March 2012 – Tips & Topics

Looking over the topics I have covered in all these nine years, not one issue of TNT was devoted to spirituality and religion. That perhaps speaks volumes and makes this March e-newsletter an “it’s about time you wrote about this” edition.

I am drawing on two recent articles on spiritualty and religion. I am knitting together pearls of wisdom from both articles and quoting from these. The first article is by a friend and colleague, Tom Peltz, MEd, LMHC, LADC-1, CAS, who is in a private-practice office in Beverly Farms, Massachusetts. In 2011 he was awarded the Lora Roe National Alcoholism and Drug Counselor of the Year award from NAADAC, The Association for Addiction Professionals.

The second reference is by James Lake, M.D., Chair of the International Network of Integrative Mental Health (www.INIMH.org) and he is in private practice on the California central coast. He wrote in the March issue of Psychiatric Times. Here are the references:

(1) Peltz, Thomas A (2012): “Facing spirituality head-on” Addiction Professional, February 28, 2012. http://www.addictionpro.com/print/article/facing-spirituality-head

(2) Lake, James (2012): “Spirituality and Religion in Mental Health: A Concise Review of the Evidence” Psychiatric Times, March 2012 Volume XXIX, No.3 pp 34-38.
https://www.cmellc.com/landing/pdf/A12001031.pdf

TIP 1

Why is Spiritualty and Religion not addressed or under-addressed in mental health and addiction services?

* Both clinicians and religious personnel feel inadequate to deal with spirituality in co-occurring disorders and toss the clinical football to each other.

While spirituality has been more integrated into 12 Step addiction treatment, in most other behavioral health disorders, it is “viewed as a scary ‘hands-off’ area better left to the religious person than to the tightly scheduled, objective, evidence-based therapist. So too, however, I find many religious people would rather have the therapist work with a person with co-occurring disorders, perhaps because of clergy’s own discomfort with the issue of how some symptoms of addiction and mental illness present themselves.” (1)

* The focus on brain diseases and biomedicine excludes spirituality; historically, psychological theories pathologized or dismissed spirituality; the central role of spirituality in other cultures and traditions has been ignored.

“Just as science eliminated “spirit” and “vital energy” from its discourse, the role of spirituality and religion has been increasingly marginalized in biomedicine. Historically, “priests and other spiritual adepts were regarded as healers, and gifted healers were elevated to the status of priest, or shaman. By the early 20th century, psychoanalysis had pathologized or outright dismissed the psychological dimensions of spiritual experience and the relevance of spirituality in mental health. While conventional biomedicine does not acknowledge the direct role of spirituality in health, many cultural practices and traditions e.g., Chinese medicine, Ayurveda, Tibetan medicine assume that spirituality is centrally involved in health.” (2)

TIP 2

What are definitions of religion and spirituality?

Here is what Tom Peltz says:

* “It is important right from the beginning of treatment to explore both religion and spirituality, because they can be quite different. I find it is upon examining these differences that a person begins to risk opening up and sharing deeper details of their journey in health.

I keep the distinction very simple. Spirituality is a relationship based in three parts: a relationship with oneself, with others around us, and with a higher power. When we were using, it was an unhealthy relationship. Once we are clean and sober, it is one where we are learning how to be healthy. Religion is a man-made institution based upon a myth, in which ritual and tradition is practiced. “What do you believe?” is quite different from “What sort of relationship do you have?” Both can be important, however.” (1)

Now Dr. Lake:

* “Religion is an organized system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent (God, higher power, or ultimate truth/reality).”

“Spirituality is the personal quest for understanding answers to the ultimate questions about life, about meaning, and about relationship with the sacred or transcendent, which may (or may not) lead to or arise from the development of religious rituals and the formation of a community.” (2, page 35)

TIP 3

Why religion and spirituality is an essential part of health and wellness

“Almost 90% of Americans describe themselves as religious or spiritual, and only 7% said that spirituality is not important at all in their daily lives.” (2, page 35)

Tom Peltz:

“Spirituality is not a clinical football to be tossed to the most credentialed or the least bothered-it is an essential part of wellness and it needs to be treated openly by clinical professionals. There are many spiritual examples to cite where we could find clinical factors to discuss:

* In group therapy, I remember talking with a recovering patient about getting down on his knees to pray every morning and evening. After group ended, the co-leading therapist pulled me aside and said she would never say this sort of thing to a patient because she is Jewish and Jews don’t kneel.

* While working on an inpatient psychiatric unit, I remember with horrible vividness how long I became stuck in discussing spirituality with the first alcohol detoxifying patient with bipolar disorder I ever met. Unknown to me at the time, this man had a very actively psychotic, religious delusional thought disorder. Once was enough for me to try to have a conversation with him about God while he was in a manic state. Once he was stabilized on medications, he became a delight to see in outpatient practice. (I understood why it is far easier to avoid the topic of spirituality, or merely to offer it a passing clinical nod, when working with individuals with co-occurring disorders.)

* A priest angrily announced among a group of care providers, “I hated dealing with him, and tried to avoid his calls. He was just an annoying alcoholic who called the rectory all the time in the middle of the night obviously drunk, asking for a place to stay.” (Please note: I am aware that assisting people in their healthy relationship with God is something that some religious people are not any more comfortable in dealing with than some therapists are sometimes.)

* A person sat crying in therapy with me because she believed she had sinned against God in that she was not naturally able to have children, and went through a fertility process. Now, years later and with several wonderful children, she is facing serious problems in her life. She believes the problems are her fault because she had decided to have children years ago, thereby sinning against God and the “natural” wishes of her body. She never had told anyone because of her fear of having “gone against God.” (1)

TIP 1

Ask about religious and spiritual beliefs to strengthen the therapeutic relationship

“When asking about religious and spiritual beliefs, it says that you are concerned with the whole person, not just a psychiatric diagnosis. Regarding the client as a whole person will strengthen the patient-physician relationship and may have beneficial effects on treatment adherence and outcomes.” (2, page 35)

Tom Peltz says a way to begin is simply to ask in the interview: “What is your religious or spiritual practice?”

Here are principles and issues that may come to the surface after that initial question:

* Accept where the person is: “Transference and/or counter-transference issues immediately can become very complicated here. A rule of thumb is to accept without challenge that what is said is the other person’s belief, not yours. With spirituality, it is always the goal to work where the patient is, to clarify what is meant, and to go deeper.” (1)

* A person’s religion and spiritualty might differ: “This question of spiritual strength and practice opens the conversation to examine how a person’s religion and spirituality might differ. I find that the patient’s radar is usually highly attuned to any disrespect, and this includes any perception of non-acceptance. Thus, the patient reveals information slowly and in layers in order to determine if the therapist can be trusted.”

For example, a patient might simply state his/her religious affiliation. Then I ask, “How often do you attend your place of worship?” At this point, I have modeled that I care enough to want to learn more about the patient’s life, rather than merely filling in a blank on my intake questionnaire. Often the response I receive involves a statement with words such as, “I don’t attend as often as I should.” (1)

* Timing of further questions and assessment is important to build trust: “The patient has opened a door, and I want to go through it and follow up on the information presented. However, if I’ve been asking a lot of questions in the intake evaluation about usage, or legal or medical issues, I might wait for several sessions in order to allow the time to be appropriate to discuss more about a patient’s religious practice.”

“When I revisit the issue, I often begin by educating about the differences I believe can exist between one’s religion and one’s spiritual beliefs. I find examining both areas to be important, as often in the addiction treatment field’s one’s spiritual and religious beliefs are not discussed. This amounts to a subtle form of abandonment in which the person becomes fragmented rather than integrated in his/her system of religion and spiritual belief.” (1)

* Identify the client’s perspectives on spirituality regardless of religious beliefs: “For people who state that they are atheist, or don’t believe in anything, I then ask about their views on nature, or on the power of something evidenced in everyday life such as love, family, or a life force (as described in the fourth edition of Alcoholics Anonymous’s Big Book). I am looking to learn about how they deal with “a power greater than oneself,” and how that fits into their concepts of relationships in their lives. I am seeking to learn what language they have constructed to speak spiritually. I find most people have been using such a language, and it is just that I might not be recognizing it to be spiritual as such.”

“I am interested, for example, if a person identifying as Catholic feels he/she doesn’t attend services often enough. Maybe it is a problem with caring for a family member at home that stops the person from attending church. Perhaps it is because he/she feels threatened by the news of priests who have abused parishioners. Perhaps it is because the person has a rigid view of obligation and has missed some times of daily devotion. The point is that without exploring the issue, the therapist might not learn what is occurring in the patient’s reality, and might jump to consider it just shame or guilt.” (1)

TIP 2

Document openly and accurately about spirituality and religion

“Spiritual words such as “hope,” “serenity,” “acceptance,” “grace,” “comfort,” “peace” and “trust” are all difficult terms to write about in patients’ clinical treatment objectives.

* I suggest we cannot leave the spiritual aspects of care for someone else to address. We need to make caring for people’s wellness our priority, and I believe that wellness includes a physical, intellectual, emotional and spiritual foundation.

* Accepting and exploring people’s spiritual and religious views and actions are important in therapeutic treatment. Offering education and support to others to work and grow freely in these areas is critical. We need to embrace and further develop spiritual work with others as a normal part of life, both personally and clinically, and to expect it as a normal part of reimbursement for our work. Finally, rather than remaining silent about what we really do in sessions, we need to learn how to document it accurately and discuss it openly, without fear of reprisal.” (1)

Documentation examples:

* Here is an example of a Problem Statement in a Treatment Plan: “Mary feels she sinned against God for having used a fertility process to conceive.”

* Here is an example of a Progress Note: “Mary is beginning to let go of her guilt for having used a fertility process. She has more hope and serenity than she has ever had for a decade; and has more peace and acceptance that she did the best she could do. While this may partially be the antidepressant effects of her medication, she derives a lot of comfort from remembering the graciousness of her God as she has reunited with her spiritual community, whom she avoided in her guilt.”

I am never quite sure how personal to get when I write SOUL each month.

Firstly, it could be a case of TMI – Too Much Information. Just give me the SAVVY and SKILLS clinical facts – none of this personal story stuff. Or, for a few readers, they actually like the personal stuff – makes the psychiatrist and trainer and consultant not so stuffy and more of a real person.

So if you are the first TMI-type reader, you can stop reading now. If you are the latter, here I go…..

I’m writing this from the Gold Coast of Australia, about an hour from where I was born and raised in Brisbane in the Sunshine State of Queensland. Ironically, my daughter and son-in-law now live here and just delivered less than two weeks ago, the most beautiful granddaughter in the world! (That is the conclusive finding of a study of six billion granddaughters in the world conducted by an important research company with me as Principal Investigator!)

I know, I can see some rolling eyes that say: “Here we go, the proud grandparent thing. OK, show me the thousand photos. I actually have insomnia now…it might help.” Grandparents out there, you know what I mean. But it is amazing to hold that little bundle and let her sleep cuddled on your chest, feeling her warmth and coziness. Have you seen how cute those little fingers and toes are? The grip of her hand on my little finger; the softness of her skin and her little head of hair.

Then at the other end of the life cycle, to be with my 97 year old, bed-ridden mother and comb her white hair – not just to comb her hair, but because the brush feels so good to her as it scratches her scalp – her arms too weak to reach up and brush her hair and scratch her scalp for herself. Or to feed her like a baby. Her mind is pretty good, which makes it all the more sad to be so dependent on others now….especially a woman who did so much for other people throughout her life.

What a contrast of emotions all in the one trip. How to get my head and heart around the joy and sadness of family at the beginning and end of life? A friend reminded me of the joke about being a new grandfather: You wake up the next morning realizing that you just slept with a grandmother!

I can’t think of a joke for the other end of life. I guess that is why I’m writing this in SOUL right now. You caught me at this moment. Some personal moments.

I am excited about two new ASAM Criteria products from The Change Companies: a new client journal and eLearning module now released and available. You can examine for yourself in more detail at The Change Companies’ website. Look for the ASAM System icon and click to see more detail. https://www.changecompanies.net

➢ The brand new e-Learning Training module on “From Assessment to Service Planning and Level of Care” eLearning Course. This course helps practitioners understand how to work with a participant’s assessment and service planning to identify the best level of care in which to provide his or her services. Skills that reinforce the module’s learning objectives are practiced and applied through interactive case studies and Dr. Mee-Lee provides real-world application and description via brief video clips throughout the module.

Five hours of NAADAC, CAADAC & NBCC and physician Continuing Education (CE) have already been approved.

➢ The brand new Interactive Journal “Moving Forward” Journal is now available. This Interactive Journal is an effective resource for guiding individualized service planning through the treatment and continuing care process. Treatment team and participant work together to identify and set goals targeted to specific dimensional needs and later reevaluate progress, allowing the participant to expand on and adjust goals. Take a look at the Interactive Journals page after you click on the ASAM system icon on The Change Companies’ website Home Page
https://www.changecompanies.net/asamcriteria/asam_products_dimension.php

Join us in late April for the April 2012 edition that will start Year 10 of Tips and Topics.

David