ORI GIN AL PA PER

Commentary: Why Do Research on Spiritualityand Health, and What Do the Results Mean?

Harold G. Koenig

Published online: 19 January 2012 Springer Science+Business Media, LLC 2012

Abstract I address two related questions in this article. First, why conduct research onreligion/spirituality (R/S) and health? Second, what are the dangers of misinterpreting or

misapplying the results from such research? If relationships are found, so what? What is

the practical value or clinical relevance of such information? Why should investigators

spend time and scarce financial resources to explore such connections? What might health

care professionals do differently as a result? How would people live their lives differently

in light of such information? Questions like these need solid answers for the field to

continue to move forward. Related to the So what? question is the issue of how results

from research in this area are translated into popular understanding and application. After

discussing why conducting research on religion and health is important, I identify a

recently published research report that focuses on the relationship between R/S and self-

control, an article that received considerable media press coverage. I present the results

reported by the authors of this study and then examine a column written about the study

that appeared in the New York Times. Finally, I explore what the findings mean, how the

media portrayed the findings, and problems that might result depending on how people

applied those findings.

Keywords Religion Spirituality Research Media Interpretation

Prior to the year 2000, over 1000 studies had quantitatively examined relationships

between religion/spirituality (R/S) and health (Koenig et al. 2001). By the middle of 2010,

at least 2,000 additional quantitative studies had appeared in the literature, resulting in over

3,000 original data-based reports on associations between R/S and mental health, physical

health, and use of health services. These reports included cross-sectional studies,

H. G. Koenig (&)Center for Spirituality, Theology and Health, Duke University Medical Center,Box 3400, Durham, NC 27710, USAe-mail: koenig@geri.duke.edu

H. G. KoenigKing Abdulaziz University, Jeddah, Saudi Arabia

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J Relig Health (2012) 51:460467DOI 10.1007/s10943-012-9568-y

prospective cohort studies, experimental studies, and randomized clinical trials (Koenig

et al. 2012). The volume of such research has been increasing rapidly in recent years (see

Fig. 1). Some health professionals have expressed concern about both the quality (Sloan

et al. 1999) and the clinical application (Sloan et al. 2000) of research findings on R/S and

health. Mainstream theologians also have concerns about the instrumental use of R/S with

the expressed purpose of maintaining or improving health (Shulman and Meador 2002).

Thus, the research field of R/S and health is getting criticism from both sides. This raises

two important issues: the value of such research and the interpretation of what the research

findings actually mean.

Why Do Research on R/S-Health?

Given the rapid increase in research in this area, it is time to carefully re-examine the role of

such research in understanding health and health care. Why spend valuable time and scarce

resources examining such relationships? What, if any, clinically useful information or

important societal implications can come out of such research? Is there really need for this

kind of research? These are questions that reviewers at the National Institutes of Health,

National Science Foundation, and private foundations such as the Templeton Foundation

often ask when deciding on whether to fund a research project in this area (Koenig 2011).

I would argue that there are numerous practical reasons for conducting religion

health research, and many of those are the same reasons used to justify the spending of

billions of dollars on research that examines other psychological, social, and behavioral

factors related to health. Here are five reasons, and these are not exhaustive.

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First, research on R/S and health might uncover certain R/S beliefs or behaviors that

could be used to help identify those at higher or lower risk of disease, allowing easier

identification of high-risk individuals to whom health resources could be directed so that

disease could be diagnosed early or prevented entirely. This is one reason why scientists

study such factors as race, ethnicity, gender, age, or sexual preference. For example, older

black men are at higher risk for cardiovascular disease than young white women. If an

older black man comes into the office with chest pain, doctors will be more likely to

suspect that the symptom is related to his heart than if a young white woman comes in with

the same complaint. Similarly, if a sexually active young homosexual male comes in with

fatigue and cough, then the physician is likely to test them for HIV and screen them for

pneumocystis carinii. Clinicians would not attempt to alter any of these individual char-

acteristics, yet research that identifies which of these factors mark individuals at high risk

can be very useful to public health experts and clinicians. If certain R/S beliefs or practices

place persons at higher or lower risk for a particular disease or mortality in general, then

doctors need to know about it.

Second, information on the relationship between R/S and health might also be important

in terms of planning ahead for health services needed by the public. Today, two-thirds of

Americans indicate that religion is an important part of daily life (The Gallup Poll 2009).

However, trends toward secularization in developed countries such as the United States

suggest that R/S involvementparticularly attendance at religious servicesmay not be as

common in 2030 years as it is today (Bruce 1992). If R/S involvement is related to better

health, greater longevity, and less need for health services, then secularization may increase

the health care needs of the population, not to mention the rates of alcohol and drug abuse,

delinquency and crime, teenage pregnancy, and other social problems that affect health and

health care costs (Koenig et al. 2012). Furthermore, if found to foster better health, faith

communities could be identified as providers of health care, natural sites using their

resources to complement existing secular resources. For example, faith communities could

serve as sites for disease screening and health education (prevention) and/or for providing

psychological and instrumental support to sick persons living in the community.

Third, R/S involvement is common in the United States and most countries around the

world. If it is related to better health, and studies show that R/S interventions improve

health, then there is no reason why those interventions couldnt be used to enhance and

support treatment in those who indicate religion is an important part of their daily life.

Clinicians need not prescribe religion to those who are not religious (nor is there likely to

be any scientific basis for doing so). However, there may be many reasons for inquiring

about the role that R/S plays in a persons life and whether he/she would prefer an

intervention that utilizes their R/S resources in treatment. For example, 7783% of adults

aged 55 or older with depression and comorbid chronic medical illness prefer to include

religion in their psychotherapy (Stanley et al. 2011). In other words, if effective and

beneficial (and not dangerous), there is no reason not to place secular therapies within a

R/S framework for patients who desire this.

Fourth, many patients have spiritual needs when hospitalized with serious medical illness,

and they often go unmet with significant consequences in terms of quality of life, satisfaction

with care, and desire for sometimes futile health care services (Balboni et al. 2007, 2010;

Williams et al. 2011). Some of those spiritual needs involve religious or spiritual struggles

for example, feeling punished by God or abandoned by their faith community. When spiritual

struggles of this type are present, there is evidence that mortality increases significantly,

independent of social, psychological, and physical health factors (Pargament et al. 2001).

Does addressing spiritual needs like this and others by a trained chaplain affect the course of

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the medical illness after discharge? If that were the case, then this has enormous practical

implicationsimplications in terms of health professionals screening for spiritual needs,

hiring chaplains to meet those needs [3646% of US hospitals have no paid chaplain staff

(Cadge et al. 2008)], and following up after discharge on spiritual needs identified during

hospitalization (and perhaps addressed through the faith community).

Finally, the public deserves to know whether there are certain beliefs or behaviors that

influence their health and well-being. This is one reason why we pay taxes. We believe that

our government is operating in our interests, and one of those interests is keeping us

informed about beliefs and attitudes, social relationships, and behaviors or lifestyles that

influence our mental and physical health. This is one reason why our government supports

research in the behavioral and social sciences. The mission of the National Institutes of

Health (part of the Department of Health and Human Services) is to: seek fundamental

knowledge about the nature and behavior of living systems and the application of that

knowledge to enhance health, lengthen life, and reduce the burdens of illness and dis-

ability (National Institutes of Health 2011). We may or may not decide to change how we

believe or live, but at least having some objective information about factors that influence

our health can help us make informed decisions.

Thus, conducting research on religion, spirituality, and health has many potential

applications and is not that different from other mainstream areas of scientific research that

explore social and behavioral influences on health. This research has direct implications for

early disease detection, disease prevention, medical outcomes (psychological and physi-

cal), ability to function, and health care practices.

What Do Research Results Mean?

To what extent are the results from research in this area accurately interpreted and

transmitted to the public? How does the popular media translate research findings on

religion, spirituality, and health to the public to facilitate their understanding, and what are

the dangers of misinterpretation or misapplication? Topics at the intersection of religion

and empirical science, especially religion and health, often drive public interest and

therefore, the media focus. Indeed, the popular media has had a field day with many of

studies in religion and health, often making sweeping (and often incorrect) conclusions

about what the studies find and what the results mean. Media coverage often makes it

difficult to separate useful, clinically or personally relevant results from exaggeration and

hype. A recent example of such media dramatization was a study that reported an asso-

ciation between religious involvement and size of the hippocampus (part of the brain that

plays an important role in memory). In this study, investigators found significantly greater

atrophy of the hippocampus in older adults (57% depressed, 43% non-depressed controls)

reporting a life-changing religious experience or indicating that they were born-again

Protestants (vs. mainline Protestants) (Owen et al. 2011). While there were many possible

scientific explanations for these findings and several practical implications, the casual

reader would never have suspected that from the media reports. In the Christian Century, amainline Protestant magazine, a comment on the study appeared under the headline,

Study suggests born again believers have smaller brains (Shimron 2011). Even a

popular article in Scientific American was titled Religious experiences shrink part of thebrain (Newberg 2011). Neither of these claims came anywhere near the truth of what was

actually found in this observational study. Thus, even in some of the most credible popular

publications, the truth often gets distorted.

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Religion and Self-Control

As an example of media misapplication, I focus here on an important research report that

examined the relationship between R/S and self-control. Following its publication, a

commentary on the study appeared in the New York Times. McCullough and Willoughby(2009) comprehensively reviewed and provided original research exploring the relationship

between religiousness and self-control or self-regulation (McCullough and Willoughby

2009). The investigators used Carver and Scheiers theory of self-regulation to explore six

hypotheses. First, they proposed that religion is related to self-control; second, they

hypothesized that religion is related to how goals are pursued; third, they predicted that

religion promotes self-monitoring; fourth, they projected that religion enhances the ability

to self-regulate; fifth, they proposed that religion promotes self-regulatory behaviors; and

sixth, they suggested that some of religions effects on health result from this enhanced

ability to self-regulate. New cross-sectional data were presented on relationships between

religion, personality, and self-control, as well as data on relationships between personal

religiosity, self-control, and future criminal activity.

Based on the results of their review and new data, researchers concluded that there is (1)

strong evidence that religion is positively related to self-control, as well as to agreeableness

and conscientiousness; (2) supportive evidence that religion influences goal selection, goal

pursuit, and goal management; (3) mixed evidence that religiousness promotes self-

monitoring; (4) reasonable evidence that religious rituals promote self-regulation; and (5)

some evidence that religions ability to promote self-control could explain some of reli-

gions associations with health, well-being, and social behavior.

The first line in the New York Times commentary, written by John Tierney on December30, is If Im serious about keeping my New Years resolutions in 2009, should I add

another one? Should the to-do list include, Start going to church? (Tierney 2008). The

writer goes on to summarize the research report above, stating that [the authors] have

reviewed eight decades of research and concluded that religious belief and piety promote

self-control. Mr. Tierneys response to this finding: This sounded to me uncomfortably

similar to the conclusion of the nuns who taught me in grade school Toward the end ofthe article, the writer states, Does this mean that nonbelievers like me should start going

to church? Even if you dont believe in a supernatural god, you could try improving your

self-control by at least going along with the rituals of organized religion.

Comment

Is the New York Times writer correct in his interpretation of the research by McCulloughand Willoughby that attending church will help him keep his New Years resolutions since

religious belief and piety promote self-control? People reading this article are likely to

think that becoming more religious will increase their self-control. Perhaps doctors should

start prescribing religious involvement to patients who have problems with self-control. I

would argue that prescribing religion to non-religious patients with self-control issues is

neither ethical nor indicated based on what Drs. McCullough and Willoughby or any other

researchers have found.

As noted earlier, there are many valuable reasons for conducting research like this on

religion and self-control. The NYT writer above, however, discussed none of them

except the one implication that is probably not true, that is, that going to church by itself

will increase self-control. Rather, the research reported by McCullough and Willoughby

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points out the potential value of R/S practices without prescribing them. The relationship

between R/S and self-control is valuable for the public to know about, but the interpre-

tation should not go beyond what the data actually say. What those data say is that based

largely on observational research, not clinical trials, there is a connection between R/S and

self-control. This does not mean that R/S causes self-control and that going to church will

increase your self-control.

An equally valid explanation of the research findings is that people with self-control are

more likely to go to church. In other words, attending church has nothing to do with

developing self-control. Instead, churches attract people into their membership who

already have it. While attending religious services may lead to exposure to sermons andreligious teachings that advocate self-control and provide a supportive social environment

that is conducive to self-control, it is also possible that persons who are genetically

endowed with good self-control are attracted to church settings where their self-control is

rewarded. This, in turn, makes them feel comfortable and good about themselves and

makes them want to continue to participate in religious activities. In contrast, those without

self-control may not be welcome in church settings because they are disruptive and a threat

to the solid citizens who make up the membership (bad examples for children, etc.).

If a randomized clinical trial were done and people were randomized to church atten-

dance or no church attendance and followed up, and self-control was found to significantly

increase in those assigned to the church attendance group compared to the non-attendees,

then we could indeed conclude that religious attendance led to, resulted in, or caused more

self-control. The research summarized and new data reported by Drs. McCullough and

Willoughby, however, did not do that.

Another problem with the interpretation of observational data like most of that reported

by Drs. McCullough and Willoughby is that it doesnt say how long one must go to church

(or how often) before the benefits to self-control begin to accrue. Nor does it say what

religious denomination enables the fastest accrual of self-control or the particular practices

that are especially potent in this regard. Nor do we know whether going to church only in

order to achieve greater self-control will actually accomplish that goalsince the research

reported by McCullough and Willoughby was conducted on people who presumably were

involved in religious practices for religious reasons, not to gain more self-control. Thus,

research often raises more questions than it answers. And it may be difficult or impossible

to answer some of those questions due to the difficulty or cost of designing a study to

answer them.

Problems with Misinterpretation

What if people who read the NYT article concluded that going to church would increase

their ability to control themselves and keep their New Years resolutions? Would that be all

bad? It might be harmless for some, but not so harmless for others. Some people might

benefit in other ways from attending religious services, even though they started going for

the wrong reason (i.e., to help them keep their New Years resolutions). Indeed, after

hearing a sermon or two, they may be motivated to change their lifestyle, discover new

purpose and meaning in life, develop a deeper relationship with God, or make new friends

in the congregation, and develop close supportive social relationships. Their self-control

may or may not improve, but their lives would improve and perhaps also their spirituality.

For others, the results may not be so benign. These people may go to church and find

after several months of attending that they were not increasing in self-control, but feeling

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very guilty about their lack of self-control and becoming discouraged about their inability

to live controlled lives like other members of the congregation. They might then stop going

altogether, concluding that religion just doesnt work and become disillusioned with

religion altogether not realizing that religion may serve other purposes besides the

development of self-control (but self-control was all they were looking for, based on the

NYT article). This is one reason why many theologians are concerned about religion and

health research. If people use religion for the primary purpose of achieving certain health

goals, then this is a misuse of religion for non-religious goals and could ultimately lead to

disillusionment and the abandonment of religion. In the Judeo-Christian tradition, this

application of the research findings on religion and health (self-control) would lead to

idolatry, where health becomes ones god and religion is used only as a means to it.

Conclusions

There are many logical completely rationale reasons for conducting research on R/S and

health, and the justification for doing so is just as strong as for any other psychological,

social, or behavioral factors that social and behavioral scientists study because those

factors influence our health and well-being. Much may be learned about the human

potential by studying the powerful package of psychological, social, and behavioral forces

that make up religion (one of the few things that people believe intensely enough in to

sacrifice their lives for). How can scientists ignore such a force in society, one that is

important to the lives of the vast majority of Americans and the vast majority of people on

this planet? They cant, but it is essential that the results of such research be interpreted and

applied by both researchers and the popular media in ways that are justified by what the

research actually finds and means.

Acknowledgment Thanks to Dan G. Blazer, M.D., Ph.D., for his review and comments on this article.

Conflict of interest The author has no conflicts of interest.

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