Examining the spirituality-health connection
Ever since the late 1990s, there’s been an explosion in the number of studies devoted to examining the role that spirituality and religion have on health. Between 2001 and 2010, the number of research studies examining the spirituality-health connection more than doubled, from 1200 to 3000.
Improvements in pharmacology are one big reason for the shift.
Because we already have so many medical treatments at our disposal, there is more interest in examining the role of religion and spirituality in health.
Despite the increase in interest, however, the relationship between religion/spirituality and health remains nebulous and difficult to examine. Human emotions, behavior, and beliefs are nonlinear, complex, and adaptive. Linear statistical methods, which are currently used to assess this spirituality-health connection, are not the best tools to elucidate an understanding of this complex topic.
Nevertheless, hundreds of studies have shown a positive correlation between religion/spirituality and health. Let’s take a closer look at some of the complex issues surrounding this link.
Before we look at associations, it’s important to define the terms “religion” and “spirituality.”
In a 2015 review article titled “Religion, Spirituality, and Health: A Review and Update,” Koenig defined religion as follows:
Religion involves beliefs and practices related to the Transcendent. In Western traditions, the Transcendent may be called God, Allah, HaShem, or a Higher Power, and in Eastern traditions, the Transcendent may be called Vishnu, Lord Krishnan, Buddha, or the Ultimate Reality. Religions usually have rules to guide behavior on earth and doctrines about life after death.
Religion is often organized as a community but can also exist outside of an institution and may be practiced alone or in private.
For a long time, it was assumed that spirituality was at the core of being religious. However, many people who are spiritual don’t adhere to religious doctrine. Thus, the meaning of spirituality has changed. Again, according to Koenig:
Spirituality, however, has become much broader, including not only those individuals who are deeply religious, but also those who are not deeply religious and those who are not religious at all (ie, secular humanists). In fact, spirituality has become largely self-defined and can mean nearly anything a person wants it to mean.
Of note, secular humanists conceptualize human existence devoid of a higher power and instead focus on the rational self, community, and science.
Importantly, spirituality research shows that, for many, spirituality is an intrinsic part of being human and involves a sense of connectedness to others. It helps people to empathize and care for those around them. During the course of an illness, spirituality can aid with recovery by facilitating autonomy and enabling growth beyond the limitations of illness.
In the Clinical Setting
Clinicians have a different view of spirituality than do patients. This discrepancy likely contributes to the difficulty that clinicians have with incorporating spirituality into care. Although both clinicians and patients express a similar understanding of the meaning of spirituality, the role of spirituality in illness recovery is viewed differently. Consider the following passage from a 2016 study published in BMC Psychiatry.
Clients [patients] tended to regard the connections to others and religion as sources of fulfillment of their intrinsic needs for love, care, and acceptance.
Some of them even viewed themselves as providers who could use their experiences to help others. Professionals [healthcare providers], on the other hand, regarded these connections as more functional, such that clients could obtain social support from others, which in turn could help stabilise their mind and symptoms.
In clinical settings, the term spirituality is preferred to religiosity because the patient can define spirituality in a fashion that makes personal sense. Spirituality serves as a catch-all for diverse worldviews. However, in clinical studies, the encompassing nature of spirituality is difficult to pin down; whereas, there is more clarity with religious indicators. After all, things like prayer, attendance at religious services, and so forth can be quantified.
For ease and clarity, in this article, we’ll adopt the mixed terminology suggested by Koenig: religion/spirituality.
In his literature review, Koenig summarized how he and his team examined 3300 studies published before 2010 to determine associations between health and religion/spirituality. Koenig’s survey was broad and includes mental, social, behavioral, and physical health. In addition to looking at studies published before 2010, Koenig looked at associations between religion/spirituality and health in more recent research.
In a study at Columbia University, psychiatric epidemiologists used a structural MRI to examine participants at high risk for depression. Previously, these researchers found that the risk of developing depression was 90 percent lower in people whom religion/spirituality was very important. Here they found that large areas of the cortex (responsible for higher-brain function) spanning both hemispheres were thinned in participants at high-risk for depression. However, people who were religious/spiritual demonstrated less cortical thinning.
Although this study didn’t prove that religion/spirituality caused less cortical thinning, the researchers hypothesized that religion/spirituality helped protect against depression.
One study found that among 20,014 adults followed for 15 years, the risk of committing suicide was 94 percent less in participants who attended religious services at least 24 times a year compared with those who attended such services less frequently. The researchers suggest that frequently attending religious services could protect against suicide in the long-term.
Based on analysis of the 2010 Baylor Religion Survey, researchers discovered that among 1511 respondents, those with a secure attachment to God who engaged in prayer experienced fewer anxiety symptoms. In those with an insecure attachment to God, prayer was related to a greater number of anxiety symptoms. This finding is corroborated by numerous other studies.
In a small cohort of 46 adolescents with cystic fibrosis that were followed for five years, researchers found that high levels of positive religious coping, such as prayer meetings and attendance to church youth groups, was associated with a significantly lower decline in nutritional status, a slower decline in lung function, and fewer days spent in the hospital per year. Specifically, people with high levels of positive religious coping spent an average of three days a year in the hospital compared with 125 days per year in those with low amounts of positive religious coping.
Apparently, positive religious coping served as support and protection against depression and stress. Furthermore, adolescents who participated in such religious/spiritual activities were more likely to engage in positive health behaviors and use medical services appropriately.
Researchers from the University of Miami followed people who were HIV-positive for two years and assessed HIV progression by measuring viral load levels in the blood. The researchers looked at increases in viral load following the death of a loved one (i.e., bereavement) or divorce. They found that increases religion/spirituality predicted a smaller increase in viral load from baseline after a traumatic event. Of note, the researchers controlled for antiretroviral medications and baseline viral load.
In other words, in cases where all else was equal, HIV-positive participants who were more religious/spiritual experienced smaller increases in viral load—indicating more limited HIV progression—after a major life stressor than did those who weren’t religious/spiritual.
A number of recent studies have examined the spiritual needs of those dealing with serious or terminal illness. In particular, in a 2014 study published in Critical Care Medicine, Johnson and colleagues found that among 275 family members, more spiritual care activities and a greater number of discussions with chaplains resulted in increased family satisfaction with ICU care and increased family satisfaction with overall decision-making.
On a related note, oncology researchers at the Dana-Farber Cancer Institute found that chaplains and healthcare professionals fell short in addressing spiritual needs of cancer patients—especially those with terminal cancer. Overall, deficient spiritual care was linked to an increase in life-prolonging interventions during the last week of life, which ended up costing two to three times as much compared with those patients whose spiritual needs were met.
The literature is ripe with findings that tie religion/spirituality to better health. However, we must qualify these overwhelmingly positive results with the obvious limitations of such studies. Namely, causality—or the claim that religion/spirituality directly results in better health—is elusive.
For instance, scores of studies have shown that attending religious services is correlated with the lower frequency of depression. Some take this finding to mean that religion protects against depression. However, it’s very likely that people who become depressed stop attending religious services altogether. Many studies that tout an association between increased attendance to religious services and decreased depression lack longitudinal data and robust measures of service attendance and depression over time to truly establish any direction of causality. Importantly, cross-sectional data, or data taken from a single point in time, are useless to establish causality.
Takeaways for Physicians
So how do we use this data? It’s both premature and ill-advised for a physician to counsel a patient on the value of religion/spirituality in illness recovery. If a patient isn’t receptive to religion/spirituality, advice on the subject would be unwelcome and inappropriate. Any incorporation of religion/spirituality into therapy should be at the behest of the patient and reflect patient values and treatment gains. Instead, the association between religion/spirituality and health may better serve to inform clinical practice.
Here are some possible ways that physicians can better incorporate religion/spirituality into their practice of medicine.
Physicians can incorporate the use of religious and spiritual assessments into the patient interview. Of note, several diagnostic tools, such as SPIRITual History, FAITH, HOPE, and Royal College of Psychiatrists instruments, have been developed for this explicit purpose. When taking a religious or spiritual history, physicians should assume a conversational and flexible tone as well as a patient-centered approach.
Once identified by the physician, issues of complex spiritual suffering or religious difficulties can be referred to the proper religious counselor, spiritual counselor, clergy person, or faith leader.
With those who are receptive, psychotherapies that incorporate religion/spirituality may be useful. For instance, Christian cognitive-behavioral therapy has been shown to be more effective than conventional cognitive-behavioral therapy in those patients who are so inclined. Furthermore, Muslim-based psychotherapy has also been shown to be of benefit to Muslim patients suffering from bereavement, depression, and anxiety. For patients who are spiritual but not religious, mindfulness interventions may benefit.
Physicians can be more receptive to patients when these patients express an interest in religion/spirituality during illness recovery. For instance, patients with cognitive deficits may have trouble discussing abstract concepts. Nevertheless, healthcare providers should strive to understand a patient’s needs even when these needs may not be particularly cogent.
Physicians should shift away from the perspective that religion/spirituality can be used to “fix” symptoms and rectify weakness. Instead, physicians should realize that patients who are spiritual/religious often desire to help others and want to be givers.
Consequently, physicians can adopt a strength- and ability-focused perspective when treating patients. In other words, the physician can help the patient realize how religion/spirituality can be used to aid others. Perhaps the benefits of religion/spirituality with regard to health are more circuitous and derived from the generosity of character. Moreover, when the patients adopt a charitable approach to religion/spirituality, their sense of connectedness with others increases.
By Naveed Saleh, MD, MS, Reviewed by Steven Gans, MD
Diane Gaston utilizes an approach to therapy that emphasizes all aspects of the individual, including the psychological, emotional, spiritual, and physical. I specialize in PTSD trauma therapy long beach working with those who have affected and held back by past trauma and/or adverse life events. I also work individually and with couples who wish to improve their relationships.