Should physicians be concerned about the religious or spiritual lives of their patients? Is such information relevant to medical care?
During a complete medical work-up, physicians ask patients about their current medical history, past medical history, family history of illnesses, and social history. These include personal and sometimes intimate details of a person's life, including sexual orientation, high risk behaviors, and substance use and abuse. Some believe that a spiritual history should be obtained as well. Others think that knowledge of a person's religious beliefs is irrelevant to providing good medical care.
Why would some believe that information about a person's spiritual beliefs could help a physician provide medical care? One major argument is that medical illnesses are life stressors and personal spiritual beliefs have the potential to influence responses to stress and illness. A person's spiritual world can be important in determining how that person copes with illnesses and adapts to treatments. Some may argue that physicians who ignore this aspect of their patients' lives are overlooking important information that the medical team can use to help a person deal with illnesses. This logic depends on the belief that there is an interaction between a person's spiritual belief system and his or her ability to respond to illnesses.
On the other hand, some physicians believe that medicine is based purely on science and that spiritual beliefs are irrelevant to the pathophysiological processes underlying the illnesses and to a patient's response to treatment. Some believe that talking about spirituality should be avoided, just like talking about political views should be avoided.
Psychiatric illnesses add fascinating dimensions to this discussion. When evaluating severely depressed patients, psychiatrists must review the potential for suicide. It is common for the psychiatrist to hear from the patient that "my religious beliefs prevent me from committing suicide." In this context, spiritual beliefs may actually be life-saving.
It is difficult for psychiatrists to ignore the intersection of religion and medicine. Psychiatrists learn quickly about the belief systems that motivate an individual and work with these belief systems in order to assist a person in recovering from psychiatric illness. A patient's belief system can be helpful in terms of choosing a particular psychotherapeutic approach, encouraging compliance with medications, and reinforcing the benefits of lifestyle factors including exercise, diet, and social relationships. This does not mean that a psychiatrist must share the same spiritual beliefs as his or her patient; it means that the psychiatrist should have the ability to understand what is important to the patient and utilize that information to best help the patient.
These issues become even more fascinating and complex when the psychiatrist is working with an individual who develops a psychotic illness and incorporates religious beliefs into his or her psychotic symptoms. It is not uncommon for patients to experience religious delusions such as the belief that they are God or that God is commanding them to lock themselves in a room, chant, and not eat or drink. Sometimes, patients believe that the devil is commanding them to do violent and evil acts. Similarly, some patients believe that they hear God's voice directly speaking to them and that God has given them special abilities or powers.
In assessing psychotic symptoms, the cultural background of the patient must be taken into consideration. In fact, understanding a patient's symptoms requires understanding the cultural context of the symptoms. For example, "speaking in tongues" is part of the religious practice of some denominations. This phenomenon may appear odd or even bizarre to outside observers, but within the cultural religious context such behavior is understandable and accepted. The very definition of the psychiatric term "delusion" takes this into account by stipulating that a delusion is a fixed false belief outside the context of the person's culture. Assessing such symptoms often requires conversations with others who belong to the same culture or religion in order to determine whether the patient's ideas and actions are out of the ordinary when compared to other members of their community.
When symptoms are deemed abnormal and out of cultural context, most psychiatrists avoid challenging these beliefs. Rather, they initiate treatments with antipsychotic medications in order to help a person's thinking and behavior return to baseline. Often, after the delusions and hallucinations disappear, the person returns to his or her pre-psychotic belief system. Psychiatrists are taught to accept each person as an individual without being judgmental about the nature of the person's basic beliefs. The religious beliefs a person professes when exhibiting delusions or hallucinations may be very different from the person's belief system when the psychotic symptoms improve.
One of our mentors taught us that the more we understand the various forces that help individuals cope, the better we will be as psychiatrists. This mentor encouraged us to become as familiar as possible with religions but never to encourage patients to adopt our own personal beliefs.
Some medical specialists may never need to think about the relationship of spirituality to health. Administering an eye exam, for example, probably does not require information about the patient's spirituality. Psychiatry is one field of medicine where the more you know about a person and the less judgmental you are, the more you may be able to help.
One reason that the field of psychiatry is so fascinating is the breadth of issues that psychiatrists encounter. This is our sixteenth post and we have covered a broad range of topics such as systems neurosciences, conflicts of interests, involuntary hospitalization of patients, and the role of spirituality in treatment. We will continue to post topics that demonstrate the diversity of this medical discipline as we attempt to demystify psychiatry.
This column was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD.
