Religious Beliefs, Spirituality, and Intention

Excerpt from: Freinkel A, Lake J.  Religious Beliefs, Spirituality, and Intention.

In Lake, J and Spiegel, D (ed.),

Clinical Manual of Complementary and Alternative Treatments in Mental Health.

Washington, DC: American Psychiatric Press, Inc. 2006.

Introduction

An existential “divide” separates many patients and physicians, and this divide probably interferes with the quality of care that patients receive. According to surveys of patients, as many as 77% of individuals who seek medical care feel that their religious or spiritual beliefs are directly related to their health concerns, while only 16% of conventionally trained physicians or nurses ever inquire about these important matters (King 1994; Anderson 1993). Significantly, 92% of surveyed family practice physicians believed they were competent to address religious issues with patients. Furthermore, 37% disclosed that they had prayed with patients and of those, 89% believed that praying with their patients had beneficial effects on the problem that was being addressed. In a large multi-center trial, two thirds of patients felt that physicians should be aware of their spiritual beliefs and a third wanted to be asked about these beliefs. Ten% said they would be willing to give up time discussing medical issues in order to discuss spiritual beliefs. (MacLean 2003.)

In contrast, while some studies have demonstrated that physicians are generally unwilling to pray with patients, physicians are open to doing so if a patient so requests. (Monroe 2003) One important contribution to this literature comes from focus-group work done at Johns Hopkins. (Hebert 2001) The researchers found that the patients want to share their spiritual beliefs, but only if they believe physicians respect their values.

An important and understudied area of this research is the extent to which physicians themselves believe in God and the healing power of prayer. Clear regional and specialty differences exist with respect to this question. For example, the number of family physicians who disclose religious beliefs is about equal to that of the general population in Kansas-about 80%. (Daaleman 1999) In one of the only surveys of psychiatrists' religious beliefs, only 23% expressed a belief in God-however, 92% stated that it is appropriate to concern themselves with their patients' religious or spiritual beliefs. (Neeleman 1993.) Given the above cited findings, it is reasonable to imagine that however open-minded psychiatrists are, it may be difficult for their patients to relate to them along these lines. While newer data might provide a more accurate picture of current attitudes, the most recent available data (1978-1982) suggest that psychiatrists have little interest in spirituality. In fact only about two% of studies in the peer-reviewed psychiatric literature include a religious variable. This includes studies of substance abuse, including twelve step programs based on shared spiritual beliefs. (Larson 1986).

The above findings suggest that patients and physicians have shared beliefs about the roles of religion, spirituality, and prayer in illness and health. However, for reasons that remain unclear, shared beliefs seldom influence the day-to-day practice of medicine. In spite of the apparent significance of religion and prayer in healthcare from the perspectives of both patients and physicians, discussions of the evidence supporting religious and spiritual beliefs and practices in physical and mental health are seldom included in conventional medical training programs in Western countries (Puchalski 1998). Strong historical relationships between religious beliefs and health stand in stark contrast to the failure of contemporary medicine to address these important issues. Recent studies have brought a renewed sense of legitimacy to the role of prayer in maintaining health and treating illness, and have opened the door to novel understandings of the role of human intention in healing. Two central themes are addressed in this chapter: relationships between religious beliefs and mental health; and evidence for the efficacy of prayer and other spiritual practices as treatments of mental illness.

Influences of Religious Beliefs on Specific Psychiatric Disorders

Because most data on the relationship between religious practices and mental health come from epidemiologic surveys or retrospective analyses, it is difficult to make strong arguments for direct beneficial effects of a religious or spiritual practice on any particular psychiatric disorder. Furthermore, the prevalence of specific mental health problems is different in disparate religious groups (Koenig 1994). Significant findings from published research studies are discussed in this section.

A meta-analysis of 89 studies on religion and mental health showed that regular involvement in organized religious activity is associated with a relatively reduced risk of depressed mood (Koenig 1995). Most studies on religion and mental health provide limited clinical data because they examine relationships between general beliefs (i.e.,“religiosity”) and broad measures of mental or emotional well-being. Recent studies have used factor analysis to deconstruct religiosity into discrete dimensions. A survey study of over 3000 adolescent girls found that two dimensions of religiosity, personal devotion and participation in a religious community, were correlated with moderately reduced risk of depression in non-mature adolescent girls and highly reduced risk (up to 43%) in more mature girls (Miller 2002). Another survey study used in-person interviews with over 1000 pairs of adult twins in efforts to clarify associations between specific factors of religiosity and specific psychiatric disorders (Kendler 2003). Religiosity was deconstructed into seven specific factors: general religiosity, social religiosity, involved God, forgiveness, God as judge, unvengefulness, and thankfulness. Social religiosity and thankfulness were associated with reduced risk for alcohol and substance abuse, anti-social behavior, major depressive disorder, generalized anxiety disorder, panic disorder and bulimia. Four different factors--general religiosity, involved God, forgiveness, and God as judge, predicted reduced risk for substance abuse and anti-social behavior- but not other major psychiatric disorders. These findings are limited by the cross-sectional design of the study, thus it is not possible to infer causal relationships between discrete factors of religiosity and specific psychiatric disorders. In a similar fashion, McClain (Lancet, 2003) showed that there is a relationship between spiritual well being and alleviation of end-of-life despair. Nonetheless, if a clinician learned about research findings showing a relationship between an herb and improved mental health, he or she would probably feel comfortable making a causal inference on this basis. In view of the strong evidence supporting the mental health benefits of religious involvement, the hesitation with which most psychiatrists approach this dimension of human experience as a potentially useful adjunct to conventional care is difficult to understand.

Relationships between religious beliefs or affiliation with organized religion, and specific psychiatric disorders are complex and difficult to delineate. A review of 80 published and unpublished studies revealed that organized religious affiliation was generally associated with decreased risk of depressed mood, however private religious activities and certain religious beliefs did not predict lower risk (McCullough 1999). Findings of a survey of elderly men (N=832) with medical problems suggest that cognitive, but not somatic symptoms, of depression are less severe in individuals who use religious coping (Koenig 1995). Elderly depressed patients who participate in an organized religious activity have fewer symptoms, less severe symptoms, and are less likely to commit suicide (Koenig 1997). Depressed medically hospitalized elderly patients who had strong religious beliefs were significantly more likely to have complete remission of mood symptoms compared to those who did not hold strong religious or spiritual beliefs (Koenig 1998). This effect was not related to frequency of participation in organized or private religious practices.

Findings of a large survey study suggest that religious beliefs are associated with improved self-management of symptoms in patients with Bipolar Disorder (Mitchell 2003). Findings from the NIMH Epidemiologic Catchment Area survey (N=2,969) support the view that regular weekly attendance at religious services is associated with significantly lower incidences of most anxiety disorders including agoraphobia, generalized anxiety disorder, social phobia in general, and a relatively higher incidence of Obsessive-compulsive Disorder in younger individuals with strong religious beliefs (Koenig 1993). Religious beliefs and practices are an important source of encouragement, social support and insight among individuals who suffer from chronic severe mental illness, including schizophrenia (Sullivan 1993). Support groups built around shared spiritual themes have beneficial effects on self-esteem, quality of life and community involvement in schizophrenics (Sageman 2004).

Rates of alcohol and drug abuse are generally lower in groups that follow organized religious practices (Adelekan 1993). Feelings of deep personal devotion and conservative religious values are correlated with a generally reduced risk of alcohol or substance abuse and dependence, and this relationship is somewhat stronger in adolescents than adults (Miller 2000). 12-Step programs incorporating both religious and spiritual values have a strong record of success in prolonging abstinence in recovering alcohols and narcotics abusers (Carroll 1993). Death anxiety is less among individuals who follow a religious or spiritual practice in which belief in an afterlife plays a central role (Klenow 1989; Chibnall 2002). While religious beliefs or practices do not cause schizophrenia or other psychotic disorders, deeply held religious beliefs can exacerbate delusions (Tateyama 1993).