Saturday, September 24, 2016

Canadian Psychiatric Association, Toronto - Religion in Psychiatry

Religion and Psychiatry: issues around practice , therapy , and therapeutic implications,
Shabir Amanullah, MD FRCPC
Fiona McGregor , MD FRCPC
Gary Chaimowitz, MD FRCPC
Kupuswamy Shivakumar, MD FRCPC

I was glad to see the topic “Religion in Psychiatry, Issues around Practice, Therapy and Therapeutic Implications.” It was one of the most important presentations that attracted me to this conference.
In “Spiritual Brain”, Montreal Neuroscientist Mario de Beuregaard speaks eloquently of the pseudoscience of atheism and secularism.  Jeffersonian division of State and Church was not about silencing religion but rather about ‘power’.  The major  political externalization of aetheism to date is the  genocidal communist regimes.  Religious people, especially Christians, are the most persecuted in the world.   So many of my patients speak of their abuse, especially the torture victims,  and the disregard they experienced for their spiritual practices when they went to psychiatrists who ignorant of what moved them most.
Shabbir Amanulla MD FRCPC was most  enlightening. I so enjoyed the medical and psychiatric evidence that Dr. Amanulla presented. He is from India and described the diversity and respect that exists there with regard to medicine and religion. That’s exactly what I saw in this old culture when I was there visiting with the psychiatrists in Mumbai.  There was none of the arrogance of youthful Canadian culture in that old and diverse country.  I loved his stories he told cringing of his patients there and here.  I made notes of his slides. They’re a poor representation of the fullness of his elegant presentation.
Dr. Amanulla presented:

1.4 % of world is atheist

12% of Britain - Non religious

Canadian study by Baetz
54% of psychiatrists reported belief in God compared with 71% of patients

Psychiatrist less likely than patients to attend religious services
47% indicated it was appropriate to include spirituality as part of assessment
50% often or always did
17% of patients reported that their psychiatrist often or always did

Dr. Amanulla commented on the discrepancy here and wondered about the difference in perception of psychiatrists and patients.

47% reported that would like to know religious orientation of their psychiatrist

24% - a consideration selection of a psychiatrist

US Study - Curlin 2007

Psychiatrists versus physicians 
1144 multiple specialities from across USA
psychiatrists less likely to believe

Physician Inquiry re Patients spiritual beliefs
nearly half of patients may have spirutal/relgious belief
  • physician having belief would be more trusted

Mental Health

Dr. Amanulla commented on the prresentation yesterday on Yoga and psychosis 
Mind body activity
He noted that in India - people know the incredible power of prayer
Gandhiji’s Talisman -Bhajan Vaishnava Jana To
Vayshya vacant
He spoke of the power of spiritual music to calm  -Music therapy drawing on soothing religious sources

Mental health - definition, individual definition, internet, information
  • had patients draw their idea of mental health
He spoke to discussing how their religious supports could help them to wellness
Encouraged the study of the patients religion and understanding their ideas and beliefs, a search for ‘meaning’ ( I couldn’t help but think of Victor Frankl)
He discussed some practices (mindfulness meditation, rituals, groups) which could be useful
Encouraged talking with religious leaders important to the patient, arranging consultation with the permission of the patient if that was indicated.
He discussed boundaries at length

Dr Amunullah opened the floor for discussion with many stories and thoughts shared by audience individuals.  An atheist quoted Neitze but acknowledged the ‘usefulness’ of religion, Another quoted Thomas Szasz,.  A psychiatrist spoke to her work with a Catholic patient’s belief, a Muslim resident spoke of her anxiety about boundaries and thankful to hear where the line was etched in the sand today.  I spoke of the need for spirituality training for psychiatrists working in addiction and referenced Dr. Carl Jung and Dr. Rabbi Twerski’s in this regard.  

Dr. Fiona MacGregor

Dr. MacGregor presented on  the western predominantly white Christian movement to the separation of church and state and the arrival of Secularism. She quoted Charles Tayor who’d written a Secular Age. (I remember well when our pastor, Rev Peter Elliott, Christ Church Cathedral, spoke of this in sermons he gave some 10 years ago. I bought the book which is a tough read and hard to unpack.  Hitchens is more entertaining but I still preferred the lessons that followed the Bertrand Russell and C.S.Lewis letters, I learned long ago studying  philosophy and theology.  Much of the presentation was ‘history’ but provided a superb basis for the overall discussion.   It brought to mind Field of Blood the glorious history of church and violence written by Karen Armstrong and pointing its finger firmly at the political. 

Dr. MacGregor was really at the cutting edge of discussion in psychiatry and spirituality.  Again I took notes which are a poor representation of the much broader presentation.   Dr. MacGregor only used her headings and slides  as points to lead to broader discussions of psychiatry and cases.  

History
Priory of St. Mary of Bethlehem built in London 1247 to house “distracted people’
1547 replaced by Bethlehem Hospital , secular authorities take over, increasing abuse
1796 -William Tuke and Quakers start “Moral Treatment” The York Retreat
1813 Friends Asylum, Philadelphia
Phillippe Pinel Paris

Modernism allows us to see the universe as a system before our gaze whereby we can grasp the whole in a kind of tableau - Charles Taylor

1517 - Martin Luther
John Calvin - work is just as sacred as the Priesthood
John Locke - theory of the mind - separation of church and state - father of enlightenment
Adam Smith - Labour Theory of Value - influence on economics and capitalism

(I’ve thought of these critical events in western civilization but so appreciated the way Dr. MacGregor summarized them)

Secularism 
a move from a society where belief in god is unchallenged and indeed unproblematic, to one in which it is understood to be one option among others - the result is a radical pluralism which, as well as offering unprecedented freedom, creates new challenges and instabilities - Charles Taylor

Patients say “I’m not religious. I’m spiritual’….what’s the difference - we’re all individuals"

You have to be ‘true to yourself’  so commonly heard today but derived from the 17th century

Our patients have all sorts of beliefs and we have to wonder where that is coming from

Manifestations of Religion -Allport 1958

Institutional Religon - beliefs and practice conducted in community for example attending services or attending study groups of sacred texts

Interiorized religion - Beliefs internalized, the individual


Dr. Amanullah and Dr. MacGregor didn’t just present theoretical academic material but went onto provide practical suggestions. 

Approach - (from KOENIG 2008)
  • taking a spiritual history

Our biggest problem is concern for boundaries - come with powerful role - must make sure we’re not putting our views on someone else (I thought of proselytization and how my patients objected to this from Christians, Jews, Muslims, Hindus and Atheists.)

FICA (Puchalski 2006)
How do we assess them  
Do you have spiritual beliefs that help you cope with stress
 What role do your beliefs have in regaining health
Are you part of a religious or spiritual community, Is this a support to you and how
How would you like me as your caregiver approach this

An Anthropologist meeting another person from an unknown culture - griffith and griffith,  2002
what sustains you through this illness
 What gives you hope when coping with this illness 


At times you must challenge their belief
  • when they are suicidal?
    • when they believe suicidals will go to hell?
    • father image of god as punishing 



    Dr. Amanullah presented several cases which which showed the limits of conventional therapies with the need for these to be explored first and then the consideration of a more holistic approach to the problem within the context of the patients religious beliefs.

  • We don’t have to be of same faith.  Interesting cases regarding that.

    Shabir presented case of a nun - Depression , GAD 
    -SSRI’s SNRI’s etc been tried
    -some improvement , not much
    -always pleasant

    Case - depressed Nun
    Asked her how you use the Rosary
    -I said, you’ve tried all these medication and explained the use of rosary, looked at scriptures, Saul, follow up in  months, nurse accompanying tried behavioural techniques - came back and had no panic attacks, interacting with other nuns,

    If I had used conventional approach I would have treated her as ‘unresponsive depression’
    Should we not be meeting people where they hope? (I loved this beautiful expression of Dr. Armanullah’s “Should we not be meeting people where they hope?! Pure psychiatric brilliance.  Yes meet people where they are but also where they hope)

    Case - the priest
    Shared a humbling letter - after counselling - a patient born in Belfast, mother jewish, was raped repeated by priest, very angry , used mindfulness techniques, became a priest, came to see me , was angry with church, and with god, - I deferred any spiritual approach because of the College and not wanting trouble as it can be unfriendly towards this - but after all the conventional approaches, medication ECT, behavioural  were used I asked him about his family ,his father, he began dcrying , asked him about being repeatedly rape, then asked him to tell me about the stories in the Bible, he became calm….you say god is such a bad person, I said, ,  but you enjoy coming into see me and talking about God - this one question caused an incredible change in the patient after all the conventional approaches had failed.


You don’t do meditation techniques with pre psychotic patients just as you wouldn’t start psychoanalytic techniques with psychotic patients.

Case - Muslim woman
Grieving widow
Son, a nurse
Both very religious 
10 years of grief and sadness
prayed through the nights
man in white gown seen
every night after her prayers
scary - 'looked like my husband'

 I didn’t change medications
encouraged her to get out each day
had told her allah didn’t want us to stay in room always but to live our life

 She got out each day and a year later the depression, which wasn’t depression but complicated grief, resolved. 

Dr. Gary Chaimowitz wrote the position paper on Religion and Psychiatry for the CPA.  He did not have slides prepared but talked about the damage he’d experienced as a Jew growingup in South Africa. At the time it was  dominated by the Christian Dutch Reform with discrimination of a ‘dominant religion’.  He was afraid of ‘dominant religions’ and felt that religions had much to offer but could go awry when they had too much power. He saw this with the Catholics at St. Josephs in Halifax and spoke of his sincere desire that no one seeking help would be turned away because of their religious beliefs or the religious beliefs of the practitioners.  Again I offer my notes which do little justice to the breadth of his discussion but offer something of the gist. 



Anecdote -  (regarding the position paper I was more asked to write a paper ‘freedom from religion’

I’m from south africa

Saw dominance of culture

saw dominance of religion

More attuned to need for separation of religion and state

think of Aghanistan, syria

if you are part of dominant culture you are often blind to other

-grew up in atmosphere ‘forget about religion’ 

-dutch reformed 

-they believed they were chosen people, deeply religious people

-created massively discriminatory system



as privileged white person in school who was jewish 

I was forced to go to religious classes

complained and was taken out of classes and put in room
humiliating, demeaning.

-teachers in this liberal university were racist against me as a jew


 there are beautiful things in religion but there’s a tipping point

I think of St. Joseph’s in Halifax

Psychiatry is a religion too

It has the same delusional ideas that underpin religion

Religion when dominant can be incredibly destructive
I spent 25 years flying to James Bay and every once in a while the pentecostals came up against me. the older I get the more cynical I get
if you ask people about religion you have to be careful because they can feel shaming
I worked at St. Joseph’s Hospital with crosses on the wall
Religious organizations were there, crosses on the wall

Abortion is not our business
Physician assisted suicide is not our business

Problem is we work from public purse

Early warning sign - beginning of quest - patients picking therapists of particular gender or religion - sounds good - but organizationally a nightmare  - 

If you as a consumer - seeking out a healer - you’re not purchasing something in a store - you are entering a relationship - you are choosing help - you should be able to get care - you should be able to get care where the belief system of the provider does not interfere


This lead to the delightful discussion with the three leaders encouraging the sharing and offerings of the audience.  I dont know where Dr. Shivakumar was.  Just a trinity left.  And  no mud slinging. No arguing. Lots of individuals ‘sharing’ from their experience and the centre of themselves and their lives.  


Given the potential for controversy and debate, I was thoroughly impressed with all three presenters and the audience.  

Since the American Colleges have recommended psychiatrists have training in spirituality and the British Psychiatric Association began it’s Special Interest Group on Spirituality and Religion I have hoped that the Canadian Psychiatric Association will move forward.  This workshop at the CPA conference was definitely a reason for me to join.

 I am really glad the three presenters met me where I hoped!