Religion, Spirituality, and Mental HealthPublished on Psychiatric Times(http://www.psychiatrictimes.com)

Religion, Spirituality, and Mental HealthJanuary 10, 2010 | Schizophrenia [1], Cultural Psychiatry [2], Dependent Personality Disorder [3],Histrionic Personality Disorder [4], Major Depressive Disorder [5], Alcohol Abuse [6]By Simon Dein, FRCPsych, PhD [7]

Until the early 19th century, psychiatry and religion were closely connected. Religious institutionswere responsible for the care of the mentally ill. A major change occurred when Charcot1 and hispupil Freud2 associated religion with hysteria and neurosis. This created a divide between religionand mental health care, which has continued until recently. Psychiatry has a long tradition ofdismissing and attacking religious experience. Religion has often been seen by mental healthprofessionals in Western societies as irrational, outdated, and dependency forming and has beenviewed to result in emotional instability.3

Until the early 19th century, psychiatry and religion wereclosely connected. Religious institutions were responsible for the care of the mentally ill. A majorchange occurred when Charcot1 and his pupil Freud2 associated religion with hysteria and neurosis.This created a divide between religion and mental health care, which has continued until recently.Psychiatry has a long tradition of dismissing and attacking religious experience. Religion has oftenbeen seen by mental health professionals in Western societies as irrational, outdated, anddependency forming and has been viewed to result in emotional instability.3

In 1980, Albert Ellis,4 the founder of rational emotive therapy, wrote in the Journal of Consulting andClinical Psychology that there was an irrefutable causal relationship between religion and emotionaland mental illness. According to Canadian psychiatrist Wendall Watters, “Christian doctrine andliturgy have been shown to discourage the development of adult coping behaviors and the human tohuman relationship skills that enable people to cope in an adaptive way with the anxiety caused bystress.”5(p148) At its most extreme, all religious experience has been labeled as psychosis.6Psychiatrists are generally less religious than their patients and, therefore, they have not valued therole of religious factors in helping patients cope with their illnesses.7 It is only in the past few yearsthat attitudes toward religion have changed among mental health professionals. In 1994, “religiousor spiritual problems” was introduced in DSM-IV as a new diagnostic category that invitedprofessionals to respect the patient’s beliefs and rituals. Recently, there has been a burgeoning of

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Religion, Spirituality, and Mental HealthPublished on Psychiatric Times(http://www.psychiatrictimes.com)

systematic research into religion, spirituality, and mental health. A literature search before 2000identified 724 quantitative studies, and since that time, research in this area has increaseddramatically.8 The evidence suggests that, on balance, religious involvement is generally conduciveto better mental health. In addition, patients with psychiatric disorders frequently use religion tocope with their distress.9,10

In recent studies, at least 50%of psychiatrists interviewed endorse the view that it is appropriate to inquire about their patients’religious lives.11-13 That patients’ religious concerns have been taken seriously is evidenced by thefact that the American Psychiatric Association has issued practice guidelines regarding conflictsbetween psychiatrists’ personal religious beliefs and psychiatric practice. The Accreditation Councilfor Graduate Medical Education includes in its psychiatric training requirement, didactic and clinicalinstruction on religion and spirituality in psychiatric care.Religion and depressionStudies among adults reveal fairly consistent relationships between levels of religiosity anddepressive disorders that are significant and inverse.8,14 Religious factors become more potent as lifestress increases.15 Koenig and colleagues8 highlight the fact that before 2000, more than 100quantitative studies examined the relationships between religion and depression. Of 93observational studies, two-thirds found lower rates of depressive disorder with fewer depressivesymptoms in persons who were more religious. In 34 studies that did not find a similar relationship,only 4 found that being religious was associated with more depression. Of 22 longitudinal studies, 15found that greater religiousness predicted mild symptoms and faster remission at follow-up.Smith and colleagues14 conducted a meta-analysis of 147 studies that involved nearly 100,000subjects. The average inverse correlation between religious involvement and depression was 20.1,which increased to 0.15 in stressed populations. Religion has been found to enhance remission inpatients with medical and psychiatric disease who have established depression.16,17 The vastmajority of these studies have focused on Christianity; there is a lack of research on other religiousgroups. Some research indicates an increased prevalence of depression among Jews.18

Depression is important to treat not just because of the emotional distress but also because of theincreased risk of suicide. In a systematic review that examined 68 studies, researchers looked for arelationship between religion and suicide.8 Among these, 57 studies reported fewer suicides or morenegative attitudes toward suicide among the more religious. In a recent Canadian cross-sectionalstudy, religious attendance was associated with decreased suicide attempts in the generalpopulation and in those with a mental illness, independent of the effects of socialsupports.19 Religious teachings may prevent suicide, but social support, comfort, and meaningderived from religious belief also are important.More recent studies indicate that the relationship between religion and depression may be morecomplex than previously shown. All religious beliefs and variables are not necessarily related tobetter mental health. Factors such as denomination, race, sex, and types of religious coping mayaffect the relationship between religion or spirituality and depression.20,21 Negative religious coping(being angry with God, feeling let down), endorsing negative support from the religious community,

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Religion, Spirituality, and Mental HealthPublished on Psychiatric Times(http://www.psychiatrictimes.com)

and loss of faith correlate with higher depression scores.22 As Pargament and colleagues23(p521) state,“It is not enough to know that the individual prays, attends church, or watches religious television.Measures of religious coping should specify how the individual is making use of religion tounderstand and deal with stressors.”Very few studies have specifically addressed the relationship between spirituality and depression. Insome instances, spirituality (as opposed to religion) might be associated with higher rates ofdepression.24 On the other hand, there is a substantial negative association between spirituality andthe prevalence of depressive illness, particularly in patients with cancer.25,26

Anxiety, religion, and spiritualityGiven the ubiquity of anxiety and religion, it is surprising how little research has been done withrespect to the relationship between the two. The investigation of religious and spiritual issues inanxiety lags behind research on mental disorders such as depression and psychosis. Religiousbeliefs, practices, and coping may increase the prevalence of anxiety through the induction of guiltand fear. On the other hand, religious beliefs may provide solace to those who are fearful andanxious. Studies on anxiety and religion have yielded mixed and often contradictory results that maybe attributed to a lack of standardized measures, poor sampling procedures, failure to control forthreats to validity, limited assessment of anxiety, experimenter bias, and poor operationalization ofreligious constructs.27

Some studies have examined the relationships between religiosity and specific anxiety disorderssuch as obsessive-compulsive disorder and posttraumatic stress disorder (PTSD). Contrary to theviews of Freud,28 who saw religion as a form of universal obsessional neurosis, the empiricalevidence suggests that religion is associated with higher levels of obsessional personality traits butnot with higher levels of obsessional symptoms. Religion may encourage people to be scrupulous,but not to an obsessional extent.29,30 Although religion has been found to positively affect the abilityto cope with trauma and may deepen one’s religious experience, others have found that religion haslittle or negative effect on symptoms of PTSD.31

The relationships between generalized anxiety and religious involvement appear to be complex. In acomprehensive review of the relationship between religion and generalized anxiety in 7 clinical trialsand 69 observational studies, Koenig and colleagues8 found that half of these studies demonstratedlower levels of anxiety among more religious people, 17 studies reported no association, 7 reportedmixed results, and 10 suggested increased anxiety among the more religious.A person’s strong religious beliefs may facilitate coping with existential issues whereas those whohold weaker beliefs or question their beliefs may demonstrate heightened anxiety.32 Thesecontradictory findings may be accounted for by the fact that researchers have used diversemeasures of religiosity. Other studies have focused on death anxiety. Research conducted in theUnited States and abroad points to denominational differences as well as to differential effects ofreligion and spirituality and emphasizes the complex relationships between religious and culturalfactors.33 Studies on anxiety and religion to date have emphasized cognitive aspects of anxiety asopposed to the physiological aspects. Future studies should include physiological parameters.A number of pathways have been discussed in the literature through which religion/spiritualityinfluence depression/anxiety: increased social support; less drug abuse; and the importance ofpositive emotions, such as altruism, gratitude, and forgiveness in the lives of those who are religious.In addition, religion promotes a positive worldview, answers some of the why questions, promotesmeaning, can discourage maladaptive coping, and promotes other-directedness.Religion and coping in schizophreniaResearch in schizophrenia and religion has predominantly examined religious delusions andhallucinations with religious content. Recently, however, religion as a coping strategy and factor inrecovery has been the subject of growing interest.34 Religious delusions have been associated withpoorer outcomes, poorer adherence to treatment, and a more severe course of illness.35

A number of studies suggest that religious beliefs and practices can be a central feature in therecovery process and reconstruction of a functional sense of self in psychosis.36 On the other hand,Mohr and colleagues37 found that although religion instilled hope, purpose, and meaning in the livesof some persons with psychosis, for others, it induced spiritual despair. Patients also reported thatreligion lessened psychotic symptoms and the risk of suicide attempts, substance use, nonadherenceto treatment, and social isolation.Substance abuseGiven that most religions actively discourage the use of substances that adversely affect the bodyand mind, it is unsurprising that studies generally indicate strongly negative associations between

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substance abuse and religious involvement. In a review of 134 studies that examined therelationships between religious involvement and substance abuse, 90% found less substance abuseamong the more religious.8 These findings are corroborated by more recent national surveys andstudies in alcohol and drug use in African Americans, Hispanic Americans, and Native Americans thatsimilarly indicate negative associations between religious involvement and substance abuse.38-41

The negative effects of religious involvementNegative psychological effects of religious involvement include excessive devotion to religiouspractice that can result in a family breakup. Differences in the level of religiosity between spousescan result in marital disharmony. Religion can promote rigid thinking, overdependence on laws andrules, an emphasis on guilt and sin, and disregard for personal individuality and autonomy. Excessivereliance on ritual and prayer may delay seeking psychiatric help and consequently worsen prognosis.At its most extreme, strict adherence to the ideology of a movement may precipitate suicide.Clinical implicationsReligious issues are important in the assessment and treatment of patients, and therefore cliniciansneed to be open to the effect of religion on their patients’mental health. It is, however, importantthat clinicians do not overstep boundaries.How then can clinicians enter into their patients’ spiritual lives? Blass42 and Lawrence and Duggal43

have emphasized the importance of teaching on spirituality in the psychiatric curriculum, withresidents learning about the principles of spiritual assessment. There are a number of protocolsabout how to ask about spirituality, such as the HOPE questionnaire (Sidebar).44

After taking a detailed spiritual history, health professionalsneed to help patients clarify how their religious beliefs and practices influence the course of illness,rather than giving advice about religion. Whatever his or her religious background, the professional’smoral stance should be neutral, with no attempt to manipulate the patient’s beliefs. Clinicians mustbe aware of how their own religious beliefs affect the therapy process.45 Direct religious intervention,such as the use of prayer, remains controversial.46

A secular therapist who does not share the religious beliefs of the patient can still be effective aslong as he is alert to the need for sensitivity to religious issues and the need to become educatedabout the religion’s beliefs and practices. At times, patients’ religious views may conflict withmedical/psychotherapeutic treatment, and therapists must endeavor to understand the patient’sworldview and, if necessary, consult with clergy. It might be appropriate to involve members of thereligious community to provide support and to facilitate rehabilitation.Religion or spirituality may have therapeutic implications for mental health. Randomized trialsindicate that religious interventions among religious patients enhance recovery from anxiety anddepression.47,48 Psychoeducational groups that focus on spirituality can lead to greater

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understanding of problems, feelings, and spiritual aspects of life.49

A focus for future researchIn addition to broadening the current research focus on the effects of Christian beliefs on mentalhealth, there are a number of other issues that warrant empirical scrutiny:• The relationships between anxiety/depression and specific types of religious coping• The relationships between psychosis and normative religious experiences• The development of novel religious therapies and assessment of their effectiveness• The ethics of clinician involvement in religious matters• How collaboration between clinicians and clergy can be facilitated References: References

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initial validation of the RCOPE. J Clin Psychol. 2000;56:519-543. 24. Baetz M, Bowen R, Jones G, Koru-Sengul T. How spiritual values and worship attendance relateto psychiatric disorders in the Canadian population. Can J Psychiatry. 2006;51:654-661. 25. Fehring RJ, Miller JF, Shaw C. Spiritual well-being, religiosity, hope, depression, and other moodstates in elderly people coping with cancer. Oncol Nurs Forum. 1997;24:663-671. 26. Nelson CJ, Rosenfeld B, Breitbart W, Galietta M. Spirituality, religion, and depression in theterminally ill. Psychosomatics. 2002;43:213-220. 27. Shreve-Neiger A, Edelstein BA. Religion and anxiety: a critical review of the literature. ClinPsychol Rev. 2004;24:379-397. 28. Freud S. Obsessive acts, religious practices. In: Strachey J, trans-ed. Reprinted (1953–1974) inthe Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol 7. London: HogarthPress; 1907. 29. Lewis CA. Cleanliness is next to godliness: religiosity and obsessiveness. J Religion Health.1998;37:49-61. 30. Tek C, Ulug B. Religiosity and religious obsessions in obsessive-compulsive disorder. PsychiatryRes. 2001;104:99-108. 31. Connor KM, Davidson JR, Lee LC. Spirituality, resilience, and anger in survivors of violenttrauma: a community survey. J Trauma Stress. 2003;16:487-494. 32. Harris JI, Schoneman SW, Carrera SR. Approaches to religiosity related to anxiety amongcollege students. Men Health Religion Cult. 2002;5:253-265. 33. Abdel-Khalek AM. Death anxiety in Spain and five Arab countries. PsycholRep. 2003;93:527-528. 34. Mohr S, Huguelet P. The relationship between schizophrenia and religion and its implications forcare. Swiss Med Wkly. 2004;134:369-376. 35. Siddle R, Haddock G, Tarrier N, Faragher EB. Religious delusions in patients admitted tohospital with schizophrenia. Soc Psychiatry Psychiatr Epidemiol. 2002;37:130-138. 36. Lindgren KN, Coursey RD. Spirituality and serious mental illness: a two-part study. PsychosocRehab J. 1995;18:93-111. 37. Mohr S, Brandt PY, Borras L, et al. Toward an integration of spirituality and religiousness intothe psychosocial dimension of schizophrenia. Am J Psychiatry. 2006;163:1952-1959. 38. National Center on Addiction and Substance Abuse at Columbia University. So help me God:substance abuse, religion and spirituality. November 2001. http://www.casacolumbia.org/templates/publications_reports.aspx. Accessed November 20, 2009. 39. Nasim A, Utsey SO, Corona R, Belgrade FZ. Religiosity, refusal efficacy, and substance useamong African-American adolescents and young adults. J Ethn Subst Abuse. 2006;5:29-49. 40. Marsiglia FF, Kulis S, Nieri T, Parsai M. God forbid! Substance use among religious andnon-religious youth. Am J Orthopsychiatry. 2005;75:585-598. 41. Stone RA, Whitbeck LB, Chen X, et al. Traditional practices, traditional spirituality, and alcoholcessation among American Indians. J Stud Alcohol. 2006;67:236-244. 42. Blass DM. A pragmatic approach to teaching psychiatry residents the assessment andtreatment of religious patients. Acad Psychiatry. 2007;31:25-31. 43. Lawrence RM, Duggal A. Spirituality in psychiatric education and training. J R SocMed. 2001;94:303-305. 44. Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as apractical tool for spiritual assessment. Am Fam Physician. 2001;63:81-89. 45. Fallot R. Spirituality and religion in recovery: some current issues. Psychiatr RehabilJ. 2007;30:261-270. 46. Koenig HG. Religion and mental health: what should psychiatrists do? Psychiatr Bull.2008;32:201-203. 47. Azhar MZ, Varma SL. Cognitive psychotherapy for inherently religious clients: a two yearfollow-up. Malaysian J Psychiatry. 1999;7:19-29. 48. Propst LR, et al. Comparative efficacy of religious and nonreligious cognitive-behavioral therapyfor the treatment of clinical depression in religious individuals. J Consult ClinPsychol. 1992;60:94-103. 49. Kehoe N. Spirituality groups in serious mental illness. South Med J. 2007;100:647-648.

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Links:[1] http://www.psychiatrictimes.com/schizophrenia[2] http://www.psychiatrictimes.com/cultural-psychiatry[3] http://www.psychiatrictimes.com/dependent-personality-disorder[4] http://www.psychiatrictimes.com/histrionic-personality-disorder[5] http://www.psychiatrictimes.com/major-depressive-disorder[6] http://www.psychiatrictimes.com/alcohol-abuse[7] http://www.psychiatrictimes.com/authors/simon-dein-frcpsych-phd

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