INTRODUCTION
All along, the majority position of Psychiatry has been that Psychiatry has nothing
to do with religion and spirituality. Religious beliefs and practices have long been
thought to have a pathological basis, and psychiatrists over a century have understood
them in this light. Religion was considered as a symptom of mental illness. Jean Charcot
and Sigmund Freud linked religion with neurosis. DSM3 portrayed religion negatively
by suggesting that religious and spiritual experiences are examples of psychopathology.
But recent research reports strongly suggest that to many patients, religion and spirituality
are resources that help them to cope with the stresses in life, including those of
their illness. Many psychiatrists now believe that religion and spirituality are important
in the life of their patients. The importance of spirituality in mental health is
now widely accepted. As John Turbott[1] puts it, rapprochement between religion and
psychiatry is essential for psychiatric practice to be effective. The Royal College
of Psychiatrists, London, has a special group on Psychiatry and Spirituality. The
American College of Graduate Medical Education mandates in its special requirements
for residency training in Psychiatry, that all programs must provide training in religious
and spiritual factors that can influence mental health. The World Psychiatric Association
recently established a section on psychiatry and religion. Lukoff et al.[2] proposed
that the diagnostic entities of religious and psychospiritual problems should be incorporated
in DSM4 which has been accepted. DSM4, V 62.89 includes three categories—normal religious
and spiritual experiences; religious and spiritual problems leading to mental disturbances;
and mental disturbances with a religious and spiritual context. I understand that
the Indian Psychiatric Society has formed a task force on spirituality and mental
health which is urging the Medical council of India to include taking the spiritual
history as part of psychiatric evaluation. Even so the importance of religion and
spirituality are not sufficiently recognized by the psychiatric community. Religion
does not have a place in most of the psychiatry text books. Only very few psychiatrists
make use of religion and spirituality in the therapeutic situation.
This paper makes an attempt to bring out the importance of spirituality in mental
health.
WHAT IS SPIRITUALITY?
Spirituality is a globally acknowledged concept. It involves belief and obedience
to an all powerful force usually called God, who controls the universe and the destiny
of man. It involves the ways in which people fulfill what they hold to be the purpose
of their lives, a search for the meaning of life and a sense of connectedness to the
universe. The universality of spirituality extends across creed and culture. At the
same time, spirituality is very much personal and unique to each person. It is a sacred
realm of human experience. Spirituality produces in man qualities such as love, honesty,
patience, tolerance, compassion, a sense of detachment, faith, and hope. Of late,
there are some reports which suggest that some areas of the brain, mainly the nondominant
one, are involved in the appreciation and fulfillment of spiritual values and experiences.[3–5]
SPIRITUALITY AND RELIGION
Religion is institutionized spirituality. Thus, there are several religions having
different sets of beliefs, traditions, and doctrines. They have different types of
community-based worship programs. Spirituality is the common factor in all these religions.
It is possible that religions can lose their spirituality when they become institutions
of oppression instead of agents of goodwill, peace and harmony. They can become divisive
instead of unifying. History will tell us that this had happened from time to time.
It has been said that more blood has been shed in the cause of religion than any other
cause. The medieval holy wars of Europe; the religion-based terrorism and conflicts
of modern times are examples. We must remember that the institutions of religion are
supposed to help us to practice spirituality in our lives. They need periodical revivals
to put spirituality in place.
SPIRITUAL DIMENSION IS IMPORTANT IN MENTAL HEALTH
Mental health has two dimensions—absence of mental illness and presence of a well-adjusted
personality that contributes effectively to the life of the community. Ability to
take responsibility for one's own actions, flexibility, high frustration tolerance,
acceptance of uncertainty, involvement in activities of social interest, courage to
take risks, serenity to accept the things which we cannot change, courage to change
the things which we can change, the wisdom to know the difference between the above,
acceptance of handicaps, tempered self-control, harmonious relationships to self,
others, including Nature and God, are the essential features of mental health. Spirituality
is an important aspect of mental health. St. Augustine prayed “O God, thou created
us in thy image and our hearts will be restless until they find their rest in Thee.”
Though Sigmund Freud looked upon religion as an illusion and neurosis, Carl Jung considered
the psyche as a carrier of truth, powerfully rooted in the unconscious mind. Religion
is important, directly and indirectly, in the etiology, diagnosis, symptomatology,
treatment and prognosis of psychiatric disturbances. Lack of spirituality can interfere
with interpersonal relationships, which can contribute to the genesis of psychiatric
disturbance. Psychiatric symptoms can have a religious content. For example, the loss
of interest in religious activities is a common symptom of depression. Too much and
distorted religious practices are common in schizophrenia. It is well recognized that
some religious states and experiences are misdiagnosed as symptoms of psychiatric
illness. Visions and possession states are examples. The spiritual background of the
patient will help in the diagnosis of psychiatric disturbance. They are important
in the treatment of psychiatric disturbance because spiritual matters can be profitably
incorporated in psychotherapy. Spirituality is important in the prognosis of psychiatric
conditions. In the spiritual perspective, a differentiation must be made between cure
and healing. Cure is the removal of symptoms. Healing is the healing of the whole
person. Adversity often produces maturity. Hence in psychotherapy, the patient must
be helped to accept the handicap and transform the handicap to a life of usefulness.
SOME SIGNIFICANT CLINICAL AND RESEARCH FINDINGS
Recent studies show that religious beliefs and practices are supportive to cope with
stresses in life and are beneficial to mental health.
Thomas Ashby Wills,[6] Professor of Epidemiology and population health at Albert Einstein
College of Medicine developed a scale that determines how important is religion to
people. This was administered to 1182 children in New York. It was found that religiosity
kept children from smoking, drinking and drug abuse by buffering the impact of life
stresses. Gene H. Brody,[7] a research professor of child and family development at
the University of Georgia, Athens, found that parents who were more involved in church
activities were more likely to have harmonious marital relationships and better parenting
skills. That in turn enhanced children's competence, self-regulation, psychosocial
adjustment and school performance. Miller et al.[8] made a 10-year follow up study
on depressed mothers and their offsprings and reported that maternal religiosity and
mother-child concordance in religiosity were protective against depression in the
offspring. They also reported that low level of religiosity was associated with substance
abuse in the offsprings.[9] J. Scott Tonigan,[10] a research professor of psychiatry
at the University of New Mexico, followed up 226 patients of alcohol dependence and
reported that spirituality predicts behavior such as honesty and responsibility which
in turn promoted alcohol abstinence. Wagner and King[11] conducted a study involving
three groups—one group of patients who had psychotic illness, one group of formal
care givers, and a third group of informal caregivers. The existential needs were
the most important for the patient group, while the other groups considered material
needs such as housing and work as more important. Neeleman and King[12] surveyed the
psychiatric practices of 231 psychiatrists in London. 73% had no religious affiliation,
28% had belief in God, 61% believed that religion can protect against mental illness,
and 48% asked patients about their religious practices. Baetz et al.[13] surveyed
1204 psychiatrists and 157 psychiatric patients in Canada. 54% of psychiatrists believed
in God, 47% asked patients regarding their religious beliefs, and 55% consulted clergy
for the management of patients. Among the patients, 71% believed in God, and 24% preferred
psychiatrists who were religious. In an Australian survey, a large majority of patients
with psychiatric illness wanted their therapists to be aware of their spiritual beliefs
and needs and believed that their spiritual practices helped them to cope better.[14]
Mathai and North[15] constructed a questionnaire, consisting of 5 questions and gave
it to 70 parents of children attending child and adolescent mental health clinic.
They reported that majority of the parents believed that spiritual concerns were important
and that therapists should consider their spiritual beliefs in the management of the
problems of the children. In USA, Curlin et al.[16] conducted a study of psychiatrists
and compared them with physicians from other specialities in their religious affiliations
and found that psychiatrists showed less religious affiliations. Several empirical
studies on psychiatrists' religious characteristics have indicated that psychiatrists
are significantly less religious than the general population, their patients and other
physicians.[17],[18] In a 12-year follow up of all articles appearing in American
Journal of Psychiatry and Archives of General Psychiatry, 72% of the religious commitment
variables were beneficial to mental health; participation in religious services, social
support, prayer and relationship with God were beneficial in 92% of citations.[19]
Similar findings were reported in a review of the Journal of Family Practice.[20]
In a British epidemiological study, church going and active religion were found to
be protective to vulnerability for depression by Brown and Prudo.[21] In a detailed
study on suicide in Netherlands, Kerkoff [quoted by Sims[22]] reported that there
was a decline in suicidal rate, which was concurrent with a religious revival. A study
on the factors in the course and outcome of schizophrenia was conducted in the Department
of psychiatry, Christian Medical College, Vellore.. It was a collaborative study among
three centers—Vellore, Madras and Lucknow. A two-year and five-year follow up showed
that those patients who spent more time in religious activities tended to have a better
prognosis.[23],[24] The above reports strongly suggest that religious beliefs and
practices of psychiatric patients should be given importance. The sense of hope and
spiritual support that patients get by discussing religious matters help them to cope
better. They also suggest that the importance of religion and spirituality is not
sufficiently recognized by the psychiatric community. Mental health workers must take
it seriously since psychiatry cannot afford to ignore the importance of spirituality
and religion in psychiatry. Sims[22] gives two case histories which drives home this
fact. One is the case of Jim who suffered from Korsakov's psychosis. He was so deteriorated
that he mistook his wife for a hat. In the ward, others considered him as desolate
individual. But his behavior in the chapel was normal. In absolute concentration and
attention, he would partake Holy Communion. He did not forget anything nor did he
show any signs of Korsakov's psychosis. The other patient had chronic schizophrenia.
He used to hear a voice commanding him to jump out of the window. His simple devout
mother had taught him to resist the voice by praying to God. His mind was destroyed,
but the capacity for spiritual life was present. Unfortunately, on the final occasion,
he was too late to pray and he lost his life. Sims makes a comment, “It is unfortunate
that we as psychiatrists can be so crass as to neglect this area of life which is
clearly important to many of our patients.” Andresen,[25] in an editorial, has pointed
out that our civilization's “loss of soul” may cause psychiatric symptoms such as
depression, obsessions, addictions, and violence. She has suggested that it is the
responsibility of psychiatrists to remind the medical fraternity the necessity of
putting back the soul in medical ethics and the fact that spirituality is of vital
importance for the mental health of people.
WHAT CAN WE DO?
As pointed out earlier, spiritual values and religious practices are important in
the lives of our patients. Many of their problems may centre round existential preoccupations.
It is therefore important that we incorporate spirituality and religious practices
in our treatment protocol. We must propagate the Bio-psycho-socio-spiritual model
in our approach in psychiatry. Harold Koening,[26] in his paper Religion and Mental
health: what should psychiatrists do?, has made some suggestions in this area.
Psychiatric history should be catered to the patients' spiritual orientation and religious
practices. When we take psychiatric history, we usually ask for the denomination the
patient belongs. We do not try to find out how the patient experiences religion. What
does religion and spirituality mean to the patient. The psychiatric history should
gather information about patient's religious background and experiences in the past
and what role religion plays in coping with life stresses. Has patient had any past
negative religious experiences? Has he got spiritual and social support from the congregation
which he attends? How active is he in the religious congregation? Some religious beliefs
can be in conflict with the proposed treatment. Some religious groups are against
any type of treatment. Some religious conflicts and frustrations may be contributing
to the present psychiatric problem. Sexual abuse by religious workers, traumatic events
which turned the patient away from religious beliefs and activities, unanswered prayers,
etc. are examples. There are some questionnaires that can be used to take a history
of spirituality and religious experiences.[15
27
28] Discussion with the patient on spiritual matters and religious experiences will
strengthen the therapeutic relationship. It can also lead to reversal effect of a
personal growth of the therapist.
We should respect and support patients' religious beliefs if these help them to cope
better or do not adversely affect their mental health. For example, if a patient says
that his discipline of fasting and prayer helps him to cope better, then this has
to be encouraged. We should also challenge the beliefs that can adversely affect mental
health. This has to be done very tactfully. It is better to be neutral till we understand
the patients and the issues involved well and a good therapeutic relationship is formed.
Patients may wish to discuss with the therapist regarding their subjective experiences
and existential needs. We should spend time in listening to them.
Partnership with the religious workers is an useful area. Leavy and King[29] in their
paper, The devil in the detail: partnership between psychiatry and faith based organizations,
brings out the importance of such a partnership. They have reported that in UK, the
clergy continue to have a central role in several communities and the utility of their
involvement in the care of people with mental health problems is increasing. They
have argued the importance of examining the form and parameters of partnership between
the mental health team and the faith-based communities. For this partnership to be
effective, the mental health workers must be spiritually oriented and the religious
workers must be better informed about mental health and illness. As referred to earlier,
some religious experiences are often misdiagnosed as symptoms of mental illness and
vice versa, some psychiatric symptoms are explained as spiritual experiences. According
to Sims,[22] phenomena such as faith, prayer and magic can lend themselves to description
and definition using Jasperian phenomenology which can lead to a clear differentiation
of normal and pathological religious experiences. This emphasizes the importance of
psycho-pastoral partnership. One example of such a partnership is the Bangalore psycho-pastoral
association, which runs a very efficient half-way home for psychiatric patients. Recognizing
the importance of this, the World Council of Churches has formed an Advisory group
on mental health and faith communities, which has been active in the exploration of
strategies for an effective partnership between mental health services and faith communities.
There can be problems in such a partnership. The religious workers may be reluctant
to get involved in secular programs, leaving their spiritual fortress. Some of them
can have incorrect ideas about the causes of mental illness, which can interfere with
the treatment program. Some others can be against medical treatment. Mental health
workers can also be prejudiced against the patients' religious beliefs and practices.
As referred to earlier, research findings suggest that majority of psychiatrists do
not give importance to the spiritual and religious experiences of patients. According
to Neelman and Persaud,[30] this may be due to the following factors. Psychiatrists
are by and large less religious than other physicians; psychiatrists often come to
know of spirituality through the pathological religious symptoms of patients, which
make them prejudiced against spirituality; psychiatrists tend to have a biological
approach to mental illness, which ignores spiritual dimension; and psychiatrists may
think that religion and spirituality cause dependence and guilt feelings. All these
can be minimized with dialogue and periodical orientation programs. As John Turbott[31]
puts it, psychiatry as a whole can only benefit if the concepts and vocabulary of
religion and spirituality are more widely known and discussed among its practitioners.
It is also true that conflicts and problems arise more with religious experiences
and not with spirituality
Praying with the patient is a controversial area. Many psychiatrists will argue that
it is a dangerous ground upon which to tread. If at all it is done, it should be done
only after a strong therapeutic relationship is established and only if the patient
asks for it. Praying for the patient can be beneficial.
Research. Although there is substantial body of literature that describes the connection
between mental health and spirituality, we must develop theoretical models to understand
their relationship in practice. The statistical findings reported earlier were mainly
the results of surveys. High-quality evidence-based research is required to make the
clinical applications more objective and effective. There are ample opportunities
to do research in this area. Phenomena such as meditation, religious conversion, faith,
mystical experiences, near death experiences, and rebirth concepts are all unchartered
territories. What are their relation to normal life and psychiatric illness? What
are the neural mechanisms which influence spiritual experiences?
Treatment. If spirituality is related to mental health and if religious beliefs and
experiences are important in the life of the psychiatric patient, it is only natural
that we should include religious concepts in psychotherapy. For example, some Christian,
Gita, Buddhist and Quran passages can be profitably used to help the patient to cope
with life situation. The spiritual concepts are incorporated in the treatment program
of Alcoholic Anonymous. Seven out of the 12 AA steps relate to spirituality.
D'Souza[32] describes a new psychotherapeutic method, which is called Spiritually
Augmented Cognitive Behaviour Therapy (SACBT). This is a treatment technique, incorporating
spiritual values to Cognitive behavior therapy, which was developed and promoted at
the University of Sydney. Four key areas are emphasized—acceptance, hope, achieving
meaning and purpose and forgiveness. The patient is guided through five phases to
achieve meaning and purpose. This starts with examining the inevitables of life such
as birth and death. After desensitizing the patient to mortality, the patient is moved
to the next phase of letting go of fear and turmoil in life. The next phase examines
the patient's lifestyle aspects that avoid confronting mortality and perpetuate fear
and turmoil. The next phase involves a focus on seeking divine purpose, after examining
and accepting one's journey in life. Finally, meaning is sought by seeking meaning
for each day. This is achieved by identifying meaningful and realistic factors within
whatever limitations life and illness bring. The main techniques are empathic listening,
facilitation of emotional expression and problem solving. The use of meditation, prayers
and rituals together with monitoring effects of beliefs and rituals on symptoms form
the behavioral components of the treatment. When the patient shows negative cognition,
cognitive restructuring is employed. Generally, the treatment takes about 16 sessions,
each lasting about 1 hour. The main indications are depression and adolescent problems.
Randomized controlled trials show that SACBT produces significant improvement.