When patients suffer from severe illnesses and mental crises, they frequently ask themselves why they have become a “victim” of such a difficult situation and why or whether they “deserve” it. It is not unusual for patients to ask existential questions and to reflect on and seek out the meaning of life [1
]. Religious/spiritual people, in particular, try to find answers and deal with their hard times by turning to their belief systems and religious/spiritual practices, e.g., by reading the Bible or praying.
In the field of mental health, there are ambivalent attitudes regarding whether and how religion and/or spirituality should become a standard aspect of mental health care rather than being restricted to religious pastoral care. In continuity with a strong demarcation between psychiatry/psychology and religions/religious rituals in the 19th and most of 20th century [3
], for instance, the Austrian Federal Ministry of Health on June 17th, 2014 edited guidelines for psychotherapists to (re-)establish boundaries against esoteric, spiritual and religious practices [6
]. In addition to the stipulation to refrain from religious/spiritual methods and practices in psychiatric and psychotherapeutic practice, these guidelines also point to an increased yet perhaps unprofessional interest in esoteric and religious/spiritual issues in mental health practice. The mere avoidance of religious/spiritual practice in therapeutic settings does not yet resolve the question of how to perceive and deal with these issues in mental health care. Undoubtedly, religious/spiritual issues are part of the human mind and behavior in general—that is to say an object of behavioral sciences, psychiatry included—and they also play a role, for better or for worse, in the mental conditions of psychiatric patients.
In fact, there is a growing body of research and publications exploring the actual and potential role of religion and/or religiosity/spirituality in psychiatry and psychotherapy [7
]. Research has shown that psychiatric patients sometimes indicate religious/spiritual needs during therapy [12
]. There are patients receiving psychotherapeutic treatment who express a desire for their religious and spiritual needs to be taken into consideration by psychiatric staff members and to exercise their religious/spiritual activities without encountering prejudice. In addition, several empirical studies with psychiatric patients have found significant associations between religiosity/spirituality and mental health; e.g., depression [13
], eating disorder [19
], post-traumatic stress disorder [20
] or schizophrenia [23
], even though such studies have used different traits, tested various groups and accordingly shown inconsistent results. For instance, the American study of Miller et al.
showed the protective relationship between maternal religiosity and having MDD (major depressive disorder) with p
< 0.005 [17
]. In a study with German patients, however, the depression measured by BDI (Beck’s Depression Inventory) was not associated with RGH (Reliance of God’s Help) [24
Further studies have shown positive effects of religious and/or spiritual behaviors on mental health [22
]. For example, the study with college-aged students in Wachholz and Pargament show that a spiritual meditation group shows significantly less anxiety in comparison to relaxation or secular group meditation (respectively, p
< 0.01 and 0.05) [25
]. Also, PPANS (positive mood; the Positive Affect Scale), but not NPANS (negative mood), showed a significant difference (p
< 0.01). Plante (2008) was the first to distinguish between the intrinsic and extrinsic benefits of religious/spiritual behaviors: “Intrinsic benefits are benefits for the self helping to make someone a better and more well adjusted person [...] Extrinsic benefits involve advantages that are external to the self that benefit the person within community” [28
]. In clinical settings, even in the era of secularized societies, various religious/spiritual tools based on religious/spiritual principles are frequently used, not necessarily in connection with any particular religion. Well-known therapeutic approaches are 12-step programs or diverse mindfulness-based meditations, such as the MBSR (The Mindfulness-Based Stress Reduction) or MBCT (Mindfulness-Based Cognitive Therapy).
Taking these elements into account, it is of increasing interest to assess how mental health care providers actually deal with religious/spiritual topics in their clinical practice. How do they approach their patients’ religious/spiritual issues? According to empirical evidence, contemporary mental health specialists actually quite often encounter religious/spiritual aspects in clinical settings. Apart from pathological symptoms in the disguise of religious phenomena, they often observe positive effects from religiosity/spirituality in mental health care [29
]. Generally, mental health specialists perceive themselves as being aware of their clients’ religious/spiritual concerns. Yet, dealing with religious/spiritual matters in their clinical practice is not typically part of psychiatric staffs’ “standard” repertoire, and they do not consider such issues to be their main responsibility [32
]. For example, El-Nimr et al.
surveyed psychiatric staffs in the UK [35
] and found that (only) one quarter of psychiatrists and less than 20% of psychiatric nurses believed that psychiatrists should assess and provide spiritual care. Furthermore, over half of both groups thought that mental health professionals are not the appropriate professional group to deal with such issues. In a study by Huguelet et al.
, only 36% of Swiss psychiatric staffs had ever discussed religious/spiritual topics with their patients [34
While the presence of religious/spiritual factors in therapeutic settings requires further research and development, the international interest in religiosity/spirituality in mental health care, including its adequate integration into clinical practice, is increasing. In most German clinics, chaplains (or pastoral care providers) from different religious denominations are available to meet the explicit religious needs of patients (including rituals). The mutual perceptions, interactions and relationships between psychiatric staff and chaplains appear relevant, both for therapeutic processes (progress or regressions) as well as the spiritual “well-being” of patients. However, there are fewer studies dedicated to psychiatric staff, particularly in German-speaking countries, in comparison to the U.S. or other English-speaking countries. In addition, there are hardly any studies focusing on both of these mental health “specialists” [32
], and, to our knowledge, no study that investigates the level of correspondence between the self-perception of psychiatric staff and the “outside” perception of clinical chaplains.
Therefore, within the scope of a larger research project, we aimed at surveying both psychiatric and psychotherapeutic staff members as well as clinical chaplains in the psychiatry department with regard to religiosity/spirituality in clinical practice. In particular, we addressed the following topics: How do contemporary German psychiatric staffs deal with religiosity/spirituality during therapy? How do clinical chaplains perceive the way other psychiatric staff members deal with religious/spiritual issues? Which similarities and differences exist in these perceptions?
The present study examined how contemporary German psychiatric staffs (i.e., psychiatrists, psychotherapists and nurses) perceive their approach to religious/spiritual issues when such topics arise in therapeutic settings. Moreover, we also investigated how clinical chaplains perceive other psychiatric staff member’s attitudes and behaviors regarding religiosity/spirituality. Both perceptions are confronted with each other in this study.
Overall, psychiatric staff in our survey reported that they are considerably open to religion and/or spirituality when brought up by their patients. The majority of psychiatric staff members are ready to listen and discuss such topics with their patients. This does not differ remarkably from other studies’ results [38
]: in Curlin et al.
’s study, 97% of psychiatrists considered it appropriate to discuss religious/spiritual issues when patients want. Despite such positive attitudes towards religious/spiritual issues, the personnel’s self-assessment showed that they do not work proactively on religious/spiritual issues, and they engage even less in religious/spiritual activities with their patients. Respondents showed a particularly negative attitude towards prayer with patients, finding it generally inappropriate. Psychiatric staffs in other countries share this viewpoint and in part were even more strongly against it. For example, according to Curlin et al.
, 94% of American psychiatrists rarely or never prayed with patients [38
Interestingly, chaplains’ perceptions differed significantly from the psychiatric staff’s self-reports. Clinical chaplains agreed that psychiatric staff members neither reject nor ignore religious/spiritual issues when their patients want to address such topics in therapeutic settings. However, chaplains had significantly different perceptions than the psychiatric personnel themselves, especially regarding questions like whether these issues are part of the psychiatric staff’s professional responsibility and how they actually care by listening carefully and empathetically. Similar skepticism is also found in their rating of the psychiatrists’ and psychotherapists’ readiness to refer patients to the chaplains for religious/spiritual issues. These differences suggest that there may be a need to improve both communication and cooperation between psychiatric staff and clinical chaplains. This may become especially valuable when psychiatric staff members perceive their own limited competence in this regard, or a need and obligation to remain neutral towards religious/spiritual issues in order to avoid unprofessional behavior develops.
Appropriate ways to deal with religious/spiritual issues may vary from person to person. Previous findings show that there are different needs among different groups of patients and it is important to find ways to approach such topics sensitively. Although it is important that a psychiatric staff is open and willing to integrate religious/spiritual issues and practices into its clinical practice, psychiatric methods of patient care with religious/spiritual or even esoteric methods should not be replaced. According to the results of our study, psychiatric staffs do consider religious/spiritual issues or their patients’ religious/spiritual needs as part of their responsibility. The question remains how they can adequately deal with these issues and needs of their patients. There are various ideas on how to adequately integrate religiosity/spirituality into therapeutic settings, such as implicit and explicit integration, or spiritual care [43
]. A first step, as frequently emphasized, may be a religious/spiritual assessment or to take a religious/spiritual history, which usually takes 2–5 min [47
]. Such an assessment can enable psychiatric staff to recognize patients’ religious/spiritual resources and difficulties. However, this is not yet a common practice in psychiatric fields. Patients’ religious affiliation or related information is usually entered into the file by nurses [14
For this reason, training programs addressing religious/spiritual issues should be conducted (more) regularly and with more specific content. In Germany and Europe, only few such training programs are available [48
]. Accordingly, many psychiatric staff members do not have the possibility of participating in such a training program [29
]; in a national study with German psychotherapists, more than 80% of respondents had rarely or never participated in such a program. Nevertheless, 62.5% of the therapeutic practitioners indicated that they would find training programs with religious/spiritual topics to be beneficial. Furthermore, the differences in perception between psychiatric staff and clinical chaplains suggest that these professional groups should become more aware of the role of the other and find ways to learn more about the way of thinking and attitudes of the other, to discuss these issues as well as to cooperate more effectively. Training programs with both professional groups may be one possibility to promote such interdisciplinary communication and cooperation. This might facilitate innovative interdisciplinary teamwork for the benefit of the patients above all, but also for all staff in psychiatry and psychotherapy, clinical chaplains included. In our study, the majority of psychiatric staff members reported that they refer their patients to clinical chaplains when confronted with religious/spiritual matters of patients. In contrast, the majority of psychiatrists in the UK (72%) had not suggested visiting chaplains or religious/spiritual advisors [14
]. Chaplains as professional specialists for religious/spiritual issues can be considered an important resource for “holistic” patient care. Interestingly, the results of our study indicated that nurses were the least reluctant group to share their own religious/spiritual belief or experiences, or even to pray with patients together. This difference could perhaps be a result of nurses’ more frequent contact with patients. In addition, this difference could originate from the different roles of psychiatric staff for patients, i.e.
, for nurses especially as caregivers. Or does this difference reveal a varying level of competence or professional training between these groups?
In professional training programs it is common practice to undergo a self-assessment as well as an assessment by fellow trainees under the supervision of experts on specific issues (e.g., sensitivity). Based on the feedback of supervisors and other trainees, clinical staff can identify how consciously they deal with certain topics and learn how to work in a professionally appropriate manner while also being aware of and monitoring for potential prejudices [30
]. In this sense, self-observation as well as self-experience concerning religious/spiritual issues should be developed and encouraged within training programs to improve psychiatric staff member’s understanding of their attitudes towards religiosity/spirituality. Such measures are preconditions for competent neutrality and abstinence with regard to patients’ religious/spiritual issues, whether needs, resources or problems.
In spite of our findings, this study has a number of limitations that should be considered alongside the results. First of all, minor content differences due to the translation of English into German cannot be ignored. In our translation, we accounted for different cultural and religious backgrounds between the USA and Germany and agreed on them with the author (Curlin). In the German version, the translated term of “unsure” was removed from the mean analysis, as it conveyed an ambiguous meaning. This implies some loss of information and a limitation in the analysis of the data obtained. Although Curlin’s questionnaire has been used frequently, there is still a need for further formal validation of the instrument.
Secondly, some caution is necessary when generalizing these results to other populations of psychiatric and psychotherapeutic staff, even within Germany. First of all, the sample for the study among the psychiatric staff was limited to psychiatry and psychotherapy departments of university hospitals and faith-based clinics in Germany. Furthermore, the response rate among the psychiatric staff is relatively low with 24.43% of the hospitals ready to participate. In fact, the response rate for both university and faith-based clinics equally shows that only one-fourth of our targeted groups showed enough interest in religious/spiritual issues to dedicate some time to filling out the questionnaire (without other incentives) This may have skewed the results, as respondents could be a biased sample group and not representative of all German psychiatric staffs.
Similarly, the sample for the study among clinical chaplains was limited to chaplains belonging to Catholic German dioceses as well as their colleagues in other denominations. Other confessional chaplains ultimately showed a very low participation rate in comparison to Catholic chaplains. One possible explanation is that most of the Catholic chaplains were informed via their dioceses even before the survey, whereas other confessional chaplains were not. This shows a structural deficit in the sampling, and perhaps also varying levels of preparedness of both groups, and could possibly further skew the findings.
Third, additional studies are required, such as exploring the psychiatric staff’s observation of how clinical chaplains deal with religious/spiritual issues. Finally, the patients themselves need to be asked how they perceive the care provided by different professional groups in regard to religiosity/spirituality. Such studies are underway and will allow for an even better picture and understanding of the opinions of all groups involved. This will help to implement and improve more interdisciplinary work in this field for the benefit of the patients. Notwithstanding the already growing range of research, further studies are needed to explore whether, which and how religiosity/spirituality and its adequate integration into therapeutic processes affects therapeutic outcomes.