harold g. koenig, md

Overcoming Barriers to Spiritual Health

Harold G. Koenig, MD

Professor of Psychiatry and Behavioral Sciences

Associate Professor of Medicine

Duke University Medical Center, Durham, North Carolina USA

Adjunct Professor, King Abdulaziz University, Jeddah, Saudi Arabia

Adjunct Professor, Ningxia Medical University, Yinchuan, People’s Republic of China

Visiting Professor, Shiraz University of Medical Sciences, Shiraz, Iran

Overview

1. Differences between religion and spirituality

2. Research on religion and mental health

3. Research on religion and physical health

4. Theoretical model explaining effects

5. Clinical applications

6. Conclusions

7. Further resources

Definitions: A Thorny Issue

Religion

Spirituality

Choice of terms to use depends on

the setting and the purpose

research purposes

vs.

clinical applications

Religion

Beliefs, practices, and rituals related to the ‘transcendent,” where the transcendent is that which relates to the mystical, supernatural, or God in Western religious traditions, or to Ultimate Truth, Reality, or Enlightenment, in Eastern traditions. May also involve beliefs about spirits, angels, or demons. Usually involves specific beliefs about the life after death and rules to guide behaviors in this life. Religion is often organized and practiced within a community, but it can also be practiced alone and in private, outside of an institution. Central to its definition is that religion is rooted in an established tradition that arises out of a group of people with common beliefs and practices concerning the transcendent. Religion is a unique construct, whose definition is generally agreed upon. It can be measured and quantified for research purposes (i.e., to examine whether religious involvement affects health).

Secular Humanism

Secular humanism is a way of viewing human existence and behavior that does not involve religion, i.e., God, the transcendent, a higher power, or ultimate truth. The focus is on the rational self and the community as the ultimate source of power and meaning.

This definition is generally agreed upon, is clear, and does not overlap with other constructs. It can be measured, quantified, and its effects on health can be examined.

Spirituality

A popular expression today preferred over religion. Today, spirituality is considered personal, something individuals define for themselves. It is often free of rules, regulations, and responsibilities associated with religion. One can be spiritual, but not religious. In fact, a “secular spirituality” is often emphasized in circles where religion is in disfavor.Thus, spirituality is seen as non-divisive and common to all, both religious and secular.

The term spirituality is especially useful in clinical settings. However, because of its vague and nebulous nature, it is difficult to measure and quantify in order to examine whether spirituality has any effects on health or health outcomes.

Spirituality: An Expanding Concept

Spirituality

Religion

Traditional-Historical Understanding

Source

Secular

Mental Health Physical Health

Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide

CardiovascularDisease

Cancer

Mortality

Psych

on

eu

roim

mu

no

log

y

vs.Ex. well-being

eeds code: 48yurt

Spirituality

Religion

Modern Understanding

Source

Secular


Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide


Cancer

Mortality

Psych

on

eu

roim

mu

no

log

y

vs.Ex. well-being

eeds code: 48yurt

Spirituality

Religion

Modern Understanding - Tautological Version

Source

Secular


Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide


Cancer

Mortality

Psych

on

eu

roim

mu

no

log

y

vs.

Ex. well-being

eeds code: 48yurt

Spirituality

Religion

Modern Understanding - Clinical Application only

Source

Secular


Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide


Cancer

Mortality

Psych

on

eu

roim

mu

no

log

y

Ex. well-being

Not a Researchable Model

Definitions as used in This Talk

1. In discussing the research, I’m going to mostly use the term

“religion,” since that is what can be measured, and is

sufficiently distinct to avoid conceptual overlaps with mental

and physical health (the outcomes).

2. When discussing clinical applications, a broadly inclusive

term such as spirituality should be used and defined by

patients themselves, so as to maximize connection,

engagement and conversation.

Research on Religion and Mental Health

Religion as a Coping Behavior

1. Many persons turn to religion for comfort

2. Religion used to cope with common problems in life,

especially highly stressful situations

3. Religion often used to cope with challenges such as:

- uncertainty

- fear

- loss of control

Religious Coping – does it help?

Review of the Research

Handbook of Religion and Health

(Oxford University Press, 2001, 2012, and

2022, forthcoming)

Religion and Mental Health: Research &

Clinical Applications

(Academic Press, 2018)

Koenig, H. G., Al-Zaben, F., & VanderWeele, T. J. (2020). Religion and psychiatry:

Recent developments in research. British Journal of Psychiatry Advances, 26(5), 262-272.

Koenig, H. G., Peteet, J. R., & VanderWeele, T. J. (2020). Religion and psychiatry:

Clinical applications. British Journal of Psychiatry Advances, 26(5), 273-281.

Religious involvement is related to:

Less depression, faster recovery from depression272 of 444 studies (61%) [67% of best]

More depression (6%)

DepressionOne of the most common emotional disorders in the world,

especially among medical patients, and more disabling than any other

condition except heart disease.

eeds code: 48yurt

Citation: Miller L et al (2014). Neuroanatomical correlates of religiosity and spirituality in adults at high

and low familial risk for depression. JAMA Psychiatry 71(2):128-35

Religion/Spirituality and Cortical Thickness:

A Structural MRI Study

Areas in red indicate reduced cortical thickness

Religion NOT very important Religion very important


Less suicide and more negative attitudes toward suicide (106 of 141 or 75% of studies)

Suicide(systematic review)

>Once/Week Once/Week <Once/Week Never U.S. in 2010

0

2

4

6

8

10

12

Su

icid

e In

cid

ence

Rate

per

10

0,0

00

Pers

on

-Ye

ars

Religious Service Attendance

Nurses Health Study: 89,708 women followed from 1996 to 2010 (HR=0.16, 95% CI 0.06-0.46)

VanderWeele et al (2016). JAMA Psychiatry (Archives of General Psychiatry) 73(8):845-851

Nurses Health Study: 89,708 women followed from 1996 to 2010 (HR=0.16, 95% CI

0.06-0.46) VanderWeele et al (2016). JAMA Psychiatry (Archives of General

Psychiatry) 73(8):845-851

>Once/Week Once/Week <Once/Week Never

0

2

4

6

8S

uic

ide I

ncid

en

ce R

ate

pe

r 1

00

,00

0 P

ers

on-Y

ears


Chen, Y., et al. (2020). Religious service attendance and deaths related to drugs, alcohol, and suicide among US

health care professionals. JAMA Psychiatry, 77(7), 737-744. [16-year prospective study of 66,492 women

examining “deaths of despair” (from drugs, alcohol, or suicide); Cox proportional hazards regression models

controlling for 25 demographic, psychological, social, and physical health covariates]

Never/Almost Never < Once/Week Once/Week or More

0.00

0.25

0.50

0.75

1.00H

azard

Ra

tio

(H

R)

for

De

ath

s o

f D

es

pa

ir

Religious Attendance

HR=1.00

HR=0.66

(95% CI=0.38-1.14)

HR=0.32

(95% CI=0.16-0.62)

Religious Attendance and Deaths of Despair

Among U.S. Health Professionals (Women)

p for trend <0.001

Chen et al. 2021 Religious service attendance and deaths related to drugs, alcohol, and suicide among US

health care professionals. JAMA Psychiatry, 77(7), 737-744. [26-year prospective study of 43,141 men

(dentists, pharmacists, optometrists, osteopaths, podiatrists, veterinarians) examining “deaths of despair”

(from drugs, alcohol, or suicide); Cox proportional hazards regression models age adjusted only]

HR=1.00

HR=0.74

(95% CI=0.51-1.08)

HR=0.51

(95% CI=0.37-0.70)

Religious Attendance and Deaths of Despair

Among U.S. Health Professionals (men)

p for trend < 0.001

Never/Almost Never < Once/Week Once/Week or More

0.00

0.25

0.50

0.75

1.00H

azard

Rati

o (

HR

) fo

r D

eath

s o

f D

esp

air



Less alcohol use / abuse / dependence240 of 278 studies (86%)

[90% of best designed studies]

Alcohol Use/Abuse/Dependence (systematic review)

Illicit Drug Use(systematic review)


Less drug use / abuse / dependence155 of 185 studies (84%)

[86% of best designed studies]

[95% of RCT or experimental studies]


Greater well-being and happiness256 of 326 studies (79%)

[82% of best]

Lower well-being or happiness (3 of 326 studies, <1%)

Well-being and Happiness(systematic review)


Greater meaning and purpose42 of 45 studies (93%) [100% of best]

Greater hope29 of 40 studies (73%)

Great optimism26 of 32 studies (81%)

*All of the above have consequences for patients’ motivation for self-care and efforts toward recovery*

Meaning, Purpose, Hope, Optimism(systematic review)


• Great social support(61 of 74 studies) (82%)

Social Support(systematic review)

At least 104 quantitative peer-reviewed studies have examined

the spirituality-delinquency/crime relationship. Of those, 82

(79%) reported inverse relationships between spiritual

involvement and delinquency or crime.

Of the 60 best studies, 82% found significant inverse

relationships.

Delinquency and Crime(systematic review)

Spiritual But Not Religious

Followed 8,318 medical outpatients in United Kingdom, Spain, Slovenia,

Estonia, The Netherlands, Portugal and Chile. AIM: determine if baseline

spiritual or religious (S/R) beliefs predict onset of MDD during 12-mo f/u.

S/R beliefs measured by (1) whether understanding of life is primarily

religious, spiritual, or neither, and (2) if S/R, how strongly held. CIDI used to

make the diagnosis of MDD at 6 and 12 mo follow-ups. Controlled for:

gender, age, education, marital status, employment status, ethnicity, and

history of depression. SLE in past 6 mo and social support examined as

mediators. Results: Adjusting for confounders and mediators, those with a

spiritual view (but not religious) were more likely to experience MDD over

the next 12 months compared to those with a secular view (OR=1.32, 95% CI

1.02-1.70). When analyses stratified by country, effect especially significant in

UK (OR 2.68, 95% CI 1.52-4.71, p<0.01).

Citation: Leurent B et al (2013). Spiritual and religious beliefs as risk factors for the onset

of major depression: An international cohort study. Psychological Medicine, 43(10):2109-

2120

Spiritual But Not Religious

King et al. investigated associations between a spiritual or

religious understanding of life and psychiatric symptoms in 7,403

people in England. They found religious people were similar to

those who were neither religious nor spiritual with regard to the

prevalence of mental disorders, except that those who were

religious were less likely to have ever used drugs or to be a

hazardous drinker. On the other hand, spiritual people (spiritual

but not religious) were more likely than those who were neither

religious nor spiritual to have (a) ever used or to be dependent on

drugs, (b) abnormal eating attitudes, and (c) generalized anxiety

disorder, any phobia or any neurotic disorder.

King M, Marston L, McManus S, Brugha T, Meltzer H, Bebbington P. Religion,

spirituality and mental health: results from a national study of English

households. British Journal of Psychiatry. 2013; 202(1):68-73.

Religious Involvement

(attendance, prayer,

scripture study,

volunteering, religious

education, religious

devotion, coping)

Later Child

Enviornment

Adult

Environment

Maternal Stress &

Substance Use

Prenatal

Environment

Psychological

Early Child

Environment

Train/Model Morals

& Values; Monitoring

Caregiver Nurturing

& Support

Trauma, Losses,

Negative Life Events

Positive Cognitions,

Healthy Coping

Gene x Environment Interactions

Behavioral

Social

Healthy Lifestyle(exercise, diet, weight, no

smoking, alcohol/drugs)

Support, Prosocial

Peers, Volunteer

Prosocial Choices,

Healthy Decisions,

Virtues/Character

Individual/

Personal

Research on Religion & Health Behaviors

Religion is related to:

• More exercise/physical activity(25 of 37 studies) (68%)

• Less extra-marital sex, safer sexual practices (fewer partners) (82 of 95 studies) (86%)

• Lower weight(7 of 36 studies) (19%)

• Heavier weight(14 of 36 studies) (39%)

Exercise, Weight, Risky Behaviors(systematic review)


Less cigarette smoking, especially among the young(122 of 135 studies) (90%)

Cigarette smoking(systematic review)

Research on Religion and Physical Health

Physical Health Consequences

Those who are more frequently involved in religious activity, on average:

• Have less heart disease• Have lower blood pressure• Have lower rates of stroke • Experience less cognitive decline with aging• Experience less physical disability with aging• Have better immune function and less systemic inflammation• Have better endocrine functions (<cortisol, epi & norepinephrine)• Have lower death rates from cancer• Experience greater longevity

Of all religious characteristics, frequency of attendance at religious services is the strongest predictor of physical health and longevity.

Mortality (all-cause)(systematic review)

Religious involvement related to:

• Greater longevity in 82 of 120 studies (68%)

• Shorter longevity in 7 of 120 studies (6%)

eeds code: 48yurt

>Once/Week Once/Week <Once/Week

0.5

0.6

0.7

0.8

0.9

1.0

All

-Cau

se

Mo

rtali

ty (

HR

)


Multivariable Adjusted Hazard Ratio with 95% Confidence Intervals

(reference category "never attend", with gradient of effect p<0.001)

HR=0.87

HR=0.67

HR=0.74

Nurses Health Study: 74,534 women followed from 1996-2012

Li et al (2016). JAMA Internal Medicine 176(6):777-785


0.5

0.6

0.7

0.8

0.9

1.0

Card

iovascu

lar

Mo

rtality

(H

R)


Multivariable-Adjusted Hazard Ratios and 95% Confidence Intervals

(reference category "never attend" with gradient of effect p<0.001)

HR=0.73

HR=0.80HR=0.92

Li et al…VanderWeele (2016). JAMA Internal Medicine 176(6):777-785


0.5

0.6

0.7

0.8

0.9

1.0

Ca

nc

er

Mo

rtali

ty (

HR

)


Multivariable-adjusted Hazard Ratios and 95% Confidence Intervals

(reference catetory "never attend" with gradient of effect p<0.001)

HR=0.79

HR=0.86 HR=0.91


Mediation Analysis for the Religious Attendance –

All-Cause Mortality Effect

Depressive Symptoms (CES-D) 11% p<0.001

Current Smoking 22% p<0.001

Optimism 9% p<0.001

Social Integration 23% p=0.003

Unexplained 35%

(no mediation for alcohol use, diet quality, phobic anxiety)


0

500

1000

1500

2000

2500

C NG (NG) M (P) P NA

C

NG

(NG)

M

(P)

P

NA

Number of studies includes some studies counted more than once (see Appendices

of 1st and 2nd editions). Prepared by Dr. Wolfgang v. Ungern-Sternberg

The Relationship between Religion and Health: All Studies

Belief in,

attachment to

God

Public prac, rit

Private prac, rit

R commitment

R coping

Positive Emotions

Negative EmotionsMental Disorders

Social Connections

Ph

ysic

al H

ea

lth a

nd

Lo

ng

evity

Imm

une, E

ndocrine, C

ard

iovascula

r F

unctions

Theoretical Model of Causal Pathways

Genetics, Developmental Experiences, Personality

Decisions, Lifestyle Choices, Health Behaviors

SOURCE

R experiences

Spirituality

faith

community

PsychologicalTraits / Virtues

ForgivenessHonestyCourageSelf-disciplineAltruismHumilityGratefulnessPatienceDependability

Theolo

gic

al V

irtues:

faith

, hope, lo

ve

faith

community

*Model for Western monotheistic religions (Christianity, Judaism, and Islam)

(c) Handbook of Religion & Health, 2nd ed

Clinical Applications

Applications in Healthcare

• Physicians should take a spiritual history -- talk with patients about

these issues

• Respect, value, support beliefs and practices of the patient

• Identify the spiritual needs of the patient

• Ensure that someone meets patients’spiritual needs (pastoral care)

• Pray with patients if patient requests

• Work with the faith community, if patient consents

From: Spirituality in Patient Care (Templeton Foundation Press, 2013)

The Spiritual History1

1. Do your religious/spiritual (R/S) beliefs provide comfort?

2. Are your R/S beliefs a source of stress?

3. Do you have R/S beliefs that might influence your medical

decisions?

4. Are you a member of a faith community, such as a church,

synagogue, mosque, or temple? If yes, is it supportive?

5. Do you have any other spiritual concerns that you’d like someone to

address?

1Adapted from Koenig HG (2002). Journal of the American Medical

Association (JAMA) 288 (4): 487-493

Activities Besides Taking a Spiritual History

1. Support healthy religious/spiritual beliefs of the patient (verbally, non-verbally)

2. Ensure patient has resources to address their spiritual needs (refer to chaplain,

licensed pastoral counselor, licensed religious counselor)

3. Accommodate the inpatient environment to meet spiritual needs of patients from

all faith traditions (e.g., prayer rug for Muslims, direction to Mecca, alone space

to pray or meditate, accessibility to religious services on TV, allow visits from

chaplains, personal clergy, and possibly, members of the congregation if patient

allows)

4. Pray with patients if patient requests (controversial and need to be very careful,

especially in psychotherapy; often best to have patient say the prayer)

5 CME-qualified 45-60 min Training Videos on How to Integrate Spirituality into Patient Care (using the “Spiritual Care Team” approach)

Go to the following Duke University website:

http://www.spiritualityandhealth.duke.edu/index.php/cme-videos

http://www.spiritualityandhealth.duke.edu/index.php/cme-videos

Conclusions

1. Religious involvement (RI) is related to better mental, social, and behavioral health, and improves these aspects of health over time

2. RI is also related to better physical health, less functional disability, and less cognitive decline with aging

3. These findings have huge implications for public health and healthcare costs as RI becomes less common with each younger cohort.

4. The clinical applications of the research on religion/spirituality and health are vast in terms of provision of mental and physical health care

Further Resources

CROSSROADS…

Exploring Research on Religion, Spirituality & Health

• Summarizes latest research

• Latest news

• Resources

• Events (lectures and conferences)

• Funding opportunities

To sign up, go to website: http://www.spiritualityandhealth.duke.edu/

Monthly FREE e-Newsletter

http://www.spiritualityandhealth.duke.edu/

Summer Research WorkshopAugust 15-19, 2022

Durham, North Carolina

5-day intensive research workshop focus on what we know about the relationship

between spirituality and health, clinical applications, how to conduct research, and

how to develop an academic career in this area. Faculty includes leading spirituality-

health researchers at Duke, Yale University, Emory, and elsewhere.

-Strengths and weaknesses of previous research

-Theological considerations and concerns

-Highest priority studies for future research

-Strengths and weaknesses of measures of religion/spirituality

-Designing different types of research projects

- Primer on statistical analysis of religious/spiritual variables

-Carrying out and managing a research project

-Writing a grant to NIH or private foundations

-Where to obtain funding for research in this area

-Writing a research paper for publication; getting it published

-Presenting research to professional and public audiences; working with the media

Partial tuition Scholarships are available

Full scholarships for those in undeveloped countries

If interested, contact Dr. Koenig: [email protected]

Questions and Discussion(till 1:00)

harold g. koenig, md

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