Learning About Spirituality Improves Competency

A “process-oriented” approach to teaching residents about the importance of patients’ religion and spiritual beliefs in treatment appears to result in improved competency and professional practice on the part of students, according to a report in the December 2014 Academic Psychiatry.

The approach, which was studied in a sample of 20 residents, combined didactic lectures with classroom discussions allowing residents to reflect on their own feelings about the subject matter—including, in some cases, ambivalence or resistance—as well as clinical case presentations.

“This study suggests that the utilization of a process-oriented approach to instruction on spirituality and religion may be beneficial for psychiatry resident education,” said Rania Awaad, M.D., of Stanford University and colleagues in the paper. “[R]espect for the affective potency of this topic for residents, both personally as well as professionally, is key to effective discussion of these very important issues.”

The six-session, mandatory “Religion, Spirituality, and Psychiatry” course was delivered to psychiatry residents at Stanford Hospital and Clinics who were in PGY-4 in summer 2013 or PGY-3 in fall 2013. This course drew from a model course curriculum for teaching spirituality in patient care based on brief didactics combined with extensive process-oriented discussion facilitated by course faculty. Each session was 50 minutes long, and clinical cases were integrated throughout the curriculum.

A two-person faculty team facilitated the course, and a panel of chaplains was invited to participate in one session to discuss the interface between spiritual counsel and psychiatry.

The authors used a modified version of the Course Impact Questionnaire, a 20-item Likert scale used in previous studies of spirituality curricula in psychiatry to assess residents’ personal spiritual attitudes, competency, change in professional practice, and change in professional attitudes before and after the course. Feedback was also elicited through written comments.

The data were analyzed twice: once using the original scales and a second time using the new Attitudes Towards Spirituality in Psychiatry and Incorporating Spirituality in Clinical Practice subscales. Results showed statistically significant improvement in the Competency subscale, with an increase in mean scores from 10.74 to 14.53 (maximum score is 21). The new Incorporating Spirituality in Clinical Practice subscale also demonstrated a statistically significant difference between pre- and post-sessions; mean scores improved from 19.19 to 21.56 (maximum score 35).

Residents’ responses to qualitative questions showed an increased understanding of the subject matter, willingness on the part of residents to integrate questions assessing religiosity/spirituality more fully into their clinical practice, realizations of underplaying the importance of these issues in the clinical setting, and the emergence of transference/ countertransference issues not detected prior to this course.

The authors noted that several residents were initially resistant to the inclusion of the course in the curriculum. “The process-oriented approach permitted these residents to share their reservations and process their ambivalence toward this subject,” they noted. “Several residents reflected that being given the opportunity to do so was a helpful and, in some cases, transformative experience. Other residents commented that the sharing and processing undertaken by the class in group format throughout the course was a positive experience overall.”

John Peteet, M.D.

John Peteet, M.D., an associate professor of psychiatry at Harvard Medical School and a member of the APA Caucus on Spirituality, Religion, and Psychiatry, said the study, though small, is important because of the need for a formalized approach to teaching students about religion and spirituality. “Many patients are religious and spiritual—approximately 80 to 90 percent of people say they believe in God; the figures are somewhat less for psychiatrists—and these issues come up in therapy and in resistance to therapy,” he told Psychiatric News. “The more we understand them and how we can help patients if they have conflicts in this area, the better we can connect with our patients.”

Referencing the Mental Health and Faith Community Partnership—an initiative of APA, the American Psychiatric Foundation, and the Interfaith Disability Advocacy Coalition—Peteet said it is important to educate faith leaders about the value of psychiatry, but also to educate psychiatrists about what faith communities have to offer people with mental illness.

The first meeting of the partnership took place earlier this year, bringing together an extraordinary array of psychiatrists and mental health professionals interested in the integration of religion and spirituality in mental health care, as well as leaders from the Christian, Jewish, and Islamic traditions (Psychiatric News, August 1, 2014).

Peteet said the course described in the Academic Psychiatry report is similar to, though considerably shorter than, that offered in the Harvard-Longwood program. As the subject of religion and spirituality has gained ground as a legitimate concern of psychiatry, the number of academic institutions offering some kind of training in the area has also grown, he said.

Peteet credited George Washington University’s Institute for Spirituality and Health (GWISH), founded and directed by Christina Puchalski, M.D., a professor of medicine, as being a leader in fostering education of physicians in religion and spirituality. In 2001, Puchalski and colleagues conducted a survey of the curricula in the 144 medical/osteopathic schools in the United States to determine the courses, classes, and topics (required and elective) in spirituality and health.

According to the GWISH website, the 85 respondents reported teaching 155 spirituality/religion courses, an average of 1.8 courses per school. Of the 155 courses, 43 percent were integrated in the curriculum and 57 percent were stand-alone courses, with the majority of the courses being required. Follow-up calls to initial nonrespondents resulted in findings that 101 of the 144 schools have courses in spirituality and health.

Peteet said it is less well known how many psychiatric residencies are offering such training; he said the APA caucus may undertake a survey to determine the number of psychiatry programs offering training in religion and spirituality.

The “process-oriented approach” described in Academic Psychiatry is critical, he said. “Process, allowing students and residents to reflect on their own responses to issues around religion and spirituality, has to be a part of education in this area,” he said. “It is not something you can teach solely using didactic lectures.” ■