Religion and Spirituality in Psychiatry

Religion/Spirituality and Mood Disorders 109should be included as a regular theme, althoughthis notion may meet with hesitation and evenreluctance in others. Because the subject hasmultifarious aspects such as strict moralityand adherence to literal beliefs and intolerancetoward people of other faiths, feelings of embarrassmentor annoyance are lurking or can provokethe conviction that the clinician does nothave sufficient knowledge about religion andspirituality. Although some awareness of one’slimitations often makes sense in mental healthcare, there can be advantages to discussing religiousnessin clinical contacts. It might be worthconsidering and may outweigh the uneasinessdescribed above.The first assumption here is that mental problemsin general and mood disorders in particularoften raise questions about the meaning of life.This can either pertain to loss of meaning, orthe revelation that one’s life can be experiencedat summits of meaning itself. Avoiding the matterof the meaning of life, whether accompaniedby presumptions of a transcendent reality or not,may hide a relevant domain of the patient’s life.Without going into the field of pastoral careand theology, there are two practical ways toinclude religion and spirituality in clinical contactswith patients with mood disorders. The firstis by examining in the diagnostic phase whetherreligious or spiritual ideas manifest themselvesas psychiatric symptoms or seem to color theexpression of symptoms. The second is by establishinga mutual understanding regarding howspirituality and religiousness represent a relevantdomain in life. This can be an investment in thetherapeutic relationship, and at some time in thetreatment phase, it can lead to a referral to a pastoralcounselor.9.2. Diagnostic Phase9.2.1. DepressionPatients with depressive disorders do notoften spontaneously share their religious andspiritual views, questions, or experiences withtheir clinician or therapist. Particularly in thecase of depressed patients, due to their tendencytoward inhibition or poverty of speech, manyelements in the diagnostic interview need to beraised actively by the interviewer. This requiresadditional efforts by the interviewer to get animpression of the patient’s inner conflicts andprivate concerns, including remnants of hope.An open inquiry should avoid rapid conclusionsabout which problems might bother the patientthe most. The investigation of mood, anxiety,substance use, psychotic experiences, physicalstate, and suicidal ideation all deserve equalattention. In the initial contact, the subject ofspirituality and religiousness may be only brieflycited to show the patient that the subject will notnecessarily be ignored in the future.Several signs of depression can be experiencedin a way relating to religion. With respectto depressive mood and anxiety, cognitions suchas attributions of the currently depressed state tomoral punishment may arise and connect to feelingsof guilt or worthlessness. Anhedonia, energyloss, concentration problems, and fatigue mayconnect to a lack of purpose in everyday life andbe related to a sense of abandonment by God orloss of an inner spiritual spark. As the evidenceof discontent with God in times of depressionproves to be fairly solid, one might inform thepatient that many depressed patients experiencethese feelings and ask whether the patientrecognizes this theme. A lack of perspective, lossof hope, and loss of self-esteem may turn intothoughts about death or activate latent cognitiveschemes about self-annihilation as a lastresort. A neutral inquiry about possible belief inan afterlife, heaven or hell, or reincarnation foradherents to Hinduism or some contemporaryspiritual movements can often be added in thediscussion about pondering death.9.2.2. ManiaWhen a patient is in a manic state, the clinicianfrequently has to try to regulate the contactand avoid conflicts that would ruin the chance ofa working alliance with the patient. Furthermore,manic patients tend to be talkative and force theinterviewer to listen to facts, achievements, and