Spirituality in Psychiatry?

Dear Editor:

An 83-year-old woman was brought into my office by her 60-year-old daughter for evaluation of her recurring depression. Soon after the daughter left the room (after introducing her mother), the patient, without delay, reported that she had lost three children—an 18 year old son who died in an auto crash, a 24-year-old son who committed suicide, and a 54-year-old son who died three years ago after suffering from a painful cancerous condition for three years. She recalled having wished that he had not lived that long with the painful suffering.

“We never understand these things, but it certainly is not God's fault. We will never know,” she told me.

She believed that it was her faith in God alone that gave her the strength to continue living. She asked me how it could be expected that she not be depressed. She was also deeply concerned about her only surviving daughter who brought her to the office. She believed that her daughter had chosen to remain single for her sake.

It is the emotions emanating from such an interaction that activates the thought that a bio-psycho-socio-spiritual model would be a more compassionate and encompassing approach to patient care. This is even more evident when a patient brings it up in therapy.

Spirituality and religion—How are they different? In several circumstances we see the terms religion and spirituality being used in an interchangeable manner. Let us examine some definitions of religiosity and spirituality. Religiosity refers to “participation in or endorsement of practices, beliefs, attitudes, or sentiments that are associated with an organized community of faith.”¹ Spirituality refers to “personal views and behaviors that express a sense of relatedness to a transcendental dimension or to something greater than the self.”² There is obviously a wide overlap, but spirituality seems more clearly a personalized, internalized version—a composite of both.

Can spirituality or religion mix with science? It was Albert Einstein (1950) who said, “Science without religion is lame; religion without science is blind.” Science always searches for what can most easily be measured. Science and ethics have become increasingly secular. Freud saw religion as “universal obsessional neurosis;” Jung differed and discussed the search for spiritual enlightenment as the central core of human experience. This difference of opinions is one of the reasons Freud and Jung parted company.³

Spirituality in health. We know that faith and religion play important roles in the lives of many patients and physicians, but such concepts are yet to be incorporated into routine clinical care.

The World Health Organization defines health as , “a state of complete physical, mental, and social well-being and not merely absence of disease or infirmity,” and also suggests spiritual well being as a fourth dimension to health.

Religion and spirituality in psychiatry. Despite unprecedented levels of longevity, physical health, relative affluence, social freedom, and advances in technology, there is an increasing incidence of depression in the 21st century. This seems paradoxical but may reflect increased recognition by patients and/or physicians rather than an absolute increase in prevalence. Stress, real or perceived, among people living a rushed Western lifestyle, has risen by 45 percent over the last 30 years.⁴

Many studies have linked a lack of religious beliefs to depression. Religious commitment is associated with reduced incidences of depression⁵ and quicker recovery from depressive illness for the elderly.⁶ The reasons why religiously committed individuals are less likely to become depressed may include feelings of social connectedness, messages of healthy living, perhaps reduced drug-seeking behavior, beliefs that justice prevails at the end, belief that adverse events always have a message and a meaning, and that there is a caring, ever-present God.³

Negative effects of religion make headlines (e.g., when a parent's religious views delay medical care resulting in a child's death). Spiritual and religious protective factors, which may unlock the secrets of preventive psychiatry—the extent of which are yet to be determined—have been less publicized.³

It is said that mainstream psychiatry, for nearly five decades, has ignored religious and spiritual issues brought by patients into treatment. While less than 10 percent of psychiatrists believe spirituality is important in their practices, Janelle reports that 65 percent of patients with depression, anxiety, and other psychiatric conditions indicate that they want spirituality to play a part in their treatment.⁷

Likewise, in a study to examine attitudes about spirituality, a group of medical students were exposed to didactic material on spirituality. They reported greater understanding of the spiritual issues compared to students who did not receive this didactic instruction. There was no difference, however, in their clinical performance. The two comparative groups received identical scores for their spiritual history.⁸

Physician's stand on this issue. “A complete explanation of spirituality's positive explanation is not so important. We do not understand the mechanisms of many drugs. We know, from observing cause and effect, that they work. Likewise, we can see the effects of a person's spiritual consciousness on his outcome, so why not use that?” explains Martin Jones, a psychiatrist at Howard University College of Medicine.⁹

Some physicians believe that religious faith contributes to better health and recovery. Despite a lack of solid scientific evidence, there appears to be a growing trend to integrate religion with medical treatment. In our “illness model,” while often concerned with risk factors, physicians may have underemphasized the less publicized protective human factors, such as “connectedness” and “spirituality.”¹⁰ Religious commitment was inversely related to suicide in 13 of 16 studies reviewed.¹¹ Eighty-nine percent of alcoholics lost interest (disconnected) in religious issues during their teenage years.¹¹ People who attended church weekly were not as likely to be hospitalized, and when they were, they did not spend as much time in the hospital as those who went to church less frequently.¹² According to Gartner⁵ and Larson,¹¹ doctors can enhance their effectiveness as medical healers by considering, inquiring about, and attending to the spiritual needs of their patients. This view, however, is controversial. For example, others argue that, “Spiritual counseling is an abuse of a physician's authority. It has the power to coerce people who are vulnerable and afraid. That is not what medicine is about.”

What is being done to incorporate spirituality into healthcare? In an effort to make healthcare more comprehensive, medical educators are increasingly advocating a bio-psycho-social-spiritual model. Recent psychiatric literature suggests the need to reconsider the place of religion and spirituality in psychiatry. Religious and spiritual dimensions for millions of people are among the most important factors that structure their experience, values, behavior and illness pattern.¹³

Additionally, spirituality is incorporated into some training programs where the faculty clinical supervisors are sensitive to the bio-psycho-social-spiritual model, and focus on “whole-person” care that recognizes the importance of spiritual aspect of patient and respects their belief systems and autonomy.

A survey that may be helpful for use in psychiatric practices is from Baetz, et al., at the University of Saskatchewan, who developed the Survey on Spirituality.¹⁴

Conclusion. Consideration should be given by clinicians to address relevant spirituality issues in patient care when appropriate, and this may help broaden the scope of their total and compassionate care.

With Regards,
Murali S. Rao, MD; DFAPA
Associate Professor and Vice-Chair, Department of Psychiatry and Behavioral Neurosciences
Loyola University Medical Center, Maywood, IL 60153
E-mail: mrao1@lumc.edu