Theoretical and Clinical PerspectivesBy Simon Dein, FRCPsych, PhD | January 10, 2010
Dr Dein is senior lecturer of anthropology and medicine at University College London, School of Life and Medical Sciences, Division of Population Health. He reports no conflicts of interest concerning the subject matter of this article.
Anxiety, religion, and spirituality
Until the early 19th century, psychiatry and religion were closely connected. Religious institutions were responsible for the care of the mentally ill. A major change 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 Religion has often been seen by mental health professionals in Western societies as irrational, outdated, and dependency forming and has been viewed to result in emotional instability.3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 and Clinical Psychology that there was an irrefutable causal relationship between religion and emotional and mental illness. According to Canadian psychiatrist Wendall Watters, “Christian doctrine and liturgy have been shown to discourage the development of adult coping behaviors and the human to human relationship skills that enable people to cope in an adaptive way with the anxiety caused by stress.”5(p148) At its most extreme, all religious experience has been labeled as psychosis.6
Psychiatrists are generally less religious than their patients and, therefore, they have not valued the role of religious factors in helping patients cope with their illnesses.7 It is only in the past few years that attitudes toward religion have changed among mental health professionals. In 1994, “religious or spiritual problems” was introduced in DSM-IV as a new diagnostic category that invited professionals to respect the patient’s beliefs and rituals. Recently, there has been a burgeoning of systematic research into religion, spirituality, and mental health. A literature search before 2000 identified 724 quantitative studies, and since that time, research in this area has increased dramatically.8 The evidence suggests that, on balance, religious involvement is generally conducive to better mental health. In addition, patients with psychiatric disorders frequently use religion to cope 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 the fact that the American Psychiatric Association has issued practice guidelines regarding conflicts between psychiatrists’ personal religious beliefs and psychiatric practice. The Accreditation Council for Graduate Medical Education includes in its psychiatric training requirement, didactic and clinical instruction on religion and spirituality in psychiatric care.
Religion and depression
Studies among adults reveal fairly consistent relationships between levels of religiosity and depressive disorders that are significant and inverse.8,14 Religious factors become more potent as life stress increases.15 Koenig and colleagues8 highlight the fact that before 2000, more than 100 quantitative studies examined the relationships between religion and depression. Of 93 observational studies, two-thirds found lower rates of depressive disorder with fewer depressive symptoms 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, 15 found 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 100,000 subjects. 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 in patients with medical and psychiatric disease who have established depression.16,17 The vast majority of these studies have focused on Christianity; there is a lack of research on other religious groups. 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 the increased risk of suicide. In a systematic review that examined 68 studies, researchers looked for a relationship between religion and suicide.8 Among these, 57 studies reported fewer suicides or more negative attitudes toward suicide among the more religious. In a recent Canadian cross-sectional study, religious attendance was associated with decreased suicide attempts in the general population and in those with a mental illness, independent of the effects of social supports.19 Religious teachings may prevent suicide, but social support, comfort, and meaning derived from religious belief also are important.
More recent studies indicate that the relationship between religion and depression may be more complex than previously shown. All religious beliefs and variables are not necessarily related to better mental health. Factors such as denomination, race, sex, and types of religious coping may affect 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, 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 to understand and deal with stressors.”
Very few studies have specifically addressed the relationship between spirituality and depression. In some instances, spirituality (as opposed to religion) might be associated with higher rates of depression.24 On the other hand, there is a substantial negative association between spirituality and the prevalence of depressive illness, particularly in patients with cancer.25,26
Given the ubiquity of anxiety and religion, it is surprising how little research has been done with respect to the relationship between the two. The investigation of religious and spiritual issues in anxiety lags behind research on mental disorders such as depression and psychosis. Religious beliefs, practices, and coping may increase the prevalence of anxiety through the induction of guilt and fear. On the other hand, religious beliefs may provide solace to those who are fearful and anxious. Studies on anxiety and religion have yielded mixed and often contradictory results that may be attributed to a lack of standardized measures, poor sampling procedures, failure to control for threats to validity, limited assessment of anxiety, experimenter bias, and poor operationalization of religious constructs.27
Some studies have examined the relationships between religiosity and specific anxiety disorders such as obsessive-compulsive disorder and posttraumatic stress disorder (PTSD). Contrary to the views of Freud,28 who saw religion as a form of universal obsessional neurosis, the empirical evidence suggests that religion is associated with higher levels of obsessional personality traits but not 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 ability to cope with trauma and may deepen one’s religious experience, others have found that religion has little or negative effect on symptoms of PTSD.31
The relationships between generalized anxiety and religious involvement appear to be complex. In a comprehensive review of the relationship between religion and generalized anxiety in 7 clinical trials and 69 observational studies, Koenig and colleagues8 found that half of these studies demonstrated lower levels of anxiety among more religious people, 17 studies reported no association, 7 reported mixed results, and 10 suggested increased anxiety among the more religious.
A person’s strong religious beliefs may facilitate coping with existential issues whereas those who hold weaker beliefs or question their beliefs may demonstrate heightened anxiety.32 These contradictory findings may be accounted for by the fact that researchers have used diverse measures of religiosity. Other studies have focused on death anxiety. Research conducted in the United States and abroad points to denominational differences as well as to differential effects of religion and spirituality and emphasizes the complex relationships between religious and cultural factors.33 Studies on anxiety and religion to date have emphasized cognitive aspects of anxiety as opposed to the physiological aspects. Future studies should include physiological parameters.
A number of pathways have been discussed in the literature through which religion/spirituality influence depression/anxiety: increased social support; less drug abuse; and the importance of positive 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, promotes meaning, can discourage maladaptive coping, and promotes other-directedness.
Religion and coping in schizophrenia
Research in schizophrenia and religion has predominantly examined religious delusions and hallucinations with religious content. Recently, however, religion as a coping strategy and factor in recovery has been the subject of growing interest.34 Religious delusions have been associated with poorer 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 the recovery 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 lives of some persons with psychosis, for others, it induced spiritual despair. Patients also reported that religion lessened psychotic symptoms and the risk of suicide attempts, substance use, nonadherence to treatment, and social isolation.
Given that most religions actively discourage the use of substances that adversely affect the body and mind, it is unsurprising that studies generally indicate strongly negative associations between substance abuse and religious involvement. In a review of 134 studies that examined the relationships between religious involvement and substance abuse, 90% found less substance abuse among the more religious.8 These findings are corroborated by more recent national surveys and studies in alcohol and drug use in African Americans, Hispanic Americans, and Native Americans that similarly indicate negative associations between religious involvement and substance abuse.38-41
The negative effects of religious involvement
Negative psychological effects of religious involvement include excessive devotion to religious practice that can result in a family breakup. Differences in the level of religiosity between spouses can result in marital disharmony. Religion can promote rigid thinking, overdependence on laws and rules, an emphasis on guilt and sin, and disregard for personal individuality and autonomy. Excessive reliance 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.
Religious issues are important in the assessment and treatment of patients, and therefore clinicians need to be open to the effect of religion on their patients’mental health. It is, however, important that 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, with residents learning about the principles of spiritual assessment. There are a number of protocols about how to ask about spirituality, such as the HOPE questionnaire (Sidebar).44
After taking a detailed spiritual history, health professionals need 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’s moral stance should be neutral, with no attempt to manipulate the patient’s beliefs. Clinicians must be 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 as long as he is alert to the need for sensitivity to religious issues and the need to become educated about the religion’s beliefs and practices. At times, patients’ religious views may conflict with medical/psychotherapeutic treatment, and therapists must endeavor to understand the patient’s worldview and, if necessary, consult with clergy. It might be appropriate to involve members of the religious community to provide support and to facilitate rehabilitation.
Religion or spirituality may have therapeutic implications for mental health. Randomized trials indicate that religious interventions among religious patients enhance recovery from anxiety and depression.47,48 Psychoeducational groups that focus on spirituality can lead to greater understanding of problems, feelings, and spiritual aspects of life.49
A focus for future research
In addition to broadening the current research focus on the effects of Christian beliefs on mental health, 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
This article is part of a series: Introduction: Cross-Cultural Psychiatry Religion, Spirituality, and Mental Health Cultural Considerations in Child and Adolescent Psychiatry Cultural and Ethnic Issues in Psychopharmacology