Teaching Spiritual and Religious Competencies to Psychiatry Residents: A Scoping and Systematic Review.

PURPOSE: For many persons worldwide, mental health is inseparably linked with spirituality and religion (S&R), yet psychiatrists have repeatedly expressed doubts regarding their preparedness to address patients' spirituality or religion appropriately. In recent decades, medical educators have developed and implemented curricula for teaching S&R-related competencies to psychiatry residents. The authors reviewed the literature to understand the scope and effectiveness of these educational initiatives. METHOD: The authors searched 8 databases to identify studies for a scoping review and a systematic review. The scoping review explored educational approaches (topics, methods) used in psychiatry residency programs to teach S&R-related competencies. The systematic review examined changes in psychiatry trainees' competencies and/or in patient outcomes following exposure to these educational interventions. RESULTS: Twelve studies met criteria for inclusion in the scoping review. All reported providing residents with both (1) a general overview of the intersections between mental health and S&R and (2) training in relevant interviewing and assessment skills. Seven of these studies-representing an estimated 218 postgraduate psychiatry trainees and at least 84 patients-were included in the systematic review. Residents generally rated themselves as being more competent in addressing patients' S&R-related concerns following the trainings. One randomized controlled trial found that patients with severe mental illness who were treated by residents trained in S&R-related competencies attended more appointments than control patients. CONCLUSIONS: S&R-related educational interventions appeared generally well tolerated and appreciated by psychiatry trainees and their patients; however, some topics (e.g., Alcoholics Anonymous) received infrequent emphasis, and some experiential teaching methodologies (e.g., attending chaplaincy rounds) were less frequently used for psychiatry residents than for medical students. The positive association between teaching S&R-related competencies to psychiatry residents and patient appointment attendance merits further study. Future trainings should supplement classroom learning with experiential approaches and incorporate objective measures of resident competence.

Religiosity and spirituality in psychiatry residency programs: why, what, and how to teach?

OBJECTIVE: To propose a core curriculum for religiosity and spirituality (R/S) in clinical practice for psychiatry residency programs based on the available evidence. METHODS: After performing a review of studies on the implementation of R/S curricula and identifying the most commonly taught topics and teaching methods, an R/S curriculum was developed based on the most prevalent strategies, as well as recommendations from psychiatric associations, resulting in a fairly comprehensive R/S curriculum that is simple enough to be easily implemented, even where there is a shortage of time and of faculty expertise. RESULTS: The curriculum is a twelve-hour course (six 2-hour sessions). The topics include: concepts and evidence regarding R/S and mental health relationships, taking a spiritual history/case formulation, historical aspects and research, main local R/S traditions, differential diagnosis between spiritual experiences and mental disorders, and R/S integration in the approach to treatment. The teaching methods include: classes, group discussions, studying guidelines, taking spiritual histories, panels, field visits, case presentations, and clinical supervision. The evaluation of residents includes: taking a spiritual history and formulating an R/S case. The program evaluation includes: quantitative and qualitative written feedback. CONCLUSIONS: A brief and feasible core R/S curriculum for psychiatry residency programs is proposed; further investigation of the impact of this educational intervention is needed.

Religiosity, spirituality, suicide risk and remission of depressive symptoms: a 6-month prospective study of tertiary care Brazilian patients.

Religiosity and spirituality (R/S) are increasingly recognized as significant aspects in the evaluation of depressed patients. Limited research, however, has investigated the impact of R/S on outcomes of more severe or chronic depressed patients. The present study investigated the impact of different religiosity dimensions in tertiary care Brazilian depressed patients over suicide risk scores measured at baseline and remission of depressive symptoms in a 6-month prospective follow-up. In 277 individuals interviewed, 226 presented a diagnosis of depressive episode and 192 were assessed in the follow-up. Religiosity was evaluated using the Duke University Religion Index, comprising three dimensions of religiosity (organizational religiosity, non-organizational religiosity, intrinsic religiosity). Other potential predictors of outcomes included the Childhood Trauma Questionnaire (CTQ), Maudsley Staging of illness (MSM), Medical Outcomes Study Social Support Survey (MOS), World Health Organization Spirituality, Religiousness and Personal Beliefs instrument (WHOQOL-SRPB) and Hamilton Depression Scale (HAM-D). Results showed that almost half (46.1%) of the patients reported previous suicide attempts. Linear regression models identified that religious attendance (t-statistic -2.17, P=0.03), intrinsic religiosity (t-statistic -2.42, P=0.01) and WHOQOL-SRPB (t-statistic -3.67, P=0.00) were inversely correlated to suicide risk scores. In a prospective follow-up 16.7 % of patients (n=32/192) achieved remission of depressive symptoms (HAM-D scores ≤7). Religious attendance (OR 1.83, P=0.02) was identified as the main predictor of remission. Findings reinforce the importance of attending to religiosity/spirituality in order to improve outcomes and promote the recovery especially among severely depressed patients with increased suicide risk.

The Physician's Role in Responding to Existential Suffering: What Does It Mean to Comfort Always?

Existential suffering is commonly experienced by patients with serious medical illnesses despite the advances in the treatment of physical and psychological symptoms that often accompany incurable diseases. Palliative care (PC) clinicians wishing to help these patients are faced with many barriers including the inability to identify existential suffering, lack of training in how to address it, and time constraints. Although mental health and spiritual care providers play an instrumental role in addressing the existential needs of patients, PC clinicians are uniquely positioned to coordinate the necessary resources for addressing existential suffering in their patients. With this article, we present a case of a patient in existential distress and a framework to equip PC clinicians to assess and address existential suffering.

Integrating spirituality into the care of older adults.

ABSTRACTWe examine how to sensibly integrate spirituality into the care of older adult medical and psychiatric patients from a multi-cultural perspective. First, definitions of spirituality and spiritual integration are provided. Second, we examine the logic that justifies spiritual integration, including research that demonstrates an association between religious/spiritual (R/S) involvement and health in older adults and research that indicates widespread spiritual needs in later life and the consequences of addressing or ignoring them. Third, we describe how and when to integrate spirituality into the care of older adults, i.e. taking a spiritual history to identify spiritual needs and then mobilizing resources to meet those needs. Fourth, we examine the consequences of integrating spirituality on the well-being of patients and on the doctor-patient relationship. Finally, we describe boundaries in addressing R/S issues that clinicians should be cautious about violating. Resources will be provided to assist with all of the above.

A Closer Look at Transcendence and Its Relationship to Mental Health.

Experiences of transcendence can promote growth, creativity and altruism, but often exist in tension with critical thought and can feature problematically in certain mental disorders. Identification of the core elements in the experience of transcendence-suspending disbelief, being moved or inspired, surrendering oneself and identifying within a larger context, can clarify its relationship to psychopathology, and the basis for a clinician's role. To help individuals engage transcendent resources well, clinicians can help patients recognize how depression and trauma may interfere with engagement, masochistic and magical tendencies may distort healthy self-surrender, and vulnerability to social pressure may interfere with mature identification with a larger context or community.

A Model of Collaborative Spiritual and Psychiatric Care of Oncology Patients.

BACKGROUND: Many oncology patients see both chaplains and consultation-liaison (C-L) psychiatrists during medical hospitalizations. Studies show that spirituality and mental health influence one another, and that patients often prefer that physicians understand their spirituality. Though models of inpatient chaplaincy-psychiatry collaboration likely exist, none are apparent in the literature. In this study, we present one model of chaplaincy-psychiatry collaboration, hypothesizing that both specialties would find the intervention helpful. METHODS: From April through December 2015, the C-L psychiatry service at Brigham & Women's Hospital piloted 13 sessions of interdisciplinary rounds, where chaplains and C-L psychiatrists discussed common oncology patients. Participants completed questionnaires including quantitative and qualitative prompts before the intervention, after each session, and at the study's conclusion. RESULTS: Eighteen individuals completed baseline questionnaires. Between baseline and final surveys, the proportion of participants describing themselves as "very satisfied" with the 2 services' integration rose from 0-36%. The proportion of participants feeling "not comfortable" addressing issues in the other discipline declined from 17-0%. The most frequently chosen options on how discussions had been helpful were that they had enhanced understanding of both patient needs (83.3%) and the other discipline (78.6%). Qualitative data yielded similar themes. At conclusion, all respondents expressed preference that interdisciplinary rounds continue. CONCLUSION: This study describes a model of enhancing collaboration between chaplains and C-L psychiatrists, an intervention not previously studied to our knowledge. A pilot intervention of the model was perceived by both specialties to enhance both patient care and understanding of the other discipline.

The relationship between medicine, spirituality and religion: three models for integration.

The integration of medicine and religion is challenging for historical, ethical, practical and conceptual reasons. In order to make more explicit the bases and goals of relating spirituality and medicine, we distinguish here three complementary perspectives: a whole-person care model that emphasizes teamwork among generalists and spiritual professionals; an existential functioning view that identifies a role for the clinician in promoting full health, including spiritual well-being; and an open pluralism view, which highlights the importance of differing spiritual and cultural traditions in shaping the relationship.

Spirituality and religion in oncology.

Despite the difficulty in clearly defining and measuring spirituality, a growing literature describes its importance in oncology and survivorship. Religious/spiritual beliefs influence patients' decision-making with respect to both complementary therapies and aggressive care at the end of life. Measures of spirituality and spiritual well-being correlate with quality of life in cancer patients, cancer survivors, and caregivers. Spiritual needs, reflective of existential concerns in several domains, are a source of significant distress, and care for these needs has been correlated with better psychological and spiritual adjustment as well as with less aggressive care at the end of life. Studies show that while clinicians such as nurses and physicians regard some spiritual care as an appropriate aspect of their role, patients report that they provide it infrequently. Many clinicians report that their religious/spiritual beliefs influence their practice, and practices such as mindfulness have been shown to enhance clinician self-care and equanimity. Challenges remain in the areas of conceptualizing and measuring spirituality, developing and implementing training for spiritual care, and coordinating and partnering with chaplains and religious communities.

Why is spiritual care infrequent at the end of life? Spiritual care perceptions among patients, nurses, and physicians and the role of training.

PURPOSE: To determine factors contributing to the infrequent provision of spiritual care (SC) by nurses and physicians caring for patients at the end of life (EOL). PATIENTS AND METHODS: This is a survey-based, multisite study conducted from March 2006 through January 2009. All eligible patients with advanced cancer receiving palliative radiation therapy and oncology physician and nurses at four Boston academic centers were approached for study participation; 75 patients (response rate = 73%) and 339 nurses and physicians (response rate = 63%) participated. The survey assessed practical and operational dimensions of SC, including eight SC examples. Outcomes assessed five factors hypothesized to contribute to SC infrequency. RESULTS: Most patients with advanced cancer had never received any form of spiritual care from their oncology nurses or physicians (87% and 94%, respectively; P for difference = .043). Majorities of patients indicated that SC is an important component of cancer care from nurses and physicians (86% and 87%, respectively; P = .1). Most nurses and physicians thought that SC should at least occasionally be provided (87% and 80%, respectively; P = .16). Majorities of patients, nurses, and physicians endorsed the appropriateness of eight examples of SC (averages, 78%, 93%, and 87%, respectively; P = .01). In adjusted analyses, the strongest predictor of SC provision by nurses and physicians was reception of SC training (odds ratio [OR] = 11.20, 95% CI, 1.24 to 101; and OR = 7.22, 95% CI, 1.91 to 27.30, respectively). Most nurses and physicians had not received SC training (88% and 86%, respectively; P = .83). CONCLUSION: Patients, nurses, and physicians view SC as an important, appropriate, and beneficial component of EOL care. SC infrequency may be primarily due to lack of training, suggesting that SC training is critical to meeting national EOL care guidelines.

Possibly impossible patients: management of difficult behavior in oncology outpatients.

Angry, threatening, or otherwise disruptive behavior by patients can interfere with necessary oncologic treatment, sometimes to the point of rendering continued care impossible. We offer oncology clinicians guidance in dealing with difficult outpatients by discussing the differential diagnosis and multidisciplinary management of treatment-disrupting behavior in the ambulatory oncology setting.We review the existing literature on dealing with difficult patients and present clinical experience at a comprehensive cancer center where a formalized, institutional process for responding to disruptive outpatients has been developed.A structured, multidisciplinary approach to deal with difficult behavior in oncology outpatients can improve care and staff morale. Staff using this approach can identify causes of treatment-disrupting behavior, develop and implement appropriate behavior plans, facilitate communication, address mental health issues, and ensure that decisions to terminate a relationship with a patient are ethical, clinically justified, and supported by due process.In the future, clinical recommendations and institutional guidelines for dealing with difficult patients should be evaluated with more structured, quantitative research.

The relationship of spiritual concerns to the quality of life of advanced cancer patients: preliminary findings.

PURPOSE: Religion and/or spirituality (R/S) have increasingly been recognized as key elements in patients' experience of advanced illness. This study examines the relationship of spiritual concerns (SCs) to quality of life (QOL) in patients with advanced cancer. PATIENTS AND METHODS: Patients were recruited between March 3, 2006 and April 14, 2008 as part of a survey-based study of 69 cancer patients receiving palliative radiotherapy. Sixteen SCs were assessed, including 11 items assessing spiritual struggles (e.g., feeling abandoned by God) and 5 items assessing spiritual seeking (e.g., seeking forgiveness, thinking about what gives meaning in life). The relationship of SCs to patient QOL domains was examined using univariable and multivariable regression analysis. RESULTS: Most patients (86%) endorsed one or more SCs, with a median of 4 per patient. Younger age was associated with a greater burden of SCs (ß = -0.01, p = 0.006). Total spiritual struggles, spiritual seeking, and SCs were each associated with worse psychological QOL (ß = -1.11, p = 0.01; ß = -1.67, p < 0.05; and ß = -1.06, p < 0.001). One of the most common forms of spiritual seeking (endorsed by 54%)--thinking about what gives meaning to life--was associated with worse psychological and overall QOL (ß = - 5.75, p = 0.02; ß = -12.94, p = 0.02). Most patients (86%) believed it was important for health care professionals to consider patient SCs within the medical setting. CONCLUSIONS: SCs are associated with poorer QOL among advanced cancer patients. Furthermore, most patients view attention to SCs as an important part of medical care. These findings underscore the important role of spiritual care in palliative cancer management.

Approaching emptiness: subjective, objective and existential dimensions.

Clinicians have lacked a coherent approach to emptiness, which is both a pervasive metaphor for loss, deficiency, or alienation and a frequently cited spiritual goal. We suggest a framework for approaching emptiness that distinguishes among its subjective, objective, and existential dimensions. Clinicians can use psychodynamic and cognitive behavioral approaches to clarify schemas that distort patients' perceptions of others and of themselves, behavioral and relational approaches to help them deal with real deficiency and loss, and spiritually oriented approaches to put these into a larger context.

"If God wanted me yesterday, I wouldn't be here today": religious and spiritual themes in patients' experiences of advanced cancer.

BACKGROUND: This study sought to inductively derive core themes of religion and/or spirituality (R/S) active in patients' experiences of advanced cancer to inform the development of spiritual care interventions in the terminally ill cancer setting. METHODS: This is a multisite, cross-sectional, mixed-methods study of randomly-selected patients with advanced cancer (n = 68). Scripted interviews assessed the role of R/S and R/S concerns encountered in the advanced cancer experience. Qualitative and quantitative data were analyzed. Theme extraction was performed with interdisciplinary input (sociology of religion, medicine, theology), utilizing grounded theory. Spearman correlations determined the degree of association between R/S themes. Predictors of R/S concerns were assessed using linear regression and analysis of variance. RESULTS: Most participants (n = 53, 78%) stated that R/S had been important to the cancer experience. In descriptions of how R/S was related to the cancer experience, five primary R/S themes emerged: coping, practices, beliefs, transformation, and community. Most interviews (75%) contained two or more R/S themes, with 45% mentioning three or more R/S themes. Multiple significant subtheme interrelationships were noted between the primary R/S themes. Most participants (85%) identified 1 or more R/S concerns, with types of R/S concerns spanning the five R/S themes. Younger, more religious, and more spiritual patients identified R/S concerns more frequently (beta = -0.11, p < 0.001; beta = 0.83, p = 0.03; and beta = 0.89, p = 0.04, respectively). CONCLUSIONS: R/S plays a variety of important and inter-related roles for most advanced cancer patients. Future research is needed to determine how spiritual care can incorporate these five themes and address R/S concerns.

Provision of spiritual care to patients with advanced cancer: associations with medical care and quality of life near death.

PURPOSE: To determine whether spiritual care from the medical team impacts medical care received and quality of life (QoL) at the end of life (EoL) and to examine these relationships according to patient religious coping. PATIENTS AND METHODS: Prospective, multisite study of patients with advanced cancer from September 2002 through August 2008. We interviewed 343 patients at baseline and observed them (median, 116 days) until death. Spiritual care was defined by patient-rated support of spiritual needs by the medical team and receipt of pastoral care services. The Brief Religious Coping Scale (RCOPE) assessed positive religious coping. EoL outcomes included patient QoL and receipt of hospice and any aggressive care (eg, resuscitation). Analyses were adjusted for potential confounders and repeated according to median-split religious coping. RESULTS: Patients whose spiritual needs were largely or completely supported by the medical team received more hospice care in comparison with those not supported (adjusted odds ratio [AOR] = 3.53; 95% CI, 1.53 to 8.12, P = .003). High religious coping patients whose spiritual needs were largely or completely supported were more likely to receive hospice (AOR = 4.93; 95% CI, 1.64 to 14.80; P = .004) and less likely to receive aggressive care (AOR = 0.18; 95% CI, 0.04 to 0.79; P = .02) in comparison with those not supported. Spiritual support from the medical team and pastoral care visits were associated with higher QOL scores near death (20.0 [95% CI, 18.9 to 21.1] v 17.3 [95% CI, 15.9 to 18.8], P = .007; and 20.4 [95% CI, 19.2 to 21.1] v 17.7 [95% CI, 16.5 to 18.9], P = .003, respectively). CONCLUSION: Support of terminally ill patients' spiritual needs by the medical team is associated with greater hospice utilization and, among high religious copers, less aggressive care at EoL. Spiritual care is associated with better patient QoL near death.