Advanced Search

REGULAR | January 01, 2007

A Pragmatic Approach to Teaching Psychiatry Residents the Assessment and Treatment of Religious Patients

David M. Blass

Academic Psychiatry 2007;31:25-31.

View Article Information

Received October 28, 2005; revised March 10, 2006; accepted June 6, 2006. Dr. Blass is affiliated with Abarbanel Mental Health Center, Bat Yam, Israel, an affiliate of the Sackler Medical School, Tel Aviv University, as well as with the Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland. Address correspondence to Dr. Blass, Abarbanel Mental Health Center, 15 Keren Kayemet Street, Bat Yam, Israel, 59436; dmblass@jhmi.edu (e-mail).

Article

References

text A A A

Abstract

Objective: The authors descripe a pragmatic and atheoretical frameword for teaching psychiatry residents how to assess and treat religious patients. Results: The psychiatrist's goals in assessing the religious history are clarified. These goals differ between the assessment and treatment phases. During assessment, attention is paid to psychiatric phenomenology and careful history-taking, utilizing knowledgeable outside informants. A framework is presented for engaging religious patients, fostering therapeutic alliance, avoiding pitfalls, and facilitating treatment within the patient's religious context. Conclusions: Emphasizing knowledge of phenomenology and information gathering skills may be more effective than emphasizing broad knowledge of many religions, except for clinicians practicing within a particular religious community.

Figures in this Article

Significance of Religion for Psychiatrists

The relationship between religion and psychiatry has changed as the field of psychiatry has matured. Initially an object of respectful study by psychologists such as William James (¹), religion came to be viewed by Freud as prima facie evidence of psychopathology (²), a view that also emerged from nonanalytical viewpoints, such as the school of Rational Emotive Therapy, founded by Albert Ellis. Ellis held that all psychopathology was the product of irrational beliefs (³). Chief among these for Ellis were religious belief and practice, which he believed were by definition both a manifestation and cause of psychopathology. This presumption applied to the religious dogma and practice of any individual or group, regardless of evidence testifying to the excellent emotional health of the individual or community. That these characterizations of religion are themselves dogmatic, unsubstantiated by scientific proof, is an irony that has been noted by many (⁴—⁶).

More recently, a more neutral, if not frankly positive, attitude toward religious belief and practice has been advocated by many psychiatrists (⁷, ⁸). Rather than viewing the religious impulse and gesture as de facto objects of interpretation, organized psychiatry has adopted the stance that religious beliefs and activities can be a normal part of human life and may confer health benefits in certain circumstances (⁹). For example, the field of transpersonal psychology seeks to understand the spiritual aspects of human existence from a psychological perspective. In addition, it is now recognized that the psychiatric care of patients with religious and spiritual concerns requires skills and knowledge that transcend what is taught in traditional medical training (¹⁰).

This approach has stimulated scientific study of the effects of religious life on mental health (¹¹—¹³). Though traditional constraints of the physician-patient relationship may preclude direct recommendations for increased religious affiliation (¹⁴), these studies highlight the potential health-related benefits of religious life for certain individuals. Attempts have been made to outline a standard of care for patients with religious concerns. The APA has issued practice guidelines regarding conflicts between psychiatrists’ personal religious beliefs and psychiatric practice (¹⁵), and numerous publications articulate the role of religion in psychiatric care (¹⁶—¹⁹).

Training programs for students and residents help them acquire competence in taking a spiritual history and treating religious patients. The Accreditation Council for Graduate Medical Education (ACGME) includes in its psychiatric training requirement didactic and clinical instruction on religion and spirituality in psychiatric care (²⁰). A number of papers have been published and a training curriculum has been developed to facilitate this training (²¹—²³). Although initial training placed emphasis on the development of skills needed to collect spiritual and religious histories, subsequent curricula were broadened and now include topics such as assessment of the "quality" of religious commitment, as well as detailed descriptions of the beliefs and practices of individual religions (²³). This breadth provides a wealth of knowledge but may obscure why such knowledge is needed.

Analysis of this topic begins with a basic question: Why are psychiatrists interested in the religious and spiritual lives of patients? What distinguishes religious life from other aspects of personal life in which less interest is taken?

The two primary answers to this question are linked to the two phases of medical care: assessment and treatment. Typical care proceeds through these two phases, and the goals set and methods used during each phase are different, though some overlap may exist. In the assessment phase, the goal is data collection from the patient, knowledgeable informants, and diagnostic studies, and use of this data to formulate and classify the patient’s problems. The treatment phase proceeds based upon the diagnostic formulation.

This article outlines a method for collecting spiritual and religious histories and for considering the goals of the psychiatry-religion interface during treatment. Familiarity with the patient’s religious life can be important during both phases. Religion and spirituality are often intricately interwoven into the domains where psychiatric symptomatology arises—thought, emotion, perception, and behavior. Religious life often serves as the context within which treatment occurs, and clergy participation may be needed to facilitate treatment. Therefore, the ability to synthesize psychiatric care harmoniously with religious life may be an important determinant of the treatment’s success. Finally, at times the patient’s problems may be rooted in aspects of their religious life, such as a discrepancy between parental or communal religious expectations and the patient’s expectations, or abusive relationships with religious institutions or clergy. All of these make religion of particular interest to the psychiatrist. For purposes of this discussion, religious patients include those with religious content to their symptoms, members of defined religious communities, or those with religious or spiritual concerns in relationship to psychiatric treatment.

Assessment Phase

Patient assessment is the first step in the relationship between psychiatrist and patient and leads to a differential diagnosis and diagnostic formulation. Although history-taking facilitates formation of a strong doctor-patient relationship, its goal is not therapeutic, per se, but evaluative. The initial focus of the religious and spiritual history and the subsequent scrutiny of the collected data should be directed by this goal (⁴).

Beliefs

Certain religious beliefs expressed by the patient may seem to be delusional and thereby are of clinical interest. This may be true of patients suspected to have schizophrenia, mania, psychotic depression, delirium, or substance-induced psychosis. The clinician must assess these beliefs for delusional form, a particular challenge if the clinician is not familiar with the patient’s religion. Though there will often be ample symptomatology by which to establish the proper diagnosis, sometimes diagnostic certainty hinges upon accurate classification of the religious belief.

The reliable differentiation of a religious delusion from a non-delusional religious belief usually rests more upon the clinician having solid clinical knowledge and skill than upon having detailed knowledge of any particular religion. The core features of a belief that render it a delusion relate to its form and not its specific content (²⁴). Knowledge of these features helps the clinician formulate questions to be asked of an informant with expert knowledge of the religion. The characteristics of being "fixed," "false," and "idiosyncratic" can be assessed for all beliefs (²⁵).

The holder of a fixed belief cannot see any possible way that the belief could not be true and cannot appreciate how his or her "belief" differs from "fact." A false belief has no evidence to support it and may have nearly incontrovertible evidence refuting it. The feature that is most useful in differentiating delusions from non-delusional religious beliefs is that of being idiosyncratic, meaning that the belief is unique to the individual, not an absorbed religious teaching, a result of educational exposure, or a cultural milieu. All three of these features must be present for the belief to be considered delusional.

Assessment of idiosyncrasy is a critical step, ideally accomplished by obtaining collateral information from a knowledgeable informant, often family or clergy (²⁶). Reviewing the particular belief with the informant usually resolves the question of idiosyncrasy. A pronouncement from a reliable informant that "Nowhere in our religion’s teachings is this belief found" is reassuring in that the clinical impression of a "delusion" is accurate. The clinician should ask about the time course of the belief. Has this belief always been part of the patient’s faith, or did it only emerge with the psychiatric symptoms? Even if new, can the genesis of the belief be traced to a recent educational exposure? Answers to these questions may help clarify the true nature of the belief. Rarely will the clinician personally have sufficient knowledge of the religious belief system to make this determination without consultation from a knowledgeable informant.

Methodologically, what is most important in this assessment is not comprehensive knowledge of the religion but knowledge of the form of all delusions (both religious and nonreligious) and of the methodology necessary (informant interview) to conduct the assessment (¹⁸). Establishing connections with local clergymen who can consult in such circumstances is helpful, although a clinician working extensively with a particular religious community should obtain a deeper and more extensive knowledge and understanding of the beliefs and practices of that community (¹⁹).

Mood Symptoms

Assessment of mood symptoms (both depressed and elevated) frequently involves religious themes, even when a delusional form is not suspected. Guilt is a common feature of major depression, and the patient may claim that the guilt arises from sins committed or contemplated. Similarly, religious patients who routinely experience closeness to God may lose this feeling during periods of depression. On the other hand, guilt is also a normal reaction to sin in nondepressed individuals, and people’s relationship with God may fluctuate in intensity as a matter of course. Differentiating major depression from these normal experiences can be challenging. In elevated mood states, the patient may have increased interest in religious ideas or behavior, increased feelings of closeness to God, or increased friction with those who do not share their convictions. Sometimes these feelings and behaviors are seen in religious individuals without an affective disorder, and this differentiation may also be challenging.

As with the assessment of beliefs, accurate assessment of religiously colored mood-related phenomena derives primarily from honed clinical skills and not from exhaustive knowledge of religious practice or dogma. Evaluation of a religion-related symptom begins with learning more about that symptom. The clinician looks for a change in the patient’s previously held beliefs or attitudes. How did the patient previously express guilt or remorse? How did the patient previously characterize his or her relationship with God? Are other symptoms of affective disorder present or absent? Can a diagnosis be made on the basis of other symptomatology, obviating the need for a conclusive assessment of the religion-related symptom? Answers to these questions direct the diagnostic formulation.

With an individual whose religiousness has recently increased and who is presenting for an evaluation, the ideal approach draws upon basic clinical skills. First, it should be noted that most individuals undergoing changes in religious outlook do not end up in psychiatric consultation, suggesting that a wide net should be cast in seeking symptoms without overemphasizing the religious changes. Consultation with clergy can clarify how this individual’s religious development compares with that of others. Were the changes a product of study and introspection? Did they occur after joining a new social group or attending a new school? A detailed history should look for symptoms of elevated mood or other psychiatric abnormalities. Is the patient grandiose, irritable, and more confident than previously? Are there neurovegetative changes? Combining the clinician’s knowledge of mood disorder psychopathology with the expert knowledge provided by clergy should lead to accurate case formulation.

Obsessions and Compulsions

Some devout patients present with religious ritual behavior suspected as being compulsive. Here, too, the psychiatrist’s expertise lies in synthesizing sophisticated knowledge about the phenomenology of obsessions and compulsions with the expert knowledge obtained from informants (²⁷). It is usually not difficult to differentiate religious rituals from compulsions once the patient’s phenomenology is clearly characterized and the normative performance of the religious ritual is defined. The psychiatrist cannot have detailed knowledge of all religious rituals of all faiths, and there should be the expectation that an informant will be consulted. Religious rituals typically have a prescribed mode of performance, with specific settings, dates, times, number of repetitions, and other specific requirements for the act to be considered ritually valid. Deviations from any of these may require explanation.

Moreover, the thoughts and moods associated with standard religious ritual typically differ from those associated with compulsions. Individuals may worry that they have not performed the ritual correctly, but this typically does not lead to multiple repetitions. A second repetition, with greater attention to detail, usually suffices to relieve these concerns under nonpathological circumstances. Finally, the characteristic anxiety buildup that is discharged by performance of a compulsion is typically absent in normative religious ritual performance (²⁸).

Hallucinations

Many patients report perceptual experiences having religious content. Many religions perpetuate the belief in the existence of prophecy or other communications with spiritual beings, but this belief does not imply that all cases in which this communication is claimed are not hallucinations. Once again, a careful clinical history and examination should clarify the phenomenology. The first step is to identify the other symptoms present or absent (e.g., mood abnormalities, thought disorder, substance use, delirium, and other nonreligious hallucinations or delusions). Learning from a knowledgeable informant what the usual manifestation of prophecy is according to that religion’s credo will allow the clinician to help distinguish it from psychopathology.

Other Mood Symptoms

Many patients are assessed with emotional reactions to life circumstances due to the meaning of these circumstances to the individual. Common examples of this include grief and demoralization (²⁵). Individuals who have experienced loss, whose hopes and aspirations are frustrated or who are lonely and isolated, have had failures in relationships, or have experienced financial catastrophe, can become demoralized and down-spirited. They experience sadness but do not have major depression. The source of conflict in some demoralized individuals may be a religious or spiritual concern. Individuals working to improve a relationship with God, struggling with religious doubt, or who have lost faith in an admired teacher or leader can become demoralized. The assessing clinician must appreciate the meaning of these conflicts to the individual if the full impact of the conflict upon the patient’s mood can be appreciated. Here, too, consultation with knowledgeable informants can help make this determination.

Potential Pitfalls

In the assessment phase, a number of unique pitfalls may be encountered with religious patients. For example, religious patients may be uncomfortable sharing thoughts or feelings related to religion. This may be due to a fear of being misunderstood or to a fear that the psychiatrist has a negative view of religion and may attempt to modify the patient’s religious commitments. Alternatively, failure to establish a rapport can occur if the interview is conducted in a manner offensive to the patient’s sensitivities. Some religions have codes of conduct governing interactions between men and women, standards of modest dress or use of profanity, the violation of which may not only make a religious patient uncomfortable but also jeopardize the establishment of rapport. Having a rudimentary knowledge of the basic social mores of a particular community can help prevent significant faux pas.

If a religious patient has reservations about psychiatric treatment, a variety of strategies may be employed (¹⁷). For example, inquiring into the nature of the patient’s concerns and then attempting to address them directly may overcome these reservations. Sometimes a trusted member of the clergy can serve as a culture broker by initiating the referral, accompanying the patient to the appointment or providing reassurance that the assessment is permitted or even obligatory according to religious law.

When the clinician comes from the same religious background as the patient, a different error can occur. The psychiatrist may unwittingly assume a greater commonality of values between doctor and patient than actually exists. As a result, the clinician may be less likely to inquire about deviant or antisocial behaviors or attitudes. This error can be avoided by the clinician paying careful attention to the assumptions made about the patients and their values. Preventing this misstep is critical for two reasons. The first is to allow the clinician to learn about the patient without being biased by a priori assumptions that do not reflect who the patient truly is. The second is that harboring assumptions about the patient’s level of religious observance can unwittingly place expectations of conformity upon the patient. This could hinder development of a therapeutic alliance, particularly if an element of the patient’s struggles relate to his or her religious life (²⁹).

Treatment Phase

During the treatment phase of religious patients, familiarity with the patient’s religious life can be important, but for reasons that differ from their significance during assessment. The usefulness of this knowledge depends upon the patient’s specific condition and treatment needs. A number of examples are outlined below.

Compliance

For patients with major mental illnesses, treatment compliance can be challenging. With religious patients, factors related to religion may enhance or diminish compliance. Members of certain religious groups discredit psychiatric treatment, distrusting it because of concerns that it will lead to diminished religiousness or harboring concerns about the social stigma that could result from being identified as a psychiatric patient. Treatment of individuals from these groups may be directly undermined by lay or clerical community members, or indirectly undermined by attitudes previously inculcated. This scenario presents a great challenge that must be dealt with sensitively.

It is important not to drive a wedge between the patient and his or her religious group by undermining its credibility in the patient’s eyes. One does not want to jeopardize the patient’s community standing by pressuring the patient to violate communal norms. On the other hand, it is important not to simply accept an initial treatment refusal based upon religious grounds. Patients may misunderstand what their faith permits and prohibits. The claim that their religion prohibits psychiatric treatment may be incorrect or fabricated. The proposed treatment or the consequences of not being treated may be misunderstood. Family members or clergy members should be included in the discussion (³⁰). This is particularly the case if there is concern that the patient’s interpretation of his or her religion is colored by psychopathology or dementia.

The religious community or its leaders may become advocates for compliance in ambivalent patients. Many religions have injunctions to protect and promote health, and psychiatric treatment may be included in this rubric. A religious leader can reassure a patient that treatment is permitted or even mandatory and that the treating clinician is unlikely to try and change the patient’s religious beliefs.

Support and Rehabilitation

Patients suffering from grief, demoralization, and loneliness need increased structure and social support as an integral part of their treatment. Patients who have been struck with illness and are unable to work or engage in their usual activities often require a rehabilitation period to facilitate a return to health. The rituals and seasonal rhythms of religious life, and the social network often available in religious communities, can provide significant emotional support (³¹). These activities may promote healing by restoring a sense of belonging and purpose to one who is bereaved, lonely, and demoralized. The information obtained during the collection of the religious history can thus be used to help craft a sophisticated rehabilitation plan for the patient (¹⁶).

In addition, many religious communities have specific treatment services and charity programs available for their members, including bereavement groups, substance abuse treatment, caregiver support groups, and hospice. Some communities have their own family services, vocational rehabilitation programs, food pantries, and shelters.

It is important to note that for some patients, particularly those unaffiliated with a mainstream religion, involvement of a clergy member who views the patient’s religious practices unfavorably, or who seeks to proselytize the patient, may be counterproductive.

Guidance and Meaning

Demoralized patients and those with major mental illnesses may benefit from guidance. When a patient comes from a different religious background than the psychiatrist, there may be key variables of which the psychiatrist is unaware. Choices appearing reasonable to the clinician may be unacceptable to the patient. Clinicians must keep this in mind before dispensing advice. Having a working relationship with the patient’s clergy, or at least encouraging the patient to consult with clergy when necessary, promotes decision-making that takes a broad range of factors into account.

Patients with major illnesses or facing major life difficulties often look for meaning in their suffering, and for religious patients the reservoirs of meaning are often religious (³²). Some distress that motivates patients to seek psychiatric care derives from conflicts about the meaning or purpose of life events (³², ³³). Patients searching for meaning in their difficult circumstances may find answers from their religious traditions, religious leaders, or treatment programs that draw upon religious belief or spiritual principles to motivate and inspire recovery. The 12-step recovery program for addictions is one example. Although some patients may find psychotherapy the proper venue to explore these concerns, the desire to address them in a religious context outside of psychiatric treatment should not be seen as prima facie evidence of avoidance.

It is important to include religious and spiritual factors in the diagnostic formulation and treatment approach for patients who are facing terminal illness and referred for psychiatric consultation. There is some evidence that including spiritual factors in end-of-life care improves the quality of life in hospice patients (³⁴). Religious patients facing the end of life may want the dominant context of death to be religious, and history-taking and treatment planning should take this into account (¹⁶).

Child and Adolescent Psychiatry

Clinicians working with children from religious communities may regularly face religious issues. These clinicians interface with parochial schools and need to establish working relationships with administrators and teachers. To be effective, the clinician needs to be sensitive to the beliefs and mores of the community and beware of appearing to want to change them or draw the patient away from them. Many interventions in child psychiatry involve settings beyond the traditional medical setting, such as afterschool activities, therapeutic social activities, and vocational training (³⁵). For children of religious families, these extracurricular activities may preferably occur in environments sensitive to their religious concerns.

Psychotherapy

Psychotherapy, even when patient-centered, is not free of value judgments (⁵, ⁹). Therefore, psychotherapy with religious patients from a religion unfamiliar to the therapist can present unique challenges, and a more detailed knowledge of the patient’s religious beliefs and customs may be beneficial. Because psychotherapy can entail nuanced and subtle interactions between patient and therapist, and great sensitivity to language and symbolism, a therapist not versed in the culture, values, and idioms of the patient may be at a disadvantage. Therapeutic suggestions may depend upon conformity to religious and community standards, and possibly upon well-timed involvement of select religious or community leaders (³⁶). A therapist knowledgeable about the patient’s specific community structure, mores, and general Weltanschauung may at times be better situated to effect these therapeutic interventions (¹⁷). Nonetheless, a skillful therapist who does not share the religious beliefs of the patient can still conduct successful psychotherapy as long as he or she is alert to the need for sensitivity to religious issues and the need to become educated about the religion’s beliefs and practices.

Many developments in psychotherapeutic technique, such as the use of meditation, draw upon research into the practice of such techniques in spiritual settings. Other examples include mindfulness-based stress reduction and mindfulness-based cognitive therapy, whose effectiveness has recently been studied in controlled clinical trials (³⁷, ³⁸).

Conclusions

Asking about a patient’s religious life has become a standard part of psychiatric history-taking and is taught during psychiatric training. Establishing clear goals for the use of this information, and understanding its differential value during different phases of the clinician-patient relationship, enhances the utility of this information.

Most clinical challenges emerging during psychiatric care of religious patients are better solved using refined clinical skills than by expecting the psychiatrist to retain exhaustive knowledge of each religion. Informants can provide expert information and their input should be routinely sought. Nonetheless, certain scenarios, such as in-depth psychotherapy of religious patients or a clinician working intensively within a particular religious community, may require of the clinician a more sophisticated knowledge.

Psychiatric training programs should emphasize the goals and the methods of inquiring about the religious life of patients. Psychiatric residents should also be taught rudimentary, clinically relevant features common to many religious traditions, such as respect for tradition, elders, and sacred texts. Mentors should model a respectful stance towards religion and the effective use of the religious history in clinical practice.

Acknowledgments

This study was supported in part by the Shapiro Family Foundation, Baltimore, Md.

References

James W: The Varieties of Religious Experience: A Study in Human Nature. New York, Longmans Green, 1902

Freud S: The Future of an Illusion. New York, H. Liveright, 1928

Ellis A: Psychotherapy and atheistic values: a response to A.E. Bergin’s "Psychotherapy and religious values." J Consult Clin Psychol 1980; 48:635—639

Blass D: A conceptual framework for the interaction between psychiatry and religion. Int Rev Psychiatry 2001; 13:79—85

Bergin AE: Psychotherapy and religious values. J Consult Clin Psychol 1980; 48:95—105

London P: The Modes and Morals of Psychotherapy. London, Taylor and Francis, 1986

Neeleman J, King MB: Psychiatrists’ religious attitudes in relation to their clinical practice: a survey of 231 psychiatrists. Acta Psychiatr Scand 1993; 88:420—424

Blass RB: Beyond illusion: psychoanalysis and the question of religious truth. Int J Psychoanal 2004; 85(Pt 3):615—634

Bergin AE: Values and religious issues in psychotherapy and mental health. Am Psychol 1991; 46:394—403

Puchalski CM, Larson DB: Developing curricula in spirituality and medicine. Acad Med 1998; 73:970—974

Braam AW, Hein E, Deeg DJ, et al: Religious involvement and 6-year course of depressive symptoms in older Dutch citizens: results from the Longitudinal Aging Study Amsterdam. J Aging Health 2004; 16:467—489

Varon SR, Riley AW: Relationship between maternal church attendance and adolescent mental health and social functioning. Psychiatr Serv 1999; 50:799—805

Rabins PV, Fitting MD, Eastham J, et al: The emotional impact of caring for the chronically ill. Psychosomatics 1990; 31:331—336

Sloan RP, Bagiella E, VandeCreek L, et al: Should physicians prescribe religious activities? N Engl J Med 2000; 342:1913—1916

American Psychiatric Association, Committee on Religion and Psychiatry: Guidelines regarding possible conflict between psychiatrists’ religious commitment and psychiatric practice. Am J Psychiatry 1990; 147:542

Pargament K: The Psychology of Religion and Coping: Theory, Research, Practice. New York, Guilford, 1997

Greenberg D, Witztum E: Problems in the treatment of religious patients. Am J Psychother 1991; 45:554—565

Waldfogel S, Wolpe PR: Using awareness of religious factors to enhance interventions in consultation-liaison psychiatry. Hosp Community Psychiatry 1993; 44:473—477

Blass DM, Fagan PJ: The treatment of orthodox Jewish patients in sex therapy. J Sex Educ Ther 2001; 26:267—271

American Medical Association: Graduate Medical Education Directory 1995—1996: Program Requirements for Residency Education in Psychiatry. Chicago, Ill, American Medical Association, 1995

Waldfogel S, Wolpe PR, Shmuely Y: Religious training and religiosity in psychiatric residency programs. Acad Psychiatry 1998; 22:29—35

Grabovac AD, Ganesan S: Spirituality and religion in Canadian psychiatric residency training. Can J Psychiatry 2003; 48:171—175

Larson DB, Lu FG, Swyers JP: Model Curriculum for Psychiatric Residency Training Programs: Religion and Spirituality in Clinical Practice: A Course Outline. Rockville, Md, National Institute for Healthcare Research, 1997

Sims A: "Psyche"—spirit as well as mind? Br J Psychiatry 1994; 165:441—446

McHugh PR, Slavney PR: The Perspectives of Psychiatry. Baltimore, Md, Johns Hopkins University Press, 1998

Westermeyer J: Cultural factors in clinical assessment. J Consult Clin Psychol 1987; 55:471—478

Greenberg D: Are religious compulsions religious or compulsive? a phenomenological study. Am J Psychother 1984; 38:524—532

Greenberg D, Witztum E, Pisante J: Scrupulosity: religious attitudes and clinical presentations. Br J Med Psychol 1987; 60( Pt 1):29—37

Lawrence RM, Duggal A: Spirituality in psychiatric education and training. J R Soc Med 2001; 94:303—305

Ribner DS: Ejaculatory restrictions as a factor in the treatment of Haredi (Ultraorthodox) Jewish couples. Arch Sex Behav 2004; 33:303—308; discussion 309—310

Brown GW, Prudo R: Psychiatric disorder in a rural and an urban population, 1: aetiology of depression. Psychol Med 1981; 11:581—599

Frankl VE: Man’s Search for Meaning: An Introduction to Logotherapy. New York, Simon & Schuster, 1984

Yalom ID: Existential Psychotherapy. New York, Basic Books, 1980

Tang WR, Aaronson LS, Forbes SA: Quality of life in hospice patients with terminal illness. West J Nurs Res 2004; 26:113—128

Friedman AS, Utada A, Glickman NW: Outcome for court-referred drug-abusing male adolescents of an alternative activity treatment program in a vocational high school setting. J Nerv Ment Dis 1986; 174:680—688

Heilman SC, Witztum E: Value-sensitive therapy: learning from ultra-orthodox patients. Am J Psychother 1997; 51:522—541

Teasdale JD, Segal ZV, Williams JM, et al: Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol 2000; 68:615—623

Grossman P, Niemann L, Schmidt S, et al: Mindfulness-based stress reduction and health benefits: a meta-analysis. J Psychosom Res 2004; 57:35—43