Training psychiatric residents in the assessment of patients' spirituality has become increasingly recognized as an integral part of competent patient care (1–5). Psychiatry residencies are now incorporating spiritual assessment training into the teaching of formulations and treatment-planning (4, 5). The ACGME's “Special Requirements for Residency Training in Psychiatry” were influential in promoting the integration of spirituality into training programs. In those requirements, religion and spirituality were to be addressed in the didactic curriculum and in the “instruction about American culture and subcultures, particularly those found in the patient community associated with the training program” (6). These requirements were further reinforced in 1995 by APA's Practice Guidelines for the Evaluation of Adults (7).

The psychiatry training programs at the University of South Carolina received an award from the George Washington Institute for Spirituality and Health (GWISH) to develop a comprehensive curriculum integrating spirituality and cultural issues into didactics and clinical care. The vertical curriculum included various seminars and case conferences addressing cultural, subcultural, and spiritual issues relevant to the Deep South, a descriptive category of the cultural and geographic subregion most often including the states of Mississippi, Louisiana, Alabama, Georgia, and South Carolina. The general curriculum will be discussed at length in another column.

As a research component of the curriculum, focus was placed on the spirituality of the predominant subculture surrounding the training program, namely, a Christian, Protestant community. One local author, a self-identified “biblical counselor,” was known to advise counselors who were concerned about a possible organic cause of mental illness to “be careful that you don't send him to a physician, who will then refer him to a psychiatrist or psychologist” (8). This type of stigma within the community was the impetus for our clinical question.

This was the question we sought to address: “Can a training experience bringing psychiatry residents and seminary students together affect their beliefs, attitudes, and practices toward one another?” There is a paucity of models for how psychiatrists and their patients' spiritual care-providers can work together in the care of shared clients, but Josephson and Peteet have emphasized collaboration (9). The model curriculum as described by Larson et al. included an approach to interactive learning with the goal of addressing preconceived notions and promoting collaboration in the medical process (10). Although some psychiatric training programs have developed curricula to increase the interaction of psychiatric residents with hospital-based chaplains, most mental-health clients look to their own community-based clergy for spiritual care (11). Interaction is rare between clergy and mental-health professionals, with clergy referring fewer than 10% of those they counsel to mental-health professionals, and mental-health professionals being even less likely to refer to clergy (11). For this reason, the research experience focused on an integrated training with clergy. It was proposed that seminary students and psychiatrists would develop more positive attitudes toward each other and demonstrate an increased knowledge regarding the attitudes and skills of each other's professions. Because the surrounding area for the training programs was predominately Christian/Protestant, we chose two local seminaries within this subculture to participate.

The 6-hour training consisted of two 3-hour workshops involving mental-health trainees (N=43) and seminary students (N=41). The mental-health participants included PGY-II general-psychiatry residents, PGY-V child-psychiatry residents, and psychology interns. In the seminary student group, 52% were men and ≤31 years of age. The mental-health group had 32% men, with 59% being ≤31 years old. “Caucasian” was self-identified as race in 74% of the seminary students and 61% of the mental-health trainees. African Americans comprised 7% and 18% of the seminary and mental-health groups, respectively. The remaining self-identified as Asian, Hispanic, or Jewish. Within the seminary group, 98% of the participants identified “Protestant” as their religion. The mental-health group identified as 59% Protestant, 16% Catholic, 7% Other, 4.5% agnostic, 4.5% Hindu, 4.5% atheist, and 2% Muslim. The multidisciplinary faculty included seminary professors, psychologists, and psychiatrists, who modeled professional interactions and shared teaching throughout the training. In the first seminar, the participants became familiar with the training and skill-sets of each other's profession. The psychiatry residents and psychology interns learned about clergy training regarding counseling, as described by the several professors from the local seminaries. The seminary students learned about the differences between psychiatrists and psychologists and about the spirituality training, as described by the psychiatry and psychology training directors. Small-group interdisciplinary discussion addressed topics such as barriers for Christians in seeking mental-health treatment and stigma. In the second seminar, interdisciplinary small groups discussed guidelines for clergy in addressing mental-health issues and guidelines for mental-health professionals in addressing spiritual issues in therapy. Groups then met, by discipline, to discuss when and how to refer to the other discipline. Seminary students were provided available resource lists and instructions on navigating the system for psychiatric emergencies. Psychiatry residents learned specific issues of importance to pastors regarding mental-health professionals and making referrals. The session concluded with a case presentation involving a patient with psychiatric and spiritual issues.

Assessment Tools

The assessment of participants' spirituality has been a part of other pilot studies for programs in spirituality, with investigators developing their own assessment instruments (12–14). A review of the literature did not reveal any scales with established validity and reliability that would accurately measure the objectives of this program, which included assessing the knowledge and attitudes of clergy, psychiatrists, and psychologists toward each other and their attitudes toward mental illness. Therefore, a pilot scale, the Attitudes and Beliefs regarding Clergy and Psychiatrists/Psychologists (ABCP) was developed and administered before the first seminar and 1 month after project completion. The questions were developed collaboratively with the seminary professors and consultant research psychologist. Questions were selected to assess attitudes and beliefs about mental health, mental illness, treatment, and the roles that psychiatrists, psychologists, and clergy have in helping mentally ill persons. The questionnaire consisted of 48-item self-report measures (available upon request). Items were rated on a 3-point Likert scale, with choices of “Agree,” “Neutral,” or “Disagree.” An assessment tool specific to the topics for each seminar was administered immediately after the presentations, with participants rating, on a 5-point Likert scale (1: Not Acceptable to 5: Outstanding) the degree to which the program's goals were met. Qualitative comments were welcomed and were also captured. The Spiritual Well-Being Scale, a valid and reliable scale, was also administered before the training sessions. It yields a Total Score and two Subscale Scores: Religious Well-Being and Existential Well-Being (15). The purpose of this assessment was to collect information that could be summarized for participants in the seminars, to help provide accurate information about participating groups.

The demographic data analysis showed that there were more women in the mental-health group, with a more diverse religious and racial/ethnic identification.

The pre-test ABCP showed that seminary students and mental-health participants both had positive attitudes toward clergy, with no statistically significant difference between groups (using Poisson regression; p: NS). On both pre and post- assessments, 99% of all participants agreed “The interventions of clergy and psychiatrists/psychologists for people with emotional problems should ideally complement each other.” The post-test/pre-test ABCP, on the subset of questions regarding knowledge of clergy, changed significantly in the positive direction for the psychiatry residents. The participating seminary students, on the post-test/pre-test ABCP comparison, demonstrated significant positive change on the subset of questions addressing attitudes and knowledge of psychiatry/psychology (p=0.0011). In the statistical analysis, neutral responses were not included, and logistic regression was used to analyze post-test/pre-test results. Overall, 14 of the 50 items demonstrated statistically significant change. Representative items are shown in Table 1.

The global ratings based on the seminar evaluations were all “Very Good” to “Outstanding” for both the first and second seminar, and eight of the nine explicit goals of the program received the same ratings. These included 1) “Learned about the possible reasons for the lack of interaction between clergy and psychiatrists/psychologists in caring for people with emotional problems;” 2) “Identified some parameters in which referral to a psychiatrist/psychologist is advisable;” 3) “Identified some parameters in which referral to clergy/spiritual care-provider is advisable;” 4) “Explored ways in which clergy and psychiatrists/psychologists can work together;” 5) “Became familiar with guidelines for emergency referrals;” 6) “Became familiar with an overview of the mental-health system;” 7) “Became familiar with how to refer and work effectively with a pastor in a church;” 8) “Gained an understanding of language used in church circles in regard to mental-health issues;” and 9) “Learned about the unique knowledge/skills that clergy, psychologists, and psychiatrists receive” got ratings from “Average” to “Outstanding.”

Qualitative comments from the seminary group included “Having had some ambiguous-to-negative experiences with psychiatrists and psychologists in the past, it was very good for me to interact, to see them as human, to hear them affirm a form of counseling/therapy/treatment that is caring and focused on restoring health and wholeness of life.” Mental-health group comments included “This is good for future relationships with clergy.” Issues for the future, as noted by the group, included “Information about interacting with other faiths, as well (not just Christian)” and “Provide more referrals.”

The Spirituality Well-Being Scale analysis revealed significantly higher mean scores for seminary students for the Spiritual Well-Being Scale (p=0.0061) and Religious Well-Being Scale (p=0.0031), as compared with psychiatry residents. Psychiatry residents scored at the upper end of “Moderate” for each of these scales.

Overall, the interactive experience positively affected the seminary students' attitude and knowledge of psychiatrists. Similarly, the goals for the psychiatric residents to gain knowledge about clergy were met. A limitation of this study is that we could not determine to what degree this positive change occurred because of the specific curriculum and to what degree it was influenced secondary to the seminary students' and psychiatry residents' personal interactions and the breaking down of barriers. To establish the educational significance of the ABCP questionnaire, validation of this tool will be necessary. Another limitation is that the data on the ABCP were not collected a third time, to measure for enduring impact. Despite statistically significant changes, it is still noteworthy that 25% of seminary students did not endorse that seeing a psychiatrist is helpful for emotional problems, and only a minority agreed that psychiatrists are trained to consider their patients' spiritual beliefs and practices. It would be interesting to investigate whether these results would be modified by further seminars.

The results indicate that some baseline findings were positive before the intervention. Both psychiatry residents and seminary students already viewed potential interactions between the disciplines as positive. Another baseline positive finding was that the mental-health professionals shared a positive view of the clergy's role in helping people with emotional problems. This corresponds with studies that found comparable results for favorable outcomes of those who saw their clergy or sought professional counseling (9). The shared positive attitudes toward clergy could be related to the region and predominance of the Protestant Christian faith in both groups. In an area where there is greater religious diversity, this model could be modified to include clergy students of different religious faiths or adapted to emphasize principles of collaboration that generalize to a variety of faiths (16).