Here’s a question that I received from Good Grief (it was posted in the chat but I didn’t get it until later by email), and part of my response:
Question: "How do you integrate any type of pastoral care of spiritually sensitive guidance into psychiatric practice?"
Short Answer:
If your context is a hospital or other team setting, I'd be reaching out to your chaplains/spiritual care providers to build bridges so that you're creating collaborative approaches to care. Don't do it solo! If you're in a private practice, what are the community resources you might engage?
Longer Answer:
At root, the key is cultivating curiosity and compassion for both the broad traditions and also the unique, personalized experiences of different people's spiritual meaning-making journeys. Not every Christian patient will be the same, much less every Jewish or Muslim or Hindu or Buddhist patient or non-religious patient. So you have to be willing to be curious, turn to wonder, and ask good questions.
This takes time. My experience in the hospital was that usually the psychiatrist had maybe 10 minutes for me, at most, one or two times a week. That's just not enough time to develop the kind of trust to ask some of the questions you need to ask - like I said in the presentation, Psalm 102 is a more powerfully truthful expression of my experience than the clinical language of the DSM, but it doesn't make for a good clinical checklist. So you have to to slow down - when the system you're in makes that impossible, you have to speak up about it - and you have to cultivate some humility about what you can and can't do and be honest about those limitations. This is where a team approach, where you have relationships with chaplains/spiritual care providers, is key.
(It is my experience that, in certain medical care settings, suggestions about humility are taken as nearly blasphemous. I once sat in a room of faith leaders and clinicians organized by the American Psychiatric Association. The conversation had turned to burnout, and the clinicians/medical admin leaders were talking about all the types of programming they'd try to reduce burnout. When I pointed out that adding programming to address burnout probably won't work, and that what's needed is to confess limitations and actually rest, the response was....open laughter. Not a sustainable approach, folks. At some point, you can't do-more your way into less-burned-out).
Even Longer Answer:
I sometimes tell people what I call "A Tale of Two Psychiatrists." (These stories are included in Christ on the Psych Ward, but you're getting them free! What a deal!)
The first is a psychiatrist I saw while still early on in my diagnosis journey. That psychiatrist asked me at one point whether my faith had been helpful in keeping me from acting on suicidal ideation. I said that yes, it had been. They then said something like, "Yes, I know for some patients being afriad that you're going to hell if you commit suicide helps keep them alive." But that's not what I believe, and it isn't at all what I was talking about when I said that my faith had helped keep me alive.
To give credit where credit is due, this psychiatrist was trying to do something good - they were trying to expand the scope of their understanding of resilience factors beyond just medication to include meaning-making and faith. I appreciate the move to broaden our understanding of mental wellness and not be so reductionist in our assumptions. But I wish that psychiatrist had asked some good questions; had let me articulate my own understanding of my faith as a resilience factor; had asked some questions about, say, the importance of community support (the support of my church and my pastor, for example, in helping reduce a sense of isolation and 'burden' that is a huge contributing factor to suicidality); rather than holding such an individualized, fear-based assumption about what faith looks like. All of that takes a lot more time, of course.
The second is the psychiatrist who diagnosed me with bipolar disorder (Type II) after several months of being bounced around between various diagnoses ranging from Major Depressive Disorder to Generalized Anxiety Disorder to Borderline Personality Disorder. This particular psychiatrist, after hearing me recount my symptoms and the journey I'd been on for what felt, to me, like the billionth time, took a look at my chart and said "You have bipolar disorder. Who the hell put you on Effexor? That'll just make you manic!" I was...furious. It was one of his colleagues at the same hospital who'd put me on Effexor, and nobody had ever mentioned bipolar to me. To me, manic meant something like "thinking I could stop a train with my bare hands," and that's not how I felt at all. I wasn't euphoric, I was miserable.
((PLEASE remember - the diagnostic language you are so familiar is impenetrable to most patients, even to pretty well educated ones. Another example: early on, psychiatrists kept describing things as "rule-outs," which I assumed meant "we've ruled this out," when it means the opposite - "things were still considering until we've ruled them out." You're fluent in it - to us, it's a foreign language. That's tough to keep in mind, but it's worth it to remember.))
Anyway - the psychiatrist noticed I was visibly upset, and he stopped himself, set his pad and pen down, and took a deep breath. "Ok, let's step back for a second," he said. He explained to me what mania could mean in Type II bipolar, which was helpful. But he also said something like, "Let me talk about how these diagnostic labels work. Diagnoses are just stories. You're telling me a story of what's been going on with you. And I have some lists of symptoms with particular labels, and I'm trying to match them up to the story you're telling me, in a way that leads to good treatment that lets you live the life you want to live. That's it. Those story labels are helpful if they help you. If they're not, forget about them. They're only important if they get us to a place where you're feeling better."
I can't tell you how immensely helpful that little talk was. It helped me understand the diagnosis and also not get so wrapped around the axle of the diagnostic label. And here's what's interesting about that - it wasn't, explicitly, a conversation about my faith. But it did open the doorway to an understanding of my diagnoses as a narrative, as a story, which also opens the door for me to be an active participant in that story, as a whole person - including a person of faith.
But it also takes way more time - and I was in the privileged position, in the second scenario, of being in a longer term rehab program, which is way more expensive and often out of reach for many people suffering from mental health challenges. So there are systemic issues to be addressed, here, in terms of who has access to what kind of care, which care providers are able to slow down and treat people as whole persons instead of just symptom lists.
Reductionism is easy and quick. Holistic approaches that ask good questions, slow down enough to really listen, and confess limitations with humility, are harder, and take more time.
How do we design a system that allows for more time, more care, more listening? Big question. Smaller question to start with: How do we engage a team approach so that we're not trying to do it solo in the context of the brokenness of our current system?
I hope that helps. Thank you for asking the question - that's a wonderful place to start.
