Religion & Spirituality

in Geriatric Psychiatry

Adam Younoszai, D. O.

Medical Director

of Behavioral Health Services

Washington Adventist Hospital

• Words to pay attention to:

– Divides

– Trajectories

– “Provider”

– My “Rules” (relating to Narrative Medicine)

– Principles (relating to Narrative Medicine)

– RRICC (relating to psychotherapy)

Key Words

• Divides

– Religion and Spirituality and Medicine

• Some incorporate (e.g., 12 step)

• Some do not incorporate (inpatient setting)

– Patient and Provider

• From provider to patient

• From patient to provider

Key Areas of Focus: Divides and Trajectories

• Trajectory: Religion/Spiritual

– Positive:

• Support from God

• Support from Church

• Spiritual forgiveness

• Rituals

Key Areas of Focus: Divides and Trajectories

• Trajectory: Religious/Spiritual

– Negative:

• Questions faith

• Increased stress from questioning fait

• Trajectory: Non-religious/non-spiritual

– Positive

• No need to question faith and God

• Accustomed to coping without religion and

spirituality

Key Areas of Focus: Divides and Trajectories

• Trajectory: Non-religious/non-Spiritual

– Negative:

• Missed opportunity for 1-4 positive

religious and spiritual aspects above

• Ongoing /prolonged stress

• Decreased immune system functioning

• Decreased health-cycle

Key Areas of Focus: Divides and Trajectories

Addressing the Divides & Trajectories: Current

Movements

• Narrative Medicine

– Treatment through narration

– Connection to religion and spirituality

– Five principles and rules learned

1. Temporality: Take time to listen, care and

to recognize. Rule: Be present.

2. Singularity: Originality, “irreproducibility.”

Rule: Get to know the patient, not just the

disease

Addressing the Divides & Trajectories: Current

Movements

• Narrative Medicine

3. Causality/Contingency/Plot. Rule:

Understand context

4. Inter-subjectivity. Rule: Commune with

patient and be authentically present

5. Ethicality. Rule: Listen without judging,

except if harm is possible

Addressing the Divides & Trajectories: Current

Movements

• Religiously Integrated Psychotherapy

– First accepted: William James and G. Stanley Hall

– Then rejected for “pure science”: Freud-

Obsessional Neurosis, Skinner-negative

childhood experiences

– Now more integrated: Pargament and others,

2002 APA code of Ethics: Diversity, “Positive

Psychology” more embracing of religion and

spirituality.

Addressing the Divides & Trajectories: Current

Movements

• Divide In Need of a Bridge

– Most people are religious or spiritual

– Utilizing religion and spirituality can augment

psychotherapy to improve outcomes.

– RRICC Model

1. Respect

2. Responsibility

3. Integrity

4. Competence

5. Concern

Case Study

• History of Present Illness (HPI)

– 86-year-old Middle Eastern male with a history of

Major depressive disorder (MDD)

– Recently diagnosed with Gleason score 8

prostate cancer

– Consult placed to evaluate for depression and

possible treatment recommendations

– Patient admitted 5/9 for meeting criteria for major

depressive episode (MDE).

Case Study (continued)

• History of Present Illness (HPI) (continued)

– Denied use of drugs or alcohol

– No psychosis or mania history

– Some current anxiety symptoms

– Patient stated he felt alone when given diagnosis

• Past Medical History (PMH)

– GERD, Seasonal allergies/ asthma

• Past Psychiatric History (PPH)

– MDD (x2 prior episodes)

Case Study (continued)

• Family Psychiatric History (FPH)

– MDD, anxiety

– No psychosis or mania history

• Family Medical History (FMH)

– Sister with breast cancer, mother with diabetes,

father with colon cancer

• No Known Drug Allergies

• Social History (SH)

– Born and raised in Egypt to wealthy

parents/family

Case Study (continued)

• Social History (SH)

– Immigrated to the US at 18 for college

– Currently married with two adult (male) children

– Recently retired as anatomist at medical school

– Regularly exercises, hikes, and until recently ran

marathons

Case Study (continued)

• Mental Status Exam

– Young looking 86-year-old,

– Cooperative, pleasant, and engaged

– No psychomotor abnormalities

– Speech regular, mood “depressed”

– Affect: Mood congruent.

– Linear, logical, goal directed thought process

– Thought content free from si, hi, ah, or vh. Insight

appeared intact, as did judgment.

Case Study (continued)

• Diagnosis

– Currently depressed with MDD recurrence,

moderate

• My recommendations:

1. Check TSH

2. Start SSRI

3. Discuss sleep, and pain if any

4. Follow up with outpatient psychiatrist for meds

management

Patient’s Treatment Plan

• Patient’s plan

– Temporarily questioned his faith (negative

mentioned in start of talk)

– Began to pray

– Rented comedies

– Explored Sufism (mediation)

Patient Treatment Plan (continued)

– Poetry (Rumi)

• “Silence is the language of God. All else is

poor translation.”

• “Ignore those [things] that make you fearful

and sad, that degrade you back towards

disease and death.”

– Got surgery

– Engaged in “meaning making”

– Used the experience as an opportunity to educate

others and make a meaningful experience

Integrating Narrative Medicine in Treatment

• Narrative Medicine

– Rule from “Temporality”– I was present and took

time to listen

– Rule from “Singularity” – I got to know the patient,

not just the disease

• Active 86-year-old and good surgical

candidate

• Gleason 8 not the same in this patient

Integrating Narrative Medicine in Treatment

– Rule from “Causality/Contingency/Plot” –

Understand context

• Treated his own MDE in the past

• Trusted his desire to treat himself again, now

with prayer, poetry, and Sufisim.

– Rule from “Inter-subjectivity” – Be authentically

present

• Honest about rec. for SSRI still

• Patient knew where I stood with respect to my

proposed plan

Integrating Narrative Medicine In Treatment

– Rule from Ethicality: Do not judge

• Nothing ethically “wrong” with his preferences

for treatment

• I respected this decision

• Somewhat similar to authenticity?

RRICC Model

• Respect

– Again, repeated who he was and his decision

• Prayer, poetry, laughter

• Responsibility

– My responsibility not to ignore his desire to take

religious/ spiritual trajectory

– My responsibility to try to incorporate his interest

in Sufism into care I gave him

– In retrospect, could have consulted Imam

RRICC Model

• Integrity

– I was honest about my limitations to embrace

Islam as a faith nor to purport to be an expert

• Competence

– I read Rumi poetry and learned the basics about

Sufism

– Patient saw that I tried, this impacted him

RRICC Model

• Concern

– I was somewhat vigilant (especially toward the

beginning) of his use of Islam

– I didn’t know Islam’s stance on suicide

Conclusion

• Key takeaways

– I believe

– I wonder

– I know