Religion and Spirituality in Psychiatry

142 Harold G. KoenigIf religious beliefs are being used neuroticallyto obstruct needed changes or psychologicalinsights, then after a therapeutic relationshiphas been established the psychiatrist may need togently challenge those beliefs (as noted above).However, unless the therapist has pastoral counselingtraining and is quite familiar with the religioustradition of the patient, it may be best toseek consultation or referral to someone withpastoral counseling experience.9. PASTORAL REFERRAL ORCONSULTATIONWhenever complex religious issues or conflictsare present, the psychiatrist should always considerconsultation, referral, or co-therapy with apastoral counselor. Under certain circumstances,such referral should come sooner rather thanlater if religious issues are present and appear tobe related to the anxiety disorder. These circumstancesinclude those when the clinician is notvery knowledgeable about religious issues, whenthe particular religious background of the patientis different than the clinician’s, or when the patientrequests such referral. In religious patients withanxiety disorders, particularly if the disorder hasbeen present for many years, psychological andreligious issues are almost always deeply intertwined.This may even be true for nonreligiouspatients and is the reason why a spiritual historyis necessary for all patients.Effective pastoral consultation or referralrequires that the psychiatrist identify a pastoralcounselor whom the psychiatrist can work withand who has the skills to help patients in thesesituations. Pastoral counselors typically have fouryears of college, three years of postgraduate theologicaleducation, and either a master’s degree ordoctorate in counseling. If trained pastoral counselorsare not available, then clinicians should getto know the clergy in their area who do counselingand are open to consultation and referral(especially the clergy of patients that they maybe seeing, although that will depend on patients’preferences). It may be helpful to have a meetingor lunch with clergy before referring anyone tothem to get a sense of their experience, skills, andapproach to counseling. Community clergy varywidely in the type and extent of training, from notraining to modest exposure to counseling techniquesin seminary. Some clergy may seek additionaltraining, although that is not always true.Regardless of their level of training, clergy onaverage spend about 15 percent of their time inmarital, family, or individual counseling and areoften the first persons that religious persons go tofor help with their emotional problems.(42)Clergy should not be brought in, however, untilthe clinician has a thorough understanding of thepatient’s problems and a therapeutic relationshiphas been established. The clinician will also needto prepare the patient for pastoral involvement byemphasizing the importance of religious issuesand admitting his or her lack of expertise in thisarea, requiring consultation. Of course, beforeinvolving clergy or pastoral counselors (otherthan when obtaining informal consultation),explicit permission from the patient is needed.10. CONCLUSIONSReligious beliefs and practices are often inverselycorrelated with anxiety symptoms or disorders,but not always so. Religion helps many patientswith anxiety disorders to cope with their symptoms,and religious therapies are effective inreducing symptoms of anxiety. Religion mayalso exacerbate anxiety disorder; patients withanxiety disorder may manipulate or distort religion;and patients may use religion defensively toavoid healthy change. Clinicians with appropriatetraining can use the religious beliefs of patientsto help treat anxiety disorder by supporting,encouraging, or directly using those beliefs intherapy. Trained pastoral counselors and clergycan be helpful when religious beliefs need to bechallenged or when religious beliefs are deeplyinterwoven with psychopathology.REFERENCES1. Kessler RC , B erg lu nd P , D em ler O , Ji n R ,Merikangas KR , Walters EE. Lifetime prevalenceand age-of-onset distributions of DSM-IV