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Psychiatry has traditionally distanced itself from spiritual and religious issues. Freud described religion as “a universal obsessional neurosis . . . a regression to primary narcissism” (1), a view influenced by his personal, conflicted, experiences of faith and religion (2). Early drive theories identified religion as suppressing normal sexual desires and thus contributed for decades to psychoanalysts’ view of religion as a source of guilt and dependency. Today, psychiatrists retain a general discomfort about addressing religious or spiritual issues in clinical work and research. The “anti-tenure” effect of pursuing research in these areas has been well described and contributes to young clinicians’ avoidance of them for fear of a negative impact on their careers (3,4). Over the last 2 decades, mental health professionals have become increasingly aware of the need to incorporate patients’ spirituality into mental health assessments and treatment plans, although the psychiatric community has not fully embraced a biopsychosocial-spiritual model. This change has been driven by recognition that religion plays a central role in the lives of many North Americans: a 1996 Gallup poll found that 96% of Americans believe in God, while 21% of psychiatrists and 28% of clinical psychologists are known to be atheist or agnostic (5). In another survey, 72% of Americans agreed with the statement, “My whole approach to life is based on my religion.” By contrast, only 39% of psychiatrists and 33% of clinical psychologists accepted the statement, “My religious faith is the most important influence in my life” (6). Clearly, a disparity exists between the religiosity of the general population and that of the mental health practitioners who serve this population. The growing public interest in reincorporating spirituality into health care delivery is well documented. One study found that 94% of inpatients believe spiritual health to be as important as physical well-being, and although 77% wanted spiritual issues to be considered in their care, only 10% to 20% had conversations with their physician on the topic (7). A similar interest in religious and spiritual issues occurs in users of psychiatric services. For example, a survey comparing the spiritual needs of 51 psychiatric inpatients with those of 50 medical inpatients reported that 80% of psychiatric patients and 88% of medical patients expressed the need for prayer. In addition, 65% of psychiatric patients and 66% of medical patients expressed a need for a visit from a chaplain to pray with them (8). Are patients turning to complementary and alternative therapies to have the spiritual component of their experience acknowledged and addressed? A 1998 study of predictors of alternative health care users found that “for many individuals, the use of alternative health care is part of a broader value orientation and set of cultural beliefs, one that embraces a holistic, spiritual orientation to life” (9). Debate continues regarding the optimal ways of addressing issues related to spirituality and religion. Proponents of physician involvement can be found across specialties (10,11). They point to research findings that support a positive relationship between spirituality and health and that clinicians take a spiritual history during the assessment process and remain open to discussing spiritual issues during the course of treatment. Opponents to addressing spirituality in the context of patient care argue that scientific evidence for an association between spirituality and health status is lacking. In addition, they identify several ethical concerns regarding physician involvement in a patient’s religious or spiritual affairs (12). Although the debate about the relation between health and spiritual or religious practices continues, it is clear that patient belief systems play a key role in patient development and remain a powerful influence on responses to current illness and life demands. Therefore, it is important that psychiatrists be knowledgeable about religious and spiritual issues to be sensitive to the role these beliefs and practices play in their patients’ lives. The American Psychiatric Association (APA) has recognized that psychiatrists require a basic understanding of religious and spiritual issues and has changed its assessment and treatment guidelines accordingly. Curricular changes in US residencies have since followed. In addition, more than one-third of medical schools in the US now offer courses in religion and spirituality (13). Further, authors from the UK and New Zealand have also reviewed the need for specific education of psychiatric trainees in this area (14,15). Educational resources on religion and spirituality are increasingly available for mental health professionals (16,17). We present below a summary of training in religion and spirituality currently available to psychiatry residents in the US. We also discuss the results of a survey of currently available training on these topics in Canadian psychiatry residency programs and present a proposal for a 10-session lecture series to address the paucity of available training. Incorporation of Religion and Spirituality into US CurriculaA 1990 survey regarding religion and spirituality training in psychiatric residency programs in the US found that very few programs had training in this area (18). The APA Practice Guidelines for the Psychiatric Evaluation of Adults (19) were updated in 1995 to include gathering information on “important religious influences on the patient’s life” in the personal history and performing an evaluation that is “sensitive to the patient’s . . . religious/spiritual beliefs.” The Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Residency Training in Psychiatry (20) were amended to reflect these new guidelines. Two changes in the ACGME requirements related specifically to including didactic and clinical instruction on religious and spiritual factors. A model curriculum addressing the changed training requirements was prepared by Larson, Lu, and Swyers (21). The curriculum is organized into 11 modules that address the following topics: the relation between religion and mental health; interviewing and assessment skills; religion and spirituality in human development; working with clergy; working in the consultation-liaison setting; introduction to God images; introduction to charismatic religious experience; introduction to cults; and religious and spiritual issues in the treatment of women, substance abuse, and abused persons. The model curriculum also identified specific training objectives (Table 1).
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