Chaplains are present in many settings, but often their role in health-related contexts is limited to end-of-life care. Regretfully, chaplaincy is less common in mental health treatment programs. There are many historical reasons for this, including anti-religious sentiments espoused by Freud in the early 20th century.
However, such attitudes on the part of practitioners have not alleviated the need for spiritual care among psychiatric patients, especially given the recent rise in prevalence and severity of mental illness across the lifespan. Indeed, spirituality has great importance for many psychiatric patients, especially when it has the potential to change the course of someone’s life for the better, as in the following case.
Medication Refusal Allegedly Due to Religious Beliefs
Khalid was a young man, mid-twenties, of Middle Eastern descent, presenting with mixed depressive and manic symptoms to the McLean Hospital clinical evaluation center (psychiatric emergency room). His medical record showed multiple previous hospitalizations and a diagnosis of Bipolar Disorder Type I with psychotic features. Upon admission, Khalid was pacing, unable to sit still, and quietly mumbling to himself. He had come for an evaluation at the behest of his friend, and he was reluctant to be present, let alone to participate in treatment. He was particularly concerned about the potential side-effects of taking psychiatric medications.
In completing his clinical forms, Khalid noticed that one could refuse medication on the basis of religion, and given his Muslim background, he claimed this civil liberty. What Khalid did not understand, however, was that refusing medication on such a basis could position him for court intervention if such refusal was not truly based in religious needs. This is because physicians who suspect patients of refusing to participate in treatment without merit can take cases to court for review by a judge, who can issue an order to deliver interventions without patient consent.
While court orders can be life-saving, they are almost always disruptive and can be detrimental to patients’ recovery and the future course of their treatment. The stress of being forced to do something against one’s will can trigger an emotional decompensation, placing the patient at greater physical and mental risk, and creating a need for more extreme treatment measures. The patient may also no longer trust their care providers or adhere to treatment plans, thereby refusing all forms of treatment down the line.
Mental Health Chaplaincy & Consultation
Unfamiliar with the nuances of Islamic approaches to psychiatric and other medications, Dr. Joe Stoklosa, medical director of the unit where Khalid was placed, contacted Dr. Dost Öngür, chief of McLean Hospital’s psychotic disorders division, for a consultation. Dr. Öngür promptly referred him to consult with McLean’s chaplain, Rev. Angelika Zollfrank.
Rev. Zollfrank confirmed for Drs. Stoklosa and Öngür that Islam generally does not prohibit use of psychiatric medications, however she recognized the need to “work with” the patient and discuss his religious concerns. Dr. Stoklosa set up an appointment for Khalid to meet with Rev. Zollfrank, as a last-ditch effort to avoid an impending court order.
Building a Therapeutic Alliance
Khalid was quiet as Rev. Zollfrank entered the room. Sitting in a chair in the far corner, he glanced up, made brief eye contact, and requested a male chaplain, claiming that he would feel more comfortable with a male. Rev. Zollfrank respectfully and compassionately told Khalid that she was the only mental health chaplain at McLean; she asked if he might give their conversation a chance. Although he was reluctant – even paranoid, mistrustful, and agitated – he agreed. Throughout their brief meeting, Khalid’s interactions with Rev. Zollfrank were punctuated by sudden pacing around the room, wrapping his arms tightly across his chest, and darting his eyes to-and-fro as he spoke. Sensing his distress, Rev. Zollfrank did her best to calm him down by asking how he was feeling. Khalid initially refused to answer, but Rev. Zollfrank gently persisted and offered to bring Khalid a Qur’an and a prayer rug to their next meeting, if he wanted. Khalid willingly agreed, and they set a time to meet a few days later.
At their next meeting, Khalid was jumpy and full of energy, and as soon as Rev. Zollfrank entered the room he began speaking rapidly. He eagerly shared with Rev. Zollfrank some details about his faith, and his desire to pray and read to Qur’an. Rev. Zollfrank sat and listened to Khalid, and she validated his desire for devoutness and to follow the beliefs and practices of Islam. It helps that representatives of mental health chaplaincy programs are trained to work with people from many different religious traditions. They spent the rest of the session discussing Khalid’s favorite passages in the Qur’an, after which Rev. Zollfrank left so that Khalid could pray in private. Rev. Zollfrank did not broach the topic of medications at all during their meeting. She simply built a therapeutic alliance with Khalid and conveyed in word and deed that McLean Hospital would respect and support his religious beliefs and practices.
Spirituality and Treatment Outcomes
Rev. Zollfrank received an email message from Dr. Stoklosa the following day, reporting that Khalid had not only started to “turn the corner” with his distress, but he had agreed to start taking medications as prescribed. Dr. Stoklosa was delighted and grateful that he did not have to pursue a court order to force Khalid to get the treatment that he needed, against his will. In the end, Khalid’s recognition that his religion would be supported was critical in helping him to decide to receive treatment voluntarily.
This story is just one of many that illustrates the critical value that mental health chaplaincy can provide to patients, and treatment teams. Beyond the specifics of navigating religious needs and preferences around medication, spirituality can be comforting and beneficial to treatment outcomes in many ways. By building an alliance with patients, validating their spiritual and religious needs, providing for and supporting engagement with religious practices, and most of all showing compassion and love, those involved in mental health chaplaincy are an important part of mental health care team.
NB: Patient name, identifying information, and other details have been changed to protect confidentiality and privacy.
- “It’s Against My Religion”: The Importance of Mental Health Chaplaincy - November 25, 2020
- “It’s Against My Religion”: The Importance of Mental Health Chaplaincy - November 25, 2020
