Bartelby

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I have noticed several psychotic patients bringing this question up directly and unprompted to either my resident or me. One asked my resident when he walked through the door, another who is manic asked me after we had established rapport. In both cases the 'right' answer was pretty obvious: yes.

Problem is, I'm not. I'm more of an atheist/agnostic. So far I have just answered "yes" because the question caught me off guard and I didn't want to derail the entire interview, but this doesn't seem like a great solution. Given that this appears to be a pretty common question coming from psychotic or otherwise seriously mentally ill patients, how do you guys handle the question? I am especially interested in answers from those who are good at answering this when your beliefs are at odds with the patient's.

Also, if your answer is "don't answer" please elaborate on how to do that without offending the patient. If they are pushy about it, not answering seems to be tantamount to saying "no."
 

OldPsychDoc

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I don't find this to be as common among the overtly psychotic, as you mention, as among the more depressed/anxious/neurotic patients--but perhaps that's more due to our relative patient populations?

In any case, I try to treat the question as being asked in good faith (no pun intended). Keep in mind that a) the majority of the US is still at least nominally identifying with that faith, and b) many have been led to believe (with some justification) that as a profession we not only don't share that belief and might even be hostile to it. Therefore, I treat the question generally as an effort on the patient's part to determine whether I will understand what they are trying to communicate, and whether or not I'm likely to reject it out of hand.

So while there's no "right" way to answer this, I think the best way is to attempt to address these concerns respectfully but somewhat directly. For example: "I don't normally discuss my own beliefs in this setting, but I know that faith is very important to many of my patients. It sounds like you have a concern in that area--would you like to talk about it?" and take it from there.

Some general tips:
1) focus on the patient's beliefs, not yours.
2) encourage the patient's own healthy engagement in religious and spiritual community.
3) defer specific faith issues to the patient's spiritual advisor. (Now rarely, in certain contexts that person may be delivering a message that it's wrong for the patient to take meds, etc., so that can get sticky--but I try to make a practice of avoiding argument and confrontation with patients, so I make my recommendations, try to reinforce them, and let the patient decide, excepting of course where danger to self or others or a court order is involved.)
4) don't get enmeshed in patients' delusions. That requires that we have some competent knowledge of beliefs and practices of our own and other religions, some sense of when a belief is aberrant, etc. Pay attention to what's going on in the various subcultures locally and nationally.

Now personally, I practice in white bread middle America, so most of my patients are more conventional in their beliefs and practices. Frankly, that's my background as well--but even if I do share those values, I don't want to make that the center of the physician-patient relationship. A visit to my office is not a prayer meeting or Bible study, and I know that my Muslim and Hindu colleagues down the hall will be just as respectful of the patient's person as I am.
 

DrGachet

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Oldpsychdoc: What a wonderfully enlightening! Really shows the kind of respectful, understanding, and compassionate person you really are. I love it!
 

Seputro

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We actually had a discussion about this during one of our didactics and the situation presented was similar in that a patient would call the front office of your practice and ask the receptionist "is the psychiatrist a Christian?"

I said that I would train all the office members to answer the question with, "Dr. so-and-so will act as your psychiatrist. Our practice has the policy of not revealing the faith/religion of any of our psychiatrists."

Even though I am speaking from a resident's point of view, I think this could potentially avoid problems down the road.
 

masterofmonkeys

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I got this a lot more in the bible belt than I do where I am training now, but I still get it from time to time.

I am pretty obviously foreign with a foreign name so most assume the answer is 'no'. And it is. Usually I don't actually ever need to answer this question, but there are times when you do. As long as I am able to make clear that I respect their beliefs and have no intention of diminishing their faith or the role of faith in their life, it's not a big deal. I think I may get some help from Dharmic religion in respecting the faith of a person regardless of where it's at or what they believe (as long as it involves, you know, not being a d-bag) given our view on growth and progression of religious belief and practice.

I take a pretty similar approach as OPD does. I focus on the patient's faith and how mental illness and treatment are seen through that lens. I make it clear that faith is or can be a part of a larger psychological support structure and thus a strength, and that it is part and parcel of achieving better mental health.

In the case of some of my therapy patients, there have been times where we've had to explore thorny theological issues together, and I'm not afraid to do that. Having a good working knowledge of most world religions helps in that area.

In the strongly religious and insightful, scripture and theological issues will always play a big role in how they express themselves, their lives, and the problems they face. So I feel like we can't be afraid to explore those issues together.

Hilariously enough given my own Dharmic background, I find it a lot easier to approach these religious discussions with Christians and Jews than I do with the so-called 'Buddhists' of which we have plenty of here in this hippy/hipster town.
 
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sunlioness

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Everytime I see the subject of this thread, "Walking in Memphis" starts going through my head. :laugh:

I haven't run into this very often. I think people by and large assume that I am Christian (I am not) because of my appearance and an ethnic last name that usually suggests Catholicism. The few times it has come up, I've addressed it as others have described
 

masterofmonkeys

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OldPsychDoc

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Everytime I see the subject of this thread, "Walking in Memphis" starts going through my head. :laugh:
Argh--thanks a lot for THAT earworm... :rolleyes:
 

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I agree with OPD in the sense that more often this kind of questions come from neurotic patients rather than the psychotic ones. Nevertheless, you bring up a very important issue, i.e. self-disclosure. Patients may ask you all sort of (very) personal things (about your politics, your marital status, your ethnicity, your sexual orientation, your hobbies or sports affiliation, your past experience with drugs or alcohol, etc.). While there is no right or wrong regarding answering (or not) these questions, you should keep in mind not only your personal degree of comfort with that kind of self-disclosure, but more importantly, where does the pt come from when asking that particular question. People may ask you about your religion, let's say, for a number of reasons: they would like to know that you and him have a common background, on the contrary that he senses some sort of religious influences in what you say or do, as a means of filling in gaps in an awkward conversation, and the list could go on and on...and many times, they ask the question and they couldn't frankly care less about your answer one way or another... The question in the back of the psychiatrist's or therapist's mind is: to what extent is your disclosing personal information beneficial to the process? Sometimes it is, it can create a bridge...but very often, it can create a divide or what some would call an empathic rupture. This is why a neutral stance and finding more about the reasons he is asking the question before giving (or not giving) an answer are so important.


"Also, if your answer is "don't answer" please elaborate on how to do that without offending the patient. If they are pushy about it, not answering seems to be tantamount to saying "no."
It is not very wise to say "I don't want to answer" or something along that line, but don't feel "pushed" into answering if you think that's not a good idea. "It sounds that it's important for you to know what my religious background is and it makes me wonder why that is..." Listen to what he has to say and, based on that, you decide what to do next...There is no pre-set formula of how to answer a specific question. On a similar token, if you want to pursue Psychiatry, a good book to read in terms of diagnostic interviewing skills is Christopher Shea's book
 

kugel

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In the psych ER, I generally avoid answering anything personal with a simple, "I don't mean to be rude, but we're here to discuss what's happening in your life."

Even with the most insistent, I stick to that. Since they can see my ring, I will answer that I'm married, but that's pretty much it. With those who insist that it's important to know because of how important their own faith is to the issues at hand, I respond that I certainly think their own faith is important and that I think a lot of problems in this world would be improved if people would follow the values of their expressed faith. And that I want to be sure we involve the patient's faith as part of the solutions we explore - but to do that, I have to understand what's been happening and how they view that through their own faith.

I often throw in something about how many people today say that their faith is important to them, but then act very differently. (This sort of puts us both on the side of the "more righteous" than those "other people.")

But honestly, this is not a very common problem. It's much more common for me to ask patients if they involved in any sort of a worship group (church, temple, synagogue, etc). When they say they aren't I recommend that they become more involved. Despite my own atheism, most of my pts probably would do better if involved in a compassionate and supportive worship group. "I'm not a particularly religious person, so I'm certainly not trying to convince you of any one belief, but most of the studies I've read show that people who are connected to a worship group do better than those that aren't. Also, many of the church organizations offer low or no cost counseling - which could be of real help to you. Medications will only do so much, and counseling or therapy is going to be a big part of helping you get your life back on track. The support and comfort of a church, plus the opportunity for low-cost counseling might be very helpful in the situation you're describing. So how would you go about finding a worship group for yourself? You could go to one you've been to before, or go to ones near where you live and see if you like them, or you could ask family and friends, right? So which one would you do? Return to a previous one, or try out some near you, or ask friends if you can attend theirs to see if it fits you?"

I use the old sales technique:
1) create the market. show how the product would benefit the customer
2) suggest ways they could purchase it
3) don't ask if they want it. assume they do. ask which method they would like to use to purchase it (only ask questions for which I'm willing to accept all the possible answers) so that when they answer, they have already created a plan to pursue it

The same technique I use to try and get patients to "buy into" whatever treatment plan I'm proposing; whether that's admission, meds, not being admitted, getting off BZD's, whatever.
 
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"Ma'am, I am tonight." - Marc Cohn Walking in Memphis :cool:
 

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"Ma'am, I am tonight." - Marc Cohn Walking in Memphis :cool:
STOP IT ALREADY! All of you!
[frantically searching through my playlists to find SOMETHING to drive this song away....]
 
OP
Bartelby

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There might be, but anyone who would say such a thing hasn't seen real psychosis.
Thanks everyone for the suggestions! Lots of valuable feedback here which I plan to incorporate into my future practice. I expect that I may have to take a few tries at it before I can use these answers without sounding awkward, but they are pretty well in line with what I imagined would be a response that builds the therapeutic bond while maintaining boundaries.

I think the quote from sunlioness above captures my remaining concern, though. What do you say to a psychotic patient for whom knowing your religious status is critical (believes non-Christian doctors are controlled by Satan) who will not give the question up unless you strongly and openly refuse to answer it? I know it sounds like a hypothetical that will never happen, but this exact scenario did happen to me and is what got me thinking about this question. I think OPD is right about patient populations, I am in rural Bible belt country which might explain the unusual encounter's frequency, but still how would you all answer the psychotic patient who does not have much capacity for a thoughtful discussion like the ones mentioned above?
 

DrGachet

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:thumbup:



There might be, but anyone who would say such a thing hasn't seen real psychosis.
I have seen "real"--you mean "severe"?--psychosis and it's not easy to tell it apart from religious worldview. If you're dealing with a bright spiritual person presenting with hypomania, who is having a potential psychotic episode that is logically consistent and religiously plausible ("I need to heal people. God told me that I have to hug everyone and love them, to spread love and stop the hate."), it would be difficult to determine if he is truly receiving messages from a deity or is hallucinating.

I have taken a couple of religious studies courses in undergrads, and communication with God, miracles and magic, being special and chosen, are a part of many religions.

It would be much easier if you do not believe in duality, are a strict materialistic, empiricist, and an atheist. But if you're spiritual yourself, are "open-minded", and a philosopher at heart, you'll have to dig real deep to make a decision. Is that a prophet sitting on the bed, or a psychotic person, a healer or a patient?

If I may digress further, I think we're all deluded in our own way. Our lives rarely grounded in naked reality. We're not always mindful of death, possibility of injury/disease, etc. We are carried away by little things all the time. And then we have defensive mechanisms on top of that. Even when it comes to getting down to reality, we can not all decide on what reality is (objective/subjective, dualism, etc).

One of the easier distinctions is what is "functional" and what is not. That's where psychiatry resides, and for good reason. I can be quite confident in telling someone that he might get what he needs in a manner, one that I can explain to him, that is more efficient. Or specifically, that having unprotected sex is a risk factor for all kinds of STDs. I can not, however, tell someone that living this way is better than that way, or living, generally speaking, is better than dying. That's philosophy and spirituality.
 
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kugel

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What do you say to a psychotic patient for whom knowing your religious status is critical (believes non-Christian doctors are controlled by Satan) who will not give the question up unless you strongly and openly refuse to answer it?
"I don't know how to convince you that I'm not controlled by Satan. If I am controlled by Satan, I would certainly tell you that I'm Christian. Why don't we talk to each other and you will eventually decide what you think about me after that? And you can always call your minister to come down to talk with me and get his/her opinion about me."
 

Ibid

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http://www.rcpsych.ac.uk/pdf/Nicki%20Crowley%20%20Psychosis%20or%20Spiritual%20Emergence.pdf

The concept of a spiritual emergency is not new.

Its not surprising that a patient might enquire about the value base of their doctor to get a sense of them. Given the ever changing kaleidoscope of frustrated marital arts experts, beauty school drop outs, paramilitary vegetarians and jesus freaks that usually make up multidisciplinary teams it seems a perfectly sensible question.
 
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DrGachet

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the same thing you say to a psychotic patient for whom knowing your home address / phone number / children's names is critical: you strongly and openly refuse to answer it!
everyone draws the line for self-disclosure in different places with different patients, but you really want to err on the side of not disclosing unless you have compelling reasons otherwise. is telling this patient you are christian going to cure his psychosis? (no)
I think most people here would agree that providing your religious background is not going to cure someone's psychosis. We all need to have boundaries.

However, as you may very well know, people with psychosis are in a state of terror, fearing personal harm even at the hand of the qualified physician. I think one of the most important thing needed is to establish a sense of trust and to provide a sense of safety and predictability.

If one looks at patient's question in that context, we'll have more compassion for the person and won't reply to their question in a rejecting or needlessly harsh/abrupt manner.
 

KHE

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STOP IT ALREADY! All of you!
[frantically searching through my playlists to find SOMETHING to drive this song away....]
Let me help you....

Blame it all on my roots....I showed up in boots.....and ruined your bla....
 
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While it's appropriate to set boundaries and respectfully decline to answer the question as to whether or not one is a Christian, it is also appropriate for a patient to seek a Psychiatrist with shared spiritual values.

It is never appropriate for a Doctor to lie.