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Religion, spirituality and mental health

  • Simon Dein (a1), Christopher C. H. Cook (a2), Andrew Powell (a3) and Sarah Eagger (a4)

Research demonstrates important associations between religiosity and well-being; spirituality and religious faith are important coping mechanisms for managing stressful life events. Despite this, there is a religiosity gap between mental health clinicians and their patients. The former are less likely to be religious, and recent correspondence in the Psychiatric Bulletin suggests that some at least do not consider it appropriate to encourage discussion of any spiritual or religious concerns with patients. However, it is difficult to see how failure to discuss such matters can be consistent with the objective of gaining a full understanding of the patient's condition and their self-understanding, or attracting their full and active engagement with services.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Christopher Cook (
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This response to Koenig's1 editorial has been prepared on behalf of the Executive Committee of the Spirituality and Psychiatry Special Interest Group.

Declaration of interest


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1 Koenig, HG. Religion and mental health: what should psychiatrists do? Psychiatr Bull 2008; 32: 201–3.
2 Koenig, HG, McCullough, ME, Larson, DB. Handbook of Religion and Health. Oxford University Press, 2001.
3 Pargament, KI. The Psychology of Religion and Coping: Theory, Research and Practice. Guilford Press, 1997.
4 Kroll, J, Sheehan, W. Religious beliefs and practice among 52 psychiatric inpatients in Minnesota. Am J Psychiatry 1981; 146: 6772.
5 Neeleman, J, Lewis, G. Religious identity and comfort beliefs in three groups of psychiatric patients and a group of medical controls. Int J Soc Psychiatry 1994; 40: 124–34.
6 Curlin, FA, Lawrence, RE, Odell, S, Chin, MH, Lantos, JD, Koenig, HG, et al. Religion, spirituality, and medicine: psychiatrists' and other physicians' differing observations, interpretations, and clinical approaches. Am J Psychiatry 2007; 164: 1825–31.
7 Dein, S. Working with patients with religious beliefs. Adv Psychiatr Treat 2004; 10: 287–94.
8 Loewenthal, KM. Religious issues and their psychological aspects. In Cross Cultural Mental Health Services: Contemporary Issues in Service Provision (eds Bhui, K, Olajide, D): 5465. Saunders, 1999.
9 Swinton, J. Spirituality and Mental Health Care. Jessica Kingsley, 2001.
10 Kleinman, A. The Illness Narratives. Basic Books, 1989.
11 Care Services Improvement Partnership, Royal College of Psychiatrists, Social Care Institute for Excellence. A Common Purpose: Recovery in Future Mental Health Services. SCIE, 2007.
12 Poole, R, Higgo, R, Strong, G, Kennedy, G, Ruben, S, Barnes, R, et al. Religion, psychiatry and professional boundaries [letter]. Psychiatr Bull 2008; 32: 356–7.
13 Lepping, P. Religion, psychiatry and professional boundaries [letter]. Psychiatr Bull 2008; 32: 357.
14 Mushtaq, I, Hafeez, MA. Psychiatrists and role of religion in mental health [letter]. Psychiatr Bull 2008; 32: 395.
15 Cook, C, Powell, A, Sims, A (eds). Spirituality and Psychiatry. RCPsych Publications, 2009.
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Religion, spirituality and mental health

  • Simon Dein (a1), Christopher C. H. Cook (a2), Andrew Powell (a3) and Sarah Eagger (a4)
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It's belief systems that keeps us healthy, not religion

jeremy a holmes, Visiting Professor Psychotherapy
05 July 2010

Cook et al (Religion, spirituality and mental healthThe Psychiatrist 2010; 34: 63-64) appear to believe, on the basis of suggestive, but by no means overwhelming, evidence, that religious belief is associated with good mental health. Bruno Bettleheim, in his account of his concentration camp incarceration noted that those that survived best were those with firmly held beliefs and ideology. Hassidic Jews and the committed Marxists (atheists all) survived longer than those without a belief system. It is not religion as such that saves, but -- however derived -- a sense of community and connection,

and the capacity to put even indescribable suffering into a wider context.Religion does this, but so equally do secular belief systems, including atheistic religions such as Buddhism.
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Conflict of interest: None Declared

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Declare, declare!

Morris Zwi, Child & Adolescent Psychiatrist
05 May 2010

To me, the authors' response to Peter Bruggen's letter regarding Declarations of Interest reflects a lack of understanding of the issue of bias in regard to declarations of interest.

Surely, the most important reason for declarations of interest is to allow editors and readers to judge whether bias might have crept into a publication. Whilst the influence of the pharmaceutical industry, through financial relationships with clinicians or academics is undoubtedly a source of bias, it is not the only source of bias that should be declared.

Why should a CBT trained researcher or anyone with a particular leaning not declare that interest? It is not complicated to state succinctly that there is a potential bias. It is simple to do and aids transparency. Let the readers decide!

The authors distinction between conflicts of interest and "perspectives of interest" is, in my view splitting hairs and appears pedantic and defensive.

Declare, declare!

Declaration of interest:

1. Peter Bruggen and I worked together in 1990 and have been good friends since then.

2. I subscribe to
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Conflict of interest: None Declared

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No religion or spirituality and mental health

Clive Mackin, psychiatric nurse
26 April 2010

Many articles have been written about the importance of recognising patients' spiritual and religious beliefs and trying to understand them so that they might be better engaged with services and that there might be a better therapeutic relationship. However, little has been written concerning agnostics or aetheists views of patients. Surely this is of equal importance?

It is easy for those professionals who have religious beliefs to say a person's faith can be a source of coping - but how do they approach a person who has no beliefs? Do they try to convert them or claim to have enough faith for the two of them?

Can those professionals with strong beliefs or faith truly understand those with none? How do they align their own beliefs to ensure proper engagement and a satisfactory therapeutic relationship? The matter definitely needs further research and discussion.
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Conflict of interest: None Declared

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Research in Spirituality & Mental Health

Christopher C.H. Cook, Professorial Research Fellow
26 April 2010

We are aware that the methodology, interpretation and evaluation of research on spirituality and mental health are complex matters which are not without their controversies and difficulties. The measurement of spirituality (which is to be contrasted with religiosity in this regard) is necessarily subjective, and easily prone to confounding with psychological variables. Alongside healthy forms of spirituality there arepathological forms of spirituality, and harmful forms of religion and religious practice, which are clearly harmful to mental wellbeing (1). Notsurprisingly, therefore, there are negative as well as positive associations in the research literature charting the relationships betweenspirituality, religiosity and mental health. For this reason we did not suggest in our article that “research unequivocally shows an association between religiosity and well- being” but rather stated that “research demonstrates largely positive associations between religiosity and well-being”. Our cited reference in support of this contention was the Handbookof Religion and Health, a volume written by Harold Koenig and his colleagues which reviewed 1200 studies, that were critiqued according to methodology and outcome (2). We might also have quoted Koenig’s more recent review in the Canadian Journal of Psychiatry (3), which reaches a similar evidence-based conclusion that, although there are undoubtedly unhealthy forms of religious and spiritual involvement, the usual associations are with better coping and healthier functioning.

The editorial by Dan Blazer in the same issue of Canadian Journal of Psychiatry as Koenig’s review, cited by Hansen and Maguire, does not suggest that there is an unequivocal association between religiosity and wellbeing. Neither does it claim that “The research findings are wildly contradictory and it would be unreasonable to draw any firm conclusion on the basis of current knowledge”. Rather, Blazer summarises Koenig’s reviewas showing that “studies to date generally support a positive association between [religion and (or) spirituality] and mental health” (4). However, Blazer does importantly acknowledge that this association is “a tough topic to research”. One of the reasons that he gives for this is that it is difficult to be objective on matters about which we hold very deep beliefs. Blazer goes on to warn that ‘Neglect of the religious dimension, not to mention refusal to discuss religious matters with our patients, mayseriously cut off meaningful communication and significantly undermine thetherapeutic relationship’. He concludes that ‘even though the task is tough, neglect is even more difficult to justify’.

Clinicians, researchers and patients do hold very deep beliefs on these matters. It is for this reason that it is important not to rely onlyon impressions derived from clinical experience but also to refer to evidence based research and reviews. If we cannot eliminate bias in our interpretation of these findings, we can at least minimise it.

Christopher C.H. Cook Chair, Spirituality in Psychiatry Special Interest Group, Royal College of Psychiatrists Consultant Psychiatrist, Tees, Esk and Wear Valleys NHS Foundation Trust Professorial Research Fellow, Department of Theology & Religion, Durham University

Simon Dein Secretary, Spirituality in Psychiatry Special Interest Group, Royal College of Psychiatrists Consultant Psychiatrist, Princess Alexandra Hospital Senior Lecturer, University College London

Andrew Powell Former Consultant Psychotherapist and Honorary Senior Lecturer, Oxfordshire Mental Healthcare Trust and University of Oxford

Sarah Eagger Consultant Psychiatrist, Central and North West London NHS Foundation Trust Honorary Clinical Senior Lecturer, Imperial College London Co Chair of the National Spirituality and Mental Health Forum

Conflict of Interests: None

1.Crowley N, Jenkinson G. Pathological spirituality. In: Cook C, Powell A, Sims A, editors. Spirituality & Psychiatry. London: Royal College of Psychiatrists Press; 2009. p. 254-72.2.Koenig HG. Handbook of religion and mental health. San Diego: Academic Press; 1998.3.Koenig HG. Research on Religion, Spirituality, and Mental Health: A Review. Canadian Journal of Psychiatry. 2009;54(5):283-91.4.Blazer DG. Religion, Spirituality, and Mental Health: What we know and why this is a tough topic to research. Canadian Journal of Psychiatry. [Editorial]. 2009;54(5):281-2.
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Divine intervention in mental health

lars k hansen, consultant psychiatrist
06 April 2010

Declaration of interest: none

We thank the authors (1) for their recent article on religion, spirituality and mental health for opening up the debate about religion and its impact on mental well-being. This debate does not come a moment tosoon.

Unfortunately we feel compelled to refute the suggestions that research unequivocally shows an association between religiosity and well-being (2). The research findings are wildly contradictory and it would be unreasonable to draw any firm conclusion on the basis of current knowledge. Furthermore, the research in this area is often biased, plaguedby poor methodology (definitions of spirituality and religion are controversial, much variations exist between different faith groups, “hidden” supportive measures of any community responsible for well-being rather than religion per se) and the research is almost invariably carriedout by groups of researchers that have a vested interest in showing positives results for religiosity. The latter point also applies to Dein and colleagues’ article as the authors represent The Royal College of Psychiatrists’ Spirituality and Psychiatry special interest group. None of these points of contention are raised in the article. In our personal experience we can come to think of a handful of patients that indeed seemed to have been consoled by religious beliefs, but we can come to think of hundreds of patients who have been tormented by fear of having transgressed some bronze-age dogma about sexuality, having sinned in others ways or simply having taken their God’s name in vain. A common sight on psychiatric wards is frightened patients shivering with fear whenthey hear what they perceive to be God’s, not to mention Satan’s, voice intheir hallucinations. Some studies reports that patients with schizophrenia and religious beliefs do indeed have worse long-term outcomes than patients with non-religious delusions (3). The rigid cognitive belief system that underpins religious ideology plays straight into delusional beliefs that cause endless anguish, e.g. “If I break my pact with God (divorcing a violent husband, having sex out of wedlock etc), he will punish me”. Having met such patients gives the concept of being “God fearing” a whole new dimension. This common place suffering seems to have escaped the authors entirely.

Dein and colleagues complain that there is a gap between patients’ and psychiatrists’ level of religiosity, the patients being more religious. Initially, this observation begs the question if religion couldbe part of the complex set of etiological factors that constitutes the pathogenesis of mental illness in the first place - and perhaps - maintains it. Unquestioned belief in authorities always spells trouble which recent events in the Catholic Church so amply exemplifies. Some perturbed patients may find the certainties of religion tempting but at what cost? Nevertheless, a good point is made that we must inquire more about the patient’s religious beliefs as it can have a profound impact on lives froman early age. Yes, just think of the consistent mistreatment of women and children in some religions, beliefs in utterly unverifiable concepts (walking on water, miracles, angels with wings, devils etc.) and the survival of your own death going to heaven if you have been good but goingto hell if you have not. No wonder if you have a fragile mind that religious beliefs can push you over the edge. I remind Dr Dein and his colleagues that instead of promoting private views however strong and wellmeant they are, our traditional mandate as doctors is “first of all do no harm”.A more important question than whether “the psychiatrist should pray with the patients or not” – consider what this would entail if you had a Satanist under your care – seems to us to be how religious groups systematically have targeted vulnerable psychiatric patients in an attemptto boost flagging numbers of their congregations. It is a despicable practice that pretends to offer lonely people a “new family” for the “minor cost” of believing and sometimes financially supporting, various beliefs systems of a more or less outrageous nature. It may be advantageous to a lonely or marginalised individual to find a ready-made group of accepting individuals with whom to associate, but religious groups do not have the monopoly on providing such solace. The issue of compassion is certainly not just the preserve of religious orders.So no, it is not “time to move away from the old tendency to see religiousand spiritual experiences as pathology”. But it is time to enquire in a respectful and gentle manner about patients’ beliefs in general, not only religious ones, and for all, always remain the patients’ foothold in a reality that often for them appears broken and fragile. Religious beliefsand practices may be helpful for some in terms of companionship and certainty, but clinical evidence indicates that for others they are sources of extreme distress and contribute to ongoing mental health problems.

References1.Dein S, Cook, CCH, Powell A and Eagger S. Religion, spirituality and mental health. The Psychiatrist 2010; 34: 63-64.2.Blazer Dan G. Religion, spirituality and mental health: What we know and why this is a tough subject to research. Can J Psychiatry. 2009; 54(5): 281-282.3. Doering S, Muller E, Kopche W et al. Predictors of relapse and rehospitalisation in schizophrenia and schizoaffective disorder. SchizophrBull. 1998: 24: 87-98.
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