Religion and psychiatry: from conflict to consensus

Pargament and Lomax present religion as a “double-edged sword”, serving both as a resource and a challenge to psychiatry. This analogy may be useful in guiding further research and moving to a position of consensus a field that has been sometimes conflict-laden. Not only psychiatry has had difficulty with religion, but also religion — with its focus on mind, body and spirit — has had difficulty with psychiatry. Optimal restoration of mental health in a patient requires an ability by the psychiatrist to assemble evidence for treatment at levels ranging from cells to communities. This evidence is best informed by credible research.

Factors to be considered in research aimed at understanding religion as a resource or challenge to psychiatric treatment include the following:

• Operationalization of the definition of spirituality. Typical measures of spirituality tend to use “common denominators”, such as “I feel a connection to all life” 1, which may not accurately capture its essence. Such measures have informed research to date, but have been “impure”, in that they measure psychological wellbeing and existential or social constructs as much as they measure spirituality 2. Accordingly, conclusions based on these studies may be misleading. Furthermore, spirituality is generally measured by self-report assessment, a process that requires a level of insight in the respondents to assess some aspects about themselves against an unknown standard. Attempts to find objective validators, such as behaviors, related to spirituality are much more challenging. Here, the risk is in measuring the outcome of a spiritual life (i.e., peace or joy) rather than the spiritual essence itself, which leads to faulty conclusions.

• Measuring religiosity in a multifaith context. Each religion claims exclusivity in certain domains. Thus, using all-encompassing or generic measures while ignoring the individual tenets of specific religions serves only to compromise the measure. It would be useful to develop questions that explore what is considered core in each religion, particularly as it relates to mental health. Religious beliefs, attitudes, experiences, commitment, and maturity may be common themes, but each religion and even denominations within the same religion will have different sets of “standards” or ideals for each of these. For example, Judaism tends to emphasize God as all powerful, while Catholicism tends to emphasize God as all merciful. Different conceptions of God are associated with adaptive or maladaptive ways of religious coping 3.

• Elucidating the role of culture in religious expression. Culture may inform the way religion and spirituality are interpreted by the individual and subsequently how questions are answered. For instance, in some countries “religion” is seen as outdated and almost a pejorative term, while in others “spirituality” is seen as a mystic new age phenomenon. Studies conducted among African Americans or in the Southern United States have a completely different cultural overlay than in other areas of the United States, Canada, or Europe. In the former, there are much higher baseline rates of stated religious beliefs, and different measures may be required to actually determine the integration of religion or spirituality by the individual as opposed to the prevailing culture. As an example, religious service attendance may reflect internalized religious commitment, or compliance with social norms, or a combination of both.

• Longitudinal studies. Longitudinal studies have been advocated during the last decade, as a plethora of cross-sectional data was emerging. Cross-sectional data have been inconsistent, often showing different relationships between depression and religion, or depression and spiritual self-assessment. Causality cannot be determined, and the issue of whether psychiatric illness causes one to turn to or away from spirituality is left in question. Good longitudinal data on the relationship of depression and religious observance or commitment have begun to address both how depression may impact religiosity and how religiosity may impact depression 2. Longitudinal studies on anxiety disorders, affect dysregulation, exacerbation or reduction of guilt or shame, or serious chronic mental illness would also be enlightening. Cross-sectional epidemiologic studies have shown, anyway, that religion and spirituality are significant determinants of mental health to a similar extent as gender or income. This indicates that religion should be a variable considered in psychiatric epidemiological studies. There is also solid evidence 4 suggesting that religion is not just another measure of social support.

• Research on which aspects of religion or spirituality are sustained during a psychiatric episode or how they might be supported. A shift is required from treating mental disorder as an end goal to a patient-centered perspective in which the aim is spiritual and psychological growth. Consistent with this, Kohlberg 5 and Piaget 6 envision moral development as a sequence of stages starting with the self as the “be-all and end-all” to universal ethical principles.

Religion is unique in that it provides a link to the past and to the future. In a society where governments focus on short-term expediency, many things are thrown away, families are volatile, institutions are unstable, and cultures are less “pure” because of migration, religion clearly provides a longitudinal perspective. To understand psychiatric disorders, a longitudinal perspective, including consideration of religion and spirituality, is also needed. In those individuals where religion and mental health problems intertwine, the better the understanding psychiatrists have of potentials and pitfalls around their patients’ religious or spiritual beliefs (or loss of them), the more able they will be to help restore balanced mental health.