Psychiatric News June 18, 2004
Volume 39 Number 12
© 2004 American Psychiatric Association
p. 30
Psychiatrists Urge More Direct Focus On Patients' Spirituality
Eve Bender
Many patients have spiritual needs that when addressed in psychiatric
treatment help unearth important existential issues and strengthen the
therapeutic relationship.
Psychiatrists can do a great disservice to patients by sidestepping issues
related to religion and spirituality in clinical practice, according to a
panel of physicians who are trying to raise awareness of religion and
spirituality in the field of
medicine.
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James Griffith, M.D. (left), Christine Puchalski, M.D., and Francis Lu,
M.D., spoke at APA's annual meeting about the importance of addressing
patients' spiritual needs in clinical practice.
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They came together to address these issues at APA's annual meeting last
month at a workshop titled, "Spirituality and Religious Assessment in
Clinical Practice."
Only in the past decade has psychiatry begun to address a bias against
spirituality and religion that dates back to some of the writings of Sigmund
Freud, according to Francis Lu, M.D., a professor of clinical psychiatry at
the University of California, San Francisco, and director of the Cultural
Competence and Diversity Program in the psychiatry department at San Francisco
General Hospital.
To address some of these biases, APA issued a resource document titled
"Guidelines Regarding Possible Conflict Between Psychiatrists' Religious
Commitments and Psychiatric Practice," which appeared in the May 1990
American Journal of Psychiatry.
The guidelines state that "psychiatrists should not impose their own
religious, antireligious, or ideologic systems of beliefs on their patients,
nor should they substitute such beliefs or rituals for accepted diagnostic
concepts or therapeutic practice."
In 1995 APA issued the Practice Guideline for the Psychiatric Evaluation of
Adults, which advised psychiatrists to be "sensitive to the patient's
ethnicity and place of birth, gender, social class, sexual orientation, and
religious/spiritual beliefs." (The adult evaluation guideline appeared
in the November 1995 American Journal of Psychiatry.
Lu said that differences between psychiatrist and patient in terms of
religious or spiritual beliefs "may impact the therapeutic relationship
in terms of transference and countertransference issues."
Ignorance Can Yield Misdiagnosis
Another danger is that if the treating psychiatrist is ignorant of or
insensitive to the nuances of a person's cultural background or religious
beliefs, he or she may incorrectly diagnose the patient's behavior as
psychopathological, Lu stated.
What would normally be considered a visual or auditory hallucination may
actually be part of a religious experience for some people—a vision of
the Virgin Mary, for example—and not a symptom of a psychotic disorder,
he pointed out.
"The other error a psychiatrist can make is to incorrectly judge
certain behaviors or symptoms as related to a patient's cultural background
instead of to psychopathology," he added.
To minimize the occurrence of such mistakes, psychiatrists can use a
category in the DSM-IV-TR, "religious or spiritual
problem," which is coded on Axis I. Religious or spiritual problems are
not classified as mental disorders, Lu emphasized, but as other conditions
that may be a focus of clinical attention.
Examples given in the DSM include "distressing experiences
that involve loss or questioning of faith, problems associated with conversion
to a new faith, or questioning of spiritual values that may not necessarily be
related to an organized church or religious institution."
Lu encouraged psychiatrists to be aware of "limitations in our
knowledge and skills, as well as any biases rooted in our cultural backgrounds
and experiences... instead of assuming that we know what is
happening."
Illness Seen as Punishment
A willingness to elicit and address patients' spiritual concerns in medical
practice is "essential," not optional, emphasized Christina
Puchalski, M.D., an associate professor of medicine at George Washington
University and director of the George Washington Institute for Spirituality
and Health in Washington, D.C.
Physicians, she said, should recognize the role spirituality plays in a
patient's perception of his or her illness and how it might affect the
patient's decisions about treatment.
"I have many patients who refused to take their medications,
including those psychiatrists have prescribed to them, because of their
beliefs about what the medications or illness itself signifies," she
said.
Some patients may believe their symptoms can be cured through prayer, while
others leave their medications on the shelf because they feel their illness is
a punishment from God and "they don't deserve to be relieved of
suffering," Puchalski observed.
She stressed that spirituality may extend above and beyond subscribing to
an organized religion to include what a patient believes to be his or her
meaning and purpose in life.
The spiritual issues patients may bring up during treatment are varied and
include hopelessness, anger at God or others, reconciliation, grief, and loss,
she pointed out.
As part of her work at the institute, Puchalski teaches medical students
and residents about supportive listening and helping patients to utilize their
spiritual beliefs in coping with illnesses. "Hope, forgiveness, love,
and other spiritual values can play a role in helping people cope," she
said.
Take Patients' Spiritual History
She also teaches them how to take a patient's spiritual history using the
acronym FICA, which stands for faith and belief, importance, community, and
addressing spiritual concerns in care (see box).
Conducting a spiritual assessment is a way for clinicians to engage
elements of a patient's spiritual life and is more about listening than asking
questions, according to James Griffith, M.D., a professor of psychiatry and
neurology and director of psychiatry residency training at George Washington
University Medical Center.
Griffith advised attendees to "tune in to the ways in which the
patient is engaging in spirituality" during treatment, and if there are
no direct references to spirituality, it's acceptable for psychiatrists to ask
if spirituality or religion is an important part of the patient's life, for
instance, or if there is a spiritual community to which the patient
belongs.
If the patient denies any ties to spirituality or organized religion,
certain "existential" questions, Griffith said, can open the gates
to a discussion of spirituality. Examples include asking the patient,
"Where do you find peace?" or "What has sustained you
through hard times—where do you draw strength?" and "Why is
it important that you are alive?"
"The next step is to listen," Griffith said, for
"language that is pregnant with meaning." Patients may speak about
powerful experiences or what they regard as the ultimate truth. Ultimately,
such discussions can facilitate progress in treatment, Griffith said.
Information about the George Washington Institute for Spirituality
and Health is posted online at
<www.gwish.org>.
Related Article:
-
How to Start Dialogue on Spirituality
Psychiatr News 2004 39: 50.
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