schizophrenia and Growth" which encouraged them to compare their experiences to those of mystics, Native Amerian vision quests. and shamanic initiatory crises. Telling their stories did not result in exacerbation of symptoms (Lukoff et al., 1986).


Case Studies
Jerome Stack, a Catholic Chaplain at Metropolitan State Hospital in Norwalk, California for 25 years, observed that many people with mental disorders do have genuine religious experiences:

"Many patients over the years have spoken to me of their religious experience and I have found their stories to be quite genuine, quite believable. Their experience of the divine, the spiritual, is healthy and life giving. Of course, discernment is important, but it is important not to presume that certain kinds of religious experience or behavior are simply "part of the illness."

During manic episodes in particular, people have experiences similar to those of the great mystics.

"There is a general agreement among those who have experienced it, that religious truths are realized, the religious truths, the ones of the desert fathers and the great mystics." (p. 118)
Ed Podvoll,MD The Seduction of Madness: Revolutionary Insights into the World of Psychosis and a Compassionate Approach to Recovery at Home

One woman who had been hospitalized for a manic episode told me:

"Since being discharged my appreciation of music, poetry and the Spanish mystics has been enhanced and I have gained insight into the need of others, which has made the whole experience worthwhile."

Anton Boisen who was hospitalized for a psychotic episode and then became a minister and the founder of pastoral counseling, maintained that,
Many of the more serious psychoses are essentially problem solving experiences which are closely related to certain types of religious experiences.( p. 154)

Exploration of the Inner World : a Study of Mental Disorder and Religious Experience
Sally Clay, an advocate and consultant for the Portland Coalition for the Psychiatrically Labeled, has written about the important role that religious experiences played in her recovery following two years of hospitalization while diagnosed with schizophrenia at the Yale-affiliated Hartford Institute of Living (IOL). While hospitalized, she had a powerful religious experience which led her to attend religious services.

My recovery had nothing to do with the talk therapy, the drugs, or the electroshock treatments I had received; more likely, it happened in spite of these things. My recovery did have something to do with the devotional services I had been attending. At the IOL I attended both Protestant and Catholic services, and if Jewish or Buddhist services had been available, I would have gone to them, too. I was cured - instantly healed if you will, as a direct result of a spiritual experience.

Many years later Clay went back to the IOL to review her case records, and found herself described as having "decompensated with grandiose delusions with spiritual preoccupations." She complains that "not a single aspect of my spiritual experience at the IOL was recognized as legitimate; neither the spiritual difficulties nor the healing that occurred at the end."

Clay is not denying that she had a psychotic disorder at the time, but makes the case that, in addition to the disabling effects she experienced as part of her illness, there was also a profound spiritual component which was ignored. She describes how the lack of sensitivity to the spiritual dimensions of her experience on the part of mental health and religious professionals was detrimental to her recovery. Nevertheless she has persevered in her belief that,

"For me, becoming "mentally ill" was always a spiritual crisis, and finding a spiritual model of recovery was a question of life or death. Finally I could admit openly that my experiences were, and always had been, a spiritual journey -- not sick, shameful, or evil."
The Wounded Prophet, by Sally Clay

Thus experiences with religious/spiritual content can be explored, particularly to find direction for spiritual support. They can also play an important role in helping to redefine a person's personal mythology as noted in Lesson 4.


Spiritual Support Overview
Spiritual support involves the degree to which a person experiences a connection to a higher power (i.e., God or other transcendent force) that is actively supporting, protecting, guiding, teaching, helping, and healing. For many people, having a relationship with a higher power is the foundation of their psychological well-being. Some researchers have suggested that the subjective experience of spiritual support may form the core of the spirituality-health connection (Mackenzie et al., 2000). The recent landmark publication Handbook of Religion and Health reviewed 1600 studies, including hundreds on mental health. One chapter,"Schizophrenia and Other Psychoses," summarizes research which indicates that persons with mental disorders utilize their spiritual resources to improve functioning, reduce isolation, and facilitate healing.

The mental health professions have a long history of ignoring and pathologizing religion (Lukoff et al., 1992). For instance, Albert Ellis asserts, "The less religious [patients] are, the more emotionally healthy they will tend to be" (Ellis, 1980, p. 637). But the data show otherwise: religion is overwhelmingly associated with positive mental health.

Because individuals seek meaning when experiencing severe illnesses, and spirituality is an important coping mechanism, promoting religious and spiritual beliefs and practices is highly appropriate. Mental health professionals can provide spiritual support to people coping with mental disorders. By devoting some therapy time to exploring spiritual issues and asking questions to discover a deeper meaning in life, they can help to create the spirituality-health connection.

Spiritual support can include:

• Educating the client about recovery as a spiritual journey with a potentially positive outcome.
  
  
• Encouraging the client's involvement with a spiritual path or religious community that is consistent with their experiences and values.
  
  
• Encouraging the client to seek support and guidance from credible and appropriate religious or spiritual leaders.
  
  
• Encouraging the client to engage in religious and spiritual practices consistent with their beliefs (e.g., prayer, meditation, reading spiritual books, acts of worship, ritual, forgiveness and service). At times, this might include engaging in a practice together with the client such as meditation, silence, prayer, or singing.
  
  
• Modeling one's own spirituality (when appropriate), including a sense of spiritual purpose and meaning, along with hope and faith in something transcendent.

Mental health programs can, through their structures and culture, create environments that promote this spiritual work. New Recovery Center at Boston University is an example of a program that has adopted a recovery model incorporating a spiritual component. Curricular options include such courses as Connectedness: Some Skills for Spiritual Health, Hatha Yoga, and a Recovery Seminar. This guided exploration of personal recovery is the center's flagship course.

Work is only part of a person's life," says Hutchinson, SAR adjunct assistant professor and director of services for rehabilitation counseling. "Recovery has so much to do with quality of life. And that may not necessarily mean going back to work or going back to school. It may mean developing friendships, belonging to a church, having a healthy body and a healthy mind.

People recovering from mental disorders have rich opportunities for spiritual growth, along with challenges to its expression and development. They will find much needed support for the task when they are clinically guided to explore their spiritual lives. Thus directed, they can begin to create a positive health-promoting outcome for their spiritual journey in recovery.

Psychiatrically Hospitalized Patients
Studies have found that hospitalized psychiatric patients are as religious as the general population and they turn more to religion during such crises. In The religious needs and resources of psychiatric inpatients the authors found that 88% of the psychiatric patients reported three or more current religious needs. Psychiatric patients had lower spiritual well-being scores and were less likely to have talked with their clergy. They concluded that religion is important for the psychiatric patients, but they may need assistance to find resources to address their religious needs.

Another form of spiritual support is to address dysfunctional beliefs about their disorder that many patients hold. One study of 52 psychiatric inpatients found that 23% believed that sin-related factors, such as sinful thoughts or acts, are related to the development of their illness.
Sheehan W, Kroll J Psychiatric patients' belief in general health factors and sin as causes of illness. Am J Psychiatry 1990 Jan;147(1):112-3

This is clearly a guilt-inducing belief for which there is no evidence, and the vast majority of religious professionals would challenge. When I was a psychologist at Camarillo State Hospital, I collaborated with a rabbi who led groups for patients, and this was one of the beliefs he regularly encountered. He made a point of disputing such assertions when they were voiced, using both old and new testament citations.

But in general, intensity of religious beliefs is not associated with psychopathology. Patients who have little or no religious commitment are just as likely to have depression, anxiety or other personality disorders as patients with higher levels of religious commitment. In several studies, being highly religious is not a risk factor for psychopathology, as has been often taught in mental health training programs. The authors of one study concluded:

The notion that religion exerts a negative influence on mental health in patients was not generally supported by our findings. The primary factor in patients who display religious conflicts and anxieties seems not to be the degree of religious commitment itself, but rather their underlying psychological disease.
Psychopathology and religious commitment--a controlled study. Pfeifer S. Waelty, U Psychopathology 1995;28(2):70-7

Spiritual Assessment Defined
Spiritual assessment is the process by which health care providers can identify a patient's spiritual needs pertaining to their mental health care. The determination of spiritual needs and resources, evaluation of the impact of beliefs on healthcare outcomes and decisions, and discovery of barriers to using spiritual resources are all outcomes of a thorough spiritual assessment. At St. Elizabeth's Hospital in Washington, D.C., the Chaplain Program, headed by Clark Aist, conducts a "Spiritual Needs Assessment" on each inpatient, concluding with a treatment plan that identifies religious/ spiritual needs and problems, role of pastoral intervention, and religious/spiritual activities recommended.

When I started the year-long human sexuality training program at the UCLA Neuropsychiatric Institute, we were given the assignment to pair up and interview each other about our sexual histories--our first sexual memories, wet dreams, masturbation, petting, intercourse, sexual problems etc. After all, if we were going to ask our patients about their sexual experiences and problems, we needed to be comfortable listening to and talking openly about sexuality. Although we were all licensed mental health professionals, we had not been trained to talk with patients about their sexual functioning or problems, and this exercise was a great way to desensitize us (as in "systematic desensitization") to the topic of sexuality.

I have found the same approach to be helpful with the topic of spirituality, and have developed the following interview as a desensitization exercise for training mental health professionals to conduct assessments of spirituality. I have used it at numerous workshops and conference, and in my experience, most mental heath professionals have an untapped reservoir of spiritual depth that they have not had permission to bring it into their clinical practices. I have also used this assessment with patients in both the dual diagnosis and chronic pain groups I have led at the San Francisco VA.

The interview below was developed after consulting many assessment instruments published in books and articles, and disseminated at conference presentations. It can usually be completed in 10 minutes.

Spiritual Assessment Interview
A. RELIGIOUS BACKGROUND AND BELIEFS

1. What religion did your family practice when you were growing up?
   
   
2. How religious were your parents?
   
   
3. Do you practice a religion currently?
   
   
4. Do you believe in God or a higher power?
   
   
5. What have been important experiences and thoughts about God/Higher Power?
   
   
6. How would you describe God/Higher Power? Personal or impersonal? Loving or stern?

B. SPIRITUAL MEANING AND VALUES

1. Do you follow any spiritual path or practice (e.g., meditation, yoga, chanting)?
   
   
2. What significant spiritual experiences have you had (e.g., mystical experience, near-death experience, 12-step spirituality, drug-induced, dreams)?

C. PRAYER EXPERIENCES

1. Do you pray? When? In what way(s)?10 minutes
   
   
2. How has prayer worked in your life?
   
   
3. Have your prayers been answered?

FICA
Another approach to spiritual assessment uses the acronym FICA.

F: FAITH AND BELIEFS

1. What are your spiritual or religious beliefs?
   
   
2. Do you consider yourself spiritual or religious?
   
   
3. What things do you believe in that give meaning to your life?
   

I: IMPORTANCE AND INFLUENCE

1. Is it important in your life?
   
   
2. How does it affect how you view your problems?
   
   
3. How have your religion/spirituality influenced your behavior and mood during this illness?
   
   
4. What role might your religion/spirituality play in resolving your problems?
   

C: COMMUNITY

1. Are you part of a spiritual or religious community?
   
   
2. Is this supportive to you and how?
   
   
3. Is there a person or group of people you really love or who are really important to you?
   

A: ADDRESS

1. How would you like me to address these issues in your treatment?

FICA is described in more detail at the Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians web site.

HOPE Assessment
Yet another approach to spiritual assessment is entitled HOPE, where

• H--sources of hope, strength, comfort, meaning, peace, love and connection
  
  
• O--the role of organized religion for the patient
  
  
• P--personal spirituality and practices
  
  
• E--effects on medical care and end-of-life decisions
  

Questions used in this approach are on included in this article:

Spirituality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual Assessment GOWRI ANANDARAJAH, M.D., and ELLEN HIGHT, M.D., M.P.H American Family Physician

EXERCISE: Take 10 minutes and answer the questions for the FICA or the Religious and Spiritual History.


Resources on Spiritual Crises and Psychosis
Below are some interviews with experts on spiritual emergencies, as transpersonal psychology has been calling them for 20 years, that provide clinical perspectives on the growthful potential of such crises.

Visionary Experience or Psychosis?
John Perry, MD worked extensively with individuals in the midst of acute psychotic episodes at Diabysis, the residential treatment center he founded. This link presents a Jungian growth model for acute psychotic episodes.

Spiritual Crisis
Christina Grof, author of books on spiritual emergency and co-founder of the Spiritual Emergency Network, describes her own transformative spiritual crisis.

Spiritual Emergency Resource Center
A guide for clinicians and a self-help resource for people integrating a spiritual crisis. Several personal experiences are online, and people can post theirs in an online discussion forum.

Sacred Transformations
Personal stories of spiritual emergencies, visions, awakenings, and their effects.

The Spiritual Emergence Network (SEN@CIIS)
The SEN@CIIS Information and Referral Service offers support and resources for individuals experiencing difficulties with their spiritual growth (415-648-2610).

Spiritual Emergence Service
A non-profit Canadian society staffed by volunteers that offers information and referrals for people in psychospiritual crisis.

Religious and Spiritual Issues
Since I found myself identifying with Buddha and Christ, I searched for sites to learn more about who these figures were, their life stories, their messages. During my Jungian analysis, I learned to view Buddha and Christ as ideal models of my own inner self.

tricycle.com:
Buddhist Basics, The Basics of Buddhism.

Frequently asked questions about the life and death of Jesus Christ
The answers are given from a traditional Christian perspective: Who


Shamanism
Both reading about shamanism, particularly shamanic initiatory crises, and participating in neoshamanic groups played a key role in integrating my episode. Below are some of the resources that I found relevant to my own experiences.

The Soul of Shamanism: Western Fantasies, Imaginal Realities
This interview with Daniel C. Noel, PhD, Professor of Religious Studies, explores the meaning and value of neoshamanic experiences, such as I encountered in my work with shamans. Shamanic practices provide a controlled way to access the ecstatic states of consciousness that I had first encountered in my spiritual emergency.

The Way of the Shaman
Interview with Michael Harner, PhD, author of several books, including The Jivaro, Hallucinogens and Shamanism, and The Way of the Shaman. Dr. Harner is a former professor of anthropology and is currently the director of the Center for Shamanic Studies, which teaches Westerners how to live and practice as shamanic healers.

WWW Library on Shamanism

LSD and Religious Experiences
Fundamentally, I view my episode as an intense and disorienting mystical experience that served as my spiritual awakening. It was triggered by taking LSD for the first time. Huston Smith, PhD, Professor Emertus of Philosophy at MIT and author of numerous books on comparative religion, maintains that LSD-related religious experiences occur and are valid.

. . . given the right set and setting, the drugs can induce religious experiences indistinguishable from ones that occur spontaneously. Nor need set and setting be exceptional. The way the statistics are currently running, it looks as if from one-fourth to one-third of the general population will have religious experiences if they take the drugs under naturalistic conditions, meaning by this conditions in which the researcher supports the subject but doesn't try to influence the direction his experience will take. Among subjects who have strong religious inclinations to begin with, the proportion of those having religious experiences jumps to three-quarters. If they take them in settings which are religious, too, the ratio soars to nine out of ten.

Do Drugs Have Religious Import? by Huston Smith, PhD, The Journal of Philosophy, Vol. LXI, No. 18, September 17, 1964

The Psychedelic Library
This site has several articles on psychedelic drugs and religious experience by Alan Watts, Walter Houston Clark, and others.

Yet adverse reactions to psychedelic drugs do occur. A literature review concluded that broadly speaking, there are two types of adverse outcome:

Acute, short-lived reactions are often fairly benign, whereas chronic, unremitting courses carry a poor prognosis. Delayed, intermittent phenomena ("flashbacks") and LSD-precipitated functional disorders that usually respond to treatment appropriate for the non-psychedelic-precipitated illnesses they resemble, round out this temporal means of classification.
— Strassman RJ. Adverse reactions to psychedelic drugs. A review of the literature. J Nerv Ment Dis 1984 Oct;172(10):577-95.

A Critical Review of Theories and Research Concerning Lysergic Acid Diethylamide (LSD) and Mental Health, Chapter 2: Psychosis
By David Abrahart. LSD has also been linked to triggering psychotic episodes which don't always have a positive outcome, as this MA thesis shows in summaries of studies on this issue.

Self-Help Resources
Early Psychosis - A Care Guide
This material has been developed to provide information about preventive intervention in early psychosis - a relatively new area to many of those involved in the care and management of people with psychotic disorders. The pack consists of a series of ten modules covering all aspects of preventive intervention in early psychosis, from recognition of incipient psychosis to psychosocial and medical interventions and ongoing management.

Thrivenet
Resource for learning about resilience, thriving, and how to gain strength from adversity. Includes article form psychologist Al Siebert, PhD, and stories of survivors.

National Mental Health Consumers' Self-Help Clearinghouse
A consumer-run national center serving the mental health consumer movement.

Recovery, Inc.
Recovery Inc. is a mental health self-help program based on the work of Abraham A. Low, MD. They are nonprofit, nonsectarian and completely member managed. Recovery, Inc. has been active since 1937 and has groups meeting every week around the world.

Schizophrenia.com
A not-for profit information, support, and education center for people diagnosed with schizophrenia,parents, spouses, offspring. Contains information on Causes, Diagnosis, Medications, Success Stories, Support Groups.

It's About Time: Discovering, Recovering and Celebrating Consumer/Survivor History

Support Coalition International
A consumer group focused on human rights in the mental health system, and publisher of Mind Freedom, a magazine devoted to this issue.

Coping with Schizophrenia
Frederick J. Frese,PhD describes Twelve Aspects Of Coping For Persons With Schizophrenia, including denial, delusional thinking, medications, social deficits, consumer groups and self-help.

Recovery Model in Mental Health
People can recover from mental illness Daniel Fisher, M.D., Ph.D. and Laurie Ahern

Is Mental Illness A Disease? by Thomas S. Szasz, MD

Peter R. Breggin, MD
has written extensively about the overuse and side effects of psychiatric medications.

New Recovery Center
Article from Boston University web site about a program that offers holistic approach to mental disorders.

Web Casts
FaithNet NAMI
The Broken Covenant
Reverend Jerome Stack, C.P.P.S., Department of Mental Health, Metropolitan State Hospital, Norwalk, CA

Spirituality Is Not The Same As Religion by Jerome Stack

Newsgroups
alt.support.schizophrenia
alt.support.schizophrenia

Religious and Spiritual Resources
FaithNet NAMI

The Broken Covenant
Reverend Jerome Stack, C.P.P.S., Department of Mental Health, Metropolitan State Hospital, Norwalk, CA

SPIRITUALITY IS NOT THE SAME AS RELIGION by Jerome Stack

Spiritual Emergencies Course
A free course on spiritual crises that can present as or overlap with mental disorders

Discussion Lists
Schizoph Send mail to listserv@utcc.utoronto.ca and include in the body of message only the following: sub schizoph yourfirstname yourlastname

Newsgroups
alt.support.schizophrenia
alt.support.schizophrenia

Case Library
Strengthened by Schizophrenia
Michael Allen's story of thriving with schizoprenia

Personal Stories of Coping with Schizophrenia

Ian Chovil's Homepage

Frederick J. Frese, PhD
From patient to head psychologist at a mental hospital

Sally Clay
An advocate and consultant for the Portland Coalition for the Psychiatrically labeled, a group run by and for ex-psychiatric patients, Sally describes the role religion played in her recovery

Joshua Beil's Recovery from Visions

Case from Diabysis

Jaqueline Chapman's Jouney from Patient to Therapist
Chapman, J and Lukoff, D. The Social Safety Net In Recovery From Psychosis: A Therapist's Story, Hospital and Community Psychiatry, 1996

Myths in Mental Illness Case
Case study of an individual who was hospitalized for 2 months while in what he continues to view as a "mental odyssey"
Lukoff, D. and Everest, H. The Myths in Mental Illness. Journal of Transpersonal Psychology,17:123-153, 1985

Reprinted from People Who (Experience Mood Swings Fears Voices and Visions

The Ex-Patients' Movement: Where We've Been and Where We're Going
By Judi Chamberlin, National Empowerment Center.


Appelbaum, D. (1988). The right to refuse treatment with anti psychotic drugs: Retrospect and prospect American Journal of Psychiatry, 145, 413 419.

Doubleday. Chamberlin, J. (1979). On our own: Patient-controlled alternatives to the mental health system. New York; McGraw-IIill.

Chamberlin, J. (1987). The case for separatism.

Ian L Parker and E. Peck (Fds.), Power in strange places (pp. 24- 26). London, England:Good Practices in Mental Health.

Chamberlin, J, Rogers, J.A, and Sneed, C.S. (1989). Consumers, families, and community support systems. Psychosocial Rehabilitation Journal, 12, 93-106.

Dain, N. (1989). Critics and dissenters: Reflections on 'anti-psychiatry' in the United States. Journal of the History of the Behavioral Sciences, 25, 3-25.

National Association of Psychiatric Survivors. (No date). Goals and philosophy statement. Unpublished manuscript.

Reports to the President for the President's Commission on Mental Health. (1978). Volume 1. Washington, D.C.: United States Government Printing Office.

Riese v. St Mary's Hospital, 209 Cat App. 3rd, 1303, 1987. Rivers v. Katz, 67 N.Y, 2nd, 485, 1986.

Szasz, T. (1961). The myth of mental illness. New York: Hoeber-Harper. Szasz, T. (1970). The manufacture of madness. New York: Deli.

Szasz, T. (1989, July). The myth of the rights of mental patients. Liberty, pp. 19-26.

Copyright David Lukoff, Ph.D.

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