Associate Professor of Psychiatry, Duke University Medical Center; Esther Colliflower Associate Professor of the Practice of Pastoral and Moral Theology, Duke Divinity School; Co-Director, Theology, Medicine, and Culture Initiative, Duke Divinity School, Durham, NC.
Dr. Kinghorn has no financial relationships with companies related to this material.
CGPR: What is spirituality, and how does it differ from religion?
Dr. Kinghorn: In the research literature, spirituality is described as individual and existential, related to an individual’s search for meaning and purpose. Religion is defined in terms of institutions, rituals, rules, structures, and history. It’s how the spiritual quest takes form over time through the formation of specific religious movements, like Buddhism or Judaism or Christianity, and through specific religious practices and communities. Some people consider themselves spiritual but not religious, while for others, religion is nearly inextricable from culture and from heritage, so religion often is associated with other forms of identity.
CGPR: What’s the relationship between spirituality, religion, and mental health?
Dr. Kinghorn: The behavioral aspects of religious practice are usually associated with positive physical and mental health outcomes. Religious service attendance is associated with a lower risk of all-cause mortality and a lower risk of health behaviors like alcohol misuse and smoking among US adults (Chen Y et al, JAMA Psychiatry 2020;7(7):737–744). Religious service attendance is inversely associated with several psychological distress outcomes like depression, anxiety, hopelessness, and loneliness, and it is positively associated with a number of psychosocial well-being outcomes like positive affect, life satisfaction, social integration, and purpose in life.
CGPR: What is the impact of religion on older adults?
Dr. Kinghorn: Adults ages 65 and older in the US are the most likely of any age group to say that religion is important in life, to attend religious services, to pray frequently, and to meditate. Older adults engage with spirituality and religion at higher rates as a way of coping with illness. They have often made some degree of peace with aging and mortality, and some do this by leaning on their spiritual and religious commitments and communities.
CGPR: How do you incorporate spirituality into your clinical practice?
Dr. Kinghorn: I ask about how a patient’s spiritual or religious perspective connects with other dimensions of who they are. I want to understand how their faith or spirituality connect to their cultural or racial background, family of origin, and socioeconomic situation. In my role as a middle-aged White male psychiatrist, I try to attend to dynamics of power. These topics can be intimate and feel vulnerable. I’m cautious about making sure that I’m not leading and not forcing patients to tell me things that they are uncomfortable talking about. I also build collegial relationships with health care chaplains around me. Chaplains are often skilled at navigating religious, spiritual, and existential questions in a religiously diverse patient population.
CGPR: How do you take a spiritual history?
Dr. Kinghorn: I typically start by asking an open-ended question: “Do you consider yourself a religious or spiritual person?” I recommend that clinicians download a religious-spiritual assessment tool. The one that’s best known is called “FICA: A Spiritual History Tool.” (Editor’s note: FICA is available online at www.tinyurl.com/2s4evefe.) This tool doesn’t presume that somebody is formed in a religious tradition, and it allows people to talk not only about what’s important to them, but also about how they would like spirituality to affect their relationship with the clinician.
CGPR: Can you walk us through spirituality assessments, such as the FICA?
Dr. Kinghorn: FICA is an acronym where “F” stands for Faith, belief, or meaning. I start by asking: “Do you consider yourself spiritual? Do you have spiritual beliefs that help you cope with stress at different times? What gives you meaning?” Next, I move onto “I,” which stands for Importance: “What importance does your spirituality have in your life?” “C” refers to Community. I would ask: “Are you part of a spiritual community?” Finally, “A” stands for Address and care. At this stage, I might ask: “How would you like me, your health care provider, to address these issues in your health care?” Another approach to spirituality assessment is the HOPE approach (Anandarajah G and Hight E, Am Fam Physician 2001;63(1):81–89). This is also an acronym. Here, “H” stands for sources of Hope, meaning, comfort, strength, peace, love, and connection; “O” stands for questions about Organized religion; “P” stands for Personal spirituality practices; and “E” stands for Effects on medical care or end-of-life issues.
CGPR: Are there times when a spiritual assessment is not appropriate?
Dr. Kinghorn: I wouldn’t necessarily ask all of the questions above when patients present in states of acute psychosis where religion is involved in a broader pattern of psychotic ideation. If I know that a patient has a history of religious trauma—for example, someone who is a survivor of sexual abuse by clergy—then I address these questions carefully. I would still ask: “Given what you’ve chosen to share about your history, what role does spirituality or religion have in your life?” It’s a open-ended question that signals to patients that they don’t have to talk about this, but if they want to, it’s not out of bounds. If they want to bring up the topic, I’m somebody who can hear what they have to say.
CGPR: Disclosure can be tricky in psychiatry. Are there cases when you bring up your own beliefs to join with the patient?
Dr. Kinghorn: My default is not to disclose early on in a relationship because I don’t want my disclosure to affect how the patient approaches their own spirituality or religion. There are times when I talk in depth about how important spirituality or religion is to a patient. If they say that they read the Bible, I might ask: “What texts are important to you?” People will often cite a common text, like the psalm “The Lord Is My Shepherd.” In some cases, I’ll ask: “I wonder what about that psalm is meaningful to you?” I might even pull a Bible off my shelf and ask: “I wonder if you could look at this and tell me if there are specific words that are meaningful to you?”
CGPR: How do you respond if a patient comes right out and asks you if you believe in God, or wonders what your religion is—especially if it’s before you know them well?
Dr. Kinghorn: It depends on the patient. If I believe that a patient is trying to test me or that a disclosure would harm the working alliance, I’ll say: “Thank you for asking. I really want to hear what you believe, though, and why it’s important to you.” But most of the time, patients ask this sort of thing when they are describing their own spiritual experiences or religious commitments and they are afraid of being judged or pathologized. Sometimes I’ll say: “I do believe in God,” but mostly I try just to be curious and to ask open and nonjudgmental questions about their experience. That goes a long way. To be clear, I don’t believe that any clinician is ever obligated to talk about their own religious commitments or identity.
CGPR: Can you describe an example when praying with a patient was appropriate?
Dr. Kinghorn: One of my patients was facing multiple cancer diagnoses. As he had recently made the decision to forgo further invasive treatments, I realized I was likely speaking with him for the last time. The patient and his wife spoke meaningfully about his peace with death and about how his faith was important to him. I knew that he was in a place of spiritual peace, so I asked: “I want you to feel free to say no to this, but I wonder if you’d be willing for me to pray for you?” The patient and his wife both immediately said: “Yes, we’d love that.” And I did. I named before God that I was not going to be working with this patient much more, but that this was a chance to know that he and his wife would be held in God’s hands as they went through the next weeks. I had a nice conversation with the patient’s wife after his death, and she mentioned how much they had appreciated that conversation.
CGPR: How do you assess whether it’s appropriate to pray with a patient?
Dr. Kinghorn: Praying alongside a patient, especially when it’s in a one-on-one setting, is a deeply intimate experience. You’re coming before God in a way that feels vulnerable. There are times when a clinician can pray with a patient responsibly and with integrity. However, it has to be a situation in which the vulnerability of prayer is the right thing for the patient. For the most part, I don’t pray with patients. If a patient asks me to pray and I don’t feel like it’s in their best interest, I’ll say: “I’d love to sit here and be with you if you’d like to pray.”
CGPR: Some patients have been harmed by religious practices. What is your approach when religion has affected patients negatively?
Dr. Kinghorn: In most cases religion and spirituality are helpful, but it’s important to affirm that religion can harm and has harmed deeply. We see this when religion is invoked as a way of justifying vaccine refusal or justifying political polarization around public health mandates. I typically don’t question a patient’s religious commitments or say: “I think you’re wrong about this article of faith.” Instead, I carefully ask how their stance on a certain issue, like refusing vaccines, relates to their broader life commitments or to the values of their religious community. Religion can reinforce unhealthy forms of patriarchy, and it can send messages to minorities that they are not accepted in a community. Additionally, religious communities are sites of trauma. Many people have sustained sexual abuse inflicted by religious leaders, which is a profound betrayal of spiritual trust. If an older adult has an ambivalent feeling about religion, this may be rooted in unresolved trauma sustained in a religious context. When there are issues of religious harm or religious conflict, I try to understand how trust has been broken and how that affects someone’s trust in the therapeutic relationship. I explore what it means to earn and regain trust so that we can have difficult conversations about moving forward.
CGPR: Can you provide an example of religious conflict in a medical setting?
Dr. Kinghorn: A family may not want a loved one to be taken off a ventilator because of their belief that it’s important to give God a chance to work a miracle. This is seen as a religious conflict, but it’s often tied to much broader issues. For instance, people from marginalized racial communities have learned not to trust medical systems. Chaplains and faith community leaders can help discern whether this is an accepted idea of the community or not.
CGPR: How do you use spirituality or religion to inform your suicide risk assessment?
Dr. Kinghorn: In the suicide prevention literature, protective factors include religious practice and identification with religious traditions that have proscriptions against suicide. I always ask patients about their spiritual or religious practice and how they use religion or spirituality to cope with chronic stress. I’ll take note of religious trauma because that may be associated with a positive suicide risk. From Catholic patients, I often hear: “I am dissuaded from suicide because of my faith,” or: “If I were to die by suicide, I would go to hell.” Modern Catholic teaching doesn’t equate death by suicide with damnation or with separation from God; it’s much more nuanced. But in the moment, I don’t challenge a patient’s belief because it may be what keeps them engaged in treatment and not acting on their suicidal thoughts.
CGPR: Thank you for your time, Dr. Kinghorn.
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