Spirituality is Not a Four-Letter Word

In our climate of strong religious convictions and polarizing public fights over doctrine, breaching the topic of religion and spirituality as a young physician can seem like the shakiest of shaky ground. For the inexperienced psychiatrist, the struggle is real. We are scared of offending people with any of the intimate questions we ask, and religion feels no less private than sexual history. Religion and spirituality, when approached correctly, can provide a beautiful window into the psyche of our patients. It’s also unavoidable—religious topics are an ACGME-required part of our psychiatric training.

My father was a Lutheran pastor, and my mother was raised a born-again Christian; I grew up in a progressive but religious household. My father loved ministering to sick people in hospitals, and he handled parishioners’ deaths with fearless compassion. I believe I mirror some of my dedication to patient care based on his example. In times of severe illness, however, even the strongest faith can be questioned. When my mother was diagnosed with ALS, she spoke of wondering what she had done, spiritually, to deserve her fate. I think she struggled with the issue until her life ended.

Despite knowing this, I don’t always ask my patients about spirituality. Why not? Too often, as trainees, we feel the need to narrow our exam to what is necessary for an assessment; we give a treatment recommendation and then move on. But religion and spirituality are at the core of most patients’ lives: a 2014 Gallup poll revealed that 86 percent of the general population is religious or spiritual. And our colleagues are, too: 76 percent of psychiatrists, according to one survey. More science: high intrinsic religiousness can predict more rapid remission of depression, especially in patients with poor physical functioning. Religious and spiritual involvement appears to buffer patients from stress, and offering therapies augmented with a spiritual component to religiously or spiritually oriented patients is associated with increased efficacy of treatment. Nonetheless, the potentially negative effects of religion should not be overlooked; we’ve all encountered the gay or lesbian patient who feels deep shame due to a prohibitive religious upbringing.

So how do we incorporate religion into our training and our care? A fan of checklists, I have used the following four questions (which were developed by a consensus panel of the American College of Physicians) as a basic approach to the spiritual history:

• Is faith (religion, spirituality) important to you?

• Has faith been important to you at other times in your life?

• Do you have someone to talk to about religious matters?

• Would you like to explore religious or spiritual matters with someone?

Here are some additional tips gleaned during residency:

• Engage hospital chaplains in your inpatient psychiatric and consult-liaison work, utilizing them for patient interviews and family meetings, when appropriate.

• With permission, collaborate with your patient’s pastor or spiritual guide for context and coordination. When doing cognitive-behavioral therapy for psychosis, for example, a patient with religious delusions may be able to question the delusional content more safely with his or her pastor.

• If a patient asks you about your religious beliefs or spirituality, deal with it like any other personal question, responding with, for example: “I’m wondering why this question came up. What do you imagine?” Once the motivation has been explored, it becomes a judgment call. Less experienced practitioners may want to avoid disclosure as a rule; however, in the right setting, it could deepen the therapeutic alliance. For example, a patient struggling with feeling internal religious judgment could have a corrective emotional experience when the therapist reports that he or she does not share that same religious judgment of the patient. In the end, every psychiatrists needs to be prepared to tackle this issue, so careful self-reflection is highly suggested.

• Listen to spiritual or religious concerns carefully, but avoid giving an opinion. (I have found that aligning myself religiously has the potential to disrupt the therapeutic alliance.)

As residents, we are so intently focused on keeping patients alive and learning psychiatry that we sometimes miss the intangible parts of our work. Regardless of our religious beliefs, or lack thereof, patient care can be a way to serve a higher power and receive spiritual nourishment. Evidence-based treatment and spiritually informed care are compatible. As we help patients share their spiritual beliefs with us, our work becomes deeper and more meaningful and can lead us to the core of the human experience. ■