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Religion and mental health: what should psychiatrists do?

  • Harold G. Koenig (a1)
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Religious beliefs and practices of patients have long been thought to have a pathological basis and psychiatrists for over a century have understood them in this light. Recent research, however, has uncovered findings which suggest that to some patients religion may also be a resource that helps them to cope with the stress of their illness or with dismal life circumstances. What are psychiatrists doing with this new information? How is it affecting their clinical practices? Studies of psychiatrists in the UK, Canada and the USA suggest that there remains widespread prejudice against religion and little integration of it into the assessment or care of patients. In this paper I discuss a range of interventions that psychiatrists should consider when treating patients, including taking a spiritual history, supporting healthy religious beliefs, challenging unhealthy beliefs, praying with patients (in highly selected cases) and consultation with, referral to, or joint therapy with trained clergy (Koenig, 2007). Religion is an important psychological and social factor that may serve either as a powerful resource for healing or be intricately intertwined with psychopathology.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Baetz, M., Griffin, R., Bowen, R., et al (2004). Spirituality and psychiatry in Canada: psychiatric practice compared with patient expectations. Canadian Journal of Psychiatry, 49, 265271.
Charcot, J. M. (1882) Lemon d'ouverture. Progrè's Médical, 10, 336.
Curlin, F. A., Odell, S.V., Lawrence, R. E., et al (2007a) The relationship between psychiatry and religion among US physicians. Psychiatric Services, 58, 11931198.
Curlin, F. A., Lawrence, R. E., Odell, S., et al (2007b). Religion, spirituality, and medicine: psychiatrists' and other physicians' differing observations, interpretations, and clinical approaches. American Journal of Psychiatry, 164, 18251831.
Freud, S. (1927) Future of an illusion. In (1962) Standard Edition of the Complete Psychological Works of Sigmund Freud (ed. & transl. Strachey, J.). Hogarth Press.
Koenig, H. G., McCullough, M. E. & Larson, D. B. (2001) Handbook of Religion and Health, pp. 514554, Oxford University Press.
Koenig, H. G. (2007) Spirituality in Patient Care (2nd edn). pp.161174, Templeton Foundation Press.
Koenig, H. G. (2008) Research on religion, spirituality and mental health: a review. Canadian Journal of Psychiatry, in press.
Larson, D. B., Thielman, S. B., Greenwold, M. A., et al (1993) Religious content in the DSM–III–R glossary of technical terms. American Journal of Psychiatry, 150, 18841885.
Lawrence, R. M., Head, J., Christodoulou, G., et al (2007) Clinician's attitudes to spirituality in old age psychiatry. International Psychogeriatrics, 19, 962973.
Neeleman, J. & King, M. B. (1993) Psychiatrists' religious attitudes in relation to their clinical practice: a survey of 231 psychiatrists. Acta Psychiatrica Scandinavica, 88, 420424.
Neeleman, J. & Persaud, R. (1995) Why do psychiatrists neglect religion? British Journal of Medical Psychology, 68, 169178.
World Christian Database (2007) Atheists/Nonreligious by Country. (http://worldchristiandatabase.org/wcd/).
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
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Religion and mental health: what should psychiatrists do?

  • Harold G. Koenig (a1)
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eLetters

Religion and Mental Health

Edwin N Harnell, Psychiatric Nurse
18 August 2008

A recent editorial in the Psychiatric Bulletin by Harold Koenig, (Duke University Medical Centre, Durham, North Carolina, USA) advocates the taking of a spiritual history from psychiatric patients, praying with patients, as well as consulting with and referring to religious leaders. He states in the editorial,

“Religious beliefs and practices have long been thought to have a pathological basis and psychiatrists for over a century have understood them in this light. Recent research however has uncovered findings which suggest that to some patients religion may also be a resource that helps them to cope with the stress of their illness or with dismal life circumstances”

While I think there is some evidence for both these suppositions not all psychiatrists view religion negatively and intense religious beliefs are in my experience just as likely to have a negative impact on an individual’s mental health as a positive one.

Psychiatry has at various times in its history been misused in detaining political dissidents and justifying eugenics programs of the 20th century. The founding father of psychoanalysis Sigmund Freud spoke of Religion as an illusion maintaining that it was a fantasy structure from which man must be set free if he is to grow in maturity. Freud viewed “God” as being a version of the father figure and religious beliefsas essentially infantile and neurotic. Freud’s protégé Carl Jung however took an altogether more sympathetic view of religion and was particularly interested in the positive appreciation of religious symbolism. Jung feltthat the question of God’s existence was unanswerable by the psychoanalystand adopted a strictly agnostic stance on religion generally.

Dr Koenig states his interest in the subject, he is funded by the centre for Spirituality Theology and Health at Duke University but he is also at pains to point out that maladaptive religious beliefs should be challenged and where they are contributing to or intertwined with a psychopathology then a respectful but neutral stance is best adopted initially.

Quoting from the World Christian database Koenig states that only 12%of the British population is non religious and that atheists comprise just1.4 % of the population. Against this background Koenig advocates the taking of a “spiritual History” as well as a psychiatric and medical one. The spiritual history should he says

“gather information about the patients religious background and theirexperiences during childhood, adolescence and adulthood and determine whatrole religion has been played in the past and plays now in coping with present life problems”

Negative as well as positive experiences with faith and clergy are ofimportance as are theological questions such as disappointment with unanswered payers and the belief in a personal God. Dr Koenig makes the valid point that certain religious beliefs can conflict with certain treatment options and doom those therapies to failure. Dr Koenig advocates gently probing the patient’s spiritual beliefs even if the patient is not religious or returning at a later date if resistance is metwith once a firm therapeutic alliance has been established.

Most controversial perhaps is Dr Koenig’s suggestion that in certain cases praying with a patient can have a powerful positive therapeutic effect. Dr. Koenig is at pains to point out that this can be a potentially dangerous intervention and should never occur until the psychiatrist has a complete understanding of the patients spiritual beliefs and it should only be done at the patients request and if the psychiatrists feels comfortable doing it.

This last point in particular raised some hackles in the comments section, A group of psychiatrists from the North Wales NHS Trust wrote:

“Even when psychiatrists share a faith, the introduction of a completely non clinical activity carries a grave danger of blurring of therapeutic boundaries and creates ambiguity over the nature of the relationship”

They describe psychiatry as “Applied bio psychosocial science” and say that psychiatrists work within a clear set of humanitarian and ethicalprinciples. Praying with patients, they suggest, would break those principles leaving psychiatrists outside the boundaries of their legitimate expertise (and outside their comfort zone?), leading them to become “generic healers” with the loss of usefulness and legitimacy that this would imply.

There are a number of assertions here that need to be challenged, theassertion that a religious approach would necessarily blur any therapeuticboundaries and the potentially false distinction made between clinical andreligious activity. Psychiatric nurses talk about therapeutic relationships and alliances, Psychiatrists talk of boundaries and of the dangers when those boundaries are not maintained. It is also interesting I think that the psychiatrists see themselves as “scientists” who’s humanitarian and ethical principles might be at risk from allowing religion in the door and the term “generic healer” only serves to emphasise their separateness from the rest of us.

However their concerns expressed over challenging maladaptive religious beliefs I share. However this is not because I am uncomfortableapplying my own values to situations involving patients, I feel my values are compatible with maintaining an appropriate degree of therapeutic neutrality because I happen to think my values are on the whole good ones.I suspect my diffidence in enquiring into an individuals religious beliefsstems from the same source as my reluctances to enquire into their sexual orientation one of pure embarrassment. It’s odd, I feel quite comfortableasking all sorts of intrusive questions into someone’s personal relationships, why they have decided to end their life for instance but I feel unable to enquire if they believe in a God or what their sexual orientation is.

(The British Humanist Association quotes figures from a MORI poll andthe National; census which puts the numbers of those who describe themselves as atheist at between 15.5 and 36%)

The Author would describe himself as an atheist.
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Conflict of interest: None Declared

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Support for Koenig

Larry Culliford, Psychiatrist and author
21 July 2008

My onetime colleague and spiritual brother Rob Poole and his associates have expressed opinions which are to be respected. However theymay be in error when claiming that Koenig's editorial (Koenig 2008) is attempting "to shift the boundaries of psychiatry". There are no such boundaries, only pseudo-boundaries.Although human experience can be thought of in terms of physical, biological, psychological, social and spiritual dimensions (Culliford, 2002), there are no limits to or rigid cut-offs between them. They are indivisibly interconnected. Psychiatrists acknowledge continuous, fluid and potent interactions between the realms of biological brain and psychological mind, also between minds and society. Why not therefore recognize equally powerful, frequently healthy and therefore relevant movements of energy between minds and souls or whatever we experience as spiritual? The eminent psychiatrist George Vaillant has recently, for example, written about the close relationship between spiritual experience and positive emotions likejoy and hope (Vaillant 2008).I have marshalled elsewhere (Culliford 2007a) some arguments in favour of paying attention to the spiritual lives of psychiatric patients. To avoid doing so risks two important things: firstly, missing opportunities to improve rapport ("getting alongside patients" to use Poole et al's terminology) and patient compliance; secondly, clinicians missing similar opportunities for additional personal growth through the reciprocal effects of compassionate intervention. Health care is a two-way process, and I have described in my book 'Love, healing and happiness' (Culliford 2007b) how this kind of growth comes about. Poole and his colleagues need not be too alarmed because none of this necessarily has anything to do with religion. In developing a non-denominational language of spirituality (using terms like "spiritual awareness", "spiritual practices", "spiritual values" and "spiritual skills") members of the Spirituality and Psychiatry SIG have taken pains to avoid some of the risks they outline. I look forward to continuing the "serious debate" for which they say "there is an urgent need". To repeat, however, where boundaries do not exist, they cannot be blurred.

DECLARATION OF INTERESTLarry Culliford is on the executive committee of the College's Spirituality and Psychiatry SIG. He has been paid to lecture on spirituality and mental health care, spirituality and health care, also spirituality and education. Until 2008, he taught a Student Selected Component to 3rd year medical students at Brighton and Sussex Medical School on 'Spirituality and health care'.

REFERENCESCulliford L (2002) 'Spiritual care and psychiatric treatment: an introduction.' Advances in Psychiatric Treatment 8 249-261Culliford L (2007a) 'Taking a spiritual history.' Advances in Psychiatric Treatment 13 212-219Culliford L (2007b) 'Love, healing and happiness: spiritual wisdom for secular times.' Winchester, O Books.Koenig HG (2008) ‘Religion and mental health; what should psychiatrists do?’ Psychiatric Bulletin, 32, 201-203.Vaillant G (2008) 'Positive emotions, spirituality and the practice of psychiatry.' Mens Sana Monographs 6 48-62.
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Conflict of interest: None Declared

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Psychiatrists and role of religion in mental health

Imran Mushtaq,MRCPCH,MRCPsych, Associate Specialist-Child & Adolescent Psychiatrist
26 June 2008

Koenig’s message (Psychiatric Bulletin, June 2008, 32, 201-203) is very clear for psychiatrists that they should respect patients' religious beliefs and a sensible way to address this is through time investment in taking a spiritual history, respecting and supporting patients' beliefs. Challenging beliefs and referrals to clergy should be welcomed but praying with patients is highly controversial and should be treated with caution.

There is a fine line between religiosity and religious conviction becoming a part of a complex delusional system. In clinical experience some patients are not religious prior to the onset of their mental illness. For such patients, becoming religious may be indicative of a relapse of their mental illness.

Religion and psychiatry are usually considered as two totally different ways of healing. A number of UK, USA and Canadian studies confirm that psychiatrists are less likely to be religious in general, and are more likely to consider themselves spiritual but not religious. Religious physicians are less willing than non religious physicians to refer patients to psychiatrists (Curlin et al, 2007a). The Australian experience is not different either (D’Souza et al, 2006).

References:

CURLIN, F. A., ODELL, S.V., LAWRENCE, R. E., et al (2007a) The relationship between psychiatry and religion among US physicians. Psychiatric Services, 58, 1193 –1198.

D'Souza et al (2006) Spirituality, religion and psychiatry: its application to clinical practice. Australasian Psychiatry, Volume 14, Number 4, 408-412(5).

Authors:

Imran Mushtaq, MRCPCH, MRCPsych, Associate Specialist-Child and Adolescent Psychiatrist, Sp-CAHMS, Eaglestone Centre, Standing Way, MiltonKeynes MK 6 5AZ

Mohammad Adnan Hafeez, MRCPsych, Forensic Psychiatrist Edenfield Centre, Greater Manchester West Mental Health NHS TrustBury New Road Prestwich M25 3BL

Declaration of Interests: None declared.
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The neglect of the non-believer

Peter Lepping, Consultant Psychiatrist/Associate Medical Director/Honorary Senior Lecturer
26 June 2008

Correspondence in Response to the Recent Article on religion and mental health (Koenig, 2008).

I was amazed and alarmed to read Koenig’s article on religion and mental health and the president’s lukewarm support of the article as it presents no scientific evidence that any of the suggested working practices improve patient care. The few figures it uses are not supported by other studies. Koenig claims that only 1.4% of the British population are atheists. His source is the World Christian Database, hardly an unbiased source of information. This low level has no face validity to anyone working in this country. A recent study (Huber & Klein, 2008) funded by the conservative Bertelsmann Institute looked at religious beliefs in 18 countries (8 of them European) across the developed and the developing world. It used a very broad definition of religion and spirituality focussing on Pollack’s work on the belief in the transcendence as the core of substantial spirituality (Pollack, 2000). In other words, it looks for the belief in something spiritual that may or may not be related to formal religion. They professionally polled tens of thousands of people in the 18 countries making it by far the largest and most comprehensive study into the subject so far.

Their findings confirms Britain to be amongst the least spiritual countries amongst the 18 examined across a wide range of factors includingprayer, church attendance, personal religious experience, religious reflection, pantheistic influence etc. It finds that across European Christians more than 10% of those who formally belong to a church do not believe in anything spiritual at all. This makes census data potentially quite unreliable when it comes to assessing people’s real religious believes. In Britain 19% of those polled were classed to be highly religious, 43% as religious, 38% as non-religious using a broad definition of spirituality. 55% of Britons consider prayer to be non-significant for their lives and only 33% have personal religious experiences.

Far from religion being pervasive throughout the majority of society,in Britain at least the opposite seems to be the case. Moreover, there is already a well organised provision of support for people who follow organised religion in all hospitals with easy access to religious elders and prayer rooms. However, no provision exists for non-believers who look at questions of meaning of life and morality in a non-spiritual way. It isthat group that is disadvantaged rather than those who follow organised religion. It follows that rather than insisting on getting a “spiritual history” of each patient we should show respect to those who can discuss meaning of life without spirituality and find solution to identify and facilitate their needs in an increasingly secular society.

Yours sincerely

Dr P Lepping, MRCPsych, MSc

References

HUBER S & KLEIN C (2008): http://www.bertelsmann-stiftung.de/bst/de/media/xcms_bst_dms_23399_23400_2.pdf

KOENIG HG (2008), religion and mental health: what should psychiatrists do? Psychiatric Bulletin, 32, 201-203

POLLACK D (2000), What is religion? In Waltraud Schreiber (ed.), The religious dimension in history lessons in European schools: an interdisciplinary research project, p.55-81, Neuried: ars una (in German)
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Religion, psychiatry and professional boundaries.

Rob Poole, Consultant Psychiatrist
26 June 2008

We were alarmed to read the editorial on religion and mental health (Koenig, 2008). Some of the assertions are highly contentious, and we believe some of the recommendations for clinical practice are inappropriate. The invited commentary by the President of the Royal College of Psychiatrists (Hollins, 2008) is cautious, but nonetheless seems to endorse Koenig’s point of view. In doing so, she lends a certain credibility to Koenig’s recommendations. Closer integration of religion and psychiatric practice is a key aspiration of an element within the Spirituality and Psychiatry Special Interest Group of the College. We believe that there is an urgent need for a serious debate on the implications of such attempts to shift the boundaries of psychiatry and the other mental health professions.

Koenig uses some statistics that are questionable. For example, the World Chrisitian Database may say that 1.4% of the British population are atheist, but the British Humanist Association website cites recent figuresfrom the National Census, a Home Office survey and a MORI poll ranging from 15.5% to 36%. However, it is his fundamental argument that is seriously flawed.

Koenig uses the rhetorical ploy of suggesting that religion is denigrated and under attack by psychiatrists. He states that psychiatry has traditionally regarded religion and spirituality as intrinsically pathological. We have been involved in mental health care in the UK since 1978, and none of us has ever known this to be suggested by a mental health professional. He states that there is wide spread psychiatric prejudice against religious faith and that psychiatrists commonly do not understand the role of religion in patients’ lives. However, the research that he cites can be interpreted as suggesting that psychiatrists, by and large, believe that religion can be both helpful and problematic to patients and that they enquire about religious matters when these are relevant. As the salience of religious issues will vary between patients, this seems to us to be the appropriate approach.

Our major concern about Koenig’s paper is his suggestions for practice. No one could seriously challenge some of his assertions, for example that we should always respect people’s religious or spiritual beliefs and that we should some times make referrals to or consult with appropriate priests or religious elders. However, these are well established parts of routine practice. They are within the limits of existing codes of professional behaviour. Some of his other suggestions constitute serious breaches of professional boundaries, for example:

1.Psychiatrists should routinely take a detailed ‘spiritual history’, even from non-believers. He recommends that when patients resistthis, the clinician should return to the task later. This seems to us to be intrusive and excessive. The insistence that even non-believers have a spiritual life shows a lack of respect for those who find meaning within beliefs that reject the transcendent and the supernatural. 2.Some spiritual or religious beliefs should be supported and others challenged. This involves the application of the clinician’s values, whichis incompatible with the maintenance of an appropriate degree of therapeutic neutrality. It is unnecessary and inappropriate for cliniciansto take a position on highly sensitive matters of personal conviction, such as the existence and nature of evil, the meaning of unanswered prayerand doctrinal intolerance of homosexuality. 3.It is sometimes appropriate to pray with patients. Even when patient and psychiatrist share a faith, the introduction of a completely non-clinical activity carries a grave danger of blurring of therapeutic boundaries and creates ambiguity over the nature of the relationship.

We have personal experience of dealing with the adverse consequences of religious breaches of therapeutic boundaries. For the most part, these have been well intentioned but ill advised; for example, patients who wantto pray with psychiatrists at one point in their treatment can become persistently distressed over having done so when their mental state changes. We have encountered more worrying breaches of boundaries where clinicians have proselytised in the consulting room. Occasionally we have encountered frankly narcissistic practice, where clinicians have been emboldened by the certainties of a charismatic faith and take the positionthat their personal beliefs and practices cannot be challenged because they are supported by a higher authority than secular professional ethics.

The problem with blurring the boundaries, by inviting an apparently benign spirituality into the consulting room, is that it makes it more difficult to prevent these abuses. Having moved the old boundary it is then very difficult to set a new one.

Psychiatrists will always have to understand patients who are different to them in gender, class, ethnicity, politics and religious faith. Understanding patient’s lives, the contexts they exist in and the resources that give them strength is a key skill in psychiatric practice (Poole and Higgo, 2006). Religion can be an important source of comfort and healing, though it can also be a source of distress. Of course, it canbe intertwined with psychotic symptoms. Spiritual matters, however, exist in a different domain from psychiatric practice. There are others in our communities who have a proper role in helping patients spiritually and whocan be an important source of advice to us. Quite apart from the obvious dangers inherent in confusing these roles, it is completely unnecessary todo so.

Psychiatry has done much to improve the lot of people with mental illness, though it has also been guilty of some major historical errors. Our professional roles and professionalism are under sustained attack froma variety of sources (Poole and Bhugra, 2008). In order to resist these attacks, we need to be clear about our important and distinctive roles in helping people with mental illness. Psychiatrists are essentially applied biopsychosocial scientists, who work within a clear set of humanitarian values and ethical principles, in order to get alongside patients and facilitate their recovery from mental illness. Psychiatry does not hold all the answers, and other professions, agencies and individuals have different distinctive roles. Within psychiatry, we have to struggle with the internal threat of crude biological reductionism. Equally, if we breakthe boundaries of our legitimate expertise and become generic healers, we will have lost all usefulness and legitimacy.

Declaration of interest

The authors have a range of personal convictions, including atheist, Buddhist, Methodist, Roman Catholic and non-denominational faith.

References

Hollins S (2008) ‘Understanding religious beliefs is our business. Invited commentary on….Religion and mental health’, Psychiatric Bulletin, 32, 204.

Koenig HG (2008) ‘Religion and mental health; what should psychiatrists do?’ Psychiatric Bulletin, 32, 201-203.

Poole R, Bhugra, D (2008) ‘Should psychiatry exist?’ International Journal of Social Psychiatry, 54 (3), 195-196.

Poole R, Higgo, R (2006) ‘Psychiatric interviewing and assessment’, Cambridge: Cambridge University Press.
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