Religious Training and Religiosity in Psychiatry Residency Programs

Shimon Waldfogel, M.D. Paul R. Wolpe, Ph.D. Yochi Shmuely, D.S.W.

The authors present the results of a survey that inquired into the religious life of 121 residents from 5 psychiatric residency programs. In addition, the study sought to explore the didactic and supervision experience of the residents regarding religious issues. The authors results show that this group of residents appears to be more religious than what has been reported before in prior studies of psychiatrists religious beliefs. While didactic exposure was limited, those who received didactic exposure were more likely than those who did not to believe that religion is important in the clinical setting, and the former also felt more competent to recognize and attend to a patients religious and spiritual issues. Still, most residents felt competent to address religious issues in their clinical encounter. The implications of the results are discussed as they relate to training. (Academic Psychiatry 1998; 22:2935)

mericans report extremely high levels of religious belief and behavior compared with most other Western countries: for example, over 90% of Americans say they believe in God, the highest percentage of any western industrialized country (1). Religious beliefs and values therefore contribute to the formation of identity in many people and thus may inuence, in subtle or overt ways, the persons life course. This includes the life course of psychiatrists as well as the life course of patients, yet the bulk of research on religion and psychiatry has generally ignored the religious beliefs of psychiatrists and focused instead on the religious beliefs and behaviors of their patients. The relationship of religious beliefs to the profession of psychiatry may be more profound than is commonly acknowledged. The religious beliefs of psychiatrists may have an inuence on the therapeutic philosophy they adopt and on the way they reACADEMIC PSYCHIATRY

spond to the religious issues of patients (24). Yet the training that psychiatrists receive in religion is limited; for example, one study of residency directors in psychiatry found that didactic instruction on all aspects of religion was infrequent and incomplete (5). A number of authors have therefore called for increased research and training in religious issues in medical school and residency, as well as in the general psychiatric community (1,57). Further recognition of the importance of religion in the clinical setting is addressed in the 1990 American Psychiatric Association (APA)
Dr. Waldfogel is assistant professor, Department of Psychiatry and Human Behavior, Jefferson Medical College, Philadelphia, Pennsylvania. Dr. Wolpe is faculty associate, Center for Bioethics, and assistant professor of Sociology, University of Pennsylvania, Philadelphia. Dr. Shmuely is post-doctoral fellow in epidemiology at SmithKline Beecham. Address reprint requests to Dr. Waldfogel, 1651 Thompson Building, 1020 Sansom Street, Philadelphia, PA 191075004. Copyright 1998 Academic Psychiatry.

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guidelines regarding possible conicts between psychiatrists religious commitment and psychiatric practice (8). Additionally, the new DSM-IV category (V62.89religious and spiritual problem) acknowledges the APAs recognition that religious and spiritual issues may be a valid focus of psychiatrists attention (9). For a variety of reasons, psychiatrists are not representative of the general population in their religious beliefs (10,11). Psychiatrists, like physicians in general, also differ in such characteristics as social class (12) as well ethnicity and race (13) from the average patient. We know little about the effects of such variables on the philosophies, practice styles, and medical specialty choices of psychiatry residents. We report the results of a survey inquiring into the religious life, beliefs, and training of psychiatric residents. METHODS A condential questionnaire (available from the rst author) on religion and psychiatric residency was distributed during the 19921993 academic year to residents through peer meetings at the following psychiatric residency programs: Beth Israel in New York, Case Western Reserve in Ohio, Thomas Jefferson University Hospital in Pennsylvania, the University of Texas at San Antonio, and the University of Virginia. These schools are not noted for their afliation with religious institutions, and so are not the schools of choice for those looking for a psychiatric residency with a strong religious orientation. The completed questionnaires were returned to the authors by the residency director or the chief resident. A total of 121 questionnaires were returned out of 152 that were distributed (response rate79.6%). The survey included questions about the residents religious background, beliefs, afliations, and behaviors; the degree to which the resident believes religion inu30

enced his or her choice of medicine as a career and psychiatry as a specialty; the frequency and type of instruction on religious issues the resident received during medical training; and the residents attitudes and experiences in encountering religious issues among patients. A religiosity scale made up of Questions 1, 3, 4, and 5 of Table 3 was constructed. For comparison of continuous data, two-tailed t-tests and an analysis of variance were used. RESULTS Demographics and Religion The residents came from a variety of religious backgrounds, with Catholics (29%) and Jews (12%) overrepresented among residents compared with the general population. Also, a signicant number of residents indicated either no afliation or other categories (16% and 14%, respectively) (see Table 1). Forty-three percent of the residents had attended at least some religious day or afternoon school before college, and onefth (19%) had attended a religiously afliated college. Table 2 summarizes the distribution of residents by age, race, gender, and postgraduate year (PGY). Race had a signicant impact on the residents religiosity, with African American residents as a group signicantly more likely than non-African Americans to report that they believe in God, that religion is important in their lives, and that belief in God is important in their
TABLE 1. Afliation Catholic Mainline Protestanta No religion Other Jewish Other Protestant
a

Religious afliation n (%) 35 (28.9) 20 (16.5) 19 (15.7) 17 (14.0) 15 (12.4) 15 (12.4)

Episcopal, Methodist, Lutheran, Presbyterian.

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daily lives (F 4.3, df 3, P0.01). No signicant difference was found in religiosity by gender, age, or postgraduate year of training. Religious Inuences in the Life of the Psychiatric Resident A ve-item Likert-type scale was used to assess the residents agreement or disagreement with a number of statements about religious beliefs and attitudes (see Table 3). While over three-quarters of the residents reported that they believed in God, only 13% believed that the Bible is the literal word of God. Close to 70% of the residents reported that religion is important in their lives, and nearly three-quarters of the residents believe that religion can help solve personal problems. Forty-nine percent of the residents pray at least weekly, though only about 22% attend religious services weekly (Table 4), compared with 32% of a national sample of persons under the age of 30 (14). Forty-nine percent of the residents reported that their
TABLE 2. Variables Age 32 years old 31 years old Race White African American Asians Other Gender Male Female Postgraduate year (PGY) of training PGY-1 PGY-2 PGY-3 PGY-4 Fellow
a

religious beliefs had either signicantly or somewhat affected their choice of medicine as a profession, and 36% felt that their religion signicantly or somewhat inuenced their choice of psychiatry as a career (Table 5). The residents religious afliations were not correlated with the choice of psychiatry as a specialty. However, religious afliation was signicantly related to the choice of medicine as a career (F2.8, df5, P0.05), with other Protestants scoring highest, followed by Mainline Protestants, Catholics, Jews, the other religion group, and the no religion group. The 4-part religiosity scale
TABLE 3. Religious belief n (%) Agree 1. Belief in God 2. Belief that the Bible is the literal word of God 3. Religion is important in my life 4. Prayer is important in my life 5. Religion can help solve personal problems 6. Religion is important in the clinical setting 92 (76.7) Not Sure 9 (7.5) Disagree 19 (15.8)

15 (12.5) 20 (16.7) 85 (70.8)

82 (67.8)

7 (5.8)

32 (26.4)

Demographic characteristicsa n (%) 80 (66.1) 40 (33.1) 73 (60.8) 20 (16.7) 2 (20.0) 3 (3.3) 60 (50.0) 60 (50.0) 22 (18.3) 29 (24.2) 33 (27.5) 30 (25.0) 6 (5.0)

68 (56.2) 10 (8.3)

43 (35.5)

88 (73.9) 20 (16.8) 11 (9.3)

50 (41.3) 41 (33.9) 30 (24.8)

TABLE 4.

Religious activity n (%) Once a Week A Few Times a Year Rarely or Never

For each one of these questions, there was a resident who did not answer.

1. Attendance at religious services in the last year 26 (21.7) 44 (36.7) 50 (41.7) 2. Private prayer 59 (48.8) 17 (14.0) 45 (37.2)

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(made up of Questions 1, 3, 4, and 5 from Table 3) was signicantly correlated with religious afliation among residents (F17.3, df5, P0.001), with Mainline Protestants scoring highest, followed by other Protestants, Catholics, Jews, and other religion. Religion in Medical Training Twenty-seven percent of all residents and 29% of PGY-3 through PGY-5 residents reported that religion was discussed or presented in their didactic program (Table 6). About 39% of the PGY-3 to PGY-5 residents reported that religion was discussed during supervision. Twenty-eight percent (n33) of the residents reported that their religious beliefs changed during medical training, 60% (n20) of whom reported that their religious beliefs grew stronger. Those who reported that their religious beliefs changed
TABLE 5. Religion and choice of medicine n (%) Signicantly Somewhat 1. Extent that beliefs impact on medicine choice 2. Extent that beliefs impact on psychiatry choice None

(got stronger or got weaker) during medical training scored signicantly higher on the religiosity scale than those who reported no change (t2.4, df72.3, P0.05). There were some signicant differences between those who encountered either didactic or supervision exposure to religious issues in training and those who did not. There was no signicant difference between the two groups in how often the residents reported encountering patients with clinically signicant religious issues; however, there was a signicant relationship between having either didactic or supervision exposure and stating that religion is important in the clinical setting (Didactic: t3.02, df57.5, P0.005; supervision: t3.61, df92.95, P0.001). Religious Issues in the Clinical Setting About 25% (25.2%) of the residents reported encountering a patient with clinically signicant religious issues at least weekly (daily and weekly, Table 7). A high percentage of the residents, 84%, did report feeling somewhat to very competent in their ability to recognize and attend to a patients religious and spiritual issues. There was, however, a signicant relationship between didactic or supervision exposure and feeling competent to recognize and attend to a patients religious and spiritual issues (Didactic: t2.36, df51.98, P0.05; supervision: t2.35, df83.97, P0.05). Only 9% of the residents agreed that it is acceptable to pray with patients, whereas 21% were not sure. Twelve percent believed it was acceptable to reveal their religious convictions in the clinical setting, whereas 24% were not sure. Only 8% of the residents reported feeling tension between their religious beliefs and their role as a physician. DISCUSSION It has been suggested that a religiosity gap exists between the general public and menVOLUME 22 NUMBER 1 SPRING 1998

18 (15.0)

41 (34.2) 61 (50.8)

12 (10.1)

31 (26.1) 76 (63.9)

TABLE 6.

Religious issues in training n (%) Yes No

1. Discussed religious issues during didactic training as resident 2. Discussed religious issues during supervision 3. Religious beliefs changed during medical training

32 (26.9)

87 (73.1)

45 (37.8)

74 (62.2)

33 (27.5)

87 (72.5)

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WALDFOGEL ET AL.

tal health professionals (15). For example, while 72% of the general public endorse the statement my whole approach to life is based on my religion, only 39% of psychiatrists and 33% of psychologists endorse the statement (2). Yet the psychiatric residents who responded in our study appeared to have stronger religious convictions and identication than prior studies of practicing psychiatrists (10). The sampling of the psychiatric trainees population in this study is limited to only the ve programs listed earlier; therefore, our ndings may not be generalizable to all residents. While this is a substantial limitation, we have no reason to believe that the residents religiosity inuences their selection of these particular programs. In addition, the response rate may have been inuenced by the residents religiosity. We have no way to ascertain the reasons for nonresponse. The residents appeared to act more upon their religious beliefs through religious activity, such as prayer, than in other studies of psychiatrists (10). It would be interesting to explore whether a generation of more religiously oriented psychiatrists is entering the profession, or whether there is something in the nature of psychiatric pracTABLE 7. Clinical issues

tice that tends to suppress religious belief and practice over time. Of particular interest in this study was the number of residents who stated that their religious beliefs inuenced their choice of medicine as a profession and to a lesser degree psychiatry as a specialty. Yet, while a signicant number of residents in this sample reported having a strong religious orientation, there is a general lack of attention to this area in residency training. Didactic instruction in formal lectures and supervision appears to be limited and of undetermined quality. Those residents who received didactic and/or supervision exposure to religious issues, however, tend to believe that religion is important in the clinical setting, and they feel more competent to address these issues with their patients. Even without such training, most residents report that they feel at least somewhat competent in addressing religious issues in the clinical setting, although an actual assessment of the residents competence in this area would be of great interest. The lack of didactic instruction as well as supervision addressing religious issues is in contrast to the importance of religion in the lives of Americans as well as the residents themselves. Bergin (2) noted the con-

n (%) Daily 1. Encounters patients with clinically signicant religious issues 5 (4.2) Weekly 25 (21.0) Monthly 36 (30.3) Rarely 53 (44.5) Not Competent 19 (16.1) Rarely 103 (85.8) Disagree 83 (69.8) 77 (63.7)

Very 2. Believes self competent to recognize and attend to religious and spiritual issues 14 (11.9) Weekly 3. Discusses own religious beliefs with patients 6 (5.0) Agree 4. Believes it is acceptable to pray with patients 5. Believes it is acceptable to reveal religious beliefs 11 (9.2) 15 (12.4)

Somewhat 85 (72.0) Monthly 11 (9.8) Not Sure 25 (21.0) 29 (24.0)

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tradiction between the importance the mental health worker attributes to religion in his or her own life and that which he or she attributes in the clinical encounter. A curriculum for addressing religious issues during residency training has been developed as part of the work of the Association of Academic Psychiatry Task Force on Cultural Diversity in conjunction with the National Institute for Health Care Research (available from the National Institute for Healthcare Research, 6110 Executive Blvd., Ste. 908, Rockville, Md 20852. Phone: 800/ 580NIHR). This approach may prove to be a useful starting place for a more thorough assessment of the nature and inuence of formal training in addressing clinically based religious issues during residency. Most residents reported that religion is important in their own lives and in the clinical setting, yet they also reported seeing few patients with signicant religious issues in treatment. This may indicate a failure to actually address religious issues in the clinical setting, which may lead to incomplete assessment of the patients problem and neglect of potentially benecial religiously related interventions (7). Additionally, it could be that people with religious concerns do not seek help from psychiatrists but rather from their clergy. By ignoring this dimension of the patients life, the psychiatrist may be sending the unintended message that the religious aspect of the patients identity is out of bounds in the clinical encounter. Therefore, training psychiatrists to better address this area of patient care is important. CONCLUSION Although these results are not necessarily generalizable to all psychiatric residencies, this study shows that religion is important personally to a large number of psychiatric residents; that they recognize its importance in the clinical encounter; and that they benet, in terms of feelings of increased clinical
34

competence, from didactic and clinical instruction about religious issues. Two areas of consideration therefore emerge. First, it is important to make the residency program a religiously hospitable place, to explore and address conicts that may emerge for the resident in working with religious issues. Second, the resident should be taught to include the patients religious beliefs in his or her understanding of the whole person. The religious dimension of the patients life should be conceptualized in a manner that will help in the healing process in mental illness. This may include the role of religion as a social support for patients, the use of religion as a protective defense, and/or the relationship between some types of psychopathology and religious content. This does not necessitate the endorsement of any particular religious belief during training, or even of religion in general, but rather the teaching of a conceptualization of religion in psychological terms. Addressing the patients religious and spiritual beliefs in a nonjudgmental manner will allow the resident to recognize how these beliefs affect the patient and may lead to treatment recommendations that are consistent with the patients belief, including referral to a professional who can address the particular religious issues of the patient. An earlier version of this paper was presented at the American Psychiatric Association Annual Meeting, May 1993, San Francisco, California.

References

1. Gallup G, Castelli J: The Peoples Religion: American Faith in the 90s. New York, Macmillan, 1989 2. Bergin BE: Values and religious issues in psychotherapy and mental health. Am Psychol 1991; 46:394403 3. Galanter M, Larson D, Rubenstone E: Christian psychiatry: the impact of evangelical belief on clinical practice. Am J Psychiatry 1991; 148:9095

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4. Klausner S: Psychiatry and Religion. New York, Free Press, 1964 5. Sansone RA, Khatain K, Rodenhauser P: The role of religion in psychiatric education: a national survey. Academic Psychiatry 1990; 14:3438 6. Larson DB, Sherrill KA, Lyons JS, et al: Associations between dimensions of religious commitment and mental health reported in the American Journal of Psychiatry and Archives of General Psychiatry: 19781989. Am J Psychiatry 1992; 149:557559 7. Waldfogel S, Wolpe PR: Using awareness of religious factors to enhance interventions in consultation-liaison psychiatry. Hospital and Community Psychiatry 1993; 44:473477 8. American Psychiatric Association Committee on Religion and Psychiatry: Guidelines regarding the possible conict between psychiatrists religious commitment and psychiatric practice. Am J Psychiatry 1990; 197:542 9. American Psychiatric Association: Diagnostic

and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association; 1995, 10. Bergin AE, Jensen JP: Religiosity of psychotherapists: a national survey . Psychotherapy 1990; 27:37 11. American Psychiatric Association Task Force on Religion and Psychiatry: Psychiatrists viewpoint on religion ministry. Washington, DC, American Psychiatric Association, 1975 12. Ziem G: Medical education since Flexner. Health 1977; 76:814, 23 13. Shea S, Fullilove MT: Entry of black and other minority students into US medical schools. N Engl J Med 1985; 313: 15191525 14. Princeton Religion Research Center: Religion in America 19921993. Princeton, NJ, Princeton University, 1993 15. Lukoff D, Lu F, Turner R: Toward a more culturally sensitive DSM-IV: psychoreligious and psychospiritual problems. J Nerv Ment Dis 1992; 180:673682

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