Religion and Spirituality in Psychiatry

136 Harold G. Koeniga small dose of lorazepam, which he was to takeforty-five minutes before leaving home. The psychiatristalso gave him a referral to a therapist.Although the medication helped, it sedated himand made him feel sleepy at work, so he stoppedthe medication. Concerned about the cost of seeinga therapist, he instead sought help from therabbi at the synagogue he was attending.The rabbi listened carefully to Phil and thencame up with a suggestion. He encouragedhim to say quietly (but out loud) to himself theTwenty-third Psalm as he came closer and closerto the feared street. He was to recite the entirepsalm before reaching the street, and then, justbefore crossing, he was to start over and repeatthe entire psalm as he was crossing the street.After being sure that the light was green, the signalto cross was present, and no cars were coming(or had stopped), he was to step out into thecrosswalk and walk across while saying the psalmand thinking about the meaning of each verse.Th e first time he tried this, it didn’t workwell. His anxiety level continued to rise as he gotcloser and closer to the street, and by the timehe actually got there, he was so anxious that heforgot the words to the psalm. His mind racedwith fear, he got discouraged, and he went backhome, calling in sick for the day. Nevertheless,he tried it again the next day as his rabbi hadinstructed. The second time wasn’t quite as badas the first time, and at least he rememberedthe words of the psalm and got across the street(more, however, because he was afraid of losinghis job if he missed two days in a row). Over thenext week, he carried out this ritual every daygoing to and returning from work. Although hisanxiety level fluctuated from day to day, his feargradually began to decrease. After three weeksof this practice, he was able to cross the streetwith only minor anxiety and from then on didnot miss work again for that reason.5. APPLICATIONS TO CLINICALPRACTICEResearch findings and case reports such as thosedescribed above have many potential clinicalapplications that have to do with both the assessmentand treatment of patients with anxietydisorders.5.1. AssessmentThe most important application involves the psychiatristtaking a thorough and detailed spiritualhistory from the patient and perhaps from othersources as the patient gives permission (family,friends, and/or clergy). How detailed thatspiritual assessment is depends to some extenton whether the psychiatrist is only prescribingmedication, prescribing medication and doingtherapy, or doing therapy alone. Even if onlymedication is being prescribed, the spiritualassessment can provide information on whetherthe patient has religious beliefs that might conflictwith the taking of medication.Does the patient feel that taking medicationis consistent with his or her religious beliefs?How does the patient’s family and faith communityfeel in this regard? Is this acceptable, or istaking medication seen as counter to religiousbeliefs emphasizing a complete dependence onGod? Anything less than complete dependenceon God (such as taking medication or relying ontherapy from a mental health professional) maybe viewed by some as unfaithful. The religiouspatient’s compliance with the prescribed treatment,especially over the long term, will dependheavily on the answers to such questions. If thepsychiatrist brings up these concerns right fromthe start and allows the patient to discuss themin a supportive, accepting, and understandingatmosphere, then the patient will feel free to discussthese issues with the psychiatrist at a laterdate should they become relevant.If psychotherapy is contemplated, or even simplepsychological support, then a more detailedspiritual assessment will be needed to more fullyunderstand the role that religious beliefs play inthe patient’s coping and in the dynamics of hisor her psyche. This should initially be done in apositive and supportive manner. Does the patienthave any religious or spiritual beliefs? Are thesebeliefs important to the patient? If so, when did