EDITORIAL
Holistic approach in mental health care
Mythili Hazarika
Senior Lecturer of Clinical Psychology, Department of Psychiatry, Gauhati Medical College Hospital, Guwahati, Assam, India
Hazarika M. Holistic approach in mental health care. Dysphrenia. 2014;5:3-5.
Correspondence: hazarika.mythili@gmail.com
Nothing in life is more wonderful than faith – the one great moving force which we can neither weigh in the balance nor test in the crucible . . . Faith has always been an essential factor in the practice of medicine . . . Not a psychologist but an ordinary clinical physician concerned in making strong the weak in mind and body, the whole subject is of interest to me.
-William Osler[1]
Psychiatry and spirituality
The existence of mind is a mystery but we all validate the spirit, mind, body connection in our life. How we think impacts our body, and our thoughts are impacted by how connected we feel to our spirit. We are not just a person with a body. We are a spiritual being with a mind that affects every aspect of us from the top of our head to the tips of our toes. Patients want to be seen and treated as whole persons, not as diseases. A whole person is someone who has physical, emotional, social, and spiritual dimensions. For many patients, spirituality is an important part of wholeness, and when addressing psychosocial aspects in psychiatry, this dimension of their personhood cannot be ignored.[2]
It is interesting to note that psychiatry have undergone three revolutions. The first is in the middle ages, when mental illness was accepted as an illness, rather than a curse of God, as previously believed. Subsequently, mental illness moved from the realm of religion to medicine. This period was also known as the ‘age of enlightenment’. The second revolution was the ‘age of psychoanalysis’. The third revolution is considered the ‘age of deinstitutionalisation’. Now we believe to have entered the fourth revolution, the ‘age of empowerment of the consumer’.[3] In this age, the contribution of the spiritual dimension to ‘whole person therapy’ is greatly felt.
Spirituality, mindfulness and health
Spirituality relates to one’s own experience of transcendence.[4] By ‘spiritual’, it is generally meant a transcendent relationship between the person and the higher being – ‘a quality that goes beyond a specific religious affiliation’.[5] By contrast, the term ‘religion’ refers to belonging to, and the beliefs and practices of, an organised church or religious institution.[6]
Mindfulness practice has been found to be clinically effective at cultivating greater awareness of the unity of mind and body, as well as of the ways the unconscious thoughts, feelings, and behaviours can undermine emotional, physical, and spiritual health. The mind is known to be a factor in stress and stress-related disorders, and meditation has been shown to positively affect a range of autonomic physiological processes, such as lowering blood pressure and reducing overall arousal and emotional reactivity. Until recently, the primary purpose of mindfulness practice has been viewed as religious or spiritual, although its health benefits have long been recognised or at least proclaimed by various spiritual lineages. It wasn’t until Herbert Benson’s ground-breaking research in the 1970s on meditation, which he termed the relaxation response, that any form of meditation was scientifically recognised as a practice with health benefits. Not long after Benson’s work, Jon Kabat-Zinn pioneered the secular use of mindfulness in the health care setting. Since that time there has been an explosion of research demonstrating the widely varied and effective uses of mindfulness. Today, many people use mindfulness outside of its traditional religious or cultural settings to promote both physical and psychological well-being.[7]
Although at this time, mindfulness meditation is most commonly taught and practiced within the context of Buddhism, its essence is universal. Yet it is no accident that mindfulness comes out of Buddhism, which has as its overriding concerns the relief of suffering and the dispelling of illusions.[8] Mindfulness is defined by Kabat-Zinn as paying attention on purpose to what is happening in the present moment without judgement. Its cultivation is both an ancient practice for the development of deep experiential spiritual understanding and a contemporary mind-body technique for relaxing the body, calming the mind, and gaining psychological self-awareness and insight. Mindfulness is the first mind-body-spirit intervention to be widely adopted in mainstream health care. It has also been developed into mindfulness-based cognitive therapy (MBCT), dialectical behaviour therapy (DBT), acceptance and commitment therapy (ACT), and other mental health interventions which are now evidence-based practices.
Mindfulness-based stress reduction (MBSR) is a secular behavioural medicine programme that has roots in meditative spiritual practices. Thus, spirituality may partly explain MBSR outcomes. In a study by Jeffrey et al.,[9] 279 middle aged male participants completed an online survey before and after an eight-week MBSR programme. Findings suggest a novel mechanism by which increased daily spiritual experiences following MBSR could partially explain improved mental health as a function of greater mindfulness. Hence the concept of MBSR, spirituality, and healing is established.
MBSR has evolved into a popular form of complementary treatment that has been clinically proven beneficial for people struggling with a variety of health problems. Kabat Zinn summarised findings: Overall, controlled clinical studies carried out by the centre have documented symptom reductions of between 29% and 46% among participants. Breaking it down by condition, people with heart disease experienced a 45% reduction in symptoms; high blood pressure, 43%; pain, 25%, and stress, 31%. In this issue of Dysphrenia, Nehra et al.[10] showed that MBSR programme is highly effective for reducing perceived stress and health complaints in patients with coronary heart diseases.
Stress and spirituality are connected in more ways than one can imagine. It is not only for the treatment and rehabilitation issues of the patients but each one of us at some point in life think about existential issues. What is our purpose in life? Why do we exist? And in examining spirituality one fundamentally looks at the ways in which people fulfill what they consider to be the purpose of their lives. Although the relationship between religious practice and health is well established, the relationship between spirituality and health is not as well studied. But in some studies, it is reported that participation in the MBSR programme showed significant improvements in spirituality, state and trait mindfulness, psychological distress, and reported medical symptoms. Increases in both state and trait mindfulness were associated with increases in spirituality.[11]
Though MBSR is a clinically standardised meditation that has shown consistent efficacy for many mental and physical disorders, less attention has been given to the possible benefits that it may have in healthy subjects. In a meta-analytic review, MBSR showed a nonspecific effect on stress reduction in comparison to an inactive control, both in reducing stress and in enhancing spirituality values, and a possible specific effect compared to an intervention designed to be structurally equivalent to the meditation programme. A direct comparison study between MBSR and standard relaxation training found that both treatments were equally able to reduce stress but MBSR was able to reduce ruminative thinking and trait anxiety, as well as to increase empathy and self-compassion.[12]
One interesting study on MBSR on medical students was carried out by Rosenzweig et al.[13] Medical students confront significant academic, psychosocial, and existential stressors throughout their training. The purpose of this study was to examine the effectiveness of the MBSR intervention in a prospective, nonrandomised, cohort-controlled study in second-year medical students. Baseline total mood disturbance (TMD) was greater in the MBSR group compared with controls. Despite this initial difference, the MBSR group scored significantly lower in TMD at the completion of the intervention period. Significant effects were also observed on Tension–Anxiety, Confusion–Bewilderment, Fatigue–Inertia, and Vigor–Activity subscales. MBSR proved to be an effective stress management intervention for medical students which helped them to deal with existential issues during patient care. Hence the study indicated the significance of spiritual awakening and mindfulness in total mind, body, and spiritual care.
Mindfulness is, therefore, relevant throughout the lifetime of the physician, and is arguably a core characteristic of clinical practice. Historically, mindfulness has been a foundation practice of major spiritual traditions and is uniquely suited to support medical professionals as they contend with the existential stressors of suffering and mortality. However, mindfulness practice is unencumbered by any sectarian belief system and is readily taught within a secular, biomedical culture.[14]
Spiritual assessment and intervention
To examine ourselves as well as to examine the prevalence and clinical presentations of major mental disorders and their relationship to religious and spiritual problems, the doctors and clinicians should be required to learn about the ways in which religion and culture can influence a person/patient’s needs. In order to do this the first step is for doctors to acknowledge the importance of spirituality and religious beliefs in the lives of their patients. Therefore, all medical students and graduates should be trained to take a spiritual history as part of history taking. Knowledge of a patient’s spiritual history should come as naturally as asking patients about their personality, interpersonal relationships, marital history, hobbies and interests.[15] A consensus panel of the American College of Physicians suggested four simple questions that physicians may ask ill or seriously ill patients (i) ‘Is faith (religion, spirituality) important to you?’, (ii) ‘Has faith been important to you at other times in your life?’, (iii) ‘Do you have someone to talk to about religious matters?’, (iv) ‘Would you like to explore religious or spiritual matters with someone?’.[16]
Cox argues that ‘if mental health services in a multicultural society are to become more sensitive to user needs, then eliciting religious history with any linked spiritual meanings should be a routine component of a psychiatric assessment, and of preparing a more culturally sensitive care plan’. It may therefore be beneficial to adapt existing therapies to the patient’s spiritual perspective. And there is evidence that cognitive therapies may be more effective if they take a patient’s religious beliefs into account.[17] There is evidence to suggest that many seriously ill patients use religious beliefs to cope with their illness.[2] Religious and/or spiritual involvement is a widespread practice that predicts successful coping with physical illness, and with depression associated with physical illness.
Spiritually augmented cognitive behaviour therapy, has also shown efficacy in randomised controlled studies in patients who rated spirituality as important or very important using the patients’ spiritual needs survey. It has also shown to have improved treatment adherence and higher satisfaction than the control arm in patients with schizophrenia who had recovered from psychosis.[18] Sometimes it is seen that taking a spiritual history is often a powerful intervention in itself. Chaplains or influential spiritual persons are increasingly becoming a pivotal part of the multidisciplinary team in the United Kingdom, which is according to them, justified on the basis that religious and spiritual needs are prevalent among patients with acute and chronic mental illness. Religious professionals may be the first ‘port of call’ for those with mental health problems, and there is a need for collaboration between religious and mental health professionals.[5]
Conclusion
Considering these issues and approaching questions of spirituality and religiosity with patients will not only improve patient care and the patient–doctor relationship, but in time may well come to be seen as the salvation of biomedicine. Our calling as physicians and clinicians is to cure sometimes, relieve often, and comfort always. The comfort is conveyed when a psychiatrist or mental health clinician supports the core that gives a patient’s life meaning and hope. Spirituality is the need of the hour both for our own healing and stress reduction, and also for healing our patients in need.
Source of support: Nil. Declaration of interest: None.
References
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