Religious Understanding as Cultural Competence: Issues for Clinicians

SPECIAL REPORT: DIVERSITY & CULTURAL COMPETENCE

Spirituality and religiosity are terms referring to various dimensions of life related to the sacred and divine. Religiosity refers to the nature and extent of public and private religious activity, including belief in God, prayer, and place of worship attendance. Religiosity is usually linked to formal religious traditions (such as Christianity), institutions (such as mosques), sacred texts (such as The Book of Mormon), and a definitive moral code (such as the Decalogue). Spirituality can be an important part of religion but can also exist independent of extant faith traditions, involving a variety of more individual subjective beliefs and activities related to the sacred.

According to data recently released by the Pew Forum, religiosity has significantly declined in the Western world.¹ However, religiosity remains extremely high in the United States, especially when compared with other English-speaking countries, such as Canada, Australia, and the United Kingdom. In the US, recent surveys indicate that 91% of Americans believe in God and 60% describe themselves as a being religious.² These figures are even higher among groups such as African Americans. Given these high rates of religiosity, this article focuses on religiosity rather than spirituality.

TABLE 1 - The FICA tool for spiritual assessment

TABLE 2 - Proposed activities for a psychiatrist in a religiously competent clinical consult

TABLE 3 - Religious activities that can be supported by a religiously competent clinician

TABLE 4 - Components of a religiously competent clinic

Interestingly, psychiatrists have one of the lowest rates of religiosity in the US. Numerous studies indicate that psychiatrists are significantly more likely to be atheists than other physicians and the general population. In an extensive 2003 survey, Curlin and colleagues³ found that 65% of psychiatrists believe in God compared with 77% of other physicians. This is an increase from previous surveys conducted in the 1980s, which regularly reported that only around 40% of psychiatrists and psychologists were theists, compared with 90% of the US general population.⁴

These figures can partially explain the historically ambivalent relationship between religion and psychiatry that persists to this day. This ambivalence has resulted in a traditional reluctance to incorporate religious perspectives into everyday psychiatric practice, which may have been compounded by psychiatry’s ongoing transformation from a biopsychosocial understanding of mental illness to a “bio-bio-bio” model.⁵

This is despite the fact that a well-established corpus of research indicates a positive association between religiosity and mental health.^6,7 Religiosity has consistently been identified as a factor that can promote healing and facilitate recovery amongst those with various physical and mental illnesses.^8,9 Religion can create a sense of coherence that can be deployed as a resource in the face of adversity, distress, and suffering.¹⁰ It can also provide access to a community of people who can offer material, moral, emotional, and social support.¹¹ This is especially the case for underserved minority populations such as African Americans, who find much solace in their religiosity, often in the absence of other institutional support.¹²

Person-centered care is now seen as integral to the practice of modern medicine. Such person-centered care involves harnessing the person’s preexisting strengths and social resources to facilitate recovery. Research indicates that persons with mental illness may feel that their religiosity is often under-harnessed by clinicians as a therapeutic tool.¹² As such, improving religious competence among clinicians is vital if everyday psychiatric care is to become truly person-centered.

What is religious competence?

Religious competence refers to skills, practices, and orientations that recognize, explore, and harness patient religiosity to facilitate diagnosis, recovery, and healing. Religious competence involves the learning and deployment of generic competencies, including active listening and a nonjudgmental stance. It is also an overarching orientation, providing a safe place for discussion of religious issues and identities received in a humble, respectful, and empathetic manner.

Given the high rates of religiosity in the US, an inquiry into religion should become a routine aspect of assessment and follow-up. Conducting this inquiry in a sensitive manner is an essential component of religious competence. Taking appropriate action based on the elicited information is also key to religious competence.

What does it mean to display religious competence?

Asking the right questions and using the elicited information to support religious activities that might facilitate recovery is a core component of religious competence. This involves having an open mind and recognizing the importance of religiosity for some patients, regardless of the clinician’s own beliefs. Fortunately, an existing body of work indicates how best to elicit religious and spiritual information, which can be usefully deployed in the clinic.

Three examples of religious competence are given below in the case vignettes. All are derived from our clinical and research activities. Key identifying information has been omitted, changed, or blurred to maintain anonymity and make patient identification impossible.

CASE VIGNETTE

A 48-year-old man with a dual diagnosis of substance use disorder and schizoaffective disorder has recently obtained social housing, although previously he had spent lengthy periods homeless and unemployed. During a routine assessment, the patient stated that social housing gave him the solitude and privacy to pray, read scripture, and reconnect with God. He stated that God was telling him to abstain from alcohol and make a contribution to the community in return for his blessings.

The patient stated that he wanted to obtain gainful employment. His community-based psychiatrist had built up good relationships with local places of worship over the years and suggested that the patient contact certain ministers who might be able to help find a volunteer position. Lacking confidence, the patient asked the psychiatrist to make the contact on his behalf. The psychiatrist agreed and discovered that a local church had a part-time paid janitorial position available. With the psychiatrist’s support, the patient successfully obtained this position, which had a notable impact on the patient’s recovery.

Puchalski^13,14 has developed an easy-to-use tool, the FICA (Table 1). The FICA consists of 4 simple questions that can be used to do a spiritual assessment. Posing the questions and using the information in the treatment plan would be a display of religious competence. Koenig¹⁵ posits another 5 activities that may help religiously inclined patients (Table 2). These activities take religious competence to another level-for example, by sensitively challenging beliefs, praying with patients, and consulting with clergy.

Many of these activities, especially praying with patients, raise boundary concerns and have been the subject of considerable controversy. Koenig is careful to point out that these activities should generally be conducted at the patient’s request and definitely with patient permission. Activities such as prayer and challenging beliefs may be best used only when a strong therapeutic alliance is already established and when the physician and patient are from the same faith traditions (although silent prayer can be used).

Similarly, challenging patient beliefs should be approached with the utmost caution and only when clearly related to recovery (eg, if the patient is self-harming because he or she believes that God wants them to be punished for a sin). In any talk about religion, patients must be free to disengage or change the topic, and clinicians should also drop the topic if there is a clear lack of interest. In general, the patient must guide these kinds of delicate discussions.

Research indicates that religiously inclined patients engage in numerous religious activities to support their recovery.^8,9,15 These include private activities pursued alone or with the family. Prayer may be the most common, but these activities also include devotional readings; listening to spiritual music; and contemplating sermons on TV, the Internet, or the radio.¹² They can also involve public activities, which are more social in orientation, such as going to a place of worship or attending a sacred-text study group. All of these activities can foster a sense of coherence and social support that is health-promoting and may be encouraged (Table 3).

The clinician may encourage the patient to engage in regular prayer or consultation of sacred texts, if this appears to be a source of strength and support. The moral codes associated with a patient’s religious worldview might influence healthy behavior and decision making (eg, religious injunctions to abstain from or limit alcohol consumption). These moral codes can be harnessed by the psychiatrist to help meet clinical goals-eg, by recommending that a religiously inclined patient with substance use disorder join Alcoholics Anonymous.

The clinician may also encourage patients to use communal and social networks associated with their religious congregation to garner social, emotional, and instrumental support to aid recovery-eg, in finding employment or volunteer opportunities. Clinicians may also keep a list of religious organizations and congregations that have demonstrated that they are especially open to and supportive of people living with mental illness.

CASE VIGNETTE

A 40-year-old woman with psychosis complained that her sister was tamper-ing with her cell phone and television, had been spying on her, and was using “special technology” to monitor her telephone calls. When asked what would help in her recovery, she expressed the need to meet with “a Spiritual Baptist person” for advice. The psychiatrist suggested inviting a spiritual healer from this tradition to a follow-up consultation, and the patient agreed.

During the consultation, the healer stated that systematic fasting, prayer, and herbal remedies were needed. Instead of rejecting this approach, the psychiatrist worked with the patient and healer to enact the spiritual treatment. The psychiatrist convinced the patient and healer that taking prescription medication must be considered an integral part of this process. The psychiatrist was also able to ensure that caloric intake during fasting remained medically acceptable.

By remaining supportive and open-minded, the psychiatrist was able to keep the patient engaged with psychiatric services throughout the spiritual healing process. He was able to monitor medication use, fasting, herbal remedies consumed, and any change in symptoms, which had a beneficial effect on service engagement and recovery.

A religiously competent clinician may seek the patient’s preference for involving family members or clergy in the treatment process. Once a trusting relationship has been cultivated, the clinician can ask the patient about the religious views of key family members. Family may be invited to the consulting room to discuss religious matters if they are important to the patient and seem to have an important role in diagnosis, treatment, or recovery.

If the patient agrees, religious leaders from the community may be invited to follow-up sessions to clarify the role of the religious community in the patient’s life, delineate available resources, reinforce adherence to treatment, and contextualize symptoms with religious overtones. A religiously competent clinician strives to remove barriers between positive religious resources and medical caregivers while maintaining professional and ethical standards of health care.

CASE VIGNETTE

A 32-year-old woman had been raped, which resulted in pregnancy and severe PTSD symptoms. Far from rejecting the pregnancy, she felt that the baby was a gift from God and ruled out termination. Social workers were concerned about her parenting capacity. The young mother also seemed socially isolated. As such, forced placement of the newborn with a foster family was being considered.

At this stage, the woman was referred to a psychiatrist for a further assessment. The psychiatrist sensitively inquired about the patient’s religiosity, which revealed that the patient attended a supportive church. With the patient’s permission, the psychiatrist met with leaders of the church community and discovered that they wanted to support the young mother and child. It was agreed that the mother and child would relocate to the home of a family that attended the patient’s church. The family and church would provide social and instrumental support to both mother and child. The clinical team would monitor this situation and keep channels of communication open with the church. Both mother and child progressed well in this context.

Numerous scholars have noted that patients often use theological and moral concepts to understand their mental illness and its origin and ramifications. These include concepts such as demons, sin, forgiveness, hope, and salvation.¹⁶ Psychiatry has traditionally viewed concepts such as sin as limiting; indeed they have attempted to replace these concepts with those derived from social science, such as “deviance,” although not all psychiatrists secularize these concepts.¹⁷ A religiously competent clinician will attempt to understand what such concepts mean to patients and work with them to assist recovery, rather than attempt to disabuse them of these notions.

Taking such a stance can facilitate a better therapeutic alliance in diverse ways. First, many patients report that clinicians routinely ignore existential matters such as religion, which are of prime subjective importance; this frequently leads to treatment discontinuation.¹⁸ Second, concepts such as person-centered care and the renewed recovery paradigm forcefully emphasize the importance of harnessing personal strengths and resources to foster recovery.¹⁹ Third, research indicates that religiosity is health-promoting, and attention to these issues may actually lead to better outcomes in religiously inclined patients.^6,15

While this article has focused on the religiously competent clinician, it should be noted that religious competence consists of more than optimizing the clinical interaction. It also involves reorienting mental health services. Indeed, clinics and staff that are religiously competent may be better placed to engage people with mental illness for whom religion is important and to enhance their recovery processes.

Mental health service professionals could consider weaving religion and spirituality into their routine procedures or partnering with religious leaders to engage and retain religiously inclined patients. This already occurs in many hospital and VA settings, where ministers from a range of religions and denominations serve the needs of patients, with growing explicit collaborations. Such a model could be extended to community mental health centers, where chaplains could be made more readily available to support patients. Clinics (in collaboration with patients) could also organize religious activities, such as spiritual-reading groups or peer prayer groups. Key events in the liturgical calendars of various religions could be acknowledged or celebrated while respecting state and federal law. Some of these potential activities are listed in Table 4.

Conclusion

Working with religion in the clinic is a delicate endeavor, but one that will improve recovery outcomes if handled appropriately. Clinical staff must be open to talking about religion during evaluations and follow-up sessions. Staff should ask open-ended questions about patients’ religious and spiritual beliefs and activities in a culturally safe setting. Patients will often disclose their religious beliefs and activities when they trust their treatment team and when the clinic is perceived as a culturally safe setting. Equally, clinicians must be sensitive to patients who are not religious or for whom religious discussions may be distressing. This especially may be the case for survivors of clerical sexual abuse or religious persecution abroad. Individual judgment is paramount to ensure that the clinical interaction is supportive rather than threatening to the patient.

In recent years, there is some evidence of a growing rapprochement between religion and psychiatry, with the aim of better integration of the two.²⁰ For example, the American Psychiatric Association and many residency programs have taken steps to promote the importance of religion and spirituality in practice and training.²¹ This can only be of benefit to patients who are religious. The further application and use of religious competence in the clinic can foster recovery and promote healing. As such, the implementation of religious competence in clinical practice should be encouraged, hopefully becoming a routine aspect of person-centered psychiatric care.

Disclosures:

Dr Whitley is Assistant Professor in the department of psychiatry at the Douglas Mental Health University Institute of McGill University in Montreal. Dr Jarvis is Associate Professor in the department of psychiatry at the Culture and Mental Health Research Unit of the Jewish General Hospital and McGill University. The authors report no conflicts of interest concerning the subject matter of this article.

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