Indian Journal of Psychological Medicine

PRESIDENTIAL ADDRESS
Year
: 2019  |  Volume : 41  |  Issue : 2  |  Page : 103--107

Spirituality in psychiatry practice


Padma Sudhakar Thatikonda 
 President, Indian Psychiatric Society, South Zonal Branch 2017-2018, Department of Psychiatry, Sri Padmavathi Medical College for Women, SVIMS University, Tirupati, Andhra Pradesh, India

Correspondence Address:
Dr. Padma Sudhakar Thatikonda
Professor and Head of the Department of Psychiatry, Apollo Institute of Medical Sciences and Research, Murakambattu, Chittoor - 517 127, Andhra Pradesh
India




How to cite this article:
Thatikonda PS. Spirituality in psychiatry practice.Indian J Psychol Med 2019;41:103-107


How to cite this URL:
Thatikonda PS. Spirituality in psychiatry practice. Indian J Psychol Med [serial online] 2019 [cited 2019 Mar 23 ];41:103-107
Available from: http://www.ijpm.info/text.asp?2019/41/2/103/253377


Full Text



Presidential Address delivered at the 50th annual conference of Indian Psychiatric Society South Zonal Branch on 28th October 2017 at Vythiree Village, Waynad, Kerala

Dear esteemed members, brothers and sisters, and ladies and gentlemen,

It's indeed a long-cherished dream, now realized, to be the president of our association.

At the outset, I wholeheartedly thank you for reposing confidence in me and for electing me to this coveted position, to serve the association. Luckily, it turned out to be the golden jubilee year.

Many great thinkers, teachers, wise men, and stalwarts of Indian Psychiatric community had served as Presidents of our association. I promise to serve to the best of my abilities to take it to further heights. The journal, Indian Journal of Psychological Medicine, is abstracted and indexed in EBSCO databases, Expanded Academic ASAP, Indian Science Abstracts, ProQuest, Pubmed Central and Scopus, and actively competing with the national journal. All the past distinguished editors and the present editor Dr. M.S. Reddy had played a big role in accomplishing this great task with such distinction and I wish the future editors would follow their advice and the great tradition.

I started my career in psychiatry, way back in 1979 out of my passion and personal choice rather than by compulsion. Indeed, I am indebted to Prof. N.V. Ramana Rao for his guidance and advice in molding me to be a Psychiatrist and a teacher. I consider him as my first Guru and mentor and thank him from this platform and acknowledge the same as his proud student. He was also instrumental in shaping the careers of many eminent contemporary Psychiatrists in Andhra Pradesh. My namaskarams to him.

On this occasion, I submit that I am born and brought up in the holy city of Tirupati till I left for my postgraduation in 1979 and came back to Tirupati to serve my alma mater from 1985 again till today. It is very apt that hailing from the spiritual capital of Andhra Pradesh, I will talk about Spirituality in Psychiatric practice. This is one of the topics which is neither properly taught nor learnt in PG training in India. Rather one is taught not to be very involved about the religion and spirituality in patients' treatment.

Though the WHO defines health as physical, psychological, and social well-being and not merely the absence of infirmity, the spiritual dimension is always stressed as another dimension. There is no equivalent secular term for Spirituality. It can be different from Religion and has nothing to do with Religiosity. It is more abstract than the common understanding one has about the religion.

Spirituality is the individual way of understanding the nature and relate oneself to it and transcendent with the cosmos including everything in existence. The identity of whom I am and what I am is the essence of Spirituality. This is commonly achieved by many forms from religious beliefs and practices, but not always so. An atheist will also have a spiritual dimension.

From Carl Sagan to Neil De gasse Tyson to Stephen Fleming, those who did not believe in the existence of God had been quick to point out, we are part of a bigger cosmic phenomenon and star dust. This star dust spreads all over the universe and one's ability to relate to it to get a sense of belongedness and meaning to life is Spirituality.

One's Spirituality such as physical matter cannot be measured but is dependent on the culture, religion, and inner experiences and the relations that is developed over a period of time, to be part of this creation. It gives meaning to the life and decides the purpose of life. In the practice of Psychiatry over a period, one will start understanding how important it is to understand and accept patients' spiritual reserves as it counts both in analyzing and managing the psychological symptoms of any Psychiatric ailment.

The present narrative concentrated on the relationship of religion, spirituality and their application in Psychiatry practice. Relevant evidences had been quoted from both the international and Indian literature along with personal anecdotes to highlight the importance of incorporating religion, spirituality and cultural aspects into day today practice.

Freud declared Religion and Spirituality as defense against childish helplessness. Surely such infantilism is destined to be surmounted (The future of Illusion, 1927).[1] He declared that clinging onto Religion is a passive retreat from the problems and outright denial of pain and suffering.

Even in DSM III, there was a mention of religious hallucinations and delusions but no further elaboration (Richardson, 1992).[2] All the major text books of Psychiatry and Psychology had conveniently avoided Religion and Spirituality and its importance in their contents (Weaver et al., 1998)[3]

Religious groups on their part continue to reciprocatetheir negative attitude to psychiatric treatment and prohibited adherence to treatment. This had facilitated an impression to most of the psychiatrists that spirituality and religion are against Science of mental health. Among the American Psychiatrists the religious levels are lower compared with general population and other physicians. This led Psychiatrists' inability to estimate the salience of religion to patients. This naturally resulted in lack of adequate education and training to psychiatrists to understand and address the patients' spiritual needs and reserves.

In the last 20 years, there is a sharp rise in scientific interest in the relationship between the religiosity and psychological functioning and spirituality and health. Many commonly held stereotypes talk about nonreligious approach is better in managing Psychiatric ailments. Now, a significant body of theory and research indicate that religion is a source of strength and resilience for many people including those with serious psychiatric ailments. There is no denial that religion can be problematic, if it is not understood and properly dealt with among the patients. The Religion and Spirituality is a double-edged weapon.

As a leading researcher in this field, Pargament (1997)[4] makes reference to the transactional model of stress and coping (Lazarus and Folkman 1984)[5] as a potential point of departure for understanding and organizing research on religiosity and spirituality. Notably, he has focused on the process of religious coping behavior with some additional emphasis on religious appraisals or attributions in response to various life stressors (e.g., Pargament and Hahn, 1986;[6] Pargament K et al., 2002).[7] Pargament continues to expand the application of these religious and spiritual domains in the coping process, most recently addressing the importance of spiritual attachment (connection) to God as a key factor in driving the religious coping process (Belavich and Pargament, 2002).[8] Following Pargament's lead, a handful of researchers have started to apply the transactional model to their investigation of spirituality, coping, and health (e.g., Stolley et al., 1999).[9]

These interactions have to be understood properly by the treating doctor. Sociocultural context is not the only one, but spiritual values play a big role in establishing the therapeutic relation and trust, which would ultimately affect the outcome of many mental health problems.

In Indian understanding, the influence that had been for many generations of the effect of Sri Madbhagavadgitha on the philosophy of life cannot be denied. As one envisages, spirituality in Indian context means the abstracts of one's belief systems and value systems – which may be equated to Antharathma. The concept of Athma and its divine relationship is like an undercurrent in the lives of many Indians. The very fact that Athma is only part of Larger Paramathma and its eternal wish for fusion with Paramathma dictates the behavior of Indian mind. The mind has Indriyas, both Gnana (sensory) and Karma (motor), the Gunas (emotions), the Medhas (intellect), and the Buddhi (discretionary capacity) all constitute Antarathma (the inner soul), which decides how to react to various pleasures and pains. If the reaction results in the well-being of the creation and good of the universe, it is dharma and whichever is not dharma is adharma. The dharma as decided by Antharathma could be relative but that the one decided and accepted by the nature. It is the real truth.

The act of Dharma results in Punya and what is not Punya is papa (sin). There is no equivalent word for Punya in western vocabulary. The punya and papa that s accumulated in the previous birth results in all the good and bad that happens in the present birth. It does not mean that it is all predetermined. One can change the destiny with good deeds, thoughts, and emotions. These concepts actually make an individual an Indian in general and a Hindu in particular. This has been reflected in the acceptance of stress better in Indians. This probably explains why guilt is less common among Hindu patients. This aspect can be better utilized in making the mentally ill patients to work with their difficulties more meaningfully.

This gives meaning and purpose and holds out hope and healing in events of subjective loss, connects with the beyond (The Ultimate truth) and leads to better coping and resilience.

Even in western countries, the recent studies have found that spirituality may serve as a physiological and psychological resource for coping with stress (Koeing, 2001).[10]

A persons' sense of spirituality informs his/her awareness of self in relation to the society and reminds one about the social responsibilities. This is one of the essence of mental health well-being (Swinton, 2012).[11]

All along, the majority position of psychiatry even in India has been that psychiatry has nothing to do with spirituality. Religious beliefs and practices have long been thought to be having pathological basis and were understood in that light. Probably one has to understand the importance of spirituality not in the context of the causation of the illness rather in the management (Verghese 2008).[12]

[INLINE:1]

The detailed review about and of the Indian mind and traditional medicine and the relevance of incorporating these methods into the contemporary psychiatric practice had been deliberated (Avasthi, 2017)[13]

These are about 724 studies of association between religious involvement and mental health.

Out of this 66% (about 476) showed a positive associations (Koeing, 2001).[10] Altruism, gratitude, and forgiveness – have been associated with positive outcome both in health and disease (Berry et al., 2001).[14]

World Psychiatric Association's section on religion, spirituality and psychiatry, the spirituality and psychiatry special interest group in Royal College of psychiatrists, and majority of APA members have endorsed the incorporation of spirituality in the psychiatric treatment (see the respective websites and blogs).

The psychiatrist has to value the spiritual concepts of patients' life and enlarge that for getting positive outcomes.

Mindfulness, Yoga, and Meditation all have become important not only in the treatment of mental health problems but also in maintaining the positive mental health. Various regions of the brain, particularly the prefrontal and anterior cingulate cortex, are observed to undergo changes during different religious spiritual practices. The neurobiology, neurochemistry and neurophysiology of meditation have been studied and evidence of its usefulness in psychiatry had been established beyond doubt.

The Yoga science has been accepted worldwide as a procedure to get better physical and psychological well-being,

The UN general assembly had accepted June 21 to be considered as “World Yoga Day” to get all the benefits of yoga for the people around the world.

In fact, June 21 is the longest day of the year in the northern hemispheres; the summer solstice in northern hemispheres marks the transition into Dakshinayana.

There is broad variety of yoga schools, practices, and goals in Hinduism, Buddhism, and Jainism. Hatha yoga and Raja yoga are well known in the Orient. Yoga entered the west following the success of Swami Vivekananda deliberations with the western scholars in 19th and early 20th centuries.

Yoga, though was clearly considered as a physical exercise in Indian traditions, has meditative and spiritual components. Many studies have tried to determine the effectiveness of yoga as a complimentary intervention for cancer, schizophrenia, asthma and heart disease; the results have been mixed and inconclusive. But many studies pointed that yoga may reduce the risk factors and aid in patients' psychological healing process.

The Yoga world comes from Sanskrit, meaning to “connect.” Yuj samardhan means – to concentrate. Yoga include Gnana yoga, Bhakthi yoga, Karma yoga, Laya yoga, and Hatha yoga. Pathanjali described Asthanga yoga (raja) the ultimate goal being sandhi, attaining bliss or joining the universal consciousness. The tantric practices is a matter of debate and is difficult to practice. Mahavatar Babaji' kriya yoga mentally directs one's life energy to revolve upward and downward around six spinal centers (medullary, cervical, dorsal, lumbar, sacral, and cocccygeal complexes). It may look unscientific as neither anatomy nor physiology can identify – this life energy or chakras in a rationalistic and scientific view.

Yoga invariably gives an opportunity to the person to look into something, which is beyond imagination and connects to the bigger version of self. Looking into one's self or introspection can slowly generate lot of insights and liberate us from and show an answer to much ongoing stress.

Most of the patients try to practice it and find varying degrees of solace from it. At least it makes them more disciplined, in their habits, schedules, and offers a short lasting relaxation and recreation for individual.

[INLINE:2]

In many anxiety disorders, dysthymias, and stress-related disorders, psychiatrists cannot deny the importance of these symptom reducing strategies.

Probably Maharshi Mahesh Yogis “Transcendental meditation” is one of the most scientifically studied Yoga techniques in other countries which had shown at least significant improvement in stress-related and anxiety disorders. Some tall claims made in some of the studies conducted in intellectual disability, restricted their acceptance even by Indian psychiatrists.

I shall conclude by narrating two incidents related to respecting the culture and spirituality of the populations whom we treat. I thought, the psychiatry students should be properly taught on this issue during their training.

There was an episode of mass pseudoseizures (which was later diagnosed as Disassociation disorder under ICD 9) in a village primary school students – about 60 km from Tirupati and the Department of Psychiatry was asked to investigate and treat them. There were about 80 students in the school who one after the other would lose consciousness, fell on ground, and made multiple bizarre body movements for varying periods, once the class teacher entered the class. Locals were under the impression that the school building was haunted because of a death in the neighborhood and afraid that they attempted to exorcise the school building itself by collecting some funds.

The students were examined and many of them could be suggested to go into a trance and only one patient who first fell down in the class unconscious had generalized tonic-clonic seizure. He was investigated and was put on anticonvulsant medication. The remaining students were individually given strong suggestions and aversion therapies after inducing a seizure by suggestion in the school itself. About 10 resistant cases were shifted to hospital as in patients and were dealt with in detail. The Education Department and the Department of Psychiatry held a few parent teacher meetings in the school and the whole mechanism was explained with some documentaries on pseudoseizures; it took almost 3 months to bring back the situation to total normalcy.

After 3-months follow-up, only one student continued to get the pseudoseizures and was taken to Chennai by the family for further management. In this incident, unless the Psychiatrist understands the belief systems and religious flavor it would have been difficult to manage the problem. Confrontational attitude would have resulted in revolt among the parents and possibly they could have boycotted the visit by the team. Very careful handling was needed satisfying everybody's belief system. This was crucial for the success of the intervention (SVMC – Journal 2nd issue 1991).

In another incident, the district collector ordered the department to look into a case where local faith healer was beaten up for exorcism, as one of his client died with a mysterious illness. After assessment, the faith healer himself was found to be suffering from paranoid schizophrenia and because of his grandiosity, he claimed that he was responsible for the death. He was removed to the Psychiatry ward and was treated. But a group of faith healers and tantric practitioners were requested to participate in a crash course of sensitizing them in recognizing the common psychotic illnesses (in that Mandal of the district with about 80,000 population). This was done to prevent any future incidents of this sort.

The result was the number of patients attending the department from that catchment area was doubled in the following year compared to the previous year. This incident again showed that people were ready to cooperate if the psychiatrist understands their sensitivities.

Going with the tide for the benefit of the community should be the aim of any agency. The proper education and sensitization would go a long way in gaining the confidence of the populations rather than confronting them not to practice such things. The help of some of the missionaries and NGOs in promoting integration of religion into therapeutics may not be a bad idea unless it is done with no other ulterior motive. The collective spiritual strength if utilized properly can enhance the number of patients seeking the interventions and maintaining compliance to a high level.

Definitely the present-day society in many parts of the country had moved away from what had been quoted. Still, it may not be bad ideas to take these faith healers into confidence teach them to identify psychotic illnesses at an early stage and get these patients referred for treatment as early interventions always result in better outcomes.

In the same way, encouraging the patient to participate in all spiritual discourses and religious rituals as long as they do not hamper their involvement in the psychiatric interventions would probably result in better quality of life both for the family and the patient.

It is better to introduce these concepts into young trainees' mind that will help them cultivate a positive attitude toward the religion and spirituality of their patients. This would also help them to have an insight in the limitations of our ability to treat various mental health problems.

When Hippocrates said Medicine is more of an art than a science, it was definitely true in those days. But even today, it is definitely true to say that Psychiatry in its toddler stage is definitely an art, more than a science.

I should end quoting Sadguru of Isha foundation Sri Jaggi vasudev,

“Our lives become beautiful not because we are perfect.

Our lives become beautiful because we put our heart into what we are doing.”

So, let us put our hearts into our endeavor to help the suffering populations by understanding them in holistic manner.

Long live IPS,

JAI HIND.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Freud, Sigmund [1927] from Starcery, James (1961) ed: The Future of an Illusion. Norton-ISBN 978-0-393-00831-9.
2Richardson JT, editor. Regulating Religion: Case studies from Around the Globe. Springer Science and Business Media; 2012. Social science-578 pages.
3Weaver AJ, Samford JA, Larson DB, Lucas LA, Koenig HG, Patrick V. A Systematic review of research on religion in four major psychiatric journals: 1991-1995. J Nerv Ment Dis 1998;186:187-90.
4Pargament KL. The Psychology of Religion and Coping: Theory, Research and Practice. Guilford Press; 1997. doi: 10:2307/3512468.
5Lazarus RS, Folkman S. Stress, Appraisal and Coping. New York: Springer pub. co.
6Pargament KI, Hahn J. God and the just world-casual and coping attributions to God in health situations. Journal of scientific study of religion 1986;25:193-207.
7Pargament K. God Help Me: Advances in the Psychology of Religion and Coping. Archiv Für Religionspsychologie/Archive for the Psychology of Religion 2002;24:48-63. Available from: http://www.jstor.org/stable/23912399.
8Belavich TG, Pargament KL. The role of attachment in practising spiritual coping with a loved one in surgery. J Adult Develop 2002;9:13-29.
9Stolley JM, Katheim CB, Harold GK. Prayer and religion coping for caregivers of persons with Alzheimers disease and related disorders. Am J Alzheimres Dis Relat Disord 1999;14:181-91.
10Koeing HG, Cohen HJ, Blazer DG, Pieper C, Meador KG, Shelp F, et al. Religious coping and depression among elderly, hospitalised medically ill men. Am J Psychiatry 1992;149:1693-700.
11Swinton J. From inclusion to belonging-a practical theology of community disability and humanness. J Relig Disabil Health 2012;16:172-90.
12Verhese A. Spirituality and mental health. Indian J Psychiatry 2008;50:233-7.
13Avasthi A, Kate N, Grover S. Indianisation of Psychiatry, utilizing mental concepts. Indian J Psychiatry 2013;55:S136-44.
14Berry JW, Worthington EL Jr., Parrot L. Dispositional forgivrness: Development and construct validity of transgression narrative narrative test of forgiveness (TNTF). Pers Soc Psychol Bull 2001;27:1277-90.