Spirituality in psychiatric education and training

Robert M Lawrence MPhil MRCPsych Anita Duggal MSc MRCPsych

J R Soc Med 2001;94:303305
`. . . 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 scientic 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 JudaeoChristian and Hindu, our aim
is to present a dispassionate argument.
Psychiatry has a history of ignoring, conicting with and
attacking religion
1
, dismissing spiritual experience as
`universal obsessional neurosis', ego regression
24
, psycho-
sis
5
, pathological thinking in need of modication, or a sign
of emotional imbalance
68
. 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'
912
.
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
1316
. 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 endswitness the
professionally sanctioned murders of psychiatric patients
in Nazi Germany
19
.
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 reected
by the absence of an evidence base on the subject
2224
. Of
mainstream psychiatric publications, only 3% refer to the
religious afliation 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 psycholo-
gists
25
.
Is religion good for the health? Scientic 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
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 credibility
30
. 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 consequencesan 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
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 rst is observable and in principle quantiable,
the second mostly subjective. Spirituality enjoys `vertical'
P
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J O U R N A L O F T H E R O Y A L S O C I E T Y O F M E D I C I N E V o l u m e 9 4 J u n e 2 0 0 1
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@sghms.ac.uk
and `horizontal' dimensions, encompassing both transcen-
dental 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 camps
38
.
Common prayer was said to have reduced post-traumatic
stress in Jewish teenagers after the 1990 Gulf War
39
. Some
psychiatric patients appear to derive much comfort and
support from pastoral care while in hospital
40
.
Religious and spiritual variables seem best suited to
qualitative rather than quantitative exploration. Any
detailed numerical scale
41
of spirituality/religiosity might
be alien to current clinical practice, intruding on a
comprehensive and spontaneous history.
INTEGRATION
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 afliation 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 nally 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 afliation. 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
inuenced 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 psycho-
pathology, and should be brought more to the fore in the
training of modern psychiatrists.
Acknowledgment We thank Professor Peter Millard for
comments and advice.
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