The Intersections of Ethical, Religious, and Spiritual Issues in Mental Health Care
Panelists-
Abraham Nussbaum, M.D., Director of Adult Inpatient Psychiatry / Assistant Professor, Denver Health / University of Colorado SOM
Nancy Kehoe, RSCJ, PhD / Assistant Professor of Psychology, Harvard SOM
Michael A. Norko, MD, MAR / Associate Professor of Psychiatry, Yale SOM
Psychiatry, psychology, and other mental health disciplines self-consciously understand themselves as applied disciplines of the neurosciences. In these disciplines, great attention is paid to the biomarkers and imaging studies which reveal the neural circuits underlying mental illness. Comparatively little attention is paid to the person in whom these neural circuits operate. Yet when persons participate in psychiatric care, whether as patients, practitioners, or caregivers, they inevitably experience ethical questions.
When we emphasize the neuroscientific underpinnings of mental health disciplines, it means, first, that the ways that neuroscientific accounts build on and inform particular accounts of human health and wellbeing are assumed rather than discussed. Second, it means that when ethical questions are engaged in psychiatry, widely accepted principles—generalized virtues and cultural competence—are emphasized at the expense of the particularities of the persons experiencing these ethical questions. Third, it means the ways religious and spiritual practices inform ethical questions are typically neglected by practitioners in the contemporary mental health disciplines.
In a forthcoming Oxford University Press anthology entitled Ethics in Psychiatry and Religion, leading scholars working at the interface of psychiatry and religion will provide mental health practitioners with a conceptual framework for understanding how religious and spiritual practices inform ethical decision-making. The authors consider questions including how to distinguish healthy from unhealthy religious practices and how to approach a patient experiencing an existential, moral, or spiritual distress. In this panel presentation, three contributors to the book will address aspects of these questions.
The first panelist will discuss the role of faith leaders in addressing mental illness and ethical dilemmas. Faith leaders are spiritual and religious guides for their communities, which entails multiple levels of commitments, a commitment to the care of soul of the individual, a commitment to the congregation as a whole, sometimes a commitment to the larger body of the congregation. The orientation of faith leaders is to focus on the spiritual well-being of those in his/her charge and to keep God/Yahweh/Allah, the deity, at front and center. The training of faith leaders has seldom included an in-depth understanding of mental illness. Yet faith communities are made up of human beings struggling with life and all its challenges, including mental illness. Because of the stigma attached to mental illness, frequently the presence of a mental illness in an individual is hidden from the faith leader and the congregation. This can create ethical dilemmas for the leader.
In this presentation, we will reflect on some of those dilemmas by using several cases drawn from particular religious traditions. The very nature of an ethical dilemma is the complex nature of the situation and the various constituencies involved in the resolution of the situation, the good of the individual over against the good of the whole. Faith leaders are always called to balance these two and frequently must do so in the context of confidentiality. In this presentation, we will look at the ethical guidelines that various religious denominations hold and the guidelines of mental health associations and apply them to the cases.
The second panelist will discuss how the ethical questions particular to inpatient psychiatric settings pose significant challenges to the religious and spiritual practices of patients and practitioners alike. Contemporary inpatient psychiatry settings typically operate with a focus on outcome-based care, with admission and discharge tied to specific symptoms, rather than to a consideration of their meaning within the lives of patients. The contemporary mental health practitioner has limited incentive to, say, distinguish scrupulosity from obsessive-compulsive disorder, possession from dissociative disorder, and ecstatic experiences from hypomania. In addition, there is often limited cultural space for a practitioner to live out his or her own religious and spiritual practices.
For patients receiving inpatient psychiatric care, it is common to consider their capacity to make decisions about their health and well-being. After all, many people receiving inpatient psychiatric care do so as involuntary patients within locked facilities after they have been determined to lack the capacity to leave the hospital. It is less common to consider what kind of access a hospitalized patient should have to the religious and spiritual practices they desire. When should a patient be given or restricted from access to religious texts and ritualized objects? When should a patient be allowed to receive faith leaders as visitors? As participants in their treatment? These questions will be engaged with consideration of the interrelationships between medical indications, patient preferences, quality of life, and the contextual features of inpatient psychiatric care.
The third panelist will discuss some of the ethical considerations related to religion and spirituality in forensic psychiatry settings. The practice of forensic psychiatry involves activities related to evaluation of defendants or other individuals involved in the justice system, as well as treatment services for individuals ordered into treatment by the courts – most often for restoration of competence to stand trial and for individuals found not guilty by reason of insanity. The treatment of psychiatric patients in high security inpatient settings resembles general inpatient psychiatry in many ways, but the nature of the risks being managed in these settings generates additional considerations. One of these is that some items used in religious practices are considered contraband in security settings, including rosaries, prayer beads, and phylacteries.
Another treatment concern unique to forensic care is the relevance of remorse in assessing an individual’s recovery and current level of risk when the individual has committed one or more serious acts of violence. Remorse is one component of an individual’s level of insight about the crime, its antecedents and the prevention of future violence. These constructs have parallels to forgiveness and reconciliation that are seldom addressed, and for which there are no readily available processes in the criminal justice system.
In performing forensic evaluations, mental health practitioners are expected to pursue goals of objectivity, truth-telling, and respect for persons. This entails a skeptical, questioning approach that differs from the practice of customary clinical therapeutic work. Yet authors have discussed the concept of “forensic empathy” and the ethics of a receptive empathic stance as opposed to an expressive empathic stance that might encourage the evaluee to forget the evaluator’s warnings about the non-confidential nature of forensic evaluations. Compassion and a spiritual openness to the suffering of another are still possible within this forensic encounter, but must be employed skillfully to remain within expected ethics boundaries. Each of these areas will be explored, with further discussion invited.
Abraham Nussbaum, M.D., Director of Adult Inpatient Psychiatry / Assistant Professor, Denver Health / University of Colorado SOM
Nancy Kehoe, RSCJ, PhD / Assistant Professor of Psychology, Harvard SOM
Michael A. Norko, MD, MAR / Associate Professor of Psychiatry, Yale SOM
Psychiatry, psychology, and other mental health disciplines self-consciously understand themselves as applied disciplines of the neurosciences. In these disciplines, great attention is paid to the biomarkers and imaging studies which reveal the neural circuits underlying mental illness. Comparatively little attention is paid to the person in whom these neural circuits operate. Yet when persons participate in psychiatric care, whether as patients, practitioners, or caregivers, they inevitably experience ethical questions.
When we emphasize the neuroscientific underpinnings of mental health disciplines, it means, first, that the ways that neuroscientific accounts build on and inform particular accounts of human health and wellbeing are assumed rather than discussed. Second, it means that when ethical questions are engaged in psychiatry, widely accepted principles—generalized virtues and cultural competence—are emphasized at the expense of the particularities of the persons experiencing these ethical questions. Third, it means the ways religious and spiritual practices inform ethical questions are typically neglected by practitioners in the contemporary mental health disciplines.
In a forthcoming Oxford University Press anthology entitled Ethics in Psychiatry and Religion, leading scholars working at the interface of psychiatry and religion will provide mental health practitioners with a conceptual framework for understanding how religious and spiritual practices inform ethical decision-making. The authors consider questions including how to distinguish healthy from unhealthy religious practices and how to approach a patient experiencing an existential, moral, or spiritual distress. In this panel presentation, three contributors to the book will address aspects of these questions.
The first panelist will discuss the role of faith leaders in addressing mental illness and ethical dilemmas. Faith leaders are spiritual and religious guides for their communities, which entails multiple levels of commitments, a commitment to the care of soul of the individual, a commitment to the congregation as a whole, sometimes a commitment to the larger body of the congregation. The orientation of faith leaders is to focus on the spiritual well-being of those in his/her charge and to keep God/Yahweh/Allah, the deity, at front and center. The training of faith leaders has seldom included an in-depth understanding of mental illness. Yet faith communities are made up of human beings struggling with life and all its challenges, including mental illness. Because of the stigma attached to mental illness, frequently the presence of a mental illness in an individual is hidden from the faith leader and the congregation. This can create ethical dilemmas for the leader.
In this presentation, we will reflect on some of those dilemmas by using several cases drawn from particular religious traditions. The very nature of an ethical dilemma is the complex nature of the situation and the various constituencies involved in the resolution of the situation, the good of the individual over against the good of the whole. Faith leaders are always called to balance these two and frequently must do so in the context of confidentiality. In this presentation, we will look at the ethical guidelines that various religious denominations hold and the guidelines of mental health associations and apply them to the cases.
The second panelist will discuss how the ethical questions particular to inpatient psychiatric settings pose significant challenges to the religious and spiritual practices of patients and practitioners alike. Contemporary inpatient psychiatry settings typically operate with a focus on outcome-based care, with admission and discharge tied to specific symptoms, rather than to a consideration of their meaning within the lives of patients. The contemporary mental health practitioner has limited incentive to, say, distinguish scrupulosity from obsessive-compulsive disorder, possession from dissociative disorder, and ecstatic experiences from hypomania. In addition, there is often limited cultural space for a practitioner to live out his or her own religious and spiritual practices.
For patients receiving inpatient psychiatric care, it is common to consider their capacity to make decisions about their health and well-being. After all, many people receiving inpatient psychiatric care do so as involuntary patients within locked facilities after they have been determined to lack the capacity to leave the hospital. It is less common to consider what kind of access a hospitalized patient should have to the religious and spiritual practices they desire. When should a patient be given or restricted from access to religious texts and ritualized objects? When should a patient be allowed to receive faith leaders as visitors? As participants in their treatment? These questions will be engaged with consideration of the interrelationships between medical indications, patient preferences, quality of life, and the contextual features of inpatient psychiatric care.
The third panelist will discuss some of the ethical considerations related to religion and spirituality in forensic psychiatry settings. The practice of forensic psychiatry involves activities related to evaluation of defendants or other individuals involved in the justice system, as well as treatment services for individuals ordered into treatment by the courts – most often for restoration of competence to stand trial and for individuals found not guilty by reason of insanity. The treatment of psychiatric patients in high security inpatient settings resembles general inpatient psychiatry in many ways, but the nature of the risks being managed in these settings generates additional considerations. One of these is that some items used in religious practices are considered contraband in security settings, including rosaries, prayer beads, and phylacteries.
Another treatment concern unique to forensic care is the relevance of remorse in assessing an individual’s recovery and current level of risk when the individual has committed one or more serious acts of violence. Remorse is one component of an individual’s level of insight about the crime, its antecedents and the prevention of future violence. These constructs have parallels to forgiveness and reconciliation that are seldom addressed, and for which there are no readily available processes in the criminal justice system.
In performing forensic evaluations, mental health practitioners are expected to pursue goals of objectivity, truth-telling, and respect for persons. This entails a skeptical, questioning approach that differs from the practice of customary clinical therapeutic work. Yet authors have discussed the concept of “forensic empathy” and the ethics of a receptive empathic stance as opposed to an expressive empathic stance that might encourage the evaluee to forget the evaluator’s warnings about the non-confidential nature of forensic evaluations. Compassion and a spiritual openness to the suffering of another are still possible within this forensic encounter, but must be employed skillfully to remain within expected ethics boundaries. Each of these areas will be explored, with further discussion invited.