Adm Policy Ment Health (2014) 41:835–844 DOI 10.

1007/s10488-014-0536-6 
ORIGINAL ARTICLE 

State of Spirituality-Infused Mental Health Services in Los Angeles 

County Wellness and Client-Run Centers 
Ann-Marie Yamada 
• 
Andrew M. Subica 
• Min Ah Kim 
• 
Kevin Van Nguyen 
• Caroline S. Lim 
• 
Rev. Laura L. Mancuso 
Published online: 24 January 2014 © Springer Science+Business Media New York 2014 
Abstract  Spiritual  coping  is  associated  with  positive  mental  health  outcomes  for  individuals  with  serious  mental 
illness,  yet  spirituality-infused  services  are seldom offered in public sector mental health agencies. The Los Angeles 
County  Department  of  Mental  Health  introduced  a  policy  addressing  spirituality  in  2012.  This  study  explored  the 
breadth  and  degree  to  which  spirituality-infused  activities  were  being  offered  in  53  Los  Angeles  wellness  and 
recovery  centers  after  the  policy  was  widely  disseminated.  More  than  98  %  of the centers offered options for spiri- 
tuality-infused  activities;  one-third  offered  spirituality-  focused  groups.  Los  Angeles’s  progress  may  guide 
implementation of spirituality-infused services in other state or local public mental health systems. 
Keywords Serious mental illness 4 Psychosocial rehabilitation 4 Policy 4 Religion 4 Community mental health 
services 
Introduction 
Wellness approaches for recovery-oriented mental health services are offered within public sector mental health 
systems to address the needs of individuals with serious mental illness such as schizophrenia or bipolar disorder. 
Recovery from the impairment and stressors of these ill- nesses is promoted by offering activities to enhance 
strengths, adapt behaviors, and restore emotional, physical, and spiritual equilibrium through empowerment, self- 
determination, and the inclusion of multiple dimensions of the self in treatment (Swarbrick 2007). Advocates of the 
wellness approach contend that consumers are more likely Electronic supplementary material The online version of 
this article (doi:10.1007/s10488-014-0536-6) contains supplementary material, which is available to authorized 
users. 
to engage in treatment, manage their illness, maintain good health, and avoid hospitalization when they self-define 
the essential tools for their recovery and lifestyle (Copeland A.-M. Yamada (&) 4 A. M. Subica 4 M. A. Kim 4 K. 
Van Nguyen 4 C. S. Lim School of Social Work, University of Southern California, 669 West 34th Street, 
Montgomery Ross Fisher Bldg, 102C, 
2002; Swarbrick 2007). The great diversity among con- sumers served in public sector mental health agencies 
requires that a broad array of wellness-focused services are Los Angeles, CA 90089, USA 
offered in order to reflect a myriad of recovery needs 
and e-mail: amyamada@usc.edu 
preferences. M. A. Kim 
Spirituality has been identified as one of eight 
wellness e-mail: minahkim.korea@gmail.com 
dimensions of recovery (Substance Abuse and Mental 
Present Address: M. A. Kim 
Health Services Administration 2011) and one of 11 core recovery factors (Gordon et al. 2013) that promotes phys- 
School of Social Welfare, Research Faculty, Yonsei University, 
ical wellness by lessening symptoms of chronic 
diseases 50 Yonsei-Ro, Seodaemun-Gu, Seoul 120-749, Korea 
(Balboni et al. 2007; Koenig 1998; Koenig et al. 2001). 
Rev. L. L. Mancuso PO Box 41812, Santa Barbara, CA 93140, USA e-mail: spiritofhealing@gmail.com 
The  leading  health  care  accrediting  body  has  made  spiri-  tuality  a  health  care  imperative  by  mandating  spiritual 
assessment for every patient in accredited health care 

123 
 
836 Adm Policy Ment Health (2014) 41:835–844 
123 organizations (Joint Commission Accreditation 2011). In 
hope, self-esteem, social support, and decreased 
anxiety, addition, the federal government has sought to establish 
psychosis, substance abuse, and suicide. 
relationships with faith communities to support commu- 
For individuals with serious mental illness, 
spirituality nity-based mental health treatment (Hester 2002). Yet, 
may be an essential coping mechanism (Corrigan et 
al. until recently, a lack of clear policy and practice parame- 
2003). In one study, nearly 80 % of consumers 
reported ters within public mental health systems of care has 
daily use of religious coping strategies to manage 
their restricted or even prohibited the use of spirituality-infused 
psychiatric distress (Tepper et al. 2001) and in 
another wellness approaches to address the needs of individuals 
study, more than one-third of participants sought 
spiritual with mental illnesses, especially those with the most 
assistance from clergy (Wang et al. 2003). Spiritual 
coping complex and severe forms of illness. 
practices such as prayer and worship have been shown to enhance recovery by instilling a positive sense of self, 
Spirituality in Recovery-Oriented Mental Health 
promoting hope, increasing quality of life, and 
reducing Services 
psychiatric symptomatology and suicide (Fallot 1998; Huguelet et al. 2007; Koenig et al. 2012; Mohr 2013). 
Spirituality is an expansive, conceptually vague construct 
Spirituality-infused recovery services such as 
spirituality- without a single widely accepted definition (Koenig et al. 
focused groups also appear to promote recovery by 
2012). Although spirituality once centered on religion, it is 
increasing consumers’ self-esteem, spiritual support, 
psy- now contextualized as an individually defined construct, a 
chosocial functioning, connection with self and 
others, and secular ‘‘search for the sacred,’’ that may or may not 
treatment goal success (Mohr 2011; Phillips et al. 
2002; involve religion (Pargament 1999). Within the context of 
Wong-McDonald 2007). Spirituality has been 
identified as public mental health services, spirituality is often defined 
a resource, especially for many individuals from 
histori- as a process of promoting opportunities for meaningful 
cally underrepresented ethnic and racial groups 
(Gillum connections in one’s life, whether these connections are 
and Griffith 2010), and may influence individualized 
with self, others, nature, or a higher power (California 
approaches to recovery among consumers, thus, 
repre- Mental Health and Spirituality Initiative 2011). Therefore, 
senting an important facet of culturally competent 
care all activities that a public mental health consumer might 
(Bellamy et al. 2007; Lindgren and Coursey 1995). 
participate in to build meaningful connections, regardless 
Despite these strengths, spirituality has been, for 
the of their relation to religion or belief in the supernatural, 
most part, underutilized in wellness and 
recovery-oriented may fall within the domain of spirituality and spiritual 
services (Weisman de Mamani et al. 2010). 
Underlying activity. This broad, inclusive definition of spirituality 
reasons may include provider misattributions of 
spirituality makes up the framework for the current exploration of 
as being synonymous with organized religion, 
concerns existing spirituality-infused services within a large public 
that spiritual or religious beliefs may exacerbate 
delusions, mental health system. Spirituality-infused services tend to 
poor recognition of spirituality’s importance to 
consumers, integrate spiritual elements into interventions in order to 
insufficient training in spiritual assessment or 
supports promote recovery. Spiritual integration may occur by 
(Huguelet et al. 2006; Koenig et al. 1998), and 
discomfort adapting existing interventions (e.g., adding meditation to a 
on the part of providers in discussing spirituality or 
religion stress reduction workshop) or by developing new treat- 
(Starnino et al. 2012). Part of this discomfort may 
stem ments. These activities may be geared toward connecting 
from their conflation of religion with spirituality. 
Previous with the self (e.g., yoga or meditation), others (e.g., sports 
findings suggest that religion, in particular, but not 
spiri- or conversations), or nature (e.g., hiking or nature walks). 
tuality as a whole, may have adverse effects on 
psycho- In both scenarios enhancement of spirituality is not an 
pathology, functioning, religious delusions, and 
treatment expected outcome, but a tool used by individuals with 
(Koenig 2007; Siddle et al. 2002, 2004). Similarly, 
mental illness to address everyday challenges (Galanter 
administrators often misinterpret the federally 
mandated et al. 2012). 
separation of church (i.e., religion) and state as 
prohibiting For individuals with mental illness, spirituality has 
spirituality-infused services. Some consumers’ 
reluctance produced beneficial mental health effects, supporting its 
to discuss spirituality with providers (Huguelet et al. 
2006) inclusion in recovery-oriented mental health services 
and preference to seek spiritual support from 
faith-based (Mohr 2013). A systematic review of the spirituality and 
institutions (Husaini et al. 1994) have also 
contributed to mental health literature by Koenig et al. (2001) indicated 
the limited integration of spirituality into mental 
health that nearly two-thirds of the 724 published studies reported 
systems of care. The net result is that spiritual 
discussions significant positive relationships between spirituality and 
are infrequently initiated with consumers, missing 
potential mental health, with spiritual involvement corresponding to 
therapeutic opportunities to support engagement in 
spiri- increased life satisfaction, purpose and meaning in life, 
tual coping practices (Huguelet et al. 2006; Kehoe 1999). 
 
Adm Policy Ment Health (2014) 41:835–844 837 
Study Context 
those pertaining to and in accordance with consumers’ recovery needs and goals while considering also whether Los 
Angeles County has the second-largest population and 
they infringe on other consumers’ rights (e.g., the 
right to is among the most ethnoculturally diverse counties in the 
participate in secular activities). Whereas these 
parameters United States, with an approximate ethnic/racial composi- 
may restrict providers from offering some 
potentially tion as follows: 47 % Hispanic/Latino, 28 % White, 14 % 
therapeutic interventions, they also provide impetus 
for Asian, 9 % African American, and 4.5 % multiracial (US 
development of a variety of sanctioned activities. 
Census Bureau 2010). The diversity of the population 
Because acceptance and infusion of spirituality by 
provided mental health services necessitates consideration 
public mental health systems is still in its infancy, 
the of culturally sensitive approaches, including the infusion of 
current study required qualitative methods be used to 
spirituality into wellness and recovery plans of consumers 
explore the state of spirituality-infused activities 
within the (e.g., not showing favoritism for one religion or spiritual 
Los Angeles County DMH. The aim was to detail 
the belief over another). There is no one size fits all approach 
extent to which wellness and client-run centers 
infused that is viable in developing mental health services in 
spirituality into their mental health recovery 
activities response to consumer needs in Los Angeles. 
centers 2–3months after the practice guidelines for The 
Los Angeles County Department of Mental Health 
including spirituality in clinical services were posted 
on (DMH) is the largest provider of public mental health 
internal and public Internet sites and introduced via 
train- services in the United States with an annual operating 
ings and agency meetings. This exploratory research 
study budget exceeding $1.5 billion dollars (County of Los 
was designed to address two primary research 
questions: Angeles 2010). Its services are based on psychosocial 
What is the prevalence of spirituality-infused 
services in recovery principles that include promoting hope, self- 
existing centers specializing in services for 
individuals determination, respect, cultural sensitivity, and achieve- 
with serious mental illness? How are 
spirituality-infused ment of meaningful roles (Markowitz 2001), with the 
wellness and recovery-oriented services 
conceptualized in overarching goal of helping consumers to lead productive 
terms of the approach taken by these centers to offer 
them? and fulfilling lives. 
A secondary question considered whether the 
prevalence of Wellness and client-run centers are central to this effort, 
spirituality-infused services differed between 
wellness offering peer support as a principal therapeutic component 
centers and the more consumer-driven client-run 
centers. (County of Los Angeles DMH 2005). Peer support has been demonstrated to be cost-effective, to address 
impor- tant consumer psychosocial needs, and to be as effective as 
Methods professional-driven services (Mowbray et 
al. 1988; Solo- mon 2004). The primary differentiating characteristics of 
Participating Agencies and Informants wellness 
centers versus client-run centers are that the latter do not provide health screening and psychiatric services 
Our sampling strategy was to obtain a purposeful 
sample and exclusively hire peers, (i.e., individuals with personal 
of centers that offer specialized wellness and 
recovery- experience of mental illness). Wellness centers typically 
oriented services to persons with serious mental 
illness. strive to employ an equal mix of professional and peer 
Fifty-four DMH-affiliated direct service and 
contracted staff. Both types of programs operate as community sup- 
peer-run centers in Los Angeles County had working 
phone port and resource centers (Hodges and Hardiman 2006; 
numbers from lists that included *60 centers 
identified Swarbrick 2007), facilitating community-based activities 
from publically available directories that were cross- 
that nurture a sense of purpose, hope, and social inclusion. 
checked with DMH websites and consultation with 
DMH To further support this mission, the Los Angeles system 
administrators. Fifty-three such centers participated. 
Of the of care actively pursues new opportunities to promote 
53 centers, 42 (79.2 %) were wellness centers and 11 
community inclusion of consumers through collaboration 
 (20.8 %) were client-run centers. Data were 
collected from and connections between mental health agencies and faith- 
52 informants (one informant coordinated services 
for two based organizations. In 2012, the Practice Parameters for 
centers and provided data for both). All informants 
were Spiritual Support (County of Los Angeles DMH 2012) was 
required to affirm they were knowledgeable 
regarding crafted to guide staff in the assessment and integration of 
the activities offered at the center. Thirty percent (n 
= 16) spiritual interests of clients in relation to their wellness and 
of the informants were directors and the remaining 
infor- recovery. The parameters support the use of spirituality as 
mants were administrators (e.g., clinical supervisor, 
ser- a consumer-driven component of services, and prohibit 
vices coordinator, administrative assistant) and 
clinical proselytizing or referring consumers to specific faith-based 
staff members (e.g., case manager, therapy intern, 
peer organizations. Spirituality-infused activities are limited to 
advocate). 

123 
 
838 Adm Policy Ment Health (2014) 41:835–844 
Data Collection Procedure 
One-on-one  semi-structured  phone  interviews  were  con-  ducted  by  two  graduate  students  and one postdoctoral fel- 
low.  The  interviewers  were  provided  a  specific script to ensure the questions were asked in a consistent manner and 
were  trained  by  the  first  author  to  use  probes  to  elicit  additional  details  on  a  topic  as  described  Gilchrist  and 
Williams  (1999).  The  average  interview  was  *20  min  long.  The  program  director  was  invited  to  participate  or  to 
nominate  a  staff  member  he  or  she  thought  could  best  describe  the  current  activities  within  the  center.  When  a 
director could not be reached, data were gathered from available clinical or peer staff. 
Project activities were reviewed by the University of Southern California’s ethical committee (institutional review 
board)  and  classified  as  involving program evalu- ation procedures that did not meet the federal definition of human 
subjects  research  (Protection  of  Human  Subjects  2009).  Therefore,  the project was not subject to formal review and 
written  informed  consent  was  not  required.  Ethical  treatment  of  informants  included  informing  them  of  the  study 
purpose  and  voluntary  nature  of  their  participa-  tion.  Although  no  informant  names  are  provided  in  this  paper  or 
elsewhere,  informants  could  not  be  assured  of  confidentiality  because  centers  are  identified  in  a  directory  that was 
prepared  for  administrators  within  the  Los  Angeles  DMH  (Yamada  et  al.  2012)  and  is  available  as  an  on-line 
supplementary file. 
Measures 
To  assess  spirituality-infused  activities being offered, an a priori list of spiritual-based wellness activities was devel- 
oped  based  on  those  used  previously  by  the  California  Mental  Health  and  Spirituality  Initiative  (Lukoff  and 
Mancuso  2010)  along with additional activities obtained from a comprehensive review of the spirituality and serious 
mental  illness  literature.  Spiritual  activities  were  catego-  rized  into  domains  that  were  determined by the investiga- 
tors.  Content  and  face  validity  of  finalized  domains  were  established  through  expert  consensus, which consisted of 
DMH  clergy  advisory  committee  members  agreeing  that  each  item  assessed  relevant  dimensions  of  spirituality- 
infused services. 
The  semi-structured  interview  was  composed  of  initial  open-ended  questions  followed  by  a  closed-ended  list  of 
spirituality-infused  activities.  Informants  were first asked, ‘‘Does your center presently have any activities related to 
spirituality  and/or  body–mind–spirit  wellness?’’  After  describing  their  center’s  activities,  informants  were asked to 
report whether these activities had occurred during the prior year. Follow-up questions prompted interviewees to 

123 
indicate  if  their  center  presently  offered  five  types  of  spirituality-infused  services:  (1)  spiritual  support  groups,  (2) 
services  involving  religious  or  faith-based  practices/  beliefs,  (3)  programs  intended  to  promote  inner  peace  or 
wellness,  (4)  recreational  activities,  and  (5)  community  involvement  activities.  For  each  service  category,  inter- 
viewees  were  read  a  list of possible activities and were asked to indicate which were offered. In the spiritual support 
group  domain,  informants  responding affirmatively were prompted to specify the type of group facilitator (e.g., staff 
member,  clinician,  peer,  or  volunteer),  whether  or  not  the  activity  had  started  during  the  previous  year,  and  any 
restrictions  for  participation  in  the  activity  (e.g.,  open,  ongoing,  closed, or time limited). Open activities were those 
available  to  any  consumer  wishing  to  participate;  closed  activities  restricted  involvement  to  a  fixed  set  of  core 
participants;  and  time-limited  activities  maintained  firm  discontinuation  dates.  Lastly,  informants  were  asked  to 
share examples of any spiritual activities not included in the predetermined list. 
Data Analysis 
Open-ended  responses  were  transcribed  into  Microsoft  Office  Excel  to  facilitate  comparisons  and aggregation. Chi 
square  tests  were  conducted  to  detect  possible  differences  in  frequency  of  each  domain  by  agency  type  (i.e., 
wellness  centers  vs.  client-run  centers).  Descriptive  analyses  were  then  performed  to  calculate frequencies for each 
spiritu-  ality-infused  activity  using  SPSS  Version  16.0  for  Win- dows. Data from open- and closed-ended questions 
were  equally  valued  in  addressing  the  research  questions:  after  presenting  the  initial  unstructured  results,  we 
included  both  types  of  data  to  explore  the  types  of  spirituality-infused  activities  (see  Palinkas  et  al. 2011, for more 
details on the use of mixed-method designs). 
Results 
Presence of Spirituality-Infused Activities: Open-Ended Responses 
Informants  were  asked  to  respond  to  an open-ended ques- tion about whether or not their centers offered spirituality 
activities,  mind–body–spirit  wellness  activities,  or  both.  The  majority  of  the  53  centers  (77.4  %,  n  =  41)  were 
affirmed  to  have  these  activities  based  on  the  answers  provided  by  the  informants.  When  asked  to  briefly describe 
these  activities,  participants  from  13  centers  (24.5  %)  described  activities  with  spirituality  in  the  title  (e.g., 
Spirituality Group, Spirituality and You), 15 centers (28.3 %) reported activities involving meditation (e.g., 
 
Adm Policy Ment Health (2014) 41:835–844 839 
Meditation Morning, daily meditation), 10 (18.8%) 
Table 1 Spirituality-infused activities by domain in 
Los Angeles described activities incorporating mindfulness techniques (e.g., dialectical-behavioral therapy, mindful 
recovery 
County Department of Mental Health Wellness and Client-Run Centers 
group), and six (11.3 %) specified activities involving yoga 
Activitya n (%) or tai Chi. Only five centers (9.4 %) 
described services that involved religious themes (e.g., spiritual religion class, God Box, Bible study). 
In  response to this open-ended item, informants also reported specific spirituality-infused wellness activities other 
than  those  provided  as  examples  in  the  closed-ended  survey.  These  activities  included  Zumba  (a  dance  fitness 
program),  Reiki  (channeling  the  body’s  inner  energy  for  healing),  gratitude,  kung  fu,  flower  therapy,  self-empow- 
erment, and Japanese water-coloring. 
Spiritual support groups Spirituality-focused groups 12-Step programs Religious activities Reading spiritual material Reading 
religious text Prayer Bringing religious community leaders into center Religious services Sacred cultural activities 14 (26.4) 29 
(54.7) 
9 (17.0) 6 (11.3) 4 (7.5) 4 (7.5) 2 (3.8) 2 (3.8) 
Presence of Spirituality-Infused Activities: 
Prayer vigils 1 (1.9) Closed-Ended Responses 
Ritual ceremonies 1 (1.9) Self-awareness activities Ninety-eight percent (n = 52) of the centers reported 
Meditation 29 (54.7) offering spirituality-infused 
activities when participants 
Mindfulness 24 (45.3) were asked about specific 
types of these activities. Nine 
Nature walks 20 (37.7) centers (17 %) offered 
activities in all five spirituality- 
Yoga/tai Chi 15 (28.3) infused wellness domains. 
In contrast, six centers (11.3 %) 
Recreational activities offered activities in only one 
domain. Of these six centers, 
Craft making 35 (66.0) four offered spiritual 
support groups and two offered self- 
Journal writing/poetry 34 (64.2) awareness 
activities. The frequencies of spirituality-infused 
Drawing/painting 31 (58.5) activities varied across 
the five domains and are listed by 
Music/drumming 27 (50.9) domain in Table 1. An 
expanded version of this table with 
Singing/chanting 19 (35.8) activities specific to 
each center can be found in an on-line 
 Dancing 18 (34.0) supplementary file. Chi square 
tests indicated no significant 
Community inclusion differences between wellness 
centers and client-run centers 
Community volunteering 20 (37.7) with respect to 
prevalence of spirituality-infused activities 
Spirituality-related social events 14 (26.4) (p C 
.05). Responses to the structured survey items are 
Outings to religious sites 7 (13.2) reported, 
followed by examples of open-ended comments. 
Respondents (N = 53 centers) indicated whether each activity was 
Spiritual Support Groups 
currently offered by their center during the summer of 2012 a Activities correspond to the closed-ended options read 
to respondents More than half (64.2 %, n = 34) of the centers offered spiritual support groups; the great majority of 
these groups were 12-step recovery groups (85.3 %, n = 29) and to a 
targeting a singular spiritual approach (e.g., only 
medita- lesser extent, spirituality-focused process groups (41.2 %, 
tion, exclusively yoga). These spirituality-focused 
process n = 14), which we considered to most directly represent 
groups primarily used an open group format (71.4 
%, the typical approach to integration of spirituality into 
n = 10) inclusive of all consumers and were 
facilitated by therapy groups. According to informants, spirituality- 
staff members or community volunteers and just as 
fre- focused process groups emphasized the exploration of 
quently by peers. All except one center provided 
spiritu- spirituality to promote wellness, whereas 12-step recovery 
ality-focused process groups to members once per 
week, groups incorporated spirituality as one of many compo- 
with group duration ranging between 60 and 90 min. 
These nents of the structured program (Alcoholics Anonymous 
groups were reportedly offered for only a few 
months at 2001). 
some centers and as long as 6 years at others. The spiri- 
Some spirituality-focused process groups were descri- 
tuality-focused process groups widely differed in 
approach bed as introducing consumers to multiple spiritual mind– 
and content. According to open-ended comments, 
for body approaches (e.g., meditation, yoga, and mindfulness), 
example, one center offered a group centered on 
providing which distinguished them from self-awareness activities 
consumers with spiritual support and assistance with 

123 
 
840 Adm Policy Ment Health (2014) 41:835–844 
123 attending church services. An informant from another 
reported, followed by journal and poetry writing, 
drawing center described the group approach as didactic, incorpo- 
and painting, music and drumming and dancing. 
Follow up rating teaching material and group discussion. With respect 
responses described music and drumming as 
including to content, different groups used different religious or faith 
music therapy groups, drum beating, guitar playing, 
choir, tenets, spiritual themes (e.g., grief, gratitude, forgiveness, 
and karaoke. Many informants also noted that the 
centers love), and spiritual approaches (e.g., mindfulness, yoga, 
offered spirituality-infused recreational activities 
that were meditation). In addition to spirituality-focused groups and 
not on our list, such as opportunities for artistic 
creation, 12-step groups, open-ended descriptions of spiritual sup- 
performance art, photography, and gardening 
groups. Other port groups included self-empowerment groups for coping 
open-ended responses described sporting activities 
such as with self-stigma, grief and loss groups, and anger man- 
basketball, bowling, and fitness with video games. 
Occa- agement groups. 
sional recreational activities included social dances, holi- day singing, art shows, open-mike nights, and plays. While 
Religious Programs 
many of these activities do not appear to be spirituality- infused, the informants considered them to provide benefits 
Religious programming was the least commonly reported 
they equated with our definition of spirituality (i.e., 
domain, with 28.3 % (n = 15) of the centers reporting 
building meaningful connections in one’s life). 
activities involving organized religions such as Christian- ity, or Buddhism. As presented in Table 1, the most fre- 
Community Inclusion Outings quently reported 
religious activities involved consumers reading religious-themed materials or sacred religious texts 
Community inclusion outings were reported by 
approxi- such as the Bible. For example, open-ended responses 
mately half (50.9 %, n = 27) of the centers, with 
com- noted that several centers offered activities that allowed 
munity volunteering, charity work, and 
spirituality-related members to bring inspirational religious material into the 
social events most commonly reported in this 
domain. group to promote discussion. A few participants also 
Examples of community volunteering activities 
included reported holding religious services in their facilities, such 
working at local food banks and animal shelters. 
Spiritu- as memorial services for members or a weekly service led 
ality-related social events included attending 
community- by a Catholic priest from the community. 
based holiday celebrations such as Kwanzaa, Christmas, Hanukkah, Day of the Dead, and candle-lighting ceremo- 
Self-Awareness Programs 
nies at Thanksgiving. One center also reported that their Spanish-speaking support group conducted regular educa- 
Self-awareness programs were the second most frequently 
tional presentations about mental illness at religious 
con- reported spirituality-infused activity, with 83 % (n = 44) of 
gregations in their community. centers reporting 
activities in this domain. Approximately 75 % (n = 33) of the centers reporting self-awareness 
Presence of Spirituality-Infused Activities: Synopsis 
activities offered one to two types of activities and the 
of Responses remaining 25 % (n = 11) offered three 
or four different self-awareness activities. Meditation (including relaxation) 
Eleven informants initially stated that their centers 
and mindfulness were the primary spirituality-infused self- 
(21.2 %) did not offer activities involving spirituality 
or awareness programs offered, followed by nature walks in 
mind–body–spirit wellness. Yet, when responding to 
the nearby parks, scenic gardens, or foothills, and yoga and tai 
closed-ended list of activities within the five 
domains, 10 Chi programs. In addition, some participants described 
of these centers reported the presence of spirituality- 
other self-awareness programming not on our list of activ- 
infused activities from the list. None of the activities 
ities, such as stress-management groups and healthy living 
reported by these 10 centers directly involved 
religion. activities that involved nutrition monitoring and exercise. 
Overall, participant responses to our open- and closed- ended questions confirmed that wellness centers provide a 
Recreational Activities 
variety of spirituality-infused activities. Furthermore, all reported activities were consistent with our five a priori 
Recreational activities were the most frequently endorsed 
spirituality domains. For example, the open-ended 
activity domain, with 84.9 % of responding centers offer- 
responses for the inclusion of activities such as 
meditation, ing spirituality-infused recreational services. Of the 45 
mindfulness, yoga, and tai Chi were representative 
of self- centers providing recreational activities, 86.7 % (n = 39) 
awareness programs; Bible study and God Box were 
offered more than one type of recreational activity. Craft 
indicative of religious programs; and kung Fu, Reiki, 
and making (e.g., jewelry, cards, crocheting) was most often 
flower therapy represented recreational activities. 
 
Adm Policy Ment Health (2014) 41:835–844 841 
Discussion 
have produced promising early results (Mohr 2011; Phillips et al. 2002; Wong-McDonald 2007). Our finding that 
many Our findings revealed a high prevalence of spirituality- 
participants reported efforts to develop 
spirituality-focused infused activity in wellness and client-run centers. Given 
groups to meet the recovery needs of consumers was 
the benefits associated with spiritual coping (Bellamy et al. 
consistent with published reports describing newly 
devel- 2007; Fallot 1998; Koenig et al. 2012), it is encouraging 
oped spirituality-focused groups in public mental 
health that nearly every center supported consumers’ recovery by 
agencies in New York (Revheim et al. 2010), Florida 
offering spirituality-infused activities. Our results also 
(Weisman de Mamani et al. 2010), Massachusetts 
(Kehoe showed that consumers were offered a variety of options 
1999), Ohio (Phillips et al. 2002), and Switzerland 
(Mohr covering multiple dimensions of spirituality. These options 
2011). Because many of these earlier 
spirituality-focused were highly diverse, ranging from spirituality-focused and 
interventions were introduced in the literature via 
initial 12-step recovery groups to creative writing, yoga, Bible 
tests of feasibility and community-based pilot 
studies study, and involvement with charity services. Further, as 
(clinical services are not typically run with 
comparison spirituality is a resource that is consumer-driven, it is 
groups,) it is difficult for administrators to locate 
empiri- especially encouraging that we did not find a difference in 
cally supported models to guide program 
development in the availability of spirituality-infused activities between 
their own agencies. Recently however, more 
standardized wellness centers and client-run centers. 
spirituality-focused group manuals have been 
developed to Findings indicate that most centers offered spirituality- 
ease the burden on providers of constantly 
reinventing such infused activities that did not involve organized religion, 
groups. For example, the New York State Office of 
Mental challenging the assumption that religious-oriented content 
Health commissioned a manual to promote the 
mental is the primary component of such services. Less than 10 % 
health of their culturally diverse consumers through 
spiri- of surveyed centers reported that consumers were partici- 
tuality (Galanter et al. 2012), and another manual 
com- pating in explicitly religious-oriented programming. 
missioned by the Los Angeles DMH (Suhayda 2012) 
was Whereas religious practices are often endorsed as personal 
developed to serve as a cornerstone of culturally 
responsive coping approaches among individuals with serious mental 
care. Yet, as these systematic spirituality-focused 
groups illnesses (Bellamy et al. 2007; Koenig et al. 2012), 
become more widely accessible, we caution 
administrators adopting this broader conceptualization of what constitutes 
to recognize that interventions developed for one 
commu- spirituality-infused services may reduce staff hesitation of 
nity may not contain the necessary cultural relevance 
or incorporating religion into mental health services. This 
personalization of spiritual activities for different 
com- hesitation is understandable; we are not denying that any 
munities and may require careful adaptation to local 
norms integration of spirituality, especially when involving reli- 
and values. gion, is without challenges. However, we 
suggest that a 
It is important that consumers and staff members 
are first step for public mental health systems to overcome 
knowledgeable regarding the state of 
spirituality-infused these obstacles is to adopt an expanded paradigm of spir- 
programming in their centers and across centers to 
ituality in mental health. Our findings indicate that most 
encourage connecting consumers with spiritual 
activities centers sought to meet the spiritual needs of their culturally 
best suited to their needs or preferences. By 
conducting this diverse consumer populations by modifying preexisting 
exploratory study, we were able to provide a 
summary clinical services to accommodate spiritual content, rather 
snapshot of available services at each center 
(Yamada et al. than introducing new spirituality programs. This approach 
2012), which will be made available to staffs and 
admin- may offer a possible early step for other agencies desiring 
istrators throughout the Los Angeles County system 
of to develop spirituality-infused services. 
care. For example, a provider might encourage 
consumers Defining spirituality in mental health is immensely 
wanting to explore a variety of approaches to 
spirituality to complex because narrow definitions risk excluding or 
seek services from the nearest of the nine centers 
offering undermining the unique spiritual practices some consumers 
activities across all five spirituality wellness 
domains. find helpful (thereby violating a core tenet of psychosocial 
Other consumers may have a strong preference for a 
par- recovery) while broad definitions may result in labeling 
ticular activity found at a specific site and could be 
linked any activity as spiritual. In developing any new spirituality- 
accordingly. Further research is needed to determine 
infused activity, a consumer-centered approach is neces- 
potential outcomes related to matching consumers 
with sary to introduce services responsive to the needs and 
spiritual needs to specific centers, particularly in 
light of preferences of the particular consumers served. 
possible billing challenges associated with cross-center 
The literature describing previous efforts to integrate 
referrals. spirituality into wellness and client-run 
centers has focused 
In addition to providing spirituality-infused 
activities primarily on spirituality-related group interventions that 
within their centers, public mental health systems could 

123 
 
842 Adm Policy Ment Health (2014) 41:835–844 
123 provide further support to consumers in recovery by 
limited to the participating centers during the time 
period developing relationships with community faith-based 
of the study due to the fluid and dynamic nature of 
activ- organizations. This networking could increase the ability of 
ities in these centers. The high participation rate of 
eligible faith-based communities to reach out to consumers in crisis 
centers did provide a representative view of 
activities or provide additional needed support outside the scope of 
within the Los Angeles DMH. We constrained the 
primary the DMH. Despite concerns over sanctioning religion into 
findings reported to a brief period to increase the 
validity of the secular public sector, developing these formal networks 
informant reports and because the purpose of this 
paper may enhance wellness and well-being by strengthening 
was to provide a current snapshot of 
spirituality-infused community support for consumers in recovery. Research 
activities. Future studies are needed to assess the 
sustain- indicates that many persons experiencing first-episode 
ability of spirituality-infused activities over time and 
to mental illness seek help from clergy rather than mental 
identify whether new trends or policies alter the 
availability health professionals and continue obtaining spiritual 
or nature of these activities. The disproportionate 
number assistance from clergy after beginning treatment (Wang 
of wellness centers in relation to consumer run 
centers is et al. 2003). Therefore, clergy may become potent 
also a limitation. Understanding any detailed 
variation in resources for public mental health agencies seeking to 
the types of spirituality-infused activities offered 
within bolster community support and inclusion of their 
each type of center will require further in-depth 
exploration consumers. 
that was beyond the scope of the current study. Another limitation is that our findings were based on subjective 
Applying the Los Angeles Spirituality Policy 
knowledge of the staff members reporting the 
information. Parameters to Other Systems of Care 
Regardless of the potential for biased reporting, our research questions required that we examine staff member 
 Given that Los Angeles County DMH is the largest public 
perceptions of spirituality-infused wellness services. 
We mental health system in the country and serves one of the 
used closed-ended questions validated by 
expert-consensus most culturally diverse consumer populations, it is impor- 
to organize responses as our intent was not to further 
val- tant to consider the core elements of its policies and pro- 
idate the types of spiritual activities, but simply to 
dem- grams that are likely relevant to other systems of care. The 
onstrate the varied options offered in these centers. 
Future effectiveness of the Los Angeles spirituality policies lies in 
studies might compare the reliability of informant 
report to the extent to which it offers practical guidance to providers. 
that of objective data such as fliers of center 
activities and By having access to written guidelines, providers are able 
might collect additional data based on validated 
measures to deliver spirituality-infused services, including religious- 
of spirituality. based activities that fall within 
specific ethical and legal 
In accordance with our goals, the current study 
focused parameters of clinical care. The effective use of these 
only on the presumed positive presence of 
spirituality- guidelines also stems from the lack of inclusion of every 
infused activities. Substantive negative consumer 
outcomes possible scenario in favor of general considerations that 
of offering such activities have yet to be brought to 
the offer guidance for decision making. For additional support, 
attention of the DMH spirituality committee; 
however, administrators and community-based clergy identified as 
there is need for center directors to share their 
respective members of the DMH spiritual care committee are avail- 
experiences with each other to reduce replication of 
any able for consultation, as needed. In addition, DMH has 
undesired effects of newly implemented activities. 
Addi- developed a multi-tiered training program that begins with 
tional study is needed to assess and shed light on any 
a review of the relevant policies and ends with skill- 
challenges inherent in offering these types of options 
to building exercises in spiritual assessment so providers 
consumers. For instance future research could 
support the might effectively elicit consumers’ conceptualizations of 
collection of case examples of problem-solving 
around any their spirituality as it relates to their recovery (Hodge 2004; 
conflicts that arise, including issues regarding 
separation of Huguelet et al. 2011; Mohr 2013). This construction and 
church and state. dissemination of clear parameters 
for spiritual care could 
Consumer perspectives were not solicited in this 
study, be replicated within other systems of care to facilitate the 
but the content of the closed-ended questions was 
origi- national growth of spirituality-infused programming in 
nally developed and used to assess the views of 
consumers public mental health care. 
and family members as part of a state-wide initiative (see Lukoff and Mancuso 2010). Our own pilot work with 
Study Limitations and Future Research Directions 
consumers in developing a spirituality intervention within one DMH center also supports the broad approach we 
took Caution is warranted when interpreting the results of this 
in defining spirituality. Fundamentally, the activities 
exploratory study. The generalizability of the findings is 
offered at the centers are either consumer initiated or 
 
Adm Policy Ment Health (2014) 41:835–844 843 
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