The Relationship Between Psychiatry and Religion Among U.S. Physicians

This study's methods have been described in detail elsewhere ( 12, 13 ). In 2003 we mailed a confidential, self-administered, 12-page questionnaire to a stratified random sample of 2,000 practicing U.S. physicians age 65 or younger, chosen from the American Medical Association Physician Masterfile, a database intended to include all physicians in the United States. We oversampled psychiatrists to increase the power of analyses presented here. Physicians received up to three separate mailings of the questionnaire, and the third mailing offered $20 for participation. This study was approved by the University of Chicago Institutional Review Board.

This study showed that, in comparison with other physicians, psychiatrists are less religious in general, are less likely to be Protestant or Catholic, and are more likely to be Jewish or nonreligious. These results are similar to findings from two and three decades ago ( 1, 2, 3 ) but are in contrast with a 1993 study in which psychiatry residents were found to be more religious than the profession as a whole ( 25 ). Thus the question arises about how long the field of psychiatry will display a religious profile that is not shared by other medical specialties. However, the persistence of this religious profile over multiple decades suggests that movements toward integrating religion, spirituality, and psychiatry are rooted in psychiatrists' recognition that religion is important to patients, rather than changes in psychiatrists' religious characteristics.

The finding that religious physicians are less likely to want to refer patients to a psychiatrist or a psychologist parallels earlier studies. Larson and colleagues ( 26 ) reported that clergy members refer patients more often to religious psychiatric clinics, whereas psychologists and psychiatrists more often refer patients to psychoanalytic and hospital outpatient settings. Similarly, Koenig and colleagues ( 27 ) found that psychiatrists refer patients to chaplains less frequently than to other professionals. In response to mild or moderate symptoms of mental distress, religious and nonreligious physicians appear to look for help in different places, with the result that the religious characteristics of physicians determine to some extent whether their patients receive evaluations from psychiatrists.

Psychiatry's unique religious profile has implications for efforts to provide culturally competent care for patients. For several years psychiatry has recognized that the cultures of both the patient and the physician affect how mental health concerns are described and evaluated, and cultural differences may hinder communication, the ability to make correct diagnoses, and the development of trusting relationships ( 28 ). However, providing culturally competent care and tailoring therapies to the religious patient's worldview may be especially challenging for psychiatrists. First, differing religious characteristics may introduce a cultural obstacle from the start. Second, cultural factors may have unique significance in psychiatry, because psychiatrists more frequently encounter patients struggling with emotional, personality, and relationship problems. Patient care might therefore improve to the extent that psychiatric training emphasizes providing culturally competent care for patients with differing religious characteristics.

Another implication of these data is that religious patients who prefer to see like-minded psychiatrists ( 29 ) may have difficulty finding a match because their religious group is underrepresented among psychiatrists. There is some indication that nonreligious therapists can effectively integrate religious components into treatments ( 30 ), but psychiatrists who are not religious themselves might not accurately predict when therapies will conflict with religious worldviews ( 30 ). In addition, some patients may find it difficult to trust their psychiatrists for fear they will suggest changing deeply held religious beliefs ( 26 ), and others may avoid treatment altogether if they view seeking psychiatric treatment as a failure to trust God ( 31 ). These data underscore the need to train psychiatrists to work with patients who may have religious views that are quite different from their own and raise questions about what contributes to physicians' choosing psychiatry as a specialty.

Because our data set is a cross-sectional survey, we can only speculate about why religious physicians may opt for nonpsychiatric careers and may be disinclined to refer patients to psychiatrists. Psychiatric residency program directors report they are not deterred by a candidate's religiosity and consider religion to be irrelevant to the recruitment process ( 32 ). Yet something about psychiatry may dissuade religious medical students from applying to psychiatric residencies. Perhaps psychiatry's historical ties to psychoanalysis ( 33 ), especially the antireligion statements of Freud and the liberal political views of many influential psychoanalysts of the 1950s–1960s ( 34 ), continue to influence religious physicians' views toward the field. Alternatively, while psychiatry's prior focus on psychoanalysis has given way to a renewed interest in somatic etiologies of mental illness and pharmaceutical therapies ( 33 ), religious physicians might still shy away from psychiatry if they believe psychiatry now overemphasizes biological processes. The training of psychiatrists or the cultural environment within psychiatry might also be factors if they affect psychiatrists' religious worldviews by providing competing explanations and understandings.

This study has several limitations with respect to the hypothetical clinical vignette. Physicians' referral preferences were measured only in reference to a single clinical scenario with an ambiguous presentation of grief and depression, and we would expect that preferences would vary less in reference to clinical situations with more severe and unambiguous psychiatric illness. The vignette did not specify the religious characteristics of the hypothetical patient, and it is possible that religious physicians and religious patients self-aggregate to such an extent that differences in referral preferences reflect differences in the religious characteristics of physicians' patient populations. In addition there is some ambiguity about whether the results reflect a relative unwillingness among religious doctors to refer patients to psychiatrists and psychologists or reflect a relative affinity for referring patients to religious professionals. Furthermore by lumping psychiatrists and psychologists into one response category for referral, we may have introduced a certain amount of survey error. Although the response rate was better than average ( 35 ) and we did not find substantial evidence to suggest response bias ( 12, 13 ), religious and other characteristics may have systematically affected in unmeasured ways physicians' willingness to respond. Finally, we do not know how physicians' self-reported preferences translate into their actual practices. Future studies should use experimental vignettes that cover a broader spectrum of clinical presentations that are relevant to clinical psychiatry.

This study indicated that psychiatrists continue to be less religious than nonpsychiatrist physicians. Historic tensions between psychiatry and religion may continue to shape the interaction between the two realms. However, psychiatrists and other physicians should work to see that such tensions do not unduly compromise patients' opportunities to receive appropriate spiritual or psychiatric care.

This work was funded by grant support (Integration of Religion and Spirituality in Patient Care Among U.S. Physicians) from the Greenwall Foundation and by grant K23-AT002749 from the National Center for Complementary and Alternative Medicine and by the Robert Wood Johnson Clinical Scholars Program (Dr. Curlin, Dr. Chin, and Dr. Lantos). The funding agencies did not have any role in the design, conduct, analysis, and interpretation of the study, nor in the preparation of the manuscript. The authors are indebted to the University of Chicago Templeton Network for their feedback on a draft of this article.

The authors report no competing interests.

Dr. Curlin, Dr. Chin, and Dr. Lantos are affiliated with the Department of Medicine, University of Chicago, 5841 S. Maryland Ave., MC 2007, Chicago, IL 60637 (e-mail: [email protected]). Mr. Odell and Mr. Lawrence are with the Pritzker School of Medicine, University of Chicago. Dr. Meador and Dr. Koenig are with the Department of Psychiatry, Duke University, Durham, North Carolina.