A pragmatic approach to teaching psychiatry residents the assessment and treatment of religious patients

World Psychiatric Association-Asian Journal of Psychiatry Commission on Psychiatric Education in the 21st century

Psychiatric practice faces many challenges in the first quarter of 21st century. Society has transformed, as have training requirements and patient expectations, underlining an urgent need to look at educational programmes. Meanwhile, awareness has grown around psychiatric disorders and there are evolving workforce trends, with more women going to medical school and specialising in psychiatry. Trainee psychiatrists carry different expectations for work-life balance and are increasingly becoming conscious of their own mental health. A tendency to see health as a commodity and the litigious nature of society has elicited additional pressures for healthcare professionals. Cartesian mind-body dualism has created further complexity and this can often be frustrating for patients and care-partners alike. In many cultures across Asia and beyond, patients can present with physical symptoms to express underlying psychological distress with increasing physical investigations. Simultaneously, in various countries, a shift from asylums to community-based interventions and then home treatments have changed psychiatric care in remarkable ways. These changes have added to pressures faced by mental healthcare professionals. However, trainees and other mental healthcare professionals continue to receive similar training as they did a generation ago. The tensions and differences in ideology/orientation between different branches of psychiatry have made responses to patient needs challenging. Recognising that it is difficult to predict the future, this World Psychiatric Association-Asian Journal of Psychiatry Commission makes recommendations that could help institutions and individuals enhance psychiatric education. This Commission draws from existing resources and recent developments to propose a training framework for future psychiatrists.

Teaching Spiritual and Religious Competencies to Psychiatry Residents: A Scoping and Systematic Review

PURPOSE

For many persons worldwide, mental health is inseparably linked with spirituality and religion (S&R), yet psychiatrists have repeatedly expressed doubts regarding their preparedness to address patients' spirituality or religion appropriately. In recent decades, medical educators have developed and implemented curricula for teaching S&R-related competencies to psychiatry residents. The authors reviewed the literature to understand the scope and effectiveness of these educational initiatives.

METHOD

The authors searched 8 databases to identify studies for a scoping review and a systematic review. The scoping review explored educational approaches (topics, methods) used in psychiatry residency programs to teach S&R-related competencies. The systematic review examined changes in psychiatry trainees' competencies and/or in patient outcomes following exposure to these educational interventions.

RESULTS

Twelve studies met criteria for inclusion in the scoping review. All reported providing residents with both (1) a general overview of the intersections between mental health and S&R and (2) training in relevant interviewing and assessment skills. Seven of these studies-representing an estimated 218 postgraduate psychiatry trainees and at least 84 patients-were included in the systematic review. Residents generally rated themselves as being more competent in addressing patients' S&R-related concerns following the trainings. One randomized controlled trial found that patients with severe mental illness who were treated by residents trained in S&R-related competencies attended more appointments than control patients.

CONCLUSIONS

S&R-related educational interventions appeared generally well tolerated and appreciated by psychiatry trainees and their patients; however, some topics (e.g., Alcoholics Anonymous) received infrequent emphasis, and some experiential teaching methodologies (e.g., attending chaplaincy rounds) were less frequently used for psychiatry residents than for medical students. The positive association between teaching S&R-related competencies to psychiatry residents and patient appointment attendance merits further study. Future trainings should supplement classroom learning with experiential approaches and incorporate objective measures of resident competence.

Religious/spiritual care needs and treatment alliance among clinical mental health patients

WHAT IS KNOWN ON THE SUBJECT?: The relationship between patient and professional is one of the cornerstones of successful treatment in mental health care. For part of the mental health patients, a similar outlook on life with their caregiver(s) is important. Attention to religion/spirituality (R/S) in mental health care is likely to influence the relationship between a patient and mental health professional, for patients preferring so. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Patients, who appreciate and experience personalized attention to R/S in conversations with practitioners and nurses, are likely to receive the highest therapeutic benefit from their relationship with their mental health professionals Patients who welcome personalized attention to R/S in conversations but find themselves unsupported in this regard experience significantly lower levels of treatment alliance than do those whose needs are met or those who do not express such needs For religious and nonreligious patients attaching importance to a similar outlook on life with practitioner or nurse, this experience was also related to a better relationship, compared with patients preferring so but experiencing a different outlook on life. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Personalized attention to R/S in conversations is recommended, both for practitioners and nurses. In case of a different outlook on life between a patient and mental health professional, addressing R/S with an open and respectful attitude may prevent negative effects on a patient's treatment experience. ABSTRACT: Introduction Attention to religion and spirituality (R/S) in mental health care has increased and may benefit treatment alliance. Aim To describe the association of (un)met R/S care needs with treatment alliance and compliance among mental health patients. Methods Patients in a Christian and a secular mental health clinic (n = 201) filled in a questionnaire. Scales of met and unmet R/S care needs (range 0-14) were regressed on the Working Alliance Inventory (WAI), Service Engagement Scale and Medication Adherence Report Scale. Ancova analyses were performed for the fourteen R/S care needs separately. Results In the Christian clinic, met R/S care needs were associated with a higher WAI score (p = .001) and unmet R/S care needs, with a lower WAI score (p = .000). For the Secular clinic, the same trends were observed, but insignificant. Items with the strongest associations were conversations about religious distress with a nurse (p = .000) and a similar outlook on life with practitioner (p = .001) or nurse (p = .005). (Un)met R/S care needs were not associated with treatment compliance. Discussion and implications for practice We recommend personalized attention to R/S in conversations. A (perceived) similar outlook on life with mental health professionals may be beneficial for religious and nonreligious patients.

Training Psychiatry Residents in Descriptive Psychopathology: A Systematic Review

PURPOSE

Descriptive psychopathology (DP, sometimes called psychopathology or phenomenology) is the language of psychiatry and is dedicated to the description of mental symptoms. Due to its importance, there is an ongoing case to put it back at the heart of psychiatry and its training. This study seeks to examine the literature on how to train psychiatry residents in DP, including reported educational interventions and educational methods.

METHOD

The authors conducted a systematic review following the PRISMA and BEME guidelines to identify literature on how to train psychiatry residents in DP. In May 2019, they searched in Embase, ERIC, PsycINFO, PubMed, Scopus, and Web of Science; of 7,199 initial results, 26 sources were finally included for analysis. The assessment tools were the CRAAP test, Kirkpatrick's 4 levels, and (when applicable) the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

The mean CRAAP score was 38.885 of a possible 50 (SD 0.983; range: 36.859-40.910). Fourteen sources (53.8%) had some kind of training evaluation: Kirkpatrick's level 1 was present in nearly all (13) and was the highest in half of them (7). Regarding the educational interventions, the mean MERSQI score was 10.592 of a possible 18 (SD 2.371; range 9.085-12.098). Lectures were the most widely reported educational method (5); among those in clinical settings, the live supervised interview with feedback was the most usual (4).

CONCLUSIONS

Despite its core importance as the language of psychiatry, the literature about training psychiatry residents in DP is scarce and heterogeneous. General lack of training evaluation and ongoing overemphasis on Kirkpatrick's levels 1-2 at the expense of levels 3-4 are causes for concern. During the review process, the authors identified a selection of educational interventions that could serve as the basis for the design of new training efforts in both clinical and nonclinical settings. Topics for future research are also suggested, such as the role of DP in competency-based training frameworks now in vogue and a series of neglected contents. Finally, the combined use of the CRAAP test and the MERSQI may be useful for future systematic reviews in medical education.

Assessing Transcendental Experiences vs Mental Illnesses

In our experience, being able to differentiate between mental illness and transcendent experiences has led patients to remain engaged in treatment. This is important since those who have experienced religious preoccupation are the least likely to seek out mental health care. We have developed a "Transcendent Assessment Tool" to assist clinicians and clients in discerning whether an experience is a delusion or part of a transcendent experience.

A Descriptive Study of a Spirituality Curriculum for General Psychiatry Residents

OBJECTIVE

The study collected data on the attitudes of residents toward religion and spirituality in their practice after taking part in a 3-year curriculum on spirituality during their residency.

METHODS

This is a descriptive, single-site study with psychiatry residents as subjects. A questionnaire was given to the residents at the end of their third year of residency (N = 12).

RESULTS

The responses heavily endorsed the religiousness/spirituality curriculum to be helpful and meaningful. Residents consider addressing spiritual and religious needs of patients to be important (76.9%) and appropriate. For majority of the residents (69.2%), there is strong agreement in the management of addictions having spiritual dimensions. Residents also strongly agreed that treatment of suffering, depression, guilt, and complicated grief may require attention to spiritual concerns (92-100%).

CONCLUSION

Regardless of cultural or religious background, the residents endorsed the curriculum as a worthwhile experience and increased their appreciation of the place of spirituality in the holistic care of patients with psychiatric conditions.

Competence of medical students and residents in psychiatry regarding spirituality, at a South African school of clinical medicine

OBJECTIVE

Elsewhere, curricula for undergraduate and postgraduate psychiatry have been extended to include the role of spirituality. It has also become important to establish how, within accepted professional boundaries, spirituality should be incorporated appropriately into the current model for South African practice and training. The objectives included exploring, analyzing, and describing the views and experience of local academic psychiatrists on this topic.

METHODS

This study was designed as an explorative, descriptive, phenomenological qualitative investigation. In-depth, semi-structured interviews were conducted with individual academic specialist psychiatrists as the primary data source.

RESULTS

Data saturation was achieved after 13 interviews. "Training of spirituality in psychiatry" emerged as one of six main themes from the integrated interview and literature content. All participants proposed that spirituality must be included in undergraduate medical and specialist psychiatric training. They have suggested that a mentorship model should be considered, which implies the reorientation of the teachers of psychiatry in this regard.

CONCLUSIONS

This view concurred with the international medical literature, recommending that spirituality has to be incorporated into specialist psychiatric practice and training, but within professional boundaries and with all faith traditions and belief systems considered equally.

Understanding and addressing religion among people with mental illness

This article reviews recent advances in the domain of psychiatry and religion that highlight the double-edged capacity of religion to enhance or damage health and well-being, particularly among psychiatric patients. A large body of research challenges stereotyped views of religion as merely a defense or passive way of coping, and indicates that many people look to religion as a vital resource which serves a variety of adaptive functions, such as self-regulation, attachment, emotional comfort, meaning, and spirituality. There is, however, a darker side to religious life. Researchers and theorists have identified and begun to study problematic aspects of religiousness, including religiously-based violence and religious struggles within oneself, with others, and with the divine. Religious problems can be understood as a by-product of psychiatric illness (secondary), a source of psychiatric illness (primary), or both (complex). This growing body of knowledge underscores the need to attend more fully to the potentially constructive and destructive roles of religion in psychiatric diagnosis, assessment, and treatment. In fact, initial evaluative studies of the impact of spiritually integrated treatments among a range of psychiatric populations have shown promising results. The article concludes with a set of recommendations to advance future research and practice, including the need for additional psychiatric studies of people from diverse cultures and religious traditions.

Introducing spirituality into psychiatric care

Spirituality is important to many psychiatric patients, and these patients may be moved toward recovery more effectively if their spiritual needs are addressed in treatment. This, however, is rarely given expression in the psychiatric services of teaching hospitals. In order to develop this potential area of improved care, we (1) evaluated the differential attitudes of patients and psychiatric trainees toward the value of spirituality in the recovery process, (2) established a program of group meetings conducted by psychiatric residents and staff where patients can discuss how to draw on their spirituality in coping with their problems, and (3) established related training experiences for psychiatric residents. The results and implications of these three initiatives are presented.