The relevance of religion and spirituality to psychiatric practice

Key messages

• Religious/spiritual beliefs, values and practices of the individual, their families and of their communities, have the potential to influence the course of mental illness and attitudes towards people living with mental illness.
• Religion/spirituality may be relevant for people across a wide variety of individuals and communities in Australia and New Zealand, including Māori, Pasifika and Aboriginal and Torres Strait Islander peoples.  Psychiatrists should acknowledge that matters of religion and/or spirituality are of core relevance to the expression and treatment of mental disorders.
• The exploration of religion/spirituality may constitute an essential component of clinical assessment.
• Where indicated, there are benefits to considering religion/spirituality within treatment planning although psychiatrists must not step outside their scope of practice by providing direct religious/spiritual instruction.
• Psychiatrists should be aware of the evidence base for psychiatric treatments which incorporate religious/spiritual principles.
• Psychiatrists should demonstrate respect for patients and their families by acknowledging their religious/spiritual beliefs and practices.
• In their role as medical practitioners, psychiatrists should be careful not to unduly influence the religious/spiritual views of their patients. 

Definitions

Although religion and spirituality lack universally agreed definitions, it is useful to refer to those provided by the World Psychiatric Association (WPA) for the purposes of this position statement.

• Spirituality pertains to the human experience in relation to the transcendent/sacred as well as to values, meaning and purpose in life (WPA, 2016).
• Religion is often understood to be the institutional form of spirituality consisting of the systems and practices of a community in relation to a divine or eternal guiding presence (WPA, 2016).

This position statement will refer to ‘religion/spirituality’ to mean ‘religion and/or spirituality’ in recognition of the fact that many individuals have their own understandings of these concepts.

Background

Religion/spirituality is relevant to the practice of psychiatry insofar as it can affect the lived experiences of people living with mental illness, as well as their families and communities (WPA, 2016; RCPsych, 2013). For many people, religion/spirituality is an integral component of who they are and an intrinsic part of the way they relate to their environments. It also has the capacity to influence the way they engage and interact with others, including health professionals, and the way they perceive and experience symptoms such as mood, thought disorders or hallucinations. A person’s religion/spirituality may also take on greater significance during times of trauma, crisis, death of a loved one, illness or transition, as well as in later life.

Good clinical practice is based on a biopsychosocial model which demonstrates the need for health professionals to consider the interaction of biological, psychological and social/cultural factors in the provision of holistic health care (Engel, 1977). For this reason, psychiatric practice may require consideration of the religious/spiritual beliefs, values and practices of the individual, as well as their families and communities, as these factors have the potential to influence the course of mental illness and attitudes towards people living with mental illness (RCPsych, 2013). Accordingly, the RANZCP Code of Ethics notes that ‘psychiatric care shall consideration of patients’… spiritual well-being’ (RANZCP, 2010). The Australian Medical Association (AMA) also notes in its Code of Ethics that doctors should ‘recognise the role of other support services including… religious, spiritual and cultural advisers’ (AMA, 2016). 

Religion/spirituality may be relevant for a range of individuals and communities across all cultures, religions, denominations and social groups. People often have multiple, and sometimes conflicting, cultural identities, and a person’s cultural heritage is only one facet of their identity. Psychiatrists should be knowledgeable about a wide range of religious/spiritual beliefs. At the same time, they should exercise care not to make assumptions about an individual’s beliefs based on their appearance or cultural and/or religious/spiritual affiliations.

Proper consideration of religion/spirituality includes a recognition of the different ways in which religion/spirituality can affect mental health outcomes. For some people, religion/spirituality may be a potential source of strength and support which can be beneficial in a person’s journey of recovery. Alternately, some people may associate religion/spirituality with trauma. It is important to recognise that religion/spirituality may be symbols of abuse and oppression for some, while being symbols of strength and healing for others.

Evidence

Research into the interface between religion/spirituality and psychiatry and mental health can give conflicting results. Religion/spirituality can be associated with both positive and negative influences on mental health depending on a variety of factors (Koenig, 2012). One meta-analysis of studies over two decades found evidence that religious/spiritual involvement was associated with better mental health with respect to some mental disorders including depression. However, it also found some evidence that both low and extremely high levels of religious engagement corresponded with increased prevalence of depression (Bonelli and Koenig, 2013). As such, it would be too simplistic to suggest that religious/spiritual engagement has a net positive or negative impact.

Incorporation of religious/spiritual practices into holistic care may be beneficial to people with a diverse range of religious/spiritual beliefs. For example, the Strong Spirit Strong Mind model has demonstrated success in treating substance use issues among Aboriginal and Torres Strait Islander peoples (Dudgeon, Milroy and Walker, 2014) while the Turamarama Declaration demonstrates a Māori approach to suicide prevention (Durie, 2017). Cognitive–behavioural therapy has been adapted to integrate principles from Christianity, Judaism, Islam, Buddhism and Hinduism, with demonstrated benefits for people of those faiths (Pearce et al., 2015; Hook et al., 2010). Similarly, meditation or mindfulness practices may be relevant to many religions and spiritual practices (MAPPG, 2015).

Religion and spirituality in psychiatric assessment and treatment

Psychiatrists should respect the religious/spiritual beliefs and practices of their patients and consider them within the context of assessment and treatment. It is important that psychiatrists are fully respectful of the individual’s beliefs, lack of beliefs and/or opposition to beliefs. As noted in both the RANZCP and AMA Codes of Ethics, psychiatrists must not discriminate against patients on the basis of their religion or religious affiliations (RANZCP, 2010; AMA, 2016).

Psychiatrists should be well-informed and open to matters relating to religion/spirituality while being aware of their own beliefs to ensure an unbiased approach. Where appropriate, psychiatrists may discuss the religious/spiritual beliefs of their patients. Although psychiatrists need not hide their religious/spiritual affiliations, they should exercise caution when discussing their own beliefs and be careful not to unduly influence the religious/spiritual views of their patients.

The exploration of religion/spirituality may constitute an essential component of clinical assessment. This may be achieved through the use of simple screening questions or the taking of a religious/spiritual history (Payman, 2016; Saguil and Phelps, 2012). An important part of this process is distinguishing between religious/spiritual beliefs and experiences and symptoms of mental illness in order to assess whether there is a need for mental health intervention. A person’s relationships with religious/spiritual communities and institutions may also be relevant, and may at times be a source of trauma.

Religion/spirituality should be considered alongside other social, environmental and cultural determinants to achieve a more holistic understanding of the person’s needs and supports. A person’s religion/spirituality may affect their health and health-care needs, their ability to understand and cope with their illness, their experience of symptoms, and the support and care that they may receive from family, friends and their community (Koenig, 2012).

There may be benefits to giving consideration to religious/spiritual issues within treatment planning for people who would like to have these considered. Most Mental Health Acts in Australia and New Zealand include provisions regarding the cultural and religious/spiritual needs of patients, often making particular reference to Indigenous groups (RANZCP, 2017). 

When considering the role of religious/spiritual therapies, it is worth considering the roles of the psychiatrist and the community in addressing spiritual and psychiatric issues. However, psychiatrists must always be mindful of privacy and confidentiality concerns, and should ensure to have the valid consent of their patient as some people may not want their religious/spiritual communities involved due to concerns regarding communal pressure and/or stigma.

Where therapies are suitably based in psychiatric practice, psychiatrists should be knowledgeable of what research has been conducted before commencing treatment. Otherwise, it may be suitable to liaise, or encourage contact, with a religious/spiritual or cultural leader or community organisation for pastoral care and consideration of religious issues while separately maintaining psychiatric treatment. This should only ever be done with the valid consent of the patient.

The benefits of incorporating religion/spirituality into treatments may be of particular relevance for people from Indigenous backgrounds who often hold a holistic view of health. This may include linking physical, mental and spiritual dimensions, as well as the cultural, communal, ancestral, historical and environmental dimensions. Māori, Aboriginal and Torres Strait Islander and Pasifika peoples may have traditional healing practices and rituals which should be taken into account when providing care. Traditional healing practices may also be relevant to individuals from other traditional societies. Psychiatrists should refer to the RANZCP’s online resources relating to cultural competency and responsiveness.

Recommendations

The RANZCP recommends that psychiatrists:

• ensure the provision of holistic assessment and care taking account of a person’s ‘body, mind and soul’, encompassing their physical, psychological, sociocultural and religious/spiritual needs and values
• be knowledgeable about a wide range of religious/spiritual beliefs and should exercise care not to make assumptions about an individual’s beliefs based on their appearance or cultural and/or religious/spiritual affiliations
• be willing to work with members of religious/spiritual communities in support of the well-being of individuals, and their families and communities, only ever with the valid consent of the individual
• abide by the RANZCP’s Code of Ethics at all times including respecting the religious/spiritual beliefs and practices of patients and colleagues, and protecting their interests regarding privacy and confidentiality
• be careful not to unduly influence the religious/spiritual views of their patients.

Responsible committee: Section of History, Philosophy and Ethics of Psychiatry 

References

Australian Medical Association (2016) Code of Ethics. Available at: https://ama.com.au/positionstatement/code-ethics-2004-editorially-revised-2006-revised-2016 (accessed 10 April 2017).

Bonelli RM, Koenig HG (2013) Mental disorders, religion and spirituality 1990 to 2010: A systematic evidence-based review. Journal of Religion and Health 52: 657–73

Dudgeon P, Milroy H, Walker R (2014) Working Together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practices. Canberra: Commonwealth Government.

Durie M (2017) Indigenous suicide: The Turamarama Declaration. Journal of Indigenous Wellbeing: Te Mauri – Pimatisiwin 2(2): 59–67.

Engel GE (1977) The Need for a New Medical Model: The Challenge for Biomedicine. Science 196(4286): 129–36.

Hook JN, Worthington EL, Davis DE, Jennings DJ, Gartner AL, Hook JP (2010) Empirically supported religious and spiritual therapies. Journal of Clinical Psychology 66(1):46–72.

Koenig HG (2012) Religion, spirituality, and health: The research and clinical implications. International Scholarly Research Network 2012: doi: 10.5402/2012/278730.

Mindfulness All-Party Parliamentary Group (MAPPG) (2015) Mindful Nation UK. London: The Mindfulness Initiative.

Payman V (2016) The importance of taking a religious and spiritual history. Australasian Psychiatry 24(5): 434–6

Pearce M, Koenig HG, Robins C, Nelson B, Shaw S, Cohen H, King M (2015) Religiously Integrated Cognitive Behavioral Therapy: A New Method of Treatment for Major Depression in Patients With Chronic Medical Illness. Psychotherapy 52(1): 56–66. Royal Australian and New Zealand College of Psychiatrists (2018) Code

Royal Australian and New Zealand College of Psychiatrists (2018) Code of Ethics. Available at: RANZCP Code of Ethics (accessed 12 January 2022).

Royal Australian and New Zealand College of Psychiatrists (2017) References to Aboriginal and Torres Strait Islanders and Māori in Australian and New Zealand Mental Health Acts. Available at: Aboriginal and Torres Strait Islanders and Maori - mental health legislation (ranzcp.org) (accessed 12 January 2022).

Royal Australian and New Zealand College of Psychiatrists (2018) Our history. Available at: www.ranzcp.org/About-us/About-the-College/Our-history.aspx (accessed 15 January 2018).

Royal College of Psychiatrists (UK) (2013) Recommendations for psychiatrists on spirituality and religion. Available at: www.rcpsych.ac.uk/pdf/ps03_2013.pdf (accessed 27 January 2017).

Saguil A, Phelps K (2012) The Spiritual Assessment. American Family Physician 86(6): 546–50.

World Psychiatric Association (2016) WPA position statement on spirituality and religion in psychiatry. Available at: www.wpanet.org/detail.php?section_id=8&content_id=1821 (accessed 11 September 2017). 

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.