Creativity, Spirituality, and Mental Health

in tolerating states of emptiness could arise from the child's early negotiations of separation from her or his mother.

In her article, "Some notes on psychoanalytic ideas about mysticism" (1987b), Milner observes that in her lengthy analysis with Susan, a schizophrenic patient, she remembered an occasion on which Susan produced many variants of a circle. At first Milner attempted to interpret the circle as standing for the breast, but this symbolic equation did not seem to advance the therapy. Gradually, she states, she tried looking at it instead as an ego state and remembered a series of zen ox-herding pictures that culminated in the empty circle. She was then led to think about a "bad" blankness and a "good" blankness and came to see that a "good" blankness was necessary to the creative process (Milner, 1987b). She used the phrase "divine ground of one's being" for what happens to the sense of self "when consciousness does suffuse the whole of the body from inside and all focused images are got rid of, an inner action that seemed to be a kind of dialectical reunion of body and mind" (Milner, 1987b, p. 263). This state is the crux of regenerative emptiness.

For Milner, the central paradox of mysticism is that "I" and "not I" exist at the same time. There must be an "I" in order for the "I" to die. This insight is crucial to understanding Milner's view of the relationship between mysticism and mental health. In The Suppressed Madness of Sane Men (1987b), Milner explains that the basic identifications that make it possible to find new objects require an ability to tolerate a temporary loss of self, a temporary giving up of the discriminating ego. This might be called the "aesthetic moment" (p. 97). If, however, the child has become aware of separateness too soon or too continually, the illusion of union can be "catastrophic chaos rather than cosmic bliss" (p. 101), or the illusion may be given up and premature ego development occurs. Dragstedt notes that for Milner, illusion can be seen as the "device by which the person 'marks off a boundaried space of felt sameness where awareness of paradox can be contained" (Milner, 1969, p. 477). She believed that the framed space of illusion was essential to a number of growth-enhancing enterprises, including painting a picture and the experience of concentration.

In "The ordering of chaos" (1987b), Milner discusses two patients, both with artistic gifts, who had difficulty with symbolism. One (Susan) would say in response to an interpretation involving symbolism, "but a thing either is or it isn't, it must be one thing or the other" (p. 232). The other would insist that the literal meaning was the only possible meaning. Milner notes that both patients had mothers who were severely mentally ill. She explains:

I suggest that such a human environment forces a child into desperate clinging to the phase of thinking that does distinguish between the "me" and the "not-me", because this is the only protection against an impossible confusion between their own and their parents' inner problem.... And the result is that whole areas of their experience become cut off from the integrative influence of reflective thinking. What they are essentially in need of is a setting in which it is safe to indulge in reverie, safe to permit a con-fusion of "me" and "not-me". (Milner, 1987b, p. 232)

Creativity, Spirituality, and Mental Health

This practice raised many questions. First, Milner asks, Is it possible that by embracing inner poverty one can escape from the fear of actual poverty - loss of friends, reputation or livelihood? She remembered that as a girl she was interested in how the poor, who often seemed to be happy, managed to live. She queries: did the mantra really put an end to her anxiety, and was the subsequent uprush of constructive ideas an effect of its use or merely accidental? Whichever was the case, Milner concludes that the mantra forestalled an inner drive to suffer anxieties and inferiorities when she was faced with confident and self-assured people, thus averting insecurities about her self-worth.

This inner gesture, in Milner's view, was also helpful in achieving inner psychic growth, in that it required periodically losing one's sense of identity. Paradoxically, in A Life of One's Own Milner became more and more aware of what she called a central core - or "I-ness" (Dragstedt, 1998).

Emptiness and Mysticism

The notion of emptiness is central to Milner's work. She believed that far from being pathological, embracing "nothingness" can be a way to psychological health (Sayers, 2002). Milner writes both about how to "attain" or "accept" emptiness and the benefits of doing so. Moreover, emptiness is not an end goal in and of itself for Milner, but rather a means of opening oneself to something else. This something else she frequently calls "Answering Activity." Eastern religious teachings express a similar idea: emptiness paradoxically leads to an experience of fullness. Emptiness is first discussed in An Experiment in Leisure. Milner writes:

When I think of all the books I ought to read, instead of vowing to read them and then worrying because there are so many things to do, I can accept the poverty of my knowledge, accept the fact that I don't know all these things, accept the emptiness. And I can do the same when people criticize me, I can accept my poverty in their eyes, say "Yes, I am like that". And curiously enough, after doing this, I feel actually richer, instead of the lack I had felt before, while trying so hard to think up reasons why they were wrong. (Field, 1937, p. 43)

This type of emptiness is brought about though relinquishing the clinging to self. When Milner deliberately accepted loss and emptiness in the face of criticism, "the peace and richness was just as though I had come into a kingdom" (Field, 1937, p. 147).

Milner also discusses emptiness as a truth of the Gospels - that it is only by a repeated giving up of every kind of purpose, a voluntary dying upon the cross, that the human spirit can grow and achieve wisdom. Richness came only when, naked of expectancy or hope, she faced her experience: "the inescapable condition of true expression was the plunge into the abyss, the willingness to recognize that the moment of blankness and extinction was the moment of incipient fruitfulness ..."

Creativity, Spirituality, and Mental Health

have been identified as positive factors influencing mental health. Religious faith, for example may impact mental health through generating optimism and hopeful expectations in God's rewards. Among older adults, for example, it has been shown that: 1) religious faith provides hope for change and healing, 2) religious involvement influences well-being by providing social support, and 3) prayer and religious worship affect mental health through the effects of positive emotions (Levin and Chatters, 1998).

In the twenty-first century, religious and spiritual dimensions of culture remain important factors structuring human experience, beliefs, values, behavior, and illness patterns. Sensitivity to the cultural dimensions of religious and spiritual experiences is deemed essential for effective psychiatric treatment. The majority of the world's population relies on complementary and alternative systems of medicine for healing. It follows that in order for a psychiatrist to effectively work with an indigenous healer, he or she must have some understanding of the patient's cultural construction of illness, including the meaning of religious content. Religious cultures are powerful factors in modifying individual attitudes toward life and death, happiness and suffering. The subspecialty of transcultural psychiatry has gained momentum and clinical relevance from an interest in similarities and differences between cultures and the effect of culture on treatment plan. In this view, religion is a "container of culture:" rituals, beliefs, and taboos of religion are profoundly important to the nature and structure of society as vehicles whereby values, attitudes, and beliefs are transmitted from generation to generation (Cox, 1996; Rhi, 2001).

Finally, religion and spiritual issues have been identified as research agendas for the development of DSM-V. Examination of religion in history-taking and cultural formation processes and spirituality as a factor in self-identity, self-care, insight, self-reliance, and resiliency, are being promoted. Research on the similarities and differences between religious and spiritual issues across ethnic and cultural groups is being encouraged, as is research on the transgenerational process of acquisition or transmission of religious and spiritual norms and their impact on diagnosis (Kupfer, First, and Reiger, 2002).

To conclude, Swiss psychiatrist Carl Jung wrote in 1933:

Among all my patients in the second half of life - that is to say, over thirty-five - there has not been one whose problem in the last resort was not that of finding a religious outlook on life. It is safe to say that every one of them fell ill because he [sic] had lost what the living religions of every age have given to their followers, and none of them had been really healed who did not regain his religious outlook, (p. 229)

While this book is not predicated on regaining a religious outlook, it is my hope that a realization of the richness of possibility inherent in spiritual and creative resources will be a byproduct of reading it. Psychiatrist M. Scott Peck addressed

Creativity, Spirituality, and Mental Health

have functioned as competing belief systems for providing life meaning and purpose (Levin and Chatters, 1998; Rhi, 2001).

From Freud's work through the 1976 report on mysticism by the Group for the Advancement of Psychiatry (GAP), there has been a tendency to associate spiritual experiences with psychopathology. The report of GAP on "The Psychic Function of Religion in Mental Illness and Health" (1968) acknowledged that religious themes often surfaced during psychoanalysis and that religion could be used in both psychically healthy and unhealthy ways. Yet the residue of nineteenth-century interest in religious insanity could still be found in the glossary of the Third Edition of the DSM (Diagnostic Statistical Manual) and in the 1989 edition of the Oxford Textbook of Psychiatry (Foskett, 1996; Thielman, 1998; Larson, Milano, Weaver, and McCullough, 2000).

In order to redress lack of sensitivity to religious and spiritual dimensions of problems that may be the focus of psychiatric treatment, a new V-code category for DSM-IV was proposed, psychoreligious or psychospiritual problem. The impetus for the proposal of a new diagnostic category emerged from transpersonal clinicians and the work of the Spiritual Emergence Network. Their focus was on spiritual emergencies - forms of distress associated with spiritual practices and experiences. The proposal had the following goals: 1) to increase accuracy of diagnostic assessments when religious and spiritual issues were involved, 2) to reduce occurrence of medical harm from misdiagnosis of religious and spiritual problems, 3) to improve treatment of such problems by stimulating clinical research, and 4) to encourage clinical training centers to address the religious and spiritual dimensions of experience (Lukoff, Lu, and Turner, 1992).

The DSM-IV category was accepted under "Religious or Spiritual Problem" as follows: "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 that may not necessarily be related to an organized church or religious institution" (АРА, 2000, p. 741). Frequently reported religious problems in the literature are a loss or questioning of faith, change in denominational membership or conversion to a new religion, intensification of adherence to the beliefs and practices of one's own faith, and joining, participating in, or leaving a new religious movement or cult. Spiritual problems cited in the literature involve conflicts concerning an individual's relationship to the transcendent and questioning of spiritual values. Moreover, questioning of spiritual values may be triggered by an experience of loss or a sense of spiritual connection. Spiritual problems also may arise from spiritual practices, e.g., someone who begins meditating as a spiritual practice and starts to experience perceptual changes. As well, mystical experiences and near-death experiences can lead to spiritual problems and were focus for concern by the Spiritual Emergence Network. It was argued that inappropriately diagnosing disruptive religious and spiritual experiences as mental disorders can negatively influence their outcome. For example, some clinical literature on mysticism has described

Creativity, spiritualitygroups, and Mental behaviorth

fulfillment. Spiritual interventions for eating disorders include theistic-oriented therapy, spirituality groups, zen in the context of dialectical behavior therapy, and grief work as part of interpersonal therapy. Other treatment modalities include meditation, yoga, storytelling, ritual, and music. To speak in metaphors is to draw upon imagination, and the creative process involves connecting with and expressing one's voice - critical to recovery from an eating disorder.

In the book's concluding chapter I tell my own fictional story of Jesus' sister Salome, who in my account suffers from mood and eating issues. In offering an interpretation of the story, I include insights from Julia Cameron's The Artist's Way: A Spiritual Path to Higher Creativity (2002). Cameron highlights the healing role of creativity in her own life; she also offers a systematized program for others to recover their "blocked artist selves." Her notion of creativity as innate is consistent with Milner's view and with other theoretical perspectives. Both Milner and Cameron suggest that creativity can help one access one's "inner divinity" or creative unconscious.

Creativity, Spirituality, and Mental Health

(1995), written from a theological perspective, draws upon Winnicott to explore the origins of hope in childhood. Similarly, Erikson (1964) associates hope with early trust. In my work as a mental health chaplain, I attempt to assist patients in imagining a more positive future, often drawing upon the resources of story and metaphor from sacred texts to do so. The ability to fantasize enables humans to hope, tell stories, and to heal, and I find that narrative therapy, story telling, and the use of metaphor are well-suited to a religious context.

The mood disorders unit of the psychiatric hospital where I work offers a unique testing ground for investigating the relationship between mental health, creativity, and religious experience. In Touched with Fire (1993), Kay Redfield Jamison explores the connection between an artistic temperament and mania, and Goodwin and Jamison, in their classic text Manic-depressive Illness (1990), suggest that many religious leaders may have suffered from manic-depressive illness. Religion frequently serves as a template for manic and hypomanic visions and experiences, and patients understandably experience confusion when their visions are diagnosed as delusions. Yet there is meaning in every delusion, whether it entails believing one is the Second Coming of Christ or thinking one is the Queen.

From 2006 to 2009,1 was involved in a research project with the Stress and Anxiety Research Unit of the Institute for Mental Health Research (IMHR), University of Ottawa. The first pilot study was oriented around using a spiritually-based therapy for the treatment of generalized anxiety disorder. Our treatment protocol drew upon Roger Walsh's book Essential Spirituality: The Seven Central Practices to Awaken Heart and Mind (1999). My academic training is in theology, religious studies, and pastoral counseling. Since beginning to work in a mental health context in 2005,1 have attended training workshops in a number of therapeutic modalities, including cognitive behavior therapy, interpersonal therapy, acceptance and commitment therapy, spiritually integrated therapy, and group therapy. All these have informed the way I think and work.

Creativity, Spirituality, and Mental Health

Questions I intend to explore include: Can creative expression render mental illness more manageable? Can spirituality do the same? Just how far can spirituality and creativity take one on the journey to recovery? Is creativity in and of itself healing? The idea that many writers, artists, musicians, etc., suffer from mental illness will be explored. If true, is the reason because creative people are naturally more sensitive, and thus more vulnerable to mental instability? Or is there something else going on, a relationship between the state of mind of the artist and that of an individual in a manic episode? Over the centuries a number of charismatic religious leaders have been accused of suffering from mental disorders. This list includes not only cult leaders such as Marshall Applewhite, founder of Heaven's Gate, and Shoko Asahara, founder of Aum Shinrikyo, but also Martin Luther, who initiated the Protestant Reformation, and George Fox, founder of the Quaker tradition.

In days past, religion was blamed for causing mental illness. Current research leads away from this cause and effect relationship. In Religion, Culture and Mental Health (2007), for example, Kate Loewenthal indicates that there is little evidence that religious factors play a causal role in mental disorders. Religious beliefs, in her view, can help to entrench some symptoms, but these same beliefs can be helpful in relieving others. While Loewenthal focuses on religion in various cultural settings, here the focus is on ways that religion and spirituality can be used in treatment. Can spirituality be a catalyst for recovery from illness? If so, how might this happen? Can creative expression help one live more authentically, and, if so, how is this linked with living a spiritual life? These are some of the questions I will explore throughout the book.