Religion and Spirituality in Psychiatry and Mental Health: Clinical Considerations

SPECIAL REPORT: LIFESTYLE PSYCHIATRY

Care for individuals with severe mental illness was historically largely institutionalized in faith-based settings. Yet, modern psychiatry ("medicine of the soul") often viewed religion and spirituality (R/S) with skepticism and even hostility, which corresponded with the suspiciousness of modern psychiatry within religions.¹ Although a loss of public faith has challenged both religion and psychiatry, we are seeing a growing realization of their mutually enriching relationship, and research is increasingly showing strong and consistent positive effects of R/S beliefs and practice in overall mental well-being and in particular mental health conditions.^2,3

Although psychiatrists, especially in the United States, have traditionally been particularly secular, they need to care for the large proportion of patients for whom R/S is important and handle their mental health and engagement with care.^4,5 The World Psychiatric Association and the American Psychiatric Association have recognized the crucial role of R/S and the need to incorporate those dimensions in psychiatric training and patient care.^6,7 Religious communities are increasingly attuned to the mental health needs of their members and open to collaborations with professionals. Definitely, the field of interaction between R/S, psychiatry, and mental health is ripe for impactful research and innovation in the care for patients and communities, or, using words from Jesus Christ in the Bible, "white for harvest" (John 4:35).

This article aims to provide clinicians with an overview of how R/S often intersect with the mental health of their patients, informing and improving their assessment and care. Although there is a growing proportion of people identifying as spiritual but not religious, R/S substantially overlap in theory and are often indistinguishably blended in the lives of most individuals. Given this reality, this article will follow the approach of research and literature on the topic, which often deals with R/S together, noting instances of practical distinction.^2,8,9

Case Vignettes

The following fictional vignettes illustrate the role of R/S in the psychopathology, coping, and management of individuals from diverse religious and spiritual backgrounds in the US.

Vignette 1: Ms Perez

“Ms Perez” is a 26-year-old South American Catholic woman who recently immigrated with her toddler. She struggles with traumatic memories, sadness, and scrupulosity, and she has a precarious financial situation. Some of her first experiences with older members at her new parish made her feel unwelcome and stigmatized, yet she finds relief in talking frequently to the priest. The priest notices an unhealthy obsessive pattern and the history of trauma and encourages her to check in with the parish mental health ministry. The ministry offers her the opportunity to join a spiritual support group for immigrant women at the parish and connects her with professional counseling, delivered by a community lay provider at the parish offices, as well as with an external psychiatrist for specialized assessment and care. Alongside those services, she continues to receive regular spiritual direction and confession from the priest. She participates in the social and worship activities of the parish's young adult group, where she feels accepted, forgiven, supported, and loved by God and the community.

Vignette 2: Mr Elmi

“Mr Elmi” is a 38-year-old Muslim man born to immigrants from the Middle East who had fled a very violent war. Since his early twenties, he has struggled with severe mood swings. Although his condition has had a significant impact on his academic and professional performance and often damaged his marriage, he has never received care due to the reluctance of his family to publicly expose his situation and their lack of trust in Western psychiatry. His parents have also attributed his afflictions to the influence of evil spirits that are punishing their son for abandoning their country of origin. After his condition can no longer be hidden from their wider religious community in their neighborhood, a Muslim psychiatrist and an Imam offer to collaborate in his care, integrating mental health care for his finally diagnosed bipolar disorder with faith-based accompaniment in prayer and understanding of his religious heritage and the impact of trauma on his parents. His marked improvement after these interventions are in place is appreciated by his family, who progressively gain an understanding of the problem, develop more supportive attitudes, and feel at peace, finally relieved from the evil spirits.

Vignette 3: Ms Cohen

“Ms Cohen” is a 75-year-old, widowed, and retired Jewish American woman. Since her young adult years, she has not been particularly religious or spiritual, yet she has fondly endorsed the core ethical values instilled in her by her parents. She has been struggling with complex, prolonged grief since the death of her husband, with whom she had been married for more than 3 decades. After she started interpersonal therapy, marked improvements in her daily functioning led to her being motivated to dedicate the last stage of her life to flourishing. She has found how other widows endure their grief with the support of faith and spiritual and transcendental meaning and practices. She is eager to revisit some of the traditions from her parents and her youth and considers incorporating other practices from other traditions, such as yoga, mindfulness, and meditation, in an eclectic fashion. She asks her therapist whether those might mingle well with therapy and help her further gain peace and flourishing in her grief, as well as a healing connection with her deceased husband.

Vignette 4: Mr Harris

“Mr Harris” is a 49-year-old African American Baptist Christian man who is divorced. Since a young age, he has suffered from recurrent depression and alcohol use disorder, which started after the death of his mother and worsened after an accident that left him in chronic pain. He has never consistently engaged in psychotherapy, motivational interviewing, or pharmacological treatment due to his sense of a lack of rapport with providers and a health care system insensitive to his sociocultural background and racial experiences. His increased financial instability and alcohol dependence, alongside his loss of faith and religious practice, have brought him to a point of intense and concrete suicidal ideation. When he discloses his despair while getting a haircut, his barber, who is trained in the recognition of mental health signs through a community-partnering local program, encourages him to seek help at a Black church. Though initially skeptical, he progressively finds himself at home among his peers. He engages with and benefits from counseling at the church-affiliated clinic, joins the church's 12-step group, resumes Sunday worship, and becomes a peer advocate and counselor. Although still with chronic pain and frequent cravings for alcohol, he is at peace in the conviction that Jesus saves him and has spared his life to be a witness to the healing of faith and a supporter of peers who are in despair.

As reflected in the vignettes above, R/S offers, for many individuals, resources for meaning, community, and integrative mental health care for the whole person. R/S has the potential to blend well with professional mental health care and promote long-term healing. Community-based resources and partnerships help promote access to culturally sensitive care, especially for underserved populations, including ethnic minority and migrant groups. The following sections of the article will describe the scientific and conceptual bases, as well as the practical applications, for psychiatrists and mental health professionals to better care for their patients, many of whom embody stories similar to those illustrated in the vignettes.

Research, Practice, Conceptual Models, and Challenges

A growing body of research, which includes large longitudinal cohorts examining outcomes for individuals who report varying degrees of importance given to R/S and actual participation, has shown consistent and strong positive effects on life satisfaction, general physical health, and certain mental health conditions.^9,10 Solid protective effects have been demonstrated in depression, suicidality, and substance use, with more mixed or inconclusive indications for anxiety, obsessive-compulsive disorders, psychosis, and other disorders; there is some evidence for possible limited or negative effects in specific populations.^3,9 Positive effects have been seen for the specific dimension of frequent participation in religious worship, to the point that it has been suggested that there is a causal relationship, and that approximately 40% of the increased incidence in suicide in the US between 1999 and 2014 could be attributed to a decline in religious attendance.¹⁰ In addition, spiritual practices from Eastern religious traditions, such as yoga and mindfulness, which are nowadays common secularized practices in the West, have shown health benefits and are integrated in some evidence-based therapies.⁹ Growing implementation research is exploring the feasibility and potential of collaborations between the mental health sector and faith-based organizations to support, in particular, underserved communities.¹¹

Less is known about the mechanisms of these effects. Some of the biggest challenges in religion, spirituality, and health research are the theoretical difficulty and perhaps practical impossibility of discerning the "active ingredients" (more likely, patterns) that drive the effects and their mechanisms of action. The question also remains whether the mental health benefits of R/S can be obtained through removing or bypassing faith and institutional foundations of certain practices, such as in secular and New Age syncretic meditation, artificial intelligence, technology, or psychedelics.¹² In general, positive effects are driven by the strong and enduring grounding and coping power of R/S's core values (such as compassion and forgiveness), the healthy lifestyles and respect for one’s life that those promote, and the social support and compassion of faith-based communities. Negative effects stem from sometimes seen aspects such as scrupulosity, intolerant hatred, and individualism, along with stigma and discrimination within communities, all of which are often misrepresentations of religions.¹³

From a biopsychosocial lens, the field of neurotheology is emerging as the study of the brain correlates with R/S values and practices, while acknowledging highly complex intraindividual and interpersonal human dimensions.¹⁴ R/S intersect with general and physical health in multiple and synergistic effects through the biopsychosocial model, to the point that an integrative biopsychosocial-spiritual paradigm would see spirituality not as a dimension that is parallel and overlapping with the others, but rather permeating and integrating them all.¹⁵ A deeper understanding of such interactions requires a dive into philosophy and theology, with integrative models such as the Catholic Christian Meta-Model of the Person that confront the reductionisms of the dualistic, materialistic paradigms in secular neuroscience and psychiatry.¹⁶

In the realm of routine clinical practice of mental health professionals and in public health, all of the cited research and explanatory or conceptual models translate to the fact that R/S often present as part of the psychopathology or coping and supportive resources of patients. Patients’ R/S beliefs and practices often influence their explanations of disease, their attitudes toward treatment, and their help-seeking behaviors, representing opportunities for more comprehensive clinical assessments and holistic, sustainable treatment interventions.

Recommendations for Clinical Assessment and Interventions

Given patients’ needs and opportunities of R/S in their mental health, clinicians are called to routinely incorporate R/S into assessments and interventions in an environment of cultural humility, and to foster collaborations with faith-based organizations and leaders through frameworks such as Community Outreach and Professional Engagement (COPE) to further support patients and communities.¹⁷

The DSM-5-TR Cultural Formulation Interview (CFI), with its supplementary module Spirituality, Religion, and Moral Traditions, includes guidance for an exploration of the patient's spiritual, religious, and moral identity and the role of those in the patient's life and mental health issues, noting their potential as coping resources and as sources of stress and conflict.¹³ Apart from assessment, CFI can support treatment by helping build culturally sensitive rapport and engagement with patients and identifying aspects of the R/S lives of patients that might cultivate beneficial aspects and address the negative.

Lifestyle psychiatry focuses on habits and behaviors that strongly positively or negatively affect mental and overall health. It empowers patients to take the lead in their recovery and health maintenance journeys through their daily actions beyond clinician-provided treatments. The model supported by the APA includes R/S within connectedness, 1 of the 6 pillars of lifestyle psychiatry.^18,19 Although the dimensions of lifestyle are interconnected, R/S especially intersect connectedness and all lifestyle pillars, as, for instance, major traditions emphasize temperance in eating and occasional fasting, cultivation of interior peace, a balanced life of activity and rest, and avoidance of harmful substances.¹⁸ Lifestyle psychiatry can also be a valuable practical framework for informing assessment and treatment and for engaging patients in the integration of their faith, values, and practices into the cultivation of physically and mentally healthy habits (Table).

Concluding Thoughts

The often seen as parallel and conflicting realms of religion, spirituality, psychiatry, and mental health are recently converging due to mutual need and in light of robust research on their strong and generally beneficial associations. R/S practices and communities are showing as valuable assets for patients and promising avenues for their clinicians to better understand and serve them. Clinicians will benefit from learning with research and explanatory and practical frameworks; they should incorporate universal and as-needed R/S assessments and interventions into their practices.

R/S, psychiatry, and mental health can and should better understand one another. We should partner to synergize them to respond to the global syndemic crisis of mental health and other threats to human health, societies, and ecology, with both empirical evidence and supernatural hope.

Dr Pereira-Sanchez is a child, adolescent, and adult psychiatrist from Spain, and a New Yorker since 2019. He is dedicated to local and global mental health, with leading involvement in pioneering and award-winning efforts to improve mental health, especially for underserved populations. He’s currently a global mental health and implementation science research fellow at Columbia University, where he is coleading multilateral partnerships between mental health, academic, government, and nonprofit sectors with local Catholic churches in underserved Hispanic neighborhoods in New York, New York, including his parish.

Acknowledgements

The author thanks his colleague and friend, Djibril Moussa, for his clinical insights and feedback in the conception and crafting of the case vignettes. The author is also very grateful to the National Institutes of Health, Columbia University, and Milton Wainberg and Connie Svob for their support for his current postdoctoral research training. A final word of thanks to religious leaders and communities that support the mental health of their members all over the world, and in particular, the colleagues at the Church of St Elizabeth and the International Association of Catholic Mental Health Ministers.

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