Jan 8, 2020
Norko, MD, professor of psychiatry at Yale University in New
Haven, Conn., spoke with Lorenzo
Norris, MD, MDedge Psychiatry editor in chief, about
incorporating patients’ spiritual and religious histories into
Dr. Norko, lead author of a paper
exploring whether religion is protective against suicide, sat down
with Dr. Norris at the 2019 fall meeting of the Group for the
Advancement of Psychiatry, or GAP.
Evidence, questions to consider about religion and
- Various spiritual and religious factors are linked to decreased
rates of suicide behaviors and attempts, including weekly
attendance to worship services, personal beliefs about the
preciousness of life, and commitment to a faith practice. Which
specific parts of religious and spirituality are protective? Are
the protective factors the social connection or the spiritual
- Those who attend worship services weekly are at lower risk of
suicide. It’s unclear whether weekly attendance is a proxy for the
social connectedness or for the level of internalization of the
- Commitment to a faith is measured by a consistent and strong
belief in the faith tradition. Just because someone says they
belong to a faith tradition does not automatically mean a person is
at lower risk of suicide.
- Strong alignment with the faith also is protective. Alignment
is different from commitment, because if patients are doubting or
their personal beliefs conflict with long-held religious
traditions, this can increase patients’ suicide
Questions to ask about spirituality and religion in
- A spiritual and religious history is essential to a psychiatric
evaluation, because asking about religion lets the patient know
that this is a welcome topic. Examples of questions a clinician can
ask include: “Is there any faith tradition that you belong to? How
important is your faith or beliefs? Is there anything about your
religious beliefs you think are important to your mental health
Difficult areas to navigate with religion and
- Lack of expertise or personal experience with religion can be a
barrier. It is important to remember that patients usually welcome
curiosity about their religious beliefs and emotional lives.
Clinicians need not be experts in religion, but they can be alert
to the salient values and notice whether the person is struggling
with certain beliefs. Clinicians also can encourage patients to
talk to their clergy.
- When someone asks a clinician, “What is your faith practice?”
this can be approached as an informed consent question. The
clinician can ask how talking about their own beliefs or faith
practices will deepen and help the therapeutic work of the
- If a person is feeling let down by a certain failing of their
religious community, therapy is a good place to explore what
strengths and succor they had received from their religion. Therapy
also can be used to guide patients toward additional places, or
even substitutes, to meet their needs.
- Understanding patients’ faith background and beliefs can help
clinicians reframe certain crises, especially if the psychiatrist
and therapist have talked discussed those crises with patients over
time. It’s more useful to understand patients’ faith before the
crisis, because grasping for a spiritual or religious answer at the
last moment can feel inauthentic.
Norko et al. Can religion protect against suicide? J
Nerv Ment Dis. 2017. Jan;205(1):9-14.
Kruizinga R et al. Toward a fully-fledged integration of
spiritual care and medical care.
J Pain Symptom Manage. 2018 Mar;55(3):1035-40.
Thomas LP et al. Meaning-centered psychotherapy: A form of
psychotherapy for patients with cancer. Curr
Psychiatry Rep. 2014 Oct;16(10):488.
Lawrence RE et al. Religion and suicide risk: A systematic
Arch Suicide Res. 2016;20(1):1-21.
D’Souza R, George K. Spirituality, religion and psychiatry: its
application to clinical practice.
Australas Psychiatry. 2006 Dec;14(4):408-12.
FICA Spiritual History Tool: https://smhs.gwu.edu/gwish/clinical/fica/spiritual-history-tool,
which is based on Puchalski C and Romer AL. Taking a spiritual
history allows clinicians to understand patients more fully. J
Palliat Med. 2000 Spring;3(1):129-37.
George Washington University Institute for Spirituality and
Health (GWISH): https://smhs.gwu.edu/gwish/