Given that two of the great world religions, Judaism and Islam, had major holy days occur this week, it seems fitting to address the topic of our patients’ existential and spiritual needs and how we can address them in our psychiatric practices.
I think it’s safe to say that most of us did not receive much, if any, training in these topics during residency. I would go further and say that most of us were taught that such issues are not in our purview when providing psychiatric care to our patients. So, I believe, not only were we not trained properly, but we were also misguided.
I don’t agree with the approach of ignoring such concerns. I would even say that at least for some of our patients, NOTHING is more important than finding a way to resolve these very concerns. Helping the patient address and resolve such concerns may be the difference between life and death – in rare cases – and, more commonly, the difference between a life well-lived and one that is unnecessarily pained and pinched.
I think that psychiatrists have an important role to play in addressing existential and even spiritual concerns. Let me first say what I do not have in mind: I am not advocating that you play the role of a religious authority figure to your patient. There are some psychiatrists who explicitly choose to present themselves as professionals who will play a religious role in their patients’ lives. For example, one could be a “Christian Psychiatrist” and, if you’re one, I would love to hear from you about your approach and experience. But this is explicitly not what I am recommending for the rest of us. Rather, I believe our role should be to help bring to the patient’s awareness their existential and spiritual concerns, to help the patient articulate them, to address the concerns that can be appropriately addressed in psychiatric care, and to refer other more explicitly religious concerns to be addressed by the patient’s religious authority figure. In this article I’ll discuss existential concerns and leave discussion of more explicitly spiritual and religious concerns for next week.
There are four existential challenges that all of us as humans face that can impact mental health:
- Facing the knowledge of our own death.
- Facing isolation, both of an interpersonal type that occurs when we are disconnected from others, and an existential type in which we realize an unbridgeable gulf exists between ourselves and others.
- Facing freedom and the responsibility to choose and to accept the choices that we make.
- Facing the sense of meaninglessness that can lurk behind our daily activities and concerns.
These four existential challenges have been articulated by Dr. Irvin Yalom, one of my most important influences. In addition to being a talented author of several fiction and non-fiction books, Dr. Yalom is the author of the textbook, Existential Psychotherapy, from which I drew these four existential challenges. Let me focus in particular on two of these challenges today, isolation and meaninglessness. They are of interest to me currently, as I am preparing my lecture on suicide assessment and management (one of my favorite topics) for the MasterPsych Conference. Weird but true!
Two recent theories, that attempt to explain suicidal behavior both highlight the role of isolation – or lack of connectedness – and meaninglessness as important suicide risk factors. One theory, The Interpersonal Theory of Suicidal Behavior, focuses on “thwarted belongingness,” a sense of being a burden on others, and hopelessness as suicide risk factors. The second theory, The Ideation-to-Action Framework 3-Step Theory (3ST) hypothesizes that: 1) pain and hopelessness can lead to suicidal ideation, 2) a lack of connectedness can predispose to escalation of cognitions to suicidal behaviors, and 3) having the capacity to act is then a necessary condition for suicide attempts to occur.
Is there any reason that we cannot assess for and help the patient overcome a sense of isolation and meaninglessness? I don’t think there is any reason.
So, for example, encourage the veteran with PTSD to become a peer counselor, thus increasing his or her sense of belonging and meaning and purpose. Get the patient with an addiction who is stable in sobriety to become a sponsor for other recovering addicts – it’s part of the 12th step. Get the patient with schizophrenia or another major mental disorder to be hired by their rehabilitation program, whether as a lunch room attendant or peer counselor or driver.
See, not complex or earth-shattering, and just as important as, and for some patients, even more important than the meds we prescribe.
Dr. Viktor Frankl, psychiatrist and author as well as Holocaust survivor, has a simple yet profound equation: Despair equals suffering minus meaning. So, the greater the sense of meaning one has in one’s life, the less despair one experiences and the more suffering one can bear.
So providing patients with an outlet to get more connected, develop a greater sense of belonging, and a greater focus on helping others, will help get them ‘out of their minds’ and into the lives of others. I end with a quote:
“After a few years running this site, and having read so many of your emails and feedback, all I can tell you is that the uniting factor of people that visit this site is a lack of love and connection in their lives.”– Unnamed founder of LostAllHope.com
Until next time,
“If I am not for myself, who will be for me? If I am not for others, what am I? And if not now, when?”
– Rabbi Hillel