Ethics Document Offers Guidance on Religious/Spiritual Issues in Care

Abstract

Back to table of contents Previous article Next article Clinical & ResearchFull AccessEthics Document Offers Guidance on Religious/Spiritual Issues in CareMark MoranMark MoranSearch for more papers by this authorPublished Online:9 Feb 2021https://doi.org/10.1176/appi.pn.2021.2.22AbstractThe resource document provides a roadmap—not prescriptive answers—for navigating questions about how religious and spiritual issues may interface with psychiatric care.Should a psychiatrist pray with a patient who requests it? Is it ethical for a psychiatrist to advertise that he or she is a Christian (or Jewish or Muslim)? Can a patient’s spiritual or religious life be used to enhance treatment? Is it helpful to treatment when the psychiatrist and patient share the same religious values? When is it appropriate to refer a patient to a pastor, rabbi, or other spiritual or religious expert?Those are some of the questions that have prompted the APA Ethics Committee to write the “Resource Document on the Interface of Religion, Spirituality, and Psychiatric Practice” and post it on APA’s website. The resource document is not prescriptive—the answers to such questions and others may depend on contextual and other factors in the treatment of individual patients—but provides a broad framework for how to think about and address questions about the interface of treatment and religious or spiritual values.Charles Dike, M.D., leader of the work group that wrote the APA resource document, says that dating back to the time of Freud, psychiatry has been regarded as unsympathetic to religion.Robert A Lisak“The ethical boundaries in this area, as in many areas, cannot be reduced to absolute rules but are best addressed by a commitment to the basic principles of providing compassionate, respectful, medically appropriate care and avoiding gratifying the psychiatrist’s needs or personal beliefs at the expense of the patient,” the document states. Charles Dike, M.D., chair of the Ethics Committee work group that wrote the document, told Psychiatric News, “The resource document is intended as a roadmap for how to navigate this very difficult area that we all confront in the treatment of patients.”Dike said the document expands on a single existing opinion about religion and psychiatric treatment previously published by the committee in response to a question posed by a member. (The Ethics Committee fields questions from APA members about ethical issues in practice and provides answers that are published as “opinions.”)“The existing position of the Ethics Committee was one brief response to a question that we thought was not comprehensive enough to address all of the nuances of this issue,” Dike said in an interview. “The question focused only on a Christian perspective, and we felt we needed to expand to address questions that have arisen over time addressing religion and spirituality generally.“The reason we thought this was really important is that for a long time psychiatrists have really struggled with knowing where the boundaries are regarding integrating spirituality and religion into mental health care.” He noted that dating to the time of Freud, who regarded religion as an illusion and a neurosis, psychiatry has historically been seen as unsympathetic to religion.In 2006, the APA Corresponding Committee on Religion, Spirituality, and Psychiatry issued the “Resource Document on Religious/Spiritual Commitments and Psychiatric Practice.” The new resource document states: “Although [the basic principles in the 2006 document] remain valuable and important, additional dimensions of the relationship between religion, spirituality and psychiatric practice deserve attention.“For example, from the patient’s perspective, those with strong spiritual and religious beliefs sometimes feel misunderstood or even judged by their psychiatrist. They question why their psychiatrist is neglecting their spirituality and religion when formulating their mental health concerns and initiating treatment. On the other hand, psychiatrists may question the extent to which they can ethically engage in exploring and understanding the religious and spiritual beliefs of their patients and how to best integrate them into patient care.“The question becomes, Where and how do the tenets of religion and spirituality intersect with the biopsychosocial model of modern psychiatric treatment in psychotherapy, in psychiatric research, and even in the use of psychiatric medications?”Vast Research Shows Positive Effects of ReligionThe 10-page resource document emphasizes that incorporation of religious and spiritual beliefs into care is consistent with the medicine-wide focus on culturally sensitive care. “Religion and spirituality are often major components of cultural identity. … A psychiatrist’s ability to consider the relevance of patients’ religious and spiritual beliefs to the understanding, etiology, diagnosis, and treatment of psychiatric disorders … is paramount in providing patient-centered psychiatric care.”There are circumstances when a patient’s religious beliefs may cause harm to a patient: Patients may avoid beneficial treatments when they conflict with their religious beliefs, and other patients may seek types of treatment that are known to be harmful—such as conversion therapy for patients who are distressed about their homosexuality. Some patients may use their religious beliefs to justify suicide, violence, and self-neglect or abuse at the hands of partners or parents.Spiritual Assessment Can Guide TreatmentA “spiritual assessment” of patients can allow psychiatrists to discuss spirituality with them in ways that are not intrusive while communicating a respectful openness on behalf of the psychiatrist, according to the APA Ethics Committee’s “Resource Document on the Interface of Religion, Spirituality, and Psychiatric Practice.”The resource document cites as a model the “FICA” (Faith, Importance, Community, Address) mnemonic developed by Christina Puchalski, M.D., and a group of primary care physicians. The model allows for a rapid screen of multiple dimensions of spirituality, exploring the patients’ unique beliefs, the importance of these beliefs to patients, whether they share these beliefs with a community group, and how they would like their beliefs to be addressed in care.A description of the model was published in The Journal of Palliative Care in 2000, posted here.Examples of questions, grouped according to each of the four components of the mnemonic, include: “Do you consider yourself spiritual or religious?” (Faith and Belief); “What importance does your spirituality have in your life, and has your spirituality influenced how you take care of yourself and your health?” (Importance); “Are you a part of a spiritual community?” (Community); and “How would you like your psychiatrist to address these issues in your health care?” (Address in Care).“Psychiatrists can then meaningfully consider their patients’ cultural, religious, spiritual, and personal ideals and work toward expanding connections between those ideals and mental health when making treatment decisions,” the resource document states. Despite this, “a vast body of literature supports the fact that religion and spirituality are usually associated with positive health outcomes,” the document notes. Religion and spirituality help many people to conceptualize their life experiences, values, beliefs, and behavior and “can help patients to find hope, meaning, and purpose while trying to live with sometimes devastating psychiatric symptoms.”Because so many adults hold religious and spiritual beliefs, it is important for psychiatrists to ask their patients about their religious and spiritual commitments to properly assess, formulate, and treat them. One way that psychiatrists can accomplish this is by taking a spiritual assessment of their patients at the beginning of treatment, and throughout treatment, as appropriate (see box).Expanding Biopsychosocial CareFrom the perspective of the psychiatrist, the resource document notes that religious orientation is not incompatible with ethical practice.Should a psychiatrist pray with a patient who requests it? The document states, “[I]t may be appropriate for a psychiatrist to pray with a patient if the patient has initiated a request that the psychiatrist pray with them and if the psychiatrist feels comfortable praying with the patient in a way that respects the patient’s religious beliefs.”A shared religious perspective between the psychiatrist and the patient can be helpful to patients. But it could also result in a situation in which the patient withholds information (such as an extramarital affair or use of illicit drugs) that would be regarded as a conflict with those shared beliefs.When appropriate, psychiatrists may incorporate their patients’ religious and spiritual values into treatment and are encouraged to be open minded about their patients’ preferences. However, psychiatrists must not offer or promote treatments known to be harmful or nonbeneficial to patients. Although at times a psychiatrist’s self-disclosure about his or her spiritual or religious beliefs and practices may benefit patients, the psychiatrist must maintain appropriate boundaries when discussing these issues and never impose personal spiritual or religious beliefs on patients, according to the resource document.So, should a psychiatrist advertise his or her religious affiliation? “Although it is common for psychiatrists to list areas of interest and expertise in their professional credentials, … it is generally preferable for psychiatrists to indicate an openness to religious and spiritual issues rather than represent themselves as a religious psychiatrist of any one particular faith.”Finally, the resource document emphasizes that there may be instances in which referral to a priest, pastor, rabbi, imam, or other religious leader may be appropriate as an adjunct to psychiatric treatment.Dike said that this is compatible with an evolving understanding of the “biopsychosocial” model of care, which sees a patient’s religious and spiritual life as integral. “We know that you can’t treat an individual without taking into account the biological, psychological, and social aspects of the patient. We are realizing that also includes incorporating the spiritual beliefs and practices of the patient.” ■“Resource Document on the Interface of Religion, Spirituality, and Psychiatric Practice” is posted here.The APA Foundation’s “Mental Health: A Guide for Faith Leaders” is posted here.“Taking a Spiritual History Allows Clinicians to Understand Patients More Fully” is posted here. ISSUES NewArchived