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How Do We Handle Religion in Mental Health Settings?

The Key is to Respect the Individual's Views

My religious friend once asked me point-blank, “if you don’t believe in God, how can you see someone who does as anything but delusional? As a mental health professional, how do you counsel such a person?”

It’s a tough question for me. I’ve been a psychiatrist for almost 15 years. In that time, I’ve seen thousands of patients. Many are non-believers. But for others, faith is integral to who they are. In these cases, am I in a bad position to give care?

The first time I encountered this question, I was a patient, not a health provider, visiting a therapist in college.

When I walked in, nervous about talking to a stranger, I was taken aback by her gold cross pendant and the Christian picture hanging in her office. I’d been feeling isolated, depressed and unsure about my future; an unrequited crush didn’t help matters. As an Asian-American agnostic-atheist wary of any mental health provider, I feared that the doctor would shove her beliefs down my throat.

But though I wasn’t raised religious, I’d grown up around enough Christians to know how important the values of charity and empathy were in theory, if not always in practice. I hoped that she used these items as symbols of those values and would be kind. Fortunately, she was. I only saw her a few times, but her caring manner was enough to get me back on track.

Religion and psychotherapy have had a rocky co-existence. Sigmund Freud grew up Jewish but developed atheistic views as he founded the tenets of psychoanalysis. Religion, he said, was an illusion, a defense mechanism that civilizations used to institute morality. But Carl Jung, his most famous mentee and rival, believed the opposite. To him, incorporating spirituality and mysticism in psychotherapy was crucial. To heal, the unconscious had to connect to larger, unknowable forces in the universe and approach the divine.

This tension is obvious in many psychiatry training programs. In my training program, questions of religion and spirituality in clients were not openly discussed or taught. We are told to ask about “religious background” as a part of a social history assessment, but it’s not clear what to do with that information.

Even the American Psychiatric Association has laid out only general standards. In a 2006 paper, they advise maintaining respect for patients’ values, beliefs, and worldviews; not imposing one’s own religious beliefs onto patients; and fostering recovery “by making treatments decisions with patients in ways that respect and take into meaningful consideration their cultural, religious/spiritual, and personal ideals.” Psychiatrists are advised to maintain their religious boundaries. Asking a nonreligious patient to pray with you, or denigrating a religious patient’s commitments as “psychopathological,” for example, are no nos.

With my nonreligious background, my therapeutic approach has been to remain nonjudgmental. It can be awkward when a patient asks me if I’m religious or believe in God, usually after they’ve lost a loved one. I try to deflect the question back to them. “If you believe in God and going to church,” I say, “those are important ways for you to draw strength at this difficult time.”

But I’m also in a unique position to help those who aren’t religious or who are struggling with those issues. I remember several young clients who developed depression and stress after leaving their religious communities. One young man decided after his science classes in college that he could not reconcile his religious beliefs with the larger questions about the universe and evolutionary biology. His hometown was small and conservative. When he decided to leave his church, he lost all of his friends; even his family shunned him.

“I’ve lost everything,” he told me. “Even God.”

I, too, had felt some isolation from my Korean-American community (which is majority Christian) because of my religious views. I understood the difficult situation he faced.

Without revealing my situation, I wanted to let him know that I felt particular empathy for his situation. I sensed his loneliness and isolation, and I wanted to make sure he realized there was hope. In that moment, I was able to give him encouragement. “You were brave for standing up for your beliefs,” I told him. “Your journey has to be your own, but you are not alone.”

The question of faith is also challenging when clients are facing religious delusions driven by obsessions, psychosis or mania. Some conditions are characterized by “hyper-religiosity,” where the person is fueled by intense religious obsessions: sometimes virulent guilt and self-hatred during psychotic depressions or schizophrenic breaks where they view themselves as “sinners” ruled by “the devil.” Some actually hear God’s voice or believe they are Jesus Christ.

One client I saw was suffering from schizo-affective disorder and refusing to eat because God told her to fast. Severe psychosis caught her in this ritual starvation; we even brought a psychiatrist of the same religion to speak to her to see if he could convince her that her fasting was toxic to her health and not what God would want. Unfortunately, it didn’t work. Only electroconvulsive therapy snapped her out of it.

Another potential tripwire is when someone’s religion contradicts mental health recommendations or advises against something viewed as medically necessary. There has been some skepticism about mental health and psychiatry espoused by some religious people, who in certain cases feel that faith alone is all that is necessary to treat someone. Medications and psychotherapy in these situations are viewed as wasteful, even signs of weakness or sin. This approach can be openly dangerous when someone has a truly severe mental illness. The famous pastor Rick Warren has campaigned against these types of views after the tragic loss of his son to suicide and severe depression. As he put it, “mental, physical, spiritual, and relational illness often all go together. You got to [work on] all four.”

The bottom line for me is a humanistic approach to all patients, regardless of their background or creed. It’s important to respect an individual’s particular language and style of relating to their universe, in order to make a therapeutic connection. Given the pain and suffering of humanity, I understand why people are religious, even if I don’t find answers in it for myself. If others do, it is still my job to encourage that healing process in any form. And if others don’t, I am strongly there for them as well.

This article was first published in The Washington Post on January 26, 2015.

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