Religion, spirituality and psychiatry: a new era in mental health care
Harold G. Koenig, M.D.
Professor of Psychiatry & Behavioral Sciences. Associate Professor of Medicine, Duke University Medical Center. Geriatric Research, Education and Clinic Center Durham VA Medical Center
The publication of this special issue of Revista de Psiquiatria Clinica represents a landmark in the field of religion, spirituality and mental health in Brazil and other Portuguese speaking countries. To my knowledge, this will be the first psychiatric journal to devote an entire issue to the subject. The articles contained here are written by the most important Brazilian researchers in the field, and include several papers from researchers outside of Brazil as well. In this foreword/editorial, I provide a brief summary of how the field of religion, spirituality and mental health has developed, provide my vision for the future of the field, and stress the importance of collaboration between Brazilian clinicians and scientists in ensuring that the psychological, social, and spiritual needs of patients are adequately addressed.
Many of the first hospitals to care for persons with mental illness were operated by monks and priests, and "moral" treatment (that valued the role of religion and the contributions of clergy in care) became the dominant type of psychiatric care in the United States and Europe in the early 1800s. However, this all changed in the early 1900s with the writings of Sigmund Freud in psychiatry and G. Stanley Hall in psychology (Koenig, 1995). These writers believed that religion promoted neurosis and that psychological theory would ultimately replace religion as a world-view and source of treatment. Such negative attitudes toward religion were not based on scientific research or systematic study, but rather on the personal opinions and beliefs of these early leaders. For most of the 20th century, as a result, the field of mental health care would undervalue and often devalue the religious beliefs and practices of patients, as evidenced by writings as late as 1980s and 1990s that strongly spoke against religion (Ellis 1988; Watters, 1992).
However, some stirrings of change began within the mental health field in the 1990s and the turn of the 21st century. Systematic research began to demonstrate that religious persons were not always neurotic or unstable, and those with deep religious faith actually seemed to cope better with life stress, recover more quickly from depression, and experience less anxiety and other negative emotions than those who were less religious (Larson et al, 1992; Koenig et al., 1992, 1993; Koenig et al., 1998; Koenig, 2006). Furthermore, researchers in the United States were not the only groups reporting such findings, but also scientists in Canada (Baetz et al., 2002; Gee & Veevers, 1990; Harvey et al., 1987; OConnor & Vallerand, 1989), Great Britain (Shams & Jackson, 1993; Cook et al., 1997), Ireland (Maltby, 1997), Spain (Luna et al., 1992), Switzerland (Pfeifer & Waelty, 1995), Germany (Schwab & Petersen, 1990; Siegrist, 1996; Becker et al., 2006), the Netherlands and other areas of Europe (Braam et al., 1997; Braam et al., 2004), Malaysia (Razali et al., 1998; Azhar et al., 1994), Thailand (Tapanya et al., 1997), Australia (Francis & Kaldor, 2002; Wollin et al., 2003), Nigeria (Ndom, 1996), Egypt (Thorson, 1998), the Middle-East (Anson et al., 1990; Abdel-Kalek, 2006),and India (Verghese et al., 1989).
In fact, a PsycINFO online search (a database containing 2.3 million research studies and academic articles from 49 countries in 27 languages) using the terms "religion," "religiosity, "religious beliefs," and "spirituality" reveals some interesting trends. When I restricted the search years to 1971 to 1975, I uncovered 1113 articles. When I repeated the search and restricted the articles to those published between 2001 and 2005, this yielded 6,437 articles, an increase of over 600% in 30 years. Thus, there appears to be a rapid increase in research and academic discussions related to the relationship between religion, spirituality and mental health.
Given that religion is important to the vast majority of Brazilians and others living in South America, it is not surprising that there might be interest in the link between religious involvement and mental health. Of the 6,437 religion-spirituality articles published between 2001 and 2005, 20 involved papers on religion, spirituality and health in Brazilians. Six of the 20 articles reported quantitative results from research studies, and four of these focused on mental health. I briefly review the latter reports here.
The first studied 110 Spiritualists attending a well-known Kardecist Center in Sao Paulo. Socialization, happiness, religiosity, mediumship, personality, and general dissociative experiences were measured using standard scales (Negro et al., 2002). Mediumship activity was associated with increased dissociative experiences, but good scores on socialization and adaptation. A second study involved 989 consecutive patients admitted in a psychiatric unit in a Brazilian hospital (Dalgalarrondo et al., 2004a). Catholics and Protestants (the majority being Pentecostals) were compared on symptoms, diagnoses, length of stay, and clinical outcomes. Protestant patients were younger, more likely to be female, had less education and were less likely to be married. Compared with Catholics, Protestants were more likely to have schizophrenia and were less likely to have substance abuse disorders. There was no difference in length of stay or clinical status at the time of discharge. Investigator explained that the results may be due to patterns of help seeking by the largely Pentecostal Protestant group from lower socioeconomic backgrounds.
A third study examined 2,287 students attending four public and three private schools (Dalgalarrondo et al., 2004b). Use of alcohol, tobacco, medicines, and illicit drugs was examined within the past month. Students with no religious affiliation or without a religious education were significantly more likely to use illicit drugs (ecstasy or cocaine). The final study examined the effects of religious affiliation (Pentecostal, Spiritualists, and Catholics) on substance use and mental health (the latter measured by GHQ-12, with higher scores indicating more psychological morbidity) in 1,796 students (Dalgalarrondo et al., 2005). Pentecostals used less tobacco, alcohol and drugs and had lower GHQ-12 scores; Spiritualists used more psychoactive substances and had higher GHQ-12 scores; and Catholics scored halfway in between the other two groups. These four studies give the reader some sense of the kind of research in this area now being done in Brazil.
Why all the interest in this area? Why study the relationship between religion, spirituality and mental health? There are several reasons. The results of such research have important implications regarding the clinical care of patients. Knowing the impact that religious beliefs may have on the etiology, diagnosis, and outcome of psychiatric disorders will help psychiatrists better understand their patients, appreciate when religious or spiritual beliefs are used to cope with mental illness, and when they may be exacerbating that illness. The vast majority of research thus far in healthy populations suggests that religious beliefs and practices are associated with greater well-being, better mental health, and more successful coping, especially during situations of high stress. This is also true to some extent for psychiatric patients, who often face tremendous environmental and psychosocial stress from their disorders and are in need of effective coping strategies for dealing with this. On the other hand, a few studies also indicate an association between religious involvement and greater psychopathology (see article on religion and psychotic disorders in this issue).
Because of the role that religious and spiritual beliefs may have in psychiatric illness, it is important that psychiatrists conduct a spiritual history during which they explore the beliefs of the patient that may be influencing the mental illness and how the patient is coping with the illness. Furthermore, much more research is needed to better understand how the many different religious belief systems in Brazil and other countries of South America interact with and influence mental disorders.
Thus, the area of religion, spirituality and mental health is a research and clinical area with great potential. It is my hope that this trail blazing issue of the Journal may excite further research and discussion that will ultimately lead to recognition by clinicians of the importance of religious and spiritual beliefs in the mental health and mental illnesses of the patients we serve, thereby ushering in a new era of whole person culturally sensitive psychiatric care.
Abdel-Khalek, A.M. - Happiness, health, and religiosity: Significant relations. Mental Health, Religion and Culture 9(1):85-97, 2006.
Anson, O.; Antonovsky, A.; Sagy, S. - Religiosity and well-being among retirees: A question of causality. Behavior, Health, and Aging 1:85-97, 1990.
Azhar, M.Z.; Varma, S.L..; Dharap, A.S. - Religious psychotherapy in anxiety disorder patients. Acta Psychiatrica Scandinavica 90:1-3, 1994.
Baetz, M.; Larson, D.B.; Marcoux, G.; Bowen, R.; Griffin, R. - Canadian psychiatric inpatient religious commitment: an association with mental health. Canadian Journal of Psychiatry 47(2):159-166, 2002.
Becker, G.; Momm, F.; Xander, C.; Bartelt, S.; Zander-Heinz, A.; Budischewski, K.; Domin, C.; Henke, M.; Adamietz, I.A.; Frommhold, H. - Religious belief as a coping strategy: an explorative trial in patients irradiated for head-and-neck cancer. Strahlentherapie und Onkologie 182(5):270-276, 2006.
Braam, A.W.; Beekman, A.T.F.; Deeg, D.J.H.; Smith, J.H.; van Tilburg, W. - Religiosity as a protective or prognostic factor of depression in later life; results from the community survey in the Netherlands. Acta Psychiatrica Scandinavia 96:199-205, 1997.
Braam, A.W.; Hein, E.; Deeg, D.J.; Twisk, J.W.; Beekman, A.T.; Van Tilburg, W. - Religious involvement and 6-year course of depressive symptoms in older Dutch citizens: results from the Longitudinal Aging Study Amsterdam. J Aging Health 16(4):467-489, 2004.
Cook, C.C.; Goddard, D.; Westall, R. - Knowledge and experience of drug use amongst church-affiliated young people. Drug & Alcohol Dependence 46(1-2): 9-17, 1997.
Dalgalarrondo, P.; Banzato, C.E.M.; Botega, N.J. - Increased frequency of schizophrenia among Brazilian Protestant inpatients. Jornal Brasileiro de Psiquiatria 53(3):143-152, 2004a.
Dalgalarrondo, P.; Soldera, M.A.; Filho, H.R.C.; Silva, C.A.M. - Religion and drug use by adolescents. Revista Brasileira de Psiquiatria 26(2):82-90, 2004b.
Dalgalarrondo, P.; Soldera, M.A.; Filho, H.R.C.; Silva, C.A.M. -. Mental health and drug use among catholic, pentecostal and spiritualist youth. Jornal Brasileiro de Psiquiatria 54(3):182-190, 2005.
Ellis, A. - Is religiosity pathological? Free Inquiry 18:27-32, 1988.
Francis, L.J.; Kaldor, P. - The relationship between psychological well-being and Christian faith and practice in an Australian population sample. Journal for the Scientific Study of Religion 41(1):179-184, 2002.
Gee, E.M.; Veevers, J.E. - Religious involvement and life satisfaction in Canada. Sociological Analysis 51: 387-394, 1990.
Harvey, C.D.H.; Barnes, G.E.; Greenwood, L. - Correlates of morale among Canadian widowed persons. Social Psychiatry 22:65-72, 1987.
Koenig, H.G.; Cohen, H.J.; Blazer, D.G.; Pieper, C.; Meador, K.G.; Shelp, F.; Goli, V.; DiPasquale, R. - Religious coping and depression in elderly hospitalized medically ill men. American Journal of Psychiatry 149:1693-700, 1992.
Koenig, H.G.; Ford, S.; George, L.K.; Blazer, D.G.; Meador, K.G. - Religion and anxiety disorder: An examination and comparison of associations in young, middle-aged, and elderly adults. Journal of Anxiety Disorders 7:321-42, 1993.
Koenig, H.G.; George, L.K.; Peterson, B.L. - Religiosity and remission from depression in medically ill older patients. American Journal of Psychiatry 155:536-42, 1998.
Koenig, H.G. - Faith and Mental Health. Philadelphia, PA: Templeton Foundation Press 2005.
Koenig, H.G. - Religion and depression in older medical inpatients. American Journal of Geriatric Psychiatry, in press 2006.
Larson, D.B.; Sherrill, K.A.; Lyons, J.S.; Craige, F.C.; Thielman, S.B.; Greenwold, M.A.; Larson, S.S. - Dimensions and valences of measures of religious commitment found in the American Journal of Psychiatry and the Archives of General Psychiatry, 1978-1989. American Journal of Psychiatry 149:557-559, 1992.
Luna, A.; Osuna, E.; Zurera, L.; Gracia-Pastor, M.V.; Castillo del Toro, L. - The relationship between perception of alcohol and drug harmfulness and alcohol consumption by university students. Medicine and Law 11:3-10, 1992.
Maltby, J. - Personality correlates of religiosity among adults in the Republic of Ireland. Psychological Reports 81 (3, Part 1):827-831, 1997.
Ndom, R.J.E.; Adelekan, M.L. - Psychosocial correlates of substance use among undergraduates in Ilorin University, Nigeria. East African Medical Journal 73:541-547, 1996.
Negro, P.J.; Palladino-Negro. P.; Louza, M.R. - Do religious mediumship dissociative experiences conform to the sociocognitive theory of dissociation? Journal of Trauma & Dissociation 3(1):51-73, 2002.
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Pfeifer, S.; Waelty, U. - Psychopathology and religious commitment: A controlled study. Psychopathology 28:70-77, 1995.
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Tapanya, S.; Nicki, R.; Jarusawad, O. - Worry and intrinsic/extrinsic religious orientation among Buddhist (Thai) and Christian (Canadian) elderly persons. International Journal of Aging and Human Development 44:73-83, 1997.
Thorson JA (1998). Religion and anxiety: Which anxiety? Which religion? In H. Koenig (ed), Religion and Mental Health. San Diego: Academic Press, pp. 147-159
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Watters, W. - Deadly Doctrine: Health, Illness, and Christian God-Talk. Buffalo, New York: Prometheus Books 1992.
Wollin, S.R.; Plummer, J.L.; Owen, H.; Hawkins, R.M.; Materazzo, F. - Predictors of preoperative anxiety in children. Anaesthesia & Intensive Care 31(1):69-74, 2003.
Funding provided by NIMH grant R01-MH57662 (Dr. Koenig).
Publication in this collection
16 Oct 2007
Date of issue