Post on 09-Mar-2018
Religion, Spirituality, Geriatric Mental Health:
Research & Clinical Applications
Harold G. Koenig, MD
Professor of Psychiatry and Associate Professor of Medicine
Duke University Medical Center, Durham, North Carolina USA
Adjunct Professor, King Abdulaziz University, Jeddah, Saudi Arabia
Adjunct Professor, Ningxia Medical University, Yinchuan, People’s Republic of China
Session I Research Background (9:00-10:30) • Definitions • Use of religion to cope • Review of early research (prior to 2010) • Review of latest research at Columbia, Duke, etc (2010-2015) • Theoretical model to explain effects • Further resources Break (10:30-10:40) Session II Clinical Applications (10:40-11:30) Reasons for addressing spirituality in geriatric mental healthcare How and when to address spirituality Duke - Adventist Health System Project Discussion (11:30-12:00)
Overview
Definition of Terms Religion
Beliefs, practices, and rituals related to the Transcendent, where in Western
traditions, the Transcendent is also called God, Allah, HaShem, or a Higher Power,
or in Eastern traditions, may be called Vishnu, Krishna, Buddha, or Ultimate
Reality. Religions usually have doctrines about life after death and rules to guide
behavior. Religion is often organized as a community, but can also exist outside of
an institution and may be practiced alone and in private.
Secular Humanism
Secular humanism views human existence without reference to religion, i.e., God,
the transcendent, a higher power, or ultimate truth. The focus is on the rational
self, science, & community as the ultimate source of power & meaning.
Spirituality
According to the traditional definition, spirituality was the core of what it meant to be
religious, i.e., describing those who were deeply religious, living a life dedicated and
surrendered to the Divine. The modern definition of spirituality, however, has become
much broader, including not only those who are deeply religious, but those who are
superficially religious & those who are not religious at all (secular humanists).
Important points to take away 1. Religion is more specific and easily measured – and is a
more useful construct when conducting research that seeks to identify specific characteristics of the individual that prevent disease or alter disease course.
2. Spirituality is an ideal term to use in clinical settings when talking to and engaging with patients, where patients should be allowed to define the term for themselves. However, it is not useful for conducting research given its vague, nebulous, and largely self-defined nature.
Sigmund Freud Future of an Illusion, 1927
“Religion would thus be the universal obsessional
neurosis of humanity... If this view is right, it is to be
supposed that a turning-away from religion is bound to
occur with the fatal inevitability of a process of
growth…If, on the one hand, religion brings with it
obsessional restrictions, exactly as an individual
obsessional neurosis does, on the other hand it comprises
a system of wishful illusions together with a disavowal of
reality, such as we find in an isolated form nowhere else
but amentia, in a state of blissful hallucinatory
confusion…”
Sigmund Freud Civilization and Its Discontents
“The whole thing is so patently infantile, so
incongruous with reality, that to one whose
attitude to humanity is friendly it is painful to
think that the great majority of mortals will
never be able to rise above this view of life.”
Religion as a Coping Behavior
1. Many persons turn to religion for comfort when
stressed
2. Religion used to cope with common problems in life,
especially those experienced by older adults in the
setting of physical and psychiatric illness
3. Religion often used to cope with challenges such as:
- uncertainty
- fear
- pain and disability
- loss of control
- discouragement and loss of hope
Religious Coping - definition
The use of religious beliefs or practices to cope with and make sense of negative life experiences (and sometimes positive ones, too). For example, in Western religious traditions, behaviors such as praying to derive comfort and hope in emotionally trying times; reading religious writings for inspiration and guidance; attending religious services to be uplifted by singing and worshiping together as a group; seeking support from members of one’s congregation, or giving support to others for religious reasons. RC may also involve cognitive processes, including beliefs about a better life after death when pain and suffering will be no more, or beliefs in a loving, caring God who is in control, has a purpose for the world and individuals in it, and has the power to transform difficult circumstances so that good outcomes are possible. Thus, both behaviors and beliefs are involved in RC.
0
0.1-4.9
5.0-7.4
7.5-9.9
10
5.0%
5.0%
22.7%
27.3%
40.1%
Self-Rated Religious Coping
The Most Important Factor
Large Extent or More
Moderate to Large Extent
None
Responses by 337 consecutively admitted patients to Duke Hospital (Koenig 1998)
Small to Moderate
Stress-induced Religious Coping
America’s Coping Response to Sept 11th:
1. Talking with others (98%)
2. Turning to religion (90%)
3. Checked safety of family/friends (75%)
4. Participating in group activities (60%)
5. Avoiding reminders (watching TV) (39%)
6. Making donations (36%)
Based on a random-digit dialing survey of the U.S. on Sept 14-16
New England Journal of Medicine 2001; 345:1507-1512
How Religion Influences Coping
1. Positive world view 2. Meaning and purpose 3. Psychological integration 4. Hope (and motivation) 5. Personal empowerment 6. Sense of control (prayer) 7. Role models for suffering (facilitates acceptance) 8. Guidance for decision-making (reduces stress) 9. Answers to ultimate questions 10. Social support (both human and Divine) Not lost with physical illness or disability
Example of Religious Coping (JAMA 2002; 288 (4): 487-493)
1. 83 years old
2. Multiple serious medical problems
3. Chronic, progressive, unrelenting pain
4. Traditional medical treatments ineffective
5. Alternative medical treatments ineffective
6. Limited material resources – lives alone
7. But, doing well psychologically
8. Positive, hopeful and optimistic
9. Functioning independently- without assist
10. Concerned with meeting others’ needs
11. How does she do it? Religion, she says
Religion – How does it help to cope?
"I don’t dwell on the pain. Some people are sick
and have pain and it gets the best of them.
Not me. I pray a lot…. I believe in God,
and I give my whole heart, body, and soul over to him…
Sometimes I pray and I'm in deep serious prayer and
all of a sudden, my pain gets easy. It slackens up and
I drop off to sleep, and wake up and I can do things
for myself. So prayer helps me a lot – I give God my
heart and soul – and you don’t have to worry about
nothing. He leads you and directs you,
and he takes care of you. And I believe in that.
That is my belief."
Religious Coping – does it really help?
Systematic Review of the Research
1887 to 2010
Handbook of Religion and Health
(Oxford University Press, 2001, 2012)
with some recent research (2014-2015)
highlighted
Religious involvement is related to: Less depression, faster recovery from depression 272 of 444 studies (61%) [67% of best] More depression (6%)
Depression The most common emotional disorder found in medical settings
20% with major depression
20% with minor depressive disorders
Citation: Miller L et al (2014). Neuroanatomical correlates of religiosity and spirituality in adults at high
and low familial risk for depression. JAMA Psychiatry 71(2):128-35
Religion/Spirituality and Cortical Thickness:
A functional MRI Study
Areas in red indicate reduced cortical thickness
Religion NOT very important Religion very important
Is Emotional Disorder Different in the
Religious?
Is depression the same in those with deep religious faith?
Even if depressed, research suggests that deeply religious
people experience more positive emotions:
-greater purpose and meaning
-greater optimism and hope
-more gratitude and thankfulness
-more generosity
Koenig HG, Berk LS, Daher N, Pearce MJ, Belinger D, Robins CJ, Nelson B, Shaw SF, Cohen
HJ, King MB (2014). Religious involvement, depressive symptoms, and positive emotions in
the setting of chronic medical illness and major depression. Journal of Psychosomatic
Research 77:135–143
1st 2nd 3rd 4th 5th
130
140
150
160
170
180
190
200
Religiosity Quintiles
Po
sitiv
e E
mo
tio
ns
10
15
20
25
30
35
40
45
50
Be
ck D
ep
ressio
n In
ven
tory
Religious Psychotherapy Study
132 persons with major depressive disorder and chronic
medical illness (the majority over age 50) randomized to
Religious CBT vs. Conventional Secular CBT
65 from Durham County, North Carolina (Duke University)
67 from Los Angeles County (Glendale Adventist)
Ten 50-minute psychotherapy sessions by telephone over 12
weeks
5 religious-integrated psychotherapies:
Christian
Jewish
Buddhist
Muslim
Hindu
Manuals and workbooks now up on our Duke website: http://www.spiritualityandhealth.duke.edu/index.php/religious-cbt-study/therapy-manuals
And soon to have a training video on website as well
Religious
Cogn-Behav
Therapy
Public prac, rit
Private prac, rit
R commitment
R coping
Optimism,Meaning & Purpose
Social Support
DysfunctionalCognitions &Behaviors
Ph
ysio
log
ica
l C
ha
nge
s(S
tre
ss H
orm
one
s,
Imm
unity,
Inflam
ma
tion
)
Genetic Influences
Chronic Physical Illness and Disability
R experiences
HumanVirtues
Gratefulness
Altruism
Generosity
Majo
r D
epre
ssiv
e D
isord
er
DemographicInfluencesAge, Race, Gender,Education
vs.
Research Study for Treatment of Depression in Chronically Ill, Disabled
Conventional
Cogn-Behav
Therapy
Results
Baseline Week4 Week8 Week12 Week24
0
4
8
12
16
20
24
28M
ean
BD
I sco
re
Time
CCBT
RCBT
Group by time interaction B=0.50, SE=0.55, t=0.91, p=0.36, Cohen’s d=0.10, favors RCBT
Koenig et al. Journal of Nervous and Mental Disease 2015; 203(4):243-251
Treatment response in those with HTR1A genotype C/C (B for group by time interaction=3.33,
SE=1.17, df=62, t=2.86, p<0.01, n=28, Cohen’s d=0.73, in those with low religiosity)
Koenig et al. Austin Journal of Psychiatry & Behavioral Sciences 2015; 2(1): 1036
0 4 8 12
10
15
20
25
30
De
pre
ssiv
e S
ym
pto
ms (
BD
I)
Week
Conventional CBT
Religious CBT
Difference significant between RCBT and SCBT at 12 week f/u (t=-2.10, p=0.038) in per-protocol analysis
Koenig et al. Depression & Anxiety 2015, in press
Religious involvement is related to: Less suicide and more negative attitudes toward suicide (106 of 141 or 75% of studies) Why? A religious worldview gives people a reason for living – it gives
life meaning -- especially those with chronic disabling medical illness, or faced with life-threatening medical diagnoses
Suicide (systematic review)
Religious involvement is related to: Less alcohol use / abuse / dependence 240 of 278 studies (86%) [90% of best]
Alcohol Use/Abuse/Dependence (systematic review)
Illicit Drug Use (systematic review)
Religious involvement is related to: Less drug use / abuse / dependence 155 of 185 studies (84%) [86% of best] [95% of RCT or experimental studies]
Loss of Faith and PTSD Symptoms
1,385 veterans from Vietnam (95%), World War II and/or Korea
(5%) involved in outpatient or inpatient PTSD programs. VA
National Center for PTSD and Yale University School of Medicine.
Weakened religious faith was an independent predictor of use of VA
mental health services—independent of severity of PTSD
symptoms and level of social functioning. Investigators concluded
that the use of mental health services was driven more by their
weakened religious faith than by clinical symptoms or social
factors.
Fontana, A., & R. Rosenheck. Trauma, change in strength of
religious faith, & mental health service use among veterans treated
for PTSD. Journal of Nervous & Mental Disease 2004; 192:579–
84.
Treating Moral Injury in PTSD (seeking funding support)
Spiritually-oriented Cognitive Processing Therapy (SOCPT) for
Moral Injury in older Veterans/Active Duty U.S. Military with
PTSD or sub-threshold PTSD
Now conducting un-funded pilot studies at Charlie Norwood
VAMC, Durham VAMC, San Antonio VAMC, and Houston VAMC
Seeking $300,000 to conduct pilot study involving SOCPT vs.
Conventional Secular CPT in 75 older Veterans with PTSD
symptoms (often revived when sick)
Ultimate goal is a multi-center study to establish SOCPT as an
evidence-based treatment for moral injury in PTSD (using
psychologists), and then develop a version for VA chaplains and
train them to administer it
Religious involvement is related to: Greater well-being and happiness 256 of 326 studies (79%) [82% of best] Lower well-being or happiness (<1%)
Well-being and Happiness (systematic review)
Religion and Well-being in Older Adults
Religious categories based on quartiles (i.e., low is 1st quartile, very high is 4th quartile)
Low Moderate High Very High
Church Attendance or Intrinsic Religiosity
Wel
l-b
ein
g
The Gerontologist 1988; 28:18-28
Religion and Well-being in Older Adults
Religious categories based on quartiles (i.e., low is 1st quartile, very high is 4th quartile)
Low Moderate High Very High
Church Attendance or Intrinsic Religiosity
Wel
l-b
ein
gThe Gerontologist 1988; 28:18-28
Religious involvement is related to: Greater meaning and purpose 42 of 45 studies (93%) [100% of best] Greater hope
29 of 40 studies (73%) Great optimism
26 of 32 studies (81%) *All of the above have consequences for older adults’ motivation for self-care and efforts toward recovery*
Meaning, Purpose, Hope, Optimism (systematic review)
Religious involvement is related to: • Great social support (61 of 74 studies) (82%)
Social Support (systematic review)
0
500
1000
1500
2000
2500
C NG (NG) M (P) P NA
C
NG
(NG)
M
(P)
P
NA
Number of studies includes some studies counted more than once (see Appendices
of 1st and 2nd editions). Prepared by Dr. Wolfgang v. Ungern-Sternberg
The Relationship between Religion and Health: All Studies
Models and Mechanisms How might religion influence health in later life? Theoretical model involving causal pathways and constructs along pathways that help explain the religion-health relationship – next slide
Belief in,
attachment to
God
Public prac, rit
Private prac, rit
R commitment
R coping
Positive Emotions
Negative EmotionsMental Disorders
Social Connections
Ph
ysical H
ea
lth a
nd
Lo
ng
evity
Imm
une, E
ndocrine, C
ard
iovascula
r F
unctions
Theoretical Model of Causal Pathways
Genetics, Developmental Experiences, Personality
Decisions, Lifestyle Choices, Health Behaviors
SOURCE
R experiences
Spirituality
faith
community
PsychologicalTraits / Virtues
ForgivenessHonestyCourageSelf-disciplineAltruismHumilityGratefulnessPatienceDependability
Theolo
gic
al V
irtues:
faith
, hope, lo
ve
faith
community
*Model for Western monotheistic religions (Christianity, Judaism, and Islam)
(c) Handbook of Religion & Health, 2nd ed
Research now being done to
understand the underlying
biological mechanism that may
help explain WHY religious
involvement is related to better
physical health in later life and
greater longevity
Duke Stressed Caregiver Study
251 family caregivers (ages 40-75) caring for severely disabled
family member
151 from Durham, North Carolina (Duke)
100 from Los Angeles County (Glendale Adventist)
Outcomes: (1) develop new 10-item comprehensive and
sensitive measure of religious commitment
(2) examine religiosity and caregiver adaptation
(3) examine religiosity and caregiver telomere length
Poor Caregiver Adaptation (depressive symptoms,
perceived stress, caregiver burden)
0 1 2 3 4 5 6 7 8 9 10
60
65
70
75
80
85
90
95
100C
are
giv
er
Ad
ap
tati
on
(lo
w s
core
s indic
ate
bett
er
adapta
tion)
Deciles of Religious Involvement
Koenig et al. (2016). Journal of the American Geriatrics Society, in press (January)
40-44 45-49 50-54 55-59 60-64 65-69 70-75
5300
5400
5500
5600
5700
5800
5900T
elo
me
re L
en
gth
(b
p)
Age, years
Religious involvement and
Telomere Length
Results: Pending
Conclusions
1. Religion is easier to measure than spirituality, so most of the research supporting clinical applications in geriatric mental health care has to do with religious involvement
2. Religion is commonly used by older adults to cope with chronic medical illness and psychiatric illness
3. Religious involvement is associated with less emotional disorder, greater well-being, less substance abuse, and greater social support – especially in older adults
4. Consequently, religious involvement is also related to better physical health and greater longevity
Further Resources
Oxford University Press, 2012
June 2014
CROSSROADS…
Exploring Research on Religion, Spirituality & Health
• Summarizes latest research
• Latest news
• Resources
• Events (lectures and conferences)
• Funding opportunities
To sign up, go to website: http://www.spiritualityandhealth.duke.edu/
Monthly FREE e-Newsletter
Summer Research Workshop August 15-19, 2016
Durham, North Carolina
5-day intensive research workshop focus on what we know about the relationship
between spirituality and health, applications, how to conduct research and develop an
academic career in this area. Leading spirituality-health researchers at Duke, Yale
University, Johns Hopkins, and elsewhere to give presentations:
-Strengths and weaknesses of previous research
-Theological considerations and concerns
-Highest priority studies for future research
-Strengths and weaknesses of measures of religion/spirituality
-Designing different types of research projects
- Primer on statistical analysis of religious/spiritual variables
-Carrying out and managing a research project
-Writing a grant to NIH or private foundations
-Where to obtain funding for research in this area
-Writing a research paper for publication; getting it published
-Presenting research to professional and public audiences; working with the media
Partial tuition Scholarships are available
If interested, contact Dr. Koenig: Harold.Koenig@duke.edu
Discussion (till 10:30)
Break 10:30-10:40
Time is NOW to Start Addressing Spiritual Issues in Geriatric Mental Health Care
10:40-11:30
Reasons for Doing So
1. Many older adults have spiritual needs and religious beliefs related to psychiatric illness that influence satisfaction with care, healthcare costs, and compliance with psychiatric treatment
2. Religion influences coping with illness and affects the older adult’s emotional state and motivation to recover
3. Emotional state likely influences physical health outcomes, which in term may affect depression, anxiety or other emotional problems
4. Religious beliefs influence older adults’ decisions about mental health care, especially compliance with treatments (and can negatively influence it unless religious beliefs are addressed)
5. Standards of care (JCAHO) require respect for patients’ cultural and spiritual beliefs, especially in substance abuse treatment and behavioral health
Applications in Geriatric Mental Health
Care
• Mental Health Professionals (MHPs) should take a spiritual history
-- explore these issues with their older patients
• Respect, value, support beliefs and practices of the patient
• Identify (A) spiritual issues involved in the mental health
disturbance, (B) spiritual resources, and (C) spiritual needs
• Ensure that someone meets patient’s spiritual needs (as part of
mental health care provided or by referral to pastoral counselor)
• Pray with older patients if patient requests (be sensible, though)
From: Spirituality in Patient Care (Templeton Foundation Press, 2013)
Contents of the Spiritual History
1. Do your spiritual or religious beliefs provide comfort? If no, did
they ever? If yes, how?
2. Are your spiritual or religious beliefs a source of stress, or in some
way related to what you are going through now?
3. Do you have religious beliefs that might influence your decisions
about taking medication or receiving psychotherapy?
4. Are you a member of a faith community, such as a church,
synagogue, or mosque? If yes, is it supportive? If not, was this ever a
source of support (and if so, why are you not involved now)?
5. Do you have any other spiritual concerns that you’d like to talk
about? (either with me or with a pastoral counselor)
1Adapted from Koenig HG (2002). JAMA 288 (4): 487-493
1. Increased volume of psychiatric knowledge (that MHP is responsible for)
2. Increased need to document and deal with Electronic Medical Record 4. Increasingly complex medical problems that go with chronic illness in an
aging population
5. Must also address needs of the caregiver / family
6. Increased time spent dealing with insurance companies, and their growing reluctance to pay for medications
7. Greater and greater struggle to get reimbursed from Medicare
8. More and more patients to see in less and less time (patients more and more dissatisfied, increased pressure of lawsuits)
Challenges to Addressing Spirituality Issues
In Geriatric Mental Health Care
The Result: 1. MHPs feeling harried and time-pressured
2. Medical errors, unnecessary tests, reduced patient compliance
3. MHP has problems at home because of demands of work
4. Work becomes just a job for pay
5. Lost sense of “calling” or why went into mental health profession
6. Not caring anymore
7. Coping by turning to alcohol or drugs
8. Burnout – no time, no desire, and no capacity to provide whole person geriatric mental health care
Inquiring about and addressing the spiritual aspects of mental health care depends not only on psychiatrists and other mental health professionals
The Health Care System must make it possible to inquire about and address Spiritual Issues as part of Geriatric Mental Health Care
Hospital System Changes that might facilitate MHPs inquiring about and addressing spiritual issues
1) Give MHP the time to address the mental, social, and spiritual needs of older adults (i.e., fewer patients)
2) Hire adequate staff that can help with doing the “busywork” (documentation, checks, assistance with EMR, writing prescriptions, etc.) so that this does not use up precious MHP time
3) Focus on scheduling, decrease “no shows”, improving patient flow, structure clinic setting in a way that minimizes MHP downtime, simplify EMR
4) Hire adequate numbers of social workers and pastoral counselors who are trained to address the spiritual/religious needs of elders
5) And provide training on why, how, and when to address spiritual issues in the mental health care of older adults
Duke – Adventist Health System Project
The Spiritual Care Team: Health professionals integrating spirituality into whole person health care together
Spiritual Care Team
1. The psychiatrist/psychologist may have very little time or
training to address older adults’ spiritual issues. Therefore, other team members need to take up the slack by providing practical assistance and support.
2. The “Spiritual Care Team” includes mental health staff such as the nurse, clinic manager, receptionist, social worker, and chaplain (or pastoral counselor); will vary depending on setting
3. Each member of the spiritual care team has a specific role to play --- to enable the provision of whole-person geriatric mental health care to patients and caregivers
What does “providing whole person geriatric mental health care” look like? 1. The psychiatrist or lead mental health clinician conducts a
spiritual history in order to identify and document spiritual issues likely to influence care
2. Spiritual needs are addressed by someone, and follow-up occurs to ensure that spiritual issues are addressed
3. An atmosphere is created that is open to discussing this subject with older patients and doing so in a supportive manner, recognizing the benefits to health and well-being
Spiritual Care Team Members and Roles
1. Psychiatrist/Psychologist – identifies and documents spiritual issues, resources and needs – takes spiritual history 2. Spiritual care coordinator – coordinates the addressing of
spiritual needs (if psychiatrist/psychologist not trained) 3. Nurse/s – assists (or is) the spiritual care coordinator
4. Chaplain or pastoral counselor - addresses the spiritual
issues and/or needs of the patient [depending if available] 5. Social worker - works with other team members to develop
long-term plan and arrange for long-term follow-up 6. Receptionist/other clinic staff – ensures religious affiliation
in EMR
Lead Mental Health Professional
1. Conducts a spiritual history
2. Documents responses (in EMR, if privacy can be assured)
3. Ensures someone addresses spiritual issues identified
4. Is willing to discuss spiritual concerns related to psychiatric
care with patient and/or family
5. Follows up to ensure that spiritual issues are addressed
Spiritual Care Coordinator (often a nurse or clinic manager)
1. Duties - obtains information from spiritual history - coordinates the addressing of spiritual needs - prepares patient for pastoral care referral, if needed - provides spiritual support to other team members
2. Training - reads “Spirituality in Patient Care” (Templeton Press, 2013) - watches all 5 CME videos and is familiar with content
3. Person best suited for this role - has a strong, active spiritual life - is a strong leader, but gentle and sensible - has good relationship with other mental health professionals - has good relationship with other team members & patients
Role of the Chaplain / Pastoral Counselor 1. The only person on the spiritual care team trained to address
the spiritual needs of patients
2. After receiving a referral, the chaplain will do a comprehensive spiritual assessment (different from MHP’s)
3. The chaplain will clarify spiritual needs and then come up with a “spiritual care plan” to address those needs
4. The chaplain will work with the social worker to implement the spiritual care plan after hospital discharge or following clinic visit, and follow up to ensure needs are met 5. The chaplain will work with Spiritual Care Coordinator to meet the spiritual needs of members of the team
Working Together to Achieve Common Goals 1. Each member of the spiritual care team has a specific responsibility 2. Assuming each member of the spiritual care team does his or her
job, the following goals will be achieved: • Patients’ spiritual needs related to psychiatric care will be identified • Those needs will be addressed effectively • “Whole person” geriatric mental health care will be delivered • An atmosphere will be created where the patient/family feels free to discuss spiritual issues related to psychiatric care • MHP time is minimized • Each member of the team will feel emotionally and spiritually supported by one another
Conclusions • There are many scientific, financial, and common sense
reasons for assessing & addressing spiritual issues in geriatric
mental health care
• But, there are many challenges to doing so, often related to
lack of time and MHP’s discomfort with subject
• Lack of training is the most important barrier
• The Health Care System has a role to play in enabling MHPs
to address older adults’ spiritual issues in mental health care
• Collaboration as a team is essential for success
Discussion (till 12:00)