COVER STORY

The Bible tells us to lay hands on the sick and they shall recover and will continue to do that without the fear of the spread of any virus. Pastor Tony Spell, Life Tabernacle Church, Baton Rouge, LA1

Can prayer on behalf of those with serious illness be of benefit to a cohort of anonymous recipients? We recently became aware of a randomized, controlled study aimed at answering precisely this question for a population of patients with COVID-19 in the intensive care unit.2 Whatever ones religious or spiritual beliefsor lack thereofthis study raises profound questions and concerns for psychiatrists. For example, what is the effect on patients and their families if their prayers for ailing loved ones are not answered? What is the potential for religious and spiritual interventions to relieveor to exacerbatethe stress of the COVID-19 pandemic? In this article, we explore the double-edged sword of religious and spiritual responses to the pandemic.

The upside of religion and spirituality during the pandemic

A recent survey sponsored by the American Psychiatric Association highlighted the adverse psychological effects of the current pandemic and the prominent place of religious faith in addressing these effects.3 The survey results indicate that nearly half of Americans (48%) are anxious about the possibility of contracting coronavirus; about 40% are anxious about becoming seriously ill or dying from coronavirus; and even more Americans (62%) are anxious about the possibility of family and loved ones getting coronavirus. The APA survey is cited in a new Department of Health and Human Services (DHHS) resource for faith-based leaders assisting their communities to manage the challenges COVID-19 presents to their faith and lives. Importantly for our topic, DHHS cites research that one in four people who seek help for mental health concerns turn to faith leaders before they seek help from clinical professionals.4

Indeed, there is a long philosophical and historical relationship between religion, spirituality, and healing, as well as a modern body of solid empirical evidence showing the beneficial effects that traditional religion and more contemporary spirituality have on physical and mental health.5 Although there is valid criticism of the methodological limits of some studiesincluding, for example, the difficulty in establishing causalitymost health care practitioners, including mental health professionals, have seen these benefits for many patients under their care.

For example, a rigorous 16-year follow-up study showed that women (N = 74,534) who attended religious services more than once per week experienced 33% lower all-cause mortality, including cancer and heart disease, compared with women who had never attended religious services.6 Li and colleagues noted that, There may be many pathways from attendance at religious services to health and that effects on depressive symptoms, smoking, social support, and optimism were potentially important mediators. No single mediator explained more than about 25% of the effect.

Even more pertinent to psychiatry findings from a study published in the American Journal of Psychiatry suggest that persons who endorsed religion and spirituality as being of high importance in their lives had only one-tenth the risk for depression (especially recurrent depression), compared with those for whom religion was of less or no importanceno matter the nature of the religious or spiritual beliefs.7 This association held true even more strongly if an individual had a depressed parent.

We might just say, all well and good: religion and spirituality, through 1 or more mechanisms, can have a positive impact on heart disease and depression. But how could religious belief and spiritual practice be helpful in the worldwide COVID-19 pandemic when we do not even have a vaccine? Intuitively, it might seem more likely that, in the context of such a devastating plague, certain religious beliefs would only worsen fear and despairperhaps conjuring up images of apocalyptic plagues and divine punishment for sin, or leading people to feel that God had abandoned them and then to reject religion and spirituality completely.

Although scientific research on this issue is not yet available, news stories and public opinion polls suggest that the picture is actually more ambiguous, and that there is both an up- and a downside to religion and spirituality in COVID-19, as we will discuss in the remainder of this article.

Many mainstream churches, synagogues, mosques, and templesfaced almost overnight with the need to promote public health restrictions and cancel the services that are the heart of much communal worshipdeveloped an online presence that reduced isolation and offered solidarity in prayer, medication, and religious reading.8

Moreover, a recent Gallup Pollagain belying the scenario that COVID-19 will lead to a loss of faith or negative expressions of religiosityhas found that the COVID-19 crisis has enhanced spirituality and religion for many Americans. During the period when the pandemic was rapidly spreading to many parts of the US (March 28-April 1), 19% of those interviewed felt their faith or spirituality had gotten better during the crisis. Commenting on this finding, Gallup senior scientist Frank Newport, PhD,9 observed that One of the traditional roles of religious individuals and religious entities has been to serve a positive, integrative, pro-social, charitable function in crisis situations.

The downside of religion and spirituality

In our view, the best available evidence points to a predominantly positive effect of spirituality/religion on mental health and coping, especially during times of crisis. However, as Mosqueiro and colleagues10 observe, there is also a downside to this relationship . . . [as] religion can be a major source of stress for many people.

Thus, Rosmarin, Malloy, and Forester11 have described what they call a spiritual struggle in some individuals, defined as any dysfunctional religious or spiritual belief that is capable of generating or exacerbating suffering. This is also called negative religious coping and may include religious guilt, the belief that God is malicious, and the fear of [divine] retribution.11

In the context of the coronavirus pandemic, clinicians may need to consider the following questions: What happens to religiously oriented people when things go badly, despite their faith and prayer, when for example, a loved one dies of COVID-19 despite the prayers and faith in God of family members? Might the family think that they did not pray hard enough or were not cheerful and positive enough? Or that their loved one was somehow unworthy of being saved? Consider how people of faithespecially someone with a psychiatric disorder, such as major depression, obsessive-compulsive disorder, or posttraumatic stress disorderwould feel if a priest, rabbi, or other religious leader assured them that if they attend a large religious gathering, God will protect them from COVID-19; and later, the individual becomes ill and learns that other members of the congregationincluding, the leader himselfhave died of COVID-19. This is exactly what befell a respected Virginia pastor who had promised his congregation that God is larger than this dreaded virus.12 Not only may the members of that congregation experience an exacerbation of their underlying mental health condition, they may also lose trust in the very community and beliefs that were providing support and purpose.

We are not aware of any systematic research that has examined these questions with respect to the COVID-19 pandemic, which is still at a relatively early stage. However, studying these issues may have important implications for psychiatry and mental health treatment. For example, Rosmarin and colleagues11 found that spiritual struggle (negative religious coping) was a strong predictor of greater symptoms of both depression and mania and appears to be a common and important risk factor for depressive symptoms. However, religious affiliation, belief in God, and frequency of religious service attendance were all unrelated to affective symptoms. These findings suggest that it is not religious belief or religiously oriented behavior per se that negatively affects mood; but rather, the dimension of spiritual struggle and its accompanying cognitions (eg, God must be punishing me, I must be unworthy of being saved).

Negative religious coping may be more common among faiths and congregations that encourage the belief that people can will themselves into remission from some disease through prayerand that continued disease is a sure sign that the person has failed in some respect. Thus, Christina Puchalski, MD, MS, FACP, FAAHPM, Director of the George Washington University Institute for Spirituality and Health, reports Ive had very religious patients who told me that my church group said I didnt pray hard enough, because otherwise my diabetes would have been cured.13

We wonder how such a self-blaming belief may be playing out in very religious patients who are suffering prolonged and severe bouts of COVID-19but again, we are not aware of research in this area, at this stage of the pandemic. Nevertheless, we note with concern CNN reporter Miguel Marquezs observation at a recent protest against restrictions imposed in the wake of the COVID-19 pandemic.14 Marquez caught sight of a truck that bore the message, Jesus is my vaccine.14 As clinicians, we wonder what happens to people of strong religious faith when the Jesus vaccine does not work for them or their families.

Psychiatry and religious faith

Healthy religious and spiritual expression has almost always offered solace in disaster, consolation in bereavement, hope in sickness, and peace in death, for millions of human beings over the millennia. These are powerful reasons why, despite Freuds prediction in Civilization and Its Discontents nearly 100 years ago, that religion was a mass delusion that reason would soon banishreligious and spiritual expression has retained its vital significance in human life. Until quite recently, Freuds view captured the ambivalent, if not frankly adversarial, relationship psychiatry has had, historically, with religious belief. In our view, such animus is not in the best interest of our religiously oriented patients. Fortunately, as Professor of Medical Humanities, Farr Curlin, MD,15 has noted, This historical antagonism appears to be waning.

We believe that mental health and religious professionals must work together to help persons of faith toward an authentic understanding of spiritual practice and religious devotion. Furthermore, we believe that certain religiously based misconceptions can actually work against the interests of the patient. For example, a purely instrumental view of prayer can inhibit what we would call the experience of relational openness to God. In this regard, Daniel Sulmasy, MD, PhD,16 a former Franciscan monk and philosopher physician, has pointed to the danger of trying to control or manipulate Gods power, even for a good purpose, such as healing . . . . Dr Sulmasy specifically relates this to the matter we raised at the beginning of this articlethat of the unanswered prayer. He writes:

One approach to these mysteriesespecially in some Asian religions and in existential psychotherapyis to shift the focus of prayer from the narrowness of ones ego to a wider vision of the self that encompasses empathy for the suffering of others. Religious leaders have urged the faithful to see the immense human anguish and economic dislocation the pandemic has wrought as an invitation to spiritual transformation. Thus, the Abbott of Wat Pasukatoa Buddhist monastery in Thailand, the Venerable Phra Paisal Visalo,17 offers this sage advice, regarding the COVID-19 pandemic:

Conclusion

Like any intervention with the power to effect emotional change, religious and spiritual approaches to serious illness have risks and benefits. As psychiatrists, we need to understand both the positive and negative interactions of religion and spirituality with the particular patients physical and emotional needsand this will likely differ considerably from patient to patient. We can address maladaptive responses stemming from religious guilt and fear, while supporting beliefs and practices that foster hope and resilience. Finally, we believe that psychiatry can play a useful role in re-framing the distressing aspects of the current pandemic in the altruistic and prosocial terms so eloquently expressed by Phra Paisal Visalo.

Dr Pies is Professor, Department of Psychiatry, SUNY Upstate Medical University, Syracuse, NY and Tufts University School of Medicine, Boston, MA; he is Editor in Chief Emeritus of Psychiatric Times (2007 to 2010). Dr Geppert is Professor, Department of Psychiatry and Internal Medicine, and Director of Ethics Education, University of New Mexico School of Medicine in Albuquerque, NM; she is also Health Care Ethicist, Ethics Consultation Service, VA National Center for Ethics in Health Care. She is also an Editorial Board Member of Psychiatric Times and serves as the Ethics Chair.

References

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2. Gjelten T. Clinical Study Considers the Power of Prayer to Combat COVID-19. NPR. May 1, 2020.

3. American Psychiatric Association. New Poll: COVID-19 Impacting Mental Well-Being: Americans Feeling Anxious, Especially for Loved Older Adults are Less Anxious [press release]. Washington DC; March 25 2020.

4. Wang PS, Berglund PA, Kessler RC. Patterns and correlates of contacting clergy for mental disorders in the United States. Health Serv Res. 2003;38:647-673.

5. Koenig HG. Religion, spirituality, and health: the research and clinical implications. ISRN Psychiatry. 2012;2012:278730.

6. Li S, Stampfer MJ, Williams DR, VanderWeele TJ. Association of religious service attendance with mortality among women. JAMA Intern Med. 2016;176:777-785.

7. Miller L, Wickramaratne P, Gameroff MJ, et al. Religiosity and major depression in adults at high risk: a 10-year prospective study. Am J Psychiatry. 2012;169:89-94.

8. Amy J, Schor E, Lavoie D. Worshippers go online, those at services keep at distance. Associated Press. March 15, 2020, 2020.

9. Newport F. The Religion Paradox. Polling Matters. May 8, 2020. Gallup. https://news.gallup.com/opinion/polling-matters/310397/religion-paradox.aspx

10. Mosqueiro BP, de Rezende Pinto A, Moreira-Almeida A. Spirituality, religion and mood disorders. In: Rosmarin DH, Koenig HG, eds. Handbook of Spirituality, Religion and Mental Health. London: Academic Press; 2020:1-19.

11. Rosmarin DH, Malloy MC, Forester BP. Spiritual struggle and affective symptoms among geriatric mood disordered patients. Int J Geriatr Psychiatry. 2014;29:653-660.

12. NBS News, Bishop who preached God is larger than this dreaded virus dies of COVID-19. April 14, 2020.

13. Shomon MJ. Living Will With Hypothyroidism, revised ed. New York, NY: HarperCollins; 2005.

14. Marquez M. Jesus is my vaccine is one of the more colorful messages. https://twitter.com/miguelmarquez/status/1252262768591491072?lang=en

15. University of Chicago Medical Center. Psychiatrists: Least Religious but Most Interested in Patients Religion. Science News. December 11, 2007.

16. Sulmasy DP. The Rebirth of the Clinic: And Introduction to Spirituality in Health Care. Washington, DC: Georgetown University Press; 2006.

17. Lewis C. Senior Thai Monk Offers a Buddhist Perspective on Dealing with COVID-19. Buddhistdoor. March 25, 2020.

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The Upside and Downside of Religion, Spirituality, and Health - Psychiatric Times