Guidelines regarding possible conflict between psychiatrists' religious commitment and psychiatric practice

Religion, Spirituality, and Ethics in Psychiatric Practice

ABSTRACT

The interface of religion, spirituality, and psychiatric practice has long been of interest to the ethical psychiatrist. Some prominent early psychotherapists had a strained relationship with religion and spirituality. They posited that religion and spirituality were forms of mental illness, which discouraged the discussion of these values during treatment despite the fact that many patients subscribed to a religious or spiritual viewpoint. Contrarily, others supported a harmonious relationship with religion and spirituality and served as trailblazers for the incorporation of religion and spirituality into psychiatric treatment.As the field of psychiatry continues to evolve, additional dimensions of the relationship between religion, spirituality, and psychiatric practice must be explored. Today, many modern psychiatrists appreciate the importance of incorporating religion and spirituality into treatment, but questions such as whether it is ethical to practice psychiatry from a particular religious or spiritual viewpoint or for psychiatrists to advertise that they subscribe to a particular religion or spirituality and to engage in religious or spiritual practices with their patients remain nuanced and complex. In this resource document, the authors put forth and examine the ramifications of a bio-psycho-social-religious/spiritual model for psychological development and functioning, with this fourth dimension shifting the focus from symptom reduction alone to include other aspects of human flourishing such as resilience, meaning-making, and hope.

Why psychiatry might cooperate with religion: The Michigan Society of Pastoral Care, 1945-1968

The early decades of the pastoral care movement were characterized by a remarkable collaboration with psychiatry. While historians of the religious aspects of this movement have noted the reliance of pastoral care on psychiatry and psychology, it has been less clear how and why mental health professionals elected to work with clergy. This paper uses the Michigan Society of Pastoral Care (MSPC), one of the early training programs for hospital chaplains on the model of the Boston-based Institute for Pastoral Care, as a window to explore the interactions between psychiatry and religion at mid century. Raymond Waggoner, the nationally recognized and well-connected chair of the psychiatry department at the University of Michigan, was instrumental in expanding the influential pastoral care program at his hospital and in his state as part of his bigger mission of emphasizing the fundamental role of psychiatry in American life. Waggoner played a key role within the MSPC, in conjunction with leaders within the medical departments of the major hospitals in the state. All of the members of the MSPC viewed psychiatry's insights as essential for pastoral care, with the caveat that chaplains should remain pupils, not practitioners of psychotherapy.

Patterns of religiosity and spirituality of psychiatrists in Brazil and the implications for clinical practice: a latent profile analysis

BACKGROUND

Although there is consensus, in psychiatry, over the inclusion of religious and spiritual aspects when evaluating and treating the patient, investigation of these dimensions is rare. There is evidence as to the relationship between psychiatrists' religious/spiritual beliefs and their willingness to discuss a patient's religion and spirituality (R/S). Due to the lack of information about how psychiatrists in Brazil deal with R/S in patient care, the aim of the present study is to analyze the religious/spiritual profile of these professionals and to ascertain its influence on attitudes and behavior in clinical practice.

METHODS

Five hundred and ninety-two psychiatrists from Brazil answered a questionnaire about R/S in clinical practice. The latent profile analysis was used to search for differences of religious/spiritual profiles. The ANOVA and Pearson's chi-square tests were employed to identify any correlation between clinical opinion and behaviors according to the different profiles.

RESULTS

Two religious/spiritual profiles were identified (entropy value > 0,96): the so called "less religious" group (n = 245), comprised predominantly by men, professionally more experienced, with a higher level of academic education (Master or PhD degrees) and were the ones who least enquired about their patients' R/S; and the "more religious" psychiatrists (n = 347) those who had higher consideration for R/S on health, and who more often addressed R/S with their patients and therefore usually ascribed importance to include R/S in their professional training.

CONCLUSION

The latent profile analysis produced two distinct classes between the Brazilian psychiatrists according to their R/S views: the more religious professionals, who investigate the patient's R/S in a more detailed manner, and the less religious, who tend to disregard this aspect.

Religion and Spirituality, Meaning, and Faith in American Psychiatry From the 19th to the 21st Century

Since the beginning of American psychiatry, we have discovered and rediscovered connections among religion, spirituality, meaning, and mental health. In the 19th century, religion was an embedded attribute of moral therapy, the framework for treatment in mental institutions. During the decades in the 20th century when psychoanalysis was ascendant in the profession, some psychiatrists collaborated with the emerging field of pastoral care. As biological psychiatry has come to dominate the profession, though, pastoral care providers and some psychiatric researchers have identified gaps in the human interactions that characterize ideal and meaningful encounters with patients. This article examines how religion has been mobilized in American psychiatry over the centuries within institutional settings, but also looks at a broad consideration of faith in psychiatrists' clinical interventions, how that has affected their interactions with religious ideas and people, and where they have found meaning and purpose in mental health care.

Religion and psychiatry: clinical applications

In an earlier article we reviewed the latest research on the relationship between religious involvement and mental health, the effects of religiosity on mental health and well-being over time and the impact of religious interventions. Here we focus on clinical applications that may be useful to psychiatrists and other mental health professionals. We discuss general clinical applications relevant to all patients (e.g. taking a spiritual history, supporting/encouraging religious beliefs, referring to clergy), violations of clinician–patient boundaries and the need to ensure that religious/spiritual interventions are patient-centred. We describe evidence-based religious interventions and how to identify appropriate patients for this approach. Finally, we explore situations in which religious beliefs and practices may be a problem, not a resource, and make recommendations on how to address such cases. Case vignettes illustrate clinical situations that mental health professionals are likely to encounter. Although the focus is on the North American context, we note how practice and culture in the UK may differ.

Integrating spirituality into the care of older adults

ABSTRACTWe examine how to sensibly integrate spirituality into the care of older adult medical and psychiatric patients from a multi-cultural perspective. First, definitions of spirituality and spiritual integration are provided. Second, we examine the logic that justifies spiritual integration, including research that demonstrates an association between religious/spiritual (R/S) involvement and health in older adults and research that indicates widespread spiritual needs in later life and the consequences of addressing or ignoring them. Third, we describe how and when to integrate spirituality into the care of older adults, i.e. taking a spiritual history to identify spiritual needs and then mobilizing resources to meet those needs. Fourth, we examine the consequences of integrating spirituality on the well-being of patients and on the doctor-patient relationship. Finally, we describe boundaries in addressing R/S issues that clinicians should be cautious about violating. Resources will be provided to assist with all of the above.

Depressive Symptoms in Newly Diagnosed Lung Carcinoma: Prevalence and Associated Risk Factors

Background

Depression is a recognized complication of lung cancer underreported in developing countries such as Malaysia. Treating and identifying depression in cancer patients increases survival and quality of life. Our objectives are to study prevalence of depressive symptoms in newly diagnosed lung carcinoma, and examine the relationship of depressive symptoms with other influencing risk factors.

Methods

A 2-year, cross sectional study February 2015–February 2017, was conducted at Hospital Tengku Ampuan Afzan, and Penang General Hospital. One hundred and three patients with newly diagnosed, biopsy confirmed primary lung carcinoma were recruited. Self-rated patient's identification sheet, validated Center for Epidemiologic Studies Depression (CES-D), and Dukes University Religion Index score from three different main languages were used.

Results

Prevalence of current depressive symptoms (CES-D total score ≥16) is 37.9%. The result suggests prevalence of those at high risk of moderate to major depression, may need treatment. Multivariate analysis reveals those with good Eastern Cooperation Oncology Group factor (η2=0.24, p<0.001) married (η2=0.14, p<0.001) with intrinsic religiosity (IR) (η2=0.07, p<0.02) are more resistant to depression.

Conclusion

One in three of lung carcinoma patients, are at increased risk for depression. Clinicians should be aware that risk is highest in those with poor performance status, single, and with poor IR. We suggest routine screening of depression symptoms as it is feasible, to be performed during a regular clinic visit with immediate referral to psychiatrist when indicated.

How psychiatrists think about religious and spiritual beliefs in clinical practice: findings from a university hospital in São Paulo, Brazil

Objective:

To examine the relationship between psychiatrists’ religious/spiritual beliefs and their attitudes regarding religion and spirituality in clinical practice.

Methods:

A cross-sectional survey of religion/spirituality (R/S) in clinical practice was conducted with 121 psychiatrists from the largest academic hospital complex in Brazil.

Results:

When asked about their R/S beliefs, participants were more likely to consider themselves as spiritual rather than religious. A total of 64.2% considered their religious beliefs to influence their clinical practice and 50% reported that they frequently enquired about their patients’ R/S. The most common barriers to approaching patients’ religiosity were: lack of time (27.4%), fear of exceeding the role of the doctor (25%), and lack of training (19.1%). Those who were less religious or spiritual were also less likely to find difficulties in addressing a patient’s R/S.

Conclusion:

Differences in psychiatrists’ religious and spiritual beliefs are associated with different attitudes concerning their approach to R/S. The results suggest that medical practice may lead to a religious conflict among devout psychiatrists, making them question their faith. Training might be of importance for handling R/S in clinical practice and for raising awareness about potential evaluative biases in the assessment of patients’ religiosity.

The discourse on faith and medicine: a tale of two literatures

Research and writing at the intersection of faith and medicine by now include thousands of published studies, review articles, books, chapters, and essays. Yet this emerging field has been described, from within, as disheveled on account of imprecision and lack of careful attention to conceptual and theoretical concerns. An important source of confusion is the fact that scholarship in this field constitutes two distinct literatures, or rather meta-literatures, which can be termed (a) faith as a problematic for medicine and (b) medicine as a problematic for faith. These categories represent distinct theoretical lenses for viewing the intersection of faith and medicine. Observations about these two approaches are offered, along with insights about why the discourse on faith and medicine should become better integrated into discussions of religion and science.

Methodological guidelines to investigate altered states of consciousness and anomalous experiences

Anomalous experiences (AE) (uncommon experiences or one that is believed to deviate from the usually accepted explanations of reality: hallucinations, synesthesia, experiences interpreted as telepathic…) and altered states of consciousness (ASC) have been described in all societies of all ages. Even so, scientists have long neglected the studies on this theme. To study AE and ASC is not necessary to share the beliefs we explore, they can be investigated as subjective experiences and correlated with other data, like any other human experience. This article presents some methodological guidelines to investigate these experiences, among them: to avoid dogmatic prejudice and to 'pathologize' the unusual; the value of a theory and a comprehensive literature review; to utilize a variety of criteria for pathology and normality; the investigation of clinical and non-clinical populations; development of new appropriate research instruments; to be careful to choose the wording to describe the AE; to distinguished the lived experience from its interpretations; to take into account the role of culture; to evaluate the validity and reliability of reports and, last but not least, creativity and diversity in choosing methods.

A preliminary survey on the religious profile of Brazilian psychiatrists and their approach to patients' religiosity in clinical practice

BACKGROUND

Although there is evidence of a relationship between religion/spirituality and mental health, it remains unclear how Brazilian psychiatrists deal with the religion/spirituality of their patients.

AIMS

To explore whether Brazilian psychiatrists enquire about religion/spirituality in their practice and whether their own beliefs influence their work.

METHOD

Four hundred and eighty-four Brazilian psychiatrists completed a cross-sectional survey on religion/spirituality and clinical practice.

RESULTS

Most psychiatrists had a religious affiliation (67.4%) but more than half of the 484 participants (55.5%) did not usually enquire about patients' religion/spirituality. The most common reasons for not assessing patients' religion/spirituality were 'being afraid of exceeding the role of a doctor' (30.2%) and 'lack of training' (22.3%).

CONCLUSIONS

Very religious/spiritual psychiatrists were the most likely to ask about their patients' religion/spirituality. Training in how to deal with a patient's religiosity might help psychiatrists to develop better patient rapport and may contribute to the patient's quicker recovery.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Clinical implications of spirituality to mental health: review of evidence and practical guidelines

OBJECTIVE

Despite empirical evidence of a relationship between religiosity/spirituality (R/S) and mental health and recommendations by professional associations that these research findings be integrated into clinical practice, application of this knowledge in the clinic remains a challenge. This paper reviews the current state of the evidence and provides evidence-based guidelines for spiritual assessment and for integration of R/S into mental health treatment.

METHODS

PubMed searches of relevant terms yielded 1,109 papers. We selected empirical studies and reviews that addressed assessment of R/S in clinical practice.

RESULTS

The most widely acknowledged and agreed-upon application of R/S to clinical practice is the need to take a spiritual history (SH), which may improve patient compliance, satisfaction with care, and health outcomes. We found 25 instruments for SH collection, several of which were validated and of good clinical utility.

CONCLUSIONS

This paper provides practical guidelines for spiritual assessment and integration thereof into mental health treatment, as well as suggestions for future research on the topic.

Toward competency-based curricula in patient-centered spiritual care: recommended competencies for family medicine resident education

Spiritual care is increasingly recognized as an important component of medical care. Although many primary care residency programs incorporate spiritual care into their curricula, there are currently no consensus guidelines regarding core competencies necessary for primary care training. In 2006, the Society of Teachers of Family Medicine's Interest Group on Spirituality undertook a three-year initiative to address this need. The project leader assembled a diverse panel of eight educators with dual expertise in (1) spirituality and health and (2) family medicine. The multidisciplinary panel members represented different geographic regions and diverse faith traditions and were nationally recognized senior faculty. They underwent three rounds of a modified Delphi technique to achieve initial consensus regarding spiritual care competencies (SCCs) tailored for family medicine residency training, followed by an iterative process of external validation, feedback, and consensus modifications of the SCCs. Panel members identified six knowledge, nine skills, and four attitude core SCCs for use in training and linked these to competencies of the Accreditation Council for Graduate Medical Education. They identified three global competencies for use in promotion and graduation criteria. Defining core competencies in spiritual care clarifies training goals and provides the basis for robust curricula evaluation. Given the breadth of family medicine, these competencies may be adaptable to other primary care fields, to medical and surgical specialties, and to medical student education. Effective training in this area may enhance physicians' ability to attend to the physical, mental, and spiritual needs of patients and better maintain sustainable healing relationships.

Special issues in the care of ultra-orthodox Jewish psychiatric in-patients

This article reviews the literature regarding psychiatric care of ultra-orthodox Jewish patients. The discussion describes common areas of difficulty working with members of this population in an in-patient setting, including ritual observance, gender dynamics, and countertransference. It provides guidelines for mental health professionals to distinguish between culturally-appropriate and pathological behavior in an effort to avoid misdiagnosis, and offers strategies for overcoming these challenges. It suggests possible adjustments to standard treatment plans which may prove effective in this population and recommends further resources, including the involvement of trained chaplains, for especially complicated situations.

Talking with patients about spirituality and worldview: practical interviewing techniques and strategies

Psychiatrists now recognize that religion and spirituality are important to much of the populace and that attending to them probably will improve clinical psychiatric practice. This article presents a practical guide for addressing some of the key interviewing skills needed to explore a patient's framework for meaning-the patient's religion, spirituality, and worldview. It offers guidelines on the process of the interview, including ways to initiate conversation in this area, with suggestions and specific questions for a more thorough exploration of the patient's religious and spiritual life.

Psychosis or Faith? Clinicians' Assessment of Religious Beliefs

This study investigated mental health professionals' assessment of the pathognomonic significance of religious beliefs. A total of 110 participants reviewed 3 vignettes depicting individuals possessing the religious beliefs associated with Catholicism, Mormonism, and Nation of Islam. The religious beliefs of the individuals in the vignettes were identified as either being integral to a religious tradition or not and also as either resulting in a threat to harm another or not. Identifying beliefs as religious resulted in lower ratings of pathology for 2 of the religions, and beliefs that did not involve a threat to harm also were rated lower for the same 2 religions. The results reveal a disjuncture between recommendations of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) and clinicians' judgments.

Religion and spirituality in child and adolescent psychiatry: a new frontier

This article introduces the interface between child and adolescent psychiatry and religion and spirituality. Developmental psychopathology has become increasingly diverse in its study of risk and protective factors for child and adolescent psychopathology. The effect of religion and spirituality on clinical conditions is among those factors. This review addresses (1) historical aspects of the relationship between psychiatry and religion/spirituality, (2) definitional issues, and (3) unique factors in child and adolescent work. Considering these factors and some general principles of intervention, it prepares the reader for other articles in this issue. The article concludes with some observations on the "secular family".

Formulation and treatment: integrating religion and spirituality in clinical practice

Developing scientifically sound and clinically meaningful case formulations is so challenging that it may verge on becoming a "lost art." Pressures (scientific, economic, and cultural) remain that prevent child and adolescent psychiatrists from getting a complete understanding of the patient and family. Including a strong consideration of data related to religion, spirituality, and worldview may seem only to complicate an already arduous task. The clinician who includes these factors in treatment is faced with decisions of when to discuss these issues, how to discuss them and in what depth, and finally, when to refer to a religious/spiritual professional. Nonetheless, the importance of these factors in the lives of many children and families leaves no option but to address them as directly as possible. It is well worth the effort and, in many cases, will open new areas for clinical improvement in patients.

Religious involvement, spirituality, and medicine: implications for clinical practice

Surveys suggest that most patients have a spiritual life and regard their spiritual health and physical health as equally important. Furthermore, people may have greater spiritual needs during illness. We reviewed published studies, meta-analyses, systematic reviews, and subject reviews that examined the association between religious involvement and spirituality and physical health, mental health, health-related quality of life, and other health outcomes. We also reviewed articles that provided suggestions on how clinicians might assess and support the spiritual needs of patients. Most studies have shown that religious involvement and spirituality are associated with better health outcomes, including greater longevity, coping skills, and health-related quality of life (even during terminal illness) and less anxiety, depression, and suicide. Several studies have shown that addressing the spiritual needs of the patient may enhance recovery from illness. Discerning, acknowledging, and supporting the spiritual needs of patients can be done in a straightforward and noncontroversial manner. Furthermore, many sources of spiritual care (e.g., chaplains) are available to clinicians to address the spiritual needs of patients.

Spiritual recovery movements and contemporary medical care

When confronted by the threat of illness, general medical and psychiatric patients may turn to treatments that have a spiritual orientation but lack empirical validation. This article examines the nature of contemporary movements that offer these treatments and their impact on medical care. A typology of spiritually oriented recovery movements is presented, including those associated with established religions, holistic medicine, or programs for self-liberation. Possible mechanisms for their behavioral and physiologic impact on health status are discussed. The psychological appeal of these treatments is analyzed in light of the way sick people may attribute meaning to illness and may then become engaged into a spiritual recovery movement, achieve a sense of self-efficacy through affiliation, and finally comply with putative "healing" practices. Although some spiritual recovery movements provide hope in the face of illness and even offer therapeutic benefits, they may also discourage patients from getting appropriate medical treatment and promote harmful regimens. Options are discussed for mental health professionals' response to the spiritual orientation of their patients and options for future research.

Religious issues in the capacity evaluation

The authors explore the difficulties present in the capacity evaluation of patients with strong religious beliefs. The article reviews the legal protection for treatment refusal on religious grounds as well as psychiatry's approach to religion. Clinical cases encountered in an urban hospital are presented to highlight how the conflicts among psychiatric, religious, and legal issues can be resolved. Suggestions are made for incorporating an exploration of religious values into the capacity assessment.

Psychiatry and ethics: the problematics of respect for religious meanings

Over the past two decades American psychiatrists have had to address the emergence of an increasingly fervent religious pluralism. Particularly in cases of socially controversial new religious movements (NRMs), distressed families have pressured psychiatrists to assess the mental state of recruits to such sects, often labeled "cults." At this inevitably acrimonious interface between family values and religious liberties, psychiatrists have for the most part resisted pressures to medicalize religious conversions. This article provides an historical review of American psychiatric response to NRMs with respect to nosology and practice. It introduces this response in the more general context of ethics and the problematics of respect for religious meanings.