Spirituality and Health

Studies demonstrating health benefits of religion are many and growing in number, and some claim the results are ripe for application in clinical settings.1,2 However, others argue that the research is not nearly as good or consistent as portrayed, and caution against acting rashly on inconclusive evidence.3,4 The goal of this supplement is to determine what this growing body of research means for Australian practitioners and patients. Religion involves beliefs and practices related to the sacred, where the sacred is defined as God, the numinous (mystical or supernatural) or ultimate truth. Religion is a unique construct, different from other psychological and social phenomena. Spirituality, on the other hand, is more difficult to define, as its definition today has changed — from one based in religion to a more diffuse concept, self-defined by each individual. The result is that there is no widespread agreement on what spirituality means, producing a real challenge when trying to measure it. Attempts to measure spirituality have taken two approaches: Asking questions about religious involvement; Asking questions about positive psychological characteristics, such as meaning and purpose in life, connectedness to others, peacefulness and high personal values. There are two problems with the latter way of defining and measuring spirituality. The first is that atheists might claim that they are neither religious nor spiritual — yet argue, rightly, that their lives have purpose and meaning, that they experience connection with others, and that they maintain high personal values. The second problem with defining spirituality in terms of positive psychological characteristics is that doing so produces a construct that is really a quasi-indicator of mental health. This makes it difficult or impossible to interpret research on the relationship between spirituality and health, especially mental health. Correlating a construct defined by indicators of mental health (spirituality) with another mental health construct (eg, wellbeing, life satisfaction, depression or anxiety) will always lead to an association between the two. Such an approach could also lead to false relationships between spirituality and physical health, given the strong links between mental and physical health. The word spirituality, when used in research, should be restricted to those things that have something to do with the sacred (as defined above). If there is no connection with the sacred, then it should not be referred to as spiritual or spirituality. We already have psychological and social terms to deal with concepts that all humans have in common, regardless of belief, and I think we should keep these concepts distinct from religious terms. I realise that many others in both the United States and Australia will not share this opinion, including a number of authors who have contributed to this supplement. From a purely scientific standpoint, if we are to study the relationships between religion, spirituality and health, it is essential to have constructs that are clear and non-overlapping. For these reasons, I refer mainly to religion when discussing relationships with mental and physical health. My definition of religion, however, is quite broad and means a lot more than just institutional religion or religious affiliation. Another reason for using religious language when discussing the research is that most published research has really been examining religion, even if it is presented and discussed in terms of spirituality. However, when talking with patients in clinical practice, there are good reasons for using the word spirituality, rather than religion. Research shows that, while many patients do not distinguish between being religious or spiritual,5 others feel alienated from institutional religion and see themselves more as spiritual than as religious. This may be particularly true for patients in Australia. The term spirituality is vague enough to allow patients themselves to define the playing field. Why should religion and health be connected? The argument is a rational one. If religious people have a world view that gives hope and meaning in the face of stress and loss, if they have social support from other members of the religious community, and if they live healthier lifestyles by smoking less, drinking less, and making more conservative, less risky decisions in marriage, the workplace, and recreational activities, there is good reason to expect that they will have better physical health as well. All of these factors influence health in ways that are increasingly being understood through the field of psychosomatic medicine.6 It should not be surprising, then, that in 2006 more than 70 published research studies examined the relationships between religion, spirituality and health, many finding positive relationships.7 The articles in this supplement review research on religion, spirituality and health relevant to Australian patients and practitioners and discuss the application of that research to clinical practice. Although not all of the research comes from Australia, the articles provide an important summary and background that will assist Australian researchers in designing and implementing future research. While most of the articles do not contain original research, they begin to address some of the research gaps identified by Peach in 2003.8 Williams and Sternthal9 assess the importance of religion and spirituality to Australians and discuss the evidence for both positive and negative effects of religion on health (→ Spirituality, religion and health: evidence and research directions). Eckersley10 looks at the relationship between spirituality, religion and health in a broad cultural context (→ Culture, spirituality, religion and health: looking at the big picture), while Wilding11 presents a case study to illustrate the meaning of spirituality at a personal level (→ Spirituality as a sustenance for mental health and meaningful doing: a case illustration). The different approaches to spiritual assessment in health care practice are summarised by Rumbold12 (→ A review of spiritual assessment in health care practice), and Winslow and Wehtje-Winslow13 raise a number of ethical issues relating to the provision of spiritual care (→ Ethical boundaries of spiritual care). Jantos and Kiat14 present evidence on the health benefits of prayer (→ Prayer as medicine: how much have we learned?), and D’Souza15 suggests ways in which clinicians can approach the subject of spirituality with their patients (→ The importance of spirituality in medicine and its application to clinical practice). Hopkins and colleagues16 focus on evidence-based strategies that could be implemented by church-associated organisations to reduce high-risk behaviours in young people (→ Developing healthy kids in healthy communities: eight evidence-based strategies for preventing high-risk behaviour), and, at the other end of the age spectrum, MacKinlay and Trevitt17 provide a model of spiritual tasks in later life (→ Spiritual care and ageing in a secular society). The contributions presented here suggest that spirituality and religion are important to many Australian patients, and that the spiritual needs arising from religious beliefs should be identified and addressed as part of whole person health care. They also suggest that much more research in this area is needed in Australia. While some of the findings of US research may be applicable to Australian patients, there are important cultural differences between the two countries that may influence the relationship of religion to health and the needs of patients in this regard.

Harold G Koenig MD

Levels of spirituality and religious beliefs and behaviour are relatively high in Australia, although lower than those in the United States. There is mounting scientific evidence of a positive association between religious involvement and multiple indicators of health. The strongest evidence exists for the association between religious attendance and mortality, with higher levels of attendance predictive of a strong, consistent and often graded reduction in mortality risk. Negative effects of religion on health have also been documented for some aspects of religious beliefs and behaviour and under certain conditions. Health practices and social ties are important pathways by which religion can affect health. Other potential pathways include the provision of systems of meaning and feelings of strength to cope with stress and adversity.

David R Williams PhD, MPH · Michelle J Sternthal MA

Many people use prayer, and some studies have shown a positive association between prayer and improved health outcomes. This article explores four possible mechanisms by which prayer may lead to improved health. While acknowledging the efficacy of prayer and recognising the needs of patients, prayer, being a personal spiritual practice, cannot be prescribed, nor should it be used in place of medical care.

Marek Jantos MA · Hosen Kiat MB BS

Religion provides things that are good for health and wellbeing, including social support, existential meaning, a sense of purpose, a coherent belief system and a clear moral code. But these benefits can also come from other sources. Conversely, religion is shaped by its social context in ways that affect its social role. Religion is no panacea when it comes to improving health. Religion’s role in health needs to be examined in a broad context, especially the ways in which culture influences religion’s expression of the spiritual.

Richard M Eckersley BSc(Hons), MScSoc

Recent international and Australian surveys have shown that there is a need to incorporate the spiritual and religious dimension of patients into their management. By keeping patients’ beliefs, spiritual/religious needs and supports separate from their care, we are potentially ignoring an important element that may be at the core of patients’ coping and support systems and may be integral to their wellbeing and recovery. A consensus panel of the American College of Physicians has suggested four simple questions that physicians could ask patients when taking a spiritual history. Doctors and clinicians should not “prescribe” religious beliefs or activities or impose their religious or spiritual beliefs on patients. The task of in-depth religious counselling of patients is best done by trained clergy. In considering the spiritual dimension of the patient, the clinician is sending an important message that he or she is concerned with the whole person. This enhances the patient–physician relationship and is likely to increase the therapeutic impact of interventions. Doctors, health care professionals and mental health clinicians should be required to learn about the ways in which religion and culture can influence patients’ needs and recovery.

Russell D'Souza MD, FAPA, MPM

The recent surge of interest in links between spirituality and health has generated many assessment approaches that seek to identify spiritual need and suggest strategic responses for health care practitioners. The interpretations of spirituality made within health frameworks do not do justice to the way spirituality is understood in society in general. Spiritual assessment should not impose a view or definition of spirituality, but should seek to elicit the thoughts, memories and experiences that give coherence to a person’s life. Spiritual assessment tools should not be used without adequate exploration of the assumptions made. Assessment processes need to be adequately conceptualised and practically relevant.

Bruce D Rumbold PhD

In an age that features technologically sophisticated medical interventions, patients still desire spiritually nurturing health care. Attention to patients’ spiritual needs and resources in the clinical setting may raise a number of ethical questions. Five ethical guidelines are offered as illustrations of norms that respect patients’ preferences and preserve health care professionals’ integrity.

Gerald R Winslow PhD · Betty J Wehtje-Winslow PhD

In the past 10–20 years there has been increasing interest in the relationship between spirituality and health. I interviewed six patients from community mental health centres, using a phenomenological approach to explore how concepts of spirituality, occupation and mental illness/mental health are related. One person’s story is presented to illustrate the issues. Four main themes were identified: Spirituality is a phenomenon that provides meaning to life. Spirituality can help a person cope with mental illness. Spiritual beliefs can make everyday occupations more meaningful and health-enhancing. Some people find it valuable to engage in shared occupations that focus on spirituality. Spirituality is an important and relevant issue to be discussed between patients and health practitioners, provided that practitioners can exercise sensitivity, caution, tolerance and acceptance of values that may differ from their own.

Clare Wilding BAppSc(OT), MAppSc(OT)

Australian youth engage in behaviour that threatens their health and wellbeing. National surveys report that about a third of young Australians have tried an illicit drug. High rates of substance use and risky sexual behaviour among young Australians suggest that effective prevention efforts based on empirical evidence need to be expanded. Church-associated organisations are an untapped resource that could be used to improve the health and welfare of young people. We describe eight evidence-based elements to consider in designing strategies to prevent high-risk behaviour in young people.

Gary L Hopkins MD, DrPH · Duane McBride PhD · Helen H Marshak PhD · Kiti Freier PhD · John V Stevens Jr JD · Wendi Kannenberg MPH · James B Weaver III PhD · Stephanie L Sargent Weaver PhD · Peter N Landless MMed, FCP(SA), FACC · Jonathan Duffy BEd, MPH

Providing spiritual care is about tapping into the concept of spirituality: core meaning, deepest life meaning, hope and connectedness. The search for meaning, connectedness and hope becomes more significant as older people are faced with the possibilities of frailty, disability and dementia. Spirituality, ageing and meaning in life can be discussed in the context of an alternative view of “successful ageing”. A model of spiritual tasks in older age can help explain the spiritual dimension and provide a starting point for spiritual assessment.

Elizabeth B MacKinlay PhD · Corinne Trevitt RN, MN, GradDipGerontics