INTRODUCTION AND OVERVIEW

‘Spirituality’ means different things to different individuals and there is no one way of exploring or expressing it. The search for meaning is ubiquitous to humankind, and being able to make meaning of life, and especially adversity, can have an enormously protective effect on people’s mental health when coping with major life events. Most commonly, people take spirituality and religion to be synonymous, but there are many other ways, aside from religious practice, of exploring and expressing spirituality—through philosophical enquiry, the pursuit of science, creativity, relationships, environmentalism, altruism and social justice, to name a few.

Spirituality, in the broad sense described above, is relevant to healthcare because it has a direct impact on a range of health determinants, mental health, lifestyle choices, relationships and coping. This chapter explores the relationships between spirituality, meaning and health.

SPIRITUALITY, RELIGION AND MEANING

Most people who call themselves ‘spiritual’ do so within a religious context. Although religion and spirituality overlap, they are not the same thing. Because of the religious connotations, many people avoid the word ‘spirituality’ altogether and instead use a term such as ‘meaning’, as in the following quote by Jung:

The terms most commonly used in the medical and psychological literature examining these phenomena are ‘religious commitment’ or ‘religiosity’, which refer to the ‘participation in or endorsement of practices, beliefs, attitudes, or sentiments that are associated with an organised community of faith’.² One can be ‘extrinsically religious’ by adopting the trappings of religious behaviours and attitudes, but holding a strong commitment to a religious ideology or core values is associated with being ‘intrinsically religious’. Intrinsic religiosity is more protective for mental health than extrinsic religiosity. ‘Spirituality’ overlaps with intrinsic religiosity and refers to things that are hard to define and measure, such as ‘personal views and behaviours that express a sense of relatedness to the transcendental dimension or to something greater than the self’.³ It can encompass things such as a belief in a higher being, meaning, purpose and connectedness.

It is important that patients, and doctors for that matter, define, explore and express ‘spirituality’ or ‘meaning’ in a way that is relevant to one’s own views, culture and background. Whatever our background, an active search for meaning is an integral part of what makes us human and able to cope with adversity. Everybody looks for meaning in one way or another—through, for example:

The search for meaning helps to keep individuals and communities healthy.⁴ It is the lens through which we look at the world.

In the following discussion, the terms ‘religious commitment’, ‘religiosity’ and ‘churchgoers’ are used because they are the terms used in the research. The findings should be taken in the context of the above discussion about religion, spirituality and meaning.

SPIRITUALITY, MENTAL HEALTH AND SUICIDE

In view of predictions that depression will soon be the leading burden of disease⁵ and the escalating trends in youth suicide rates,⁶ there may be too little attention being given to the protective factors against mental illness. One important protective factor for mental health is a sense of meaning, spirituality or religion. It has become increasingly clear in reviews of the literature that spirituality has a positive impact on social, mental and emotional health.^7,8 Therefore, a possible contributing factor to the widespread decline in mental health in developed and materially wealthy societies is a lack of meaning and spiritual fulfillment. Whether it is the cause or a marker for other phenomena is hard to say. This is seen among doctors as well as in the general public. Doctors who rate themselves as having lower levels of spiritual wellbeing are more prone to depression and poor health.⁹

Studies suggest that most doctors believe religion and spirituality (R/S) has a significant influence on health¹⁰ and that R/S:

Doctors with high religiosity are substantially more likely to:

Among doctors, the least likely to have religious beliefs are psychiatrists. Psychiatrists are also more likely to call themselves spiritual but not religious. Doctors with strong religious beliefs are less likely to refer patients to psychiatrists and more likely to refer patients to clergy or religious counsellors for mental health problems.¹¹ The ignoring of issues related to religion, meaning and spirituality is reflected in medical and psychological education and practice, where religious issues are often marginalised or pathologised.¹² This has been entrenched for some time. Freud, for example, described religion as ‘a universal obsessional neurosis’ and the ‘mystical experience of unity’ as a ‘regression to primary narcissism’.¹³ Jung, one of the early pioneers of a more modern approach to psychotherapy, saw the search for meaning as the central human motivation. Some people undoubtedly have significantly negative experiences in their religious life and upbringing, and religious content is not uncommonly a part of psychosis. Furthermore, although most mainstream religious groups, and the individuals who are a part of them, tend to be moderate and tolerant in their practices and integration into multicultural societies, some religious groups and individuals do tend towards aggressive and intolerant forms of fundamentalism.¹⁴ Such an expression of religiosity appeals to some of the more alienated members of the community and has produced some of the most aggressive and difficult to understand crimes in modern times. Despite this, there is gathering evidence confirming the overall protective effect of ‘religiosity’ on mental and physical health, and it will be a significant aspect of many patients’ ability to cope with and recover from illness. According to large population studies of adolescents, among the most important of protective factors are ‘connectedness’ and ‘spirituality’.¹⁵

Unfortunately, the negative attitude in many quarters of contemporary medicine and psychiatry is out of keeping with the weight of evidence, which clearly shows that having a healthy spiritual life is beneficial for mental and physical health. The findings are consistent, whether the studies are prospective (following people forward over time) or retrospective (looking back at the past). The relationship seems to hold whether the studies control for other lifestyle and socioeconomic factors or not. It seems to hold whether the studies examine the prevention of, coping with or recovery from illness. Causal relationships between religiosity and good health are sometimes hard to be sure about, but it is certain that something is going on. However, it must be acknowledged that, in cases where a religion or member of the clergy has been responsible for negative experiences, alternative expressions of spirituality that do not include organised religion are likely to be of greater value to that individual.

A number of studies link a lack of religiosity to depression. Religious commitment is associated with a reduced incidence of¹⁶ and significantly faster recovery from depression for the elderly.¹⁷ Those with high levels of ‘religious involvement’, ‘religious salience’ and ‘intrinsic religious motivation’ are at reduced risk of depression.¹⁸ Furthermore, religious commitment is inversely related to suicide risk,^19,20 including risk in those with a comorbidity such as childhood abuse²¹ and psychosis.²² There is a fourfold increased risk for adolescent suicide for ‘non-churchgoers’ compared to regular attendees.²³ No study has shown an increased risk for people with a regular spiritual or religious dimension to their lives. Despite the overall positive associations between spirituality and mental health, some questions still remain to be resolved. For example, Sorri and colleagues²⁴ found a high incidence of intense religious activity in 18% of suicide victims, as well as a greater severity of mental illness in either deeply religious or completely non-religious suicide victims. This contrasts with the findings of Krause,²⁵ which suggest that self-esteem was highest in highly religious and non-religious groups, but was lowest in those of intermediate religious devotion. The explanation for some of this might lie in how things like ‘intense religious activity’ (e.g. obsessive and anxiety-driven adherence to strict religious doctrines and practices) and ‘highly religious’ (e.g. religion is a deep and integrated part of a person’s life) are defined. The issue of the role of religious commitment to mental health is consequently far from being settled.²⁶

SPIRITUALITY AND SUBSTANCE ABUSE

Studies suggest that religiosity protects against drug and alcohol abuse,²⁷ one of the most commonly used and maladaptive ways of dealing with mental health problems. The risk of substance abuse is probably increased two- to threefold for those without a religious dimension to their lives. One study showed that 89% of alcoholics had lost interest in religious issues in their teenage years, whereas among those without an alcohol problem only 20% had lost interest.²⁸ Doctors are also a high-risk group for substance abuse. Religious commitment while in medical school has been found to be protective against the development of an alcohol problem in later life.²⁹

Religious affiliation, even where alcohol abuse has become a problem, protects against extremely heavy use with all its associated extreme health and social consequences. For those recovering from substance abuse, greater spiritual or religious involvement, interest or practice can have a positive effect on recovery. Programs based on such principles as Alcoholics Anonymous and the 12-Step Program can be beneficial for appropriately motivated patients,^30,31 although such programs will not be of benefit to all.³² Adolescents can also benefit from programs that include meaning or spiritually focused content.³³

PHYSICAL HEALTH

The significant role that a spiritual life plays in fostering good mental health, healthy lifestyle and the ability to cope with adversity goes part of the way to explaining why it is also associated with reduced risk for physical illnesses such as hypertension, heart disease and cancer,^34–37 and with a longer life expectancy (Box 12.1). A population study over 9 years showed that death from all causes was significantly reduced and life expectancy increased (75 years versus 82 years) for those who attended church regularly. Again, these findings were not entirely explainable by accepted lifestyle and social variables.^38,39 Although most of this research has been carried out in Western countries, if studies were done in other countries with other religious or spiritual traditions they would probably produce similar findings.

BRAIN SCIENCES AND SPIRITUALITY

Some say that spiritual experiences can simply be explained as chemical and electrical changes in the brain. Biological and neural correlates of spiritual experiences have been identified through functional MRI and, to an extent, can be artificially induced through drugs or electrical stimulation. During religious recitation, religious subjects activate areas of the prefrontal and parietal cortex.⁴³ Activity in the temporal lobes of the brain is also associated with a number of religious and psychological phenomena, including blurring of interpersonal or ego boundaries.^44,45 Whether the neurological changes are the cause of psychological or spiritual phenomena or the effect of them is a source of ongoing debate.

WHY MIGHT SPIRITUALITY BE PROTECTIVE?

Having an active spiritual life can protect people against various problems by:

Religious experience is among the hardest fields of psychology and sociology to study because it is not easily defined, isolated and measured.

RELEVANCE TO CLINICAL MEDICINE

Spirituality has tended to sit uneasily alongside medical science and practice. Valid concerns and questions arise as to the appropriate level and manner of spiritual content in medical consultations. Overall, spiritual issues tend not to be discussed between doctors and patients, perhaps because doctors believe that these issues have little impact upon physical and mental health, that it would be unscientific to discuss them, or that having such discussions is the role of someone more specifically trained to deal with them. However, evidence suggests that most patients wish to discuss spiritual issues with their doctors in particular situations, such as when dealing with major and life-threatening illness. Over four out of five people:

This suggests that, from a patient’s perspective at least, spiritual issues are very relevant to the doctor–patient relationship.

Some of the key points about the interaction between spiritual issues and medicine are identified by D’Souza as follows:⁴⁷

Unfortunately, a perceived lack of holism is a central reason that many patients look outside the biomedical model for their healthcare.⁴⁸ Gauging a patient’s spiritual interests and involvement, or exploring the ways in which they search for meaning, should form an important part of a thorough medical history, especially when dealing with mental health issues and major illness. One cannot really be said to know another person well without considering such questions. Approaching the management of conditions like depression or terminal illness will take place without an understanding of a person’s deepest motivations, fears and hopes.

A consensus panel of the American College of Physicians suggested four simple questions that physicians could ask patients:⁴⁹

Four basic considerations should be kept in mind when taking a spiritual history:⁵⁰

Broaching philosophical and spiritual issues within the medical consultation obviously requires skill and sensitivity on the part of the doctor. It also requires courage, trust and openness on the part of the patient. It cannot take place meaningfully and successfully without cultural tolerance and the ability to be non-dogmatic. When done effectively it facilitates counselling and psychotherapy.⁵¹ Each patient needs to explore spiritual issues in their own way.

If a doctor is not religious, it does not relieve them of the responsibility to respectfully enquire about such issues. It is then up to the patient as to how far they take the conversation. Part of inviting discussion in a respectful way is the doctor taking care not to push a line of thought, whether it be religious or secular. Religious, spiritual or philosophical sensitivities and biases can make discussion divisive and difficult. If significant spiritual or religious issues are uncovered then the doctor may be able to direct the patient to the best avenue for follow-up. More in-depth questions about spirituality and religion should be referred to culturally appropriate ‘non-medical experts’.

THE SEARCH FOR MEANING

For many, especially the young, the search for meaning is becoming a rarer commodity, in the hustle and bustle of modern life with its increasing focus on material concerns. There is an obvious need for balance between material concerns and those related to meaning and values.

The search for meaning is a basic human need, and a prerequisite for growth and understanding. It is the firm foundation upon which we build resilience and gives life its richness, direction and fulfillment. There are many ways of searching for meaning, but it is up to each of us to search for it in a way that is meaningful to us. We all make meaning out of what happens to us, whether we are aware of it or not. Even the vigorous questioning of religious assumptions or dogma is an active search for meaning. It simply means that it is being sought through enquiry, reason and the search for knowledge.