Michael A. Norko, MD, MAR

Can spirituality be used as a tool in treatment? In this video, Dr Michael Norko briefly discusses spirituality and its role in clinical care. Colleagues also summarize their recent presentations on spirituality and religion in psychiatric practice.

Although not a substitute for therapeutic measures, a patient’s spiritual “framework” can hold the key to therapeutic breakthroughs. At a recent workshop, John R. Peteet, MD; Michael A. Norko, MD, MAR; Wai Lun Alan Fung, MD, ScD; and Theresa A. Yuschok, MD presented their experiences in teaching residents and others about spirituality in psychiatry and how and when it can and should (and should not) be used as a tool in treatment. In this video, Dr Michael Norko briefly discusses spirituality and its role in clinical care [for the transcript, 

]. Highlights of the presentations below.


Dr Peteet described a semester-long course for PGY-IV residents in the Harvard Longwood Psychiatry Residency Program he has co-led with Dr Mary McCarthy for the past 18 years since receiving a Templeton curriculum award. The primary aim of the course is to help residents deal more effectively with spiritual and religious issues arising in therapy, including their ethical, transferential, and countertransferential aspects.

Standard sessions include: invited presentations by a researcher in the physiology of spirituality, a psychoanalyst who discusses a resident’s case, and an expert in high intensity groups (cults); discussion of a framework for understanding the role of the clinician in the patient’s spiritual life; and an interview of a patient for whom emotional and spiritual issues are intertwined. Residents select among several other invited presentations, eg, on Haitian, Pentecostal, or Muslim spirituality, or on spiritual care at the end of life. An annotated bibliography and the use of selected papers introduce residents to the growing literature in this area, but the most successful sessions help them articulate what they themselves bring to encounters with patients for whom spirituality is a resource, a source of conflict or both.

Dr Peteet is Associate Professor in the Department of Psychiatry, Harvard Medical School, and Medical Director (Psychiatry), Adult Psychosocial Oncology Program, Dana-Farber Cancer Institute, in Boston.


Dr Norko described the 12-week elective course he teaches in the Department of Psychiatry at Yale University School of Medicine, along with Mary Dansinghani, MDiv, chaplain at the Connecticut Mental Health Center in New Haven. The course was structured upon the recommendations of the Model Curriculum for Psychiatric Residency Training Programs: 

Religion and Spirituality in Clinical Practice-A Course Outline

, published by National Institute for Healthcare Research in 1997-with additional input from colleagues such as Dr Peteet [for Dr Norko's video transcript, 

The attendees have included psychiatry residents and psychology post-docs, licensed clinicians of various mental health disciplines, patients, volunteers and peer counselors, and a chaplaincy intern. Pre- and post-survey data have demonstrated substantial improvements in participants’ skills and knowledge in assessing religious/spiritual/worldview (RSW) beliefs; distinguishing normative RSW beliefs from pathological phenomena; incorporating patients’ RSW beliefs into therapeutic interventions when appropriate; understanding ethical and boundary issues related to such interventions; and familiarity with a range of mental health literature on RSW concerns. Participants also felt better equipped to collaborate with clergy, chaplains, and other pastoral caregivers in the care of their patients, and more aware of resources related to various faith traditions to assist in the care of patients.

Dr Norko is Associate Professor of Psychiatry, Yale University School of Medicine, Law & Psychiatry Division; Director of Forensic Services, Connecticut Department of Mental Health and Addiction Services in New Haven, Connecticut; and Deputy Editor of the 

Journal of the American Academy of Psychiatry and the Law.


In his presentation, Dr Fung discussed educational issues on spirituality/religion in psychiatry residency from a Canadian perspective. He provided a general overview of the rationale for such training for psychiatric residents, as well as highlighted the key developments of such curricula in the US and Canada. He then described a recent needs assessment survey with the psychiatric residents at the University of Toronto (U of T)-the largest psychiatric residency program in Canada-on their attitudes, behaviors, and competencies toward the provision of spiritually informed care. He conducted this survey with U of T psychiatric residents, Drs Jen Fink and Jerome Perera. It was revealed that residents' attitudes were generally quite positive towards the provision of such care, though most residents did not feel competent in providing such care-which might have affected how often they would provide such care in practice.

Some significant barriers identified included time constraints in clinical care, as well as the perceived lack of training. Dr Fung concluded by highlighting that even though recognized as clinically important, few Canadian psychiatry residency programs have instituted formal spirituality/religion curricula. He also emphasized on the importance of addressing attitudinal changes of learners (eg, through experiential learning) in such spirituality/religion curricula-in addition to imparting knowledge and skills (especially those clinically-relevant and time-efficient).

Dr Fung is Assistant Professor of Psychiatry, University of Toronto Faculty of Medicine, and Medical Director of Research, North York General Hospital Department of Psychiatry, in Toronto, Ontario, Canada. He serves on the Executive Committee of the American Psychiatric Association Caucus on Spirituality, Religion and Psychiatry-presided by Dr Peteet.


Rather than an elective course, Dr Theresa Yuschok highlighted what all psychiatry residents need to know about spirituality in clinical practice, integrated into their clinical experiences. Early on, trainees need to be familiar with ethical values of respect, no imposition of beliefs or substitution for standard care, as outlined in the “APA Resource Document 2006-04 on Religious/Spiritual Commitments and Psychiatric Practice.” To fulfill the JCAHO requirement of taking a spiritual history, they should know some standard open-ended questions regarding religious affiliation, spiritual practices, beliefs as a source of hope/comfort versus stress/guilt, and how beliefs affect their psychiatric care. As trainees hone their diagnostic skills, they learn to discern psychopathology (manic religiosity, psychotic hallucinations, delusional beliefs) from spiritual experiences (eg, elation, NDE, conviction, or grace).

The consult service offers an opportunity to interact with hospital chaplains and recognize when to refer to a religious professional to address spiritual struggles, refusal treatment, doctrine, or specific rituals. Psychodynamic psychotherapy supervision can illuminate the transference of childhood dynamics onto religious experiences and the potential countertransference pitfalls. Most developmental and cognitive psychotherapy promotes ego-strength to manage adult life; however, midlife crisis challenges the centrality of the ego and presents the opportunity to align the ego with something larger than itself. Dr Yuschok, quoting Rilke, proposes we prepare residents “to dive into these increasing depths,” by gradually developing these clinical skills and knowledge of increasing complexity.

Dr Yuschok is a Medical Instructor at Duke University Department of Psychiatry; Director of Durham VAMC Mental Health Clinic; Faculty Affiliate of Duke Trent Center for Bioethics, Humanities and History of Medicine; and President of the C.G. Jung Society of the Triangle Area of North Carolina.

These speakers led a workshop titled “Spirituality, Religion and Psychiatry: Educational Challenges and Opportunities” in October at the American Psychiatric Association Institute on Psychiatric Services meeting in Philadelphia.


One of the interesting things about spirituality and psychiatry is the mismatch between a number of our patients that have theistic beliefs and the number of psychiatric practitioners who [also] have theistic beliefs. In America, more than 90% of people say that they have a belief in God, and varying percentages of them say that they would like to talk about their spiritual beliefs in different settings. Yet, when psychiatrists are asked about their belief in God, only about 40% of them say that they have theist beliefs. A recent study . . .  suggested that [percentage] was more like 70% to 75% among residents . . . there’s a growing interest among a younger generation of professionals that might encourage this.

Many of our patients say that they would like to talk about spirituality [but] they feel inhibited when they [meet] with their psychiatrists. I did a series of workshops at a retreat center a few years ago, and there [was] a group of 35 to 40 men in the audience. [In talking about their experiences of meeting with psychiatrists] and wanting to talk about their religion . . . one of [the audience members said their psychiatrist told them] flat out, “Sorry, I don’t do God.” That seems to me to be anti-therapeutic; it is not the way most of us are trained. We are trained to ask open questions. We’re trained to be patient-centered in the way we work with people. We’ll talk about all sorts of things with patients.

Talking about religious or spiritual beliefs is not all that different from what we’ve all been trained to do. Whether someone is talking about their relationship or their job, spirituality is another part of [a patient’s] life if it’s important to them-and particularly if it is a source of strength or a source of conflict-those are very important avenues to explore in therapy. I don’t think it takes a lot of special training.

It only takes [willingness] to be open to explore the patient’s experience and to listen to what they have to say and look for opportunities to make interpretations or interventions, just like we do in any form of psychotherapy. It shouldn’t be all that different from what we normally do, but many therapists and psychiatrists are afraid that maybe they’ll be accused of proselytizing or they feel like if they’ve had no training in religion per se that they can’t “go there,” that it is a wholly different terrain, that clergy and pastoral caregivers should deal with it . . . yet there’s so much overlap and so much rich material there to be dealt with in therapy that fewer people should be rigid about that barrier.

One of the things that we try to do in our course is to try to make people feel more comfortable, to give them at least some knowledge of the literature, to talk about concepts, to make them feel like it is at least something that they have heard about so that they won’t feel so uncomfortable trying to [talk about spirituality] when it is appropriate.


There are two ways to go with that. One would be to talk about the literature on religion and spirituality in mental health. [However], the literature has several components to it, one of which is people that have religious and spiritual beliefs actually tend to have fewer problems. They tend to live longer; they tend to have fewer medical problems; they have fewer problems with substance use; [and] they have fewer mental disorders.

It’s not a causal phenomenon; at least there is no evidence to suggest causality. So you cannot take someone who has no spiritual practice and who doesn’t belong to any community of faith and suggest to them that they go to some church group and that will help them. It does not seem to work that way. But if people would just understand that (1) religion and spirituality are important to many of our patients and (2) that importance is actually tied to positive health . . . Another presentation that would be useful [would be] to have someone with 20 years of experience incorporating religion and spirituality into psychotherapy and into psychiatric practice and give a series of anecdotes about how that was useful . . .

A patient’s spiritual “framework” can hold the key to therapeutic breakthroughs.

[Editors note: This article was posted on November 13, 2013, and has since been updated.]

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Spiritual Matters: Inspiring Clinical Care

Whether you credit the idea to Niels Bohr or Yogi Berra, it is true that predictions are very difficult to make, especially about the future. It is a daunting task, yet  obviously an intriguing one, to try to imagine what our field will be like in 10 years or more.

To cope with the limits of prognostication, article size, and personal knowledge (and to limit the extent of how wrong I may be proved by time), I will focus here on events in the realms of ethics and law in psychiatry and the inevitable conflicts between science and public policy and economics that have their origin in those spawning grounds. I will comment on 2 general areas:

• Conflicts related to people our society fears and feels justified in stigmatizing-including sex offenders and people with serious mental illness
 • The limits of the sciences of prediction and the ways in which our fears lead us to ignore those limits


 I will begin by mentioning an important area of active development that deserves fuller description than can be managed within this article: advances in neuroscience and their relationships to questions in psychiatry and the law. Significant research is being conducted in this area, with a notable available literature.

 While some advances are likely to be more readily applicable and easily acceptable to the practice of forensic psychiatry-such as the application of neuroscience data about memory to the assessment of amnesia claims and malingering-I am less optimistic about the application of neuroimaging and other advances to questions of criminal responsibility.

Better scientific understanding of neural mechanisms is not likely to settle fundamental questions of morality, ethics, and interpersonal justice as applied to the specific determinations that must be made in the legal arena.

 Although there are scholars who argue for greater scientific optimism, I do not believe we are likely as a society to accept a mechanistic view of personhood or a neurodeterministic view of personal responsibility that is unfiltered by the screen of functional capacity.

 I do expect, however, that there will be both steps and missteps in that direction in individual legal cases.


 So where are we likely to be in 10 years or so? We are likely to be working hard to find our way out of very difficult sociopolitical-economic problems of our own making. The record numbers of Americans who are imprisoned will continue, because we have not been able to exercise political control of our communal anxiety with options less concrete than the construction and utilization of larger prisons. Incarceration has soared in America, despite a fall in violent crime rates.

The Pew Center on the States recently released its report “One in 100: Behind Bars in America 2008.” That report highlights these sad and troubling facts: we now incarcerate more than 1 in every 100 adults in America; also, 1 in 9 black men between the ages of 20 and 34 is imprisoned.7 At the same time, violent crime rates have dropped, and only 25% of that drop is attributable to increased rates of incarceration.8 Between 1994 and 2005, the adjusted violent crime rate in this country decreased more than 59%.9 During that same period, the prison count increased by more than 36%; it tripled between 1987 and 2007.

The good news is that lawmakers are already taking notice of the crippling effects on economies and public policy of the costs of incarceration. Within 10 years, the idea that we ought to spend more money on reducing the causes of crime is likely to be a mainstream notion. So what does this have to do with psychiatry? The Department of Justice reported in 2006 that more than 56% of state prisoners and 64% of local jail inmates have mental health problems.

 More than half of these individuals have severe mental illness.

 Mental health leadership from the Substance Abuse and Mental Health Services Administration, the National Association of State Mental Health Program Directors, the National Alliance on Mental Illness, the NIMH, the American Psychiatric Association, and many other organizations has significantly stimulated interest in decriminalization of mental illness. This interest will continue to grow and become an increasing force during the next 10 years.

There are various active efforts to attenuate the criminalization of mental illness. These include drug courts, mental health courts, “competency courts,” and a range of other diversion and reentry approaches that are described as part of the Sequential Intercept Model.

 If we think of criminal justice system involvement (CJSI) as a “disorder” for which people with mental health problems are at risk, we can think in terms of primary, secondary, and tertiary prevention strategies.

The existing use of tertiary prevention of CJSI, such as jail diversion and community reentry programs, at the front and back doors of the criminal justice system involves extensive coordination between criminal justice and mental health service systems.

 These interventions will certainly expand as they demonstrate impressive reductions in criminal recidivism and in increased cost savings.

Secondary prevention programs (eg, crisis intervention teams) in which mental health providers train and provide support to local police agencies, direct individuals with mental illness to treatment rather than arrest and incarceration.

 Such interventions will also continue to expand in the next decade.

The biggest area for growth will be the challenges of primary prevention of CJSI among people with severe mental illness. To accomplish this goal, we will need to reinforce mental health systems to make them more accessible and to equip clinical staff members with skills to deal with risk-relevant deficits (ie, criminogenic needs) as specific foci for treatment interventions on an individual case basis.

 Our mental health systems must-and will-become more pro-active in addressing CJSI, rather than participating mostly in developments that are reactive to the political and economic pressures of the criminal justice system. In the next 10 years, much more significant progress will be made on this front.


 We are doing much worse in the area of managing sex offenders. We continue to expand the misuse of psychiatry to enable preventive detention of persons we have already punished for their criminal acts. Most of this activity is fueled by fearsome publicly sensationalized details of individual cases of sexual abuse of children. Despite the fact that the rate of substantiated cases of child sexual abuse decreased 49% between 1992 and 2004, and instances of rape decreased 82% from 1979 to 2005, we have nonetheless expanded our use of sexually violent predator laws, especially since the Supreme Court ruled such laws constitutional in 1997

Twenty-two states, the District of Columbia, and federal jurisdictions now have enacted legislation that requires the acknowledged legislative invention of a new category of “mental abnormality” to justify using mental health commitment as the vehicle for incapacitation beyond a full prison sentence. Such a practice is otherwise prohibited in our system of justice. We experience the stress of civilization in turmoil and externalize our anxiety in part by demonizing certain classes of people, such as sex offenders.

These laws serve to alleviate public anxiety by asserting that we are able to “do something” about the problem, yet there is no evidence that this “something” is actually effective. More­­over, incarceration is enormously expensive. Estimates of bed need continuously rise because we cannot really define the end point of the mental abnormality that occasioned the confinements in the first place. Our best actuarial instruments for sexual offense risk assessment cannot take adequate account of response to interventions in reducing risk.

In 10 years, we will be more fully confronted with the dilemma of exhausted public resources for expanding confinement, and the use of this methodology will have crested. We will be forced to do what we should have done all along-which is to invest more extensively in research and the development of expertise in care and management of problem sexual behavior and to think more clearly and dispassionately about appropriate public policy.


 Similar problems will continue to plague us in the next decade regarding the issue of violent behavior by persons with mental illness. In the past  20 years, we have made substantial progress in our understanding of the relationships between mental health factors and violent behavior. We have seen growth in the accuracy of risk assessment using actuarial and structured clinical judgment instruments. But what we know does not truly assist us in our common clinical decisions because we are not able to make meaningful clinical distinctions among the populations of high-risk people that we serve on a daily basis.28

Improvements in our ability to make these distinctions are likely to be limited.29 We do not have adequate empirical investigation of dynamic risk or of the relationship of intraindividual changes with risk of violence.20 But we are coming to the realization that all the people we serve deserve the best treatment we have available, not just those we identify at highest risk for  violence.28,30

Thus, in 10 years, scientific investigations are likely to be devoted extensively to dynamic risk research. The data will demonstrate the continued significant impact of active substance abuse and anger/irritability as important dynamic variables. To the extent that we can operationalize the measurement of dynamic functioning, certain functional deficits will be identified that correlate with violence. We will be more circumspect about applying group statistics to individual cases, and will be more conversant with intraindividual change as a better way to address the latter.

Mental health diagnoses or even particular symptoms will not emerge further as highly predictive of violence. This will encourage libertarian advocates for persons with mental illness who wish to restrict further the use of involuntary commitment for psychiatric care. There will be confusing and ill-conceived legal decisions about such matters, which will unfortunately-and wrongly-portray psychiatrists and patients as enemies. The adversarial uses of risk assessment research will provide heat, but not much light, in resolving these tensions.

We have not, and probably will not soon heed the advice of such scholars as Mullen31 and Lindqvist and Skipworth32 about the requirements for the ethical use of risk assessment in clinical practice. Their advice includes the notion that appropriate risk assessments must be linked to risk management strategies that ameliorate the risk and must always have the benefit of the patient in mind.

If we continue to talk so prominently in our literature about risk, we will fail to combat the stigma and fear produced by tragedies like Virginia Tech. Instead, we must take seriously the notion of function-which serves all persons who struggle with the effects of illness-without embracing models of fear and extrusion/confinement.33 We must ask what the rehabilitative task is for every individual who faces limitations and disability, and  we must provide services equally to all who need them, without reference to risk.32

A decade from now, we will be further along this road because containment of people labeled as risks will be too costly and because further advances in dynamic risk research will not identify discrete groups of risky people (other than people who are actively using substances). Such advances will inform our clinical assessments of dangerous impairments in functional capacity and our interventions for functional improvement. With such knowledge, recovery ideology will finally have its practical evocation at the clinical level.

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Whether you credit the idea to Niels Bohr or Yogi Berra, it is true that predictions are very difficult to make, especially about the future. It is a daunting task, yet obviously an intriguing one, to try to imagine what our field will be like in 10 years or more.

Author | Michael A. Norko, MD, MAR

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