Sie sind auf Seite 1von 19

http://tps.sagepub.

com
Transcultural Psychiatry
DOI: 10.1177/1363461506070788
2006; 43; 634 TRANSCULT PSYCHIATRY
James K. Boehnlein
Ahead
Religion and Spirituality in Psychiatric Care: Looking Back, Looking
http://tps.sagepub.com/cgi/content/abstract/43/4/634
The online version of this article can be found at:
Published by:
http://www.sagepublications.com
can be found at: Transcultural Psychiatry Additional services and information for
http://tps.sagepub.com/cgi/alerts Email Alerts:
http://tps.sagepub.com/subscriptions Subscriptions:
http://www.sagepub.com/journalsReprints.nav Reprints:
http://www.sagepub.co.uk/journalsPermissions.nav Permissions:
http://tps.sagepub.com/cgi/content/refs/43/4/634 Citations
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
Religion and Spirituality in Psychiatric Care:
Looking Back, Looking Ahead
JAMES K. BOEHNLEIN
Oregon Health and Science University
Abstract Cultural psychiatry has been an important contributor to the
enhanced dialogue between psychiatry and religion in the past couple of
decades. During this time, religion and spirituality have become more
prominent in mainstream psychiatry in a number of areas of study and
clinical care, including refugee and immigrant health, trauma and loss,
psychotherapy, collaboration with clergy, bioethics, and psychiatric
research. In looking towards the future, there is a great deal of promise for
future enhancement of the study of religion and spirituality in psychiatric
education, research, and clinical care.
Key words psychiatry religion religious studies spirituality
For most of the 20th century there was a great deal of tension between
psychiatry and religion, but during the past couple of decades in
psychiatry there has been a greater understanding of the relevance of
religious thought and practice in psychiatric assessment and treatment.
Cultural psychiatry has been a major contributor to this enhanced
dialogue between psychiatry and religion because it is an area of psychiatry
that requires the integration of the biological and social sciences, and the
humanities, including religion and spirituality. In its attempts to explain
the full range of human behavior, including behavior associated with
mental illness, psychiatry has often needed to go well beyond the world of
natural science into the philosophical realm.
Vol 43(4): 634651 DOI: 10.1177/1363461506070788 www.sagepublications.com
Copyright 2006 McGill University
transcultural
psychiatry
ARTICLE
December
2006
634
08 070788 Boehnlein 30/11/06 1:25 pm Page 634
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
All religions offer some type of explanation of how the universe was
created, how life is maintained, and what happens when life ceases to exist.
Moreover, all religions attempt to give their followers explanations for lifes
meaning, including rationales for the reality of human suffering (Boehn-
lein, 2000). Religious symbols, beliefs, myths, and rites enable individuals
and groups to deal with the ultimate conditions of existence that are
experienced by members of every society (DeCraemer, Vansina, & Fox,
1976). From the standpoint of the individual as part of a social unit,
religion serves as a source of conceptions of the world, the self, and the
relations between them (Geertz, 1973). Both religion and cultural
psychiatry are concerned with how identity is dened and how this de-
nition is affected by interpersonal, social, and cultural processes. For much
of history, the separate functions of religious practice and healing were
performed by a single individual in most world cultures. Only with the
explosive growth of scientic knowledge in the 20th century have the roles
of religious and medical healers become separate.
Psychiatry and religion can be parallel and complementary frames of
reference for understanding and describing the human experience and
human behavior. Although placing different degrees of emphasis on the
relative importance of mind, body, and spirit in dening human nature,
the objective and subjective perspectives of psychiatry and religion can be
integrated in comprehensive patient care in cultural psychiatry.
In the last 25 years religion and spirituality have become more promi-
nent in mainstream psychiatry in a number of different areas:
1. As the worlds population has become more migratory over this time,
there has been more exposure to diverse cultural and religious
traditions in western cosmopolitan societies. This has required
psychiatrists to be more knowledgeable about the backgrounds and
traditions of immigrants and refugees resettling in these countries;
2. Trauma and loss among these migrant populations, war veterans, and
survivors of civilian trauma and natural disasters have received much
more attention during the last several decades. Religious and spiri-
tual beliefs and practices have relevance for trauma recovery;
3. Also in the past several decades, various new approaches to
psychotherapy have been developed that actually have their roots in
religious and spiritual traditions. Moreover, the processes and goals
of some psychotherapies and spiritual practices are remarkably
similar;
4. After a long history of antagonism among mental health
professionals and clergy, there has been a rapprochement that has
focused on the overlapping goals of each profession to foster growth,
resiliency, hope and meaning for individuals and groups;
Boehnlein: Religion and Spirituality in Psychiatric Care
635
08 070788 Boehnlein 30/11/06 1:25 pm Page 635
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
5. Medicine and psychiatry have faced many ethical challenges as the
frontiers of science have outpaced societys ability to grasp change or
adequately debate the ethical implications of the rapid evolution of
knowledge. Consequently, in debates on a number of complex issues
in bioethics, medicine has needed to draw upon philosophical
traditions that often have their roots in religion and spirituality;
6. Psychiatric research in recent decades has increasingly focused on the
role of religion and spirituality in mental health and illness. This
research has implications for future psychiatric care and for psychi-
atric training.
All of these issues will be explored in more detail in this article as I review
the past few decades of cultural psychiatry and look towards the future.
International Mental Health
A discussion of psychiatry and religion has particularly become more
timely now because of a resurgence of interest in religious belief and
practice in many parts of the world, and because of the increased
movement of the worlds population, with the subsequent assimilation of
a variety of belief systems and practices throughout the world (Boehnlein,
2000). Mental health providers in developed countries increasingly are
treating immigrants and refugees whose backgrounds are much different
from their own, so it is important for them to understand cultural belief
systems, including religious thought and practice, that relate to mental
health and illness. Acculturation can also bring about change in religious
traditions, just as it can inuence dynamic changes in other areas of life
for individuals and groups.
An increased awareness of religion in contemporary societies in recent
years has both positive and negative aspects (Boehnlein, 2000). From a
positive point of view, religious belief systems may provide meaning for
individuals or groups. This includes survivors of various types of trauma
such as war, civil violence, torture and natural disasters. Historically, a
broad spectrum of religious organizations also have funded and operated
mental health services in various countries, so it is important for organ-
ized psychiatry and clinicians to be knowledgeable about the historical
belief systems and political structures of these organized religions so that
the effectiveness of services can be enhanced.
From a negative point of view, any religious fundamentalism, regard-
less of belief system, can be damaging not only to individual mental
health and social adjustment but also to peaceful coexistence among
cultures. Unfortunately, many areas of the globe in recent decades, such
as Northern Ireland, the Balkans, Africa, and the Middle East have seen
Transcultural Psychiatry 43(4)
636
08 070788 Boehnlein 30/11/06 1:25 pm Page 636
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
the politicalization of religious beliefs resulting in the destruction of lives
and cultures. This is a very important realm for psychiatry because
survivors of regional war trauma and violence frequently emigrate to
other countries, where they subsequently attempt not only to acculturate
but also to place their traumatic experiences into a meaningful context.
Another source of tension in the current era is the tension between
religious resurgence in many parts of the world and the increase in secu-
larization in developing societies. This tension frequently leads to a polar-
ization of beliefs and perspectives, and the hardening of attitudes and
opinions when, in fact, religious and secular perspectives may be comple-
mentary in understanding the human condition and human behavior.
Trauma and Loss
The complex existential and spiritual issues associated with trauma and loss
are central to both religious faith and the process of posttraumatic recovery.
During and after traumatic events, individuals frequently report great
cognitive dissonance between what they observe and experience in reality
and what they previously believed were stable, secure, and predictable
relationships, not only with other individuals but also with the supernat-
ural or the metaphysical (Boehnlein, 1987a). The person recovering from
the trauma does not have to be religious in a formal sense to experience
this dissonance; how the person was socialized to reconcile the pain of loss
is what is important (Eisenbruch, 1984). Incorporating religious and
spiritual perspectives in the clinical assessment of patients takes into
account the effects of philosophical viewpoints, cultural values, and social
attitudes on disease (Fabrega, 1975). Religious teachings recognize the tran-
scendental meaning of suffering and the fact that suffering, such as agony,
despair, pain and conict, belongs to the totality of life (Rhi, 2001).
All the major world religions have belief systems, values and practices
that allow survivors to adjust to and create meaning from severe loss and
trauma. Buddhism, Hinduism, Islam, Judaism and Christianity all have
oral traditions that facilitate the creation of meaning and hope for the
future. It is now being recognized that patients bring these traditions with
them to psychiatric treatment and psychotherapy, and they form an
integral part of identity. The nature of the relationship between religious
faith and negative life events can be complex: For some individuals,
religious faith may enhance the ability to cope with negative life events,
while for others, negative life events may result in greater religious faith
(Connor, Davidson, & Lee, 2003).
Yet, experiencing massive trauma can also result in a collapse of faith.
The human experience of useless cruelty, such as in the Holocaust, where
the goal of the perpetrators is the suffering of others solely for the sake of
Boehnlein: Religion and Spirituality in Psychiatric Care
637
08 070788 Boehnlein 30/11/06 1:25 pm Page 637
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
suffering rather than for a military or political aim (Langer, 1998), is an
apt example. It illustrates well the problem of theodicy, the difculty of
defending divine justice in the face of great evil and suffering; if God is
all-loving he would not be able to tolerate the appalling suffering that is
evident in the created order and, if he is almighty, he would be able to do
something about it (Bowker, 1970).
In the context of specic religious traditions, Judaism holds open the
possibility of being restored to a right relationship with God through
atonement; Christianity teaches that repentance for sin, accompanied by
turning to God and asking to be united with Christs sacrice, brings
forgiveness and the gift of a new life (Christian trauma survivors often
mention the loss of God as one of their greatest losses); Buddhism incor-
porates the acceptance of life as it comes, including traumatic events (rein-
carnation is a major tenet of Buddhism, along with Karma, the belief that
a persons actions in this life will affect ones existence in the next) (Sparr
& Fergueson, 2000). In Islam, given that death to an individual is divinely
ordained, the survivor need not bear the guilt of a loss (Elbedour, Baker,
Shalhoub-Kevorkian, Irwin, & Belmaker, 1999). In most of the religions
of the world, pain, suffering, atonement and forgiveness are interrelated
in theology and in everyday life. The relative importance of each, and their
interaction, may vary among the major religions, but they are central
issues that affect recovery from great trauma and loss (Boehnlein, 2006).
Religious traditions in the West generally include a more active
approach to suffering and trauma, whereas eastern traditions prescribe a
somewhat more reective position. Both of these traditions can be seen in
psychotherapeutic approaches to trauma recovery. In PTSD recovery,
spiritual awakening can play a role in relieving survivor guilt (Khouzam
& Kissmeyer, 1997). And there are a number of similarities between the
spiritual process of repentance and the process of psychotherapy as, in
both processes, the individual undertakes a journey of transformation that
includes painful introspection; the working through of rage, guilt, or
shame related to the experience of evil optimally involves seeking a proper
balance of justice, repentance and forgiveness (Schimmel, 2002). This is
not an easy task, however, for the survivor and there can be tension also
between religious traditions and the process of psychotherapy or psychi-
atric treatment. Normal and expected human interactions such as anger,
hate and the urge for revenge can be overwhelming, thus preventing reso-
lution of the intense mix of emotions that occur after trauma. And,
religious traditions that place healing in the hands of God may conict
with western psychotherapies that place a premium on individual power,
control, and responsibility.
Greater levels of personal resilience have been associated with more
favorable outcomes in PTSD (Connor et al., 2003). Religion and
Transcultural Psychiatry 43(4)
638
08 070788 Boehnlein 30/11/06 1:25 pm Page 638
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
spirituality may contribute to this resilience by providing guidance for the
survivor on complicated moral questions, along with a social network of
individuals with shared values and beliefs who can provide support and
guidance. Also, success in psychotherapy in the treatment of PTSD
requires overt questioning, on the part of the patient and the clinician, of
the congruence of their respective models of illness causation, and ideas
for treatment (Boehnlein, 1987b). It also allows for discussion that focuses
on beliefs and values, which are central concerns for trauma survivors.
Psychotherapy
Spiritual and religious traditions also have had a signicant inuence on
the development of some contemporary schools of psychotherapy in
general psychiatry and addictions. Exploring subjective experience of
belief as a motivating force (Sims, 1994) is an important area of study and
practice. One conceptual viewpoint that arises from recent ndings in
cognitive science (interactive realism) asserts that each of us in our inter-
action with others, if the interaction is characterized by mutual
acceptance, brings forth a shared domain that is value laden; for
psychotherapy this process can be described as a process of coconstruc-
tion whereby the therapist and patient jointly bring forth a change in the
being of each participant (Bathgate, 2003). Yet, in the realm of psychother-
apy and spirituality, the therapist needs to be cautious and aware because
there is a signicant potential for the abuse of the therapeutic relationship
if the therapist communicates a personal agenda that abandons the prin-
ciple of psychotherapeutic neutrality (Lomax, Karff, & McKenny, 2002).
Johnson and Westermeyer (2000) note that Marsha Linehan (1993a,
1993b) developed a therapeutic modality Dialectical Behavioral Therapy
(DBT) that is an integration of two areas: Her work in suicide prevention
and behavior therapy, and her experience as a student of a Zen master and
Benedictine monk. They point out that the main goals of Linehans
therapy are to enhance dialectical patterns of cognitive functioning and to
change extreme behaviors to more balanced and integrated responses to
the moment. DBT does not function on maintaining a stable, consistent
environment, but instead aims to help the patient become comfortable
with change. According to Linehan, the three main polarities of DBT are:
(1) The need for patients to accept themselves as they are and the need to
change; (2) the tension between patients getting what they need and losing
what they need if they become more competent; and (3) patients main-
taining personal integrity versus learning new skills that will help them
emerge from their suffering.
Johnson and Westermeyer (2000) also point out DBTs partial roots in
eastern religions by noting that Linehan described dialectical thinking as
Boehnlein: Religion and Spirituality in Psychiatric Care
639
08 070788 Boehnlein 30/11/06 1:25 pm Page 639
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
the middle path between universalistic thinking and relativistic thinking,
which interestingly, also form similar poles in an ongoing debate in
anthropology and cultural psychiatry. Dialectical thinking assumes that
truth and order evolve and develop over time. Goals of this process consist
of integrating contradictory points of view, learning to be comfortable
with inconsistency, and avoiding simplistic explanations. This method is
applied to patients with borderline personality disorder, who often have
difculty receiving new information and who tend to search unsuccess-
fully for absolute truths. Extremes and rigid behavior patterns are signals
that a middle way has not been achieved.
Psychoanalysis offers another example of the importance of religion and
spirituality in the history of psychotherapy, although there has been a great
deal of tension in this relationship dating back to Freud. However, over the
past 20 years the relationship between psychoanalysis and religion has been
changing as Freuds reductionist understanding of religion and his evalu-
ation of it as an expression of infantile needs has been rejected by numerous
psychoanalytic writers (Blass, 2004). William Meissner (2000), an analyst
and Jesuit priest, notes that one of the most signicant contributors to the
redirection of psychoanalytic thinking about religion was Erik Erikson
(1962, 1969), not only in his ingenious broadening of the scope of analytic
concepts regarding personality development and the formation of identity,
but particularly in his interpretations of Luther and Gandhi. Meissner
points out that Erikson was able to connect the most profoundly spiritual
aspects of human experience with fundamental infantile roots and
dynamics without entertaining the reductionistic fallacy that had plagued
earlier efforts (Meissner, 1987; Zock, 1990). Erikson (1962) wrote,
Must we call it regression if man thus seeks again the earliest encounters of
his trustful past in his efforts to reach a hoped-for and eternal future? Or
do religions partake of mans ability, even as he regresses, to recover
creatively? At their creative best, religions retrace our earliest inner experi-
ences, giving tangible form to vague evils and reaching back to the earliest
individual sources of trust; at the same time, they keep alive the common
symbols of integrity distilled by the generations. If this is partial regression,
it is a regression which, in retracing rmly established pathways, returns to
the present amplied and claried. (p. 264)
A third example that illustrates the signicant convergence of religion and
psychotherapy is the development of existential psychotherapy in the mid
and late 20th century, following the horrors of the Second World War.
Although this school of psychotherapy does not have a religious base, it
has a foundation in European philosophical traditions which deal inti-
mately with profound questions that religion also confronts, such as the
concept of evil (Prins, 1994), and the meaning of loss and death. The
Transcultural Psychiatry 43(4)
640
08 070788 Boehnlein 30/11/06 1:25 pm Page 640
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
problem of evil can be expressed in theological or secular terms, but it is
fundamentally a problem about the intelligibility of the world as a whole;
the problem of evil belongs essentially neither to ethics nor to metaphysics,
but forms a link between the two (Neiman, 2002).
Yalom (2002), a key gure in the development of the school of existen-
tial psychotherapy, denes it as a dynamic therapeutic approach that
focuses on four ultimate concerns pertaining to existence, specically
death, isolation, meaning, and freedom. He notes that existential
psychotherapy and religious consolation also share common methods
the one-to-one relationship, the mode of confession, inner scrutiny, and
forgiveness of self and others. And, in a further parallel that has great
relevance to the creation of meaning, he notes that religion and
psychotherapy have each developed methods of quelling the dysphoria of
isolation and loneliness. This emphasis on isolation and loneliness has
contributed to the growth over the past several decades of the importance
of group and family psychotherapies, which are based on strengthening
social relationships and connections.
Clergy
There are a number of issues central to the relationships between psychi-
atrists and clergy that are important for patient care, and which have
appropriately received more attention in recent years (Larson, Milano,
Weaver, & McCullough, 2000; Weaver, Koenig, & Larson, 1997). For
example, given a better understanding of the interface between religion
and psychiatry in our culture, psychiatrists in the future will need to
become increasingly sensitive to their patients religious backgrounds and
expressions during evaluation and treatment. Moreover, psychiatrists will
need to seek special knowledge about religious traditions that are
unfamiliar to them. Such knowledge will help them to better identify the
ne line between healthy religious expression and psychopathology. And
mental health professionals will need to seek input from clergy familiar
with the religious beliefs, practices, and experiences of their patients.
Clinicians and clergy share a number of qualities that have been uni-
versally identied as central to the efcacy of healers, including
communicating the expectation that suffering will be relieved, conveying
a knowledgeable manner, drawing together key individuals in the persons
life, and generating hope for an improved existence (Frank, 1961). In
addition, one of the functions of a healer in psychiatric or religious
practice is to help reestablish an equilibrium between a person and his or
her environment, whether that environment is the natural world, inter-
personal relationships, or the persons struggle with meaning, beliefs, or
values (Boehnlein, 1987b). Therefore, mental health practitioners and
Boehnlein: Religion and Spirituality in Psychiatric Care
641
08 070788 Boehnlein 30/11/06 1:25 pm Page 641
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
clergy have separate yet complementary roles in restoring patients to
health.
Larson et al. (2000) also note that milder forms of depression, mild to
moderate anxiety, and minor adjustment and coping difculties that
plague a portion of the population can be handled quite well in the
pastoral care setting. They point out that initial screening for more severe
psychiatric disorders can occur at the religious-community level to ensure
early recognition and timely referral to psychiatric professionals; after
diagnosis and treatment have been initiated by mental health
professionals, clergy can assist in the follow-up of such patients by
supporting the treatment plan, monitoring treatment compliance, and
observing for deterioration.
Bioethics
Contemporary multicultural societies face immense challenges in
developing appropriate ethical guidelines in biomedicine. The biological
sciences have needed to turn to the perspectives offered by the great
religious traditions that are grounded in philosophy and the social sciences
to develop guidelines in how to approach many complex moral and ethical
issues. Many of these dilemmas center around questions of when life
begins and ends, and who has the power to inuence the course of life and
death.
At the beginning of life, controversies such as embryonic stem cell
research and abortion deal with the question of when life begins, inter-
twined with cultural debates about individual and group rights and
responsibilities. At the end of life, the societal debate about physician-
assisted suicide and euthanasia deals with similar issues.
These issues are difcult and complex because they involve thought,
discussion and debate about the most personal and central aspects of
human existence, including individual identity and integrity. Consider-
ation of these issues also includes debate about the relative value of human
autonomy and social imperatives, along with the appropriate role of
religious beliefs in a multicultural society.
Social attitudes toward illness and death are highly inuenced by each
cultures values that have their roots in philosophical, religious, social, and
political structures, all of which inuence each other. Unfortunately,
historical and legal traditions tend to rigidly compartmentalize these
elements that form the core of social values and policy. But, on a practi-
cal level, physicians personal concepts of ethical practice cannot be judged
apart from societys broader ethical traditions, as professional ethics derive
from general social and moral principles in a specic historical era, and
within a predominant culture (Boehnlein, Parker, Arnold, Bosk, & Sparr,
Transcultural Psychiatry 43(4)
642
08 070788 Boehnlein 30/11/06 1:25 pm Page 642
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
1995). In addition, an individual physicians views of issues in medical
ethics cannot be judged totally apart from his or her personal, social, and
religious background.
Physician-assisted suicide (PAS) is an excellent example of a con-
temporary medical issue in which social and religious paradigms can
conict although, in reality, there are areas of common ground. Physicians
who hold opinions on either side of the PAS debate, and in between, all
view their beliefs and actions as compassionate, and in the best interests
of the patient. For those supporting physician-assisted suicide, the import-
ance of patient autonomy in end-of-life decisions outweighs social or
professional reservations that would forbid the practice. Proponents
believe they are showing their professional care and compassion by valuing
the patients autonomy, and they believe that there is a professional ethical
obligation to relieve patient suffering, including the option of physician-
assisted suicide. For those who oppose physician-assisted suicide, patient
autonomy, although important, is outweighed by the social nature of the
issue (the patients interpersonal relationship with family members and
the physician; nancial hardships that could favor physician-assisted
suicide as an option other than one of last resort), and by a belief in the
absolute value of life itself, regardless of how quality of life is judged at any
specic stage of life. These competing paradigms continue to be debated
in contemporary medicine and politics (Hamilton & Hamilton, 2005),
with input from both secular and religious perspectives.
Therefore, in order to deal with these contemporary ethical issues, such
as PAS, psychiatrists and other physicians must be able to draw upon a
broadly based intellectual tradition in the social sciences and humanities,
including the comparative study of religion. This ideally should begin in
medical education and residency training when physicians medical values
are being formed. Education and training should introduce young
physicians to the inuence of religious cultures on the patients worldview,
the meaning of suffering, and the creative inuence of spirituality on the
maturation of personality (Rhi, 2001).
Scientic and religious perspectives do not need to be mutually exclus-
ive. Since the mid 1990s, a large number of medical schools have begun
to include topics related to spirituality and medicine in their curricula,
including spiritual assessment as part of a routine history; clinical and
ethical boundaries during discussions of spiritual and religious issues;
research in spirituality and healthcare; and, spiritual issues in palliative
care (Puchalski & Larson, 1998). Including these topics in medical
education serves to enhance general communication skills, particularly
when discussing sensitive topics in a compassionate and nonjudgmental
manner (Lo et al., 2002). Yet, at the same time, the psychiatrists own
spirituality or religiousness may be the strongest predictor of inquiry
Boehnlein: Religion and Spirituality in Psychiatric Care
643
08 070788 Boehnlein 30/11/06 1:25 pm Page 643
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
into a patients spirituality or religiousness (Baetz, Grifn, Bowen, &
Marcoux, 2004).
Fortunately, in the past decade the importance of these topics in
organized psychiatry and psychiatry training programs has begun to
increase (Larson, Lu, & Swyers, 1997; Lukoff, Lu, & Turner, 1995; Turner,
Lukoff, Barnhouse, & Lu, 1995). Knowledge, skills and attitudes related to
training in religion and spirituality include: Understanding the unique
impact of religious/spiritual experiences in physical and psychological
development; differential diagnosis of religious/spiritual experiences and
their effect on the course and treatment of psychiatric disorders; trans-
ference and countertransference; providing appropriate psychotherapeutic
interventions that reect an understanding of patients religious/
spiritual experiences; and, awareness of the psychiatrists own
religious/spiritual experience and the impact on identity and worldview
(Lu, 2000).
Research in Religion and Spirituality: Present and
Future
Current research in religion, spirituality, and psychiatry is structured along
enduring paradigms that originated centuries ago. Augustianism, named
after St. Augustine (354430 AD) conceptualizes religious belief as tran-
scending objective reality, whereas Thomism, named after St. Thomas
Aquinas (12241274 AD) describes religious faith as dependent upon
reason and as accessible to empirical methods (Neeleman & Persaud,
1995). Despite its unknown nature, several features of spirituality can be
measured and, given suitable statistical methods to control for confound-
ing, its effect on peoples lives can be assessed (King & Dein, 1998). But
this systematic quantitative study of religion and mental health was
traditionally quite rare, it most often used a single static measure of
religion rather than multiple dynamic measures, and has started to slowly
increase only over the past decade (Larson et al., 1993; Larson, Pattison,
Blazer, Omran, & Kaplan, 1986; Weaver et al., 1998).
Recent studies have shown that many, if not most, Americans use
religion to help them cope, particularly during times of acute stress
(Koenig, 1995; Koenig, McCullough, & Larson, 2001). In a recent national
survey conducted by the Centers for Disease Control and Preventions
National Center for Health Statistics on the use of alternative medicine in
the U.S., 43% of respondents had prayed for their own health (Barnes,
Powell-Griner, McFann, & Nahin, 2004). Among clinical populations,
studies that have used measures based on psychiatric nosology have found
religious commitment to be benecial (Baetz, Larson, Marcoux, Bowen, &
Grifn, 2002; Larson et al., 1992). For example, it has been shown in
Transcultural Psychiatry 43(4)
644
08 070788 Boehnlein 30/11/06 1:25 pm Page 644
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
numerous studies that high levels of religious involvement predict a
reduced risk for substance misuse, and that the relationship between social
religiosity and the risk of illness is consistent with the hypothesis that
religious activity can be a potent form of social integration (Kendler et al.,
2003).
Koenig (2000) notes that further studies are necessary to compare the
effects of religious coping with those of nonreligious coping behaviors
(e.g., distracting activities, support from family) on mental health and
emotional wellbeing. He further points out that, although recent research
has emphasized the health-promoting effects of devout religiousness, rela-
tively few investigations have attempted to identify the specic elements
of religious coping that are benecial, or to isolate types of religious coping
that are detrimental to health.
Koenig also notes that, with a few exceptions (Blazer & Palmore, 1976;
Idler & Kasl, 1992; Koenig et al., 1992), most research examining the
relationship between religiousness and mental health has been cross-
sectional; although cross-sectional studies provide information about
association, they do not elucidate causality or direction of effect. In the
future, longitudinal, prospective studies or clinical trials will be necessary
to yield information about the time sequence of events. Religiosity may
alter the risk of illness, the experience of illness may have an effect on
religiosity, or a third factor may inuence both (Kendler et al., 2003).
However, some studies have begun to show associations between
cultural and spiritual orientation and specic psychiatric outcomes. For
example, a recent study by Garroutte, Goldberg, Beals, Herrell, and
Manson (2003) suggests that American Indians with strong levels of
cultural spiritual orientations have relatively lower rates of self-reported
attempted suicide. In the published literature overall, results of studies of
the interrelationship between religion and mental health tend to show that
religiosity seems to exert a salutary effect on health, and that there is a
trend toward better health and less morbidity in the presence of higher
levels of religiosity (Levin, 1994). A wide range of research ndings in the
eld, and even contradictory ndings, likely are related to the fact that
religion is a multifaceted construct and different aspects of religiosity are
differentially related to mental health; using institutional religiosity as the
dening characteristic produces the weakest (and the only negative) corre-
lations across the board, ideology produces stronger effects, and personal
devotion produces the greatest correlations (Hackney & Sanders, 2003).
One of the most promising areas for future research in spirituality and
medicine is in palliative and end-of-life care. The impact of afterlife beliefs
on health, particularly the inuence of those beliefs on survival, terminal
illness, and hopefulness, has been virtually ignored. In a study of spiritual
wellbeing and psychological functioning in terminally ill cancer patients,
Boehnlein: Religion and Spirituality in Psychiatric Care
645
08 070788 Boehnlein 30/11/06 1:25 pm Page 645
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
spiritual wellbeing offered some protection against end-of-life despair; in
study participants low in spiritual wellbeing, depression was highly cor-
related with a desire for hastened death (McClain, Rosenfeld, & Breitbart,
2003). In another study with terminally ill cancer patients some of the
same authors found that spirituality had a more powerful effect on
psychological functioning than beliefs held about an afterlife (McClain-
Jacobson et al., 2004). At the end of life, the benecial aspects of religion
may be primarily those that relate to general spiritual wellbeing rather
than to specic religious practices.
Another promising area for research that is only exploratory at this
point is the relationship among specic physiological health measures,
mortality, and religion/spirituality. As an example, recent research has
suggested that regulation of the proinammatory cytokine interleukin-6
(IL-6) may be abnormal in patients with major depression (Alesci et al.,
2005; Penninx et al., 2003). A study that prospectively examined the
relationship between religious attendance, IL-6 levels, and mortality rates
in a community-based sample of older adults found that religious atten-
dance was signicantly related to lower IL-6 levels and lower mortality
rates, and that IL-6 levels mediated the prospective relationship between
religious attendance and mortality (Lutgendorf, Russell, Ullrich, Harris, &
Wallace, 2004).
Conclusion
There is certainly a great deal of promise for the future relationship
between psychiatry and religion in research, as well as in patient care and
education. With the continuing growing importance of cultural psychiatry
in all areas of psychiatric work, there is great potential in the future for an
exciting synergy of efforts that will positively inuence cross-cultural
psychiatric treatment, and the understanding of religion and spirituality.
At the same time, as described in this article, there are a number of chal-
lenges to the eld in attempting to objectively study the variables that
inuence the relationships among religious and spiritual beliefs, societal
values, conceptions of mental health and illness, and psychiatric nosology
and treatment. But, it is an ideal eld for the convergence of the bio-
logical sciences, the social sciences, and the humanities, in an attempt to
more completely understand identity and meaning, social relationships,
and the complexity of the human condition across all cultures and faiths.
References
Alesci, S., Martinez, P. E., Kelkar, S., Ilias, I., Ronsaville, D. S., Listwak, S. J., et al.
(2005). Major depression is associated with signicant diurnal elevations in
Transcultural Psychiatry 43(4)
646
08 070788 Boehnlein 30/11/06 1:25 pm Page 646
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
plasma interleukin-6 levels, a shift of its circadian rhythm, and loss of
physiological complexity in its secretion: Clinical implications. Journal of
Clinical Endocrinology and Metabolism, 90(5), 25222530.
Baetz, M., Grifn, R., Bowen, R., & Marcoux, G. (2004). Spirituality and
psychiatry in Canada: Psychiatric practice compared with patient expec-
tations. Canadian Journal of Psychiatry, 49, 265271.
Baetz, M., Larson, D. B., Marcoux, G., Bowen, R., & Grifn, R. (2002). Canadian
psychiatric inpatient religious commitment: An association with mental
health. Canadian Journal of Psychiatry, 47, 159166.
Barnes, P. M., Powell-Griner, E., McFann, K., & Nahin, R. L. (2004). Complemen-
tary and alternative medicine rise among adults: United States, 2002. Advance
Data, Centers for Disease Control and Prevention, National Center for Disease
Statistics, 343, 27, 2004.
Bathgate, D. (2003). Psychiatry, religion, and cognitive science. Australian and New
Zealand Journal of Psychiatry, 37, 277285.
Blass, R. B. (2004). Beyond illusion: Psychoanalysis and the question of religious
truth. International Journal of Psychoanalysis, 85, 615634.
Blazer, D. G., & Palmore, E. (1976). Religion and aging in a longitudinal panel.
Gerontologist, 16, 8285.
Boehnlein, J. K. (1987a). Clinical relevance of grief and mourning among
Cambodian refugees. Social Science and Medicine, 25, 765772.
Boehnlein, J. K. (1987b). Culture and society in posttraumatic stress disorder: Impli-
cations for psychotherapy. American Journal of Psychotherapy, 41, 519530.
Boehnlein, J. K. (2000). Introduction. In J. K. Boehnlein (Ed.), Psychiatry and
Religion: The Convergence of Mind and Spirit (pp. xvxx). Washington, DC:
American Psychiatric Press.
Boehnlein, J. K. (2006). Religion and spirituality after trauma. In L. Kirmayer, R.
Lemelson, & M. Barad (Eds.), Understanding Trauma: Integrating Biological,
Clinical, and Cultural Perspectives (pp. 259274). New York: Cambridge
University Press.
Boehnlein, J. K., Parker, R. M., Arnold, R. M., Bosk, C. F., & Sparr, L. F. (1995).
Medical ethics, cultural values, and physician participation in lethal injection.
Bulletin of the American Academy of Psychiatry and the Law, 23(1), 129134.
Bowker, J. (1970). Problems of suffering in religions of the world. New York:
Cambridge University Press.
Connor, K. M., Davidson, J. R. T., & Lee, L. C. (2003). Spirituality, resilience, and
anger in survivors of violent trauma: A community survey. Journal of
Traumatic Stress, 16, 487494.
DeCraemer, W., Vansina, J., & Fox, R. C. (1976). Religious movements in central
Africa. Comparative Studies in Society and History, 18, 458475.
Eisenbruch, M. (1984) Cross-cultural aspects of bereavement, I: A conceptual
framework for comparative analysis. Culture, Medicine, and Psychiatry, 8(3),
283309.
Elbedour, S., Baker, A., Shalhoub-Kevorkian, N., Irwin, M., & Belmaker, R. H.
(1999). Psychological responses in family members after the Hebron
massacre. Depression and Anxiety, 9, 2731.
Boehnlein: Religion and Spirituality in Psychiatric Care
647
08 070788 Boehnlein 30/11/06 1:25 pm Page 647
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
Erikson, E. H. (1962). Young man Luther: A study in psychoanalysis and history
(1958). New York: W. W. Norton.
Erikson, E. H. (1969). Ghandis truth: On the origins of militant nonviolence. New
York: W. W. Norton.
Fabrega, H. (1975). The need for an ethnomedical science. Science, 198, 969975.
Frank, J. D. (1961). Persuasion and healing. Baltimore, MD: Johns Hopkins
University Press.
Garroutte, E. M., Goldberg, J., Beals, J., Herrell, R., & Manson, S. M. (2003). Spir-
ituality and attempted suicide among American Indians. Social Science and
Medicine, 56, 15711579.
Geertz, C. (1973). The interpretation of cultures. New York: Basic Books.
Hackney, C. H., & Sanders, G. S. (2003). Religiosity and mental health: A meta-
analysis of recent studies. Journal for the Scientic Study of Religion, 42(1),
4355.
Hamilton, N. G., & Hamilton, C. A. (2005). Competing paradigms of response to
assisted suicide requests in Oregon. American Journal of Psychiatry, 162,
10601065.
Idler, E. L., & Kasl, S. V. (1992). Religion, disability, depression, and the timing of
death. American Journal of Sociology, 97, 10521079.
Johnson, D. R., & Westermeyer, J. (2000). Psychiatric therapies inuenced by
religious movements. In J. K. Boehnlein (Ed.), Psychiatry and religion: The
convergence of mind and spirit (pp. 87108). Washington, DC: American
Psychiatric Press.
Kendler, K. S., Liu, X. Q., Gardner, C. O., McCullough, M. E., Larson, D., &
Prescott, C. A. (2003). Dimensions of religiosity and their relationship to
lifetime psychiatric and substance use disorders. American Journal of
Psychiatry, 160, 496503.
Khouzam, H. R., & Kissmeyer, P. (1997). Antidepressant treatment, posttraumatic
stress disorder, survivor guilt, and spiritual awakening. Journal of Traumatic
Stress, 10, 691696.
King, M., & Dein, S. (1998). The spiritual variable in psychiatric research. Psycho-
logical Medicine, 28, 12591262.
Koenig, H. G. (1995). Faith and spirituality as a means of coping with stress.
Theology News and Notes, 42(68): 22.
Koenig, H. G. (2000). Religion and future psychiatric nosology and treatment. In
J. K. Boehnlein (Ed.), Psychiatry and religion: The convergence of mind and
spirit (pp. 169185). Washington, DC: American Psychiatric Press.
Koenig, H. G., Cohen, H. J., Blazer, D. G., Pieper, C., Meador, K. G., Shelp, F., et
al. (1992). Religious coping and depression in elderly hospitalized medically
ill men. American Journal of Psychiatry, 149, 16931700.
Koenig, H. G., McCullough, M. E., & Larson, D. B. (2001). Handbook of religion
and health. New York: Oxford University Press.
Langer, L. L. (1998). Preempting the Holocaust. New Haven, CT: Yale University
Press.
Larson, D. B., Lu, F. G., & Swyers, J. B. (1997). A model curriculum for psychiatry
residency training programs: Religion and spirituality in clinical practice.
Rockville, MD: National Institute for Healthcare Research.
Transcultural Psychiatry 43(4)
648
08 070788 Boehnlein 30/11/06 1:25 pm Page 648
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
Larson, D. B., Milano, M. G., Weaver, A. J., & McCullough, M. E. (2000). The role
of clergy in mental health care. In J. K. Boehnlein (Ed.), Psychiatry and
religion: The convergence of mind and spirit (pp. 125142). Washington, DC:
American Psychiatric Press.
Larson, D. B., Pattison, E. M., Blazer, D. G., Omran, A. R., & Kaplan, B. H. (1986).
Systematic analysis of research on religious variables in four major psychi-
atric journals, 19781982. American Journal of Psychiatry, 143, 329334.
Larson, D. B., Sherrill, K. A., Lyons, J. S., Craigie, F. C., Thielman, S. B., Greenwold,
M. A., et al. (1992). Associations between dimensions of religious commit-
ment and mental health reported in the American Journal of Psychiatry and
Archives of General Psychiatry: 19781989. American Journal of Psychiatry,
149, 557559.
Larson, D. B., Thielman, S. B., Greenwold, M. A., Lyons, J. S., Post, S. G., Sherrill,
K. A., et al. (1993). Religious content in the DSM-III-R glossary of technical
terms. American Journal of Psychiatry, 150, 18841885.
Levin, J. S. (1994). Religion and health: Is there an association, is it valid, and is
it causal? Social Science and Medicine, 38, 14751482.
Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality
disorder. New York: Guilford.
Linehan, M. M. (1993b). Skills training manual for treating borderline personality
disorder. New York: Guilford.
Lo, B., Ruston, D., Kates, L. W., Arnold, R. M., Cohen, C. B., Faber-Langendoen,
K., et al. (2002). Discussing religious and spiritual issues at the end of life: A
practical guide for physicians. Journal of the American Medical Association,
287, 749754.
Lomax, J. W., Karff, S., & McKenny, G. P. (2002). Ethical considerations in the inte-
gration of religion and psychotherapy: three perspectives. Psychiatric Clinics
of North America, 25(3), 547559.
Lu, F. G. (2000). Religious and spiritual issues in psychiatric education and
training. In J. K. Boehnlein (Ed.), Psychiatry and religion: The convergence
of mind and spirit (pp. 159168). Washington, DC: American Psychiatric
Press.
Lukoff, D., Lu, F. G., & Turner, R. (1995). Cultural considerations in the assess-
ment and treatment of religious and spiritual problems. Psychiatric Clinics of
North America, 18, 467485.
Lutgendorf, S. K., Russell, D., Ullrich, P., Harris, T. B., & Wallace, R. (2004).
Religious participation, interleukin-6, and mortality in older adults. Health
Psychology, 23(5), 465475.
McClain, C., Rosenfeld, B., & Breitbart, W. (2003). Effect of spiritual well-being
on end-of-life despair in terminally-ill cancer patients. Lancet, 361,
16031607.
McClain-Jacobson, C., Rosenfeld, B., Kosinski, A., Pessin, H., Cimino, J. E., &
Breitbart, W. (2004). Belief in an afterlife, spiritual well-being and end-of-life
despair in patients with advanced cancer. General Hospital Psychiatry, 26(6),
484486.
Meissner, W. W. (1987). Life and faith: Psychological perspectives on religious experi-
ence. Washington, DC: Georgetown University Press.
Boehnlein: Religion and Spirituality in Psychiatric Care
649
08 070788 Boehnlein 30/11/06 1:25 pm Page 649
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
Meissner, W. W. (2000). Psychoanalysis and religion: Current perspectives. In J. K.
Boehnlein (Ed.), Psychiatry and religion: The convergence of mind and spirit
(pp. 5369). Washington, DC: American Psychiatric Press.
Neeleman, J., & Persaud, R. (1995). Why do psychiatrists neglect religion? British
Journal of Medical Psychology, 68, 169178.
Neiman, S. (2002). Evil in modern thought: An alternative history of philosophy.
Princeton, NJ: Princeton University Press.
Penninx, B. W., Kritchevsky, S. B., Yaffe, K., Newman, A. B., Simonsick, E. M.,
Rubin, S., et al. (2003). Inammatory markers and depressed mood in older
persons: Results from the Health, Aging and Body Composition Study.
Biological Psychiatry, 54, 566572.
Prins, H. (1994). Psychiatry and the concept of evil. British Journal of Psychiatry,
165, 297302.
Puchalski, C. M., & Larson, D. B. (1998). Developing curricula in spirituality and
medicine. Academic Medicine, 73, 970974.
Rhi, B. Y. (2001). Culture, spirituality, and mental health. Psychiatric Clinics of
North America, 24, 569579.
Schimmel, S. (2002). Wounds not healed by time: The power of repentance and
forgiveness. New York: Oxford University Press.
Sims, A. (1994). Psyche: Spirit as well as mind? British Journal of Psychiatry, 165,
441446.
Sparr, L. F., & Fergueson, J. F. (2000). Moral and spiritual issues following trauma-
tization. In J. K. Boehnlein (Ed.), Psychiatry and religion: The convergence of
mind and spirit (pp. 109123). Washington, DC: American Psychiatric Press.
Turner, R. P., Lukoff, D., Barnhouse, R. T., & Lu, F. G. (1995). Religious or spiritual
problem. A culturally sensitive diagnostic category in the DSM-IV. Journal of
Nervous and Mental Disease, 183, 435444.
Weaver, A. J., Koenig, H. G., & Larson, D. B. (1997). Marriage and family thera-
pists and the clergy: a need for clinical collaboration, training, and research.
Journal of Marital and Family Therapy, 23, 1325.
Weaver, A. J., Samford, J. A., Larson, D. B., Lucas, L. A., Koenig, H. G., & Patrick,
V. (1998). A systematic review of research on religion in four major psychi-
atric journals: 19911995. Journal of Nervous and Mental Disease, 186(3),
187189.
Yalom, I. (2002). Religion and psychiatry. American Journal of Psychotherapy, 56,
301316.
Zock, H. (1990). A psychology of ultimate concern: Erik H. Eriksons contribution to
the psychology of religion (International Series in the Psychology of Religion).
Atlanta, GA: Editions Rodopi.
James K. Boehnlein, MD, is currently Professor of Psychiatry at the Oregon
Health and Science University, and Associate Director for Education of the
Veterans Administration Northwest Network Mental Illness Research, Education,
and Clinical Center (MIRECC). After receiving his MD degree at Case Western
Reserve University and psychiatry training at the Oregon Health and Science
University, he received a masters degree in medical anthropology at the University
Transcultural Psychiatry 43(4)
650
08 070788 Boehnlein 30/11/06 1:25 pm Page 650
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from
of Pennsylvania as a Robert Wood Johnson Clinical Scholar. His career research
interests have centered on cultural psychiatry, with particular emphasis on refugee
mental health and cultural aspects of psychological trauma. This clinical research
has been centered in both the Intercultural Psychiatric Program of the Oregon
Health and Science University and the Veterans Administration, along with
educational efforts in undergraduate and continuing medical education. He is
currently President of the Society for the Study of Psychiatry and Culture.
Address: Department of Psychiatry (UHN 80), Oregon Health and Science
University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA. [E-mail:
boehnlei@ohsu.edu]
Boehnlein: Religion and Spirituality in Psychiatric Care
651
08 070788 Boehnlein 30/11/06 1:25 pm Page 651
at UNIV WASHINGTON LIBRARIES on January 17, 2010 http://tps.sagepub.com Downloaded from

Das könnte Ihnen auch gefallen