Indian Physician's Perspectives on Spirtuality and Stigma Aliviation in Psychiatry-Ramakrishnan Et Al JRH Jan 2014

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Journal of Religion and Health ISSN 0022-4197 J Relig HealthDOI 10.1007/s10943-014-9822-6

Indian Health Care Professionals AttitudeTowards Spiritual Healing and Its Role inAlleviating Stigma of Psychiatric Services

P.Ramakrishnan, A.Rane, A.Dias,J.Bhat, A.Shukla, S.Lakshmi,B.K.Ansari, R.S.Ramaswamy,R.A.Reddy, A.Tribulato, et al.

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ORI GIN AL PA PER

Indian Health Care Professionals Attitude TowardsSpiritual Healing and Its Role in Alleviating Stigmaof Psychiatric Services

P. Ramakrishnan A. Rane A. Dias J. Bhat A. Shukla

S. Lakshmi B. K. Ansari R. S. Ramaswamy R. A. Reddy

A. Tribulato A. K. Agarwal N. SatyaPrasad A. Mushtaq

P. H. Rao P. Murthy H. G. Koenig

Springer Science+Business Media New York 2014

Abstract Persons with mental illnesses in India and rest of developing world continue toconsult religious/spiritual (R/S) healers or traditional, complementary and alternative

medicine (TCAM) professionals prior to seeking psychiatric services that are devoid of

spiritual components of care. We aim to understand TCAM and allopathic professionals

perspectives on patients R/S needs within mental health services, cross-sectional study

was conducted at five TCAM and two allopathic tertiary care hospitals in three different

Indian states; 393 participants completed RSMPP, a self-administered, semi-structured

survey questionnaire. Perspectives of TCAM and allopathic health professionals on role of

spirituality in mental health care were compared. Substantial percentage, 43.7 % TCAM

and 41.3 % allopathic, of participants believe that their patients approach R/S or TCAM

practitioners for severe mental illness; 91.2 % of TCAM and 69.7 % of allopaths were

satisfied with R/S healers (p = 0.0019). Furthermore, 91.1 % TCAM and 73.1 % allopaths

P. RamakrishnanAdiBhat Foundation, R-90, Greater Kailash-I, New Delhi 110048, India

P. Ramakrishnan A. Tribulato A. K. AgarwalHELP Foundation of Omaha, 105 N 31st Avenue, Omaha, NE 68131, USA

P. Ramakrishnan (&)Center for Study of World Religions (CSWR), Harvard Divinity School, Harvard University, 45Francis Ave, Cambridge, MA 02138, USAe-mail: [email protected]; [email protected]

A. RaneInstitute of Psychiatry and Human Behavior, Bambolim, Goa, India

A. DiasDeptartment of Preventive and Social Medicine, Goa Medical College, Bambolim, Goa, India

J. BhatDeptartment of Pediatrics, Goa Medical College, Bambolim, Goa, India

A. Shukla N. SatyaPrasadB.R.K.R. Govt. Ayurvedic Medical College, Hyderabad, India

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J Relig HealthDOI 10.1007/s10943-014-9822-6

Author's personal copy

(p = 0.000) believe that mental health stigma can be minimized by integrating with

spiritual care services. Overall, 87 % of TCAM and 73 % of allopaths agreed to primary

criterion variable: spiritual healing is beneficial and complementary to psychiatric care. A

quarter of allopaths (24.4 %) and 38 % of TCAM physicians reportedly cross-refer their

grieving patients to religious/TCAM healer and psychiatrist/psychologist, respectively; on

logistic regression, significant (p \ 0.05) predictors were clinical interactions/references tor/s healers. Providing spiritual care within the setup of psychiatric institution will not only

complement psychiatric care but also alleviate stigma against mental health services.

Implications on developing spiritual care services like clinical chaplaincy are discussed.

Keywords Stigma Spirituality Chaplaincy Integrative Psychiatry Ayurveda TCAM Mental illness

Introduction

Patients with mental health problems were often known to seek care in religious/spiritual (r/

s) healing centers (Weiss et al. 1986; Janakiramaiah et al. 1979) prior to visiting psychiatrist

or mental health clinics. Decades of development in mental health services may seem to have

improved this scenario (Mishra et al. 2011); yet because of lack of public awareness and

stigma to mental health facilities, substantial numbers of patients suffering from mental

disorders are still reported to be visiting traditional, complementary and alternative medicine

(TCAM) and/or r/s healers (Lahariya et al. 2010; Chandrashekar et al. 2009; Raguram et al.

2002; Chadda et al. 2001) prior to approaching psychiatrists. Such a pathway to mental health

services is also common in other parts of the developing world (Giasuddin et al. 2012;

Sorsdahl et al. 2009; Dejman et al. 2008; Kuloglu et al. 2003). Reportedly, modern medical/

psychiatric institutions as well as the psychiatrists are often avoided due to stigma (Chadda

et al. 2001; Shrivastava et al. 2013). Stigma is understood as suffering from social discon-

nectedness, such as discrimination fears, feelings of rejection or avoidance by others, of

S. LakshmiGandhi Naturopathic Medical College, Hyderabad, India

B. K. Ansari A. MushtaqCentral Research Institute of Unani Medicine, Hyderabad, Andhra Pradesh, India

R. S. RamaswamyNational Institute of Siddha Medical Sciences, Chennai, India

R. A. ReddyJ.S.P.S Govt. Homeopathic Medical College, Hyderabad, India

P. H. RaoSweekaar-Upkaar Rehabilitation Institute for Handicapped, Osmania University, Secunderabad, India

P. MurthyNational Institute of Mental Health and NeuroSciences, Bangalore, Karnataka, India

H. G. KoenigDepartment of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC,USA

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blame or shame, or perceptions of hostility (Karnieli-Miller et al. 2013; Rao et al. 2008;

Bogart et al. 2008; Hsiao et al. 2006). Researchers are coming to understand spiritual care

with its ability to establish interpersonal compassion and empathy as a powerful tool to

improve social interconnectedness (Falb and Pargament 2012; Wright and Neuberger 2012;

Dhar et al. 2012) and alleviate stigma. R/s institutions in India and other developing countries

seem to provide pleasant, nonthreatening and reassuring care that validates self-worth

through engaging the patients in socially useful activities (Raguram et al. 2002; Halliburton

2003; Campion and Bhugra 1997), thus improving their social interconnectedness. Signifi-

cantly better outcomes of mental illnesses in these countries (Jablensky 2000) may be due to

availability and access to r/s institution-based care (Raguram et al. 2002).

Contrary to what happens in India and other developing countries, patients with mental

disorders in high-income/developed countries seek help primarily from general physicians,

who may later refer them to psychiatrists (Steel et al. 2006; Gater et al. 2005; Andrews et al.

2001; Amaddeo et al. 2001). And, due to a rapidly evolving paradigm of integrative mental

health care, patients in developed nations have started to receive spiritual (Carey and Medico

2013; Nieuwsma et al. 2013) and alternative medical therapies such as acupuncture and

herbal remedies, as part of mainstream health care system (Lake et al. 2012). Modern health

care professionals in developed nations have begun to refocus on spiritual and traditional

healing techniques because of growing consumer demands (Crammer et al. 2011; Wu et al.

2009; Fabian et al. 2005; Menniti-Ippolito and De Mei 1999); some leading medical journals

are dedicating space for alternative treatments that are evidence based (Lake et al. 2012;

Greeson et al. 2011). This paper aims to understand TCAM and allopathic professionals

perspectives on the interplay between spirituality and psychiatric services, based on their

personal preferences as well as on their clinical observations and interpretations of mental

health-seeking behavior of patients in India. Because of the close association between

spiritual care and TCAM services (Crammer et al. 2011; Wu et al. 2009; Hsiao et al. 2008),

we hypothesize that TCAM professionals will be more likely than allopathic professionals to

support spiritual care as complementary to medical/psychiatric care.

Materials and Methods

This paper is part of serial publications from our multicentered research study; detailed

methodology of this study can be found elsewhere (Ramakrishnan et al. 2013). However,

briefly, this study is based on a cross-sectional survey conducted between January 2010 and

December 2011 at seven preselected tertiary care medical, two allopathic and five TCAM

institutes in three different states in India. Since there were no previous studies of this type to

guide us, we assumed 50 % of the professional staff to favor the primary criterion variable,

and using the sample size calculator, we arrived at a sample size of 400 volunteer partici-

pants in each of the study groups (TCAM and allopathy). The sample size of allopathic group

was met with Goa University Medical College at Bambolim in the state of Goa. Since this

study focused on mental health issues, we included Sweekaar-Upkaar, a mental health

institute of Osmania University, Secunderabad, Andhra Pradesh, into this group to have an

oversampling of mental health professionals in the allopathic group. Sample size of TCAM

group was reached with the inclusion of one each of the five types of TCAM systems of

medicine practiced in India. These systems of medicine are collectively called as department

of AYUSH (acronym for Ayurveda, YogaNaturopathy, Unani, Siddha and Homeopathy).

AYUSH is a federal organization that governs the education, clinical training and patient

care activities of TCAM institutes in India. Four TCAM institutes from the state of Andhra

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Pradesh participated in this study; they were BRKR Govt. Ayurvedic Medical College,

Gandhi Institute of Yoga and Naturopathy, Central Research Institute of Unani Medicine,

JSPS Govt. Homeopathic Medical College and the fifth one was the National Institute of

Siddha Medical Sciences (NIS), from Chennai, state of Tamil Nadu. Since TCAM institutes

do not have specialized departments of psychiatry, health care professionals from these

institutes interested in mental health care were specifically reinvigorated to participate in this

study. Sub-investigators at each of the study centers encouraged the participants to complete

their surveys through three or more personal meetings and/or phone calls. They also col-

lected all completed and returned surveys which were then submitted to principal investi-

gator in a secure manner. About 10 % of the non-responders at two of the institutes with

most number of non-responders, one TCAM (BRKR Ayurvedic) and another allopathic

(Osmania-Sweekar) institute, were contacted randomly using electronic random number

generator. Reasons for their non-response and their r/s characteristics were studied to

understand whether they differed from those who returned the completed survey. The

findings of this short non-responders survey were analyzed and factored into our discussion.

Religion and Spirituality in Medicine: Physician Perspective (RSMPP) (Curlin et al. 2005,

2006, 2007), a self-administered, semi-structured survey questionnaire was used in the study to

understand participants r/s beliefs, practices and their perspectives on its role in clinical

medicine; the wordings of the items in the RSMPP were modified and adapted for usage by

non-physician health care professionals such as nurses and therapists. A specially developed

supplementary questionnaire that included questions to explore participants views on r/s care

in mental health care services was also used. Adaptation of RSMPP and supplementary

questionnaire was developed by a team of investigators from HELP Foundations clinics,

Omaha, using Question Appraisal System-1999 (QAS-99) (Willis and Lessler 1999). The

primary criterion variable was physicians agreement with the following statement: Spiritual

healing has some benefits, and it could be a complement to modern medical treatment

answer choices were strongly agree, agree, disagree or strongly disagree. Predictor variables

were clustered into participants (a) personal r/s characteristics (Table 1), (b) clinical obser-

vations and interpretations of patients spiritual care needs as well as participants attempts to

address them (Table 2) and (c) participants and patients referral/self-referral practices related

to mental health, stigma and spiritual healing (Table 3). The control variables (Table 1)

include participants age, gender and religious affiliation. Obtained data were double entered

with 100 % verification into an Excel spreadsheet and later analyzed using open source,

SigmaXL and Systat statistical software. Overall population estimates for participants r/s

characteristics were obtained and measured against their agreement/disagreement with crite-

rion variable. We utilized the Students t test, Pearsons v2 test and multivariate binomiallogistic regression. Individual institutional breakup of data is not presented in the tables.

Results

The response rate among TCAM group was 48 % (N = 192), while that in allopathy group

was 50.6 % (N = 201). Non-responders data (N = 14, not in the tables) revealed lack of

time as the reason for non-response by six (42.9 %) of them, while the rest, eight

(57.1 %), stated that they forgot to submit (in spite of repeated reminders). All of them

agreed (strongly agree or agree) that spiritual care can be complementary to modern

medical care, i.e., the criterion variable. This group of non-responders and original

responders did not differ in r/s characteristics.

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Demographic Characteristics (Data Not in Tables)

The mean age of participants in the allopathic group was significantly (p = 0.0000) higher

(34.49 years) compared to the TCAM group (29.19 years). Most of (72.4 %) TCAM

responders were in the age group of 20 and 29 years, while only 41.3 % of allopaths

belonged to this group (p = 0.0000). Females formed a larger percentage among TCAM

(63.5 %) as compared to those in allopathic group (53.7 %); gender difference was not

statistically significant (p = 0.1780). Health care professionals participating in this study

included physicians, nurses and therapists; staff physicians and residents in training

together formed most ([84 %) of the participants in both groups. Only 6.8 % of therapyand none of nursing staff responded from TCAM institutes as compared to 17.4 % of

therapists and 14.4 % of nurses responses in allopathic groupthese occupational group

Table 1 Religious/spiritual characteristics of health care professionals in the study

R/S variables TCAM Allopathic Analysis

N = 192 (%) N = 201 (%) v2, df, p value

Religious affiliation

1. Christianity 11 5.73 43 21.39 51.58730.0000

2. Hinduism 124 64.58 133 66.17

3. Islam 49 25.52 7 3.48

4. Others 4 2.08 7 3.48

To what extent do you consider yourself a Religious person? Would you say you are Very religious 45 23.44 16 7.96 17.341

30.0006

Moderately religious 96 50.00 120 59.70

Slightly religious 40 20.83 48 23.88

Not religious at all 8 4.17 10 4.98

To what extent do you consider yourself a Spiritual person? Would you say you are Very spiritual 44 22.92 22 10.95 14.335

30.0025

Moderately spiritual 90 46.88 98 48.76

Slightly spiritual 53 27.60 60 29.85

Not spiritual at all 3 1.56 13 6.47

Belief: Do you believe in God?

Yes 181 94.27 182 90.55 1.64620.4391

No 4 2.08 2 0.99

Undecided 6 3.13 10 4.98

Do you believe there is life after death?

Yes 109 56.77 71 35.32 16.86220.0002

No 45 23.44 55 27.36

Undecided 36 18.75 64 31.84

Do you think God or another supernatural being ever intervenes in patients health?

Yes 129 67.19 109 54.23 6.31620.0425

No 22 11.46 33 16.42

Undecided 37 19.27 52 25.87

Counts do not equal N due to partial non-responses

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Table 2 Physicians clinical observations and interpretations on patients behavior related to their physical,mental and spiritual health needs

Questionnaire item (Q no. inbrackets) on clinical observationsand their interpretation

Response(codes)

TCAM Allopathic Analysisv2, df,p valueN = 192 (%) N = 201 (%)

In your experience, how often haveyour patients received emotionalor practical support from theirreligious community?

Never ? rarely 44 22.92 52 25.87 0.16620.9204

Sometimes 65 33.85 74 36.82

Often ? always 41 21.35 43 21.39

In your experience, how often haveyour patients mentioned r/s issueslike God, prayer, scriptures, etc.?

Never ? rarely 46 23.96 46 22.89 1.18620.5528

Sometimes 72 37.50 71 35.32

Often ? always 35 18.23 46 22.88

Potential negative influences of R/S:considering your experience, howoften do you think R/S causesguilt, anxiety or other negativeemotions that lead to increasedpatient suffering?

Never ? rarely 80 41.67 82 40.80 3.13920.2082

Sometimes 44 22.92 55 27.36

Often ? always 44 22.92 32 15.92

Potential positive influences of R/S:considering your experience, howoften do you think R/S givespatients a positive, hopeful state ofmind?

Never ? rarely 9 4.69 8 3.98 4.43620.1088

Sometimes 42 21.88 42 20.90

Often ? always 142 73.96 129 64.18

General interpretationOverall, how much influence do you

think religion/spirituality has onpatients mental health

Verymuch ? much

153 79.69 141 70.15 3.17720.2042Some 27 14.06 39 19.40

A little/verylittle to none

7 3.65 10 4.98

Is the influence of religion/spirituality on mental healthgenerally positive or negative?

Generallypositive

139 72.40 125 62.19 5.58430.1337Generally

negative10 5.21 6 2.99

Equally positiveand negative

37 19.27 53 26.37

It has noinfluence

3 1.56 6 2.99

In the following clinical situations,how often do you inquire aboutreligious/spiritual issues?

(a)faces a frightening diagnosis orcrisis

Never ? rarely 54 28.13 69 34.33 5.59620.0609

Sometimes 46 23.96 45 22.39

Often ? always 67 34.90 46 22.89

(b) faces the end of life Never ? rarely 27 14.06 62 30.85 23.12220.0000

Sometimes 30 15.63 25 12.44

Often ? always 107 55.73 67 33.33

(c) suffers from anxiety ordepression

Never ? rarely 23 11.98 67 33.33 45.36620.0000

Sometimes 46 23.96 49 24.38

Often ? always 110 57.29 48 23.88


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differences were statistically significant (p = 0.0000). Medical specialties of TCAM and

allopathy cannot be compared because of innate differences in their pathophysiology and

clinical management of illnesses, yet it is to be noted that majority of participants in

TCAM group were internists/general medicine (23.9 %), while those in the allopathic

group were mental health professionals (20.9 %); data not in the tables.

Table 3 Professionals and patients referral/self-referral practices with regard to mental health care

Questionnaire item (Q no. inbrackets) on clinicalobservations and theirinterpretation

Response (codes) TCAM Allopathic Analysisv2, df,p valueN = 192 (%) N = 201 (%)

A patient presents to you withcontinued deep grievingtwo months after the deathof his wife.

If you were to refer thepatient, to which of thefollowing would you preferto refer first?

A religious place forhealing

50 26.04 14 6.97 45.56230.0000TCAM 47 24.48 35 17.41

A psychiatrist orpsychologist

73 38.02 138 68.66

Others (specify) 10 5.21 3 1.49

Please answer to the best ofyour knowledge about thebehavior among the public.

If a patient is severelymentally ill, to which of thefollowing would they preferto visit first?

A religious place forhealing

54 28.13 52 25.87 0.67130.8799TCAM 30 15.62 31 15.42

A psychiatrist orpsychologist

89 46.35 93 46.27

Others (specify) 10 5.21 7 3.48

Public in general tries toconsciously avoid seeing apsychiatrist for any mentalillness:

How true is this statement?

Almost alwaysusually true

137 71.35 158 78.60 7.04540.1336Sometimes true 40 20.83 24 11.94

Usually almost nevertrue

9 4.69 7 3.48

In your experience withreligious/faith healers, haveyou been

Very satisfied 13 6.77 8 3.98 16.92840.0020

Satisfied 80 41.67 54 26.87

Dissatisfied 5 2.60 19 9.45

Very dissatisfied 4 2.08 8 3.98

I have had no priorexperience

86 44.79 101 50.25

Stigma associated withmental illness can bereduced (if not eliminated)by integrating spiritualityinto psychiatry; to whatextent do you agree withthis statement?

Strongly agreeagree 175 91.15 147 73.13 29.86910.0000

Disagreestronglydisagree

2 1.04 33 16.41

Spiritual healing has somebenefits, and it could be acomplement to modernmedical treatment.

Strongly agree 65 33.85 30 14.93 16.64430.0008

Agree 102 53.13 118 58.71

Disagree 13 6.77 16 7.96

Strongly disagree 1 0.52 5 2.49


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Religious/Spiritual Characteristics

Religious affiliations were collapsed into four groupsChristianity, Hinduism, Islam and

Others; the other category included fewer members in categories such as Atheists,

Agnostics, Buddhists and no preference. Participants were predominantly Hindu by

religious affiliation in both the study groups (64.6 % of TCAM and 66.2 % of allopaths).

However, among other religions, there were significant differences between the study

groups (p = 0.0000) with the second most common religious affiliation being Islam

(25.52 %) in TCAM and Christianity (21.39 %) in the allopathic group. Among the

individual TCAM institutes, Hindus predominated in ayurvedic (73 %), Yoganaturopathy

(81 %), Siddha (91.7 %) and homeopathy (87.9 %) institutes, while the largest religious

group in Unani was Islam (93.2 %) (data not in the tables). A significantly greater number

(p \ 0.005) of TCAM participants considered themselves to be very religious (23.44 %compared to 7.96 % of allopathy group) and very spiritual (22.92 % compared to

10.95 % of allopathy group). Significantly (p = 0.0425) larger percentage of TCAM

participants (67.19 %) believed that God or other supernatural being could intervene in

patients health/illness than those in allopathic (54.23 %) group. Again, significantly

greater number (p = 0.0002) of TCAM respondents (56.77 %), compared to allopaths

(35.32 %), believed in the concept of life after death (Table 1).

Clinical Observations and Interpretations on Patients Behavior Related to Their

Physical, Mental and Spiritual Health Needs (Table 2)

Almost equal numbers of TCAM (55.7 %) and allopathic (58.2 %) participants report their

patients bring up r/s issues such as God or prayer or scriptures during their clinical visits.

They also report, almost, in equal numbers (TCAM, 55.2 % and allopaths, 58.2 %) about

their patients receiving (sometimes, often or always) emotional support from their religious

community. Some of the participants in both the groups (45.8 % of TCAM and 43.3 %

allopaths) reportedly believe r/s to have potential negative influence such as to cause guilt,

anxiety and/or negative emotions, while a majority among them (95.8 % TCAM, 85.1 %

allopaths) believe in its potential positive influence such as providing hopeful state of

mind. Overall, a majority in both TCAM and allopathic groups believe that r/s influence

patients mental health (93.8 and 89.6 %, respectively), generally in a positive way (72.4

and 62.2 %, respectively); these differences were not statistically significant. However,

significantly (p = 0.0000) greater percentage of TCAM participants (71.3 %) reported to

inquire r/s needs of their patients facing end of life (as against 55.8 % allopaths) or

suffering from anxiety or depression (81.3 % TCAM vs. 48.2 % allopaths).

Clinical Observations of Patients Mental Health-Seeking Behavior, Interpretations

Thereof and Referral Practices of Professionals (Table 3)

A vignette-based question posed to the participants revealed a significant difference

(p = 0.0000) in the referral practices of TCAM and allopaths; 50.5 % of TCAM physi-

cians would refer a deeply grieving patient (2 months after the death of his wife) to a

religious place of healing or to TCAM professionals, while majority (68.7 %) of allopaths

reported referring such a patient to a psychiatrist or psychologist. However, very inter-

estingly, about a quarter (24.4 %) of allopathic physicians and 38 % of TCAM physicians

reportedly cross-refer such a grieving patient to a religious/TCAM healer and psychiatrist/

psychologist, respectively. About 91 % of participants in both the study groups believe

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public to consciously avoid seeing a psychiatrist for any mental illness; another clinical

vignette-based question revealed almost equal numbers of TCAM (43.7 %), and allopaths

(41.3 %) believe that severely mentally ill patients, among the general public, to be

visiting a religious/TCAM healers, while about 46 % of participants in both the groups

believe public to be approaching a psychiatrist/psychologist. Of those professionals who

had experience with r/s healers, 90.6 % of TCAM as against 62 % of allopathic profes-

sionals reported satisfaction with those spiritual healers (p = 0.0019). A majority in both

the groups (91.2 % TCAM and 73.1 % allopaths) agree that stigma associated with mental

illness can be reduced (if not eliminated) by integrating spirituality into psychiatry, yet the

difference was significant (p = 0.0000). And, as hypothesized, a significantly

(p = 0.0008) greater percentage (87 %) of TCAM professionals as against 73.6 % of

allopaths agreed with the criterion variable; spiritual healing to be complementary to

modern medical treatment; the findings hold good even after statistically controlling for

age and religion variables, and religious affiliation does not affect the referral practices

(data not in tables).

Multivariate Binomial Logistic Regression (Table 4)

Significant variables from parametric tests were included in a stepwise manner, creating

three different models of binomial logistic regression to test their predictability of the

criterion variable. We evaluated the predictability of the models by the area under ROC

(receiver-operating characteristic) curve (AUC). In the first and second models, partici-

pants personal spiritual characteristic was the significant predictor (p B 0.005). How-

ever, in the final model, rather than personal r/s characteristics, clinical behavior such as

physicians attention/inquiries into patients r/s needs (during patients anxiety and

depression, odds ratio 0.244) and referring (deeply grieving) patient to specialists (r/s

places vs. TCAM healers or psychiatrists, odds ratio 1.145) influenced the predictive

outcome. Participants belief that integration of spiritual and psychiatric services will

alleviate stigma was yet another predictor (odds ratio 2.119). Though the predictability of

this final model improved over first and second models (area under ROC increased from

0.747 to 0.910; McFaddens Rho-square improved from 0.099 to 0.367), the sensitivity did

not improve much as compared to specificity.

Discussion

This is probably the first of the scientific papers from India to report on the perspectives

and practices of health care professionals from two differing, often at loggerheads, medical

systems, TCAM and allopathy. Though, as we hypothesized, TCAM professionals pre-

ferred to refer a deeply grieving patient to religious/TCAM healers, it is also evident that

even allopathic professionals, up to a fourth of them, report to refer such patients to

religious/TCAM healers. On the same note, a large percent of TCAM professionals were

also reportedly referring mentally disturbed patients to psychiatrists. This cross-referral

behavior of TCAM and allopathic professionals may be indicative of their belief in a

collaborative approach to mental health care. No doubt, majority of participants in both the

groups agree on the possibility of stigma alleviation by integrating spiritual and psychiatric

services. Though the survey questionnaires were equally distributed to medical profes-

sionals in all the departments in our allopathic group, mental health professionals formed

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the majority of specialists to complete and submit their responses, perhaps indicating a

greater comfort with spiritualitypsychiatry collaboration?

There are several limitations of the study. The institutions were not randomly selected;

respondents belong to diverse health disciplines, with an overrepresentation of trained

mental health professionals among the allopathic respondents. It is also to be noted that

medical specialties in TCAM and allopathic and TCAM professional allopathy cannot be

compared because of innate differences in their understanding of pathophysiology and

clinical management of illnesses. Participation was voluntary, with approximately less than

half the respondents completing the survey. On methodology and statistical analysis, self-

reported surveys are imperfect measures of actual practices; religious and other charac-

teristics may have systematically affected physicians willingness to respond in non-

measurable ways. Notwithstanding the significant results, noticeable imbalance across

covariate groups was observed. Alternate approaches were proposed that meant collapsing

the lower sample categories into one or other existing category to increase the overall

power, so we can strongly conclude with significant results. This will need additional

resources as well as further improvement in data collection, management, analysis and/or

computation.

Implications of this Study

This study can be considered as one of the firsts of collaborative partnerships between

TCAM and allopathic professionals for studying ways to improve mental health services in

India. This is the first of its kind of studies which focuses on the role of spirituality in

mitigating stigma to mental illness and mental health institutions. As the Indian mental

health program tries to find ways to improve its services, findings from this study may

encourage policy makers to understand the importance of including spiritual care provider

into health care services. However, such services and those spiritual care professionals may

need to be trained in the evidence-based model of care; this brings us to our understanding

on the need for developing spiritual care departments and education programs, such as

Clinical Pastoral Education (CPE, http://www.acpe.edu/), as seen in USA, Canada, UK,

Australia and few other advanced/developed nations. While such hospital-based spiritual

care services is a need in India and other developing nations, the subject of spirituality may

also form the basis for integrating TCAM and allopathic medical education programs

(Ramakrishnan et al. 2013). It may also lead to integration of hospital- and community-

based r/s institutions for continuity in patients spiritual care needs following hospital

discharge. Findings from this paper recognize the potential of supportive mental health

care services of r/s communities in the society. Our suggestions for developing such

institutions also allude to preventing disasters from non-scientific and unethical/non-

humane practices at spiritual institutions such as Erawadi (Quack 2012; Antony 2002;

Selvaraj and Kuruvilla 2001; Murthy 2001; Trivedi 2001). We may need further studies to

understand ways of developing integrative spiritual care programs in hospital settings in

India.

Conclusions

Spirituality and modern medical/psychiatric services can complement each other to pro-

vide holistic care to mentally ill patients. Integration with spiritual care services may infuse

spiritual components of compassion, empathy and other esthetics into the care process to

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123


provide a validating and nonthreatening environment reminiscent of r/s institutions that the

public prefers as their choice for their mentally ill patients. The findings from this study

may provide compelling reasons for developing spiritual care services and educational

programs to be implemented in Indian medical educational institutions and especially

mental health care programs. Development of hospital-based programs for spiritual care

services may not only alleviate stigma and improve usage of mental health programs but

also form a scientific role model for the community-based r/s institutions serving mentally

ill patients in the society.

Acknowledgments This study was made possible by the generosity in time, personal and financial supportof HELP and AdiBhat Foundations in USA and India, respectively. HELP Foundation is a nonprofitorganization in Omaha, NE, USA, serving the underprivileged population with its community-based urgentcare clinics. AdiBhat is a nonprofit organization founded in New Delhi to develop spirituality as a medicalsubject. We would like to profusely thank Dr. F. A. Curlin (University of Illinois, Chicago, Illinois, USA)for providing their RSMPP survey questionnaire and allowing us to adapt it to the cultural and technicalneeds of our study in India. We appreciate the support of Dr. Vijay Kumar, Commissioner of the Statedepartment of AYUSH, for permitting us to conduct the study at the AYUSH institutes in Hyderabad,Andhra Pradesh. We would sincerely thank Dean, Dr. V. N. Jindal, for his permission to conduct the study atGoa Medical College, Goa. Thanks to Dr. M. S. Kulkarni at Goa Medical College and Dr. S. Gandham,University of Washington, for their invaluable statistical inputs. We also like to appreciate all the staff atHELP Foundation for participating in the focus group discussions and other research processes leading tothe development of our supplementary survey questionnaire. Finally, we would like to thank all our researchrespondents for donating their invaluable time and providing their opinions and perspectives toward asuccessful completion of this study.

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Indian Health Care Professionals Attitude Towards Spiritual Healing and Its Role in Alleviating Stigma of Psychiatric ServicesAbstractIntroductionMaterials and MethodsResultsDemographic Characteristics (Data Not in Tables)Religious/Spiritual CharacteristicsClinical Observations and Interpretations on Patients Behavior Related to Their Physical, Mental and Spiritual Health Needs (Table 2)Clinical Observations of Patients Mental Health-Seeking Behavior, Interpretations Thereof and Referral Practices of Professionals (Table 3)Multivariate Binomial Logistic Regression (Table 4)

DiscussionImplications of this Study

ConclusionsAcknowledgmentsReferences

Documents

Indian Physician's Perspectives on Spirtuality and Stigma Aliviation in Psychiatry-Ramakrishnan Et Al JRH Jan 2014