JRSM > Volume 94, Number 6 > Pp. 303-305

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Spirituality in psychiatric education and training

Robert M Lawrence MPhil MRCPsych     Anita Duggal MSc MRCPsych  

Neurodegeneration Research Group, c/o Division of Geriatric Medicine, St George's Hospital Medical School, Cranmer Terrace, London SW17 0RE, UK

Correspondence to: Dr R M Lawrence E-mail: rlawrenc{at}sghms.ac.uk

	INTRODUCTION

TOP INTRODUCTION SPIRITUALITY IN PRACTICE FORM AND CONTENT INTEGRATION REFERENCES

 

‘... And the Lord God formed a man's body from the dust of the ground and breathed into it the breath of life. And the man became a living person.’ (Genesis 2,2)

How are traditional principles of morality, in diverse races and cultures, to be accommodated within a system of medical education based on scientific rationality? A longstanding question concerns spirituality, which has become increasingly disconnected from the sciences of ‘the mind’. In this paper we focus on psychiatry, where the disconnection seems to us particularly serious. Although our backgrounds are Judaeo—Christian and Hindu, our aim is to present a dispassionate argument.

Psychiatry has a history of ignoring, conflicting with and attacking religion¹, dismissing spiritual experience as ‘universal obsessional neurosis’, ego regression^2,3,4, psychosis⁵, pathological thinking in need of modification, or a sign of emotional imbalance^6,7,8. In the USA at least, this mode of thinking may be changing. In its published guidelines the American Psychiatric Association invites professionals to respect the patient's beliefs and rituals without enforcing diagnosis or treatment at odds with the individual's morality. In 1995 a new diagnostic category was also introduced in the DSM-IV, entitled ‘religious or spiritual problems’^9,10,11,12.

Both formal religions and some non-denominational philosophies recognize the existence of dimensions of reality that lie beyond our senses. Such mysticism has been dismissed by some in alienating, if not pathological, terms; yet mystical experience and ascetism can be presented as agents of transformation and maturation^13,14,15,16. For example, individuals who have recovered from a near-death experience are said to display increased moral maturity and tolerance, with a renewed vision of life and its meaning^17,18.

Psychiatry purports to be a value-free science, which seeks not to judge conduct in moral terms but to search for biological and psychological determinants. In extreme form, this moral disconnection makes the trained psychiatrist vulnerable to misuse for political ends—witness the professionally sanctioned murders of psychiatric patients in Nazi Germany¹⁹.

Around 70% of the general population but only 40% of psychiatrists express a belief in God^20,21. Lack of professional interest in the spiritual dimension is reflected by the absence of an evidence base on the subject^22,23,24. Of mainstream psychiatric publications, only 3% refer to the religious affiliation of patients. In child and adolescent psychiatry as many as 18% of studies consider elements of spirituality; but in these the authorship tends to be mental health professionals other than psychiatrists or psychologists²⁵.

Is religion good for the health? Scientific evidence does not allow us to conclude that it is either good or bad^26,27. There is, however, reason to believe that generations of psychiatric trainees have kept clear of research in spirituality for fear of adverse effects on their career; and such neglect will have further widened the ‘religiosity gap’ between doctors and patients^28,29.

	SPIRITUALITY IN PRACTICE

TOP INTRODUCTION SPIRITUALITY IN PRACTICE FORM AND CONTENT INTEGRATION REFERENCES

 
When assessing a case, western psychiatrists are trained to set aside their own spirituality, and in the process they tend to discard that of the patient. Some commentators have reasonably argued that this can lead to misdiagnosis and inappropriate treatments, together with loss of trust and professional credibility³⁰. Similar comments might, of course, be made of other specialties; but a sensitivity to spirituality and religious beliefs is less pressing, in, say, medicine or surgery. There, failure to note the spiritual dimensions of a case will only rarely have serious consequences—an example being religious objection to blood transfusion. In psychiatry, the omission could be seen as neglect to carry out a complete, fair and thorough assessment.

	FORM AND CONTENT

TOP INTRODUCTION SPIRITUALITY IN PRACTICE FORM AND CONTENT INTEGRATION REFERENCES

 
How, then, is a spiritual assessment to be conducted? First the psychiatrist must confront the general and cultural parameters of spirituality, then explore the more formal, behavioural, aspects as highlighted by the presence or absence of faith-driven behaviours, religious rituals and practices. Religion and spirituality can be regarded as the two main components of the phenomenology of a person's faith. The first is observable and in principle quantifiable, the second mostly subjective. Spirituality enjoys ‘vertical’ and ‘horizontal’ dimensions, encompassing both transcendental aspiration and compatible social networks, and its main purpose has been categorized as giving stable meaning to life, important to the integrity of the ego and its permanence^31,32. Attendance at religious rituals has been associated with enhanced wellbeing and ability to cope with loss and physical illness^33,34. It is also said to help prevent ‘nervous breakdowns’ and to have a protective effect against suicide^35,37. Holocaust victims found religion helpful in overcoming the trauma of the concentration camps³⁸. Common prayer was said to have reduced post-traumatic stress in Jewish teenagers after the 1990 Gulf War³⁹. Some psychiatric patients appear to derive much comfort and support from pastoral care while in hospital⁴⁰.

Religious and spiritual variables seem best suited to qualitative rather than quantitative exploration. Any detailed numerical scale⁴¹ of spirituality/religiosity might be alien to current clinical practice, intruding on a comprehensive and spontaneous history.

	INTEGRATION

TOP INTRODUCTION SPIRITUALITY IN PRACTICE FORM AND CONTENT INTEGRATION REFERENCES

 
Here we offer a proposal for integration. Spiritual matters and religion should become part of clinical psychiatric assessment. The aim is to go beyond religious affiliation and practice and to reach a non-judgmental understanding taking into account general and cultural beliefs and values, whether they have contributed to personal and social integration or the opposite, and finally whether they were sustained or rejected in later life. The psychiatrist would then be in a position to consider how this deeper understanding could be used to reinforce professional trust, credibility and therapeutic alliance.

Assessment of religious values, we suggest, may be as important and as sensitive as gathering an appropriate sexual history. In view of the moral aspects, there is always the risk that the patient may be reticent. A patient with feelings of guilt might be wary of a psychiatrist of the same religious denomination, whilst in other cases the patient might wish the psychiatrist to share his or her affiliation. Whatever his or her religion, the moral stance of the professional should be neutral, with no attempt to manipulate that of the patient. This on its own requires special training, and demands awareness of how an assessment might be influenced by personal beliefs and values. The matter is particularly cogent in a multicultural society, where the psychiatrist's failure to fully grasp the range and meaning of an individual's cultural heritage is all too often followed by rejection of psychiatric help.

In this paper we do not argue that only religious people have answers to the meaning of life. Rather, we suggest that the spiritual dimension is intrinsic to any culture, and in many cultures almost inextricably entwined with conduct, morality, personal expectations and concepts of shame and psychological and social reward.

Whilst especially in the western world religious practice may be less prominent than in the past, spirituality has not necessarily declined. As a part of human personality it is probably important in coping mechanisms if not psychopathology, and should be brought more to the fore in the training of modern psychiatrists.

	Acknowledgments

 
We thank Professor Peter Millard for comments and advice.

	REFERENCES

TOP INTRODUCTION SPIRITUALITY IN PRACTICE FORM AND CONTENT INTEGRATION REFERENCES

 

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