Religion and Spirituality in Psychiatry

This book, which is carefully conceived and well referenced, does justice to its title. But you may ask, how relevant, really, is the issue of religion and spirituality to the practice of psychiatry? Does it have a place in a discipline that is increasingly evidence based and oriented toward biologically grounded research?

In answering this question, you might consider where many patients actually turn for help with their medical problems. The surprisingly high prevalence of alternative medical techniques that people prefer, ones often grounded in religion and spirituality traditions, became clear in data from a national probability survey (1) and subsequent related studies. One-third of all adults had used these unconventional approaches in the previous year, and prayer was principal among those chosen. In fact, one-quarter of the respondents suffering from anxiety or depression had opted for alternative medical approaches—more than the proportion that turned to professionals for help. Such people often do not report this to psychiatric caregivers, if indeed they seek conventional treatment at all, and insurers are increasingly looking to alternative and complementary techniques to provide interventions that may be less expensive than our evidence-based therapies.

Given the advances we've seen in contemporary science, one might think that there would be a decline in people's spiritual orientations relative to scientific findings. But actually, the opposite may be the case. Since the 1960s, when less than a quarter of people surveyed reported having had religious or mystical experiences, they now constitute the majority (2). At the same time, belief in God or a higher power—typically a deity who plays an active role in people's lives—continues to be espoused by at least 90% of the population.

Is the coming generation of psychiatrists attentive to this issue, which apparently is influential in the emotional lives of many patients? In surveys we have conducted, psychiatric residents underestimate by far the importance that patients lend to religion and spirituality in coping with illness (3). Furthermore, when our own residents are asked to present a case related to religion or spirituality, almost without exception they present a patient suffering from religion-related delusions, rather than positive, meaningful experiences. These views are consistent with many of their psychiatric faculty and also with the way religious issues are represented in DSM. This bias against seeing religion and spirituality as a meaningful part of patients' emotional lives is bolstered as well by reading our principal academic journals, which are oriented toward a methodology of experimental controls and statistical modeling, quite at variance with an openness to the subjective and idiosyncratic beliefs patients may espouse. A paucity of religion and spirituality-related research also derives from the fact that many of the research paradigms relevant to understanding the intensity of people's beliefs lie more in the social-psychological and anthropological domains. Contemporary psychiatric research rarely deals with such issues.

Perhaps, then, psychiatrists should read this book. It draws together a diversity of topics that illustrate clearly how religion and spirituality are pertinent to psychiatrists. One chapter, for example, on neuropsychiatric issues, reviews recent literature on the relationship between specific neurotransmitters and spiritual and meditative experiences. In associating this literature with genetic correlates of these experiences, the author posits a heuristically useful model for the relationship between physiologic systems and the nature of spiritual and religious practices. This illustrates both the breadth of emerging findings in this research area and opportunities to expand on it.

From an entirely different perspective, another chapter discusses the issue of self-identity as it relates to spiritual experiences. It draws on a wide variety of psychoanalytic writers, from a mystically related Jungian perspective to a developmental model drawn from John Bowlby to the clinical psychoanalytic work of Ana-Maria Rizzuto. Case examples given here are illustrative of the value of understanding how religion and spirituality can bear on the practice of dynamically oriented psychotherapy.

Harold Koenig, a coeditor of the book, offers a chapter on how religion and spirituality issues can play a role in the work of a consultation-liaison psychiatrist. The topics discussed here and elsewhere in the book illustrate well how the clinician in such a setting needs to be very attentive to religion and spirituality in relation to patients in cases where anxiety and depression are generated in coping with medical illness. A broad array of medical problems, from dealing with pain to the treatment of substance abuse, are discussed as well.

Chapters like these make the relevance of religion and spirituality to the work of a practicing psychiatrist clearer, and they underline the value of introducing it more actively into psychiatric training. To this end, one chapter offers two examples of four questions that can be used in psychiatric assessment, as well as a longer list of topics that can be addressed. In our experience, religion and spirituality have often been thought to be of marginal importance in patient assessment on teaching units and often relegated to a social worker's evaluation. So we ask residents to pose only one question to all their patients: "Spirituality can be important to people. Does spirituality help you deal with your problems?" The residents are typically quite surprised by the positive responses they receive. We have also introduced resident-run spirituality groups on our training units, in parallel with conventional ones.

Although this book is quite comprehensive, not all aspects of religion and spirituality can be addressed in the depth they might deserve. Sociobiologic research, for example, could be covered, as it has given us models for the cognitive and affiliative underpinnings of religiosity, particularly in relation to altruistic commitments. Buddhist approaches could be dealt with in more depth. Religious orientations out of the mainstream, like Christian Science, Mormonism, even Santeria, would illustrate how clinicians may encounter traditions unfamiliar to them and their colleagues.

Some problematic areas in the religion and spirituality domain also merit attention (the book is, in essence, pro-religion and spirituality): highly religious psychiatrists may sometimes miss out on salient clinical problems because they overemphasize religious commitment with their patients (APA has a position statement on this). Religious movements may be cultic or even destructive—plenty in the news on this—and a clinician may be asked to consult to a family or even to the press on this topic. Overall, however, the authors in this volume illustrate in an excellent manner the value and depth of an issue that deserves more attention from our profession than it currently receives.