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