Part I: The Growing Focus in Clinical Care
Part ll, to be published in the next Newsletter, will
provide a review of published research findings on spirituality and
mental health
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David B. Larson MD, MSPH
President, International Center for the Integration of Health and
Spirituality
Adjunct Professor, Departments of Psychiatry and the Behavioral
Sciences
Duke University Medical Center, Durham, NC, and
Northwestern University Medical School, Chicago, IL, USA
Susan S. Larson MAT
Editor, Research Reports
International Center for the Integration of Health and
Spirituality, Rockville, MD, USA
Introduction
Patient spirituality, a once disregarded dimension, is emerging
in research and clinical care as a relevant factor in mental
health. Internationally, psychiatry's professional associations
have highlighted the need for developing sensitivity to this life
dimension. A growing number of US psychiatric residencies now
include training on how to address patient spirituality in clinical
care. Quantitative research in the last 15 years in the U.K, the
US, and other countries has discovered aspects of this complex
dimension generally linked with beneficial mental health
outcomes.(1,2) Research
has also helped clarify aspects of negative religious
coping.(3)
This two-part article summarizes some of the changes in focus,
clinical education, and assessment in the field of psychiatry, as
well as reviews research findings investigating spirituality and
mental health.
Part I will discuss the growing professional recognition of
spirituality as a relevant mental health factor in clinical care
and research, and discuss some of the recent changes in residency
training and clinical assessment to include patient
spirituality.
Part II will briefly summarize some of the published research.
Findings include positive clinical associations of spirituality
with mental health in the areas of 1) prevention, coping, and
recovery from depression, 2) suicide prevention, 3) substance abuse
prevention and treatment, 4) coping with surgery and severe medical
illness, 5) enhancing health behaviors, and 6) links with
longevity. Research also identifies potential harmful aspects of
some spiritual/religious beliefs or attitudes.
(Note: For an extensive overview, the Handbook of Religion and
Health, Oxford University Press 2001, reviews more than 1,200
published research studies, providing findings on the positive and
negative effects of spirituality and religion on physical, mental,
and social health from childhood to old age.(1) For research summaries and reviews, and other
resources please also visit the International Center for the
Integration of Health and Spirituality website: http://www.icihs.org/)
Renewed Professional Focus
Regarding psychiatry's renewed focus on spiritual factors, Dr.
Ahmed Okasha from Egypt, past president of the World Psychiatric
Association (WPA), stated that religion has remained "an important
factor in most patients' lives, no matter where in the world they
live." Speaking at the world congress of the WPA in 1999, he urged
colleagues to make a more concerted effort to include "the
philosophical and empirical study of the spiritual variable in
mainstream psychiatric research." He emphasized psychiatrists would
be better able to help their patients if "the vocabulary and
concepts of religion were more familiar to trainees and
practitioners." Failure to become more sensitive to this dimension
can increase the distance between psychiatrists and those they
serve--their patients, he noted.(4)
In the U.K., the Royal College of Psychiatrists identified the
need to consider spiritual issues in 1992. The College noted "the
need to emphasize the physical, mental and spiritual aspects of
healing in the training of doctors in general and psychiatrists in
particular. Religious and spiritual factors influence the
experience and presentation of illness."(5)
In fact, a survey of 200 London psychiatrists in 1993 found 90%
viewed religious beliefs as relevant to patient mental health and
"to be considered during assessment and therapy...but interventions
in this area, such as referral to and liaison with the clergy, were
extremely rare."(6)
In his Royal College of Psychiatry Presidential address in 1994,
Dr. Andrew Simms stated: "For too long psychiatry has avoided the
spiritual realm...but psychiatrists have neglected it at their
patients' peril. We need to evaluate the religious and spiritual
experience of our patients in etiology, diagnosis, prognosis and
treatment."(7) Dr. D. Crossley followed up in
1995 in the British Journal of Psychiatry, underscoring both the
clinical and research neglect of attending to patient religion and
identifying steps to take to address this neglect.(8)
In the US the American Psychiatric Association (APA) in 1990
issued "Guidelines Regarding Possible Conflict Between
Psychiatrists' Religious Commitment and Psychiatric
Practice,"(9) noting the usefulness for
psychiatrists to obtain clinical data and information on "the
religious or ideological orientation and beliefs of their patients
so that they may properly attend to them in the course of
treatment."
The guidelines underscored that "no practitioner should force a
specific religious, anti-religious, or ideological agenda on a
particular patient." The Guidelines provided an example of a
psychiatrist whose worldview differed from those of a devoutly
religious patient. The psychiatrist interpreted the patient's
long-standing religious commitment as "foolishly neurotic." The
Guidelines noted, "Because of the intensity of the therapeutic
relationship, the interpretations caused great distress and
appeared related to a subsequent suicide attempt." The APA's
"Practice Guidelines for the Psychiatric Evaluation of Adults" in
1995 also further called for a respectful, clinical
assessment.(10) In the last three years, the
APA's annual meeting has included a large number of symposium and
workshops on spirituality and religion.
Relevance Affirmed by World Health Organization
The World Health Organization (WHO) published a position paper
on how to assess quality of life across cultures stressing the
importance of recognizing religion/spirituality and personal
beliefs.(11) The WHO's six broad domains of
quality of life relevant across cultures included: 1) the physical
domain, 2) the psychological domain, 3) level of independence, 4)
social relationships, 5) environment, and 6)
spirituality/religion/personal beliefs.
The WHO report commented that spirituality/religion/personal
beliefs might affect quality of life by helping persons cope with
difficulties in their life, by giving structure to their
experience, ascribing meaning to spiritual and personal questions,
and more generally by providing the person with a sense of greater
well-being. For many people religion, personal beliefs, and
spirituality are a source of comfort, well-being, security,
meaning, sense of belonging, purpose and strength, the report
stated. However, the report noted some people feel that religion
can have a negative influence on their life. Consequently, research
which can help identify clinical benefits or harms of
spirituality/religion allows each facet to emerge.
Life Dimension or "Disorder": Past Theoretical Assumptions
Historically, psychiatry, at least in the US, has often taken a
less than neutral stance in assessing the role of
religious/spiritual beliefs in a person's life. Freud viewed
religion as "a universal obsessional neurosis...infantile
helplessness...a regression to priMary narcissism."(12) Contemporary US psychologist Albert Ellis, best
known for his significant work on Rational Emotive Therapy,
wrote:
Religiosity is in many respects equivalent to irrational
thinking and emotional disturbance...The elegant solution to
emotional problems is to be quite unreligious...the less religious
they are, the more emotionally healthy they will be.(13)
Freud's suppositions reflect his personal avowed
atheism,(14) with his viewpoint embodied in
his theoretical assumptions.(15) Yet to
dismiss the spiritual/religious dimension as inherently
pathological suggests a rather simplistic, non-neutral stance
regarding a dimension of life centrally important to many.
Furthermore, it lacks openness to recognition of the potential
positive role religion/spirituality may play in some patients'
lives.
Systematic Research Reviews Find Clinical Benefits
To bring objectivity to these theoretical assumptions,
researchers investigated to what degree these assertions of
religion/spirituality as psychopathology have found support in
quantitative research in four leading western psychiatry
journals.
A systematic review of psychiatric research published in the
American Journal of Psychiatry in 1986 surveyed all articles
published in psychiatry's top four general psychiatry journals
during five years. These included the British Journal of
Psychiatry, Canadian Journal of Psychiatry, American Journal of
Psychiatry, and the Archives of General Psychiatry. This
comprehensive review found only 3 of the 2,348 quantitative studies
contained a religious variable as the central focus of the study.
Only 1 study used a state-of-the-art measure, a multi-dimensional
religious commitment questionnaire previously tested for
reliability. Only 2.5% of the quantitative studies included any
religious variable including denomination, with more than
three-fifths of this already small 2.5% using just a single item of
denomination, inadequate in measuring beliefs, attitudes, or
frequency of practices.(16) Consequently,
studies of religious or spiritual commitment in psychiatry seemed
to fall far short of the level needed to build such definitive
theoretical constructs.
In the studies that did include a religious variable,
researchers investigated whether findings would confirm US
psychiatry's historical presupposition of harm. A systematic review
of all quantitative articles published during more than 10 years in
the American Journal of Psychiatry and the Archives of General
Psychiatry found 72% of the findings revealed a positive clinical
association between religious commitment and mental health, 16%
were negative and 12% were non-significant.(17) Furthermore, parallel findings emerged in
systematic reviews in the fields of family medicine(18) and epidemiology research.(19) High levels of benefit, if not higher, are
documented in the recent Oxford Handbook of Religion and
Health.(1) Similar reviews are now needed of
journals beyond the US to assess whether studies reveal similar
findings.
Understanding Prevalent Patient Religious Coping
At least two US studies have documented desires of psychiatric
patients for spiritual support, with more research needed. A 1995
survey of 30 psychiatric patients with diagnoses including
schizophrenia, bipolar disorder, unipolar depression,
schizoaffective disorder, and personality disorder, found:
· A substantial 83% felt that spiritual belief had a positive
impact on their illness through the comfort it provided and the
feelings it fostered of being cared for and not being alone.
· 57% attended religious services as well as prayed at least
daily. However, a quite sizeable 38% expressed discomfort with
mentioning their spiritual or religious concerns with their
therapist.(20)
· A 1997 survey compared spiritual needs of 51 psychiatric
inpatients with 50 general medical inpatients matched for age and
sex: Some 80% of the psychiatric inpatients and 86% of the medical
inpatients considered themselves spiritual or religious
persons
A substantial 48% of psychiatric patients and 38% of medical
inpatients reported they were "deeply religious."
When asked to what degree they relied on religion as a source of
strength:
68% of psychiatric patients and 72% of medical patients indicated
"a great deal."
Only 10% of psychiatric patients and 2% of medical patients
indicated "not at all."
The study also found that 88% of the psychiatric patients and 76%
of the medical patients reported having three or more specific
spiritual/religious needs while hospitalized. These included
· the need to know God's presence (84% of psychiatric patients, 82%
of medical patients)
· the need for prayer (80% of psychiatry patients, 88% of medical
patients) and
· the need for a visit from a chaplain to pray with them (65% of
psychiatric patients and 66% of medical patients).(21)
Historically, many US doctors have remained unaware of the central
role religious faith might play in helping patients deal with
illness. For example, one study at Duke University Medical Center
found that 44% of hospitalized medical patients indicated that
religious beliefs were the most important factor in coping with
their illness. However, only 9% of physicians recognized this
central role.(22) Religious issues often have
remained neglected. The new focus in psychiatric residency training
to become more aware of a patient's religious values and beliefs
encourages more responsive care.
Illness and Spiritual Crisis
Why might patients pronounce the potential relevance of
spirituality to their care? A decline in mental or physical health
often precipitates a spiritual crisis. Patients often start to
question their purpose in life, the meaning of their work, their
relationships, and their personal identity, as well as their
ultimate destiny. Furthermore, patients may draw upon their
spiritual/religious beliefs in dealing with anxiety about their
diagnosis, pain from their illness, a sense of isolation, and
feelings of loss of control.(23,24)
Religious practices and beliefs may promote a positive,
optimistic world-view that gives meaning, which in turn provides a
sense of purpose and direction and enhances hope and
motivation.(25)
Ethical Concerns in Addressing Patients' Spirituality
A few healthcare professionals have argued that
spiritual/religious issues have little place in medical care,
calling spirituality a "non-medical agenda," (26) although these comments referred to medicine and
not necessarily psychiatry or mental health care. Yet for those
patients for whom spirituality and religion are significant, the
ethical responsibility suggests the importance of attention to
spirituality.(27)
Consequently, the physician who is committed to the patient's
best interests should consider when and how best to respond to
patient spirituality, if the patient deems it relevant, with the
physician or psychiatrist doing so within appropriate professional
boundaries. Because patients often draw on their
religious/spiritual beliefs in the context of their serious
illness, physicians who have no such belief systems themselves can
still consider how best to respect and, when appropriate, support
patients' beliefs that may assist them in coping with illness.
Psychiatric Residency Education
Mandates of the US Accreditation Council (ACGME) for Graduate
Medical Education in 1994 required educating psychiatry residents
about religious and spiritual factors as a potentially relevant
dimension of patients' lives.(28) To meet the
need for instruction in addressing patients' religious/spiritual
issues, a group of US psychiatrists from diverse religious
persuasions-Buddhist, Hindu, Jewish, Christian, Moslem, and
agnostic- formulated a model curriculum released in May 1996 at the
APA annual meeting for use by psychiatric residencies in supporting
the development of their own programs. The Model Curriculum for
Psychiatric Residency Training Programs: Religion and Spirituality
in Clinical Practice: A Course Outline(29)
provides three core units, eight accessory units and suggested
learning formats.
Residency training courses build on curricula now in more than
two-thirds of US medical schools focusing on spirituality and
medicine.(30) The Association of American
Medical Colleges (AAMC) also has provided curriculum objectives
that underscore the importance of addressing patients' spiritual
issues as part of becoming a compassionate doctor, stating
physicians should seek to understand the patient "in the context of
the patient's beliefs and family and cultural values."(31)
Also, from 1997-2000 in the conjunction with the then National
Institute for Healthcare Research, now the International Center for
the Integration of Health and Spirituality, the John Templeton
Foundation awarded 16 outstanding programs in psychiatry and
spirituality, including 13 general programs and 3 in child and
adolescent. Awardees included Harvard, Baylor, and Georgetown.
The programs cover a variety of topics and use a number of
different teaching approaches. Residents learn how to perform an
in-depth spiritual-religious-values assessment as well as how to
recognize spiritual strengths, distress, and supports. Patient
interviews, either live or videotaped, are used to demonstrate
psychopathology involving religious content on the one hand, or how
spiritual/religious beliefs and practices can provide support or
strength during psychiatric illness, on the other.(32) Teaching approaches have included clinical case
conferences and group supervision to teach residents how to address
and work with patients' spiritual issues. Some programs have panel
discussions by members of the clergy or patients of various
religious/spiritual backgrounds.
Aspects of the professional therapeutic relationship are also
discussed with issues of transference and countertransference in
relation to the spiritual aspects of the psychiatrist-patient
relationship. Boundaries and ethical considerations are
addressed.
(For more information on residency curriculum, please see
"Spirituality in Psychiatry Residency Training Programs," in the
International Review of Psychiatry (2001), 13, 131-138.31)
Assessment
In taking a spiritual or religious history a psychiatrist has
the opportunity to learn more about a patient's spiritual/religious
resources, potential motivations, or possible defenses without
either advocating or disparaging a patient's particular religious
beliefs.
Possible areas or inquiry might include the following: (For a
fuller discussion please see "Religion and Mental Health: Evidence
for an Association," International Review of Psychiatry (2001) 13,
67-78,(25) or "Spirituality and Religion in Psychiatric Practice:
Parameters and Implications. Psychiatric Annals 2000;
30(8):549-555.(33)
- What is the patient's spiritual/religious background?
- Are spiritual/religious beliefs supportive and positive, or
anxiety-provoking and punitive?
- What role did spirituality/religion play in childhood, and how
does the patient feel about that now?
- What role does spirituality/religion play now in a patient's
life?
- Is religion/spirituality drawn upon to cope with stress? In
what ways?
- Is the patient a member of a religious community? How
supportive do they perceive it to be?
- What is the patient's relationship with their clergy like?
- Are there any spiritual or religious issues the patient would
like to discuss in therapy?
- Does the patient's spiritual/religious beliefs influence the
type of therapy he or she would be most comfortable with?
- Does the patient's spiritual/religious beliefs influence how he
or she feels about taking medication, indicating views that may
impact compliance?
After assessing the patient's religious background and spiritual
needs, the psychiatrist may need to coordinate resources to meet
those needs when appropriate. This may involve collaborating with a
mental health professional trained in spiritual or religious
issues, or skilled chaplains or clergy in an outpatient setting,
or, in the case of inpatients, when appropriate, authorizing visits
from a hospital chaplain, or the patient's clergy, or a friend from
church, synagogue, mosque, or temple.
SumMary of Part I
A renewed focus by psychiatry's professional organizations
recognizes the potential relevance of patient spirituality/religion
in clinical care. Quantitative research findings have generally
pointed to benefits to mental health not merely harm, as some
theorists had proposed. The acknowledgement of the World Health
Organization of spirituality as one component of well-being across
cultures along with patient surveys in the US have documented the
potential relevance of spirituality/religion to many patients.
To better understand the role patient spirituality might play in
either positively helping patients cope with mental illness on the
one hand, or negatively adding to the conflict or distress on the
other, psychiatry residency programs in the US are now
incorporating curricula on addressing patient spirituality. This
includes learning to take a spiritual/religious history to assess
whether this dimension is relevant or important to the patient and
discovering how it might help or hinder, and then learning how to
potentially address these issues in the treatment setting.
References
1. Koenig HK, McCullough ME,
Larson DB. Handbook of Religion and Health. Oxford: Oxford
University Press, 2001
2. Gartner J, Larson DB, Allen G.
Religious commitment and mental health: A review of the empirical
literature. Journal of Psychology and Theology 1991;19(1):6-25
3. Pargament KI, Koenig HG,
Tarakeshwar N, Hahn J. Religious struggle as a predictor of
mortality among medically ill elderly patients: a two-year
longitudinal study. Archives of Internal Medicine 2001; 161:
1881-1885
4. K.H. WPA official urges
colleagues to heed role of religion and mental health. Psychiatric
News September 17, 1999; p.6, 23
5. Kehoe R., Moore A, Pearce J,
et al. Developing training themes from HRH's delivery. British
Journal of Psychiatry 1992; 160:569
6. Neeleman J, King MB.
Psychiatrists religious attitudes in relation to their clinical
practice: a survey of 231 psychiatrists. Acta Psychiatrica
Scaninavica 1993; 88: 423
7. Sims A. Psyche-spirit as well
as mind. British Journal of Psychiatry 1994; 165:441-446
8. Crossley D. Religious
experience with mental illness: Opening the door on research.
British Journal of Psychiatry 1995; 166:284-286
9. American Psychiatric
Association Committee on Religion and Board of Trustees. Guidelines
regarding possible conflict between psychiatrists' religious
commitment and clinical practice. American Journal of Psychiatry
1990; 1474:542
10. American Psychiatric
Association. Practice guidelines for the psychiatric evaluation of
adults. American Journal of Psychiatry 1995; 152(11): 63-80
11. The World Health
Organization Quality of Life Assessment (WHOQOL): Position paper
from the World Health Organization. Social Science Medicine 1995;
41(10):1403-1409
12. Freud, Sigmund. (1907).
Obsessive actions and religious practices. In Standard Edition of
the Complete Works of Sigmund Freud, vol. 9, London: Hogarth, 1959:
126-127
13. Ellis, A. Psychotherapy and
atheistic values. Journal of Consulting and Clinical Psychology.
1980; 48: 635-639
14. Pfister O. Psychoanalysis
and faith. The Letters of Sigmund Freud andOskar Pfister. Edited by
Meng H,.Freud EL, eds. New York: Basic Books, 1963
15. Kung H. Freud and the
Problem of God. New Haven: Yale University Press, 1979
16. Larson, DB, Pattison, EM,
Blazer, DG, Omran, AR, and Kaplan, BH. Systematic analysis of
research on religious variables in four major psychiatric journals,
1978-1982. American Journal of Psychiatry 1986; 149: 329-334
17. Larson, DB, Sherrill, KA,
Lyons, JS, Craigie, FC, Thielman, SB, Greenwold, MA, Larson, SS.
Dimensions and valences of measures of religious commitment found
in the American Journal of Psychiatry and the Archives of General
Psychiatry 1978 through 1989. American Journal of Psychiatry. 1992;
149:557-559
18. Craigie FC, Larson DB, Liu
IY. References to religion in the Journal of Family Practice:
Dimensions and valence of spirituality. The Journal of Family
Practice 1990; 30(4):477-480
19. Levin JS, Vanderpool HY. Is
frequent religious attendance really conducive to better health?:
Toward an epidemiology of religion. Social Science and Medicine
1987; 24:589-600
20. Lindgren KN, Coursey RD.
Spirituality and serious mental illness:A two-part study.
Psychosocial Rehabilitation Journal 1995; 18(3), 93-111
21. Fitchett G, Burton LA,
Sivan AB. The religious needs and resources of psychiatric
patients. Journal of NervoUS and Mental Disease 1997;
185:320-326
22. Koenig HG, Bearon LB, Hover
M, et al. Religious perspectives of doctors, nurses, patients and
families. Journal of Pastoral Care 1991; 45: 254-267
23. Koenig HG, Larson DB,
Weaver AJ. Research on Religion and Serious Mental Illness in
Spirituality and Religion in Recovery From Mental Illness. Edited
by Fallott RD, ed. San Francisco: Jossey-Bass, 1998; 80:81-95
24. Koenig HG. Use of religion
by patients with severe medical illness. Mind/Body Medicine 1997;
2(1):31-43
25. Koenig HG, Larson DB.
Religion and mental health: evidence for an association.
International Review of Psychiatry 2001; 13:67-78
26. Sloan RP, Bagiella E,
Powell T. Viewpoint: Religion, spirituality, and medicine. Lancet
1999; 353:664-667
27. Post SG, Puchalski CM,
Larson DB. Physicians and patient spirituality: Professional
boundaries, competency, and ethics. Annals of Internal Medicine
2000; 132(7): 578-583
28. Accreditation Council for
Graduate Medical Education. Special Requirements for Residency
Training in Psychiatry. Chicago: Accreditation Council for Graduate
Medical Education; 1994
29. Larson DB, Lu FG, Swyers
JO. Model Curriculum for Psychiatric Residency Training Programs:
Religion and Spirituality in Clinical Practice: A Course Outline.
Rockville, MD: National Institute for Healthcare Research, 1997
30. Puchalski CM, Larson DB.
Developing curricula in spirituality and medicine. Academic
Medicine 1998; 73(9):970-974
31. Association of American
Medical Colleges. Report I: Medical Schools Objective Project.
Washington, DC: Association of American Medical Colleges,
1998:2-4
32. Puchalski CM, Larson DB, Lu
FG. Spirituality courses in psychiatry residency programs.
Psychiatric Annals 2000; 30(8)543-548
33. Meador KG, Koenig HG.
Spirituality and religion in psychiatric practice: Parameters and
implications. Psychiatric Annals 2000; 30(8):549-555