religion & spirituality in geriatric psychiatry · –no psychosis or mania history • family...
TRANSCRIPT
Religion & Spirituality
in Geriatric Psychiatry
Adam Younoszai, D. O.
Medical Director
of Behavioral Health Services
Washington Adventist Hospital
• Words to pay attention to:
– Divides
– Trajectories
– “Provider”
– My “Rules” (relating to Narrative Medicine)
– Principles (relating to Narrative Medicine)
– RRICC (relating to psychotherapy)
Key Words
• Divides
– Religion and Spirituality and Medicine
• Some incorporate (e.g., 12 step)
• Some do not incorporate (inpatient setting)
– Patient and Provider
• From provider to patient
• From patient to provider
Key Areas of Focus: Divides and Trajectories
• Trajectory: Religion/Spiritual
– Positive:
• Support from God
• Support from Church
• Spiritual forgiveness
• Rituals
Key Areas of Focus: Divides and Trajectories
• Trajectory: Religious/Spiritual
– Negative:
• Questions faith
• Increased stress from questioning fait
• Trajectory: Non-religious/non-spiritual
– Positive
• No need to question faith and God
• Accustomed to coping without religion and
spirituality
Key Areas of Focus: Divides and Trajectories
• Trajectory: Non-religious/non-Spiritual
– Negative:
• Missed opportunity for 1-4 positive
religious and spiritual aspects above
• Ongoing /prolonged stress
• Decreased immune system functioning
• Decreased health-cycle
Key Areas of Focus: Divides and Trajectories
Addressing the Divides & Trajectories: Current
Movements
• Narrative Medicine
– Treatment through narration
– Connection to religion and spirituality
– Five principles and rules learned
1. Temporality: Take time to listen, care and
to recognize. Rule: Be present.
2. Singularity: Originality, “irreproducibility.”
Rule: Get to know the patient, not just the
disease
Addressing the Divides & Trajectories: Current
Movements
• Narrative Medicine
3. Causality/Contingency/Plot. Rule:
Understand context
4. Inter-subjectivity. Rule: Commune with
patient and be authentically present
5. Ethicality. Rule: Listen without judging,
except if harm is possible
Addressing the Divides & Trajectories: Current
Movements
• Religiously Integrated Psychotherapy
– First accepted: William James and G. Stanley Hall
– Then rejected for “pure science”: Freud-
Obsessional Neurosis, Skinner-negative
childhood experiences
– Now more integrated: Pargament and others,
2002 APA code of Ethics: Diversity, “Positive
Psychology” more embracing of religion and
spirituality.
Addressing the Divides & Trajectories: Current
Movements
• Divide In Need of a Bridge
– Most people are religious or spiritual
– Utilizing religion and spirituality can augment
psychotherapy to improve outcomes.
– RRICC Model
1. Respect
2. Responsibility
3. Integrity
4. Competence
5. Concern
Case Study
• History of Present Illness (HPI)
– 86-year-old Middle Eastern male with a history of
Major depressive disorder (MDD)
– Recently diagnosed with Gleason score 8
prostate cancer
– Consult placed to evaluate for depression and
possible treatment recommendations
– Patient admitted 5/9 for meeting criteria for major
depressive episode (MDE).
Case Study (continued)
• History of Present Illness (HPI) (continued)
– Denied use of drugs or alcohol
– No psychosis or mania history
– Some current anxiety symptoms
– Patient stated he felt alone when given diagnosis
• Past Medical History (PMH)
– GERD, Seasonal allergies/ asthma
• Past Psychiatric History (PPH)
– MDD (x2 prior episodes)
Case Study (continued)
• Family Psychiatric History (FPH)
– MDD, anxiety
– No psychosis or mania history
• Family Medical History (FMH)
– Sister with breast cancer, mother with diabetes,
father with colon cancer
• No Known Drug Allergies
• Social History (SH)
– Born and raised in Egypt to wealthy
parents/family
Case Study (continued)
• Social History (SH)
– Immigrated to the US at 18 for college
– Currently married with two adult (male) children
– Recently retired as anatomist at medical school
– Regularly exercises, hikes, and until recently ran
marathons
Case Study (continued)
• Mental Status Exam
– Young looking 86-year-old,
– Cooperative, pleasant, and engaged
– No psychomotor abnormalities
– Speech regular, mood “depressed”
– Affect: Mood congruent.
– Linear, logical, goal directed thought process
– Thought content free from si, hi, ah, or vh. Insight
appeared intact, as did judgment.
Case Study (continued)
• Diagnosis
– Currently depressed with MDD recurrence,
moderate
• My recommendations:
1. Check TSH
2. Start SSRI
3. Discuss sleep, and pain if any
4. Follow up with outpatient psychiatrist for meds
management
Patient’s Treatment Plan
• Patient’s plan
– Temporarily questioned his faith (negative
mentioned in start of talk)
– Began to pray
– Rented comedies
– Explored Sufism (mediation)
Patient Treatment Plan (continued)
– Poetry (Rumi)
• “Silence is the language of God. All else is
poor translation.”
• “Ignore those [things] that make you fearful
and sad, that degrade you back towards
disease and death.”
– Got surgery
– Engaged in “meaning making”
– Used the experience as an opportunity to educate
others and make a meaningful experience
Integrating Narrative Medicine in Treatment
• Narrative Medicine
– Rule from “Temporality”– I was present and took
time to listen
– Rule from “Singularity” – I got to know the patient,
not just the disease
• Active 86-year-old and good surgical
candidate
• Gleason 8 not the same in this patient
Integrating Narrative Medicine in Treatment
– Rule from “Causality/Contingency/Plot” –
Understand context
• Treated his own MDE in the past
• Trusted his desire to treat himself again, now
with prayer, poetry, and Sufisim.
– Rule from “Inter-subjectivity” – Be authentically
present
• Honest about rec. for SSRI still
• Patient knew where I stood with respect to my
proposed plan
Integrating Narrative Medicine In Treatment
– Rule from Ethicality: Do not judge
• Nothing ethically “wrong” with his preferences
for treatment
• I respected this decision
• Somewhat similar to authenticity?
RRICC Model
• Respect
– Again, repeated who he was and his decision
• Prayer, poetry, laughter
• Responsibility
– My responsibility not to ignore his desire to take
religious/ spiritual trajectory
– My responsibility to try to incorporate his interest
in Sufism into care I gave him
– In retrospect, could have consulted Imam
RRICC Model
• Integrity
– I was honest about my limitations to embrace
Islam as a faith nor to purport to be an expert
• Competence
– I read Rumi poetry and learned the basics about
Sufism
– Patient saw that I tried, this impacted him
RRICC Model
• Concern
– I was somewhat vigilant (especially toward the
beginning) of his use of Islam
– I didn’t know Islam’s stance on suicide
Conclusion
• Key takeaways
– I believe
– I wonder
– I know