This article begins by briefly reviewing the historical tension between religion and psychiatry. We then review the mental health benefits associated with religion and spirituality, followed by the negative aspects of religion and spirituality. We conclude by reviewing what this literature means for the assessment and treatment of psychiatric patients.
HISTORICAL TENSION BETWEEN RELIGION AND PSYCHIATRY
Historically, there has been notable disagreement and conflict between psychiatry and religion. As psychiatry was emerging as a discipline, religion was quickly labeled as problematic. In 1907, Sigmund Freud  described religion as a ‘universal obsessional neurosis’. Freud’s atheistic stance was widely adopted by the practitioners of psychoanalysis, further cementing psychiatry’s position as unfriendly to religion. At the same time, the medicalization of mental health alienated a number of clergy who perceived psychiatry as ‘anti-Christian’ or ‘dangerous’ . This antagonism between psychiatry and religion persisted through most of the 20th century, with some recent authors even suggesting that significant figures in religious history such as Abraham, Moses, Jesus, and Saint Paul may have suffered from psychosis .
In the last 30 years, however, American psychiatry has evolved toward a more positive and receptive stance toward religion and spirituality. This is due in part to an increased appreciation for the significance of patients’ culture, as well as increasing evidence that religion and spirituality can have salutary effects in mental health . As a sign of this increasing acceptance, in 2011 about 79% of U.S. medical schools offered some variation of spirituality in their curriculum, and 75% of those schools required medical students to take at least one course in spirituality .
POSITIVE ASPECTS OF RELIGION
Research has shown that religion and spirituality are generally associated with better mental health. Religion and spirituality tend to have a positive influence on patients’ overall quality of life [7,8]. Greater religion or spirituality has been associated with lower levels of depressive symptoms [9–11], fewer symptoms of posttraumatic stress , fewer eating disorder symptoms , fewer negative symptoms in schizophrenia , less perceived stress , lower risk of suicide , and less personality disorder . Additionally, a higher level of certainty in one’s belief system is associated with greater psychological health . Religion or spirituality has been shown to act as a protective factor with a positive effect on adherence to psychiatric treatment .
There is a negative relationship between religiousness and substance abuse . Among those recovering from substance abuse, higher levels of religion and spirituality are associated with a more optimistic life orientation, increased resilience to stress, greater perceived social support, and lower levels of anxiety . Religion and spirituality may also play a role in promoting an attitude that facilitates openness to change and compliance with treatment, particularly in the context of programs that draw heavily on Twelve-Step groups .
Positive religious coping
Religion is often used by patients as a positive means of coping with difficult situations . Positive religious coping methods (e.g., spiritual support, positive religious reframing of stressors, and spiritual connectedness) are significantly associated with and predictive of better mental health and psychological well being generally [20–22]. Specifically, positive religious coping correlates with reductions in depression and anxiety . The use of positive religious coping combined with religious condemnation of suicide may be protective against suicide . Positive religious coping is also associated with better social relations and mental health-related quality of life . Positive religious coping is a predictor of posttraumatic growth (the experience of positive change after trauma) following cardiac surgery  and among military veteran cancer survivors .
Community and support
Participation in a religious community is an important factor when considering the beneficial effects of religion and spirituality. Individuals suffering from mental illness appear to benefit from being surrounded by a supportive religious community [10,28]. Attending religious services regularly has been shown to protect against major depression , and is associated with decreased suicide attempts [30,31]. Greater frequency of religious attendance correlates with less distress after negative life events . For recovering alcoholics, religious or spiritual involvement appears to mediate a reduction in alcohol use by promoting negative beliefs about alcohol and providing social modeling . Increased religiosity in a community can buffer the community against psychological distress caused by a natural disaster .
Religious beliefs and practices may help people to better cope with stressful life circumstances and give them comfort, meaning, a sense of control, and hope . Religious involvement correlates with better mental health in the areas of suicide, depression, and substance abuse . Religious beliefs and practices are related to greater life satisfaction, positive affect and higher morale . Specifically, belief in God, but not religious affiliation, has been associated with better psychiatric treatment outcomes . Individuals with a positive and accepting image of God demonstrate fewer anxiety and depressive symptoms . Similarly, belief in a benevolent God is associated with less social anxiety, paranoia, obsession, and compulsion .
NEGATIVE ASPECTS OF RELIGION
There are negative aspects to religion and spirituality as well. People who manifest a greater extrinsic religious and spiritual orientation (i.e, use their religion for nonreligious or antireligious ends) report lower well being . For psychotic patients, incorporating religious and spiritual themes into their delusions may lead to greater conviction in delusional beliefs, greater severity of symptoms, and lower levels of functioning , as well as less compliance with psychiatric treatment [40,41]. There is also the risk that the idea of something ‘sacred’ may become attached to harmful things, such as tyrannical authority figures or drugs and alcohol .
Negative religious coping
Negative religious coping (also referred to as ‘religious struggle’ or ‘spiritual struggle’) tends to be associated with poorer mental health outcomes [22,28]. Spiritual struggles can be categorized under three types: divine, or difficulties and anger with God; interpersonal, or negative encounters with other believers; and intrapsychic, or internal religious guilt and doubt . Each type of spiritual struggle has been associated with psychological distress . Spiritual struggle is associated with greater depression [23, 25, 44–46] regardless of the patients’ general level of religiousness . Negative religious coping is associated with greater frequency and intensity of suicidal ideation , worse anxiety [23, 25, 44, 46], less well being [23, 44], increased distress [21, 27], more grief , and increased alcohol problems .
Miscommunication and misunderstanding
Increased religion or spirituality can also present increased opportunities for miscommunication and misunderstanding in the mental health setting.
Religious and spiritual beliefs influence medical decision-making and may conflict with medical advice . For example, activity of faith is associated with a greater frequency of doctor’s advice conflicting with that of a spiritual leader . Religious affiliation can also be associated with delays in seeking treatment for mental illness .
Misunderstanding about mental illness may also be present in the interactions among religious group members. Some members of the African-American lay community reported a belief that schizophrenia is caused by possession by evil spirits or punishment by God . It has been documented that patients presenting with religious delusions receive less support from their religious communities . Negative interpersonal interaction within a religious context has also been linked with greater levels of depressive symptoms .
Individuals with negative or punitive images of God report higher symptoms of depression, anxiety, paranoia, obsession, and compulsion [37,38]. These negative images of God can turn religion from a potential resource into a source of spiritual struggle . For some individuals, religious beliefs may increase guilt or lead to discouragement as they fail to live up to the standards of their faith tradition . Doubts about religious teachings or beliefs, although common, may give rise to emotional distress, including depression and anxiety . For some, religion plays a role in incentivizing suicide. Some patients wish to die in order to be with God or to live another life after death. Others attempt suicide after a break with a religious community or because of delusions and hallucinations with religious content .
CONSIDERATIONS FOR PSYCHIATRIC PRACTICE
Religion and spirituality are part of the cultural context in which mental illness occurs. Assessing religiosity or spirituality is essential in order to achieve an understanding of the whole person, including their needs and struggles. However, mental health clinicians need to consider their own inherent religious biases and how they may result in the minimizing or pathologizing of a patient’s religiosity or spirituality. Clinicians would benefit from learning about different religious and spiritual traditions and asking about patients’ religious ideals, practices, and faith communities in order to better understand the nuanced differences between religion and disease . A clinical framework informed on religion and spirituality allows the providers to be open to their patients’ sacred experiences. This can promote more positive self-representation andimprove the patient– provider relationship, simultaneously removing the distractions that arise if a provider’s focus is impaired by his or her belief or unbelief in the reality of these experiences .
Although not all clinicians have to incorporate religious and spiritual experiences in their practice, all should have the capacity to provide spiritually conscious care and maintain a respectful interest in their patients’ religiosity or spirituality . Religion influences how patients select, pursue, and organize their goals . To aid in compliance and better understand their patients, practitioners should take time to explore their concepts of illness and attempt a reconciliation with their patients’ religious views. This then allows for the opportunity for religion and spirituality to be brought into clinical management in ways that are not threatening or disturbing for the patient . It is essential to provide a safe space for patients to express and explore their feelings, including anger toward God .
In addition to the potential benefits for patients, the incorporation of religion and spirituality in mental healthcare could potentially prove a boon to providers struggling to maintain hope in their own work with despairing clients. This may be accomplished by focusing on the sacred aspects of their work and their patients’ lives .
One suggestion has been to expand the biopsychosocial model of conceptualizing patients to include a spiritual dimension. The goal of this expansion would be to help providers in the recognition of spiritual issues in their patients, and raise awareness of spiritual resources that are available to support their patients . The first step in assessing a patient’s religion or spirituality is taking a religious / spiritual history [1,50]. Taking a spiritual history may enhance trust in the doctor–patient relationship . In conducting religious and spiritual assessments, providers should focus on strengthening the therapeutic alliance, using natural conversation, being flexible, and having a patient-centered approach . Instruments have been developed for taking a religious/spiritual history, including FICA, SPIRITual History, FAITH, HOPE, and Royal College of Psychiatrists instruments . These tools or other screening protocols may help with the early identification of patients experiencing religious or spiritual struggle, a common problem among hospitalized patients . Early identification of patients with spiritual struggle would ideally help facilitate their referral for further assessment and appropriate intervention. Although some screens are being tested, further research is needed to identify the best means of screening patients for spiritual struggle [61
Any incorporation of religion and spirituality into psychiatric treatment should coalesce with patients’ values and enhance treatment gains . Some programs have already been developed that incorporate spirituality into mental health treatment. Those who participated in one such program reported an increase in practicing forgiveness, gratitude, compassion, and acceptance in their daily lives, along with reduced negative thinking patterns, reduced ego-centricity, being less judgmental, and improved self-esteem. Participants also reported improved mood, reduced symptoms of anxiety and depression, calmness, mental clarity, and improved relationships . A nondenominational spiritually based intervention pilot study showed greater efficacy compared with a control group in improving the symptoms of generalized anxiety disorder (GAD) .
Another spiritually integrated group treatment for military trauma survivors showed reductions in post-traumatic stress disorder (PTSD) symptoms . Realizing the potential for these interventions, in 2012 the Los Angeles County Department of Mental Health introduced a policy addressing spirituality. After disseminating this policy, more than 98% of the wellness and recovery centers in Los Angeles offered options for spirituality-infused activities, and one-third offered spirituality focus groups .
Trials have shown benefits of psychotherapies that incorporate religion and spirituality. Christian cognitive-behavioral therapy (CBT) was found to be superior to conventional CBT, and Muslim based psychotherapy for bereavement, depression, and generalized anxiety disorder all demonstrated significantly better results when prayer and reading the Quran was added to therapy . The use of religious texts such as the Bible in therapy may be useful in helping individuals with religious doubts . Mindfulness interventions may be enhanced by an emphasis on spiritual components, and focusing on the spiritual aspects of mindfulness practice has the potential to deepen its benefits . Religiously incorporated treatment has shown not only better improvements in areas such as stress and worry, but is also associated with greater patient satisfaction . Some treatments have also shown promise in working with people experiencing religious or spiritual struggles . Complex spiritual suffering or difficulties can be referred to a religious or spiritual counselor, pastor, or other faith leader . However, some data show that even when physicians are willing to refer patients to religious mental health providers, they may not be knowledgeable about local religious providers. Physicians also tend to be less willing to refer a patient to a religiously based practitioner for the treatment of depression and anxiety compared with a faith-based alcohol treatment .
Although research examining religion and spirituality and mental health generally indicates positive associations, there are also potentially negative aspects to religion and spirituality. As our understanding of the relationship between religion and spirituality and mental health continues to grow, there is a need for more sophisticated methodology, greater discrimination between differing cultures and traditions, and increased focus on the situated experiences of individuals belonging to particular traditions . Much of the current research on religion and spirituality focuses on Christianity. Although trials are underway examining the use of CBT in multiple faith traditions, including Christianity, Buddhist, Hinduism, Islam, and Judaism [67,73], increased attention to differing religious frameworks beyond Christianity are in need of greater scientific scrutiny . Future research is also needed to investigate how providers’ own religious and spiritual values interact with those of their patients, and whether congruency in religious and spiritual values impacts treatment efficacy . Although research exploring the mental health of religious believers is blossoming, increased attention needs to be paid to those who choose the path of nonbelief (agnostics and atheists) . With increased attention to these important matters, it is our hope that patients and practitioners in mental health will benefit.
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