Medicine: What’s spirituality got to do with it?
August 2024 Issue
Dr. Tarinee Kucchal, MBBS, Research Fellow for the Leadership & Happiness Laboratory
My family has recently started asking me when I will start having kids. I jokingly tell them I already have a hyperactive toddler: my husband. Life with Shan is interesting. On one level, Shan could put the Energizer Bunny to shame. Where most people use their weekends to rest and recover, Shan will find a way to utilize every minute of the day with some form of activity. If there is a spare 30 minutes in the day, he will find something to do with it. He calls it “optimization,” and it inevitably ends in us running back-to-back all over Manhattan—gym, basketball, breakfast meeting, bike, tennis, coffee catch up, bike again, lunch date, picnic party, second coffee catchup, soccer, drinks, dinner date, birthday drinks, movie. We can average 5 to 6 social engagements a day—and that is just Saturday. Even as we are on a holiday right now (and as he peers over my shoulder, watching me write this piece), I feel the need to return home to take a break from our break.
On another level, things that should be simple often aren’t. While he is highly effective in his work environment, at home it can be a different story. Booking an Uber is accompanied by distractions in his email, LinkedIn, and Facebook because they happened to be open. Giving instructions is generally accomplished with multiple interruptions and him rushing to do the task before you’re done talking. When things are done, it is often with shortcuts or missing details that require you to redo the task yourself. Meanwhile, the same man that can leave his clean laundry piled on the office chair for days because he is easily distracted from the task, is also the same man that will vehemently insist on doing the laundry because there is a spare five minutes before dinner guests arrive. Even the unconditional love of a wife doesn’t stop you from looking at him and wondering, “What on earth is going on in that brain?”
I was recently lamenting over such frustrations with one of my best friends, Isioma. Isi and I met on a medical research fellowship and quickly became like sisters. As Isi listened and laughed at stories of my husband’s proclivities, she eventually asked, “He doesn’t have ADHD, does he?”. The question made me pause. If it were anyone else, I may have brushed it off, but Isi is also a physician and a keenly observant one at that. I always accepted Shan as he was, chalking much of it up to standard husband behavior, but perhaps she had a point? Sometimes, the closer you are to something, the harder it is to see.
The DSM Criteria
The DSM (Diagnostic and Statistical Manual of Mental Disorders) has been the cornerstone of diagnostics in western psychology and psychiatry since 1952, when the DSM-1 was first published after World War II. Now in its fifth iteration, the DSM continues to be used by clinicians around the world.
To fulfill a clinical diagnosis of ADHD, an individual must demonstrate at least 5 of 18 diagnostic criteria for at least 6 months, to a degree that is maladaptive and inconsistent with their developmental level. In the United States, an estimated 7 million US children aged 3-17 years and 8.7 million adults met this criterion in 2022, and most recent evidence indicates that the prevalence of ADHD has steadily increased year on year, from 6.1% in 1997, to 10.2% in 2016. But experts continue to debate and disagree on the cause for this trend. Granted, many of these individuals will have an irrefutable diagnosis that requires medical intervention, but are the rates of ADHD genuinely increasing, or are we simply over-diagnosing and medicalizing people’s personality traits?
In the case of my husband, he clearly meets 7 of the 15 criteria, while another four could be argued over as a matter of perspective. His symptoms have remained consistent over a lifetime. My mother-in-law often shares stories of him running between four to six activities a day as a child, to quite literally calling him down for dinner as an adult, only to realize he was in Abu Dhabi that evening. She frequently laments she could never keep up with him and wished he would slow down. Our loved ones frequently joke “it’s impossible to keep up with Shan,” while others observe and sometimes admire how intense his life and personality are. Yet, at no point has his behavior appeared maladaptive or inconsistent with his developmental age. Shan was awarded a scholarship to attend a prestigious international boarding school, went on to become a lawyer admitted to the Australian supreme court, was an army officer with the Singapore military and is now a director of a private-equity fund. On all accounts, he is a successful individual with a thriving life. So, if Shan technically meets the criteria for ADHD, why has it not become maladaptive? Could it be that he has been exceptionally good at choosing environments and a profession that allows him to thrive? Has he tailored his life in a way where his tendencies are a strength and not a weakness? Perhaps he has been exceptionally fortunate to be surrounded by people that not only fill the gaps, but also embrace him as he is. We have all come to accept that much of what could be deemed pathological, is just in his nature.
Nature vs Nurture vs Metaphysical Nature
The scientific community loves the age-old debate of nature versus nurture. We have gone to great lengths to try to quantify and measure the difference. Our reliance on the scientific method takes (ironically) immeasurable importance: We ask a question, form our hypothesis and then most crucially we test that hypothesis through objective, controlled methodology using the most innovative medical technologies available to us today. But what happens when the scientific method meets its limit? Beyond our observable, measurable world lies a world of spiritual and metaphysical understanding we still struggle to comprehend.
In 1987, Dr. Jacobo Grinberg at the University of Mexico ran a series of experiments that demonstrated synchronized brain-wave patterns and shared neural responses between individuals in separate, electromagnetically shielded rooms after they intentionally bonded through meditation. Put differently, they were spiritually connected. More recently, Dr. Lisa Miller and her team at Columbia University have been researching the connection between spirituality, religion and mental health and wellbeing. So, in the debate between nature versus nurture, could we be missing a third element entirely? The metaphysical nature?
Hinduism and its associated philosophy of Vedanta, something my husband and I both follow, is predicated on the belief that our true nature is infinite happiness, and our purpose in life is to realize this. Dharma, an idea for which there is no simple translation, can be seen as purpose, duty, or right action. It refers to behaviors that are in accordance with the natural underlying order of life. When we are born, we have no conscious awareness of what our unique dharma is in the universe. Unfortunately, we weren’t born with operating manuals. Instead, we must look at our true nature, our swabhava—our inherent nature that is not dictated by one’s genetics or created in time, but tendencies, inclinations, and dispositions. It is shaped by two things: the impressions left by actions from past lives, and what your dharma is in this life. Think of your swabhava as a toolkit gifted to you at birth, to achieve your purpose for this lifetime. Fire is a simple example; its purpose is to heat or burn. Therefore, fire’s nature is to be hot, and it would be unreasonable to expect it to be cold.
Shan’s swabhava is that of someone driven, activity-prone, on-the-go, juggling multiple things at any given time, and unable to sit still. He can process lots of information and distill it quickly, and his mind moves quickly. He is profoundly extroverted, outgoing and is comfortable with risk and uncertainty. While we all feel exhausted looking at him, and cannot understand how he functions, Shan’s swabhava has always been well-suited for his career choices, be it the military, law, and now private equity. It’s not that he can simply keep up in these professions. It’s that he thrives in it.
So, science says Shan has ADHD, and spirituality says it’s his metaphysical nature. Perhaps both are correct.
The Neurodiversity/Neuroaffirming Paradigm
Modern psychology has begun to embrace what religion and spirituality may have known for a long time. While Hinduism calls it swabhava, psychology has increasingly explored the construct of neurodivergence and neuroaffirmation. Developed by autism activists in the 1990s, neurodiversity challenges traditional medical deficit-based models of disability and reframes it as the embracing of brains that are simply different from the average, “neurotypical” population. It sees each person’s neurotype as unique to them, each with their own strengths, interests and supporting needs, much like spirituality may embrace someone’s differences as their swabhava. “Different” is no longer maladaptive—it’s just different. Neurodivergence can refer to those with autism, ADHD, dyslexia, and other profiles.
Along with the evolution in perspective, there has also been an evolution in care models. Traditional care models ask individuals to mask their neurodivergent traits, forcing them to fit into society’s definition of “normal” and puts the onus of adaptation on the individual. By contrast, the more modern approach of neuroaffirming care takes a person-centered strength-based approach that embraces uniqueness and emphasizes adaptation of the environment to individual needs. Instead of asking a square peg to fit a round hole, you are carving the round hole to accommodate a square peg.
It is easy to argue that this paradigm shift is almost vedantic, or spiritual. Where in Hinduism we strive to live a life in alignment with our true nature or swabhava, leaning into our uniqueness to find environments and communities in which we thrive to fulfill our purpose, the neuroaffirming approach similarly leans into one’s uniqueness, to adapt environments and communities so that an individual can live a full and purposeful life. While limited evidence exists on the efficacy of neuroaffirming techniques, zero evidence disproves such techniques in any substantial way. It behooves the rest of the medical field to consider how it can also move forward.
Modern Medicine and Spirituality
As medical students, one of the first things we are taught is how to take a history. It includes the presenting complaint, past medical history, a “social history” that is limited to social behavior such as drinking and smoking, and a medication record. It becomes abundantly obvious that contemporary medicine and psychology see spirituality and religion as separate, and almost irrelevant, to clinical practice. On the rare occasion that we consider broaching the subject, we are often managing terminal or palliative patients. Considered an advancement at the time, Michael and Tracy Balboni’s 2018 book Hostility to Hospitality explored the indelible connection between medicine and spirituality and the practice challenges faced in incorporating these principles. Unfortunately, it is still only discussed in the context of serious illness, and remains aligned with an underlying assumption that you must either be dying or at death’s door for religion and spirituality to be relevant. Whether it is fear, or ignorance, there is a resistance toward the metaphysical in non-palliative medicine. In her book, The Awakened Brain, Lisa Miller writes extensively about the resistance she and her team faced in integrating spiritual research and understanding to clinical psychology. The neurodivergence paradigm itself hardly seems like a conscious choice by the field to embrace spirituality, but rather a welcome coincidence.
This isn’t a question about reintroducing spirituality into medicine. Medicine practiced in Mesopotamia, Egypt, and Asia Minor was underpinned by religion, where diseases were seen as violations of the world order, and physicians and priests were often one in the same. The entire art of healing was metaphysically oriented. It was Hippocrates, the father of modern medicine, who took the first decisive steps towards scientific methods by emancipating medicine from religious concepts.
I am not arguing that we ought to backtrack to pre-scientific methods. Quite the contrary: I envision a future in medicine in which we demonstrate sufficient humility about what we do and don’t know—which means leaning on the scientific method, while also venturing into the metaphysical realm that cannot be neatly captured by bench science. In 1977, George Engle moved us from the biomedical model to the biopsychosocial model that acknowledged the mind-body-society connection. Many are now asking if we are ready to take the next step toward the biopsychosocial-spiritual model, and what would that look like? Incorporating spirituality, the constructs of the metaphysical, and heightened consciousness with psychology and psychiatry feels intuitive. It is less so with other specialities.
The first challenge is for clinicians to understand what spirituality is. Today spirituality is a fluid concept that for some can be religious, and for others it is not. The most comprehensive definition I have come across thus far defines spirituality as “the search for ultimate meaning, purpose and significance, in relation to oneself, family, others, community, nature, and the sacred, expressed through beliefs, values, traditions and practices”. We are all spiritual beings, even if you are atheist. Therefore, incorporating spirituality into medicine begins with asking what spirituality means to a patient. Adapted from palliative care practices, a spiritual history invites patients to share their spiritual, religious, or existential issues, concerns, beliefs, or practices. Working with your patient, you can begin adapting your clinical approach to their spiritual needs, and research shows that the majority of patients welcome discussions on spirituality-religion, and doing so strengthens trust in the doctor-patient relationship. This starts by introducing spiritual education into medical education. In 1900, fewer than five medical schools in the United States taught students about the role of spirituality in the lives of sick patients. By 2015, over 90 percent of U.S. medical schools either contained required or elective courses on religion, spirituality and medicine. The extent to which this translates to clinical practice is uncertain.
This brings us to our next challenge—that is, understanding how implementing spiritually-informed care influences clinical outcomes. Several studies have indicated that those who consider themselves spiritual-religious experience lower levels of pain intensity and a higher pain tolerance. In clinical psychology we are starting to understand how spirituality is protective against depression and anxiety. Unfortunately, if you are a surgeon, I can’t tell you that praying with your patient before surgery will statistically significantly reduce their recovery time. The evidence doesn’t currently exist. That doesn’t mean there isn’t a relationship, but we have to start asking the right questions. Our colleagues in psychology have started to focus their research specifically on the question of spirituality and spiritual interventions on mental health outcomes, and they do it using our beloved scientific method. The same must now be done by the rest of the medical academic world to understand the direct relationship between spirituality and physical health.
The final, and possibly most difficult, challenge of incorporating spirituality in medicine is to ask what spirituality means to us, the healthcare professionals. While there are documented benefits such as a greater sense of purpose and fulfillment, wellbeing, less burnout and better coping, we have to face the reality that until we begin to see ourselves as spiritual beings, practicing in a spiritual environment, our profession and practice cannot evolve beyond the constraints of the scientific method.
To venture into the possibility of the metaphysical may seem like a tall order, but I promise you it's not. It was only eight years ago that I was introduced to this world, when my perspective dramatically shifted. Before that, I too was a little skeptical. The key is to be open to the possibilities. Likewise, meeting Shan pushed my boundaries, and while he could be considered neurodivergent, he has opened up my mind to a different way of living and thinking.
However, this shift in mindset was only possible because I saw his differences as his version of “normal”. By accepting the difference, I was able to expand my own construct of what is possible and elevate my own life. So, start by taking stock of the “Shans” in your life —perhaps even take stock of our own “Shan-ness”! Eventually, I hope you too will come to understand there are other ways to understand this world, and I hope the medical field will learn to understand itself in a different, more expansive way. And with a healthy dose of curiosity and humility, we can prepare ourselves for an exciting intellectual, and metaphysical, adventure.
Contributing editor: Bryce Fuemmeler