David B. Larson, MD

This is the last of a series of articles discussing religious and spiritual issues in psychiatry. Part III ran in August

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As previously discussed, new research has made us look much more closely at the influence of religion and spirituality on overall health. Now more than 30 psychiatric residencies including Harvard, Baylor, and Georgetown provide focused training on addressing patients' religious/spiritual beliefs. The American Psychiatric Association's 1995 guidelines to respect and respond sensitively to patients' religious/spiritual beliefs considers the positive roles-not only the negative roles-that religion/spirituality might play in the treatment of mental illness.

Larson et al. (1998) summarized the work of more than 70 mental health, physical health, and neuroscience and addiction disorder researchers to review current findings and map out future directions. Their report stated: "The data from many of the studies conducted to date are both sufficiently robust and tantalizing to warrant continued and expanded clinical investigations."




The lack of religious/spiritual commitment stands out as a risk factor for drug abuse, according to past reviews of published studies. Benson (1992) reviewed nearly 40 studies documenting that people with stronger religious commitment are less likely to become involved in substance abuse.

This study supported a review by Gorsuch and Butler (1976) who found that lack of religious commitment was a predictor of drug abuse. The researchers wrote:

Whenever religion is used in analysis, it predicts those who have not used an illicit drug regardless of whether the religious variable is defined in terms of membership, active participation, religious upbringing or the meaningfulness of religion as viewed by the person himself.

Lorch and Hughes (1985), as cited by the National Institute for Healthcare Research (1999), surveyed almost 14,000 youths and found that the analysis of six measures of religious commitment and eight measures of substance abuse revealed religious commitment was linked with less drug abuse. The measure of "importance of religion" was the best predictor in indicating lack of substance abuse. The authors stated, "This implies that the controls operating here are deeply internalized values and norms rather thanfearor peer pressure."

Developing and drawing upon spiritual resources can also make a difference in improving drug treatment. For instance, 45% of participants in a religious treatment program for opium addiction were still drug-free one year later, compared to only 5% of participants in a nonreligious public health service hospital treatment program-a ninefold difference (Desmond and Maddux, 1981).

Confirming other studies showing reduced depression and substance abuse, a study of 1,900 female twins found significantly lower rates of major depression, smoking and alcohol abuse among those who were more religious (Kendler et al., 1997). Since these twins had similar genetic makeup, the potential effects of nurture versus nature stood out more clearly.




Religious/spiritual commitment also predicts fewer problems with alcohol (Hardesty and Kirby, 1995). Studies reveal that people lacking a strong religious commitment are more at risk to abuse alcohol (Gartner et al., 1991). Also, religious involvement tends to be low among people diagnosed for substance abuse treatment (Brizer, 1993). A study of the religious lives of alcoholics found that 89% of alcoholics had lost interest in religion during their teen-age years, whereas 48% among the community control group had increased interest in religion, and 32% had remained unchanged (Larson and Wilson, 1980). Alcoholics often report negative experiences with religion and hold concepts of God that are punitive, rather than loving and forgiving (Gorsuch, 1993).

Furthermore, a relationship between religious/spiritual commitment and the non-use or moderate use of alcohol has been documented. Amoateng and Bahr (1986) reported that, whether or not a religious tradition specifically proscribes alcohol use, those who are active in a religious group consumed substantially less alcohol than those who are not active.

Religion/spirituality is also often a strong force in recovery. Alcoholics Anonymous (AA) invokes a Higher Power to help alcoholics recover from addiction. Those who participate in AA are more likely to remain abstinent after inpatient or outpatient treatment (Montgomery et al., 1995).



Surging suicide rates plague the United States, especially among adolescents. One in seven deaths among those 15 to 19 years of age results from suicide. According to the National Center for Health Statistics, suicide rates in this age group have soared 400% from 1950 to 1990.

One study of 525 adolescents found that religious commitment significantly reduced risk of suicide (Stein et al., 1992). Adolescent suicide has also been linked to prior depression. Another study of adolescents found that frequent church-goers with high spiritual support had the lowest scores on the Beck Depression Inventory (Wright et al., 1993). High school students of either gender who attended church infrequently and had low spiritual support had the highest rates of depression, often at clinically significant levels.

How significantly might religious commitment prevent suicide? One early large-scale study found that people who did not attend church were four times more likely to kill themselves than were frequent church-goers (Comstock and Partridge, 1972). Stack (1983) found rates of church attendance predicted suicide rates more effectively than any other evaluated factor, including unemployment. He proposed several ways in which religion might help prevent suicide, including enhancing self-esteem through a belief that one is loved by God and improving moral accountability, which reduces the appeal of potentially self-destructive behavior.

Many psychiatric inpatients indicate that spiritual/religious beliefs and practices help them to cope. Lindgren and Coursey (1995) reported 83% of psychiatric patients felt that spiritual belief had a positive impact on their illness through the comfort it provided and the feelings of being cared for and not being alone it engendered.

Yet Kehoe and Gutheil (1994), evaluating suicide assessment instruments, recently observed, "Although religion is noted as a highly relevant factor in suicide literature, the number of religious items included on assessment scales approaches zero." They noted the need to recognize and include religion/spirituality in suicide prevention, treatment and care.




Psychiatry still needs more research and clearer hypotheses in differentiating between the supportive use of religion/spirituality in finding hope, meaning, and a sense of being valued and loved versus harmful beliefs that may manipulate or condemn.

For example, in assessing multiple personality disorder, Bowman (1989) described rigid religious families whose harsh parenting practices border on abuse. Children from these families harbored negative images of God. Josephson (1993) described individual psychopathology linked with families whose enmeshment, rigidity and emotional harshness were supported by enlisting spiritual precepts.

Sheehan and Kroll (1990) studied 52 seriously mentally ill hospitalized patients diagnosed with major depression, schizophrenia, manic episode, personality disorder and anxiety disorder. Almost one-fourth of them believed their sinful thoughts or acts may have contributed to the development of their illness. Without the psychiatrist inquiring about potential religious concerns, these beliefs would remain unaddressed, potentially hindering treatment until discovered and resolved. Collaboration with hospital chaplains or clergy may help in some of these instances of spiritual problems or distress.




Religious/spiritual commitment may enhance recovery from depression, serious mental or physical illness, and substance abuse; help curtail suicide; and reduce health risks. More longitudinal research with better multidimensional measures will help further clarify the roles of these factors and whether they are beneficial or harmful.



American Psychiatric Association (1995), American Psychiatric Association's guidelines regarding the possible conflict between psychiatrists' religious commitments and psychiatric practice. Am J Psychiatry 152(suppl 11):64-80.

Amoateng AY, Bahr SJ (1986), Religion, family, and adolescent drug use. Sociological Perspectives 29(1):53-76.

Benson P (1992), Religion and substance use. In: Religion and Mental Health, Schumaker JF, ed. New York: Oxford University Press, pp211-220.

Bowman ES (1989), Understanding and responding to religious material in the therapy of multiple personality disorder. Dissociation: Progress in the Dissociative Disorder 2:232-239.

Brizer DA (1993), Religiosity and drug abuse among psychiatric inpatients. Am J Drug Alcohol Abuse 19(3):337-345.

Comstock GW, Partridge KB (1972), Church attendance and health. J Chronic Dis 25(12):665-672.

Desmond DP, Maddux JF (1981), Religious programs and careers of chronic heroin users. Am J Drug Alcohol Abuse 8(1):71-83.

Gartner J, Larson DB, Allen G (1991), Religious commitment and mental health: a review of the empirical literature. Journal of Psychology and Theology 19(1):6-25.

Gorsuch RL (1993), Assessing spiritual values in Alcoholics Anonymous Research. In: Research on Alcoholics Anonymous: Opportunities and Alternatives, McCrady BS, Miller WR, eds. New Brunswick, N.J.: Rutgers Center of Alcohol Studies, pp301-318.

Gorsuch RL, Butler MC (1976), Initial drug abuse: a review of predisposing social psychological factors. Psychol Bull 83(1):120-137.

Hardesty PH, Kirby KM (1995), Relation between family religiousness and drug use within adolescent peer groups. Journal of Social Behavior and Personality 10(2):421-430.

Josephson AM (1993), The interactional problems of Christian families and their relationship to developmental psychopathology: implications for treatment. Journal of Psychology and Christianity 12(4):312-328.

Kehoe NC, Gutheil TG (1994), Neglect of religious issues in scale-based assessment of suicidal patients. Hosp Community Psychiatry 45(4):366-369.

Kendler KS, Gardner CO, Prescott CA (1997), Religion, psychopathology, and substance use and abuse; a multimeasure, genetic-epidemiologic study. Am J Psychiatry 154(3):322-329 [see comments].

Larson DB, Swyers JP, McCullough ME (1998), Scientific Research on Spirituality and Health: A Consensus Report. Rockville, Md.: National Institute for Healthcare Research.

Larson DB, Wilson WP (1980), Religious life of alcoholics. South Med J 73(6):723-727.

Lindgren KN, Coursey RD (1995), Spirituality and serious mental illness: a two-part study. Psychosocial Rehabilitation Journal 18(3):93-111.

Lorch BR, Hughes RL (1985), Religion and youth substance use. Journal of Religion and Health 24(3)197-208.

Montgomery HA, Miller WR, Tonigan JS (1995), Does Alcoholics Anonymous involvement predict treatment outcome? J Subst Abuse Treat 12(4):241-246.

National Institute for Healthcare Research (1999), Spirituality Helps Curb Substance Abuse. Available at: www.nihr.org/media2/99_march_substance.html. Accessed Dec. 17, 1999.

Sheehan W, Kroll J (1990), Psychiatric patients' belief in general health factors and sin as causes of illness. Am J Psychiatry 147(1):112-113.

Stack S (1983), The effect of religious commitment on suicide: a cross-national analysis. J Health Soc Behav 24(4):362-374.

Stein D, Witztum E, Brom D et al. (1992), The association between adolescents' attitudes toward suicide and their psychosocial background and suicidal tendencies. Adolescence 27(108):949-959.

Wright LS, Frost CJ, Wisecarver SJ (1993), Church attendance, meaningfulness of religion on, and depressive symptomatology among adolescents. Journal of Youth and Adolescence 22(5):559-568.



Articles

As previously discussed, new research has made us look much more closely at the influence of religion and spirituality on overall health. Now more than 30 psychiatric residencies including Harvard, Baylor, and Georgetown provide focused training on addressing patients' religious/spiritual beliefs.

David B. Larson, MD

Articles

The Once-Forgotten Factor in Psychiatry: Research Findings on Religious Commitment and Mental Health