Much has changed in the past three decades: Twelve Step spirituality is widely valued. Psychoanalysts such as Ana-Maria Rizzuto have revised Freud’s understanding of faith. Mindfulness has become mainstream. Palliative Medicine, which includes spiritual care among its goals, has begun to influence psychiatry. Research has burgeoned into the effects of religion on health (e.g. via positive and negative “religious coping”), and into the neurobiology of spiritual experience. The Joint Commission mandates routine spiritual assessment, reflecting greater appreciation for the role of religion/spirituality as a risk or protective factor. Most patients surveyed want religion/spirituality included in therapy. Courses, papers, journals and books in this area have proliferated, many sponsored by interest groups within mental health organizations such as the American Psychological Association, the Royal College of Psychiatrists and the World Psychiatric Association. In 2014, the American Psychiatric Association engaged in a Mental Health and Faith Community Partnership, and published a Mental Health Guide for Faith Leaders. Seven doctoral programs in clinical psychology now exist within Christian universities and while psychiatrists are less religious than physicians in other specialties, Curlin et al. found in a national survey that they are more likely to say it is appropriate to ask patients about spiritual concerns (93% vs. 53%) and that they do inquire (87% vs. 49%).
Of course, major challenges remain. No consensus among psychiatrists exists about core competencies dealing with religion/spirituality, or its importance, and only a minority of psychiatry residency programs offer formal training in this area. Research funding is limited. Coordination with spiritual care providers is the exception, despite the fact that individuals are apt to consult clergy first about most mental conditions. Mental illness remains misunderstood among many religious communities: in a 2013 survey of a representative sample of Americans about mental illness, a third agreed with the statement, “With just Bible study and prayer, ALONE, people with serious mental illness like depression, bipolar disorder, and schizophrenia could overcome mental illness.” For their part, many psychiatrists suspect religion/spirituality of promoting dependence and intolerance.
I am encouraged by developments on two fronts, the first conceptual. Much of psychiatrists’ resistance to change, and their relative insularity from other disciplines, reflects historical concerns about respecting patient autonomy and effectively addressing problems (pathology). Growing attention within medicine to professionalism and patient centeredness has resonated with many psychiatrists, and those interested in treating the whole person have begun to appreciate the contributions of positive psychiatry, with its debt to positive psychology. The result has been more balance, perspective and interest in larger issues.
A second encouraging front is personal, where relationships have catalyzed numerous examples of trust and openness to pluralism and difference. These include the inclusion of chaplains in psycho-oncology rounds at my hospital; multidisciplinary grants to study spiritual competencies, spiritually integrated therapy, and the virtue of accountability; courses and symposia at national meetings bringing together differing faith perspectives on issues such as forgiveness and Islamophobia; and interdisciplinary conferences born out of painful personal experiences with mental illness and care, such as the annual Conference on the Church and Mental Health at Saddleback Church, and those led by Warren Kinghorn at Duke on ways that religious communities can care for those with mental problems. Progress on these fronts encourages me to see three principal sources of hope for the future: (1) respect for emerging science showing the practical importance of religion/spirituality to mental health, e.g. in the work of Lisa Miller, Tyler VanderWeele, David Rosmarin, Harold Koenig and Tracy Balboni; (2) globalism, with the attention it is forcing through issues such as Islamophobia, religious extremism and folk healing to the need for a cultural competence that takes into fuller account the person’s religion/spirituality identity and community of belief and practice; and (3) role models of spiritually sensitive practice, including those honored by the APA’s annual Oskar Pfister Award, such as Ana-Maria Rizzutto, Ned Cassem, Harold Koenig, Ken Pargament and John Swinton.
I have found the Annual Conference on Medicine and Religion, while not primarily focused on mental health, an important way to bring together people and ideas across disciplines and faith traditions to address the questions still facing us. Some of these include: Can generic spirituality as seen in the rise of the “spiritual but not religious” bear the weight of the moral and existential distress being more acknowledged by psychiatrists? If not, what approach can? How can chaplains and faith communities better address the often complex, multidimensional struggles of individuals living with mental illness? What can mental health clinicians learn from individuals in other fields, and what can others learn from our fraught relationship with spirituality and religion?
Psychiatry and religion/spirituality are learning more from each other, and not least, how much more we all have to learn.