As a medical student, you will encounter mental ill-health across the specialities through which you rotate. As a future doctor, you will continue to encounter it in the patients for whom you care. Indeed, it will almost certainly feature in many other aspects of your life: fellow students, friends, family, church members, even you, could all be affected. How can you best prepare yourself to engage with psychiatry now, as a medical student?

As a psychiatrist, I have reflected back on my years as a medical student to provide a practical framework to help you navigate some of the challenges and unique opportunities that may present themselves to you in the face of mental illness. I will focus on two broad themes: How does psychiatry sit within our world view as Christians? And, as a Christian, how can I effectively engage with those with mental illness?

I will cover a number of different issues that are important to be thinking about as one develops into a Christian doctor, so resources are suggested for further reading.

how does psychiatry sit within our world view as Christians?

From your earliest exposure to psychiatry, you will be encouraged to think about (and structure exam answers around!) psychopathology from a 'biopsychosocial' perspective, considering the biological, psychological and social explanations for an individual's condition. Begin thinking now about the spiritual dimension. Regardless of whether or not the individual is a Christian, there will often be a spiritual aspect to the aetiology of their presentation, which can also influence how they respond to mental illness. This may not yet have been explored by health staff but is a central aspect of holistic history taking.

mental illness as a form of suffering

Mental illness is one of many examples of suffering that we see in our world. The creation story in Genesis helps us begin to make sense of suffering, though we may never during this life fully understand suffering, especially when we are in the midst of it. In Genesis, we are told that God created the world and that it was 'very good'. (1) We then learn of how, through man's disobedience, sin and suffering entered the world (2) and separated us from God.

The Bible is full of examples of profound struggling. The classic example is that of Job, who lost everything that was important to him in his life, even the support of his friends and family. Job appears to experience symptoms of depression. However, we also learn of how Job reached a point at which he had a renewed sense of faith and reliance on God through this experience. Indeed, in Hebrews 12, we are reminded that 'No discipline seems pleasant at the time, but painful. Later on, however, it produces a harvest of righteousness and peace for those who have been trained by it' (Hebrews 12:11). In my experience, this is far easier (although still extremely challenging) to reconcile at a theoretical level than when faced with individual or (worse) personal suffering. Yet the examples of healing performed by Jesus remind us that God will in time deliver us from our state of suffering and will use that to reveal his glory. (3)

mental illness as the work of Satan

We also read in the New Testament of Jesus casting out demons. (4) While demonic possession may occasionally play a part in a patient's presentation, we should also remember the other parts of our biopsychosocial formulation; for example there is good evidence for the role of biological influences on a number of psychiatric conditions. There may also be less direct ways in which Satan may play a role in somebody's mental illness; for example, through temptation or spiritual attack people may sometimes make life choices that lead to a decline in their mental health or cause them to misuse substances.

Often, we may not fully understand what has caused a person to become mentally unwell. Uncertainty is a challenge that we face in many areas of life as Christians, so too in medicine. Yet God knows. Isaiah 55:8-9 says: '"For my thoughts are not your thoughts, neither are your ways my ways", declares the Lord. "As the heavens are higher than the earth, so are my ways higher than your ways and my thoughts than your thoughts"'.

as a Christian, how can I effectively engage with those with mental illness?

By reflecting on our own views of mental illness we can better engage with those experiencing it. Reflection can also help us offer hope of an eternity free of pain and suffering, and a restored relationship with our Heavenly Father through Christ's death on the cross.

spiritual history taking

Only when we know where a patient has come from, can we truly understand them in the present and have a sense of where we might lead them. This is the essence of history taking in any speciality and a spiritual history is at the core of it. I'm pleased to say that, in my experience, I've met few psychiatrists who are opposed to the principle. A single question such as 'do you have a faith that helps you when you are struggling?' can suffice or it can open doors to sharing your own faith sensitively. Remember, you will never have more time with patients than you do now as a medical student.

what does the GMC say about taking a spiritual history in 'Good Medical Practice'?

'Adequately assess the patient's conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values.'

'It may therefore be appropriate to ask a patient about their personal beliefs. However, you must not put pressure on a patient to discuss or justify their beliefs, or the absence of them.' (5)

As a Christian medical student, what an opportunity you have to offer something unique and life-changing to those facing the fear and despair of mental illness. You have the gospel! You have good news!

CMF's Saline Solution course looks at how we can share the Gospel sensitively and with regard to GMC Guidelines.

it's okay not to be able to help everybody all the time

Despite this, it is important to maintain perspective of oneself as working for God but not being God. God encourages us to rest. 6 As Christians our primary identity should be as a child of God and not as a doctor. You cannot hope to know all, cure all, heal all, so when it is challenged remember your primary identity. Psychiatry is famous for 'not curing people'. In fact, most of medicine is like that; chronicity is the mainstay these days, but lives can be improved nonetheless. That's okay. On a similar note, in the same way as you cannot hope to reach the whole world with the gospel, you cannot expect to have illuminating conversations with every patient. I stress this as it is easy to become absorbed in kingdom building activity and to forget to rest; establish habits of rest now as a medical student and seek to maintain them as you enter the world of work.

Know also that the patients you will like the least are often the ones you feel as though you can help the least. I am thinking particularly of patients with personality disorder (although there are plenty of management options for these patients), encountered mostly in psychiatry but when you will likely encounter at various points in your medical journey. It is okay not to like all of your patients. Have the self-insight to note when you feel negatively towards a patient and you will be in possession of a degree of self-awareness that eludes most doctors. However, remember as a Christian, that you can pray for patients with whom you have had contact at the beginning or end of the working day.

conclusion

In conclusion, encounters with those suffering with mental illness, whether it be on your psychiatry rotation or outside it, present a number of challenges but also some unique opportunities to us as Christians. It is important to be prepared for these encounters as a medical student, but also throughout your working life as a doctor.

Claire Wilson is a psychiatry trainee in London and CMF psychiatry link

taking a spiritual history

opening questions

Ideas: 'Do you have a faith that helps you when you are struggling?' 'Do you have a faith that helps you at times like these?' 'What gives you hope?' 'What keeps you going in difficult times?' 'What gives you meaning or purpose in your life?'

spiritual past

• Establish their world view.
• Has this changed during their life? Any threats to spirituality in the past? eg any major losses or mistreatment? How has this affected them?

spiritual present

• If not done already, elicit what their current beliefs are.
• Do they feel valued and that their beliefs are respected? Are they able to share their ideas openly? Do they feel that there may be a spiritual element to their current problem?
• Would they like support?

spiritual future

• Explore hopes and fears about the future. Are they worried about death and dying?

next steps

• What support, if any, would they like? Who do they confide in?
• What is available? Explore ideas with them eg within their faith community, family or friends; voluntary organisations; with faith-based counselling and hospital chaplains.

resources

further reading on mental illness and Christianity

• The Problem of Pain by CS Lewis
• Mad, Bad or Sad? edited by M Dominic Beer and Nigel D Pocock (reviewed in this edition of Nucleus - page 41)
• CMF files 32: Human suffering
• CMF files 53: Depression and cognitive behavioural therapy
• CMF files 58: Is Christian faith delusion?
• CMF files 64: Mindfulness

All CMF files are available at: cmf.org.uk/resources/publications/cmf-files

• Mindful of the Light by Stephen Critchlow. Provides helpful ways of explaining mental illness to patients.
• Tackling Mental Illness Together by Alan Thomas. Explores the church's role in supporting those with mental illness.
• Mind and Soul Foundation (www.mindandsoulfoundation.org)
• Royal College of Psychiatrists Spirituality and Psychiatry Special Interest Group (bit.ly/2y0gCj5)