There are many reasons why psychiatrists may be reluctant to address issues of spirituality/religiosity (S/R) with patients. It may be that they are generally less religious than the patient or they may be uncomfortable broaching this topic with patients. Historically, there has been conflict between psychiatry and religion. Some authors (eg, Freud) have referred to religion as an “illusion,” merely a neurotic defense against life’s vicissitudes.1 In addition, psychiatrists may feel uncomfortable being involved in a social/care network with roles that are not well defined between clinicians and clergy. However, the trend in favor of addressing S/R issues in psychiatric care is growing.2
Research shows that many patients lean on S/R both as a coping mechanism and as an explanatory model for their disorder.3,4 The consequences can be either positive or negative. This article addresses these 2 major ways S/R interacts with psychiatric disorders and describes spiritual assessment and clinical care.
Positive and negative S/R coping
Most psychiatric disorders can be understood using the stress-vulnerability model.5 The model uses the interplay of biological and psychosocial factors to determine the onset and course of the presenting disorder; that is where S/R coping comes into play. Indeed, a patient’s beliefs when facing a psychiatric disorder and its many difficulties can work as a positive or negative resource. Pargament6 suggested that religious coping serves 5 purposes:
• Spiritual (meaning, purpose, hope)
• Self-development (positive identity)
• Resolve (self-efficacy, comfort)
• Sharing (closeness, connectedness to a community)
• Restraint (helps keep emotions and behavior under control)
Positive S/R coping can help control symptoms (eg, “I always have a Bible with me. When I feel I am in danger, I read it and I feel I am protected. It helps me control my actions of violence”).7 Negative S/R can be expressed through “spiritual struggle.” Spiritual struggle can be intrapersonal or interpersonal, and/or it can be related to the patient’s representation of spiritual figures. Recent research has shown that S/R coping might be related to symptoms and outcome of mental disorders.8
After having been severely injured by a hit-and-run driver, Mrs S, a 45-year-old woman, presents with PTSD. She is a Catholic who had been deeply involved in her church before the accident. She feels guilty because she is unable to forgive the driver: she avoids going back to church and fears meeting her priest. This negative religious coping was addressed in psychotherapy.
The first line of treatment was cognitive restructuring, which allowed Mrs S to let go of her guilt by disentangling her behavior (she did not attempt to kill the driver) from her emotion (hate) and thoughts (of driver’s death). She was then able to reconnect to her religious community and to get spiritual and social support, which helped her recover (positive religious coping).
What new information does this article provide?
? Patients lean on spirituality/religiosity (S/R) both as a coping mechanism and as an explanatory model for their disorder(s). Religious coping can be positive or negative and serves many purposes, such as meaning, self-development, connectedness to a community, and restraint. Patients’ explanatory models can affect treatment adherence.
What are the implications for psychiatric practice?
? Psychiatrists should assess S/R. Spiritual assessment is likely to elicit important clinical issues in patients with psychiatric disorders.
An important issue concerning the interface between S/R and psychiatry involves patients’ explanatory models. Explanatory models are patients’ own understanding of their illness/disorder in terms of causes, characteristics, treatment, and outcome.9 Research shows that explanatory models that incorporate a spiritual vision of the illness are common in patients with psychosis as well as in patients with other disorders.10-12 Religion can be a way of coping by providing “meaning” (ie, both an explanatory model and a form of coping), which can be positive.13
Perhaps the most important clinical issue about explanatory models is their potential effect on treatment adherence. Indeed, in a study by Borras and colleagues 14 of religious beliefs in patients with schizophrenia, more than half may have representations of their illness and treatment directly influenced by their S/R beliefs—positively in 31% and negatively in 26%. Findings also indicate that more than a quarter of patients who were nonadherent or partially adherent thought that the treatment was not compatible with their beliefs.
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