Spiritual Matters: Inspiring Clinical Care

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

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, please click here]. Highlights of the presentations below.

John R. Peteet, MD
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.

Michael A. Norko, MD
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, please click here].

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.

Wai Lun Alan Fung, MD, ScD
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.

Theresa A. Yuschok, MD
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.

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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.

For the transcript, continue to the next page.

Transcript:
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.

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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.]