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Spirituality and Psychiatry

Dinesh Bhugra*1 Thomas R Osbourne2

*1PO Box 25, HSRD, Institute of Psychiatry, De Crespigny Park, London SE5 8AF. Email : d.bhugra@iop.kcl.ac.uk2PO Box HSRD, Institute of Psychiatry De Crespigny Park, London SE5 8AF*Corresponding Author

GUEST EDITORIAL Indian Journal of Psychiatry, 2004, 46(I)5-6

Introduction

Often religion and spirituality are used interchangeably.Spirituality may or may not include religion, which is relatedto an organized institution. Spirituality on the other hand isthe transcendent relationship between the person and ahigher being, a quality that goes beyond a specific religiousapplication (Peterson & Nelson 1989). Both religion andspirituality offer a sense of meaning and purpose in life andhelp keep believers in relationship to the unknown andunknowable (Lukoff et al 1995).

Why should psychiatrists be interested in spiritual valuesand religious lives of their patients? First and foremost, it isessential to know what values are forming the individual’sbeing and this moves the biopsychosocial model of aetiologyand further management. The discrepancy between theWestern Cartesian models of mind body dichotomy andthe Ayurvedic models where mind body environment andeven seasons are interlinked together needs to be understoodif the clinicians wish their patients to work with them. Sucha mind- body dualism has led to various academics to allegethat somatization is somehow an inferior way of expressingdistress. Secondly the role of religion and spirituality indeveloping models of locus of control has to be understood.If the locus of control for a psychiatric condition is seen asexternal, the individual (patient) is not blamed and theacceptance of distress may well be easier. Thirdly, culturalpsychiatry embraces aspects of social and cultural identityof individuals that are then related to the development andmanagement of distress. Although religion has been seenas opium for the masses by Karl Marx and as universalobsessional neurosis by Freud behaviourists, cognitivebehaviour therapists and others have often ignored thisimpatient aspect in the lives of many of our patients.

Relationship between Psychiatry and Spirituality

The negative view of religion and spirituality held by somepsychiatrists is based on a number of factors. A key factoris seeing religion as primitive, untestable, unverifiable andunscientific especially when psychiatry has been strugglingto establish itself as a scientific discipline, which can proveor disprove hypotheses. Psychiatry has chosen to ignore

religion as a possible source of strength and well-being andinstead focus is on its obsessionality. Religion and spiritualityhave been seen as pathological especially when thepresence of religious and spritual feelings has beenconstrued as abnormal. Patients in view of their religiousand spiritual feelings may try and hide these because theyfeel a lack of sympathy and opprobrium from the clinicians.Furthermore, psychiatrists and other mental healthprofessionals are not trained to deal with the religious andspiritual issues because they feel that they may be workingoutside the limits of their capability. Lukoff et al (1995)proposed a new diagnostic category – psycho-religious orpsychospiritual problems which was accepted by the taskforce on DSM – IV as Religious or Spiritual Problems whichdefines these as …” The category can be used when thefocus of clinical attention is a religious or spiritual problem.Examples include distressing experiences that involve lossor questioning of faith, problems associated with conversionto new faith….” One of the key problems with such anapproach is medicalization of what could be construed as“normal” loss of faith or questioning. There is evidence inthe literature to indicate that some patients with psychosisespecially in the prodromal period may seek to change theirfaith either to find stability or start afresh with a new groupof acquaintance (Bhugra, 2002).

Role of Culture and Spirituality

Culture provides a set of meanings and beliefs which givemeaning to the way an individual functions and alsoincorporates religious beliefs and religious rituals. Thecultural identity of the individual incorporates their religiousand spiritual beliefs. The worldview of individuals willinclude religious and spiritual beliefs and it has been notedthat if the therapist and the patients’ worldview diverge toosignificantly then the engagement for therapy andtherapeutic adherence are likely to be affected. Therelationship between the individual’s religious beliefs mayinfluence the way the patients and their carers approachtreatment. The interaction between culture and spiritualityis also at multiple levels and patients may have culturalvalues without religious or spiritual values. Culturedetermines psychopathology and patients therefore may

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present with symptoms, which are understandable only inthe context of the individual’s culture and religion. Religionand spiritual values influence mental health and beliefs aboutmental illness and its treatment will be affected by religiousand spiritual values e.g. some religious groups will refuseto take capsules made from gelatine. The types of religiousproblems, the clinicians may come across are loss orquestioning of faith, conversion to a new religion,intensification of adherence to beliefs and practices andjoining new religious movements and cults. The spiritualproblems may include possession or trance states, mysticalexperiences, near death experiences and spiritualemergencies. Using meditation and yoga, as reflections ofspiritual goal attainment have become commonplace andagain the clinician must take the intensity of these proceduresinto account. Obsessive-compulsive rituals may from partof spiritual reawakening.

How to assess spirituality

Religious history which includes the faith patient follows,rites and rituals they perform, religious taboos either in dietor dress they follow will give a good start for the clinicianto explore. Good mental health may well be associatedwith social support, religious ideas, feelings, experiences,orientation and worldview and any assessment must includesome of these. Both medicine (and its practice) and religionhave common values of humanitarian and moral purpose.Science without religion can be destructive and religionwithout science can become superstition (Feibelman 1096).A clear cooperation and assessment of individual’s needsis essential in ministering to the total need of the personand any assessment therefore must focus on the holisticapproach.

In differentiating psychopathology from normal religious andspiritual beliefs Greenberg and Witzum (1991) haveproposed that psychotic episodes are more intense thannormative religious experiences, are often terrifying andpreoccupying for the individual, contain special messagesfrom significant religious figures and are accompanied by

deterioration in social functioning.

The clinician’s response to these experiences can determinewhether the experience is integrated and used as a stimulusfor personal growth or whether it is used as a repressionphenomenon indicating mental instability. The clinicianscan use these phenomena in positive manner in discussionwith religious leaders to involve the patients and theirrelatives into treatment strategies. Lukoff (1985) suggeststhat good pre-psychotic functioning; acute onset of symptomstressful precipitants and positive exploratory attitudestowards the experience will enable the clinician todifferentiate behaviour psychotic episodes and religiousexperiences.

Conclusions

There is no doubt that some patients will follow their religiousand spiritual beliefs and it is essential that the psychiatristsare honest and open about discussing these with theirpatients to determine the extent of their beliefs anddifferentiate these from psychopathology. In addition, thepatients must be given every opportunity to explain theirbeliefs without being blamed or stigmatised. The role ofreligion in individual’s cultural identity must be taken intoaccount when ascertaining mental state and formulatingmanagement strategies. To this end getting away fromsimplistic mind-body dualism will allow the clinicians to planand offer a holistic management, which may be moreacceptable to their patients and carers.

REFERENCES

Bhugra D (2002): Self concept: Attraction of extreme beliefs and newreligious movements. Mental Health Religion & Culture. 5, 239-252.

Feibelman J (1963): Men of God and Science. Journal of the MississippiState Medical Association 15, 29-39.

Greenberg D & Witzum E. (1991): Problems in the treatment of religiouspatients. American Journal of Psychotherapy 45, 554.

Lukoff D., Lu FG & Turner R (1995): Cultural considerations in theassessment and treatment of religious and spiritual problems. PsychiatricClinics of North America 18, 467-486

Peterson E & Nelson K (1987): How to meet your clients Spiritual needs?Journal of Psychosocial Nursing 25, 34

Dinesh Bhugra & Thomas R Osbourne