Religious Barriers to Mental Healthcare

The help-seeking process starts with an individual’s understanding and conceptualization of psychiatric disorders (Table 1). Interpretations of psychiatric symptoms are influenced by a patient’s cultural experience, which includes religious beliefs and practices. Historically, psychiatric disorders were explained by supernatural phenomenon, such as demonic possession. Today, some religious people may believe that psychiatric disorders are caused by a “weakness in faith” and that the illness can be overcome or cured through “willpower” alone, rather than by seeking professional help from the mental health system (9). For example, in one survey, 85% of African Americans defined themselves as fairly religious or very religious, and researchers have found that there is a prevalence of a belief in this population that psychiatric disorder can be overcome by heroic striving (10). For this reason, some patients with religious affiliation may avoid contacting a psychiatrist. Even after contacting a physician, patients might avoid discussing their religious concerns with the provider because of their perception that psychiatrists are not sensitive to or knowledgeable about the religion (3, 10, 11).

Similar to patients, clergy also have various beliefs about psychiatric care and the perceived need for treatment (12, 13). In a survey conducted among 204 Protestant pastors, a significant portion of the participants attributed symptoms of depression to “lack of trust in God,” and they were less likely to agree with the biological nature of depressive disorders (12). Another study conducted on Muslim clergy suggested that while imams can recognize the need for psychiatric care in a hypothetical clinical vignette, they could still be reluctant to make referrals to the mental health system due to concerns about discrimination based on their religion (13). Since clergy are a key entry point for a quarter of religious people, the clergy’s perceptions of psychiatric disorders can lead to avoidance of referral to mental health providers.

Additional concerns among religious people may arise when they need inpatient level of care. In an observation study conducted at SUNY Downstate Hospital, Orthodox Jewish patients at the psychiatric inpatient unit experienced difficulties while following ward milieu due to conflicts with religious practice. For example, inability to pray at accustomed times exacerbated the anxiety of religious patients (14). For an outpatient treatment such as psychotherapy, nonreligious therapists can integrate religious components into their treatment; however, patients might have fears that the therapist will challenge their religious beliefs. This can be a barrier for patients who seek long-term treatments like psychotherapy (15).

It is also important to note how psychiatrists relate religion and health. Clinicians’ views of religion can shape how they interact with their patients (16) (Table 1). In a national survey, it was found that psychiatrists were less likely to be religious compared with nonpsychiatry physicians (15). Although psychiatric care promotes better understanding of patients’ beliefs, patients still report difficulty finding a psychiatrist with an understanding of their religious beliefs. This can be especially prominent in religions with a relatively low percentage of psychiatrists within the population (2).

Psychiatrists frequently encounter patients with pathological expressions of religion, such as religious delusions (17). Psychiatrists may have difficulty separating normal and pathological expressions of religiosity, which becomes a barrier to understanding their patients. In an interview study, psychiatrists reported discussing religion with their patients in only 36% of cases, although they reported feeling comfortable talking about religion in 93% of the cases (3). None of the clinicians initiated the topic themselves. Patients in the same study reported avoidance of talking about their spirituality, especially when it overlapped with their positive psychotic symptoms. In the same study, psychiatrists discussed community resources of the religion with their patients but had difficulty discussing the subjective experience of their patients’ religiosity.

While religiosity and spirituality in American society have increased (2), there has been an increase in the use of nonpsychiatric forms of mental health services and a decrease in the use of psychiatric services (5). Because clergy are often the first entry point to mental health for religious people (5, 18), it is important to understand the role of religious institutions in service delivery. Despite the fact that use of clergy for mental healthcare is associated with good outcomes (19), we have limited understanding of the structure of faith-based service delivery. A cross-sectional survey found that counseling provided by clergy has low frequency, even for individuals with serious psychiatric or substance use disorders (5). In addition, coordination between faith-based services and formal healthcare has often been lacking (Table 1). A survey on clergy suggested that faith-based providers were found to be reluctant to collaborate with formal health services due to several reasons, including lack of demand from their community, financial limitations, and lack of specialized training (20). Even among clergy who have a willingness to refer an individual to a mental health provider, the lack of familiarity with the mental health system may remain a barrier (13).