SECOND DRAFT               

Religion, Spirituality and Psychiatry: Crossing the Boundaries.

A Statement prepared by the WPA Section on Religion, Spirituality and Psychiatry.

Introduction

In the last decade, the clinical and research boundaries between religion, spirituality and psychiatry are being explored with renewed vigour. Recent advances in the brain science of the spirit (Fenwick, 2009), the greater influence of continental existential philosophy (Matthews, 2007), and the demand from user groups for a whole-person health service have facilitated these boundary crossings.

Globalisation, forced migration of political or economic refugees (Carta et al, 2005), increased awareness of the mental health causes and consequences of mass violence (Cox and Ghodse, 2007), the greater public health interest in ‘Wellbeing’, the search for ‘meaning’ and for a multi-faith religious philosophy of compassion (Armstrong, 2001; King, 2009), are other strands to consider.

This new situation is particularly challenging, however, for psychiatrists and other mental health professionals, especially in post-modern  ‘Western’ countries. After the closure of asylums with their conspicuous religious buildings, there has been a tendency  to neglect the religious dimension and existential  components of health care. Many doctors across the world instead have embraced a biomedical model of mental disorder and tended to devalue the art of medicine, the wisdom of the experienced clinician, as well as the therapy of a professional relationship (Montgomery, 2006).

It is within this challenging global situation that the World Psychiatric Association has decided to develop this  Position Statement on Religion, Spirituality and Psychiatry, prepared by the WPA Religion, Spirituality and Psychiatry Scientific Section.

International Perspectives

The World Health Organisation (WHO) had previously considered the inclusion of spiritual well-being in its definition of Health; but spirituality, existential well-being and religion has remained as a core domain of the WHO Quality of Life measures. The WHOQUOL-SRPB group (2006) recommended for example that greater attention to this domain will improve quality of life, particularly for those who report poor health or are at the end of their life.

The World Psychiatric Association (WPA) undergraduate and postgraduate curricula each included religion as a component of a contextual psychiatric assessment; and the WPA has also published International Guidelines for Diagnostic Assessment (IGDA), which articulated an integrative  approach to assessment by combining descriptive and narrative methods (Mezzich et al, 2003).  More recently, however, Musalek (2010) published in the WPA Bulletin a useful account of a Humanistic based medicine, which is closer to that advocated by Family Practitioners, such as Tournier (1986), and to Carl Rogers’ Person-Centered therapy. Okasha (1999) in a plenary lecture delivered at the  XIth World Congress of Psychiatry in Hamburg  had cogently pointed out the complexity of these tasks by emphasising that religion contained  so many unrelated variables that it cannot be considered as a uni- dimensional concept. A proposition illustrated by reference to both traditional (Islamic) and Western societies.

From an African perspective Van Staden (2006) emphasised the primacy of the person in psychiatry, and  regarded the biological, social and psychological sciences as ‘extricates’; Psychiatrists in East Africa (Sorketti et al, 2010) and South Asia (Bhugra, 2007) take for granted this  humanistic need to understand the religious and spiritual perspectives for effective work in the mental health field. In more secular individualistic countries, however, such as Sweden (De Marinis, 2003), inquiry about traditional or contemporary religious beliefs in a psychiatric assessment is commonly regarded as inappropriate, and as a possible intrusion of privacy.

Fulford et al (2010) has popularised Values-Based Medicine (VBM) as a pillar, together with factual scientific evidence, of sound medical practice. They regard religious and spiritual values as being a distinct value category that health care practitioners need to consider.

The Royal College of Psychiatrists’ Spirituality and Psychiatry Special Interest Group has recently published a multi-author book ‘Spirituality and Psychiatry’ (Cook, Powell and Sims, 2009) with chapters on suicide, psychosis and the assessment of spiritual needs, whilst Dein (2010) has included informative case histories of patients with religious delusions and possession states.

There are similarly active professional and User groups in the Netherlands, and particularly in the US where much research in this field is currently being carried out.  The International Journal of Mental Health, Religion and Culture regularly publishes scientific research in this field, and more recently the Journal of the Evaluation of Clinical Practice has articulated a conceptual challenge to a narrow reductionism in medicine and reliance on Evidence Based Medicine alone (Miles, 2009).

Definitions

Religion can be defined as systems of beliefs and practice related to the understanding of the Sacred and the Divine which are expressed in social institutions and communities. Spirituality, on the other hand, is a more universal dimension of human experience, which may be separate from religious practice and is often concerned with existential individual issues of meaning and purpose, and may relate also to a personal understanding of the Numinous.

Since religious belief and spiritual practice are both concerned with core beliefs, values and  sense of self,  an understanding of these dimensions is  important to the practice of much clinical psychiatry.

What are the mediating factors between Religion and Mental Disorder?

The pathways to explaining these connections and to facilitating boundary crossings between psychiatric practice and religious beliefs can be considered with reference to factors that are common to religion and mental disorder (e.g. genetic, biological, developmental, personality), and mediating factors, such as hope, compassion, confession and food prohibitions (Verhagen and Cox, 2010).

There is evidence of a beneficial effect of Spirituality / Religion on Mental Health (Koenig et al., 2012) but also evidence of a  harmful effect (Crowley and Jenkinson, 2009) and there is a need  for further  epidemiological  studies in all regions of the world.