Summary of the impact

Professor Christopher Cook's research on the role of spirituality in psychiatric care has had a wide-ranging effect on professional debate, policy and practice amongst psychiatrists in the UK and beyond. His argument that psychiatry should undertake a constructive and nuanced engagement with spirituality, defined broadly, has sparked widespread debate within the profession. His work with an NHS trust since 2008 has produced a set of new clinical service initiatives, and his wider influence led the Royal College of Psychiatrists to commission him to produce its first formal policy statement on spirituality and religion, adopted in 2011.

Underpinning research

Psychiatry in the UK no longer relies on a purely bio-medical model. In addition to recognition over recent decades of the relevance of social and psychological factors, the psychiatric importance of spirituality and religion is now increasingly acknowledged. Cook has played a large part in this change. A growing evidence base suggests that spirituality and religion can affect treatment outcomes for a variety of physical and mental disorders, as well as being important for `whole person' care. However, in the pluralistic and secular context of modern healthcare, `spirituality' is a controversial concept, open to varying definitions. Its place in professional healthcare practice is beset with ethical and practical problems. In particular, questions arise as to how spirituality might be defined in such a plural context, and whether and how such a definition might then be applied in clinical practice. Durham University has one of the few centres in the world to have engaged in serious theological contribution to these debates.

Cook is both a consultant psychiatrist and an Anglican priest, with research doctorates in medicine and theology, and with extensive pastoral and clinical experience. His research focuses on the relationships between spirituality, theology and health. He became a Professorial Research Fellow at St Chad's College, Durham University, in 2003, and since 2005 has been based in the Department of Theology and Religion. In that year he established the Durham Project for Spirituality, Theology and Health, of which he is Director. Its stated aims are: 1. To promote interdisciplinary and collaborative research and teaching in the subject areas of spirituality, theology and health. 2. To contribute to discussion and policy processes both in churches and other religious communities and also within health and social care services. Since its inception, the Project has involved collaboration with the University's School for Medicine and Health, with local NHS trusts and with relevant professional bodies.

Cook's extensive qualitative study of the clinical and research literature on addiction gave rise to an integrative and inclusive definition of `spirituality', which he argues is a more open and universal term than `religion'. In this definition spirituality is

a distinctive, potentially creative and universal dimension of human experience arising both within the inner subjective awareness of individuals and within communities, social groups and traditions. It may be experienced as relationship with that which is intimately `inner', immanent and personal, within the self and others, and/or as relationship with that which is wholly `other', transcendent and beyond the self. It is experienced as being of fundamental or ultimate importance and is thus concerned with matters of meaning and purpose in life, truth and values. (Cook 2004; Cook 2009)

Cook's definition has been cited by a series of other scholars, for example by contributors to M. Galanter and L. A. Kaskutas (eds), Research on Alcoholics Anonymous and Spirituality in Addiction Recovery (New York: Springer, 2008). Further research by Cook has clarified the nature and dynamics of spirituality in relation to addiction and other mental disorders, and to psychiatric treatment:

1. In Alcohol, Addiction and Christian Ethics (Cook 2006) it is demonstrated that a theological model of addiction which is compatible with scientific models illuminates the spiritual nature of the dynamics of addictive disorders. This enables an integrative approach to treatment which incorporates the best of scientific and more purely religious / spiritual approaches (such as Alcoholics Anonymous).
2. Using Cook's definition of `spirituality' as a starting point, Spirituality and Psychiatry (Cook, Sims and Powell 2009) is the first serious evidence-based attempt by a group of British psychiatrists and care professionals to address the place of spirituality in clinical practice in psychiatry. It demonstrates that a better understanding in psychiatric practice of the nature and place of spirituality in human wellbeing fosters a better understanding both of mental disorder, and of mental health service users.
3. `The Faith of the Psychiatrist' (Cook 2011) analyses the extent of current published evidence for the so-called `religiosity gap' between mental health professionals and their patients, a gap which has adverse effects upon the doctor-patient relationship and consequently undermines clinical care. The Royal College of Psychiatrists' policy (see 4.iii below) seeks to address this problem by promoting more sensitive and affirmative clinical enquiry.
4. Spirituality, Theology and Mental Health (Cook 2013) argues that good professional practice properly incorporates spirituality, and indeed cannot realistically exclude it. It further uses the theological concepts of transcendence and immanence to explain both the importance of spirituality in mental health, and also the controversies around the subject.

In numerous conference presentations and publications, Cook has demonstrated the importance of interdisciplinary engagement as a means of understanding the emerging significance of spirituality in healthcare research and practice (eg Cook et al 2011). This work explains some of the current professional controversies concerning the place of spirituality within psychiatry. It also explains why mental health service users tend to affirm spirituality as an aspect of the care that they wish to receive much more unambiguously than the professionals who provide that care. It provides a basis for a more active incorporation of spirituality into clinical assessment and treatment planning.

References to the research

Cook's research has received external funding from the Guild of Health as core support for development of the Project for Spirituality, Theology and Health: £74,257 for 2009-2012, and a further £50,788 for 2012-2015.

Details of the impact

The impact of Cook's work has arisen from his extensive engagement with psychiatric professionals across the UK. He worked part-time as a consultant psychiatrist until 2012 (and remains an honorary consultant), was chair of the Royal College of Psychiatrists' Spirituality Interest Group 2009-13, and is an advisor to the World Psychiatric Association's Section on Religion, Spirituality and Psychiatry. Through (i) his engagement with professional debates and practice on a broad front, he has (ii) shaped local initiatives more systematically, and (iii) directly formed a new national policy framework.

(i) Professional Debate. Since the Durham Project for Spirituality, Theology and Health was established in 2005, Cook has lectured widely on spirituality and psychiatry in the UK and abroad, speaking at well over 50 conferences and similar events. Delegates have typically included healthcare professionals and/or chaplains/clergy, as well as academics from various disciplines. One key event was the 2010 Durham Conference on Spirituality, Theology and Mental Health, which was unique in bringing together theologians with academics and professionals from diverse other disciplines. The resulting edited volume (Cook 2013) was published for an audience of clergy and health professionals. This conference activity has been further consolidated and underpinned by the publications cited in section 3, which are written for professional as well as academic readers and which aim to stimulate professional debate, in part by engaging with issues across traditional disciplinary boundaries — in particular, by introducing psychiatrists to relevant research in theology and the humanities. For example, an `In Debate' article in the British Journal of Psychiatry (Poole and Cook 2011), on whether prayer can be a legitimate part of good clinical practice, provoked a lively correspondence in the journal: ten further contributions were published over a three-month period.[1] These debates have had the beneficial effect of engaging the thinking of the professionals concerned and, therefore, influencing their treatment of their patients and of clients in the mental health services. A leading Irish professor of psychiatry has commented that `Professor Cook's work has contributed greatly to a nuanced understanding of the role of spirituality/religion in people's lives with particular reference to mental illness/health.' [2]

(ii) Clinical Service Initiatives. In 2008, Cook was instrumental, with clinical and chaplaincy colleagues, in establishing a spirituality working group within Tees, Esk and Wear Valleys NHS Foundation Trust. The creation of this group, which includes mental health service users, clinical staff and managers, was largely facilitated by the Durham Project for Spirituality, Theology and Health, and Cook continues to provide input on the research evidence base for policy and good practice. Under Cook's leadership, the group developed its own working definition of spirituality in the clinical setting, and based on that a spirituality care pathway (Cook et al 2012). Cook also contributed to this group's development (with the aid of professional graphic design) of a practical tool to assist patients and carers in the assessment of spiritual needs, which takes the form of a `flower'.[3a] The `flower' has been piloted in selected in-patient services within the Trust: an adult psychiatry ward, a ward for the elderly, and a learning disability service.[3b] It is under consideration by the Clinical Governance Committee for adoption more widely across the Trust as a whole. The spirituality pathway represents a significant and (to our knowledge) unique innovation which has positively influenced staff who had been doubtful about the importance of spirituality in clinical practice. A nurse working with people with learning disabilities (himself a professed atheist) has written that:

[The] guiding principle of aiming to help a person be able to flourish is why I got involved with the spirituality pathway and the work developed by Chris Cook. I consider the development of the spirituality flower a powerful and relevant tool. [3c]

The group's work on this care pathway has been presented at conferences including a 2011 national conference in London, convened by RCN Publications and attended by c. 200 nursing professionals. It provides an example of research-based good practice which both sets professional standards and also provides benefit in terms of improved spiritual care for mental health service users.[4]

(iii) National Policy. In 2004 Cook was invited to join the Executive Committee of the Spirituality and Psychiatry Special Interest Group of the Royal College of Psychiatrists, the body responsible for setting professional standards for psychiatrists in the UK. His standing in the field led to his appointment as that group's chair in 2009. In this role, he drafted a Position Statement, later entitled Recommendations for Psychiatrists on Spirituality and Religion, which was submitted to the Royal College's Policy Committee. Following revisions by Cook in response to the College's peer review process, this document [5] was adopted by the College as its official policy in 2011. As such, it is to `be followed by members' of the College, and provides the benchmark for good practice with regard to spirituality and religion for psychiatry in the UK.

The document explains the need for a statement on spirituality in relation to existing General Medical Council and Royal College policies; sets out the evidential base; and presents the practical issues that arise in relation to matters of spirituality and religion in clinical psychiatric practice. It is organised around Cook's 2004 definition of spirituality (quoted in full on p. 4), and is closely informed by his Spirituality and Psychiatry (Cook, Sims and Powell 2009) and `The Faith of the Psychiatrist' (Cook 2011). It concludes with detailed recommendations both for individual practitioners and also for organisational policy, including

• The need to consider spirituality when taking patients' personal histories
• Respect and sensitivity towards patients, families and carers, and colleagues
• Neither proselytizing mental health users nor undermining their faith
• The need to work with chaplaincies and wider faith communities

For the first time in UK mental health practice, this policy affirms a positive place for addressing spirituality and religion. It provides guidance to protect both professionals and patients from potential abuses in clinical practice, such as proselytising. It also aims to ensure that spiritual aspects of care are not neglected (for example, due to fear of accusations of proselytising) where they might be clinically significant.

The policy also requires that these principles be integrated into psychiatric training and continuing professional development (CPD). Accordingly, the Spirituality and Psychiatry Special Interest Group has submitted formal recommendations to the College's Curriculum Review Working Group [6]. The first CPD event in this field to be organised through the College's own conference centre took place in London in March 2013, with 65 professionals attending. 96.2% of respondents rated Cook's opening plenary as relevant or highly relevant to their needs. Many attendees commented that the conference `boost[ed] my confidence' or made them `more confident about asking about spiritual needs of my patients', encouraging them to be `more proactive in addressing my patient's spiritual needs'. One experienced practitioner declared an intention to `enquire specifically about S/R of patients as a routine part of initial assessments. ... This would change my previous practice.' [7]

Beyond these specific impacts, the new policy has fed back into wider professional discourse. The current president of the Royal College of Psychiatrists comments that the document has given rise to `a rigorous, open, non-biased debate'. In particular she commends the clear guidelines it has brought to `an enormous[ly] important topic', which has in the past repeatedly produced allegations of professional misconduct. `There were lots of rumblings, lots of debates, lots of disagreements.... Instead of talking about it [Cook] got it to the point of being delivered.' [8] A former President of the Royal College welcomed the policy's recommendations as `highly significant for the better practice of psychiatry ... they are already moulding practice.' [9] The debate has now moved on to the World Psychiatric Association, where proposals by Cook and a Dutch colleague for a formal Consensus Statement on this subject are now being actively debated and are the subject of lively controversy. [10]

Sources to corroborate the impact

1. Replies to `Praying with a patient constitutes a breach of professional boundaries', British Journal of Psychiatry, August - October 2011. http://bjp.rcpsych.org/content/199/2/94/reply

2. Letter from the Professor of Psychiatry, University College Dublin, 16 May 2013.

3a. `The Spirituality Flower', Tees, Esk and Wear Valleys NHS Trust.

3b. The Spirituality Flower in use on wards: photographs.

3c. Learning disability nurse in the Tees, Esk and Wear Valley NHS trust, testimonial 2013.

4. Email from the Non-Executive Director of the Tees, Esk and Wear Valleys NHS Trust, 2013.

5. Recommendations for Psychiatrists on Spirituality and Religion, Royal College of Psychiatrists Position Statement PS03/2011. http://rcpsych.ac.uk/pdf/PS03_2011.pdf

6. RCP Spirituality Special Interest Group final curriculum recommendations, September 2012.

7. `Spirituality and Clinical Psychiatry: Training and Practical Issues for Mental Health Practitioners', 1 March 2013, programme and feedback.

8. Interview with the 2011-2014 President of the Royal College of Psychiatrists, 2013.

9. Letter from the Emeritus Professor of Psychiatry, University of Leeds, 21 June 2013.

10. Peter J. Verhagen and Christopher C. H. Cook, `Proposal for a World Psychiatric Association Consensus or Position Statement on Spirituality and Religion in Psychiatry' in Peter J. Verhagen et al. (eds), Religion and Psychiatry: Beyond Boundaries (Wiley, 2009), 615-31. http://onlinelibrary.wiley.com/doi/10.1002/9780470682203.epil/pdf