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June 2009 Articles of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Baetz, M. and Toews, J. "Clinical implications of research on religion, spirituality, and mental health." Canadian Journal of Psychiatry 54, no. 5 (Mar 2009): 292-301.

Koenig, H. G. "Research on religion, spirituality, and mental health: a review." Canadian Journal of Psychiatry 54, no. 5 (Mar 2009): 283-291.


SUMMARY and COMMENT: Overviews of spirituality & health research remain the single most requested type of article for the Research Network. The Canadian Journal of Psychiatry has just published these two that focus on mental heath, in a special section that is paired with a brief editorial [--see Blazer, D. G., "Religion, spirituality, and mental health: what we know and why this is a tough topic to research," on pp. 281-282]. While these focus to some extent on a Canadian psychiatric readership, they may be very useful to a wider audience, and they should be broadly engaging for CPE students and supervisors looking for either an introduction to the field or the latest update on research. Because these two articles are themselves summaries, and because they are both conveniently available on line, then summary and comment here shall be brief.

Marilyn Baetz and John Toews begin by pointing out that research showing the positive influence of religion/spirituality on mental health outcomes is dominated by studies concentrating on religious observance, and that "this raises the question of the clinical relevance of these findings for people who are not necessarily religiously observant" [p. 292]. The authors then propose to demonstrate the broad relevance of the research by exploring the mechanisms by which spirituality may exert its influence, noting that the "different pathways by which [religion/spirituality] may influence health are likely multileveled" [p. 293]. The article addresses possible social, psychological, biological, and genetic mechanisms. Baetz and Toews, however, take their analysis a step further by highlighting practical implications: "We will attempt to answer the question of whether any empirically based approaches are open to patients who wish help of a spiritual nature" [p. 295]. They then go on to look at altruism, gratitude, and forgiveness. Chaplains may be especially interested in these sections [pp. 295-296], as well as later ones on Addressing Spirituality in Psychiatric Care [pp. 297-298] and Ethics (which several times mentions chaplains) [p. 298]. The bibliography is extensive: 130 references.

The review by Harold G. Koenig is somewhat more general and reliant on Dr. Koenig's earlier analyses of the literature. This piece is more intentionally introductory in nature, including some historical context and some explanation of basic terms. The author also presses some personal positions, such as his well-known criticism of the "meaningless and tautological" practice of defining spirituality as "good mental health and positive psychological or social traits" [p. 285] in an effort to examine how spirituality is connected with good mental health. The author's position is to define spirituality in terms of religion "where religion is a multidimensional construct not limited to institutional forms of religion" [p. 285]. He gives brief but persuasive summaries on five aspects of Religion as a Coping Behavior: regarding depression, suicide, anxiety, psychiatric disorders, and substance abuse. There is a sense here of an argument against older, entrenched views in psychiatry that religion is largely dysfunctional to mental health and a complicating factor in mental illness, to which Koenig's essential counterpoint is: "While religious delusions may be common among people with psychotic disorders, healthy normative religious beliefs and practices appear to be stabilizing and may reduce the tremendous isolation, fear, and loss of control that those with psychosis experience" [p. 289]. As with the Baetz & Toews article, this one contains a detailed bibliography: 84 references.


Suggestions for the Use of the Article for Discussion in CPE: 

Students new to the field may be most interested in Koenig article, especially as it is a good introduction to how religion/spirituality is conceived to play into coping. However, students with some sense of the religion/spirituality & health literature may find the Baetz & Toews article of special interest because of its emphasis on clinical implications. Discussion could focus on mechanisms (i.e., social, psychological, biological, and genetic) or on the clinically pertinent phenomena of altruism, gratitude, and forgiveness. The section on Ethics (p. 298) raises the question of the role of the chaplain, and students may wish to discuss the extent to which they think that clinicians ought to defer to them regarding spirituality or whether they see a role for psychiatrists (and other clinicians) in directly handling spiritual issues.


Related Items of Interest:

I. As noted above, see the prefatory editorial to this month's featured articles: Blazer, D. G., "Religion, spirituality, and mental health: what we know and why this is a tough topic to research," Canadian Journal of Psychiatry 54, no. 5 (Mar 2009): 281-282. Among Dr. Blazer's points are that "[i]t is tough to objectively study a topic about which we hold very deep beliefs" [pp. 281-282], that efforts to reach generalizable research findings tend to overlook distinctive aspects of particular religious traditions, that it is hard to sort out the differences in the ways that faith communities support their members, and that deep spiritual thoughts and feelings may be elusive for structured interview instruments just because they are often too deep for words.

II. For more on Harold Koenig's perspective, see his presentation on "Religion, Spirituality and Public Health: Research, Applications, and Recommendations," which was testimony before the U.S. House of Representatives' Committee on Science and Technology--Subcommittee on Research and Science Education, September 18, 2008. Dr. Koenig's testimony is available online [PDF] from the Committee on Science and Technology. This is an excellent overview, with more of an eye toward issues of public health than is normally found in the literature. Dr. Koenig subsequently reworked this testimony for a December 3, 2008 conference in Washington on Religious Practice and Health: What the Research Says. The presentation, titled, "Religious Practices and Health: Overview," is available online [PDF] from the Heritage Foundation.

III. While this month's articles come from a psychiatric journal, a recent issue of a psychology journal -- the Journal of Clinical Psychology -- was devoted to considering spirituality. See the following articles from the February 2009 issue (--listed here in the order in which they appear in the journal):

Worthington, E. L. Jr. and Aten, J. D. "Psychotherapy with religious and spiritual clients: an introduction." Journal of Clinical Psychology 65, no. 2 (Feb 2009): 123-130. [(Abstract:) This invited issue of the Journal of Clinical Psychology: In Session is devoted to psychotherapy with religious and spiritual clients. After offering definitions of religion and spirituality, noting areas of potential convergence and differentiating nuances, the authors highlight the prevalence and types of spirituality among both clients and mental health professionals. They describe the historical and current context for examining approaches to psychotherapy with clients who endorse religion, experience spirituality within their religion, or define themselves as spiritual even if not religious. They then summarize the subsequent articles in this issue, which offer practical guidance for practitioners.]

Post, B. C. and Wade, N. G. "Religion and spirituality in psychotherapy: a practice-friendly review of research." Journal of Clinical Psychology 65, no. 2 (Feb 2009): 131-146. [(Abstract:) The role of religion and spirituality in psychotherapy has received growing attention in the last two decades, with a focus on understanding the ways that religion and spirituality relate to therapists, clients, and treatment methods. The authors reviewed recent empirical research on religion and spirituality in psychotherapy to inform practitioners about effective ways to incorporate the sacred into their clinical work. Three main areas are covered: religion/spirituality and therapists, religion/spirituality and clients, and religious/spiritual interventions. Research indicates that therapists are open to religious/spiritual issues, that clients want to discuss these matters in therapy, and that the use of religious/spiritual interventions for some clients can be an effective adjunct to traditional therapy interventions.]

Shafranske, E. P. "Spiritually oriented psychodynamic psychotherapy." Journal of Clinical Psychology 65, no. 2 (Feb 2009): 147-157. [(Abstract:) Spiritually oriented psychodynamic psychotherapy pays particular attention to the roles that religious and spiritual beliefs, practices, and experiences play in the psychological life of the client. Contemporary psychoanalytic theorists offer multiple approaches to understand the functions of religious experience. Spirituality provides a means to address existential issues and provide a context to form personal meaning. Religious narratives present schemas of relationship and models of experiences salient to mental health, such as hope. God images or other symbolic representations of the transcendent have the power to evoke emotions, which in turn, influence motivation and behavior. While employing theories and techniques derived from psychodynamic psychotherapy, this therapeutic approach encourages the analysis of the functions religion and spirituality serve, while respecting the client's act of believing in faith. Psychotherapists address a client's spirituality by exploring the psychological meaning of such personal commitments and experiences and refrain from entering into discussion of faith claims.]

Hathaway, W. and Tan, E. "Religiously oriented mindfulness-based cognitive therapy." Journal of Clinical Psychology 65, no. 2 (Feb 2009): 158-171. [(Abstract:) The interface of religiously accommodative and oriented treatments and the cognitive-behavioral tradition is explored. In terms of Hayes' characterization of the evolution of the cognitive-behavioral tradition through three waves, considerable theoretical, clinical, and empirical work emerged to support a religiously accommodative cognitive-behavioral therapy (CBT) during the second-generation CBTs. Rather than including religion and spirituality, the third-wave CBT traditions have engaged in spiritual themes inspired heavily from Eastern religious traditions. The authors discuss the application of a religiously congruent third-wave cognitive therapy with a depressed conservatively Christian client. Some conceptual challenges and rationales for adopting such treatments with Christian or other theist clients are described.]

Richards, P. S., Smith, M. H., Berrett, M. E., O'Grady, K. A. and Bartz, J. D. "A theistic spiritual treatment for women with eating disorders." Journal of Clinical Psychology 65, no. 2 (Feb 2009): 172-184. [(Abstract:) The authors describe a psychological treatment for women with eating disorders who have theistic spiritual beliefs and illustrate its application with a case report. They begin by briefly summarizing a theistic view of eating disorders. Then they illustrate how a theistic approach can complement traditional treatment by describing the processes and outcomes of their work with a 23-year-old Christian woman receiving inpatient treatment for an eating disorder not otherwise specified and a major depressive disorder (recurrent severe).]

Delaney, H. D., Forcehimes, A. A., Campbell, W. P. and Smith. B. W. "Integrating spirituality into alcohol treatment." Journal of Clinical Psychology 65, no. 2 (Feb 2009): 185-198. [(Abstract:) Spirituality is presumed by millions of Americans to be directly relevant to problems of alcohol abuse. We summarize findings regarding the role of religion and spirituality in the prevention and treatment of substance abuse and present a case illustration. We also consider mechanisms responsible for these effects. We offer advice about why, by whom, and how religion and spirituality should be discussed with clients with substance use disorders. In a recent clinical trial, therapists trained in a client-centered approach to facilitate exploration of spirituality fostered clients' use of spiritual practices. We suggest that the therapist's ability to skillfully engage clients in a discussion of spirituality is largely determined by how the therapist balances the dual roles of authoritative expert and evocative facilitator.]

Dwairy, M. "Culture analysis and metaphor psychotherapy with Arab-Muslim clients." Journal of Clinical Psychology 65, no. 2 (Feb 2009): 199-209. [(Abstract:) Attempting to reveal unconscious content and promoting self-actualization may be counterproductive for clients who come from collectivistic cultures. Such treatment goals may expose clients to harsh confrontations with the family. Clients with dependency traits, low ego-strength, and strict families may be helped through metaphor psychotherapy or culture analysis. Metaphor therapy makes it possible to deal symbolically and indirectly with unconscious content; culture analysis can pave the way to reveal unconscious needs and enable clients to establish a new order within their belief systems and within their families. The present article describes these two therapy methods and illustrates their clinical use with an Arab-Muslim suffering from depression. Through such therapy anchored in his own culture and religion, the client altered his beliefs, became satisfied with himself, and found successful ways to adapt to his family.]

Duba, J. D. and Watts, R. E. "Therapy with religious couples." Journal of Clinical Psychology 65, no. 2 (Feb 2009): 210-223. [(Abstract:) Although 95% of married couples identify with a particular religion, there is great variation in how couples rely on their religion to define or structure their relationship. Various denominations will imply particular "rules" or will shape how the couple deals with interpersonal and family challenges, such as sexuality, parenting, and power. In this article, we review couple relationships within a religious context and advance several treatment principles for treating religious couples. We present a clinical case to illustrate marital therapy with a religious couple, with an Adlerian context.]

Aten, J. D. and Worthington, E. L Jr. "Next steps for clinicians in religious and spiritual therapy: an endpiece." Journal of Clinical Psychology 65, no. 2 (Feb 2009): 224-229. [(Abstract:) To conclude this issue of the Journal of Clinical Psychology: In Session, the authors identify several next steps for clinicians interested in religious and spiritual therapy. They call for more clinically useful definitions of religion and spirituality and suggest that new methods of clinical practice that employ both Western and Eastern religion and spirituality need to be developed and tested. The need for more clinically focused religious and spiritual assessments is highlighted. They recommend greater clergy-psychotherapist collaboration and propose that clinicians lead and collaborate with researchers to further meaningful research on religion and spirituality. Finally, the authors identify areas of graduate training that require strengthening and provide corresponding guidelines.]

IV. The Journal of Clinical Psychology regularly publishes articles relating to spirituality. In addition to the February 2009 theme issue noted in §III, above, see the following:

Murphy, P. E. and Fitchett, G. "Belief in a concerned god predicts response to treatment for adults with clinical depression." Journal of Clinical Psychology 65, no. 9 (September 2009): 1000-1008. [(Abstract:) Belief in a concerned God has been shown to be associated with lower depression through the mediation of hopelessness. This study hypothesized that this relationship would also be true longitudinally. Shortly after admission to treatment and 8 weeks later, 136 adults with clinical depression completed the Beck Depression Inventory, the Beck Hopelessness Scale, and the Religious Well-Being Scale (RWB). Logistic regression models supported an association of baseline RWB, but not baseline hopelessness, with a 50% reduction in symptoms after 8 weeks. Persons in the upper third of RWB at admission were 75% more likely to have a response to treatment than persons in the lower third. Clinicians need to be aware of the role of religion for their clients.]

Rosmarin, D. H., Pargament, K. I., Krumrei, E. J. and Flannelly, K. J. "Religious coping among Jews: development and initial validation of the JCOPE." Journal of Clinical Psychology 65, no. 7 (July 2009): 670-683. [(Abstract:) Numerous studies have underscored the importance of religious coping in psychological health and illness; however, the majority of research in this area has been conducted with Christian samples and knowledge about other religious groups is lacking. Although recent investigations have developed scales to measure religious coping among Hindus and Muslims, the potential for future research in Jewish populations remains limited as no measures of religious coping have been validated in the general Jewish community. This two-part study reports on the development and validation of the 16-item Jewish Religious Coping Scale (JCOPE). In Study 1, an exploratory factor analysis identified two factors reflecting positive and negative religious coping strategies, and the concurrent validity for the measure was evaluated by examining correlations with indices of Jewish beliefs and practices. In Study 2, a confirmatory factor analysis (CFA) verified the JCOPE's 2-factor structure, and the scale's incremental validity was evaluated by examining Jewish religious coping as a predictor of psychological distress over and above significant covariates. Results suggest that the JCOPE has good psychometric properties, and that religious coping is a significant predictor of psychological distress among Jews.] [NOTE ADDED 8/18/09]: This article featured as the July 2009 Article-of-the-Month]

V. Students may be interested in a small piece recently co-authored by a chaplain (Marti Reynolds, at the Montgomery VA Medical Center in Jackson, MS):

Reeves, R. R. and Reynolds, M. D. "What is the role of spirituality in mental health treatment?" Journal of Psychosocial Nursing and Mental Health Services 47, no. 3 (Mar 2009): 8-9. [This guest editorial draws heavily on the work of Harold Koenig.]


If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman (Network Convener) at .
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