Abstract
Objective:
Despite empirical evidence of a relationship between religiosity/spirituality (R/S) and mental health and recommendations by professional associations that these research findings be integrated into clinical practice, application of this knowledge in the clinic remains a challenge. This paper reviews the current state of the evidence and provides evidence-based guidelines for spiritual assessment and for integration of R/S into mental health treatment.
Methods:
PubMed searches of relevant terms yielded 1,109 papers. We selected empirical studies and reviews that addressed assessment of R/S in clinical practice.
Results:
The most widely acknowledged and agreed-upon application of R/S to clinical practice is the need to take a spiritual history (SH), which may improve patient compliance, satisfaction with care, and health outcomes. We found 25 instruments for SH collection, several of which were validated and of good clinical utility.
Conclusions:
This paper provides practical guidelines for spiritual assessment and integration thereof into mental health treatment, as well as suggestions for future research on the topic.
Spirituality; religion and psychology; practice guidelines; spiritual therapies; diagnosis
Introduction
Spiritual and religious beliefs are common worldwide. According to recent surveys,11. Koenig HG. Research on religion, spirituality, and mental health: a review. Can J Psychiatry. 2009;54:283-91. at least 90% of the world population is currently involved in some form of religious or spiritual practice. There is consistent evidence that religiosity and spirituality (R/S) play a role in several aspects of life, especially mental health.22. Moreira-Almeida A, Neto FL, Koenig HG. Religiousness and mental health: a review. Rev Bras Psiquiatr. 2006;28:242-50.
Three systematic reviews of the academic literature have identified more than 3,000
empirical studies on spirituality and health.33. Bonelli RM, Koenig HG. Mental disorders, religion and
spirituality 1990 to 2010: a systematic evidence-based review. J Relig Health.
2013;52:657-73.
4. Koenig HG, McCullough ME, Larson DB. Handbook of religion and
health. New York: Oxford University Press; 2001.-55. Koenig H, King D, Carson VB. Handbook of religion and health. 2nd
edition. New York: Oxford University Press; 2012. In general, individuals who
have more R/S have less depression, anxiety, suicide attempts, and substance
use/abuse, and experience better quality of life, faster remission of depressive
symptoms, and better psychiatric outcomes.11. Koenig HG. Research on religion, spirituality, and mental health:
a review. Can J Psychiatry. 2009;54:283-91.
2. Moreira-Almeida A, Neto FL, Koenig HG. Religiousness and mental
health: a review. Rev Bras Psiquiatr. 2006;28:242-50.-33. Bonelli RM, Koenig HG. Mental disorders, religion and
spirituality 1990 to 2010: a systematic evidence-based review. J Relig Health.
2013;52:657-73.
In view of this evidence, many professional organizations, such as the American
College of Physicians, the American Medical Association, the American Nurses
Association, and the Joint Commission on Accreditation of Healthcare Organizations,
recognize that spiritual care is an important component of health care and that
health care professionals should integrate it into clinical practice.66. Puchalski C. Spiritual assessment in clinical practice. Psychiatr
Ann. 2006;36:150-5.,77. Lucchetti G, Lucchetti ALG, Puchalski CM. Spirituality in medical
education: global reality? J Relig Health. 2012;51:3-19.
Concerning mental health, the World Psychiatric Association,88. Verhagen PJ, Van Praag HM, Lopez-Ibor JJ, Cox J, Moussaoui D.
Religion and psychiatry: beyond boundaries. Chichester: John Wiley & Sons;
2010. American Psychological Association,99. Ammondson I, Lukoff D, Pargament KI, Pilato R, Scammell S,Vieten
C. Spiritual and religious competencies for psychologists. Psychology of
Religion and Spirituality. 2013;5:129-44. American Psychiatric Association,1010. American Psychiatric Association. Guidelines regarding possible
conflict between psychiatrists' religious commitments and psychiatric
practice. Am J Psychiatry. 1990;147:542. and Royal College of Psychiatrists1111. Royal College of Psychiatrists. Recommendations for
psychiatrists on spirituality and religion [Internet]. 2011 Nov
[cited 2013 Aug 5].
http://www.rcpsych.ac.uk/pdf/PS03_2013.pdf
http://www.rcpsych.ac.uk/pdf/PS03_2013.p...
all have sections dedicated to R/S.
However, translating research findings into practice is not always easy. There is a discrepancy between health care professionals' perception of the importance of addressing R/S during clinical care and the actual implementation of this approach.1212. Kalish N. Evidence-based spiritual care: a literature review. Curr Opin Support Palliat Care. 2012;6:242-6.,1313. Ellis MR, Vinson DC, Ewigman B. Addressing spiritual concerns of patients: family physicians' attitudes and practices. J Fam Pract. 1999;48:105-9.
Consistently, patients, physicians, medical students, and medical educators have
assigned more importance to R/S in clinical encounters than has actually been done
in clinical care and teaching.1414. Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen J. Do
patients want physicians to inquire about their spiritual or religious beliefs
if they become gravely ill? Arch Intern Med.
1999;159:1803-6.
15. Lucchetti G, Lucchetti AG, Badan-Neto AM, Peres PT, Peres MF,
Moreira-Almeida A, et al. Religiousness affects mental health, pain and quality
of life in older people in an outpatient rehabilitation setting. J Rehabil Med.
2011;43:316-22.-1616. Mariotti LG, Lucchetti G, Dantas MF, Banin VB, Fumelli F, Padula
N. Spirituality and medicine: views and opinions of teachers in a Brazilian
medical school. Med Teach. 2011;33:339-40. Most physicians have never addressed this
issue in clinical practice1515. Lucchetti G, Lucchetti AG, Badan-Neto AM, Peres PT, Peres MF,
Moreira-Almeida A, et al. Religiousness affects mental health, pain and quality
of life in older people in an outpatient rehabilitation setting. J Rehabil Med.
2011;43:316-22. and most
patients continue to have undetected spiritual needs.1717. Clark PA, Drain M, Malone MP. Addressing patients'
emotional and spiritual needs. Jt Comm J Qual Saf.
2003;29:659-70. Several reasons may help explain the neglect of R/S issues by mental
health professionals: lack of awareness of the available evidence; lack of training
on how to deal with R/S in clinical practice1616. Mariotti LG, Lucchetti G, Dantas MF, Banin VB, Fumelli F, Padula
N. Spirituality and medicine: views and opinions of teachers in a Brazilian
medical school. Med Teach. 2011;33:339-40.,1818. Pargament KI, Lomax JW. Understanding and addressing religion
among people with mental illness. World Psychiatry.
2013;12:26-32.; influence of materialist
authors and ideologies that dismiss or pathologize R/S1919. Cloninger CR. The importance of ternary awareness for overcoming
the inadequacies of contemporary psychiatry. Rev Psiquiatr Clin.
2013;40:110-3.; historical myths of a perennial conflict between
science/medicine and religion22. Moreira-Almeida A, Neto FL, Koenig HG. Religiousness and mental
health: a review. Rev Bras Psiquiatr. 2006;28:242-50.,2020. Numbers RL. Galileo goes to jail and other myths about science
and religion. Cambridge: Harvard University Press; 2009.; the religiosity gap (mental health
professionals being less religious than general and clinical populations)2121. Lukoff D, Lu F, Turner R. Toward a more culturally sensitive
DSM-IV: psychoreligious and psychospiritual problems. J Nerv Ment Dis.
1992;180:673-82.,2222. Baetz M, Griffin R, Bowen R, Marcoux G. Spirituality and
psychiatry in Canada: psychiatric practice compared with patient expectations.
Can J Psychiatry. 2004;49:265-71.;
and institutional rivalry between medicine and religion, since both deal with human
suffering.
In psychiatry, these barriers were enhanced by the views of famous neurologists and psychiatrists in the 19th-20th centuries who suggested religion was a form of hysteria and neurosis.11. Koenig HG. Research on religion, spirituality, and mental health: a review. Can J Psychiatry. 2009;54:283-91.,22. Moreira-Almeida A, Neto FL, Koenig HG. Religiousness and mental health: a review. Rev Bras Psiquiatr. 2006;28:242-50.,2323. Vasegh S, Rosmarin DH, Koenig HG, Dew RE, Bonelli RM. Religious and Spiritual Factors in Depression. Depress Res Treat. 2012;2012:298056. As a result, when religion came up in the clinical encounter, it was often either ignored or treated as part of the pathology that had to be corrected with treatment.2323. Vasegh S, Rosmarin DH, Koenig HG, Dew RE, Bonelli RM. Religious and Spiritual Factors in Depression. Depress Res Treat. 2012;2012:298056. These negative attitudes towards religion have influenced many psychiatrists in the 20th century.2424. Neeleman J, Persaud R. Why do psychiatrists neglect religion? Br J Med Psychol. 1995;68:169-78.
In 2003, a national random sample of 1,144 U.S. physicians found that psychiatrists were less religious than other physicians. This gap and the lack of training on issues related to R/S and medicine make it more difficult for some psychiatrists to empathize with religious patients and provide appropriate, culturally competent care to these patients.2525. Curlin FA, Odell SV, Lawrence RE, Chin MH, Lantos JD, Meador KG, et al. The relationship between psychiatry and religion among US physicians. Psychiatr Serv. 2007;58:1193-8. However, this same survey found that psychiatrists were more likely than other physicians to recognize positive and negative influences of R/S and to address R/S with patients.2626. Curlin FA, Lawrence RE, Odell S, Chin MH, Lantos JD, Koenig HG, et al. Religion, spirituality, and medicine: psychiatrists' and other physicians' differing observations, interpretations, and clinical approaches. Am J Psychiatry. 2007;164:1825-31.
In summary, despite the large body of empirical evidence on R/S and mental health and the recommendations of many professional associations, the translation and implementation of this knowledge to clinical practice has remained a challenge. Within this context, evidence-based practice guidelines on R/S could help mental health professionals better understand and integrate this information into their clinical practice. Therefore, the present paper aims to further examine the role of R/S in psychiatric practice and provide sensible, evidence-based guidelines on how to conduct spiritual assessment and utilize this information in mental health treatment.
Definitions
The definition of spirituality has been subject to much debate.2727. Moreira-Almeida A, Koenig HG. Retaining the meaning of the words
religiousness and spirituality: a commentary on the WHOQOL SRPB group's
“a cross-cultural study of spirituality, religion, and personal beliefs
as components of quality of life” (62: 6, 2005, 1486-1497). Soc Sci Med.
2006;63:843-5.
28. Koenig HG. Concerns about measuring “spirituality”
in research. J Nerv Ment Dis. 2008;196:349-55.
29. Puchalski CM. Spirituality and end-of-life care: a time for
listening and caring. J Palliat Med. 2002;5:289-94.-3030. Lucchetti G, Lucchetti AL, Vallada H. Measuring spirituality and
religiosity in clinical research: a systematic review of instruments available
in the Portuguese language. Sao Paulo Med J. 2013;131:112-22. Some authors have
proposed including positive psychological constructs such as peacefulness, harmony,
meaning, purpose, and satisfaction in life in the concept of spirituality.2929. Puchalski CM. Spirituality and end-of-life care: a time for
listening and caring. J Palliat Med. 2002;5:289-94. However, other authors think that this
conceptual expansion of spirituality to include positive psychological constructs is
misguided. Spirituality is often related to these constructs, but is not equal to
them. It seems better to define spirituality as a separate construct, related to the
transcendent, the non-material and sacred aspects of existence and the
universe.2727. Moreira-Almeida A, Koenig HG. Retaining the meaning of the words
religiousness and spirituality: a commentary on the WHOQOL SRPB group's
“a cross-cultural study of spirituality, religion, and personal beliefs
as components of quality of life” (62: 6, 2005, 1486-1497). Soc Sci Med.
2006;63:843-5.,2828. Koenig HG. Concerns about measuring “spirituality”
in research. J Nerv Ment Dis. 2008;196:349-55. Therefore, the present article will use the following
definitions44. Koenig HG, McCullough ME, Larson DB. Handbook of religion and
health. New York: Oxford University Press; 2001.: 1) spirituality: the
personal quest for understanding answers to ultimate questions about life, about
meaning, and about relationship to the sacred or transcendent, which may (or may
not) lead to or arise from the development of religious rituals and the formation of
community; 2) religion: an organized system of beliefs, practices, rituals, and
symbols designed to facilitate closeness to the sacred or transcendent (God, higher
power, or ultimate truth/reality); 3) religiosity: the extent to which an individual
believes, follows, and/or practices a religion.
R/S and mental health
There is a complex interplay between mental health and R/S, so one cannot hold a simplistic perspective that labels R/S as either “good” or “bad” for health.1818. Pargament KI, Lomax JW. Understanding and addressing religion among people with mental illness. World Psychiatry. 2013;12:26-32. For example, a recent Brazilian study of 168 outpatients with bipolar disorder3131. Stroppa A, Moreira-Almeida A. Religiosity, mood symptoms, and quality of life in bipolar disorder. Bipolar Disord 2013;15:385-93. found that religion was reported as important in the participants' lives (84%), and that intrinsic religiosity (i.e., religion as an end in itself and central to the person's life) and positive religious coping (e.g., seeking support from a religious community, searching for religious meaning in life and stressors, collaborative partnership with God) were strongly associated with lower depressive symptoms and better quality of life. However, although less prevalent (18%), negative religious coping (e.g., conflicts with God or the religious community, framing disease as a punishment from God) correlated with worse quality of life. Adding to the complexity of these findings, 30% of patients reported religious beliefs that conflicted with their treatment, and 23% indicated that their religious leaders interfered with mental health treatment.3131. Stroppa A, Moreira-Almeida A. Religiosity, mood symptoms, and quality of life in bipolar disorder. Bipolar Disord 2013;15:385-93.
Similarly, high importance of religion to patients' lives and a complex mixture of mainly positive (83%) but also negative (14%) aspects of religiosity were reported by 89 Swiss outpatients with schizophrenia or schizoaffective disorder. Baseline importance of spirituality among patients with positive use of religion predicted fewer negative symptoms, higher quality of life, and better social functioning at 3-year follow-up.3232. Mohr S, Borras L, Betrisey C, Pierre-Yves B, Gilliéron C, Huguelet P. Delusions with religious content in patients with psychosis: how they interact with spiritual coping. Psychiatry. 2010;73:158-72.,3333. Mohr S, Perroud N, Gillieron C, Brandt PY, Rieben I, Borras L, et al. Spirituality and religiousness as predictive factors of outcome in schizophrenia and schizo-affective disorders. Psychiatry Res. 2011;186:177-82.
When interviewing or following up a patient, however, clinicians should bear in mind that R/S is often not a stable or fixed state in patients' lives. In the Swiss study cited above,3333. Mohr S, Perroud N, Gillieron C, Brandt PY, Rieben I, Borras L, et al. Spirituality and religiousness as predictive factors of outcome in schizophrenia and schizo-affective disorders. Psychiatry Res. 2011;186:177-82. although R/S remained stable and mostly highly important and positive for the majority of patients after 3-year follow-up, it changed (increased, decreased, changed from positive to negative or vice versa) in 37% of patients. An interesting finding was that patients who changed their religiosity, regardless of direction, displayed lower self-esteem and poorer quality of life as compared with those whose R/S did not change, even after controlling for clinical status and emotional functioning. As stated by these authors elsewhere: “spiritual and religious concerns may become part of the problem as well as part of the recovery.”3434. Mohr S, Huguelet P. The relationship between schizophrenia and religion and its implications for care. Swiss Med Wkly. 2004;134:369-76. Such findings demonstrate the need for a more refined understanding of the interplay between R/S and mental health, and underscore the need for careful exploration of R/S with patients.
Assessing R/S in clinical practice
In July 2013, we searched PubMed using the Boolean query “(spiritu*[title] OR religio*[title]) AND (clinical practice OR interview OR history) AND (psychol* OR psychiatr* OR mental).” This yielded 985 articles (empirical studies and reviews) published within the past 15 years. These articles focused primarily on mental health issues, but when appropriate, we also included papers dealing with related medical conditions. To find additional references, we screened the retrieved articles for related references. We also reviewed guidelines provided by medical associations and other published sources on spirituality and health. The most agreed-upon application of R/S into clinical practice was the need to obtain a spiritual history (SH).66. Puchalski C. Spiritual assessment in clinical practice. Psychiatr Ann. 2006;36:150-5.,3535. Puchalski C, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med. 2000;3:129-37.,3636. Lucchetti G, Bassi RM, Lucchetti AL. Taking spiritual history in clinical practice: a systematic review of instruments. Explore (NY). 2013;9:159-70. The SH explores the importance and practical implications of R/S in patients' lives as it applies to their illnesses.
When taking the SH, it is essential to be aware that R/S is a multidimensional construct that may be articulated by patients in many different ways. These dimensions include beliefs, rituals, sense of transcendental connection, views of God, ethical implications, mystical experiences, community or private religious practices, and so forth.44. Koenig HG, McCullough ME, Larson DB. Handbook of religion and health. New York: Oxford University Press; 2001.,55. Koenig H, King D, Carson VB. Handbook of religion and health. 2nd edition. New York: Oxford University Press; 2012.
It is also important to avoid assumptions based on patients' affiliation or social background. Even in the same R/S tradition, there are different subgroups with diverse practices, interpretations of sacred texts, and behavioral implications. In addition, growing multiculturalism and religious syncretism make it essential to investigate each patient's own R/S beliefs and practices.3737. Walsh F. Spiritual diversity: multifaith perspectives in family therapy. Fam Process. 2010;49:330-48.
Our group of authors recently published a systematic review of the use of instruments
for taking a SH, discussing their strengths and weaknesses on the basis of 16
attributes (including ease of memorization, validation, and range of R/S areas
covered).3636. Lucchetti G, Bassi RM, Lucchetti AL. Taking spiritual history in
clinical practice: a systematic review of instruments. Explore (NY).
2013;9:159-70. Most of the 25 instruments
were developed for general use in clinical practice, and only two were developed
specifically for mental health: the Royal College of Psychiatrists Assessment3838. Culliford L, Powell A. Spirituality and mental health
[Internet]. 2006 [cited 2010 Aug 14].
http://www.rcpsych.ac.uk/mentalhealthinformation/therapies/spiritualityandmentalhealth.aspx
http://www.rcpsych.ac.uk/mentalhealthinf...
and the Spiritual Assessment Interview.3939. SCRC. Spiritual competency resource center: spiritual assessment
interview [Internet]. 2009 [cited 2009 Aug 24].
http://www.spiritualcompetency.com/recovery/lesson7.html
http://www.spiritualcompetency.com/recov...
The FICA (faith, importance, community and
address), which obtained the highest score (covering 13 items), is a brief measure
that takes only 5 minutes to administer and is useful both in general and in
psychiatric practice when shortage of time is an issue.3535. Puchalski C, Romer AL. Taking a spiritual history allows
clinicians to understand patients more fully. J Palliat Med.
2000;3:129-37. The other highly ranked instruments were SPIRITual
History4040. Maugans T. The SPIRITual history. Arch Fam Med.
1996;5:11-6. and FAITH4141. Neely D, Minford E. FAITH: spiritual history-taking made easy.
Clin Teach. 2009;6:181-5. (covering 12 items) and HOPE4242. Anandarajah G, Hight E. Spirituality and medical practice: using
the HOPE questions as a practical tool for spiritual assessment. Am Fam
Physician. 2001;63:81-9. and the Royal College of Psychiatrists Assessment3838. Culliford L, Powell A. Spirituality and mental health
[Internet]. 2006 [cited 2010 Aug 14].
http://www.rcpsych.ac.uk/mentalhealthinformation/therapies/spiritualityandmentalhealth.aspx
http://www.rcpsych.ac.uk/mentalhealthinf...
(covering 11 items) (Box 1
Box 1 Spiritual history tools (FICA and Royal College of Psychiatrists
Assessment)
). The latter measure is the only instrument directed
specifically for mental health and takes 20-25 minutes to complete. It is more
useful for mental health professionals, as it provides a more comprehensive
exploration of psychosocial issues.
Besides assessment, the SH may also have therapeutic implications, sending a message to patients that the clinician is concerned with the whole person.4343. D'Souza R. The importance of spirituality in medicine and its application to clinical practice. Med J Aust. 2007;186:S57-9. Some studies show that assessing patients' R/S is associated with improved patient perception of healthcare quality. To our knowledge, the first study to investigate the feasibility and impact of taking a SH was by Kristeller et al.4444. Kristeller JL, Rhodes M, Cripe LD, Sheets V. Oncologist Assisted Spiritual Intervention Study (OASIS): patient acceptability and initial evidence of effects. Int J Psychiatry Med. 2005;35:329-47. These investigators studied 118 consecutive outpatients of four oncologists. Patients were alternately assigned to either usual care or usual care plus a SH, which lasted about 6 minutes on average. The SH was well-accepted by patients and oncologists. After 3 weeks, patients from whom the SH had been obtained showed less depressive symptoms, better quality of life, and a greater sense of interpersonal caring from their physicians compared to the control group. In another study,4545. Stanley MA, Bush AL, Camp ME, Jameson JP, Phillips LL, Barber CR, et al. Older adults' preferences for religion/spirituality in treatment for anxiety and depression. Aging Ment Health. 2011;15:334-43. 83% of internal medicine patients aged 55 years or older with depression or anxiety reported that it was extremely or somewhat important to discuss spiritual issues when counseling for mental disorder. No patient said it was not important at all. Patients who chose to include R/S were more likely to use positive religious coping and collaborative problem-solving styles than those who did not wish to include it.
Likewise, in a recent study of 3,141 internal medicine inpatients at a university hospital in the U.S.,4646. Williams JA, Meltzer D, Arora V, Chung G, Curlin FA. Attention to inpatients' religious and spiritual concerns: predictors and association with patient satisfaction. J Gen Intern Med. 2011;26:1265-71. 41% desired a discussion about R/S concerns during hospitalization. However, only half of those had such discussions, demonstrating a large unmet need. Another important finding was that patients who had discussions on R/S issues during hospitalization had were 40 to 120% more likely to rate the quality of their healthcare at the highest level, compared to than those who did not have such discussions. It is notable that this association between discussing R/S and patient satisfaction was present regardless of whether the patient had initially said they wanted such a discussion.4646. Williams JA, Meltzer D, Arora V, Chung G, Curlin FA. Attention to inpatients' religious and spiritual concerns: predictors and association with patient satisfaction. J Gen Intern Med. 2011;26:1265-71.
With regard to psychiatric patients, Huguelet et al.4747. Huguelet P, Mohr S, Betrisey C, Borras L, Gillieron C, Marie AM, et al. A randomized trial of spiritual assessment of outpatients with schizophrenia: patients' and clinicians' experience. Psychiatr Serv. 2011;62:79-86. conducted a randomized controlled trial to investigate the impact of taking a SH during standard care of schizophrenic outpatients. Psychiatry residents received 90 minutes of training and 10 to 40 minutes of supervision on taking a SH during a regular appointment. Potential clinical usefulness of the SH was identified by psychiatrists in 67% of patients. Patients accepted the assessment well, and more than one-quarter wished very much to discuss R/S issues with their psychiatrists. After 3 months, patients who received the SH did not differ from patients who had not with regard to reports of satisfaction with care or adherence to medication. They did, however, have better appointment attendance (only 8% receiving the SH missed appointments during the 3-month follow-up, vs. 26% of those who did not receive the SH).
In summary, there are several good instruments for taking a SH during the clinical encounter, two of which are transcribed in Box 1 Box 1 Spiritual history tools (FICA and Royal College of Psychiatrists Assessment) . What limited evidence is available suggests that taking even a short SH may raise important clinical issues, have an impact on patients' satisfaction with care, and perhaps even influence clinical outcomes.
Practice guidelines
Here we suggest practical guidelines regarding the assessment and integration of R/S into the treatment of mental health patients.
General principles
First, a number of general principles should be kept in mind when assessing or addressing R/S issues with mental health patients:
-
Ethical boundaries. The approach to R/S should be patient-centered, not prescribing, not imposing, and not proselytizing for spiritual or anti-spiritual worldviews.4343. D'Souza R. The importance of spirituality in medicine and its application to clinical practice. Med J Aust. 2007;186:S57-9.,4848. Koenig HG. The spiritual history. South Med J. 2006;99:1159-60.
-
Person-centered approach. Implies appreciation of the physical, mental, and spiritual components of human beings, in what Cloninger1919. Cloninger CR. The importance of ternary awareness for overcoming the inadequacies of contemporary psychiatry. Rev Psiquiatr Clin. 2013;40:110-3. has called “ternary awareness.” All of these aspects have etiological and recovering implications for mental-disordered patients who trust clinicians in their quest for relief, well-being, and a full life.
-
Countertransference. Given that clinicians' own spiritual or anti-spiritual values, beliefs, and personal history may raise important countertransference issues and influence clinical practice (e.g., having a strong or cold reaction, avoiding R/S issues or stressing them too much), it is important for clinicians to explore their own worldview and history of R/S issues.4949. Josephson AM, Peteet JR. Talking with patients about spirituality and worldview: practical interviewing techniques and strategies. Psychiatr Clin North Am. 2007;30:181-97.
-
Open-minded approach with genuine interest in and respect of patients' beliefs, values, and experiences. Asking patients to share about their own R/S tradition is a good way to show genuine concern about the patient and his/her values. To improve cultural competence, it is important for clinicians to learn about patients' R/S traditions.3737. Walsh F. Spiritual diversity: multifaith perspectives in family therapy. Fam Process. 2010;49:330-48.
-
Self-disclosure. Usually it is not appropriate for a clinician to disclose his/her own R/S views to patients. When clinicians and patients' worldviews are different, there may be conflict and disagreement. On the other hand, when R/S views are concordant, patients may avoid talking about issues they may perceive as inconsistent with the shared worldview. However, in some instances and when requested by the patient, clinicians should use their clinical judgment in sharing their beliefs. Such sharing may help patients feel more comfortable in sharing their experiences and beliefs related to their tradition.4949. Josephson AM, Peteet JR. Talking with patients about spirituality and worldview: practical interviewing techniques and strategies. Psychiatr Clin North Am. 2007;30:181-97.
Spiritual history: which patients, where, and how?
The guidelines discussed in this section are based on the available evidence and
on a broad review of clinical recommendations provided by professional
association guidelines,5050. National Institute for Health and Care Excellence (NICE).
Holistic support: spiritual and religious [Internet]. 2011 [cited
2013 Aug 21].
http://www.nice.org.uk/guidance/qualitystandards/endoflifecare/HolisticSupportSpiritualAndReligious.jsp
http://www.nice.org.uk/guidance/qualitys...
,5151. Practice guidelines for the psychiatric evaluation of adults.
American Psychiatric Association. Am J Psychiatry.
1995;152:63-80. journal articles,3636. Lucchetti G, Bassi RM, Lucchetti AL. Taking spiritual history in
clinical practice: a systematic review of instruments. Explore (NY).
2013;9:159-70.,4848. Koenig HG. The spiritual history. South Med J.
2006;99:1159-60.,4949. Josephson AM, Peteet JR. Talking with patients about
spirituality and worldview: practical interviewing techniques and strategies.
Psychiatr Clin North Am. 2007;30:181-97.,5252. Mohr S, Gillieron C, Borras L, Brandt PY, Huguelet P. The
assessment of spirituality and religiousness in schizophrenia. J Nerv Ment Dis.
2007;195:247-53. and textbooks written by experts in the field. In an attempt to
make these recommendations more cross-cultural, we sought input from authors
writing from a wide range of cultural perspectives.
The SH ideally should not be taken at the beginning of the interview, but after some rapport has been established, and should be conducted in a respectful and sensitive manner, with “genuine humility and openness”5353. Hodge DR, Limb GE. Native Americans and brief spiritual assessment: examining and operationalizing the Joint Commission's assessment framework. Soc Work. 2010;55:297-307. and “respectful curiosity.”3737. Walsh F. Spiritual diversity: multifaith perspectives in family therapy. Fam Process. 2010;49:330-48. The use of language from the patient's spiritual tradition may help show respect and build trust.4949. Josephson AM, Peteet JR. Talking with patients about spirituality and worldview: practical interviewing techniques and strategies. Psychiatr Clin North Am. 2007;30:181-97.,5353. Hodge DR, Limb GE. Native Americans and brief spiritual assessment: examining and operationalizing the Joint Commission's assessment framework. Soc Work. 2010;55:297-307.
Exploration of the patient's R/S may start after the patient indicates that this is important to him or her (e.g., using a religious word or object, carrying a R/S book) or by asking more general, existential questions (“What gives your life meaning?,” “What are your sources of comfort and strength when you are struggling with problems?,” “What helps you cope with your illness?”).4949. Josephson AM, Peteet JR. Talking with patients about spirituality and worldview: practical interviewing techniques and strategies. Psychiatr Clin North Am. 2007;30:181-97.,5252. Mohr S, Gillieron C, Borras L, Brandt PY, Huguelet P. The assessment of spirituality and religiousness in schizophrenia. J Nerv Ment Dis. 2007;195:247-53. These existential questions often lead to R/S when it is an important aspect of the patient's life. If the patient is not religious or spiritual, these questions are helpful in exploring his or her worldview.3737. Walsh F. Spiritual diversity: multifaith perspectives in family therapy. Fam Process. 2010;49:330-48.
Another possible approach is to take a brief SH when assessing the patient's sociocultural background or developmental history. Most reviews and guidelines recommend covering the following basic topics: 1) ask about faith and general R/S: “Are you religious, spiritual, or a person of faith? Is spirituality (or religion) important in your life?”; 2) organizational/community: “Are you part of a religious/spiritual community? Do you attend R/S meetings? Which activities? How often?”; 3) private practices: “Do you perform some private practice such as prayer, meditation, reading religious texts, or watching/listening to R/S programs or songs? When? How often?”; 4) impact: “Does your R/S influence the way you live your life and deal with your current problem? How? Some people say that R/S helps them cope with problems, and others find that R/S is related to troubles and conflicts. How is R/S affecting the way you deal with your current problem? How do your faith and religious community see your problem and treatment? Do they support it, oppose it, or are they neutral?”; 5) opening for other R/S aspects or needs: “Are there other R/S aspects of your life you would like to share? Do you have any other spiritual need that needs to be addressed?”5454. Lunder U, Furlan M, Simonic A. Spiritual needs assessments and measurements. Curr Opin Support Palliat Care. 2011;5:273-8.
This initial assessment of R/S may reveal that a more in-depth exploration of the topic is needed. Areas that often warrant further examination include:
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Style of religious coping and relationship with his/her God or higher power (e.g., collaborative vs. passive vs. self-directed).5555. Phillips LL, Paukert AL, Stanley MA, Kunik ME. Incorporating religion and spirituality to improve care for anxiety and depression in older adults. Geriatrics. 2009;64:15-8.
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Moral concerns regarding some decision to be made or action already performed. This also may raise questions regarding (self-) forgiveness.4949. Josephson AM, Peteet JR. Talking with patients about spirituality and worldview: practical interviewing techniques and strategies. Psychiatr Clin North Am. 2007;30:181-97.
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Possible sources of spiritual distress: negative religious coping (e.g., passive deferral to God, attributing all problems to the Devil), use of religious precepts to justify abuse of wives and children.3737. Walsh F. Spiritual diversity: multifaith perspectives in family therapy. Fam Process. 2010;49:330-48. It is also important to distinguish when religious struggles are causes (e.g., too rigid or intolerant precepts leading to inappropriate guilt) or consequences (e.g., excessive guilt in depression) of psychopathology.1818. Pargament KI, Lomax JW. Understanding and addressing religion among people with mental illness. World Psychiatry. 2013;12:26-32.
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R/S resources the patients has used/developed throughout his/her life, since they may be useful in coping with current problems.
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Spiritual experiences: spiritual experiences (mystical, near-death, out-of-body, mediumship) may be life-changing, but also may raise fear and doubts since they may not fit into the patient's previous worldview.2121. Lukoff D, Lu F, Turner R. Toward a more culturally sensitive DSM-IV: psychoreligious and psychospiritual problems. J Nerv Ment Dis. 1992;180:673-82. Spiritual experiences may also resemble psychotic and dissociative disorders, requiring a careful differential diagnosis. Guidelines for doing so are discussed in depth elsewhere.5656. Moreira-Almeida A, Cardeãa E. Differential diagnosis between non-pathological psychotic and spiritual experiences and mental disorders: a contribution from Latin American studies to the ICD-11. Rev Bras Psiquiatr. 2011;33:S21-36.,5757. Menezes A Jr, Moreira-Almeida A. Differential diagnosis between spiritual experiences and mental disorders of religious content. Rev Psiquiatr Clin. 2009;36:75-82.
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Spiritual development: previous positive and negative experiences regarding R/S that may have shaped the patient's current worldview. This may involve traumatic or nurturing experiences with parents, other relatives, religious leaders, and other significant persons. It is useful to ask questions about the early environment (religious or secular traditions) in which the patient was raised and focus also on significant changes in R/S beliefs or practices throughout life.4747. Huguelet P, Mohr S, Betrisey C, Borras L, Gillieron C, Marie AM, et al. A randomized trial of spiritual assessment of outpatients with schizophrenia: patients' and clinicians' experience. Psychiatr Serv. 2011;62:79-86.,5252. Mohr S, Gillieron C, Borras L, Brandt PY, Huguelet P. The assessment of spirituality and religiousness in schizophrenia. J Nerv Ment Dis. 2007;195:247-53.
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Conflicts with religious communities or with specific religious teachings.
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General religious beliefs, such as: a) about God: “What are God's most meaningful characteristics?” (punitive vs. benevolent, distant vs. personal)4949. Josephson AM, Peteet JR. Talking with patients about spirituality and worldview: practical interviewing techniques and strategies. Psychiatr Clin North Am. 2007;30:181-97.; b) about life after death5858. Flannelly KJ, Ellison CG, Galek K, Silton NR. Belief in life-after-death, beliefs about the world, and psychiatric symptoms. J Relig Health. 2012;51:651-62.; and c) reincarnation.5959. Peres JF. Should psychotherapy consider reincarnation? J Nerv Ment Dis. 2012;200:174-9.
Challenges to implementation
Given the low rate of translation of already available knowledge on R/S to clinical practice, it is useful to reflect on how to face this challenge.
As noted above, a national survey of U.S. physicians conducted in 2003 found that psychiatrists were more likely to discuss R/S issues with patients than were other specialists and general practitioners. Physicians who more often discussed R/S issues with patients were those who were religious or who received training on R/S and medicine from books or other continuing medical education (CME) materials.6060. Rasinski KA, Kalad YG, Yoon JD, Curlin FA. An assessment of US physicians' training in religion, spirituality, and medicine. Med Teach. 2011;33:944-5. Another U.S. study investigated the impact of physician religiosity on anxiety treatment provided by 896 primary care physicians and 312 psychiatrists. Although religious and non-religious physicians did not differ in referrals for psychotherapy or psychiatric treatment, religious physicians were more likely to encourage patients to use religious resources.6161. Lawrence RE, Rasinski KA, Yoon JD, Curlin FA. Religion and beliefs about treating medically unexplained symptoms: a survey of primary care physicians and psychiatrists. Int J Psychiatr Med. 2013;45:31-44.
Possible strategies to overcome barriers to implementation of the clinical guidelines proposed here include fostering clinicians' cultural competence, which will increase sensitivity to patients' R/S issues, and disseminating knowledge about available evidence regarding the impact of R/S issues on mental health and how to address R/S in clinical practice. With regard to the dissemination of knowledge, the availability of training from undergraduate to postgraduate education programs is paramount, as is the availability of CME materials, e.g., conferences, papers, books, and online resources. Triggered by research in R/S, as well as by ethical and professional guidelines regarding holistic and patient-centered care, medical schools have started to incorporate courses on spirituality and health into their curricula.77. Lucchetti G, Lucchetti ALG, Puchalski CM. Spirituality in medical education: global reality? J Relig Health. 2012;51:3-19. According to recent surveys, 90% of U.S., 59% of British, and 40% of Brazilian medical schools have courses or content on R/S.6262. Lucchetti G, Lucchetti AL, Espinha DC, de Oliveira LR, Leite JR, Koenig HG. Spirituality and health in the curricula of medical schools in Brazil. BMC Med Educ. 2012;12:78. In mental health care, the Accreditation Council for Graduate Medical Education (ACGME) guidelines underscore the importance of addressing R/S issues in psychiatric training.6363. Christina M. Puchalski DBL, Francis G. Lu. Spirituality in psychiatry residency training programs. Int Rev Psychiatr. 2001;13:131-8. In fact, a significant number of U.S. psychiatry programs include a mandatory curriculum on R/S.6464. Grabovac A, Clark N, McKenna M. Pilot study and evaluation of postgraduate course on “the interface between spirituality, religion and psychiatry”. Acad Psychiatry. 2008;32:332-7. Nevertheless, a recent survey of Canadian psychiatry residencies found that almost 72% of Canadian programs did not offer residents training to prepare them to address the interface of R/S and psychiatry.6565. Grabovac AD, Ganesan S. Spirituality and religion in Canadian psychiatric residency training. Can J Psychiatry. 2003;48:171-5. Given that patient belief systems play a key role in patient development and remain a powerful influence on responses to current illness and life demands, it is important that psychiatrists be aware of religious and spiritual issues.6565. Grabovac AD, Ganesan S. Spirituality and religion in Canadian psychiatric residency training. Can J Psychiatry. 2003;48:171-5.
Future research
Despite the wealth of empirical evidence linking R/S and mental health, much remains to be learned. The two greatest challenges are understanding the mechanisms of this association and developing interventions to implement what is already known. To reach these goals, the following research guidelines are proposed6666. Moreira-Almeida A. Religion and health: the more we know the more we need to know. World Psychiatry. 2013;12:37-8.: 1) theoretically driven empirical research to investigate hypothesis about the mechanisms by which R/S impacts health (finding these mechanisms will be important in developing new preventive and treatment approaches); 2) more studies about the actual feasibility and impact of taking a SH in mental health patients; 3) how to assess and address R/S in non-Christian contexts, such as Muslim, Hindu, Buddhist, and Native American patients (this is crucial, as the same words may have very different meanings and social implications in different cultures6767. Tanaka A, Koizumi A, Imai H, Hiramatsu S, Hiramoto E, de Gelder B. I feel your voice. Cultural differences in the multisensory perception of emotion. Psychol Sci. 2010;21:1259-62.); 4) development and testing of the effectiveness of spiritual interventions alone and/or in conjunction with conventional treatments; 5) outcomes investigated should not only focus on improvement of mental disorders, but on positive outcomes and healthy psychology (as spirituality may promote the development of “salutogenic” factors more than a decrease of “pathogenic” factors).
Conclusion
The most widely acknowledged and agreed-upon application of R/S to clinical practice is the need to take a SH, which may improve patient compliance, satisfaction with care, and health outcomes. Concerning integration of R/S into mental health treatment, most spiritual interventions have positive results (superior to control conditions or to other intervention) and seem to be highly cost-effective and beneficial to religious patients.
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60Rasinski KA, Kalad YG, Yoon JD, Curlin FA. An assessment of US physicians' training in religion, spirituality, and medicine. Med Teach. 2011;33:944-5.
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Publication Dates
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Publication in this collection
April–June 2014
History
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Received
4 Sept 2013 -
Accepted
19 Nov 2013