Spirituality & Mental Health

It had been barely four months since starting my clinical training at Harvard’s McLean Hospital and no less than 15 patients had approached me to speak about spirituality. I guess my kippah gave me away as a safe person to approach about the subject, but this was starting to get ridiculous. And so, I approached my advisor for advice.

“Rosmarin, these patients have spiritual needs that we’re not addressing.”

“I agree. I’ve been saying this for years!”

“But we need to do something about this problem. I want you to start a group to address patients’ spirituality in our program.”

And so, McLean’s Spirituality & Cognitive Behavioral Therapy group was born. Fortunately, I had received training in this subject – a rarity for a clinical psychologist, even in this age of spiritual awakening. My graduate school supervisor Kenneth I. Pargament, Ph.D. (Bowling Green State University) literally wrote the book on Spiritually Integrated Psychotherapy, and his 100+ scientific articles have consistently highlighted the importance of spiritual and religious life to psychological health. In just over one year, the group has provided spiritually-integrated treatment to over 150 patients. And feedback has been overwhelmingly positive – a full 25% of patients requested more such treatment and none provided negative comments¹.

Given Freud’s characterization of religion as neurosis, this is a big step forward.

My colleagues were somewhat surprised. “Yes, I know that a lot of people believe in God, but does it really matter to mental health?” Given the history – from Freud’s characterization of religion as neurosis, to mechanistic biological models of mental illness – marginalization and discounting of spirituality (as opposed to disparaging it) is actually a big step forward. But even a cursory glance at the empirical literature reveals that spirituality does indeed matter to mental health – in a big way.

Over 47,000 scientific articles have been written on the subject of spirituality and health (PubMed search – June 2011), of which at least half relate to psychological symptoms and wellbeing. It is now recognized that this domain can protect against depression², anxiety³, and facilitate greater self-control⁴. Moreoer, it is now patently clear that religion can (and often does) serve as a vital resource for individuals coping with life change⁵. For example, among individuals with advanced cancer, turning to religion can greatly enhance quality of life⁶. Further, simple involvement such as weekly attendance of religious services has been associated with full 7-year increase in lifespan in some studies⁷ and some have argued on this basis that church is more cost effective than Lipotor⁸.

Related Article: God vs Prozac

Stress-free Treatment

While methodological limitations have limited this area of study – owing largely to the failure of national funding bodies (e.g., the National Institutes of Health) to make research on spirituality a priority – and mechanisms of effect are therefore unclear, recent advancements have revealed fascinating findings.

In one recent study (featured on Aish.com), I created a spiritually-integrated treatment program for Jewish individuals suffering from stress and worry⁹. The project started with a trip to Israel during which I had a series of meetings with prominent rabbis. The question I posed: “Which spiritual aspects of Judaism can help people who are anxious?”

One sage responded: “Finally, after 100 years of modern psychology, you’ve decided to ask.” And he was completely right – we should have asked much sooner. The results of my study were fascinating.

Gains improved even after the program's completion.

After just two weeks of completing an electronic, self-directed program on a daily basis, participants who received the spiritually-integrated treatment reported a full 45% decrease in stress and worry. Treatment gains remained (actually, they improved) over the following six weeks without any further use of the program. What’s more, the effects of a competing condition – a known, evidence-based program for stress and worry – were no different than no treatment at all.

Another fascinating finding was the sheer number of people who participated in the study. Typically, recruiting participants for clinical trial is a painstaking process. But I had over 500 people banging down my door. I still get regular requests, and to meet this need have made the program available to the general public via my research website, jpsych.com

Correlation and Cause

The million-dollar question – or billion-dollar question as far as the pharmaceutical industry is concerned – is whether spiritually-integrated treatments can become a mainstream solution to alleviate psychological suffering en masse. Having seen the results of my program and similar studies around the globe^{10, 11, 12}, I am starting to have a little faith. Here’s why.

Over the previous century, several national organizations in the United States lobbied fiercely to promulgate biomedical models of mental illness in the public eye. The intended purpose of this movement was noble – its proponents sought to put an end to stigma and discrimination against mental illness. However, attributing all psychological functioning to a “chemical imbalance” is over-simplistic, incomplete and inconsistent with current scientific thinking. It is true that human biology – neural functioning, in particular – correlates with psychological wellbeing and distress. However, who’s to say that biology is a cause of mental illness?

Environmental factors impact emotional states.

First of all, a full decade of research on the serotonin transporter gene (5-HTTLPR) has revealed no linkage to depression; not even an interaction with stress¹³. In other words, our costly attempts to discover a genetic basis for depression have been a major disappointment. It is also now recognized that postpartum depression, long thought to be purely a function of hormonal fluctuations, is strongly influenced by psychosocial factors¹⁴ (e.g., engagement between mother and baby, plans for the future, financial strain). Moreover, there is unequivocal evidence that environmental, cognitive and behavioral factors impact emotional states. In fact, recent literature has demonstrated changes in brain activity over the course of psychotherapy without the use of any pharmacological agents^{15, 16}. In light of these findings, some contend that behavior shapes neurobiology as much as (perhaps even more than) neurobiology shapes emotion.

This has important implications for treatment. The clinical unit where I trained for the past two years – one of at McLean’s busiest units – provides intensive Cognitive Behavioral Therapy to over 800 acute psychiatric patients each year. We’re talking about patients with raw wounds from self-injury and suicide attempts. The primary purpose of our clinical program is to teach patients to use evidence-based psychosocial (non-pharmacological) strategies to shift their thoughts and behaviors, and thereby change their emotions. This may come as a surprise, as Cognitive Behavioral Therapy has historically thought to be ineffective for individuals with severe symptoms. However, over the course of treatment, patients report robust reductions in depression and anxiety, and gains in psychological wellbeing (a full standard deviation of change for depressed patients). What’s more, our medical directors typically recommend decreases in psychotropic medication over the course of treatment.

Treatment Regimen

All this being the case, why wouldn’t engaging in certain spiritual or religious activities in the course of a well thought-out treatment program have a desirable effect on human psychology? Of course, individuals on medication should not desist from their current treatment regimen and self-prescribe spiritually-based treatments in its stead. This could be dangerous and must be done only under the careful guidance of a mental health professional.

But why wouldn’t we expect that spirituality – a domain of life that has been valued since the dawn of human existence – should have a detectable impact on behavior, emotion and neural functioning? Shouldn’t these effects be particularly strong in this current juncture of world history – in the midst of economic crises and the looming threat of terrorism – when spirituality is becoming increasingly important to human life?

To this end, one of my career goals is to start a laboratory for the study of human spirituality within the Harvard Medical School system, and to launch a series of basic and applied science investigations on this important yet understudied subject. A second goal is to offer evidence-based, spiritually-integrated treatments for adults suffering from anxiety through The Center for Anxiety in New York City (centerforanxiety.org). Only through responsible scientific discovery can we understand the impact of spirituality on human psychology, and potentially increase the availability of spiritually-based treatments.

I realize that there is a long path ahead, and that this area of study is still in its early stages. It’s a good thing that I’m learning to have a little faith.

1. Rosmarin, D.H., Auerbach, R.P, Bigda-Peyton, J., Björgvinsson, T., & Levendusky, P. (in press). Integrating spirituality into cognitive behavioral therapy in an acute psychiatric setting: A Pilot Study. Journal of Cognitive Psychotherapy.
2. Smith, T.B., McCullough, M.E. and Poll, J. (2003). Religiousness and depression: Evidence for a main effect and the moderating influence of stressful life events. Psychological Bulletin, 129(4), 614-636.
3. Inzlicht, M., McGregor, I., Hirsh J.B., & Nash, K. (2009) Neural markers of religious conviction. Psychological Science, 20(3), 385-392.
4. McCullough, M.E., & Willoughby, B.L.B. (2009). Religion, self-regulation, and self-control: Associations, explanations and implications. Psychological Bulletin, 135(1), 69–93
5. Pargament, K. I. (1997). The psychology of religion and coping: Theory, research, practice. New York: The Guilford Press.
6. Tarakeshwar, N., Vanderwerker, L.C., Paulk, E., Pearce, M.J., Kasl, S.V., & Prigerson, H.G. (2006). Religious coping is associated with the quality of life of patients with advanced cancer. Journal of Palliative Medicine, 9(3), 646-657.J Palliat Med. 2006 Jun;9(3):646-57.
7. Hummer, R.A., Rogers, R.G., Nam, C.B. & Ellison, C.G. (1999). Religious involvement and U.S. adult mortality. Demography, 36(2), 273-285.
8. Hall, D.E. (2006). Religious attendance: More cost-effective than Lipitor? The Journal of the American Board of Family Medicine 19, 103-109.
9. Rosmarin, D.H., Pargament, K.I., Pirutinsky, S., & Mahoney, A. (2010). A randomized controlled evaluation of a spiritually-integrated treatment for subclinical anxiety in the Jewish community, delivered via the Internet. Journal of Anxiety Disorders, 24(7), 799-808.
10. Oman, D., Hedberg, J., & Thoresen, C. E. (2006). Passage Meditation Reduces Perceived Stress in Health Professionals: A Randomized, Controlled Trial. Journal of Consulting and Clinical Psychology, 74(4), 714-719
11. Propst, L. R., Ostrom, R., Watkins, P., Dean, T. & Mashburn, D. (1992). Comparative efficacy of religious and nonreligious cognitive behavioral therapy for the treatment of clinical depression in religious individuals. Journal of Consulting and Clinical Psychology, 60(1), 94-103.
12. Wachholtz, A. B., & Pargament, K. I. (2009). Migraines and meditation: does spirituality matter? Journal of Behavioral Medicine, 31(4), 351-66.
13. Risch, N., Herrell, R., Lehner, T., Kung-Lee, L., Eaves, L. Hoh, J., Griem, A., Kovacs, M., Ott, J. & Merikangas, K.R. (2009). Interaction between the serotonin transporter gene (5-HTTLPR), stressful life events, and risk for depression. Journal of the American Medical Association, 301(23), 2462-2471.
14. O’Hara, M.W., Schlechte, J.A., Lewis, D.A., & Wright, E.J. (1991). Prospective study of postpartum blues: Biologic and psychosocial factors. Archives of General Psychiatry, 48(9), 801-806.
15. Paquette, V., Lévesque, J., Mensour, B., Leroux, J.M., Beaudoin, G., Bourgouin, P., & Beauregard, M. (2003). Change the mind and you change the brain: effects of cognitive-behavioral therapy on the neural correlates of spider phobia. Neuroimage 18, 401-409.
16. Goldapple, K., Segal, Z., Garson, C., Lau, M., Bieling, P., Kennedy, S. & Mayberg, H. (2004) Modulation of cortical-limbic pathways in major depression. Archives of General Psychiatry 61(1), 34–41.