Hinduism and mental health

Twelve myths of religion and psychiatry: lessons for training psychiatrists in spiritually sensitive treatments

BRENT R. COYLE Department of Psychiatry Residence Training, East Tennessee State University, Tennessee, USA

AB S T R A C T Our world is Ž lled with renewed interest in spiritual dimensions. Educators and clinicians, however, have little practical guidance for these complex issues. The American Council on Graduate Medical Education’s Residency Review Committee Guidelines now require training of resident physicians in spiritual sensitivity. The current level of sophistication and rapid expansion of this powerful and complex dynamic of the profession are a challenge to psychiatrists. Problems now facing many training programmes are lack of data, negative bias and misinformation surrounding spirituality. This paper focuses on 12 common myths often associated with the interface of psychiatry and spirituality.

The Psychiatry Residency Review Committee has made a bold move with new requirements, explicitly requiring education of residents on spiritual sensitivity in a culturally sensitive context (American Medical Association, 1996).The DSM-IV statistical manual (Lukoff et al., 1992) likewise has included a V-code for a “religious or spiritual problem” (American Psychiatric Association, 1994).These two events have marked a new beginning in careful thought and study of religious and spiritual topics within the field of mental health. Additionally, consumer consciousness within health care, in which consumers increasingly play a greater role in deciding what type of care the consumer prefers or is willing to purchase, is an important factor (Barsky, 1988). Historically the general population has been more religious and spiritual than many mental health professionals (Neeleman & King, 1993). It appears we have a clear mandate to teach and practice culturally and spiritually sensitive psychiatry. But how do we teach a subject area that is unfamiliar? What have we been taught? How accurate is the information? How does one go about Ž nding answers to these questions? The answers to many of these questions may be found in accepting our own limitation and formulating fresh and proper questions.

Mental Health, Religion & Culture,Volume 4, Number 2, 2001

Mental Health, Religion & Culture ISSN 1367-4676 print/ISSN 1469-9737 online © 2001 Taylor & Francis Ltd

http://www.tandf.co.uk/journals DOI: 10.1080/13674670110059541

Correspondence to: Brent R. Coyle, Director of Psychiatry Residency Training, Department of Psychiatry and Behavioral Sciences, P.O. Box 70567, East Tennessee State University, Johnson City, TN 37614, USA; e-mail: [email protected]

Myth 1. ‘Psychiatrist’s spiritual/religious beliefs are representative of the general population’

Results of 12 Gallup Polls over the last 35 years have been surprisingly consistent. Polls have indicated that:

(1) 95% of the general population believes in God; (2) 84% of those surveyed considered religion important or very important in their

lives; (3) 78% pray on a regular basis; (4) 42% had attended a religious service within the last week (Gallup, 1985).

Intuitively, many providers are aware of the important role of religion and spirituality in the lives of the general population. In many cases these in uences form the basis of self-deŽ nition and are important factors in family tradition and social support. Religious activities consume a great amount of some patient’s time and serve as important coping strategies (Aponte, 1996; Benson, 1996; McEwen, 1998; Pargament, 1997, 1998; Smith, 1994;Waldfogel, 1997).

The term ‘religiosity gap’ has been applied to the difference that exists between mental health professionals and the general population regarding religious beliefs. The data presented in Figure 1 show relative percentages on a number of religious activities. For example, the rate at which various populations would endorse the statement ‘my whole approach to life is based on my religion’ is represented. Similarly represented are the relative percentages of non-religiousness. This is represented in the number of individuals who would label themselves as agnostic, atheistic, humanistic or otherwise non-religious and is much higher among mental health professionals.There is then what has been described as a ‘gap’ in the religious/ spiritual beliefs of psychiatrists (Larson & Larson, 1994).

There has also long been great diversity of opinions and beliefs regarding issues of religiosity and spirituality within psychiatry. Atheistic and agnostic icons such as Freud and Ellis are contrasted with others such as Jung, James and PŽ ster who espoused the importance of a spiritual nature from the profession’s inception.

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TABL E 1.

Group Religious (endorsement of the Non-religious (identify selves as statement ‘my whole approach to atheistic, agnostic, humanistic or life is based on my religion’) % otherwise non-religious) %

General population 72 9

Family therapists 62 15

Social workers 46 9

Psychiatrists 39 24

Psychologists 33 31

Psychiatrists holding religious beliefs have perhaps traditionally been seen as outliers of the profession. Recent studies have shown however, that psychiatrists who are also members of the Christian Medical and Dental Society are a highly esteemed group and largely conventional in their use of psychotropic medication for major Axis I disorders. These same individuals, however, advocate the effectiveness of Bible reading and prayer for suicidal ideation, grief, sociopathy and alcohol substance abuse (Galanter et al., 1991).

Finally, researchers have also found that there is a great disparity between mental health professional’s beliefs and their clinical practice. One example of this disparity is indicated by the fact that 46% would endorse the statement ‘my whole approach to life is based on my religion’, yet only 26% would feel that religious content was ‘important in the treatment of all or many’ of their clients (Bergin & Jensen, 1990).

Conclusion

While psychiatrists represent a broad range of opinions and clinical practices, generally, psychiatrists are not representative of the general population in their religious/spiritual beliefs.

Myth 2. ‘We know why psychiatrists are different’

Many factors may play into the “religiosity gap” of mental health professionals. Selection bias is certainly possible in at least two directions. First, it may be possible that people who are less religious are attracted to psychiatry or other mental health Ž elds as an alternative striving for purpose and meaning in life or as an alternative paradigm for understanding of human behaviour. Secondly, it is quite possible that religious people meet opposition in selecting mental health Ž elds. Although there is some evidence that representation in psychiatry is improving (Larson & Larson, 1992; Roskes et al., 1998; Sansone et al., 1990;Waldfogel et al., 1998) other studies have shown possible bias against accepting individuals who have an interest in religion and spiritual topics into graduate programmes and/or integration of those beliefs into practice (Gartner, 1986).

Physicians accepted into training are exposed to many different educational in uences.The Ž rst obvious impact on a professional’s body of knowledge would be through the reading of the most respected professional literature in the Ž eld such as textbooks.A study of psychology textbooks found that there were predominately explicit or implicit suggestions of religious psychopathology, and the discussions were almost exclusively of religious cult phenomena. The study went on to Ž nd that the amount of empiric evidence to support these discussions was very limited and potentially biased (Lehr & Spilka, 1989).While discussions of psychopathology of religiosity are absolutely necessary, there is conspicuous absence of writing on traditional religious beliefs, practices and their potential benefit. Similarly

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disregarded is the potential impact of these activities with regard to deŽ nition of self, individual or family psychological in uence or even social in uence.

Physicians in training are also clearly in uenced by the diagnostic nomen- clature. Clearly, signiŽ cant gains regarding religiosity and spiritual sensitivity have been made with the new DSM-IV; however, the DSM-III R has been found to be quite biased against religious and spiritual topics (Larson et al., 1993). Professional newsletters have held active discussions regarding the potential to label a belief in God (a belief held by 95% of the population) as ‘delusional’ (Gutheil, 1990; Harter, 1990)

Professional organizations also contribute to professional development in a very signiŽ cant way. Recently the APA adopted an ofŽ cial statement on the potential ‘Con ict Between Religious or Ideologic Commitment and Psychiatric Practice’ (see appendix) which has helped to remind us to not only be ‘respectful’ of patients beliefs, but has also bound us to not ‘impose a system of belief’ on others (American Psychiatric Association Ethics Committee, 1990). Clearly, the APA’s statement was issued in an attempt to protect against overzealous inclusion of religiously/ spiritually coercive practice. In careful consideration of the complex boundary issues and ethical considerations of the imbalance of power in the therapeutic relationship, the physician is appropriately cautioned (Coyle, 1999a).

However the statement is not as sophisticated or inclusive as it could be. Although not stated as such, there is a strong implication that the profession has been cleansed of all coercive identity. This is far from reality. While we may fall slightly short of “imposing” a belief in psychopharmacologic or psychotherapeutic beneŽ t, such coercive practice in the name of what is perceived as being beneŽ cial to the patient is daily practice (Post et al., 2000). Indeed it is our professional and ethical mandate in most clinical situations to enthusiastically advocate for these effective treatments (Beaucham & Childress, 1994; Dagi, 1995; Emmons, 1999). We practice daily with a legal mandate to impose the belief that patients must not take their own or another’s life. Few would argue for the removal of the professional’s role in coercively imposing such beliefs.We generally think it is ‘right’ to do so and a failure to do so would be deŽ cient practice.

Furthermore, the statement speaks to the preclusion of ‘subsit(uting religious) beliefs or ritual for accepted diagnostic concepts or therapeutic practice’. Again it is not expressly stated but the implication to many readers may be that there are no religious beliefs or rituals that are beneŽ cial. (More discussion in myth 6 below.) In both of these situations, what is not said and the very nature of how the statement is constructed is evidence of a subtle belief that there is nothing of substance in religious or spiritual practice to offer for the psychiatric patient.This certainly may in uence the beliefs of the psychiatric professional.

The term apostic has been used to describe those individuals raised within a theistic belief system that ultimately choose to give up that belief system to become agnostic, atheistic or otherwise non-religious.The rate of apostasy has been found to be high in psychiatrists and especially in psychoanalysts. Fewer mental health professionals who have been raised in a non-theistic system choose to adopt a theistic system (Henry et al., 1971).This leaves more people within our profession

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giving up religious beliefs than adopting them. An explanation for this practice is, however, not clearly understood.

Finally, psychiatry has grown out of the empiricism of medicine. As such, and like other forms of medicine, there is a constant desire to explain the phenomena of human existence without the inclusion of transpersonal elements. Ideally, bodily process is fully explained in physical and testable ways.The inclusion of teleological references would be actively opposed as being scientiŽ cally ungrounded. Mean- while, as was mentioned in the previous section, the great majority of the population has a perception of truth that is faith based.The fact that 95% of the population believes in God is not empirically based. People do not believe it because of a scientific study but rather on the basis of faith in some sort of improvable transcendent existence.The population believes in God because it feels correct and is validated in terms of their own experience (James, 1982).

Conclusion

Selection bias and influences of the field itself could contribute to different spiritual/religious beliefs among psychiatrists.The empiric nature of medicine is also frequently at odds with the faith-based perspective of the general population. To better capture the public’s perspective, it may be necessary for educators to actively encourage acceptance of trainees who are willing and interested in the integration of spiritual factors in training and practice.The conclusions drawn by our relative ‘deviant’ professional group’s perspective should, perhaps, be viewed with caution. While these views may be a fresh and new perspective, they also may be distorted or inaccurate.

Myth 3. ‘Psychiatrists are better for the difference’

It would be expected and natural for psychiatrists to assert mental health superiority. Ethnocentrism is a powerful force independently but when combined with extensive training and continual  attery of patients seeking our advice, our profession exists without the frequent occasion to question itself about its own mental health.

Intuitively, our consideration first turns to a definition of mental health. Although attempts have been made to define this condition (Bergin, 1991; Booth, 1991; Jensen & Bergin, 1988), interestingly, this is somewhat difficult. When one searches the leading textbooks of psychiatry, one is left wanting for such a definition. Presumably such a definition would include (perhaps not limited to):

• A high quality of relationships; • a sense of purpose, direction and meaning in life; • life satisfaction and fulŽ llment;

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• successful societal functions; • skills for effectively dealing with fear, anxiety, discouragement.

The patient hopes and expects that the treating physician ‘knows best’. Similarly, the patient hopes and expects that the psychiatrist is someone whom they can trust. In essence then, the provider is someone who is well informed by personal and academic knowledge operating within professional fiduciary responsibility to provide the best of care for the patient over any personal interests. It is within this context then, that each patient either directly or unconsciously assumes that the physician is wiser, more balanced, has more coping resources or is, in some other way ‘healthier’ or at least ‘healthy enough’ to assume the role of ‘healer’ in the therapeutic relationship.

Now in relation to our present discussion of religiosity and spirituality, is the fact that providers are less religious/spiritual a positive descriptor when it comes to an ultimate decision of character or mental well-being? For example, regarding quality of relationships, does being less religious/spiritual mean that the provider is more truthful, more skilled at intimacy, more genuine in concern, more compas- sionate or otherwise ultimately capable of a higher quality of relationships? In the Ž nal analysis, I believe many would not support such an assumption. In fact, it would seem that many intrinsic religious/spiritual beliefs and practices foster the development of many of the traits we would claim as ‘health’ and indeed, the diminished spiritual perspective of the professional would seem antithetical to this deŽ nition.

Another, perhaps more ‘evidence-based’ way to examine mental health of professionals may be to examine some of the objective indicators of health. Do psychiatrists have a lower incidence of depression? Are they without experiences of suicide? Are their marriages more stable? Do they have a low rate of substance or other addictive problems? The relatively high rates of suicide, alcohol and substance dependence and divorce rates among psychiatrists would suggest that this is not the case (Kaplan & Sadock, 1998). Granted, such a comparison of psychiatrists to the general population on these parameters is fraught with a variety of confounding variables, however upon surface examination, psychiatrists would not be a chosen population for exhibiting ideal emotional stability.

Conclusion

The psychiatric profession would be expected to deŽ ne and assert its own mental health and yet there are objective evidences of our own less-than-optimal emotional and psychological stability. Once we evolve to a cohesive deŽ nition for this concept of mental health, we may Ž nd that the beliefs and practices of intrinsic spirituality contribute to and are consistent with such a state of mind.

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Myth 4. ‘The interface of religion and psychiatry is well-studied’

A variety of descriptors might be considered for the fulfillment of reasonable criteria for being ‘well-studied’ in the Ž eld of mental health. One would expect, for example, large numbers of patients having been involved in research studies, great complexity of questions asked, careful discernment of beneŽ cial vs. pathological factors in faith, etc. One may also expect to see careful explanations why millions of people Ž nd help though religious/spiritual coping mechanisms in their daily lives. Unfortunately, such high quality is not to be found. Studies have found empiricism lacking within theological journals (Gartner et al., 1990). Family practice (Craigie et al., 1990) and sociology journals (Buehler et al., 1973) have infrequently included religious and spiritual variables. Similarly, psychology journals rarely explore these variables (Weaver, 1994). Finally, the psychiatric literature has actually lowered its rate of inclusion of religious and spiritual variables since the issue was Ž rst raised (Larson et al., 1986; Weaver, 1998). Single questions (often denominational) predominant in most of these published studies.

Despite this paucity, study and publication of issues of religious or spiritual importance has been previously described as an ‘anti tenure variable’ in that individuals wishing to study such topics may meet with diminished potential for academic success. (Larson & Larson, 1994)

Conclusion

Our current level of sophistication should, perhaps, humble our profession. We should, furthermore, be motivated to understand this fascinating dynamic more completely.

Myth 5. ‘The research conclusions are clear’

Myth 5A.‘All religion/spirituality is sick’

The purpose of this paper is not to provide a review of the relative findings of health vs. pathology associated with religiosity, however, of all the common myths, this is perhaps the most distorted. Recent reviews and bibliographic collections have pointed to many beneŽ cial effects of religion and spirituality in people’s lives (Ellison & Levin, 1998; Gartner et al., 1991; Koenig et al., 2000; Larson et al., 1996; Payne et al., 1991; Worthington et al., 1996). Older studies have clearly found that conventional religious beliefs are not a product of or associated with psycho- pathology and that in fact psychopathology probably impedes the manifestation of conventional religious beliefs and activities (Bergin, 1983; Hadaway & Roof, 1971; Stark, 1971). These reviews have indicated a generally positive effect of religion on mental health, well-being, coping, self-esteem, drug and alcohol use, suicide, reduction of death anxiety and marital and family issues. Of particular note

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are several studies that have shown religious and spiritual activities to be highly protective for alcohol and substance abuse (Gorsuch & Butler, 1976).Also, despite evidence that religious and spiritual activities are highly protective against suicide (Payne et al., 1991), researchers have found that religious assessment is absent from nearly all suicide risk assessments in current usage (Coyle, 1999b; Hoetler, 1979; Kehoe & Gutheil, 1994).

The beneŽ cial effects of religious and spiritual activities on physical health have also been covered in recent reviews (Koenig et al., 2000; Levin & Schiller, 1987). Studies have found decreased blood pressure and mortality. Others have found beneŽ cial coping mechanisms in the rehabilitation of medical conditions such as decreased depression and better ambulation following hip surgery (Pressman et al., 1990). Finally, even CCU patients may have received beneŽ cial results from intercessory prayer (Byrd, 1988; Harris et al., 1999).

Researchers have also found highly beneŽ cial effects of religion and spirituality in geriatric patients that results in higher life satisfaction, sense of well being, less depressive symptoms, less disability and perception of pain, and better adjustment (Koenig, 1990).

Conclusion. Although confirmation is necessary with many findings, there is convincing evidence that there are many highly signiŽ cant beneŽ cial effects of at least certain types of religiosity/spirituality.

Myth 5B.‘All religion/spirituality is healthy’

Freud, Ellis, Oates and others have historically warned about pathological religiosity and newer writers (Asser & Swan, 1998; Blazer, 1998; Ellis, 1980; Gartner et al., 1991; Houts & Graham, 1986; Oates, 1978; Watters Wendell, 1992) continue to warn as well. Many of the warnings are sound. Wars and other similar atrocities based on religious grounds are dramatic examples of the powerful effect of religion on individuals and societies and its potential for harm.

Again, this paper’s intent is not to provide a complete review of pathological phenomena in religion but simply an overview for work with trainees and patients. The most obvious examples of pathological and tragic religion are manifest through cults or leader deiŽ cation groups. It seems that emotionally vulnerable individuals are particularly drawn to such groups for acceptance where it may be difŽ cult to find elsewhere (Deutsch, 1980; Galanter, 1980; Galanter, 1990; Lifton, 1961). ‘Deprogramming’ of individuals was a topic of interest within our professional journals previously and fraught with all matter of controversy (Galanter, 1982; Maleson, 1981; Ungerleider & Wellisch, 1979).

More complete understanding of pathological religion lies in looking beyond such overt and ‘end-stage’ illness of belief systems to more insidious forms. First, is religion’s general resistance to psychiatry and mental health strategies. While such reserve is justiŽ ed on the basis of other assertions in this review, patients may suffer, apparently needlessly, from mental illness because of negative bias toward

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mental health treatment and fundamental distrust of the profession. This is particularly true when the religion itself offers hope and conŽ dence in its own ability to cure.This leads to the common situation, for example, of the depressed patient truly believing that all (s)he needs is more prayer, stronger belief, more faith, another healing service, etc. while rejecting the antidepressant that may ultimately provide the greatest relief. Other resistances to treatment may manifest in individuals retreating from the world in ascetic spirituality when their recovery may lie in interpersonal challenges.

Once the religious patient becomes a patient, a different set of resistances takes over. Religion and spiritual issues may be a source of transference distortions in psychotherapy as well as an area of mutual resistance or countertransference reactions (Kehoe & Gutheil, 1984). A personal example of a ‘ esh vs. the spirit’ resistance occurred in a recent patient who was referred by a fundamentalist therapist and required hospitalization for suicidal ideation.The patient eloped from the hospital, and when her actions were later questioned, she reported that she had ‘once again placed her trust in the world when she should have been placing it in God’. Luckily a disastrous suicidal death was averted in this situation but danger certainly lurks for others incapable of accessing care ‘within the world’.

The potential destructive effects of the religious group on the individual are far too complex to be discussed completely here but an overview is appropriate. The religious group’s capability of exploiting an individual is renown.The images of infamous ‘TV evangelists’ doing so are poignant but more subtle examples of exploitation of personal time and resources more commonly occur. Congregations may meet socially ‘deviant’ lifestyles with hostility and scorn.This may be deeply hurtful to the individual who has sought a religious body as a source of support for their struggles. The group’s responses may vary from healthy growth in love and acceptance of these ‘deviant’ individuals to severe assertions of ‘unpardonable sin’ and actions of excommunication or ‘shunning’.

Another powerful influence of the group plays itself out through families. The territoriality involving families in small religious communities is common and may result in difficulty for an individual to leave a religious belief/system without emotional turmoil. Simply voicing one’s dissatisfaction or disagreement with a faith community may be traumatic for the individual and the community’s response may be far less than loving and accepting. Thus, despite ‘freedom’ of religion so commonly espoused, complex family and interpersonal exigencies may make such ‘freedom’ difŽ cult to access.The individual’s response to the perceived group’s values may then be pathological submission and an impediment to separation/individuation may occur. Alternatively, the patient may choose patho- logical rebellion with a different set of emotional consequences (Oates, 1978).

Religious groups have traditionally been uncomfortable with negative emotions. My clinical experience speaks to the frequent occurrence of con icts around anger, loss, discouragement, etc., within the religious community. It is frequently a difficult stretch for acceptance of these as ‘God-given negative emotions’, despite a reasonable assumption that God could create us as wished (inclusive of negative emotions).

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In contrast to the ‘intrinsic’ generally healthy aspects of religion, the ‘extrinsic’ expression of religion is much less healthy.The psychiatric community appropriately considers dogmatic, perfectionistic, legalistic and exclusive religions psychologically unhealthy. These are all expressions of how religion may be used and applied selŽ shly rather than in community and for the beneŽ t of others.

There also seems to be some suggestion of a potential for the psychologically unhealthy to drift toward more unconventional forms of religion. Perhaps such individuals hope to normalize their disease within an accepted religious form, e.g., speaking in tongues, experiencing ‘visions’, etc. Researchers have wisely summarized this phenomenon as ‘troubled personal development and troubled religiosity go together’ (Payne et al., 1991).

Finally, two other forms of apparent pathological religiosity are worth mentioning.The Ž rst is the extrinsic form of religion that is adopted by hostile or antisocial individuals or groups. An example might be the scriptural references offered by Ku Klux Klan proponents in justiŽ cation of their antisocial acts.

The second form of falsely attributed pathology occurs when patients manifest religious content during the active stages of psychiatric illness. In light of the strongly held and deeply ingrained nature of religious/spiritual belief, these themes would be expected in the manifestation of major Axis I disorders (Spilka & Werma, 1971). In both of these examples, the religion is not the source or cause of the pathology, rather simply associated with it; not causal but simply correlated.

Conclusion. Religious and spiritual beliefs are powerful forces and as such, are capable of powerful destructive effects.

Myth 5C.‘We know which aspects are beneŽ cial effects of religiosity and which are pathological’

Gordon Alport’s important work in the 1960s attempted to distinguish ‘extrinsic’ from ‘intrinsic’ religiosity (Donahue, 1985). Extrinsic religiosity tends to use reli- gion as a means to an end, for personal reasons, to establish status or for justiŽ cation of acts.This is in contrast to intrinsic religiosity in which the person attempts to ‘live’ their religion through personal prayer and sincere seeking of God’s guidance, thus sincerely wanting to be moved to be a better person through their spiritual beliefs. It is not surprising that the more beneficial results seem to stem from intrinsic religiosity. More recent attempts have been made in using other religious commitment measures in addition to church attendance or denomination. The subdivision of beneŽ cial aspects of religion has been somewhat fruitful but much work still needs to be done (Craigie et al., 1990).

Conclusion. The effects of religion/spirituality are understandably complex and highly individualized in nature. Much careful and discerning evaluation will be necessary to determine beneŽ cial from pathological impacts of these forces on the human psyche.Truth is (hopefully) discernable and study is possible.

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Myth 6.We know what to do with the data

One of the more profound questions we currently face is what to do with the data that now exists about spiritual factors in health and wellness (Pellegrino & Thomasma, 1988; Post et al., 2000). Given what might arguably be described as robust Ž ndings of health or pathology associated with spiritual or religious factors, what avenues do we have for the implementation of such knowledge in our health care system (Bilchik, 1998; Kaldjian, 1998)?

For example, the literature is increasingly clear that spiritual and religious activities are highly preventive for substance abuse and dependence. Thus, we as practitioners are faced with a highly effective intervention for treating a difŽ cult illness but a treatment recommendation that could and would be considered coercive and unprofessional by liberal opponents. Such opponents may indeed even bring legal suit against doing so in the event that the intervention did not prove to be as useful as expected. Although this would be equivalent to suing a physician for an initial antibiotic proving to be ineffective despite statistical evidence of efŽ cacy, the tenure of the argument is vastly different since it would involve spiritual and religious domains. Our ‘separation of church and state’ sentiments arise and thus create tensions in our practical clinical decision-making and recommendations. Fortunately, within the substance abuse treatment arena, we have found a clandes- tine way of including spiritual forces in care.This is, of course, that of Alcoholics Anonymous which has its fundamental basis in spiritual principles and practice (Khantzian EJ & Mack, 1989). Both physician and patient know this reality and somehow this recommendation by the physician for a spiritually based form of care is accepted as standard and appropriate practice. Also, fortunately, it has become so standard that the failure to make such a recommendation might be considered inadequate care.

But what are we to do with other new data? The finding that traditional religious involvement is one of the strongest protective factors against suicide is a perfect example. Obviously suicide is a tragic medical problem that all members of our society would desire to quickly cure.Yet, is it the mental practitioner’s role, duty, responsibility or even obligation to recommend participation of depressed and suicidal individuals in traditional religious or spiritual practices?

On the one hand, our physician Ž duciary responsibility obligates us to do what is in the best interests of the patient without regard to our personal sentiments or beliefs. As a physician, my personal beliefs or convictions are irrelevant when it comes to making treatment recommendations that have been shown to be clinically efŽ cacious. Examine the difŽ culties that emerge even if one is allowed to proceed with this clinical obligation. Does one simply recommend religious/spiritual involve- ment of any type chosen by the individual? What is the professional’s responsibility for unfavourable outcomes that might result from involvement with an unhealthy religious group?

Now consider the opposite situation, in failing to make a recommendation for the religious/spiritual involvement. Paradoxically, the physician is safer from a medical-legal standpoint having an unresponsive patient, even a dead patient

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(Hummer et al., 1999; McCullough et al., 2000), since few families would bring a suit against you for having failed to recommend religious/spiritual involvement for a patient.

Ones’ personal convictions obviously also come to play in this situation as well. How demoralizing it would be for the conscientious practitioner to avoid recommending the practices that have been proven to be effective and s(he) believes deeply to be beneŽ cial to watch the patient experience increased morbidity or even mortality.

Clearly, these are difŽ cult problems. What sources of comfort and strength are there for the informed practitioner in this tension? First, a command of the medical research literature is vital.This is not an easy thing. Organizations such as the National Institute for Health Care Research (NIHR) and recent compendiums of available literature will provide direction for the practitioner in this regard. (Koenig et al., 2000) We have formed a group of physicians and other health care professionals that meets twice per month that attempts to review the literature in this area. Part of the complexity of doing so involves the review of a quickly growing number of publications from a vastly divergent set of disciplines.The second major area of security for the busy practitioner is using methods of gathering information about what kinds of interventions might be welcome to a given patient. We are experimenting with the use of web-based instruments that assess a given patient’s interest/openness to a given set of spiritual interventions. Although honouring an initial refusal of a spiritual intervention for the relief of a given condition would form a safe decision, one might consider going one step further. Likened to the common computer prompt, ‘are you sure you want to avoid doing this. . . . ’, the patient, then, conŽ rms a refusal of interventions that are known to be helpful.

Conclusion

Despite hard data either in support of health or pathology associated religious or spiritual dimensions, there will be ongoing impediments to the implementation of such knowledge. Practitioners will inevitably carry the burden for offering useful interventions as well as offering substandard/less useful treatment alternatives if clearly requested by persons under their care.

Myth 7. ‘Patients don’t expect or wish for psychiatrists to include religious factors in their treatment’

A myriad of publications exist supporting the public’s interest in spiritual factors in their care.The common themes in this work include the desire of patients to know the beliefs of their providers, their desires for inclusion of spiritual interventions especially during serious or potentially terminal medical interventions, a sense of spiritual or religious con ict related to current psychological distress and wishes and expectations of inclusion of spiritual aspects in their care (Anderson & Young,

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1988; Daaleman & Nease, 1994; Ehman et al., 1999; Ellis et al., 1999; King & Bushwick, 1994; Koenig et al., 1989; Kurfees & Fulkerson, ; Maughans & Wadland, 1991; McNichol, 1999; Meitzen et al., 1998; Neeleman & King, 1993; Patient Rights, 1992; Privette et al., 1994; Reese & Brown, 1997; Rudnick, 1997; Shaver et al., 1980; Sheehan & Kroll, 1990; Sloan et al., 1999;Thomason & Brody, 1999; Thompson, 1997; Turbott, 1996; Wallis, 1996; Worthington, 1986; Worthington et al., 1996). We surveyed 100 consecutive psychiatric inpatients and conŽ rmed these Ž ndings. In our work, we found that one third felt that religious con ict or sin was related to their psychiatric hospitalization (McKenzie & Coyle, 2000).We also found 41% of our inpatient population expects to have religious beliefs explored or discussed during their psychiatric inpatient stay and approximately half of the people wished for religious beliefs to be explored or discussed during their hospital stay (Brahmbhatt et al., 1999). It is simply astounding that the myth remains that people do not want to include spirituality in light of the current published data.

Conclusion

Large percentages of the general population expect and desire a spiritual component to their care. Our current question has shifted from ‘are people interested?’ to ‘how will we as a profession meet the need that clearly exists?’

Myth 8. ‘Religious concerns are separate from mental health concerns’ or, we must move toward ‘separation of church and health’

It would be tempting to simplify our professional lives by agreeing to this common fallacy. After all, mental health and psychiatry are clinical disciplines and are, therefore, commonly seen as secular disciplines. In seemingly clear contrast are the beliefs, faith, spirituality and religious behaviour of individuals. These later things are seen as personal/private matters that are not the business or concern of professional interactions.

Many additional forces weigh in favour of this schism. The household appreciation for ‘separation of church and state’ seems to further justify professional exclusion of spirit and faith matters.This has the added beneŽ t of saving time and simplifying the lives of professionals to not be concerned with such complex matters. Support for a “separation of church and health” quickly becomes shock- ingly unrealistic in at least two ways. First we will consider how religious/spiritual activities might be causal for changes in mental health followed by how variable mental health might affect the manifestation of ones experience of religion and spirituality.

First, in expansion of how ones spirituality or religious behavior might affect mental health, well-being, life satisfaction and other measures, it makes no intuitive sense that ones belief, even conviction, in a loving and personal God would not have an ultimate beneŽ cial effect on mood, well-being and the like. Similarly that

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another’s conviction in a harsh and punishing God would not affect these measures or that a third’s conviction of the absence of a God altogether might predispose to yet another set of emotional responses.

Conversely, again it is intuitive that ones mental state might affect how ones spirituality and religiosity are manifest. It would be logical to conclude that the existence of the clinical state of depression might lead to certain manifestations of religiosity/spirituality, while substance abuse or schizophrenia might lead to other manifestations of spirituality and religiosity.

Another way one might consider this falsity is by examining the findings regarding the types and acuities of mental health concerns that might be brought to a pastoral counsellor vs. mental health centre. If the mythic assertion of separate- ness were to hold, one would expect vastly different sets of concerns being brought to these two sets of providers. The research proves exactly the opposite, in the dramatic Ž ndings that individuals presenting for care at a church counseling ofŽ ce have no differences in diagnosis, are no less acutely ill or severely impaired than is found in presentation to a community mental health clinic. (McDonald & Luckett, 1983).

Conclusion

Ones spirituality/religiosity is inexorably linked with ones mental state. It is essentially unrealistic and impossible to separate the two mental phenomena.

Myth 9. ‘The provider’s beliefs have nothing to do with the therapeutic process and patients do not care about them’

This myth is likely based in a long-established ideal of the therapist as ‘blank screen’ in the therapeutic enterprise.That is, that the therapist does not allow him or herself to convey personal beliefs or values in the therapy experience, rather, only being there to facilitate the patient’s own insight. Despite the enduring nature of this conviction, writers have perhaps more convincingly argued that the therapist’s personal values do matter and are constantly at play in psychotherapy (Bergin, 1991; Giglio, 1993; Holmes, 1996; Kelly & Strupp, 1992).

In an extension of this assertion, the concepts of ‘convergence’ or ‘assimilation’ have gained importance in the research literature regarding the process of change and perception of improvement during mental health treatment. In essence, there is support for the notion that the therapist’s perceptions of patient improvement correlate closely with the extent to which patient’s beliefs change to be similar to or “assimilate” to the therapist’s.Thus, we as mental health professionals count it as patient ‘improvement’ when patients come to think and believe as we do (Beutler, 1981).

Again, much of this is intuitively obvious by personal experience. Many of us carefully choose with whom we associate with based on what we Ž nd are the

162 Brent R. Coyle

beliefs/values of others.We do this precisely because we are aware of how much these other people affect our lives.This dynamic is important even when we are totally free to explore relationships via mutual questioning and disclosure.

If the above realization were not shocking enough, the state of patient vulnerability in the interchange is profound as well. Arguably some of the most desperate of human needs often are required to precipitate a choice to seek mental health treatment. In light of strong societal, personal and family stigmatization of mental health treatment, the ultimate behaviour of sitting down before a psychiatrist for evaluation is often fraught with extraordinary angst. The power differential in the therapeutic relationship magnifies the patient’s disability in finding out values genuinely held by the provider. It is, then, not surprising to Ž nd that patient’s choice of a provider depends greatly on their perception of their provider’s beliefs (Worthington et al., 1996). Patients would like to choose a provider who has similar values and beliefs as their own. This importance is also reflected in the frequent reality of many religious clients attempting to directly question the provider regarding the provider’s personal religious beliefs.Thus the beliefs/values of the psychiatrist are highly relevant to the patient and the physician/patient encounter.

Conclusion

Patients are and should be concerned about the psychiatrist’s personal beliefs. Beliefs of the therapist are crucial to how the therapist sees the patient data, strives to ‘help’ and determines what ‘improvement’ is. The ultimate challenge is not in removing personal values but in discerning truly healthy beliefs and how to use those values to greatest therapeutic advantage without abusing the therapist’s power and the client’s vulnerability.

Myth 10. ‘If the patient brings it up I will talk about it’

To be most responsive to patient’s needs, a physician needs to be trained, practiced and established in a pattern of perceiving themselves as being competent. In this murky area of mental health nothing could be farther from the personal experience of most psychiatrists. Although training is more readily available and improving steadily (Puchalski & Larson, 1998), most established providers were never exposed to training in the interaction of spiritual/religiosity and mental health. In light of the aforementioned medical-legal and societal restraints, few have practiced extensively within an open and inclusive framework for spiritual factors. It is then likely that few would see themselves as particularly competent in this area.We also naturally tend to retreat from those things that are uncomfortable for personal reasons. It is not surprising then to Ž nd such brave confessions from a senior analyst: ‘The typical approach to the patient who brings up religion would be either to ignore it or show that it was neurotic’ (Larson & Larson, 1992).

Religion and psychiatry 163

Research confirms that patients give more accurate information if asked speciŽ c questions about problems (Greene et al., 1987; Kelley et al., 1997) and that religious and spiritual issues are potential blind spots for the therapeutic encounter (Schultz-Ross & Gutheil, in press). Similarly, with older patients, particularly, we providers are significantly less comfortable discussing religious matters than our patients (Koenig, 1990).

We may intuitively also maintain that remaining open to the spiritual issues that are of great importance to individual’s lives allows us to establish the best therapeutic alliance with individuals (Barnard et al., 1995; Jones et al., 1992). In contrast, if our patients’ religious beliefs are immediately perceived as being beneŽ cial or detrimental, we may not be fundamentally accepting our patients, which could signiŽ cantly threaten the treatment alliance.

It is clearly not in realization of these ‘truths’ but rather in terms of education, practice and perceived comfort and competence where our greatest challenges lie. To this end, perhaps a quote from someone well-acquainted with the issues may prove motivational: ‘If religious issues need to be addressed because of the potential positive or negative impact on mental health, then who should address them? Should such topics be removed entirely to the domain of the minister, priest or rabbi or does the extent and complexity of their relationship to mental health demand that the psychiatrist or the medical physician be ready to address religious issues when necessary?’ (Koenig, 1990; Jakobovits, 1975).

Conclusion

It is natural to run from that which we do not understand or lack in compe- tence. Unless we force ourselves as a medical profession to include spiritual and religious factors in our understanding and provision of mental health, we will tend to exclude it.

Myth 11.We know how to prevent mistakes in making spiritual/religious recommendations

Much of this paper has discussed the errors made out of omission of spiritual/ religious factors. Let us now brie y consider the errors of commission as well.We have already alluded to these in discussion of the APA statement regarding potential con icts regarding religious issues in myth 2. Perhaps re ection on and comparison to sexual boundary violations within psychiatric practice would be most useful in the context of this discussion (Coyle, 1999a; Howe, 1995). Most errors of commission are likened to boundary violations of a spiritual or religious sense.This analogy might be applied to not only the trainee relationship but to the clinical realm as well.This comparison is also appropriate in terms of the depth of potential damage that might occur in the application of spiritual factors and forces in training/ treatment. For example, one of the deepest emotions associated with sexual abuse

164 Brent R. Coyle

or exploitation is that of shame. In its essence, shame is associated with a funda- mental concept of unacceptability. A parallel spiritual conception would be that of ‘damnation’.Thus a disapproval or rejection of someone’s spirituality or religious practice suggests an unacceptable religious/spiritual nature that not only might be interpreted as a professional rejection but also infers a rejection/unacceptability to God (as the person understands that reality to be) by an authoritative Ž gure in the person’s life. The deeply religious individual might experience such a Godly rejection as equally or even more traumatic than the sexually exploited patient. While this may be exaggerating the point slightly for the average patient, the realm of core beliefs/values spiritually can be very vulnerable territory indeed.

The root of boundary violation concern within a training/treating relationship is found in the inequality of the partners.The authoritative or senior member of the relationship is in a position to potentially exploit the relationship because of imbalance of power.The situation then leads to potential undue in uence over the lesser member of the dyad. In a spiritual context this violation could be experienced in several ways.

Perhaps the most common is when the psychiatrist intentionally or inadver- tently forces some religious or spiritual belief on the trainee/patient. Usually this is manifest in the explicit or implied requirement to adopt a certain religious/ spiritual set of beliefs or worldview. This may be fueled by the supervision/ treating psychiatrist’s religious beliefs and convictions. For example, in the Christian worldview, the ‘great commission’ to fulŽ ll a missionary responsibility in ‘winning souls to Christ’ is a common challenge by religious leaders. It is not uncommon for such a challenge to be issued/applied to the work place.Thus, to ‘share Christ’ with those whom you associate at work is a spiritual opportunity.This rises to the level of ‘responsibility’ if one accepts the religious exclusivity common to most religious practice.Thus, failure to ‘share Christ’ or to strive for religious ‘conversion’ would be failing to potentially ‘save the soul’ of such an individual.These are weighty personal issues indeed for the devout supervising/treating psychiatrist.

These are the very issues however, that cause the greatest discomfort among opponents to inclusion of spiritual factors in training/practice.With equal conviction such concerned professionals assert that psychiatrists must have no role in asserting ultimate religious superiority.

Thus we are faced with a crucial question to ask ourselves repeatedly with our training/treating relationships. Are my words/actions intended to train/develop mental health or spiritual growth? If the latter, we have perhaps exceeded a boundary that should only be the territory of the religious leader. The devout practitioner’s personal missionary activities must be focused in other places or activities.

Even though unintended, occasionally the trainee/patient may experience an ‘a ha’ experience spiritually that might be likened to a ‘conversion’ experience or a significant shift to a transcendent perspective. Such experiences may well be profound and highly beneŽ cial. It would be expected that such an experience would be shared with their supervisor/treating psychiatrist. In the physician’s role to ‘Ž rst do no harm’, one must not be discouraging of such a transformation, yet, as

Religion and psychiatry 165

a psychiatrist, one must be careful of developing a personal agenda to have such experience happen on a regular basis. If so, it is likely to be related to some personal/countertransferential agenda as noted above.

Occasionally it may also be expected that a provider may be personally moved to a conviction that their own purpose/meaning in life lies in facilitating such conversions. If the psychiatrist reaches this conclusion, it is likely more ethical and professional to seek the required additional training and certiŽ cation necessary to fulŽ ll a religious leader role.

The distinction of teaching vs. facilitation of learning is a particularly relevant one in this discussion. Trainees and patients evolve through various stages of receptivity to these concepts. As educators and caretakers, we must be careful to not be either dismissive or overzealous of the other in their process and its own pace. Our fast-paced medical society may be out of tune with slower personal evolution.

Another common experience, unfortunately, is the inference that mental illness is due to some failure spiritually. This is a common notion among patients. One must be careful in education and patient care to minimize, even attempt to fully exclude, any suggestion of this association. While it may be true that repeated turning from and violations of perceived spiritual truths and guidance may have a negative emotional outcome (God given negative emotions?), mental health providers are best to recall the problem our psyche seems to have with processing negatives. Just as an admonition to not think about pink elephants immediately results in that very imagery, the psychiatrist is best to move trainees/clients toward positivity, e.g. love, acceptance, forgiveness, etc. rather than away from negativity, e.g. ‘sin’, ‘guilt’, etc.

Conclusions

Suggestions for avoiding ‘spiritual boundary violations’:

(1) Work toward universal spiritual themes and be inclusive (rather than toward “Bible studies”, etc. that are by deŽ nition exclusionary);

(2) Toward mental health (vs. spiritual health/spiritual conversion); (3) Toward positive aspects of mental health (vs. away from negative ones); (4) Attempt to stay in tune with trainee/patient’s pace of development (vs. being

dismissive or overzealous);

Myth 12. ‘The Ž eld of psychiatry can continue to ignore the in uence of spirituality in mental health’

Psychiatrists are, like other physicians, given a unique and vital role in our world. We are tasked with deŽ ning mental health and wellness for medicine and the world. One might argue that psychiatry has not done as well as it could in this regard.

166 Brent R. Coyle

Nevertheless, this remains our opportunity and our mandate. A failure to speak to these ultimate questions makes our profession inert, ineffective, impractical and lacking in credibility. Several points have been made in this paper for inclusion of spirituality in answering these ultimate questions.

Society ought to listen to medicine’s findings regarding health, so too, our profession’s answers should have societal impact. Medicine has always included variants of ‘life and death’ decisions.Thus psychiatrist’s question with regard to these discussions is ‘What gives us life/death emotionally and psychologically?’The wide spread interest and the adoption of spiritually sensitive inpatient and outpatient treatment is likely to continue as there is strong patient initiated support for these types of treatment. In addition, health care reform will continue to allow patients or employers to decide on what types of treatment they would like to purchase (Barsky, 1988). Finally with the inclusion of diagnostic categories and RRC guidelines mandating education as well as other educational mandates (AAMC, 1998) in culturally sensitive as well as spiritually sensitive treatments we are committed to educating our youth in new ways of thinking about and interacting with patients.

Conclusion

The seemingly natural occurrence and prevalence of various forms of spirituality in the global society further conŽ rms the importance and relevance of including spiritual factors in psychiatric care. Emotional and psychological care that excludes a spiritual dimension is incomplete and thereby inferior. Furthermore, the very credibility of our profession lies in how we will ultimately come to integrate spirituality into our understanding and treatment of the human psyche.

Summary and future directions

Despite a mandate from the Residency Review Committees for Psychiatry to teach residents about spiritual sensitivity as well as apparent widespread public interest for the incorporation of spirituality in mental health treatment, our Ž eld is Ž lled with misconceptions and false information regarding spirituality and mental health. For much of the population, spirituality plays a central role in their self- deŽ nition, life activities, coping and social support. In contrast, the mental health profession is a relatively non-religious or non-spiritual profession.This ‘gap’ has led to an under-representation in research and writing.The new RRC mandate to teach then Ž nds us in relative paucity of clear understanding of the interface of religion and spirituality with mental health or pathology. Careful study of the potential psychologically beneŽ cial aspects of traditional religious practice has been particu- larly lacking.The deŽ nitions of speciŽ c dangers of religiosity are also absent. Our profession faces a signiŽ cant number of patients who are spiritually con icted and who expect/wish for a spiritual component to their psychiatric care.We currently

Religion and psychiatry 167

must meet this challenge with relatively few resources to respond to this interest in an informed way.

How do we proceed? The wisdom of Socrates stems from the inquiry that follows from relative ignorance.There are many fundamental questions yet to be answered. What elements of religiosity or spirituality are psychologically helpful or harmful? On what are these opinions based? Which patients would like to have a spiritual component to their psychiatric care and how do we accurately pick them out? If patients wanted a spiritually sensitive approach to their care, what would that mean? What types of spiritual interventions would patients be interested in? What are the ethics of our profession responding to this interest? What types of preparation or certiŽ cation might be necessary in our Ž eld for responding to this need? What is ‘being too religious or spiritual’? Where is the point of imposing religious and spiritual beliefs vs. an obligation to recommend to patients what might be helpful for their mental health? Why are physicians and, particularly, psychiatrists less religious? Is it beneficial to be less religious? Why is the field so understudied? Why are the notions of the pathological nature of religiosity so Ž rmly held? What kinds of individuals might beneŽ t from different types of religions or spirituality? What keeps people who are participating in unhealthy religious activities persist in those activities? Are religious beliefs changeable? Do providers need to be religious or spiritual to respond to spiritual needs? These, and many other questions are the basis of our current understanding of this fascinating interface of knowledge and experience.

Conclusions

What we do know/where we are starting from at this point in the profession

(1) Psychiatrists are generally ‘outliers’ in their religious/spiritual beliefs. (2) The conclusions drawn by ‘outliers’ in matters of spirituality/religiosity must

be viewed with caution and carefully compared to the majority’s perceptions. (3) Psychiatrists come from an empirical/medical framework that constantly seeks

to exclude the transpersonal in explanation of human phenomena. (4) Much of the population psychiatrists serve comes from a ‘faith-based’

perspective. (5) Much of the population expects and wishes for inclusion of spiritual factors

in psychiatric treatment. (6) Psychiatrists know little absolute truth regarding either health/wellness or

illness/pathology and their correlation with religion/spirituality. (7) A vast amount of study and clariŽ cation of Ž ndings is required within the

profession. (8) Mental health outcomes in the context of religious/spiritual factors is crucial

in this study. (9) The profession should forcibly include members who wish to study the

interface in light of our tendency to exclude historically.

168 Brent R. Coyle

(10) Ultimate responsibility falls on the profession to deŽ ne mental health (just as other branches of the medical profession ultimately are the Ž nal authorities on a deŽ nition of health).

(11) Failure to speak about these ultimate questions of mental health makes our profession inert, ineffective, impractical, unhelpful and lacking in credibility.

(12) Our profession’s conclusions on these issues should ultimately play a primary role in the shaping of society.

(13) Mental health (or lack thereof) is inexorably linked with spirituality. (14) Psychiatrist’s beliefs are integral to the therapeutic process through the way

we see things, seek to heal and assess our effectiveness. (15) Psychiatrists will grow in understanding and competency through the mistakes

we make. (16) Psychiatric care without inclusion of spiritual dimensions is incomplete and

inferior.

Appendix

APA statement on religiosity

Psychiatrists should maintain respect for their patient’s beliefs. It is useful for clinicians to obtain information on the religious or ideologic

orientation and beliefs of their patients so that they may properly attend to them in the course of treatment.

If an unexpected con ict arises in relation to such beliefs, it should be handled with a concern for the patient’s vulnerability to the attitudes of the psychiatrist. Empathy for the patient’s sensibilities and particular beliefs is essential.

Interpretations that concern a patient’s beliefs should be made in a context of empathic respect for their value and meaning to the patients.

Psychiatrists should not impose their own religious, anti-religious or ideologic systems of belief on their patients nor substitute such beliefs or ritual for accepted diagnostic concepts or therapeutic practice.

No practitioner should force a speciŽ c religious, anti-religious or ideologic agenda on a patient, nor work to see that the patient adopts such an agenda.

Religious concepts or ritual should not be offered as a substitute for accepted diagnostic concepts or therapeutic practice.

Approved by APA Board of Trustees, December 1989 (American Psychiatric Association, 1990).

Religion and psychiatry 169

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