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Against the Stream: religion and mental health – the case for the inclusion of religion and spirituality into psychiatric care

  • Simon Dein (a1)

This paper argues for the inclusion of religion and spirituality in psychiatric care. After discussing the antagonism of psychiatrists and psychologists to religion, I present a critical overview of studies examining the relationships between spirituality, religion and diverse aspects of mental health: depression, suicide, anxiety, delinquency, drug abuse and schizophrenia. The need to assesses the impact of religion in different faith groups is discussed. Measures of religious coping, both positive and negative, may provide a more accurate portrayal as to how individuals deploy religion in their lives than global measures such as belief and attendance. I highlight the fact that there is a dearth of research on ritual, prayer and other aspects of religious experience. While many studies demonstrate positive effects of religion on mental health, others find detrimental effects. Finally I examine the clinical implications of these findings.

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Against the Stream: religion and mental health – the case for the inclusion of religion and spirituality into psychiatric care

  • Simon Dein (a1)
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We cannot prescribe religion

Rafael Euba, Consultant Psychiatrist, Oxleas NHS Foundation Trust
19 June 2018

The title and clinical implications in Dein's article emphasise the need to think of religion and spirituality in our work, including the possibility of delivering religion-based CBT, which the author argues will be more effective with believers than the standard modality. However, the body of the article does not really lead to that conclusion. Instead, this piece tries to demonstrate that religion has a protective effect against mental illness, which is a different matter, in my view.

Some clinicians may have misgivings about religion after witnessing patients suffer with cruel psychotic religious delusions, or being tortured by conflict between their religious beliefs and sexual orientation, just to mention some examples. Many of us will also be wary of any research on the benefits of religion coming from the other side of the Atlantic, a point the author acknowledges in the article. Even if we were convinced by this research and accepted the prophylactic properties of religion, it is obvious that we, as psychiatrists, cannot, and should not, prescribe, promote or recommend the acquisition of religious beliefs.

As for religion-based therapists, they already exist. They are called priests.
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Conflict of interest: None declared

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Confronting the Question of Religion and Spirituality in Clinical Practice

Jack Lennon, Doctoral Student in Clinical Neuropsychology, Illinois School of Professional Psychology
08 June 2018

Dein [1] provided a concise correspondence that argues for the inclusion of religious and spiritual practices in psychiatric settings, based in the premise that these elements are often important to individuals under psychiatric care. To the article’s benefit, there is some note of variable results across studies on the impact of religion in those with mental health concerns. However, this article straddles a grey area that is leaning toward a dogmatic view that conforms to the status quo of many countries. This form of clinical practice would willingly introduce ideology into science, potentially increasing stigma and straying from rational thought and empirical inquiry.

Freud and Ellis are noted as prominent anti-theists noted in this article [1]. One could follow the cognitive trajectory of considering these early and long-standing psychiatric tendencies as dogmatic in nature, yet it cannot be forgotten that religion and spirituality, operationally defined in the selective list of references, are unfalsifiable faith systems. The process of science, while slow-moving and incessantly changing, is based on falsifiable questions that can be repeatedly tested. We have come a great distance since those times in many aspects, less distance being traveled in other domains such as suicide prevention. To appeal to discrete, authoritative entities as if one can surmise what they would say in the 21st century is an atavistic, irrefutable form of ad hominem.

Articles utilized to support religion and spirituality in terms of overall health outcomes fail to recognize the complex nature of these questions. Dein1 cites Koenig [2], for example, which reviews religion/spirituality (R/S) and explicitly defines religion and spirituality in significantly different fashions yet reports them in combination. Dew and colleagues [3] are a prime example of how while also stating that measures of these variables are extremely heterogenous. This article reported that strongest associations were among adolescent substance users and that further study is warranted on depression, anxiety, and other psychiatric conditions. In fact, even if we are to further limit ourselves to evidence from religion-specific journals, a variety of studies report substantial limitations, a need for further research, and succumb to the same error in combining spirituality and religion [4,5]. Other studies are even more explicit regarding the limitations and nuances of such research [6] and also reports similar health outcomes among non-believers [7]. Therefore, those who report a religious denomination during treatment would have to be taken at face-value, with the practitioner never being able to know with certainty that the inclusion of religion would benefit the patient. Dein [1] recognizes and reports one of these criticisms but it is but a mere fraction of the article as a whole.

Of greatest concern to the field is inserting ideology into care, which begins to venture from standardized, empirically-supported treatment modalities. Dein [1] cited a systematic review [8] that reported improved outcomes following religion-infused cognitive behavior therapy (CBT) among religious patients. The concern here is the generalizability of such results as well as how critical the inclusion of religion in treatment is to the outcomes over time. Religion alone could potentially improve outcomes in sensical and intuitive manners, such as adding value or meaning to life [9]. It creates the opportunity to further segregate believers and non-believers, as well as those who differ in beliefs. This in-group/out-group mentality has led to increased stigma [10] and could adversely impact the health outcomes emphatically endorsed as sequelae to the inclusion of religion and spirituality.

There is clearly a need to continue researching methods that can improve treatment outcomes and this should not stray from the populations being treated, which includes those who are religious, spiritual, or a combination thereof. At the same time, the field must be cautious to combine ideology and science, which are two distinct concepts that are mutually exclusive – to find a balance would commit a middle-ground fallacy that makes psychiatric research less scientific. This is the same concern being confronted in the United States educational system and there is certainly no excuse for the inclusion of ideology into the treatment of psychiatric conditions. Patients may have particular interests in a wide range of socially-appropriate and -inappropriate beliefs and activities, but they would not be the framework or therapeutic infrastructure within which medical professionals treat these individuals. Diversity issues are important in conceptualization and a major psychiatric paradigm shift is certainly necessary, but there are severe, potentially far-reaching consequences to working “against the stream” [1] with unfalsifiable beliefs.


1. Dein S. Against the stream: Religion and mental health – the case for the inclusion of religion and spirituality into psychiatric care. BJPsych Bull. 2018; 42(3): 127-129. doi:10.1192/bjb.2017.13

2. Koenig HG. Religion, spirituality, and health: The research and clinical implications. ISRN Psychiatry. 2012. doi:10.5402/2012/278730

3. Dew RE, Daniel SS, Armstrong, TD. Religion/spirituality and adolescent psychiatric symptoms: A review. Child Psychiatry Hum Dev. 2008; 39: 381-398.

4. Unterrainer HF, Lewis AJ, Fink A. Religious/spiritual well-being, personality and mental health: A review of results and conceptual issues. J Relig Health. 2014; 53: 382-392. doi:10.1007/s10943-012-9642-5

5. Snider A-M, McPhedran S. Religiosity, spirituality, mental health, and mental health treatment outcomes in Australia: A systematic literature review. Mental Health Relig Cult. 2014; 17(6): 568-581. doi:10.1080/13674676.2013.871240

6. Zimmer Z, Jagger C, Chiu C-T et al. Spirituality, religiosity, aging and health in global perspective: A review. SSM Popul Health. 2016; 2: 373-381. doi:10.1016/j.ssmph.2016.04.009

7. Speed D. Unbelievable?! Theistic/epistemological viewpoint affects religion-health relationship. J Relig Health. 2017; 56: 238-257. doi:10.1007/s10943-016-0271-2

8. Smith TB, Bartz, J, Richards PS. Outcomes of religious and spiritual adaptations to psychotherapy: A meta-analytic review. Psychother Res. 2007; 17)6): 643-655.

9. Park C, Edmondson D. Religion as a source of meaning. Meaning, mortality, and choice: The social psychology of existential concerns [e-book]. Washington, DC, US: American Psychological Association; 2012: 145-162.

10. Lee H, An S. Social stigma toward suicide: Effects of group categorization and attributions in Korean Health News. Health Commun. 2016; 31(4): 468-477. doi:10.1080/10410236.2014.966894

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