Through the years, studies have demonstrated how religious and spiritual beliefs may positively influence the outcomes of a patient's health (1–4). Randomized, controlled trials of patients with depression and terminal diseases have shown that exploration of spiritual meaning reduces relapse and improves well-being (5). Also, the benefits provided from the practices of meditation and prayer support the role of belief systems in a patient's ability to cope (6). Negative health consequences associated with religious practices or spiritual beliefs may also be seen in situations such as avoidance of preventive measures or discontinuation of needed health care secondary to belief constructs (6, 7). Recognizing and addressing these potential associations, whether positive or negative, is the duty of an effective healthcare provider (8–10). Patients themselves may request an integrated approach to their care, including the acknowledgment of related spiritual issues. One study in a primary-care setting revealed that 95% of the patients with serious illness desired that their spiritual beliefs be addressed by their provider (11). Within this decade, psychiatry residency programs have begun to incorporate an understanding of spirituality and its effects on mental health into their competency requirements for residents (7, 12–17).

The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, included a V-code in 1994, titled “Religious or Spiritual Problem,” a nonpathological condition that may necessitate clinical care (18, 19). In 1995, APA Practice Guidelines for the Psychiatric Evaluation of Adults were updated to include the assessment of important religious influences on a patient's life in addition to performing evaluations that are sensitive to a patient's spiritual or religious beliefs (20). The Accreditation Council for Graduate Medical Education revised its program requirements for psychiatry training programs in 2001 to support these guidelines (21). Training in cultural competency within clinical practice now mandates attention to religious and spiritual issues as one indicator for effective care (22).

Providers may overestimate or underestimate the importance of spiritual factors in a therapeutic setting, leading some to conceptualize the “bio-psycho-socio-spiritual” formulation in assessment and treatment-planning (23). Defining spirituality in itself is a challenge. Josephson defines spirituality as one's world-view, “one's connection to realities larger than oneself,” while defining religion as a specific category of spirituality, including cognitive aspects, behavioral aspects, and community (24). Competent clinicians should be aware of their own spiritual world-view, and how their own beliefs may affect or bias their patient care (25, 26).

To address the challenges of training competent psychiatry residents within the context of spirituality and patient care, we instituted global curriculum changes within our general- and child-psychiatry programs. A vertical curriculum, including residents as teachers, integrated 360 evaluations, didactics, and case-conferences, and an interdisciplinary workshop was launched by several of the core faculty in our mid-sized program.

The vertical curriculum in spirituality for the PGY1–PGY5 residents and fellows was integrated into the general- and child-psychiatry training programs over the 12-month academic year. This included didactics, case-conferences, and seminars, spanning the 5 years of training, including an interdisciplinary workshop between clergy, psychology interns, and psychiatry residents. Residents as teachers were utilized within the curriculum, in addition to integration of spirituality within the 360 evaluations for residents' portfolios. The formulation of the curriculum, learning objectives, and assessment tools derived from feedback of a focus group of residents and fellows. This group of six PGY1–5 residents met on three separate occasions and developed the curriculum outline with the training directors. The results of this focus group were reviewed with the core faculty involved, which then implemented the changes with support from the department chair.

Broad educational changes included revamping the formal didactics of the acculturation series, integrating the FICA brief spiritual history into the interviewing series (6), and modeling behavior by the faculty as they address cultural and spiritual issues in the case-conference series. Seminars and a workshop involving psychologists and pastoral counselors augmented the core curriculum, but will be discussed at length in another column. Policy and procedural changes included modifying the competency-based objectives for spirituality training in the residency programs. The resident clinic templates for history and physicals were changed to include a specific area for “spiritual history” and for the “bio-psycho-socio-spiritual” formulation. The 360 evaluations were altered to include spiritual/cultural issues for the residents' self, peer, supervisory, and patient evaluations (Table 1).

Formal didactics included a range of various topics identified from the focus group (Table 2). The incorporation of the curriculum was based on a vertical model, building a foundation of understanding throughout training. A curriculum evaluation tool was used for each formal didactic, including a description of the topic, format, presenter(s), specific competency-based objectives, and separate questions addressing quality and effectiveness. The curriculum evaluation tool was printed onto colored paper to distinguish Adult from Child feedback and tracked separately by the training coordinators. The curricular evaluation tool included a set of questions assessing the effectiveness of the seminar in reaching its specific objectives. Also, it asked the residents to rate the impact the seminar had on attitude, knowledge, and acquisition of a new skill. The residents rated the impact using a 5-point Likert scale with the parameters of Negative, Moderately Negative, Neutral, Moderately Positive, and Positive. The training coordinators compiled the information for each of the seminars to provide average ratings and qualitative comments anonymously. Data were collected over the first 12-month period.

The course syllabus for PGY1 included 8 hours of didactics and discussion covering cultural/spiritual world-views, issues specific to the Southeast/South Carolina, socioeconomic factors affecting our patients, interviewing skills using a spiritual and cultural history, and clinical vignettes. The PGY2 outpatient year included 4 hours on developing the bio-psycho-socio-spiritual evaluation. Residents served as teachers for an additional 4 hours of self-chosen topics, such as spirituality and sexuality, African American spirituality, Hispanic cultures, and patients with disabilities. Other lecture series in psychopharmacology or case-formulations included specific topics of culture and spirituality. In the PGY3 curriculum, topics of hospice and death and dying were covered on the consultation–liaison seminars. During the public psychiatry rotation, the topics included spirituality and pain and addiction-recovery. The PGY4 curriculum involved development of an elective for interested residents who were assigned a faculty mentor to assist in planning a spirituality/cultural project. The Child fellowship integrated didactics within their developmental and interviewing series. Other seminars included grief and anticipating the death of a child. Also, two panel discussions of Fellows were held to review cases specific to cultural or spiritual issues. Lecturers included faculty from various disciplines, representing Psychiatry, Internal Medicine, General Surgery, Addictions, Chaplains, Masters of Divinity, and Pastoral Counselors. Discussant demographics involved 10 residents/fellows, including one international medical graduate and three African American residents. The panel discussions and resident-chosen topics were reviewed and supervised by the training directors before presentation.

The results of the first year after the curricular changes were overwhelmingly positive. Qualitative comments from the residents and fellows included “Good examples of studies and how spirituality helps;” “Reframed understanding of spirituality, especially from the view of someone with drastically different beliefs from mine;” “Increased my understanding of the relationship with mental illness;” and “I learned a new way to address spirituality and belief system in patients.” A total of 80 quantitative responses were collected from the curricular evaluation tools returned voluntarily and anonymously. In the Child program (N=18), there were 2 Neutral responses (11%) and 16 Moderately Positive-to-Positive responses to the impact questions (89%). In the general program (N=62), there were 12 Neutral responses (19%) and 50 Moderately Positive-to-Positive responses (81%). No negative impact responses were received.

This curricular change was well received by the residents and faculty overall. Many of the residents asked to participate in future years, including graduates of the program who return specifically as lecturers for the Spirituality and Acculturation Series. One limitation of the feedback obtained is that the results were collected on a voluntary basis, leaving an opportunity for bias in respondents. There may also be a regional bias regarding self-identified religiosity. Other challenges included initial hesitancy of buy-in from adjunct or peripheral faculty who were concerned about ethical issues or ambiguity in professional roles associated with the spirituality curriculum. However, after the first year of feedback and success, the hesitancy or resistance once noted in faculty meetings no longer existed. We did not obtain written faculty responses, which would have been helpful. Getting anonymous feedback from faculty would be recommended for future endeavors. Encouraging continuous processing of the changes and feedback from the residents and faculty allowed for a smooth culture of change in our program. Promoting transparency and input from the resident group was crucial in the success of this change. The Residents as Teachers aspect of the curriculum now varies from year to year, depending on the residents' interests, allowing them ownership of their education. The use of “spirituality markers” within the 360 evaluations (Table 1) helps promote continued awareness throughout residency training. Integration of mindfulness-based interventions was not included in the preliminary data, but is now taught within our cognitive-behavioral lecture series.

The cultural change in our department, incorporating a vertical spirituality curriculum, was a positive endeavor. Building on the frameworks of model curricula developed years before (14), we were able to successfully integrate a spirituality curriculum into our residency training, despite an initially guarded environment. The global changes allowed our residents and fellows to develop the necessary attitudes and skills for addressing spirituality issues routinely in their patient care.

The authors gratefully acknowledge the George Washington Institute for Spirituality and Health (GWISH) and the John Templeton Foundation for providing grant monies that enabled adjunct activities for the core curriculum (i.e., the research/workshop project and outside guest lecturers).