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An examination of the National Health Service (NHS) in the United Kingdom will illustrate this point. The NHS was launched in 1948. It is a system that assumes that good health care should be available to all people regardless of wealth. Health care is thus free at the point of use for all UK residents and is based on clinical need, not ability to pay.

The system is also designed to meet the needs of everyone; this is necessary for it to function effectively and fairly according to its expressed intentions. However, this universality inevitably problematizes and narrows the possible options for the kind of spirituality that might be acceptable within the system. In terms of spirituality, this ensures that the NHS is inevitably secular, because it cannot be connected directly with any one religion. It deals with a very broad range of people, and as such it must meet the needs of people of “all faiths and none.” The particularity of religious traditions becomes problematic within a context that requires generalities in order to function. A general, generic definition of spirituality may be thin, but it is easy to implement.

Health and social care systems such as the NHS require generalities to function effectively. At a pragmatic level, it makes sense to deprioritize the particularities of religion and to develop a general mode of spirituality to which everyone can relate. Treatments—chemotherapy, medication, physiotherapy, pain control—must be universal and applicable across the whole system. You can’t have an antibiotic that works only for one person! So, too, you can’t have a spirituality that works for only one group of people. A system would not work well if each doctor had his or her own way of doing things that might conflict with how other doctors conducted their practice. So, while there is obviously diversity within the system, the principle of generalization is necessary and established.

Within this context, people may think they are acting counterculturally and taking spirituality into the system. However, a deeper reflection indicates that the system itself shapes and forms the spirituality that is acceptable; it silently places boundaries, parameters, and brakes on the activities of spiritual care and our articulations of spirituality and compels us to work with a thin model of spirituality that dovetails neatly with what is already there.

This model of spirituality seems to resonate with the idea of a universal spirituality that everyone shares, something that abounds in the literature. However, when one runs a critical eye across the ways in which people formulate spirituality, it becomes clear that, far from being universal, it is a very Western cultural model, which assumes the primacy of Western values such as individualism, freedom, autonomy, choice, and the right of people to create their own destiny. This is clearly a cultural model of spirituality rather than a universal one. It may raise our consciousness to certain important but overlooked aspects of health care, but by claiming that “everyone has a spirituality” and seeking to make a culturally bound model appear to be universal, we risk “baptizing people behind their backs,” forcing them to accept thin, culturally bound models of spirituality and humanness that may satisfy certain desires and needs but in the end fail to meet those needs that can be discovered only as we engage with thicker descriptions. When this happens, we subliminally engage in precisely the kind of proselytizing behaviors that some consider a central danger of allowing religion to be a part of health care. There is clearly a need for a richer and thicker conversation around spirituality and mental health than is provided by current culturally bound models and approaches. The question is: What might that look like? And how might we go about achieving such a goal?

1. Emily Martin, Bipolar Expeditions: Mania and Depression in American Culture (Princeton: Princeton University Press, 2007), 10.

2. G. E. M. Anscombe, Intention, 2nd ed. (Oxford: Basil Blackwell, 1957).

3. Ian Hacking, The Social Construction of What? (Cambridge, MA: Harvard University Press, 1999), 31.

4. Thomas C. Heller, Morton Sosna, and David E. Welbery, eds., Reconstructing Individualism (Stanford, CA: Stanford University Press, 1986), 230.

5. Clifford Geertz, The Interpretation of Cultures (New York: Basic Books, 1973), 33–55.

6. Erving Goffman, Stigma: Notes on the Management of Spoiled Identity (Englewood Cliffs, NJ: Prentice-Hall, 1963), 3.

7. Goffman, Stigma, 3.

8. Goffman, Stigma, 3.

9. T. M. Luhrmann and Jocelyn Marrow, eds., Our Most Troubling Madness: Case Studies in Schizophrenia across Cultures (Berkeley: University of California Press, 2016), 27.

10. Wang, The Collected Schizophrenias, Kindle locations 225–227.

11. Karl Jaspers, General Psychopathology, trans. J. Hoenig and M. W. Hamilton, 7th ed. (Manchester: Manchester University Press, 1963).

12. A. Sims, Symptoms in the Mind: An Introduction to Descriptive Psychopathology, 3rd ed. (Edinburgh: Saunders, 2003).

13. Andrew Sims, “Is Faith Delusion?,” 2007, accessed October 28, 2019, https://www.rcpsych.ac.uk/docs/default-source/members/sigs/spirituality-spsig/is-faith-delusion-andrew-sims-editedx.pdf?sfvrsn=59a019c0_2.

14. A. C. P. Sims, “Symptoms and Beliefs,” Journal of the Royal Society of Health 112, no. 1 (1992): 42–46.

15. World Health Organization, “The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines,” accessed October 28, 2019, https://www.who.int/classifications/icd/en/bluebook.pdf?ua=1.

16. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) (American Psychiatric Publishing, 2013).

17. World Health Organization, “International Classification of Diseases (ICD) Information Sheet,” accessed October 28, 2019, https://www.who.int/classifications/icd/en/.

18. World Health Organization, “The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research” (Geneva: World Health Organization, 1993), https://www.who.int/classifications/icd/en/GRNBOOK.pdf?ua=1.

19. M. First, “Harmonisation of ICD-11 and DSM-V: Opportunities and Challenges,” British Journal of Psychiatry 195, no. 5 (1999): 382–90.

20. Ian Hacking, “Lost in the Forest,” London Review of Books 35, no. 15 (August 8, 2013): 7–8, https://www.lrb.co.uk/v35/n15/ian-hacking/lost-in-the-forest.

21. For a fascinating insight into how this way of interpreting mental health issues is becoming globalized, see Ethan Watters, Crazy like Us: The Globalization of the Western Mind (New York: Little, Brown, 2011).

22. Hacking, “Lost in the Forest,” 2.

23. Hacking, “Lost in the Forest,” 1.

24. Wang, The Collected Schizophrenias, Kindle locations 183–184.

25. Ian Hacking, “Making Up People,” in Reconstructing Individualism: Autonomy, Individuality, and the Self in Western Thought, ed. T. Heller (Stanford, CA: Stanford University Press, 1986), 99–114 (emphasis added). The interior quotation is from Arnold Davidson, “Closing Up the Corpses,” in Meaning and Method, ed. G. Boolos (Cambridge: Cambridge University Press, 2001), 24.

26. D. C. Haldeman, “Gay Rights, Patient Rights: The Implications of Sexual Orientation Conversion Therapy,” Professional Psychology: Research and Practice 33, no. 3 (2002): 260–64.

27. I am aware and a little concerned that my usage of the term “homosexuality” may be problematic. The LGBTQ community tends to avoid the term “homosexuality,” preferring to use the description “those attracted to the same sex.” I acknowledge the importance of this linguistic change while also noting that this is a useful example of the way we create and re-create people in line with the politics and expectations of the moment.

28. Sarah Baughey-Gill, “When Gay Was Not Okay with the APA: A Historical Overview of Homosexuality and Its Status as Mental Disorder,” Occam’s Razor 1, no. 2 (2002): 5–16.

29. “Asperger Syndrome,” National Autistic Society, accessed October 28, 2018, https://www.autism.org.uk/about/what-is/asperger.aspx.

30. Linda Federico-O’Murchu, “Farewell to Aspies: Some Families Reluctant to Let Go of Asperger’s Diagnosis,” Today, January 4, 2013, https://www.today.com/parents/farewell-aspies-some-families-reluctant-let-go-aspergers-diagnosis-1B7821891.

31. Federico-O’Murchu, “Farewell to Aspies.”

32. Nick O. Haslam, “Natural Kinds, Human Kinds, and Essentialism,” Social Research 65, no. 2 (Summer 1998): 291–314.

33. Thomas Insel, “Transforming Diagnosis,” National Institute of Mental Health, April 29, 2013, https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml.

34. Gary Greenberg, “Does Psychiatry Need Science?,” New Yorker, April 23, 2013, https://www.newyorker.com/tech/annals-of-technology/does-psychiatry-need-science#.

35. My point here relates to biological explanations for all mental health challenges. It is not that there is no evidence for some. It is the assumption that all problems are based in biology that is problematic.

36. Sarah Kamens, “Dr. Insel, or: How Psychiatry Learned to Stop Worrying and Love the Biomarker; A Response to RDoC” (unpublished conference paper, May 2013).

37. Alan Garfinkel, Forms of Explanation: Rethinking the Questions in Social Theory (New Haven: Yale University Press, 1981), 14.

38. Garfinkel, Forms of Explanation, 12.

39. E. Fuller Torrey, Surviving Schizophrenia: A Family Manual, 6th ed. (San Francisco: Harper, 2013).

40. Richard P. Bentall, Madness Explained: Psychosis and Human Nature (London: Penguin Books, 2004).

41. Denise Sommerfeld, “The Origins of Mother Blaming: Historical Perspectives on Childhood and Motherhood,” Infant Mental Health Journal 10, no. 1 (Spring 1989): 14–24.

42. For a further development of this point and on the history of family blaming, see chap. 5 in Anne Harrington, Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness (New York: Norton, 2019).

43. A. Malla, R. Joober, and A. Garcia, “ ‘Mental Illness Is like Any Other Medical Illness’: A Critical Examination of the Statement and Its Impact on Patient Care and Society,” Journal of Psychiatry and Neuroscience 40, no. 3 (2015): 147–50. See also S. Peerforck, G. Schomerus, and S. Pruess, “Different Biogenetic Causal Explanations and Attitudes towards Persons with Major Depression, Schizophrenia and Alcohol Dependence: Is the Concept of a Chemical Imbalance Beneficial?,” Journal of Affective Disorders 168 (2014): 224–28; J. Read, N. Haslam, and N. L. Sayce, “Prejudice and Schizophrenia: A Review of the ‘Mental Illness Is an Illness like Any Other’ Approach,” Acta Psychiatrica Scandinavica 114 (2006): 303–18; and N. Rüsch, A. R. Todd, and G. V. Bodenhausen, “Biogenetic Models of Psychopathology, Implicit Guilt, and Mental Illness Stigma,” Psychiatry Research 179 (2010): 328–32.

44. John Modrow, How to Become a Schizophrenic: The Case against Biological Psychiatry (Everett, WA: Apollyon, 1992), 147.

45. Sally Clay, “The Wounded Prophet” (unpublished paper presented at the First National Forum on Recovery from Mental Illness, National Institute of Mental Health and Ohio Department of Mental Health, April 1994).

46. John Swinton, Spirituality and Mental Health Care: Rediscovering a “Forgotten” Dimension (London: Jessica Kingsley, 2001).

47. On depression, S. Vasegh et al., “Religious and Spiritual Factors in Depression,” Depression Research and Treatment, 2012; on anxiety, L. M. Steiner et al., “Spiritual Factors Predict State and Trait Anxiety,” Journal of Religion and Health 56, no. 6 (2017): 1937–55; on PTSD, J. M. Currier, J. M. Holland, and K. D. Drescher, “Spirituality Factors in the Prediction of Outcomes of PTSD Treatment for US Military Veterans,” Journal of Traumatic Stress 28, no. 1 (2015): 57–64; on schizophrenia, S. Grover, T. Davuluri, and S. Chakrabarti, “Religion, Spirituality, and Schizophrenia: A Review,” Indian Journal of Psychological Medicine 36, no. 2 (2014): 119–24; on anorexia, Patricia Marsden, Efthalia Karagianni, and John F. Morgan, “Spirituality and Clinical Care in Eating Disorders: A Qualitative Study,” International Journal of Eating Disorders 1, no. 1 (2006): 7–12; on personality disorder, K. Bennett, K. J. Shepherd, and A. Janca, “Personality Disorders and Spirituality,” Current Opinion in Psychiatry 26, no. 1 (2013): 79–83.

48. Christina Puchalski, “Integrating Spirituality into Patient Care: An Essential Element of Person-Centered Care,” Polskie Archiwum Medycyny Wewnetrznej 123 (2013): 491–97.

49. Pamela Reed, “An Emerging Paradigm for the Investigation of Spirituality in Nursing,” Research in Nursing and Health 15 (1992): 349–57.

50. David Hay, with Rebecca Nye, The Spirit of the Child (London: HarperCollins, 1998).

51. NHS, Education for Scotland, Spiritual Care Matters: An Introductory Resource for All NHS Scotland Staff (Edinburgh: Scottish Government, 2009).

52. For a useful review of this literature, see Deborah Cornah, The Impact of Spirituality on Mental Health: A Review of the Literature (London: Mental Health Foundation, 2006).