In order to collaborate, clergy and clinicians must be able to recognize those signs and symptoms that indicate a need for consultation or referral. The DSM-IV introduced a new V code, religious or spiritual problem (V62.89), which the DSM-IV Sourcebook (Lu et al., 1997) describes as a category to employ in order to explicitly differentiate psychiatric mental disorders (e.g., schizophrenia, major depression) that require clinical attention from profound personal religious concerns that are not mental disorders but may be a focus of clinical attention because of difficulty integrating these experiences into the individual's social or emotional life (e.g., mystical experience, religious doubt). A third distinct category discussed in the sourcebook is labeled pure religious problems. These are described as emotional difficulties that people have within the context of organized religion and warrant neither clinical attention nor a DSM-IV diagnosis (e.g., mourning rituals, religious doctrine).
An example of the first category (mental disorders that present with religious ideation) would be a young man with schizophrenia who has isolated himself in his room and reports seeing God talking with His angels. This person should be treated by a clinician and referred to a mental health care professional if first brought to clergy. A vignette study we conducted with rabbis and clinical psychologists found agreement on this course of action, with one rabbi exclaiming, "We go right to the emergency room!" (Milstein et al., 2000).
Examples of the second category of presenting problems consist of emotional difficulties resulting from strong religious experiences and may include mystical experiences or questions of personal faith that leave a person with troubling questions, emotional discomfort and a sense of isolation (Lu et al., 1997). Although these problems may be a focus of clinical attention, they are not mental disorders and could receive a DSM-IV diagnosis of religious or spiritual problem (V62.89). Expertise for this type of care may not belong only to psychiatry, and therefore a collaborative approach may be most appropriate.
Psychiatry has come to recognize the importance of culture as the interpretive system through which people seek answers to complex questions (Bruner, 1990; Gaw, 1993). Religion is a central aspect of nearly every culture, and clinicians need to be familiar with the "nuances of an individual's cultural frame of reference" or else they "may incorrectly judge as psychopathology those normal variations in behavior, belief, or experience that are particular to the individual's culture" (APA, 1994). Therefore, if people come for clinical care in response to emotional difficulty associated with a loss of faith or anger at God after Sept. 11, we are ethically obligated to understand their theological perspective from within the interpretive system of their religious beliefs and wisdom traditions (Hopkins et al., 1995). This understanding could be gained through consultation with the patients' own clergy or with another trusted clergy with knowledge of these faiths. With the patient's consent, the clinician and clergy could devise a treatment plan incorporating each profession's expertise.
Finally, the third category of pure religious problems would not receive a DSM-IV diagnosis. This category includes normal bereavement, wherein the person is grieving but not depressed, and the mourner has many religious and philosophical questions. A large part of the professional role of clergy is guiding individuals and families through the rituals--as well as the emotional trauma--of death and burial. This is an area of psychological suffering with which clergy have expertise different from that of psychiatrists, and mental health care professionals could gain knowledge from them.
Once a differential diagnosis from within the three categories has been established, a subsequent psychiatric (or nonpsychiatric) response may be considered.Conduits to Care
Some clinicians who are co-religionist with their patients might choose to work without consultation. Some may believe that doctors and their patients should engage in religious rituals together, as part of the healing process. Although such interventions could be personally gratifying, Harry Stack Sullivan reminded us nearly 50 years ago that we should not work outside our scope of expertise. I would instead propose that we develop collaborative relationships with clergy. They are the experts in matters of religion.
Trauma, depression, bereavement, anxiety and loss of religious faith have all arisen in the aftermath of Sept. 11. We know that more than a year later, some people are only now beginning to discuss the effects of the attack on their emotional well-being (Goode and Eakin, 2002). We expect that clergy are seeing some of these signs, hearing their parishioners' symptoms and could, therefore, serve as conduits to appropriate clinical care. There may also be times when it is appropriate for psychiatrists to serve as conduits to clerical care.Collaboration With Clergy
Since 1998, I have worked with the pastoral care and education department at the Westchester Division of the New York Hospital, Weill Cornell Medical Center, to develop outreach programs to community clergy. At the hospital, we hosted a breakfast presentation by clinicians. After telling the clergy of the different mental health care services we offered, we had them write down a paragraph describing one or more challenging congregants. Our chaplain suggested to the participants that these congregants could be found among the 2% of parishioners seeking help who use 80% of the clergy's counseling hours.
We then organized several clergy case conferences based on the diagnostic similarity of the congregants described. The associate medical director presided over three separate meetings, and we were able to offer some specific suggestions to the clergy. At the same time they provided mutual comfort to one another through dialogue they initiated. Subsequent to this outreach, several clergy made referrals to our facility. We have also been able to engage clergy in the discharge planning of some patients who are active in their congregations.
Collaboration with clergy need not be limited to institutional outreach. Individual clinicians could begin their own network of collaboration through attending the interfaith clergy meetings that are common in most communities. The key to success is to develop ongoing reciprocal interaction. Clergy are disinclined to maintain contact with clinicians who treat them as a quiescent source of referrals (Meylink and Gorsuch, 1988). Two resources that have been very helpful in our outreach are the Mental Illnesses Awareness Guide for Clergy and Other Spiritual Leaders, distributed at no cost (APA, 1997); and the Web site for Pathways to Promise, a nondenominational organization consisting of religious congregations who seek to increase awareness about mental illness <www.pathways2promise.org>.
Currently, at the Montefiore Medical Center Geriatric Psychiatry Clinic in the Bronx, I am the principal investigator of a study funded by the National Institute of Mental Health that explores geriatric psychiatry outpatients' opinions about collaboration between clergy and clinicians. The data from this study will help us develop Project C.O.P.E. (Clergy Outreach & Professional Engagement), a study designed to measure the salutary (or harmful) effects of interaction between patients' clinicians and their clergy. We hypothesize that the effects could include improved adherence to psychiatric care because of reduced stigma and improved clinical outcomes from increased social support.
Sept. 11 taught many lessons about how all of us are capable of working across social and professional boundaries to help the injured to heal. Research on the outcomes of reciprocal collaboration between psychiatrists and clergy is a project intended to bring disparate areas of expertise to the single goal of improved mental health.