THE RELEVANCE OF SPIRITUALITY TO CLINICAL PRACTICE AND

THE RELEVANCE OF SPIRITUALITY TO CLINICAL PRACTICE AND ASSESSMENT Tom Bro wn Retired psychiatri st (recent!) As so ciate Regis trar Royal C oll ege of Psychiatrists

HISTORY OF PSYCHIATRY AND RELIGION Lots of antipathy to religion: Freud-longing for a father at the root of man’s need for religion-”The Future of an Illusion” 1927 Maudsley -OT prophets showed “striking features of madness” Mohammed “visions were of that kind which medical experience shows to be typical of epilepsy”

MAUDSLEY ON CHRISTIANS “Their follies have been the symptoms of an insane selfhood which identified itself with religion…. apeing humility with religious pride and making it more odious ”

THE BIOPSYCHOSOCIAL MODEL Pride ourselves on “holistic “ approach Biological Psychological Social ……but rarely spiritual. Many if not most, more comfortable taking a detailed sexual Hx Maybe we need a “spiritual awareness” aspect to training cf: the “Sex week” !

ARE WE REALLY HOLISTIC? Biological/psychological feuds throughout my career (to the detriment of ourselves and our patients) Feuds about which psychological model should dominate Often pay lip service to holism

Leon Eisenberg Alison Snyder Child psychiatrist who pioneered early studies of autism. Born Aug 8, 1922, in Philadelphia, PA, USA, he died of prostate cancer on Sept 15, 2009, in Cambridge, MA, USA, aged 87 years. “Psychiatry is all biological and all social. There is no mental function without brain and social context. To ask how much of mind is biological and how much social is as meaningless as to ask how much of the area of a rectangle is due to its width and how much to its height”, wrote Leon Eisenberg in 1995.

The power of medical interventions, for good and for harm, will increase enormously. However, in the next millennium, as in this one, social factors will continue to be decisive for health status. The distribution of health and disease in human populations reflects where people live, what they eat, the work they do, the air and the water they consume, their activity, their interconnectedness with others, and the status they occupy in the social order.

WHAT IS SPIRITUALITY? Lots of definitions! “. . a way of being and experiencing that comes through awareness of a transcendental dimension and is characterised by certain identifiable variables in regard to self, others, nature, life and whatever one considers to be ultimate” Elkins et al 1988 “…concerned with meaning and purpose in life, truth and values” Cook 2004

IT’S NOT THE SAME AS RELIGION (IT’S MUCH BROADER) BUT IT DOES INCLUDE AND EMBRACE RELIGIOUS BELIEFS AND VALUES

RELIGION AND MENTAL HEALTH KOENIG HG ET AL(200 1 ) HANDBOOK OF RE LIGI ON AND HEALTH, OUP Positive effects: Self rated happiness and life satisfaction Hope and optimism Meaning and purpose in life Adapting to loss/bereavement Greater social support Lower rates of suicide/depression Lower rates of substance misuse Less delinquency Better marital adjustment

RELIGION AND MENTAL HEALTH Negative effects: Stress caused by excessive devotion to religious activities (and its impact on other activities eg work/home life) Rigid legalistic thinking/judgemental attitudes/guilt/concealing certain kinds of thoughts /feelings Failure to seek medical help Stigmatising others-defining them as “other” or “different”

RELIGION AND MENTAL HEALTH A word of caution Considerable variation in attitude and practice even within the major religions eg Islam, Christianity, not to mention spiritual belief and practice out with this. ie even if you think you “know” about someone’s spirituality because its similar/the same as yours make no assumptions Allport’s work on intrinsic and extrinsic religiosity of relevance here - the benefits of religion may be confined to the former !

SPIRITUALITY OF MENTAL HEALTH PROFESSIONALS Pretty strong consensus (from research) that we are less religious than our patients Little research on importance of religious or spiritual variables (especially in medical/psychiatric journals) nurses, social workers a bit better! See work of Michael King and Andrew Sims

ISSUES FOR PSYCHIATRISTS 70% don’t believe in God (evidence based) …. and I doubt if most of the rest would describe themselves as in touch with their spiritual side (non evidence based!!) Trained in a pretty materialistic, evidence based setting –some would say reductionist cf Malcolm Jeeves “nothing buttery ”

ISSUES FOR PSYCHIATRISTS Evidence based on that which you can experience through your senses and through science (empiricism) which is good and proper in some contexts, but fails to acknowledge other routes to wisdom and knowledge Historical antipathy to religion from some of our founding fathers ( eg Freud, Maudsley, Griesinger-see earlier)

WHY DON’T WE BROACH THIS TOPIC WITH THOSE WE SEE IN A CLINICAL CONTEXT? SWI NTON 2001(QUOTING TAYLOR ET A L 1995) Spirituality = religion We feel unskilled Our own spiritual ambiguity/uncertainty Lack of time/resource Fear of imposing our own beliefs (boundary violations) Fear of intruding Psychologising (the “ nothing but” problem) Prejudice “ it isn’t important”

WHY SHOULD WE ASSESS SPIRITUALITY? KOENIG ET AL(2005) 10 reasons: 1. It promotes a positive world view 2. Helps us make sense of difficult situations 3. Meaning and purpose 4. Discourage maladaptive coping 5. Enhance social support 6. Promote “other directedness” 7. Promotes need for control 8. Provide and encourage forgiveness 9. Encourage thankfulness 10. Provide hope

ASSESSING SPIRITUALITY Quantitative methods: Royal Free Interview for Religious and Spiritual Beliefs(King et al 1995) Spiritual Involvement and Beliefs Scale (Hatch et al 1998) Clinical interview

WHAT TO ASK PATIENTS? (CULLIFORD AND EAGER 2009) Screening questions “would you describe yourself as religious or spiritual” “when things are difficult or stressful what helps you most” Importance of third party history Reflective and clarifying interview style to ensure you understand.

SPIRITUAL BEHAVIOURS-RELIGIOUS Attend worship Prayer/meditation Rituals Use of music eg hymns, chants Pilgrimage/retreats Reading sacred texts

SPIRITUAL BEHAVIOURS-SECULAR Contemplation Altruistic acts Yoga/Tai Chi Engagement with nature Contemplative reading Artistic /creative

USEFUL APPROACHES-HOPE ANDARAJAH AND HIGHT(2001) sources of Hope, meaning, love comfort Organised religion Personal spirituality and practices Effects on medical and psychiatric care

USEFUL APPROACHES-SPIRIT (MAUGANS 1996) Spiritual belief system Personal spirituality Involvement in religious/spiritual communities Ritualised practices and Restrictions Implications for medical care Terminal events planning

GUIDANCE ON ASSESSMENT MODELS 1. John Swinton “ Spirituality and Mental Health Care” 2001, Jessica Kingsley Publishers 2. Larry Culliford and Sarah Eagger “ Assessing Spiritual Needs” in Spirituality and Psychiatry eds, Cook, Powell and Sims 2009, RCPsych Publications

WHO SHOULD DO IT? Chaplains - can’t possibly assess everyone and not everyone would agree to see them! Nurses - government reviews of nursing both north and south of the border have told nurses they need to be mindful of this area Doctors - ? Most resistant group

WHEN SHOULD IT BE DONE Clinical judgement required here - very rarely should more than screening questions be asked at initial assessment Works better when therapeutic relationship has developed Offers of involvement of chaplaincy/spiritual care services should be made

SUMMARY We are less religious/spiritual than our patients Holistic approaches should include spirituality Awareness of how our own beliefs affect our approach to this is of paramount importance Don’t assume you understand because your own religious /spiritual affiliations are similar to the patients Familiarise yourself with a simple assessment approach Education about religious/spiritual beliefs other than your own

“TO ASSESS PEOPLE’S SPIRITUALITY…. . WILL ENABLE PRACTITIONERS TO REKINDLE MYTHOS AND PUT THE PSYCHE BACK INTO PSYCHIATRY. THE PSYCHE BEING OF COURSE, OUR SOUL” LARRY CULLIFORD