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Introducing spirituality, religion and culture curricula in the psychiatry residency programme
  1. Leila Kozak1,2,
  2. Lorin Boynton3,
  3. Jacob Bentley4,
  4. Emma Bezy5
  1. 1Health Services R&D Service, Department of Veteran Affairs, VA Puget Sound Health Care System, Department Of Veterans Affairs Medical Center, Seattle, Washington, USA
  2. 2Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, USA
  3. 3Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, Washington, USA
  4. 4Psychology Department, Seattle Pacific University, Seattle, Washington, USA
  5. 5Center for Spirit & Health in Seattle, Washington, USA
  1. Correspondence to Dr Leila Kozak, Health Services R&D Service, Department of Veteran Affairs, VA Puget Sound Health Care System, Department Of Veterans Affairs Medical Center, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA; leila.kozak{at}va.gov

Abstract

A growing body of research suggests that religion and spirituality may have a positive effect on mental and physical health. Medical schools have been increasingly offering courses in spirituality and health, particularly about the multi-cultural dimensions of religion and spirituality. There is a trend towards integrating the teaching of cross-cultural issues related to spirituality and religion into medical education. This trend is particularly evident in the field of psychiatry, where an increasing number of residency programmes are developing curriculum in this area. This article describes a specific curriculum in spirituality, religion and culture that was introduced in 2003 at the University of Washington Psychiatry Residency Program in Seattle, Washington. Reflections about the present and future of subject areas such as spirituality and religion in medical education and psychiatry residency are discussed.

  • Humanities
  • spirituality
  • religion & medicine
  • psychiatry
  • curriculum
  • cross-cultural studies
  • inter-professional education
  • medical education

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Introduction

A growing body of research suggests that religion and spirituality may have positive effects on health and wellbeing.1–4 American medical schools are increasingly offering courses in spirituality and health. In 1994, just 17 of the 126 accredited US medical schools offered courses on spirituality in medicine.5 The number of medical schools offering courses on spirituality increased to 39 by 1998 and continued to expand with 84 schools offering such training in 2004.6 Since 1997, the National Institute for Healthcare Research and the John Templeton Foundation have been awarding grants to medical schools to develop curricula in spirituality and medicine.5 According to the George Washington University Center for Spirituality and Healing, there are currently 32 psychiatry residency programmes that have incorporated spirituality into their curriculum.7

Emphasis on cultural sensitivity in addition to clinical competence has become a priority in medical care; as a result, religion and spirituality may be most effectively approached within the context of cultural values and expectations. In 2002, the American Medical Association published the Cultural Competence Compendium that reported on the relevance of spiritual practices and their impact on effective care.8 The compendium described an increasing numbers of policies, reports and publications that are encouraging physicians to become more knowledgeable about these practices.

Differentiating concepts such as spirituality and religion in resident training could have substantial implications for patient care across specialities. For a medical provider, differentiating between spirituality and religion and related terms may be integral to understanding psychosocial dimensions of a patient's illness. In psychiatry, such differentiation may be even more important because the role of the psychiatrist is precisely to focus on the realm of mental and social health, both of which are deeply intertwined with the religious and/or spiritual views of the patient.9

While in the last 20 years medical schools have made significant efforts to attend to the need of training medical providers in spirituality and medicine, it wasn't until recently that religion and spirituality have been incorporated into psychiatry training programmes. A 1990 survey regarding religion and spirituality training in psychiatry residency programmes in the US found that very few programmes had training in this area.10 A related “perceived failure of service providers to adequately attend to [the spiritual] component of care”11 has been reported. According to Greasley, Chiu and Gartland,11 the failure of many programmes to have such curricula may be symptomatic of a medical culture in which readily observable and measurable elements in care have assumed a prominence over more subjective, deeply personal components. To bridge this gap, a more holistic approach to care based on multidisciplinary and multicultural education in spiritual care has been proposed.11 12

In Canada, a 2001 survey of trainings in religion and spirituality in psychiatry residency programmes reported that most Canadian programmes offered minimal instruction on religious and spiritual issues in psychiatry.13 Fourteen of the 16 training programmes contacted for the survey responded, with 10 of the programmes reporting that they did not provide didactic teaching in these areas. Six of these programmes offered supervision to interested residents, usually in the context of psychotherapy supervision. The four programmes that provided didactic teaching offered between 1–4 h of instruction. Two of the responding programmes offered formal elective courses in spirituality or religion. Residents in three other programmes were reported to be involved in research related to this field.

Unlike the Canadian programmes, the mandatory curricula of US psychiatry residency programmes span the length of the residency and have both a didactic and clinical component—with the usual time dedicated to the didactic component ranging from 12 to 81 h.13 The clinical component of the US programmes includes group clinical case discussions, teaching clinical interviewing skills needed to take a religious and spiritual history, formal collaboration with chaplains, and mandatory case-based supervision during clinical rotations. Many programmes in the US offer both, research and clinical opportunities.13

As a result of the increasing awareness of the need to incorporate patients' spirituality into mental health assessments and treatment plans,13 in 1995 the American Psychiatry Association updated the Practice Guidelines for the Psychiatric Evaluation of Adults.14 The update included gathering information on “important religious influences on the patient's life” in the personal history and performing an evaluation that was “sensitive to the patient's… religious/spiritual beliefs”. The Accreditation Council for Graduate Medical Education (ACGME) amended its Program Requirements for Residency Training in Psychiatry15 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 transformation of training requirements was developed and published by Larson, Lu and Swyers.16 In accordance with ACGME requirements, the University of Washington Psychiatry Residency Program supported the development of a curriculum on Religion, Spirituality and Culture in Psychiatry that is described below.

Religion, spirituality and culture curriculum at the University of Washington psychiatry residency

Harborview Medical Center, one of the University of Washington teaching hospitals, treats culturally and spiritually diverse patients from the US, Central America, Southeast Asia, Africa, Eastern Europe and the Middle East. Because of its rich and diverse population, many clinically oriented psychiatrists, general practitioners and pastoral care staff have felt drawn to this facility over the past 20 years. A need for an organised protocol for training residents to effectively treat the mental health difficulties encountered within such a culturally and spiritually diverse population was the driving force to establish the ‘Religion/Spirituality and Culture in Psychiatry’ curriculum.

The ‘Religion/Spirituality and Culture in Psychiatry’ curriculum was developed over the course of 3 years as a didactic and clinically based curriculum for psychiatry residents. Faculty members from a variety of University of Washington departments, hospital staff, and many religious/spiritual leaders in the Seattle community collaborated to develop this curriculum. This work was partly sustained by a grant from the 2002 Templeton Spirituality and Psychiatry Award sponsored by the George Washington Institute for Spirituality & Health.

The programme has been evaluated using a standard evaluation form, the Didactics Evaluation/Attendance Form—Lecture I, developed by the psychiatry residency programme. The sessions described in this curriculum are part of the required didactics for the University of Washington School of Medicine psychiatry residents. Residents fill out the evaluation form for each didactic session. These forms are used to assess the educational value of each session and to provide information for future modifications of the curriculum. Evaluations from this curriculum have consistently shown that residents are very satisfied with the quality of the presentations, the choice of the topics and the level of the education provided by these materials. The didactic portion of the curriculum has been taught since 2003 and is very popular among psychiatry residents at the University of Washington, and it is revised and updated each year.

Core objectives of the curriculum

  • To familiarise residents with the research literature in the area of religion and spirituality in psychiatry.

  • To expose residents to a variety of religious and spiritual traditions.

  • To train residents to become competent in assessing the religious and spiritual dimensions of patients and in formulating differential diagnoses and treatment plans that take religious and spiritual issues into account.

  • To educate residents about how patients' religiosity and spirituality can affect elements of treatment.

  • To address ethical issues involved in addressing religion and spirituality in a clinical setting.

  • To educate residents about religion and spirituality in human development.

  • To provide a forum in which residents can discuss their own religious/spiritual identity and how this influences their professional work.

Curriculum structure

The curriculum spanned the 4-year residency programme and included an array of educational experiences, including didactic sessions, rotation experiences, grand rounds presentations, case conferences and field experiences. Didactic sessions were required for the 4 years while rotation experiences were required for years 1 and 2, becoming elective for years 3 and 4. Other learning experiences such as grand rounds, case conferences and field experience were elective for all years.

Didactic sessions

Didactic sessions were shaped from year 1 to year 4 according to a degree of specificity, ranging from a general background education in religious/spiritual beliefs of different world traditions, to more specific topics such as the role of religion/spirituality in the treatment of specific social groups or certain conditions. Sessions were 1 h in length. Table 1 displays a sample of didactic sessions taught in the 2002 curriculum.

Table 1

Sample of didactic sessions offered to psychiatry residents in 2002

Rotation experiences

Rotation experiences were required for second year residents, and elective for third and fourth year residents. The reason for this is that the primary care clinic where third and fourth year residents can elect to work can only accommodate two residents at a time for 6 to 12 month rotations. For example, during the second year Emergency Psychiatry rotation, residents observed faculty members taking a spiritual history while interviewing patients. This allowed the taking of a religious/spiritual history to be modelled, so residents may feel more comfortable asking their patients questions about their religious/spiritual lives. Also, residents had the opportunity to practice taking a spiritual history while interviewing patients in the presence of faculty members, who could then offer direct feedback to residents.

During the second year consultation/liaison rotation the pastoral care staff met weekly with the consult team, so that patients' religious/spiritual issues could be discussed. Further collaboration took place between pastoral care and psychiatry residents when both teams were asked to consult on the same patient.

During the third and fourth year residency rotation, residents focused on enhancing experiential learning. Residents could work in a primary care clinic that serves refugees and immigrants from a variety of ethnic groups. A receptive, non-judgemental attitude towards the patients' beliefs and treatment preferences was fostered through these rotations. This attitude was achieved by stimulating the residents' awareness of their own attitudes towards spiritual experiences and encouraging a willingness to overcome their own biases. Through this increased awareness, residents were guided to avoid stereotyping and over-generalisation of patients' beliefs and worldviews by demonstrating appreciation for diversity of spiritual beliefs, rituals and practices. A particular emphasis was placed on delivery of care at the end of life and the particulars associated with different cultural/spiritual expectations regarding death and dying.

The objectives of these rotations were twofold. First, the objective of these rotations was to ensure that residents demonstrate respect for the differences between their and their patients' views and beliefs. Second, the rotations became an opportunity to develop proficiency in taking a psychiatric history that includes eliciting religious/spiritual issues of importance to the patient. Residents were assessed in a variety of skills, including: their ability to inquire about the patient's use of religious/spiritual practices, their understanding of the impact of these practices upon patient behaviours, interviewing skills (sensitivity to communication styles, religious/spiritual language and cultural background), ability to identify healthy/unhealthy religious beliefs systems, ability to predict how the patient's beliefs might affect treatment and their ability to recognise transference/counter-transference reactions around religious/spiritual beliefs and practices.

Grand rounds presentations

Speakers with expertise in religious/spiritual and cultural issues were invited to give grand rounds presentations at the University of Washington Psychiatry Department and Harborview Medical Center. For example, residents had the opportunity to participate in presentations about the use of cross-cultural music in mental illness, about spirituality in the care of mentally ill patients with chronic pain, and about spiritual healing in South America.

Case conferences

Case conference presentations took place on a regular basis and addressed religious/spiritual issues in patients' lives. Collaboration with pastoral care staff was at the core of these conferences.

Field experiences

Residents were invited to visit centres relevant to different cultural groups and spiritual traditions, such as temples, mosques, synagogues, churches, shelters, and so on.

Feedback from residents

Residents who participated in the spirituality curriculum reported an enhanced ability to understand different cultural and spiritual perspectives, an increased comfort level in assessing religious and spiritual backgrounds of their patients and expressed a great deal of satisfaction about enjoying the exploration of their own cultural/spiritual backgrounds and how these related to patient care.

Discussion

The role of beliefs and attitudes in health and illness has been broadly documented.17–26 A growing body of research suggests that religion/spirituality may have a positive effect on coping and enhancing clinical outcomes.17–28 Attention to the patient's belief system and cultural background seems to be critical to a patient's healing process.10 In agreement with these findings, schools of medicine, nursing and other health professions have added, or are adding, curricula in areas such as religion, culture and spirituality.10 Psychiatry programmes around the US are slowly catching up and developing residency trainings that incorporate the cultural and spiritual dimension into residency curricula. The curriculum here described is an example of such curricula that has been in place for 6 years.

Conclusion

The curriculum described here represents a model for introducing spirituality into the psychiatry residency. Different models may be needed that adapt to the changing psychosocial and cultural contexts encountered in various parts of the world. Describing possible models may provide support to other programmes in the process of developing curricula of their own.

It is profoundly relevant that psychiatry education would provide a clear understanding of spiritual topics and that incorporates spiritual issues in the assessment and treatment of patients.7 Establishing a curriculum that clarifies the difference between religion and spirituality should be an important piece of the curriculum. Such differentiation is necessary to understand the psychosocial dimension of a patient's illness. In psychiatry, such differentiation may be even more crucial because the role of the psychiatrist is precisely to focus on the realm of mental and social health, both of which are deeply intertwined with the religious and/or spiritual views of the patient.7

In 1995, the American Psychiatry Association recognised that effective psychiatric practice required an understanding of religious and spiritual issues and changed its assessment and treatment guidelines accordingly.14 During the last 14 years, psychiatry residency training programmes have evolved to increasingly integrate religious and spiritual issues from a multicultural perspective.15

Psychiatry, as well as other areas of medicine, is developing a more integrative model of care. By introducing curricula addressing religion, spirituality and cultural issues in psychiatry, residency programmes are aligning with a new worldview in medicine that is shifting from a bio-psycho-social perspective into a bio-psycho-social-spiritual approach to care.29

Acknowledgments

LK wishes to acknowledge the support of the VA HSR&D Fellowship under which this manuscript has been completed. LB wishes to acknowledge the grant support from the Templeton Spirituality and Psychiatry Award sponsored by the George Washington Institute for Spirituality & Health that supported the development of the Spirituality and Psychiatry curriculum from 2003 to 2005.

References

Footnotes

  • Emma Bezy, MSW, died 21 June 2007, in Seattle, WA. This paper is published in loving memory of Emma, whose work in fostering the integration of spirituality into medical education has been an inspiration to many.

    This material is based upon work supported by Health Services R&D Service, Department of Veterans Affairs, PhD Postdoctoral Fellowship grant #TPP 61-023.

    The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

  • A version of this article has been previously presented in Spanish at the V Congreso Virtual de Psiquiatría Interpsiquis 2004. The article was published as part of the correspondent online proceedings as: Kozak L, Gardiner L, Bezy E (2004). Espiritualidad, religión y cultura: La introducción de estas áreas temáticas en programas de residencia médica psiquiátrica. Proceedings of Presented Papers of the V Congreso Virtual de Psiquiatría Interpsiquis 2004 [online publication available at http://www.interpsiquis.com/2004].

  • Funding this article was written under my fellowship assignment at HSR&D, VA Puget Sound.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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