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Religion: Psychiatric Aspects
Religion: Psychiatric Aspects Sheila M LoboPrabhu, Michael E. DeBakey V.A. Medical Center, Houston, TX, USA; and Baylor College of Medicine, Houston, TX, USA Kenneth I Pargament, Institute for Spirituality and Health at the Texas Medical Center, Houston, TX, USA; and Bowling Green State University, Bowling Green, OH, USA James W Lomax, Baylor College of Medicine, Houston, TX, USA Ó 2015 Elsevier Ltd. All rights reserved. This article is a revision of the previous edition article by G.T. Harding, volume 19, pp. 13096–13102, Ó 2001, Elsevier Ltd.
Abstract Although psychiatry and religion have a long and troubled history with each other, there are good reasons for a rapprochement. Empirical studies have shown that religion can be both a resource for the mentally ill and a source of problems. Patients also generally prefer religiously sensitive care. In recent years, the field has made promising theoretical advances, including work in the areas of religious coping and attachment. Research studies have also underscored the value of spiritually integrated approaches to psychiatric diagnosis and treatment. The article concludes with a description of promising new directions for theory and practice in psychiatry and religion.
Psychiatry and Religion: A Long and Complicated History Psychiatry and religion have a long and complicated relationship with each other. In ancient times, signs of mental disorder were understood as reflections of imbalanced body fluids, supernatural agents, or a troubled relationship between the individual and God. During the Middle Ages and early Modern period in Europe, mental illness was often interpreted as a manifestation of diabolical forces, evil spirits, or possession. The Modern era and Enlightenment heralded a shift from harsh religious explanations of madness to more biological interpretations and more humane approaches to treatment. In the twentieth century, the relationship between psychiatry and religion was strongly influenced by Freud’s psychological theories. Freud (1927) famously conceptualized religion as a response to childish feelings of helplessness in a world of chaotic forces and need for a father-figure who would provide protection and care. He maintained that religion was illusory and he suggested that it would be better for individuals to face the realities of life rather than to rely on unrealistic, childlike wishes of having a God. Freud’s harsh perspective on religion was tempered by some of his followers, such as Jung, Rizzuto, and Winnicott. Jung treated religious beliefs and behaviors in a more positive manner and provided a psychological understanding of terms such as ‘soul,’ ‘sacred,’ ‘God,’ ‘transcendence,’ and ‘evil’ (Palmer, 1997). Rizzuto (1979) outlined how the development of the relationship with a primary object (such as a parent) correlates with the transitional object that represents God. She took detailed life histories and spiritual histories from her patients to learn more about their understandings of God. Winnicott (1971) treated ‘illusion’ as a developmentally necessary bridge between the infant’s self-absorption and later involvement in reality. He viewed illusion as an essential part of human experience by which humans meet their deeper needs for artistic, symbolic, and religious
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meaning and involvement. He posited that religion can be viewed as a transitional phenomenon, neither subjective nor objective. Rather than automatically diminishing or dismissing religious experience as subjective or hallucinatory, merely because physical or objective evidence is absent, Winnicott’s writings set the stage for a more constructive view of religion. In spite of these more benevolent psychiatric perspectives on religion, some tension remains between psychiatry and religious viewpoints (Shuman, 2009). The tension is, in part, a reflection of psychiatric theory critical of religion, such as the work of Freud. However, other factors contribute to this antagonism. Psychiatrists, like other mental health professionals, tend to be less religious than their patients. For instance, 38% of psychiatrists sampled from the American Psychiatric Association reported that religion is very important to them in comparison with 58% of the American population (Shafranske, 2000). As a result of their relatively lower religiousness, psychiatrists may underestimate the salience of religion among patients and fail to appreciate or attend to the religious significance of illness to the patient and family. Furthermore, only 27% of US psychiatry residency programs train residents to work with religious patients (Bowman, 2009); therefore US psychiatrists may be ill-equipped to deal with religious issues arising in treatment (Curlin et al., 2005). In addition, psychiatrists may lack knowledge about faith-based systems that offer resources for treatment, religious and spiritual factors that exacerbate psychiatric symptoms, and religious beliefs and practices that affect treatment acceptance. Psychiatrists may be wary about discussing religion for other reasons as well, such as time constraints, fears that the patient will not be receptive, or fear of being accused of violating boundaries. Finally, although psychiatry and religion share a concern with understanding and enhancing the health and well-being of people, they offer at least somewhat different perspectives on the causes and remedies of illness. Tensions between psychiatry and religion can grow out of these differences in world views
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(Shuman, 2009; Hughes and Wintrob, 2000). For example, the medical community uses the diagnosis–treatment approach to illness, whereas many faith communities hold that symptoms originate from taboo violations and resultant guilt, and believe that confession is the appropriate response. The world views of psychiatry and religion are not necessarily contradictory or incompatible. Psychiatrists and clergy alike often keep both naturalistic and religious explanations in mind, and have used both understandings to formulate approaches to treatment and change. However, the world views of psychiatry and religion can become polarized, and when they do, antagonism and mistrust may occur. The implications of this tension are significant. Patients seeking psychiatric care may fear being labeled neurotic, pathological, or even psychotic for their religious beliefs. As a result, they may not raise religious issues during psychiatric treatment. Some religious individuals may decline or discontinue psychiatric treatment out of concern that the plausibility of their faith may be challenged or threatened. In this vein, Keating and Fretz (1990) found that more religiously committed patients had more reservations about therapy, fearing that the therapist would ignore spiritual concerns, find them bizarre, reject the idea of communicating with a higher power, or assume that the patient shared the therapist’s own religious beliefs. Psychiatrists and clergy may also keep their distance from each other. For example, clergy refer less than 10% of their clients to mental health clinicians; and mental health professionals refer even fewer of their patients to clergy (Mollica et al., 1986; Larson et al., 1988).
Rationale for Rapprochement between Psychiatry and Religion Even though there are significant historically based tensions between psychiatry and religion, there are also strong empirically based reasons for a closer working relationship between these two domains. The need for rapprochement is rooted in the centrality of religion as a cultural institution, and because the mentally ill often use religion as a resource. These conditions make sensitivity to religious factors an ethical mandate for psychiatrists. Religious beliefs, practices, and communities are deeply interwoven into the cultural fabric of the United States and other nations in the world. In the United States, for example, over 147 million people are members of religious congregations, and there are approximately 335 000 congregations in the United States (Lindner, 2010). According to the Pew US Religious Landscape Survey (2008), 58% of Americans report that they pray daily, 74% believe in life after death, 68% believe in angels and demons, 59% believe in hell, and 57% agree that it is necessary to believe in God to be moral and have good values. It is important to recognize that religion in the United States is dominated by various denominations of Christianity, although the culture is becoming increasingly pluralistic religiously. Within other countries, religion takes different forms, but it remains a critical, defining aspect of these cultures. Psychiatry recognizes that the development and course of mental illness cannot be understood outside of
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its larger cultural context. Religion is one key ingredient of this context (Pargament et al., 2013). Religious beliefs and practices are also common among people with mental illness (see Mohr, 2013, for review). Kroll and Sheehan (1989) studied 52 psychiatric inpatients in Minnesota and found that 94% believed in God, 67% in the devil, 53% prayed or consulted the Bible, and 51% attended church weekly. In a survey of the alternative health practices of people with serious mental illness (SMI), religious/spiritual activities (50%) and meditation (40%) were the most frequently reported practices (Russinova et al., 2002). Elsewhere, Pieper (2004) studied 118 patients in a Protestant mental hospital in the Netherlands, and found that 92% participated regularly in private religious activities and religious services. Many patients with mental illness indicate that religion offers valuable resources in the process of coping with their major stressors. Tepper et al. (2001) reported that 80% of a sample of 406 psychiatric outpatients with SMI in Los Angeles used religion to cope. In a comparative study of European psychiatric patients and a nonpsychiatric control group, Neeleman and Lewis (1994) found that the psychiatric patients reported a larger number of religious beliefs and practices that offered comfort during stressful life experiences. Religious professionals are another resource for people with mental illness. SMI individuals are as likely to seek treatment from clergy as from a mental health professional (Larson et al., 1988). It is important to add that religion can serve as a resource to caregivers of SMI patients. In a survey of caregivers to people with SMI, many participants reported that God is a source of comfort and strength (Murray-Swank, 2006). There are ethical mandates to consider religion when providing psychiatric care (American Psychiatric Association Principles of Medical Ethics, 2013). For example, a committee of the American Psychiatric Association (2006) stated that: “Psychiatrists should foster recovery by making treatment decisions with patients in ways that respect and take into meaningful consideration their cultural, religious/ spiritual, and personal ideals.” Some writers have cautioned against health professionals overstepping their boundaries by addressing religious issues in the context of treatment (Sloan et al., 1999). They maintain that clergy are better suited than healthcare professionals to manage patients’ spiritual concerns. Ethical standards in psychiatry, however, explicitly attend to these risks: “Psychiatrists should not impose their own religious/spiritual, antireligious/spiritual, or other values, beliefs and world views on their patients, nor substitute such commitments or religious/spiritual rituals for professionally accepted diagnostic methods or therapeutic practice” (American Psychiatric Association, 2006).
Religion Is Related to Health and Well-Being Religion can serve a number of valuable psychological functions for people with mental illness. In one project, Mohr et al. (2006) found that among Swiss schizophrenia patients religion provided a number of functions, such as hope, comfort, meaning of life, enjoyment of life, love, compassion, self-respect, and self-confidence; and one-third
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of these patients reported that they actually received social support from a religious community. In a study of 115 psychiatric outpatients in Geneva, Mohr et al. (2010) found that people who accessed positive religious coping resources experienced fewer negative symptoms and better social adaptation and quality of life 3 years later. These findings have been mirrored in other investigations of people with mental illness, in which higher levels of religiousness have been associated with the provision of meaning, hope, peace, and comfort (e.g., Fallot, 2007; Kelly and Gamble, 2005). Several studies have shown that higher levels of religious commitment and involvement are associated with lower prevalence of mental illness and more favorable mental health outcomes (Koenig et al., 2012; Shreve-Neiger and Edelstein, 2004). Religiousness has been robustly linked with lower risk of substance abuse (Johnson, 2013) and successful recovery (Simoni et al., 2002; Pence et al., 2008). Religion can provide patients with guidelines for living a sober life, a sense of power through identification with a larger spiritual force, and a new healthier source of meaning and purpose. In addition, religious commitment may lower suicide rates (Huguelet et al., 2007). Huguelet et al. (2009) reported that one-third of their cases of people with SMI believed that religion offered protection against suicide attempts by providing meaning in life, a way of coping with despair, ethical condemnation of suicide, and positive religious experiences. Studies also suggest that the involvement of clergy in patient care results in increased patient satisfaction, increased medical knowledge, and improved treatment compliance (Parkum, 1985; Saunders and Kong, 1983; Bay et al., 2008; Iler et al., 2001). Finally, in contrast to the view that religion interferes with treatment adherence, one study of 52 patients with psychosis found that religiousness was associated with greater adherence to medication (Kirov et al., 1998). Similarly, Harris et al. (2006) reported that among those with SMI, religious attendance and importance of religious beliefs were both positively correlated with outpatient mental health service use and medication use.
Mental Illness Can Be Associated with Problematic Forms of Religiousness Mental illness impacts people not only psychologically, socially, and physically, but spiritually as well. A significant number of people experience religious struggles as a result of their illness. Religious struggles reflect tension and doubt about spiritual issues within oneself, with a religious community, or with God (Pargament et al., 2005). For example, a mental illness may lead to feelings of anger toward, abandonment by, or being punished by God. In a survey of a national sample in the United States, McConnell et al. (2006) found that religious struggles were associated with a wide range of mental health symptomatology, including anxiety, depression, paranoid ideation, compulsiveness, and somatization. Although religious struggles may be triggered by psychiatric illness (i.e., secondary religious struggles), there is also evidence that religious struggles exacerbate mental health and physical health problems (i.e., primary religious struggles). Empirical
studies of a variety of religious groups in a variety of contexts have tied religious struggles to declines in mood, quality of life, physical health, and even greater risk of mortality (Cummings and Pargament, 2010). Mohr (2013) elaborates on religious struggles and their consequences among Swiss patients with schizophrenia. These include feelings of religious alienation as a result of lack of support from patients’ religious communities; a negative sense of self marked by feelings of guilt, despair, anger, fear, and suicidality; and vulnerability to the development of addictions in response to the sense of spiritual loss and emptiness. Although there is little evidence that religiousness in and of itself generally causes delusions or hallucinations, people may express psychiatric illness through a religious idiom or filter (Greenberg and Witztum, 2001). Religious delusions occur in 36% of schizophrenic patients, 33% of bipolar patients, 17% of patients with substance-induced psychosis, and 26% of patients with other psychoses (Appelbaum et al., 1999). Some patients with religious delusions have committed selfharm, suicide, or homicide (Mohr and Pfeifer, 2009). However, the psychiatrist’s task is complicated by the fact that hallucinations can be a normal part of religious experience in certain contexts, and are then experienced as positive. Nevertheless, hallucinations that scare, upset, or disrupt an individual’s life are considered pathological. Pathological hallucinations are most often auditory, but can also be visual, tactile, olfactory, or gustatory (Mohr and Pfeifer, 2009). Sims’ (1992) three criteria help to differentiate between religious belief and religious delusion. (1) The experience reported by the patient gives the impression of a delusion rather than a mere religious belief. Both the observed behavior and subjective experience are in concordance with the psychiatric symptom. (2) The presence of other psychiatric symptoms such as hallucinations or mood or thought disorder make it more likely that the individual has a religious delusion rather than mere religious belief. (3) The outcome of the experience seems more in keeping with the natural history and course of a mental disorder rather than a life-enhancing experience.
Patients with Mental Illness Want Religiously Sensitive Care Perhaps it should not be surprising that many patients would like to receive religiously sensitive healthcare, given the importance of religion as a resource and its significant implications for health and well-being. In one study, 83% indicated that their religious beliefs are closely tied to their state of mental and emotional health, and 75% said it is important to see professionals who integrate their values and beliefs into counseling (American Association of Pastoral Counselors Samaritan Institute Report, 2000). It is important to note that concerns about the openness of mental health professionals to religion and spirituality was the second most common reason for not seeking out help from this group; 15% said that they ‘fear that (their) spiritual values and beliefs may not be respected and taken seriously.’ African Americans and devout Evangelicals were particularly likely to voice these concerns. Other surveys of individuals
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in the United States dealing with physical and emotional problems lead to the same conclusion – a majority of people would like to see religion and spirituality integrated into their treatment in a sensitive and respectful fashion (e.g., Lindgren and Coursey, 1995; Stanley et al., 2011). In spite of this expressed desire, religion is not often addressed in health care. Huguelet et al. (2006) reported that, although a majority of study patients with schizophrenia rated religion as important, only 36% discussed this issue with their clinicians. In sum, there are a variety of sound empirically based reasons to justify a rapprochement between psychiatry and religion. In fact, over the past 75 years, theorists have made significant advances in conceptualizing the interplay between religion and mental health from a more balanced, nuanced perspective. These theoretical developments have led, in turn, to progress toward more spiritually sensitive psychiatric care.
Promising Theoretical Advances Recently, two theoretical approaches have been advanced that hold particularly important implications for psychiatry: coping theory and attachment theory. Coping theory, derived from ego psychology (Lazarus and Folkman, 1984), emphasizes the role of religion in helping people understand and deal with major life stressors (Pargament, 1997). Religion provides individuals with coping resources (e.g., spiritual support from a sacred entity, religious reframing of suffering, confession) to assist them in coming to terms with life events, particularly those that reveal human finitude and frailty. In this sense, religion serves an empowering, ego-strengthening function. This may help to explain the high levels of religious involvement among people grappling with mental illness, as noted above. However, people vary according to the breadth and depth of their religious resources. Some are equipped with religious frameworks of meaning, ritual, and connectedness that allow them to withstand and even transform themselves in the face of significant stressors, including mental illness. Others have religious orientations that rest on a less benevolent view of the universe, other people, and the individual’s place in the world; this group is more likely to experience profound religious struggles that compound the harsh impact of mental illness. The effectiveness of coping from the perspective of this theory has to do not only with the individual’s breadth and depth of coping resources, but also with the degree to which coping methods are well integrated with the demands of the situation, the needs and aspirations of the individual, and the larger social context. For example, active surrender of control to God’s will has very different clinical implications for the individual who must take active steps to manage an emotional illness and the individual in hospice who has exhausted all treatment alternatives. The pursuit of religious growth and development can facilitate mental health and physical health more generally or interfere with those ends when it becomes overly scrupulous. Seeking out religious support for anxiety about gender identity will have different
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implications depending on whether the individual is part of a conservative or liberal religious tradition. Attachment theory builds on the work of object relations theory and evolutionary theory. Attachment theorists have emphasized the role of religion in fostering a meaningful relationship between the self and the other (Granqvist et al., 2010). For most religious individuals, this attachment seeking involves a connectedness with a Divine other. People who pursue spirituality outside of traditional religious settings may seek a particular type of relationship with other entities or objects deemed sacred, such as nature, eminent figures, social justice, or work. Several theorists have elaborated on this notion. Ana-Maria Rizutto emphasized the importance of learning about an individual’s picture or image of God. She contends that this God image is heavily influenced by the internal representations of self and important others in the individual’s relationship world, especially parents and subsequent key attachment figures (Rizzuto, 1979). Winnicott developed the notion of transitional objects as a key intermediary reflection of how a young child begins to translate experience with early attachment figures into predictions about others when engaging new individuals in the child’s relational world (Winnicott, 1953). William Meissner extrapolated Winnicott’s notion of the transitional object into his concept of creative illusion formation as a developmental capacity that plays an important positive and healthy role in the meaningfulness of religion participation (Meissner, 1984). Meissner described how growth-producing illusions were responses to objective reality that represented the person’s capacity to transform (mere) reality into something reflective of inner significance and hope. Consistent with this theory, emerging research has found a correspondence between the quality of an individual’s parental attachments and attachments to God (Granqvist and Kirkpatrick, 2013). Thus secure attachments to parents are often tied to a secure felt connection to the Divine. Conversely, insecure attachments to parents are linked to anxious, avoidant, and ambivalent attachments to the Divine. There is also evidence that some people form a secure relationship with God in compensation for insecure relationships to parents, as in the case of religious conversions. These findings and the underlying theory on which they are based have important practical implications for psychiatry.
Promising Therapeutic Directions Psychiatrists and other mental health professionals have begun to integrate greater religious and spiritual awareness and sensitivity into various treatment orientations (Pargament, 2007). Empirical evaluations of the effectiveness of these spiritually integrated treatments have shown encouraging results. Worthington et al. (2011) conducted a meta-analysis of 51 samples from 46 studies, and compared the outcomes of religious accommodative therapies and nonreligious therapies. They found that religious/spiritual psychotherapies (R/S) were as effective as secular psychotherapies with respect to the psychological
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outcomes of patients. However, in comparison to secular psychotherapies, R/S therapies were tied to greater improvement among patients with respect to spiritual outcomes. They concluded that, for patients and contexts in which spiritual outcomes are highly valued, spiritually integrated therapies may be a treatment of choice. Although a variety of spiritually integrated treatments have been developed, most have a cognitive-behavioral therapy orientation. These treatments have been applied to several patient populations, with promising results (Propst et al., 1992; Rosmarin et al., 2010; Harris et al., 2011; Hardman et al., 2003; Margolin et al., 2007, Richards et al., 2006). Even though much of the work on spiritually integrated treatments has grown out of a cognitive-behavioral orientation, practitioners from other therapeutic orientations have also begun to integrate greater spiritual sensitivity into their treatments. These treatment modalities have in common the attempt to provide a healthy revisiting of critical periods of development within the therapist–patient relationship. There is reason to believe that such experiences occur fairly often across healthcare disciplines. However, the impact of these ‘sacred’ or at least ‘important’ moments experienced in early development and brought into treatment awaits study (Lomax and Pargament, 2011).
New Directions In recent years, great progress has been made in clarifying the interface between psychiatry and religion. Yet significant questions remain. First, because much of the work in this area has focused on western religion and medicine, it is important to extend research and practice to other cultures, particularly non-western contexts. Second, research in this arena is moving toward studies of more specific aspects of religiousness as they express themselves in specific forms of psychiatric illness (Hill and Pargament, 2003; Peteet et al., 2011). For example, it is important to consider whether mystical experiences and religious conversion contribute to destructive dissociation or positive integration among patients with significant mental illness. Similarly, research should explore the roles that patients’ understandings of ‘evil’ and ‘the Devil’ play in their illness. There is some evidence that patients who try to make sense of their illness by invoking diabolical divine agents may be at risk for mental health problems and have increased risk of mortality (Pargament et al., 2001). The language of evil and the demonic may also offer a way to find meaning in otherwise meaningless suffering. Third, longitudinal studies are needed to disentangle the complex links between religion and psychopathology; in particular, the ways in which SMI may impact religious life and the ways religious problems and resources may foster or ameliorate psychopathology. Fourth, to foster more spiritually sensitive care and respond to the dearth of education about religious issues within psychiatric training programs, new models of psychiatric training must be developed and tested (Blass, 2007). Finally, further studies are needed to determine whether spiritually integrated treatments add to the effectiveness of psychiatric treatments. It is also important to learn how psychiatric treatments,
including psychotropic medications, impact the spiritual lives of patients. These represent just a few of the many promising areas of study open to exploration by researchers in the twenty-first century.
See also: Buddhism; New Religious Movements; Religion and Health: Sociological Considerations; Religion and Sciences; Religion, Phenomenology of; Religion, Psychology of; Religion, Sociology of; Science and Religion.
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Pence, B.W., Thielman, N.M., Whetten, K., et al., 2008. Coping strategies and patterns of alcohol and drug use among HIV-infected patients in the United States southeast. AIDS Patient Care and Sexually Transmitted Diseases 22, 869–877. Peteet, J.R., Lu, F.G., Narrow, W.E. (Eds.), 2011. Religious and Spiritual Issues in Psychiatric Diagnosis: A Research Agenda for DSM-V. American Psychiatric Association, Arlington, VA. Pew Forum on Religion and Public Life, 2008. US Religious Landscape Survey. Pew Research Center, Washington, DC. Pieper, J.Z.T., 2004. Religious coping in highly religious psychiatric inpatients. Mental Health, Religion & Culture 7, 349–363. Propst, L.R., Ostrom, R., Watkins, P., Dean, T., Mashburn, D., 1992. Comparative efficacy of religious and nonreligious cognitive-behavioral therapy for the treatment of clinical depression in religious individuals. Journal of Consulting and Clinical Psychology 60, 94–103. Richards, P.S., Hardman, M.E., Berrett, R.K., Eggett, D.L., 2006. Comparative efficacy of spiritual, cognitive, and emotional support groups for treating eating disorder inpatients. Eating Disorders 14, 401–415. Rizzuto, A., 1979. The Birth of the Living God: A Psychoanalytic Study. University of Chicago Press, Chicago, IL. Rosmarin, D.H., Pargament, K.I., Pirutinsky, S., Mahoney, A., 2010. A randomized controlled evaluation of a spiritually integrated treatment for subclinical anxiety in the Jewish community, delivered via the Internet. Journal of Anxiety Disorders 24, 799–808. Russinova, Z., Wewiorski, N.J., Dane, C., 2002. Use of alternative health care practices by persons with serious mental illness: perceived benefits. American Journal of Public Health 92, 1600–1603. Saunders, T., Kong, W., 1983. The role for churches in hypertension management. Urban Health 12, 49–51. Shafranske, E.P., 2000. Religious involvement and professional practices of psychiatrists and other mental health professionals. Psychiatric Annals 30, 525–532. Shreve-Neiger, A.K., Edelstein, B.A., 2004. Religion and anxiety: a critical review of the literature. Clinical Psychological Review 24, 379–397. Shuman, J.J., 2009. Theological perspectives on the care of patients with psychiatric disorders. In: Huguelet, P., Koenig, S. (Eds.), Religion and Spirituality in Psychiatry. Cambridge University Press, New York, pp. 19–26. Simoni, J.M., Martone, M.G., Kerwin, J.F., 2002. Spirituality and psychological adaptation among women with HIV/AIDS: implications for counseling. Journal of Counseling Psychology 49, 139–147. Sims, A.C.P., 1992. Symptoms and beliefs. Journal of the Royal Society of Health 112, 42–46. Sloan, R.P., Bagiella, E., Powell, T., 1999. Religion, spirituality, and medicine. The Lancet 353, 664–667. Stanley, M.A., Bush, A.L., Camp, M.E., et al., 2011. Older adults’ preferences for religion/spirituality in treatment for anxiety and depression. Aging and Mental Health 15, 334–343. Tepper, L., Rogers, S.A., Coleman, E.M., Malony, H.N., 2001. The prevalence of religious coping among persons with persistent mental illness. Psychiatric Services 52, 660–665. Winnicott, D.W., 1953. Transitional objects and transitional phenomena. International Journal of Psychoanalysis 34, 89–97. Winnicott, D.W., 1971. Playing and Reality. Basic Books, New York. Worthington, E.L., Hook, J.N., Davis, D.E., McDaniel, M.A., 2011. Religion and spirituality. Journal of Clinical Psychology: In Session 67, 204–214.
Relevant Websites American Psychiatric Association, 2013. The Principles of Medical Ethics with Annotations Specifically Applicable to Psychiatry. Available at: http://www. psychiatry.org/practice/ethics/resources-standards. American Psychiatric Association, 2006. Religious/spiritual commitments and psychiatric practice resource document. Available at: http://www.psych. org/departments/edu/library/apaofficialdocumentsandrelated/resourcedocuments/ 200604.aspx. Newport, F., 2007. Americans more likely to believe in God than the Devil, Heaven more than Hell. Gallup News Service. Available at: http://www.gallup.com/ poll/27877/Americans-More-Likely-Believe-God-Than-Devil-Heaven-More-ThanHell.aspx.
Abstract Although psychiatry and religion have a long and troubled history with each other, there are good reasons for a rapprochement. Empirical studies have shown that religion can be both a resource for the mentally ill and a source of problems. Patients also generally prefer religiously sensitive care. In recent years, the field has made promising theoretical advances, including work in the areas of religious coping and attachment. Research studies have also underscored the value of spiritually integrated approaches to psychiatric diagnosis and treatment. The article concludes with a description of promising new directions for theory and practice in psychiatry and religion.
Psychiatry and Religion: A Long and Complicated History Psychiatry and religion have a long and complicated relationship with each other. In ancient times, signs of mental disorder were understood as reflections of imbalanced body fluids, supernatural agents, or a troubled relationship between the individual and God. During the Middle Ages and early Modern period in Europe, mental illness was often interpreted as a manifestation of diabolical forces, evil spirits, or possession. The Modern era and Enlightenment heralded a shift from harsh religious explanations of madness to more biological interpretations and more humane approaches to treatment. In the twentieth century, the relationship between psychiatry and religion was strongly influenced by Freud’s psychological theories. Freud (1927) famously conceptualized religion as a response to childish feelings of helplessness in a world of chaotic forces and need for a father-figure who would provide protection and care. He maintained that religion was illusory and he suggested that it would be better for individuals to face the realities of life rather than to rely on unrealistic, childlike wishes of having a God. Freud’s harsh perspective on religion was tempered by some of his followers, such as Jung, Rizzuto, and Winnicott. Jung treated religious beliefs and behaviors in a more positive manner and provided a psychological understanding of terms such as ‘soul,’ ‘sacred,’ ‘God,’ ‘transcendence,’ and ‘evil’ (Palmer, 1997). Rizzuto (1979) outlined how the development of the relationship with a primary object (such as a parent) correlates with the transitional object that represents God. She took detailed life histories and spiritual histories from her patients to learn more about their understandings of God. Winnicott (1971) treated ‘illusion’ as a developmentally necessary bridge between the infant’s self-absorption and later involvement in reality. He viewed illusion as an essential part of human experience by which humans meet their deeper needs for artistic, symbolic, and religious
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meaning and involvement. He posited that religion can be viewed as a transitional phenomenon, neither subjective nor objective. Rather than automatically diminishing or dismissing religious experience as subjective or hallucinatory, merely because physical or objective evidence is absent, Winnicott’s writings set the stage for a more constructive view of religion. In spite of these more benevolent psychiatric perspectives on religion, some tension remains between psychiatry and religious viewpoints (Shuman, 2009). The tension is, in part, a reflection of psychiatric theory critical of religion, such as the work of Freud. However, other factors contribute to this antagonism. Psychiatrists, like other mental health professionals, tend to be less religious than their patients. For instance, 38% of psychiatrists sampled from the American Psychiatric Association reported that religion is very important to them in comparison with 58% of the American population (Shafranske, 2000). As a result of their relatively lower religiousness, psychiatrists may underestimate the salience of religion among patients and fail to appreciate or attend to the religious significance of illness to the patient and family. Furthermore, only 27% of US psychiatry residency programs train residents to work with religious patients (Bowman, 2009); therefore US psychiatrists may be ill-equipped to deal with religious issues arising in treatment (Curlin et al., 2005). In addition, psychiatrists may lack knowledge about faith-based systems that offer resources for treatment, religious and spiritual factors that exacerbate psychiatric symptoms, and religious beliefs and practices that affect treatment acceptance. Psychiatrists may be wary about discussing religion for other reasons as well, such as time constraints, fears that the patient will not be receptive, or fear of being accused of violating boundaries. Finally, although psychiatry and religion share a concern with understanding and enhancing the health and well-being of people, they offer at least somewhat different perspectives on the causes and remedies of illness. Tensions between psychiatry and religion can grow out of these differences in world views
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(Shuman, 2009; Hughes and Wintrob, 2000). For example, the medical community uses the diagnosis–treatment approach to illness, whereas many faith communities hold that symptoms originate from taboo violations and resultant guilt, and believe that confession is the appropriate response. The world views of psychiatry and religion are not necessarily contradictory or incompatible. Psychiatrists and clergy alike often keep both naturalistic and religious explanations in mind, and have used both understandings to formulate approaches to treatment and change. However, the world views of psychiatry and religion can become polarized, and when they do, antagonism and mistrust may occur. The implications of this tension are significant. Patients seeking psychiatric care may fear being labeled neurotic, pathological, or even psychotic for their religious beliefs. As a result, they may not raise religious issues during psychiatric treatment. Some religious individuals may decline or discontinue psychiatric treatment out of concern that the plausibility of their faith may be challenged or threatened. In this vein, Keating and Fretz (1990) found that more religiously committed patients had more reservations about therapy, fearing that the therapist would ignore spiritual concerns, find them bizarre, reject the idea of communicating with a higher power, or assume that the patient shared the therapist’s own religious beliefs. Psychiatrists and clergy may also keep their distance from each other. For example, clergy refer less than 10% of their clients to mental health clinicians; and mental health professionals refer even fewer of their patients to clergy (Mollica et al., 1986; Larson et al., 1988).
Rationale for Rapprochement between Psychiatry and Religion Even though there are significant historically based tensions between psychiatry and religion, there are also strong empirically based reasons for a closer working relationship between these two domains. The need for rapprochement is rooted in the centrality of religion as a cultural institution, and because the mentally ill often use religion as a resource. These conditions make sensitivity to religious factors an ethical mandate for psychiatrists. Religious beliefs, practices, and communities are deeply interwoven into the cultural fabric of the United States and other nations in the world. In the United States, for example, over 147 million people are members of religious congregations, and there are approximately 335 000 congregations in the United States (Lindner, 2010). According to the Pew US Religious Landscape Survey (2008), 58% of Americans report that they pray daily, 74% believe in life after death, 68% believe in angels and demons, 59% believe in hell, and 57% agree that it is necessary to believe in God to be moral and have good values. It is important to recognize that religion in the United States is dominated by various denominations of Christianity, although the culture is becoming increasingly pluralistic religiously. Within other countries, religion takes different forms, but it remains a critical, defining aspect of these cultures. Psychiatry recognizes that the development and course of mental illness cannot be understood outside of
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its larger cultural context. Religion is one key ingredient of this context (Pargament et al., 2013). Religious beliefs and practices are also common among people with mental illness (see Mohr, 2013, for review). Kroll and Sheehan (1989) studied 52 psychiatric inpatients in Minnesota and found that 94% believed in God, 67% in the devil, 53% prayed or consulted the Bible, and 51% attended church weekly. In a survey of the alternative health practices of people with serious mental illness (SMI), religious/spiritual activities (50%) and meditation (40%) were the most frequently reported practices (Russinova et al., 2002). Elsewhere, Pieper (2004) studied 118 patients in a Protestant mental hospital in the Netherlands, and found that 92% participated regularly in private religious activities and religious services. Many patients with mental illness indicate that religion offers valuable resources in the process of coping with their major stressors. Tepper et al. (2001) reported that 80% of a sample of 406 psychiatric outpatients with SMI in Los Angeles used religion to cope. In a comparative study of European psychiatric patients and a nonpsychiatric control group, Neeleman and Lewis (1994) found that the psychiatric patients reported a larger number of religious beliefs and practices that offered comfort during stressful life experiences. Religious professionals are another resource for people with mental illness. SMI individuals are as likely to seek treatment from clergy as from a mental health professional (Larson et al., 1988). It is important to add that religion can serve as a resource to caregivers of SMI patients. In a survey of caregivers to people with SMI, many participants reported that God is a source of comfort and strength (Murray-Swank, 2006). There are ethical mandates to consider religion when providing psychiatric care (American Psychiatric Association Principles of Medical Ethics, 2013). For example, a committee of the American Psychiatric Association (2006) stated that: “Psychiatrists should foster recovery by making treatment decisions with patients in ways that respect and take into meaningful consideration their cultural, religious/ spiritual, and personal ideals.” Some writers have cautioned against health professionals overstepping their boundaries by addressing religious issues in the context of treatment (Sloan et al., 1999). They maintain that clergy are better suited than healthcare professionals to manage patients’ spiritual concerns. Ethical standards in psychiatry, however, explicitly attend to these risks: “Psychiatrists should not impose their own religious/spiritual, antireligious/spiritual, or other values, beliefs and world views on their patients, nor substitute such commitments or religious/spiritual rituals for professionally accepted diagnostic methods or therapeutic practice” (American Psychiatric Association, 2006).
Religion Is Related to Health and Well-Being Religion can serve a number of valuable psychological functions for people with mental illness. In one project, Mohr et al. (2006) found that among Swiss schizophrenia patients religion provided a number of functions, such as hope, comfort, meaning of life, enjoyment of life, love, compassion, self-respect, and self-confidence; and one-third
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of these patients reported that they actually received social support from a religious community. In a study of 115 psychiatric outpatients in Geneva, Mohr et al. (2010) found that people who accessed positive religious coping resources experienced fewer negative symptoms and better social adaptation and quality of life 3 years later. These findings have been mirrored in other investigations of people with mental illness, in which higher levels of religiousness have been associated with the provision of meaning, hope, peace, and comfort (e.g., Fallot, 2007; Kelly and Gamble, 2005). Several studies have shown that higher levels of religious commitment and involvement are associated with lower prevalence of mental illness and more favorable mental health outcomes (Koenig et al., 2012; Shreve-Neiger and Edelstein, 2004). Religiousness has been robustly linked with lower risk of substance abuse (Johnson, 2013) and successful recovery (Simoni et al., 2002; Pence et al., 2008). Religion can provide patients with guidelines for living a sober life, a sense of power through identification with a larger spiritual force, and a new healthier source of meaning and purpose. In addition, religious commitment may lower suicide rates (Huguelet et al., 2007). Huguelet et al. (2009) reported that one-third of their cases of people with SMI believed that religion offered protection against suicide attempts by providing meaning in life, a way of coping with despair, ethical condemnation of suicide, and positive religious experiences. Studies also suggest that the involvement of clergy in patient care results in increased patient satisfaction, increased medical knowledge, and improved treatment compliance (Parkum, 1985; Saunders and Kong, 1983; Bay et al., 2008; Iler et al., 2001). Finally, in contrast to the view that religion interferes with treatment adherence, one study of 52 patients with psychosis found that religiousness was associated with greater adherence to medication (Kirov et al., 1998). Similarly, Harris et al. (2006) reported that among those with SMI, religious attendance and importance of religious beliefs were both positively correlated with outpatient mental health service use and medication use.
Mental Illness Can Be Associated with Problematic Forms of Religiousness Mental illness impacts people not only psychologically, socially, and physically, but spiritually as well. A significant number of people experience religious struggles as a result of their illness. Religious struggles reflect tension and doubt about spiritual issues within oneself, with a religious community, or with God (Pargament et al., 2005). For example, a mental illness may lead to feelings of anger toward, abandonment by, or being punished by God. In a survey of a national sample in the United States, McConnell et al. (2006) found that religious struggles were associated with a wide range of mental health symptomatology, including anxiety, depression, paranoid ideation, compulsiveness, and somatization. Although religious struggles may be triggered by psychiatric illness (i.e., secondary religious struggles), there is also evidence that religious struggles exacerbate mental health and physical health problems (i.e., primary religious struggles). Empirical
studies of a variety of religious groups in a variety of contexts have tied religious struggles to declines in mood, quality of life, physical health, and even greater risk of mortality (Cummings and Pargament, 2010). Mohr (2013) elaborates on religious struggles and their consequences among Swiss patients with schizophrenia. These include feelings of religious alienation as a result of lack of support from patients’ religious communities; a negative sense of self marked by feelings of guilt, despair, anger, fear, and suicidality; and vulnerability to the development of addictions in response to the sense of spiritual loss and emptiness. Although there is little evidence that religiousness in and of itself generally causes delusions or hallucinations, people may express psychiatric illness through a religious idiom or filter (Greenberg and Witztum, 2001). Religious delusions occur in 36% of schizophrenic patients, 33% of bipolar patients, 17% of patients with substance-induced psychosis, and 26% of patients with other psychoses (Appelbaum et al., 1999). Some patients with religious delusions have committed selfharm, suicide, or homicide (Mohr and Pfeifer, 2009). However, the psychiatrist’s task is complicated by the fact that hallucinations can be a normal part of religious experience in certain contexts, and are then experienced as positive. Nevertheless, hallucinations that scare, upset, or disrupt an individual’s life are considered pathological. Pathological hallucinations are most often auditory, but can also be visual, tactile, olfactory, or gustatory (Mohr and Pfeifer, 2009). Sims’ (1992) three criteria help to differentiate between religious belief and religious delusion. (1) The experience reported by the patient gives the impression of a delusion rather than a mere religious belief. Both the observed behavior and subjective experience are in concordance with the psychiatric symptom. (2) The presence of other psychiatric symptoms such as hallucinations or mood or thought disorder make it more likely that the individual has a religious delusion rather than mere religious belief. (3) The outcome of the experience seems more in keeping with the natural history and course of a mental disorder rather than a life-enhancing experience.
Patients with Mental Illness Want Religiously Sensitive Care Perhaps it should not be surprising that many patients would like to receive religiously sensitive healthcare, given the importance of religion as a resource and its significant implications for health and well-being. In one study, 83% indicated that their religious beliefs are closely tied to their state of mental and emotional health, and 75% said it is important to see professionals who integrate their values and beliefs into counseling (American Association of Pastoral Counselors Samaritan Institute Report, 2000). It is important to note that concerns about the openness of mental health professionals to religion and spirituality was the second most common reason for not seeking out help from this group; 15% said that they ‘fear that (their) spiritual values and beliefs may not be respected and taken seriously.’ African Americans and devout Evangelicals were particularly likely to voice these concerns. Other surveys of individuals
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in the United States dealing with physical and emotional problems lead to the same conclusion – a majority of people would like to see religion and spirituality integrated into their treatment in a sensitive and respectful fashion (e.g., Lindgren and Coursey, 1995; Stanley et al., 2011). In spite of this expressed desire, religion is not often addressed in health care. Huguelet et al. (2006) reported that, although a majority of study patients with schizophrenia rated religion as important, only 36% discussed this issue with their clinicians. In sum, there are a variety of sound empirically based reasons to justify a rapprochement between psychiatry and religion. In fact, over the past 75 years, theorists have made significant advances in conceptualizing the interplay between religion and mental health from a more balanced, nuanced perspective. These theoretical developments have led, in turn, to progress toward more spiritually sensitive psychiatric care.
Promising Theoretical Advances Recently, two theoretical approaches have been advanced that hold particularly important implications for psychiatry: coping theory and attachment theory. Coping theory, derived from ego psychology (Lazarus and Folkman, 1984), emphasizes the role of religion in helping people understand and deal with major life stressors (Pargament, 1997). Religion provides individuals with coping resources (e.g., spiritual support from a sacred entity, religious reframing of suffering, confession) to assist them in coming to terms with life events, particularly those that reveal human finitude and frailty. In this sense, religion serves an empowering, ego-strengthening function. This may help to explain the high levels of religious involvement among people grappling with mental illness, as noted above. However, people vary according to the breadth and depth of their religious resources. Some are equipped with religious frameworks of meaning, ritual, and connectedness that allow them to withstand and even transform themselves in the face of significant stressors, including mental illness. Others have religious orientations that rest on a less benevolent view of the universe, other people, and the individual’s place in the world; this group is more likely to experience profound religious struggles that compound the harsh impact of mental illness. The effectiveness of coping from the perspective of this theory has to do not only with the individual’s breadth and depth of coping resources, but also with the degree to which coping methods are well integrated with the demands of the situation, the needs and aspirations of the individual, and the larger social context. For example, active surrender of control to God’s will has very different clinical implications for the individual who must take active steps to manage an emotional illness and the individual in hospice who has exhausted all treatment alternatives. The pursuit of religious growth and development can facilitate mental health and physical health more generally or interfere with those ends when it becomes overly scrupulous. Seeking out religious support for anxiety about gender identity will have different
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implications depending on whether the individual is part of a conservative or liberal religious tradition. Attachment theory builds on the work of object relations theory and evolutionary theory. Attachment theorists have emphasized the role of religion in fostering a meaningful relationship between the self and the other (Granqvist et al., 2010). For most religious individuals, this attachment seeking involves a connectedness with a Divine other. People who pursue spirituality outside of traditional religious settings may seek a particular type of relationship with other entities or objects deemed sacred, such as nature, eminent figures, social justice, or work. Several theorists have elaborated on this notion. Ana-Maria Rizutto emphasized the importance of learning about an individual’s picture or image of God. She contends that this God image is heavily influenced by the internal representations of self and important others in the individual’s relationship world, especially parents and subsequent key attachment figures (Rizzuto, 1979). Winnicott developed the notion of transitional objects as a key intermediary reflection of how a young child begins to translate experience with early attachment figures into predictions about others when engaging new individuals in the child’s relational world (Winnicott, 1953). William Meissner extrapolated Winnicott’s notion of the transitional object into his concept of creative illusion formation as a developmental capacity that plays an important positive and healthy role in the meaningfulness of religion participation (Meissner, 1984). Meissner described how growth-producing illusions were responses to objective reality that represented the person’s capacity to transform (mere) reality into something reflective of inner significance and hope. Consistent with this theory, emerging research has found a correspondence between the quality of an individual’s parental attachments and attachments to God (Granqvist and Kirkpatrick, 2013). Thus secure attachments to parents are often tied to a secure felt connection to the Divine. Conversely, insecure attachments to parents are linked to anxious, avoidant, and ambivalent attachments to the Divine. There is also evidence that some people form a secure relationship with God in compensation for insecure relationships to parents, as in the case of religious conversions. These findings and the underlying theory on which they are based have important practical implications for psychiatry.
Promising Therapeutic Directions Psychiatrists and other mental health professionals have begun to integrate greater religious and spiritual awareness and sensitivity into various treatment orientations (Pargament, 2007). Empirical evaluations of the effectiveness of these spiritually integrated treatments have shown encouraging results. Worthington et al. (2011) conducted a meta-analysis of 51 samples from 46 studies, and compared the outcomes of religious accommodative therapies and nonreligious therapies. They found that religious/spiritual psychotherapies (R/S) were as effective as secular psychotherapies with respect to the psychological
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outcomes of patients. However, in comparison to secular psychotherapies, R/S therapies were tied to greater improvement among patients with respect to spiritual outcomes. They concluded that, for patients and contexts in which spiritual outcomes are highly valued, spiritually integrated therapies may be a treatment of choice. Although a variety of spiritually integrated treatments have been developed, most have a cognitive-behavioral therapy orientation. These treatments have been applied to several patient populations, with promising results (Propst et al., 1992; Rosmarin et al., 2010; Harris et al., 2011; Hardman et al., 2003; Margolin et al., 2007, Richards et al., 2006). Even though much of the work on spiritually integrated treatments has grown out of a cognitive-behavioral orientation, practitioners from other therapeutic orientations have also begun to integrate greater spiritual sensitivity into their treatments. These treatment modalities have in common the attempt to provide a healthy revisiting of critical periods of development within the therapist–patient relationship. There is reason to believe that such experiences occur fairly often across healthcare disciplines. However, the impact of these ‘sacred’ or at least ‘important’ moments experienced in early development and brought into treatment awaits study (Lomax and Pargament, 2011).
New Directions In recent years, great progress has been made in clarifying the interface between psychiatry and religion. Yet significant questions remain. First, because much of the work in this area has focused on western religion and medicine, it is important to extend research and practice to other cultures, particularly non-western contexts. Second, research in this arena is moving toward studies of more specific aspects of religiousness as they express themselves in specific forms of psychiatric illness (Hill and Pargament, 2003; Peteet et al., 2011). For example, it is important to consider whether mystical experiences and religious conversion contribute to destructive dissociation or positive integration among patients with significant mental illness. Similarly, research should explore the roles that patients’ understandings of ‘evil’ and ‘the Devil’ play in their illness. There is some evidence that patients who try to make sense of their illness by invoking diabolical divine agents may be at risk for mental health problems and have increased risk of mortality (Pargament et al., 2001). The language of evil and the demonic may also offer a way to find meaning in otherwise meaningless suffering. Third, longitudinal studies are needed to disentangle the complex links between religion and psychopathology; in particular, the ways in which SMI may impact religious life and the ways religious problems and resources may foster or ameliorate psychopathology. Fourth, to foster more spiritually sensitive care and respond to the dearth of education about religious issues within psychiatric training programs, new models of psychiatric training must be developed and tested (Blass, 2007). Finally, further studies are needed to determine whether spiritually integrated treatments add to the effectiveness of psychiatric treatments. It is also important to learn how psychiatric treatments,
including psychotropic medications, impact the spiritual lives of patients. These represent just a few of the many promising areas of study open to exploration by researchers in the twenty-first century.
See also: Buddhism; New Religious Movements; Religion and Health: Sociological Considerations; Religion and Sciences; Religion, Phenomenology of; Religion, Psychology of; Religion, Sociology of; Science and Religion.
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Relevant Websites American Psychiatric Association, 2013. The Principles of Medical Ethics with Annotations Specifically Applicable to Psychiatry. Available at: http://www. psychiatry.org/practice/ethics/resources-standards. American Psychiatric Association, 2006. Religious/spiritual commitments and psychiatric practice resource document. Available at: http://www.psych. org/departments/edu/library/apaofficialdocumentsandrelated/resourcedocuments/ 200604.aspx. Newport, F., 2007. Americans more likely to believe in God than the Devil, Heaven more than Hell. Gallup News Service. Available at: http://www.gallup.com/ poll/27877/Americans-More-Likely-Believe-God-Than-Devil-Heaven-More-ThanHell.aspx.