LIBERTY UNIVERSITY JOHN W. RAWLINGS SCHOOL OF DIVINITY
The role of faith in mental healthcare: Philosophy, psychology and practice
A Paper Submitted to
the Faculty of the School of Divinity
in Candidacy for the Degree of
Doctor of Education in Christian Leadership (Ed. D) Department of Christian Leadership and
Church Ministries
By
Mary Gracias
Lynchburg, Virginia
6/2022
It is time to improve clinical approaches to faith in mental healthcare, particularly in
psychotherapy. Understood as a psychological trait, faith has potentially great personal salience
and introduces socially desirable biases into human reasoning. Therapies may have faith-
informed components, either explicitly, or (as with some forms of mindfulness) implicitly, which
may modify the patient's faith as well as producing symptomatic change.
In this narrative review, the ethics of faith's inclusion in therapy is briefly appraised. The
psychology of faith is discussed, and a model of the influence of the practitioner's faith on
therapeutic choice is presented. Finally, faith-informed approaches to practice, including their
impact on therapeutic effectiveness, are considered and recommendations made for their
optimal implementation.
Learning Objectives
1. • Understand the main types, characteristics and likely effectiveness of faith-informed
therapies versus their secular equivalents
2. • Develop a framework for effective assessment of the contribution of faith to a
patient's quality of life, and use this to balance the advantages and risks of employing a faith-
informed therapy
3. • Be aware of the unavoidability of bias in the assessment of faith, and learn how to
minimise this bias, if necessary by making a group decision
There is a need to improve current clinical approaches to faith in mental healthcare, in
particular the role of faith in the choice of psychological treatment provision (therapy). The
risks and problems of including faith in therapy have been extensively debated, and currently
the position is unresolved, with the possibility of professional censure if the wrong balance is
struck. Faith is a personal, emotionally charged issue. Conventional atheistic arguments that it is
necessarily unhelpful to promote biased and possibly false ideas in a therapeutic intervention
do not address faith's utility or salience. In this narrative review, we counter these arguments
and give recommendations on implementing faith-informed therapies in clinical practice.
Philosophical aspects of faith and therapy
The Oxford English Dictionary defines faith as confidence, reliance or trust in another
person or thing. Faith is also belief derived from testimony or authority, rather than empirical
evidence, and this includes believing in religious tenets as truths. Originally, use of the word
was exclusively religious, and that origin still colours its meaning. In the research literature,
‘faith’ is conflated with ‘spirituality’ or ‘religiosity’, particularly when discussing its behavioural
correlates. So, while it relates to the dimension whose poles are credulity and scepticism, it also
suggests a degree of awareness of something numinous, or possibly sacred, which both colours
and justifies beliefs held through it.
Despite its origins, faith is not now synonymous with religion, especially organised
religions, which combine faith with many types of reasoning, including empirical scientific
reasoning if the topic is deemed appropriate. Although many, if not all, societies have a deep-
seated belief that correct faith can promote healing, the justification of therapies by referring
to faith's foundations of belief, spiritual acceptance and authority are fundamentally opposed
to empirical scientific method as conventionally understood. Faith-based therapies therefore
require a philosophical justification applicable to both faith and science, if they are to be
employed within modern medicine: three such justifications are possible.
The first, that faith-informed therapies are justified by their demonstrated efficacy, is
discussed in detail below. However, this can only be a contingent justification for their
inclusion, and it reduces faith to a therapeutic characteristic, which does not capture its nature.
The second, that we should be guided by patient preference, including faith preference, is
currently the most generally accepted justification for them. However, we shall see that this is
not necessarily easy to implement for all faith-related ideas and beliefs, and it also redefines
faith in an inimical fashion, this time as merely something to satisfy patients’ wishes, albeit
there are separate ethical arguments for routine inclusion of such qualities to encompass
patient diversity.
A better alternative to these is the doctrine of double effect, that a single intervention may
have two (or more) consequences of varying desirability. This is most commonly discussed in
relation to end-of-life decisions. It is relevant here because a faith-informed approach might
improve the quality of treatment of the patient, but also either modify their faith, or require
the practitioner to adopt faith-informed values that are not shared, while non-therapeutic
aspects of faith might provide sufficient alternative benefit to compensate for a therapeutically
suboptimal treatment. The doctrine of double effect presumes that the intervention being
considered is beneficial in some way: it thus attaches an empirical qualifier to faith when
included in a treatment, rather than redefining the concept of faith away.
The psychology of faith
Since the late 19th century, the ‘lexical hypothesis’ has suggested that humanity's most
important individual differences might be encoded as single words, and analysis of such
descriptive words has enabled the construction of reliable and valid dimensions to account for
individual differences and underpin their variable expression: traits. Psychoanalysts have long
considered faith to be a trait. As a trait, it follows that its intensity in individuals is amenable to
study by questionnaire, and several well-validated questionnaires exist, although they largely
address faith from a Christian standpoint.
Consistent with this interpretation, faith has both genetic and environmental associations
which predict its expression in individuals, although methodological problems make its precise
function and significance hard to determine. I intend to rely on Hood's proposal that faith, as a
trait, has value because it introduces cognitive biases that contribute to social cohesion
(Reference HoodHood 2009). While some of this is a trivial implication of aspects of the
definition, such as reliance on authority, Hood has adduced psychological evidence to extend
this idea to our experience of the numinous and sacred aspects of faith.
This proposal subsumes the other major empirically based alternatives, threat avoidance
(Reference Miller and StarkMiller 2002) and power relationships (Reference Collett and
LizardoCollett 2009), as both theories presume that faith leads to a more cohesive society,
more tightly focused on achieving the intended goal. Psychological theories which focus on the
existential value of faith, rather than its social value, such as terror management theory
(Reference Vail, Rothschild and WeiseVail 2010), also explicitly include socially cohesive
psychological processes such as attachment. Convergent validation for this view has been
provided by social and ethological research (Reference Sosis and AlcortaSosis 2003), and a
‘sense of connectedness’ is central to spiritual experience (Reference de Jager Meezenbroek,
Garssen and van den Bergde Jager Meezenbroek 2012). As a trait which fosters social cohesion,
faith also requires a cultural context for proper expression, and is not captured by personality
traits alone. It seems likely that good social cohesion significantly improves the quality of our
lives, thus reinforcing and maintaining the faith we share with those around us.
From this approach to the components of faith and its consequences one can infer how the
resulting bias influences both practitioners’ and patients’ preferences for therapy, and might
compete with empirically based judgements. This is set out graphically in Fig. 1, which also
The explicit goal of the practitioner is to improve the patient's quality of life but, as the
arrows show, the practitioner will also be interested in the quality of their own life: not a bad
thing here, as a patient improving will provide professional satisfaction. The practitioner should
advise a therapy based on evidence (shown on the right of Fig. 1) but, like the patient, the
practitioner will have a trait for faith, which will bias the practitioner towards making
recommendations congruent with their own beliefs and their social network (shown inside and
to the left of Fig. 1). This bias would need to be inhibited in the practitioner (though not
normally in the patient), but practitioners are much less sensitive to their patients’ quality of
life (shown by the dashed arrow) than they are to symptom reduction.
The expression and moderation of faith-based bias affecting practitioner judgement and
practice
If the function of faith as a trait is to introduce biases that support social cohesion within
our culture, then fulfilling practitioners’ duty to respect their patients’ faith is not simple, or
easy to achieve. For example, inappropriate teleological reasoning (reasoning from assumed
intentionality: a key part of faith) may be readily induced even in those trained to avoid it
(Reference Kelemen, Rottman and SestonKelemen 2013). The ability to mentalise, a key skill for
practitioners, makes such biases more likely (Reference Banerjee and BloomBanerjee 2014).
The underlying risk may relate to individual differences in inhibitory capacity (Reference
Lindeman, Svedholm and RiekkiLindeman 2013), although this is moderated by cultural context
as well as theistic belief. It is therefore unsurprising that practitioners’ use of faith-informed
interventions is congruent with their beliefs, which also affect their theoretical orientation
(Reference Walker, Gorsuch and TanWalker 2004; Reference PotvinPotvin 2012). Practitioners’
religious beliefs are stronger than those of their teachers in relation to their personal and
professional lives (Reference Carlson, McGeorge and AndersonCarlson 2011).
Practitioners’ religious beliefs promote engagement with those of their patients,
particularly if congruent with their own (Reference Cummings, Ivan and CarsonCummings
2014), while training and experience within the context of a religious tradition increases the
likelihood of choosing interventions related to that context (Reference Walker, Gorsuch and
TanWalker 2008). Practitioners with strong faith-informed beliefs of any denomination are
therefore at risk of encouraging change in faith among patients to more closely confirm to their
own, even if formal conversion to the practitioner's faith does not occur: instead, the therapy
acts as a ‘gateway’ for the patient to acquire a new set of values congruent with those of the
practitioner. Consistent with this, patients practising mindfulness (in this context, a faith-
informed therapy, as discussed below) report increases in spirituality mediated by their practice
(Reference Labelle, Lawlor-Savage and CampbellLabelle 2015).
Overall, however, practitioners tend to be strongly secular in their beliefs, compared with
those they serve and, from the definition of faith this article prefers, secularism may behave as
another variety of faith. There is evidence for a propensity among more secular practitioners to
avoid or ignore religious issues in practice, despite advice and evidence that these may provide
a resource for at least some patients (Reference Cummings, Ivan and CarsonCummings 2014),
so committed secularists are as vulnerable to faith-informed biases as believers, although in the
direction of ignoring appropriate faith-informed practice instead.
Faith, social cohesion and quality of life
Health-related quality of life (HRQoL) is a term used to capture the overall (non-financial)
value of the impact of health changes on quality of life. It therefore includes faith-related issues
among other components that may not be culturally congruent between patients and
practitioners. This captures potential conflict between practitioners’ desire for social cohesion
within their professional groups and congruence of values with their patients.
Consistent with the accounts of practitioner faith discussed above, practitioners generally
find it hard to respond to patients’ self-assessments of their HRQoL, irrespective of discipline or
training, or to explore their patients’ spirituality even when professionally mandated to do so,
especially if less religious themselves (Reference GreenhalghGreenhalgh 2009; Reference
Frazier and HansenFrazier 2009).
This suggests that practitioners’ attachments to their own social groups’ beliefs about such
issues can withstand professionally mandated requirements to do otherwise, unless specifically
addressed. An approach to overcoming this is described later in this article, in the section
‘Delivering faith-informed therapies’. It is also consistent with other research on more general
outcome feedback, showing that practitioners’ attachments to their own evaluations (in this
model, a form of faith) moderated their responsiveness (Reference de Jager Meezenbroek,
Garssen and van den Bergde Jong 2012).
Moderating faith-based bias
Current systems of decision-making that integrate evidence and values stress the primacy
of patients’ values and recommend rationalist, secular reasoning strategies to optimise value
choice. Values-based practice (VBP) extends such ratiocination by emphasising the acquisition
of skills that enable practitioners to negotiate assessment and treatments with their patients
that include the latter's values and beliefs, as well as scientific evidence (Reference
FulfordFulford 2011).
The workbook developed for VBP recommends several behavioural strategies whose
benefit is consistent with the research just reviewed. Cultivating awareness of all values
relevant to a clinical decision, and refraining from individual selection of the ‘best’ value set
from the therapist's perspective, counters the drive towards social cohesion underpinning the
imperative salience of faith-informed judgements.
Taking time in careful reflection reduces the risk of teleological error (e.g. that it is
appropriate to offer mindfulness because it reduces suffering), and formulating decisions as
part of a sufficiently diverse group protects against perceptual bias, as does reliance on external
guidelines.
The ability to measure faith in patients, and its association with their well-being, as part of
routine outcome measurement, might help therapists to avoid unhelpful bias in faith-related
decisions. Despite the general insensitivity to HRQoL measures discussed above, there have
been promising results for oncology, where spiritual well-being scales have assisted in
clarification of different dimensions of faith and their association with more general well-being
and quality of life, including psychological well-being, and have generalised well across different
faith groups (Reference Bai and LazenbyBai 2015). However, this methodology is still in
development for mental healthcare.
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