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Overcoming Barriers to Spiritual Health
Harold G. Koenig, MD
Professor of Psychiatry and Behavioral Sciences
Associate Professor of Medicine
Duke University Medical Center, Durham, North Carolina USA
Adjunct Professor, King Abdulaziz University, Jeddah, Saudi Arabia
Adjunct Professor, Ningxia Medical University, Yinchuan, People’s Republic of China
Visiting Professor, Shiraz University of Medical Sciences, Shiraz, Iran
Overview
1. Differences between religion and spirituality
2. Research on religion and mental health
3. Research on religion and physical health
4. Theoretical model explaining effects
5. Clinical applications
6. Conclusions
7. Further resources
Definitions: A Thorny Issue
Religion
Spirituality
Choice of terms to use depends on
the setting and the purpose
research purposes
vs.
clinical applications
Religion
Beliefs, practices, and rituals related to the ‘transcendent,” where the transcendent is that which relates to the mystical, supernatural, or God in Western religious traditions, or to Ultimate Truth, Reality, or Enlightenment, in Eastern traditions. May also involve beliefs about spirits, angels, or demons. Usually involves specific beliefs about the life after death and rules to guide behaviors in this life. Religion is often organized and practiced within a community, but it can also be practiced alone and in private, outside of an institution. Central to its definition is that religion is rooted in an established tradition that arises out of a group of people with common beliefs and practices concerning the transcendent. Religion is a unique construct, whose definition is generally agreed upon. It can be measured and quantified for research purposes (i.e., to examine whether religious involvement affects health).
Secular Humanism
Secular humanism is a way of viewing human existence and behavior that does not involve religion, i.e., God, the transcendent, a higher power, or ultimate truth. The focus is on the rational self and the community as the ultimate source of power and meaning.
This definition is generally agreed upon, is clear, and does not overlap with other constructs. It can be measured, quantified, and its effects on health can be examined.
Spirituality
A popular expression today preferred over religion. Today, spirituality is considered personal, something individuals define for themselves. It is often free of rules, regulations, and responsibilities associated with religion. One can be spiritual, but not religious. In fact, a “secular spirituality” is often emphasized in circles where religion is in disfavor.Thus, spirituality is seen as non-divisive and common to all, both religious and secular.
The term spirituality is especially useful in clinical settings. However, because of its vague and nebulous nature, it is difficult to measure and quantify in order to examine whether spirituality has any effects on health or health outcomes.
Spirituality: An Expanding Concept
Spirituality
Religion
Traditional-Historical Understanding
Source
Secular
Mental Health Physical Health
Meaning
Purpose
Connectedness
Peace
Hope
Depression
Anxiety
Addiction
Suicide
CardiovascularDisease
Cancer
Mortality
Psych
on
eu
roim
mu
no
log
y
vs.Ex. well-being
eeds code: 48yurt
Spirituality
Religion
Modern Understanding
Source
Secular
Mental Health Physical Health
Meaning
Purpose
Connectedness
Peace
Hope
Depression
Anxiety
Addiction
Suicide
CardiovascularDisease
Cancer
Mortality
Psych
on
eu
roim
mu
no
log
y
vs.Ex. well-being
eeds code: 48yurt
Spirituality
Religion
Modern Understanding - Tautological Version
Source
Secular
Mental Health Physical Health
Meaning
Purpose
Connectedness
Peace
Hope
Depression
Anxiety
Addiction
Suicide
CardiovascularDisease
Cancer
Mortality
Psych
on
eu
roim
mu
no
log
y
vs.
Ex. well-being
eeds code: 48yurt
Spirituality
Religion
Modern Understanding - Clinical Application only
Source
Secular
Mental Health Physical Health
Meaning
Purpose
Connectedness
Peace
Hope
Depression
Anxiety
Addiction
Suicide
CardiovascularDisease
Cancer
Mortality
Psych
on
eu
roim
mu
no
log
y
Ex. well-being
Not a Researchable Model
Definitions as used in This Talk
1. In discussing the research, I’m going to mostly use the term
“religion,” since that is what can be measured, and is
sufficiently distinct to avoid conceptual overlaps with mental
and physical health (the outcomes).
2. When discussing clinical applications, a broadly inclusive
term such as spirituality should be used and defined by
patients themselves, so as to maximize connection,
engagement and conversation.
Research on Religion and Mental Health
Religion as a Coping Behavior
1. Many persons turn to religion for comfort
2. Religion used to cope with common problems in life,
especially highly stressful situations
3. Religion often used to cope with challenges such as:
- uncertainty
- fear
- loss of control
Religious Coping – does it help?
Review of the Research
Handbook of Religion and Health
(Oxford University Press, 2001, 2012, and
2022, forthcoming)
Religion and Mental Health: Research &
Clinical Applications
(Academic Press, 2018)
Koenig, H. G., Al-Zaben, F., & VanderWeele, T. J. (2020). Religion and psychiatry:
Recent developments in research. British Journal of Psychiatry Advances, 26(5), 262-272.
Koenig, H. G., Peteet, J. R., & VanderWeele, T. J. (2020). Religion and psychiatry:
Clinical applications. British Journal of Psychiatry Advances, 26(5), 273-281.
Religious involvement is related to:
Less depression, faster recovery from depression272 of 444 studies (61%) [67% of best]
More depression (6%)
DepressionOne of the most common emotional disorders in the world,
especially among medical patients, and more disabling than any other
condition except heart disease.
eeds code: 48yurt
Citation: Miller L et al (2014). Neuroanatomical correlates of religiosity and spirituality in adults at high
and low familial risk for depression. JAMA Psychiatry 71(2):128-35
Religion/Spirituality and Cortical Thickness:
A Structural MRI Study
Areas in red indicate reduced cortical thickness
Religion NOT very important Religion very important
Religious involvement is related to:
Less suicide and more negative attitudes toward suicide (106 of 141 or 75% of studies)
Suicide(systematic review)
>Once/Week Once/Week <Once/Week Never U.S. in 2010
0
2
4
6
8
10
12
Su
icid
e In
cid
ence
Rate
per
10
0,0
00
Pers
on
-Ye
ars
Religious Service Attendance
Nurses Health Study: 89,708 women followed from 1996 to 2010 (HR=0.16, 95% CI 0.06-0.46)
VanderWeele et al (2016). JAMA Psychiatry (Archives of General Psychiatry) 73(8):845-851
Nurses Health Study: 89,708 women followed from 1996 to 2010 (HR=0.16, 95% CI
0.06-0.46) VanderWeele et al (2016). JAMA Psychiatry (Archives of General
Psychiatry) 73(8):845-851
>Once/Week Once/Week <Once/Week Never
0
2
4
6
8S
uic
ide I
ncid
en
ce R
ate
pe
r 1
00
,00
0 P
ers
on-Y
ears
Religious Service Attendance
Chen, Y., et al. (2020). Religious service attendance and deaths related to drugs, alcohol, and suicide among US
health care professionals. JAMA Psychiatry, 77(7), 737-744. [16-year prospective study of 66,492 women
examining “deaths of despair” (from drugs, alcohol, or suicide); Cox proportional hazards regression models
controlling for 25 demographic, psychological, social, and physical health covariates]
Never/Almost Never < Once/Week Once/Week or More
0.00
0.25
0.50
0.75
1.00H
azard
Ra
tio
(H
R)
for
De
ath
s o
f D
es
pa
ir
Religious Attendance
HR=1.00
HR=0.66
(95% CI=0.38-1.14)
HR=0.32
(95% CI=0.16-0.62)
Religious Attendance and Deaths of Despair
Among U.S. Health Professionals (Women)
p for trend <0.001
Chen et al. 2021 Religious service attendance and deaths related to drugs, alcohol, and suicide among US
health care professionals. JAMA Psychiatry, 77(7), 737-744. [26-year prospective study of 43,141 men
(dentists, pharmacists, optometrists, osteopaths, podiatrists, veterinarians) examining “deaths of despair”
(from drugs, alcohol, or suicide); Cox proportional hazards regression models age adjusted only]
HR=1.00
HR=0.74
(95% CI=0.51-1.08)
HR=0.51
(95% CI=0.37-0.70)
Religious Attendance and Deaths of Despair
Among U.S. Health Professionals (men)
p for trend < 0.001
Never/Almost Never < Once/Week Once/Week or More
0.00
0.25
0.50
0.75
1.00H
azard
Rati
o (
HR
) fo
r D
eath
s o
f D
esp
air
Religious Attendance
Religious involvement is related to:
Less alcohol use / abuse / dependence240 of 278 studies (86%)
[90% of best designed studies]
Alcohol Use/Abuse/Dependence (systematic review)
Illicit Drug Use(systematic review)
Religious involvement is related to:
Less drug use / abuse / dependence155 of 185 studies (84%)
[86% of best designed studies]
[95% of RCT or experimental studies]
Religious involvement is related to:
Greater well-being and happiness256 of 326 studies (79%)
[82% of best]
Lower well-being or happiness (3 of 326 studies, <1%)
Well-being and Happiness(systematic review)
Religious involvement is related to:
Greater meaning and purpose42 of 45 studies (93%) [100% of best]
Greater hope29 of 40 studies (73%)
Great optimism26 of 32 studies (81%)
*All of the above have consequences for patients’ motivation for self-care and efforts toward recovery*
Meaning, Purpose, Hope, Optimism(systematic review)
Religious involvement is related to:
• Great social support(61 of 74 studies) (82%)
Social Support(systematic review)
At least 104 quantitative peer-reviewed studies have examined
the spirituality-delinquency/crime relationship. Of those, 82
(79%) reported inverse relationships between spiritual
involvement and delinquency or crime.
Of the 60 best studies, 82% found significant inverse
relationships.
Delinquency and Crime(systematic review)
Spiritual But Not Religious
Followed 8,318 medical outpatients in United Kingdom, Spain, Slovenia,
Estonia, The Netherlands, Portugal and Chile. AIM: determine if baseline
spiritual or religious (S/R) beliefs predict onset of MDD during 12-mo f/u.
S/R beliefs measured by (1) whether understanding of life is primarily
religious, spiritual, or neither, and (2) if S/R, how strongly held. CIDI used to
make the diagnosis of MDD at 6 and 12 mo follow-ups. Controlled for:
gender, age, education, marital status, employment status, ethnicity, and
history of depression. SLE in past 6 mo and social support examined as
mediators. Results: Adjusting for confounders and mediators, those with a
spiritual view (but not religious) were more likely to experience MDD over
the next 12 months compared to those with a secular view (OR=1.32, 95% CI
1.02-1.70). When analyses stratified by country, effect especially significant in
UK (OR 2.68, 95% CI 1.52-4.71, p<0.01).
Citation: Leurent B et al (2013). Spiritual and religious beliefs as risk factors for the onset
of major depression: An international cohort study. Psychological Medicine, 43(10):2109-
2120
Spiritual But Not Religious
King et al. investigated associations between a spiritual or
religious understanding of life and psychiatric symptoms in 7,403
people in England. They found religious people were similar to
those who were neither religious nor spiritual with regard to the
prevalence of mental disorders, except that those who were
religious were less likely to have ever used drugs or to be a
hazardous drinker. On the other hand, spiritual people (spiritual
but not religious) were more likely than those who were neither
religious nor spiritual to have (a) ever used or to be dependent on
drugs, (b) abnormal eating attitudes, and (c) generalized anxiety
disorder, any phobia or any neurotic disorder.
King M, Marston L, McManus S, Brugha T, Meltzer H, Bebbington P. Religion,
spirituality and mental health: results from a national study of English
households. British Journal of Psychiatry. 2013; 202(1):68-73.
Religious Involvement
(attendance, prayer,
scripture study,
volunteering, religious
education, religious
devotion, coping)
Later Child
Enviornment
Adult
Environment
Maternal Stress &
Substance Use
Prenatal
Environment
Psychological
Early Child
Environment
Train/Model Morals
& Values; Monitoring
Caregiver Nurturing
& Support
Trauma, Losses,
Negative Life Events
Positive Cognitions,
Healthy Coping
Gene x Environment Interactions
Behavioral
Social
Healthy Lifestyle(exercise, diet, weight, no
smoking, alcohol/drugs)
Support, Prosocial
Peers, Volunteer
Prosocial Choices,
Healthy Decisions,
Virtues/Character
Individual/
Personal
Research on Religion & Health Behaviors
Religion is related to:
• More exercise/physical activity(25 of 37 studies) (68%)
• Less extra-marital sex, safer sexual practices (fewer partners) (82 of 95 studies) (86%)
• Lower weight(7 of 36 studies) (19%)
• Heavier weight(14 of 36 studies) (39%)
Exercise, Weight, Risky Behaviors(systematic review)
Religious involvement is related to:
Less cigarette smoking, especially among the young(122 of 135 studies) (90%)
Cigarette smoking(systematic review)
Research on Religion and Physical Health
Physical Health Consequences
Those who are more frequently involved in religious activity, on average:
• Have less heart disease• Have lower blood pressure• Have lower rates of stroke • Experience less cognitive decline with aging• Experience less physical disability with aging• Have better immune function and less systemic inflammation• Have better endocrine functions (<cortisol, epi & norepinephrine)• Have lower death rates from cancer• Experience greater longevity
Of all religious characteristics, frequency of attendance at religious services is the strongest predictor of physical health and longevity.
Mortality (all-cause)(systematic review)
Religious involvement related to:
• Greater longevity in 82 of 120 studies (68%)
• Shorter longevity in 7 of 120 studies (6%)
eeds code: 48yurt
>Once/Week Once/Week <Once/Week
0.5
0.6
0.7
0.8
0.9
1.0
All
-Cau
se
Mo
rtali
ty (
HR
)
Religious Attendance
Multivariable Adjusted Hazard Ratio with 95% Confidence Intervals
(reference category "never attend", with gradient of effect p<0.001)
HR=0.87
HR=0.67
HR=0.74
Nurses Health Study: 74,534 women followed from 1996-2012
Li et al (2016). JAMA Internal Medicine 176(6):777-785
>Once/Week Once/Week <Once/Week
0.5
0.6
0.7
0.8
0.9
1.0
Card
iovascu
lar
Mo
rtality
(H
R)
Religious Service Attendance
Multivariable-Adjusted Hazard Ratios and 95% Confidence Intervals
(reference category "never attend" with gradient of effect p<0.001)
HR=0.73
HR=0.80HR=0.92
Li et al…VanderWeele (2016). JAMA Internal Medicine 176(6):777-785
>Once/Week Once/Week <Once/Week
0.5
0.6
0.7
0.8
0.9
1.0
Ca
nc
er
Mo
rtali
ty (
HR
)
Religious Attendance
Multivariable-adjusted Hazard Ratios and 95% Confidence Intervals
(reference catetory "never attend" with gradient of effect p<0.001)
HR=0.79
HR=0.86 HR=0.91
Li et al…VanderWeele (2016). JAMA Internal Medicine 176(6):777-785
Mediation Analysis for the Religious Attendance –
All-Cause Mortality Effect
Depressive Symptoms (CES-D) 11% p<0.001
Current Smoking 22% p<0.001
Optimism 9% p<0.001
Social Integration 23% p=0.003
Unexplained 35%
(no mediation for alcohol use, diet quality, phobic anxiety)
Li et al…VanderWeele (2016). JAMA Internal Medicine 176(6):777-785
0
500
1000
1500
2000
2500
C NG (NG) M (P) P NA
C
NG
(NG)
M
(P)
P
NA
Number of studies includes some studies counted more than once (see Appendices
of 1st and 2nd editions). Prepared by Dr. Wolfgang v. Ungern-Sternberg
The Relationship between Religion and Health: All Studies
Belief in,
attachment to
God
Public prac, rit
Private prac, rit
R commitment
R coping
Positive Emotions
Negative EmotionsMental Disorders
Social Connections
Ph
ysic
al H
ea
lth a
nd
Lo
ng
evity
Imm
une, E
ndocrine, C
ard
iovascula
r F
unctions
Theoretical Model of Causal Pathways
Genetics, Developmental Experiences, Personality
Decisions, Lifestyle Choices, Health Behaviors
SOURCE
R experiences
Spirituality
faith
community
PsychologicalTraits / Virtues
ForgivenessHonestyCourageSelf-disciplineAltruismHumilityGratefulnessPatienceDependability
Theolo
gic
al V
irtues:
faith
, hope, lo
ve
faith
community
*Model for Western monotheistic religions (Christianity, Judaism, and Islam)
(c) Handbook of Religion & Health, 2nd ed
Clinical Applications
Applications in Healthcare
• Physicians should take a spiritual history -- talk with patients about
these issues
• Respect, value, support beliefs and practices of the patient
• Identify the spiritual needs of the patient
• Ensure that someone meets patients’spiritual needs (pastoral care)
• Pray with patients if patient requests
• Work with the faith community, if patient consents
From: Spirituality in Patient Care (Templeton Foundation Press, 2013)
The Spiritual History1
1. Do your religious/spiritual (R/S) beliefs provide comfort?
2. Are your R/S beliefs a source of stress?
3. Do you have R/S beliefs that might influence your medical
decisions?
4. Are you a member of a faith community, such as a church,
synagogue, mosque, or temple? If yes, is it supportive?
5. Do you have any other spiritual concerns that you’d like someone to
address?
1Adapted from Koenig HG (2002). Journal of the American Medical
Association (JAMA) 288 (4): 487-493
Activities Besides Taking a Spiritual History
1. Support healthy religious/spiritual beliefs of the patient (verbally, non-verbally)
2. Ensure patient has resources to address their spiritual needs (refer to chaplain,
licensed pastoral counselor, licensed religious counselor)
3. Accommodate the inpatient environment to meet spiritual needs of patients from
all faith traditions (e.g., prayer rug for Muslims, direction to Mecca, alone space
to pray or meditate, accessibility to religious services on TV, allow visits from
chaplains, personal clergy, and possibly, members of the congregation if patient
allows)
4. Pray with patients if patient requests (controversial and need to be very careful,
especially in psychotherapy; often best to have patient say the prayer)
5 CME-qualified 45-60 min Training Videos on How to Integrate Spirituality into Patient Care (using the “Spiritual Care Team” approach)
Go to the following Duke University website:
http://www.spiritualityandhealth.duke.edu/index.php/cme-videos
Conclusions
1. Religious involvement (RI) is related to better mental, social, and behavioral health, and improves these aspects of health over time
2. RI is also related to better physical health, less functional disability, and less cognitive decline with aging
3. These findings have huge implications for public health and healthcare costs as RI becomes less common with each younger cohort.
4. The clinical applications of the research on religion/spirituality and health are vast in terms of provision of mental and physical health care
Further Resources
CROSSROADS…
Exploring Research on Religion, Spirituality & Health
• Summarizes latest research
• Latest news
• Resources
• Events (lectures and conferences)
• Funding opportunities
To sign up, go to website: http://www.spiritualityandhealth.duke.edu/
Monthly FREE e-Newsletter
Summer Research WorkshopAugust 15-19, 2022
Durham, North Carolina
5-day intensive research workshop focus on what we know about the relationship
between spirituality and health, clinical applications, how to conduct research, and
how to develop an academic career in this area. Faculty includes leading spirituality-
health researchers at Duke, Yale University, Emory, and elsewhere.
-Strengths and weaknesses of previous research
-Theological considerations and concerns
-Highest priority studies for future research
-Strengths and weaknesses of measures of religion/spirituality
-Designing different types of research projects
- Primer on statistical analysis of religious/spiritual variables
-Carrying out and managing a research project
-Writing a grant to NIH or private foundations
-Where to obtain funding for research in this area
-Writing a research paper for publication; getting it published
-Presenting research to professional and public audiences; working with the media
Partial tuition Scholarships are available
Full scholarships for those in undeveloped countries
If interested, contact Dr. Koenig: [email protected]
Questions and Discussion(till 1:00)