I have some sympathy for the character in Molière's play, who said: 'Good heavens! For more than forty years I have been speaking prose without knowing it'.[1] I have been a practising Christian for a long time, but over recent years have found myself to be labelled with what other people call 'spirituality'; it is not a direction I had expected to go in. I wanted to work out the relationship between my faith and my practice of medicine, specifically psychiatry. Meanwhile, others, who share these goals, have described their interest as 'spirituality'. I have had an interest in spirituality all this time without knowing it!

This article considers: what is meant by spirituality; potential dilemmas for the Christian; a brief digression into narrative based medicine; spirituality and psychiatry; the recent increase of interest in spirituality; outcome studies in religion and health; and what all this means for Christian doctors.

What is spirituality?

Dictionary definitions are unhelpful. For instance, in the Shorter Oxford Dictionary: spirituality is 'that which has a spiritual character, the quality or condition of being spiritual'. Spiritual means 'of, pertaining to, affecting or concerning, the spirit or higher moral qualities, especially as regarded in a religious aspect'.[2]

Koenig et al,[3] to whom I will refer later, define spirituality in a health context as: the personal quest for understanding answers to ultimate questions about life, about meaning, and about relationship to the sacred or transcendent, which may (or may not) lead to or arise from the development of religious rituals and the formation of community.

This is comprehensive but not very comprehensible!

The word religion has the same root as ligament, ligature and obligation. It is that to which I regard myself as being bound, a rope that ties me to God and to other believers. In everyday conversation, spirituality has come to mean almost the same as religion, but it is 'politically correct' as it involves those people who have no religious affiliation. Koenig et al have produced this helpful table to compare religion with spirituality, see below.

Potential dilemmas for the Christian doctor

Does the spirituality movement in medicine raise problems for the Christian doctor? Does it represent an unacceptable compromise that prevents us getting involved? Christians have much in common with agnostic searchers after truth, which we do not share with atheists and reductionist materialists (those who teach that matter is all there is). We both accept that there is more to life and health than functioning biochemical systems and well-lubricated joints. We both believe in prayer and in a reality greater than ourselves. We have much on which we can work together but at the same time we should not deny our differences. Religious people often describe themselves as pilgrims, whereas spiritual people may see themselves as searchers; holding on to faith implies moving towards a goal.

Our problems with spirituality arise directly from this difference. There is nothing uniform about spirituality; it is individualistic. A person makes a subjective choice about what they would like to see in their own spiritual life. There is not necessarily any conformity to anyone else's ideas except through some process of social osmosis. There is no ultimate authority, no set form of behaviour or practice and the reasons for carrying out spiritual activities are emotional and individual. It contains some good features but it does not necessarily have internal coherence. Sometimes spirituality appears to be like a gleaming sports car – but with no engine! The Christian starts with the living Christ, and what is individual and collective, emotional and rational emanates from our relationship with him and what we believe about him.

Spiritual awareness often arises from dissatisfaction with the materialistic order of life. Wherever we look, we find that what can be measured, what is on the surface, is important but not everything. Spirituality and religion should not necessarily be seen as opposed. In fact, throughout the last two millennia individual spirituality has occurred in the context of Christian faith, although sometimes out of line with the contemporary church authorities. Christianity has included mystics such as Julian of Norwich and St Theresa of Avila. When we discuss our faith with those who recognise the importance of spirituality but are not themselves Christians, we have to start with what we hold in common. What I greatly respect in a spiritual person is this sense of yearning - for a better world and a better self. Jesus himself risked possible contamination; 'a friend of tax collectors and sinners'.[4] We seek his kingdom by helping people understand who he is and follow him - this implies making contact with them!

Narrative based medicine

During the 1990s evidence based medicine became a mantra for British medicine. Most practitioners were convinced of the need for good quality, epidemiological evidence but also had a feeling of unease. Are the numbers being collected relevant for what we need to know? Are they accurate and reliable? Are not medicine and health concerned with more than this? We could no longer be satisfied with the dictum, 'if I cannot score it, I ignore it'. Epidemiological data could indicate cause, course and treatment required for our patient but that was not enough. We needed to take into account this person's individual characteristics, and their story. This led to the publication by Greenhalgh and Hurwitz of Narrative Based Medicine in 1998, which showed that the individual story of the patient is always relevant for the practice of medicine.[5] This includes the patient's cultural, social and religious beliefs. The recent increase in interest surrounding spirituality in medicine, which is apparent from the increased number of published journal articles, has developed alongside this feeling of disquiet concerning numerical data alone.

As Christian doctors, we knew this all along but we were remarkably unsuccessful in getting our message across to colleagues. Our own life as doctors has to have meaning and so too does each of our patient's lives. Narrative, his story, is the way in which the patient can explore that meaning for himself, and also let others know about what is significant for him. Obtaining a patient's story opens a window on her beliefs, values and aspirations. Religious belief, spirituality, a set of values matters for the patient whether the doctor realises this or not.

Spirituality and psychiatry

An operational definition of spiritual for psychiatrists and other clinicians might include:[6]

• Aims and goals - looking for the meaning in life, what one regards as essential
• Human solidarity - the interrelatedness of all, both doctor and patient; consciously and unconsciously-shared beliefs
• Wholeness of the person - the spirit is not separate from body or mind, but includes them
• Moral aspects - what is seen as good, beautiful or enjoyable, as opposed to what is bad, ugly or hateful
• Awareness of God - the connection between God and man

When set out like that, few clinicians would deny the importance of spiritual issues in the cause, course, treatment and outcome of mental illnesses. However, mental health practitioners show consistently lower rates of religious belief and practice than either their patients or the general population. In the United Kingdom, the 2001 Census revealed that 72% of the general public describe their religion as Christian. However, a study found the following contrasts:

• 73% of psychiatrists reported no religious affiliation
• 78% attended religious services less than once a month
• Only 39% of women psychiatrists, and 19% of men, believed in God
• However, 92% believed that religion and mental illness were connected and that religious issues should be addressed in treatment
• 42% considered that religiosity could lead to mental illness
• 58% never made referrals to clergy [7]

Psychiatrists' rising interest in spiritual issues

There have been surprising changes in attitude towards faith, religion and spirituality within British psychiatry over the last 50 years, and this is beginning to have an effect upon patient care.

Early 20th century European psychiatry was more than tinged with anti-clericalism (opposition to church authority). This had a powerful effect upon the mutual suspicion that later developed between the institutional church and psychiatry. At the same time, the enormous development of science meant that reductionism dominated medicine. Man was 'nothing but' an excessively cerebral erect ape; human behaviour was 'nothing but' Pavlovian conditional or Skinnerian operant conditional responses. Scientific psychiatry bought in wholesale from this world view.

Freud taught in the 1930s that belief in a single God is delusional. Many churches at the time identified Freud, his discipline of psychoanalysis and, by association, the whole of psychiatry, with atheism, seeing it as a challenge to conventional morality.

In the 1950s and 60s, psychiatry viewed the spiritual concerns of patients, and religious faith of psychiatrists and patients, with suspicion and often disapproval. Psychiatrists often believed that religion was 'bad for your health'. Religious belief amongst patients was equated with neurosis and amongst psychiatric trainees was regarded as being seriously unscientific and to be strongly discouraged. The therapeutic effectiveness of psychiatry was low and the church distrusted it for 'leading people astray'. There were a few exceptions, brave pioneers who tried to bridge the vast chasm that had opened up between psychiatry and faith, and we owe a considerable debt to them.

Psychiatric textbooks at the time virtually ignored religion. As an example, in the standard British textbook of the period there are only two references to religion in the index: '“Religiosity” in deteriorated epileptic' and, 'Religious belief, neurotic search for'.[8] The latter was aimed as an attack upon psychoanalysis but assumed that religion is for 'the hesitant, the guilt-ridden, the excessively timid, those lacking clear convictions with which to face life'.

During the 1970s, those who wanted to work out the implications of Christianity in psychiatry and others with an interest in spirituality began to meet together. More Christians entered the specialty and, significantly, there was a considerable influx into psychiatry of those from other faiths, most having qualified in medicine in other countries. People began to feel that perhaps materialism had gone too far.

In the 1980s informal groups met around the country to discuss the relation of faith to psychiatric practice. Christian churches were becoming more favourably disposed towards psychiatry, perhaps because treatment had become more effective, and more Christian trainees entered the specialty. A loosely knit Association of Christian Psychiatrists was set up in the early 80s and the first CMF breakfast at a national meeting of the Royal College of Psychiatrists (RCPsych) was held in April 1986, continuing annually ever since.

In the 90s, spirituality became more public. In 1991, Prince Charles stressed the importance of acknowledging the spiritual needs of our patients in an address to the RCPsych.[9] The Archbishop of Canterbury underlined the need for more co-operation and mutual understanding between psychiatrists and church leaders at a joint meeting of the RCPsych and the Association of European Psychiatrists.[10] As President of the RCPsych, I tried to emphasise the importance of the spiritual in 'psyche', and how this was significant for our patients.[11] There were real changes in attitude and practice in this decade, which also saw the beginnings of research in the area of mental illness and religious belief.

The Spirituality and Psychiatry Special Interest Group of the RCPsych was instituted in February 2000, perhaps the culmination of a half century of hard-won progress. The response to setting up this group was surprising, with a large number wishing to join, and meetings over-subscribed. At an early meeting an elderly psychiatrist said, 'Throughout my career I have wanted something like this'.

Religion and health: outcome studies

Does the patient's religious belief have any relevance for their health, prognosis and response to treatment? Is this true for both physical and mental illnesses? This is the substance of the Handbook of Religion and Health by Koenig, McCullough and Larson.[12] At over 700 pages and 1.5 kg it is a big book! It is a review and discussion of research that has examined the relationships between religion and a variety of mental and physical conditions; it covers the whole of medicine and is based on 1,200 research studies and 400 reviews. The two biggest sections of the book, each with ten chapters, are 'Research on religion and mental health' and 'Research on religion and physical disorders'.

The section on research and mental health discusses: religion and well-being, depression, suicide, anxiety disorders, schizophrenia and other psychoses, alcohol and drug use, delinquency, marital instability, personality, and a summarising chapter on understanding religion's effects on mental health. The authors are extremely cautious in drawing conclusions but the results are overwhelming, and if the factor being studied were smoking or plasma triglycerides, then the media would have taken them up as front-page news. To quote:

In the majority of studies, religious involvement is correlated with:

• Well-being, happiness and life satisfaction
• Hope and optimism
• Purpose and meaning in life
• Higher self-esteem
• Adaptation to bereavement
• Greater social support and less loneliness
• Lower rates of depression and faster recoveryfrom depression
• Lower rates of suicide and fewer positive attitudes towards suicide
• Less anxiety
• Less psychosis and fewer psychotic tendencies
• Lower rates of alcohol and drug use and abuse
• Less delinquency and criminal activity
• Greater marital stability and satisfaction

We concluded that, for the vast majority of people, the apparent benefit of devout religious belief and practice probably outweigh the risks.

Correlations between religious belief and greater well-being 'typically equal or exceed correlations between well-being and other psychosocial variables, such as social support'. This is a massive assertion, comprehensively attested to by a large volume of evidence. In Brown's studies on the social origins of depression,[13] various types of social support were the most powerful protective factors against depression and the above research shows that religious belief is at least as protective.

The factors that correlate with religious belief and practice and tend towards better health outcome are all measured and assessed epidemiologically and, to give some examples from those listed above:

• 80% or more of the studies reported an association between religious involvement and greater hope or optimism about the future.
• 15 out of 16 studies reported a statistically significant association between greater religious involvement and a greater sense of purpose or meaning in life.
• 19 out of 20 studies reported at least one statistically significant relationship between a religious variable and greater social support.
• Of 93 cross-sectional or prospective studies of the relationship between religious involvement and depression, 60 (65%) reported a significant positive relationship between a measure of religious involvement and lower rates of depression; 13 studies reported no association; four reported greater depression among the more religious; and 16 studies gave mixed findings.

And so on, with all the 13 factors religious belief proved beneficial in more than 80% of studies. This is despite few of these studies having been initially designed to examine the effect of religious involvement on health.

The authors develop a model for how and why religious belief and practice might influence mental health. There are direct beneficial effects upon mental health, such as better cognitive appraisal and coping behaviour in response to stressful life experiences. There are also indirect effects, such as developmental factors and even genetic and biological factors. It is a great pity that this important book is not better known and noticed but perhaps our secular and largely anti-Christian press has a vested interest in not acknowledging it.

How can we apply this?

As Christians and doctors, we know something of great value for our patient's health. However, getting this across so that it will be heard and helpful is not easy. The 'Saline Solution'[14] is a training resource developed by our sister organisation in the USA, designed to help doctors to be 'salt'[15] and bring spiritual issues into the consultation. The authors suggest that the infusion that gives life should not contain dextrose or any other contaminant; it must be at the right concentration, 0.9%, as 3% would be lethal. This is particularly true in psychiatry; not only is anything that could be construed as 'ramming religion down our patients' throats' unethical, it is ultimately ineffective. There should be no aggressive evangelism of patients; yet neither should there be denial of the patient's right to discuss his or her religious beliefs and their interconnection with mental illness.

Those of us seeking to follow spiritual values and recognise the spirituality of our patients have a great deal in common with each other. In fact, in our pluralistic religious societies, a discussion of spiritual values is the logical place for us to meet with our non-Christian colleagues and discuss important aspects concerning religion and faith. Remember the wise men from the East;[16] they knew that they were missing something. In Matthew's account, they were oriental astrologers, certainly neither Christian, nor even Jewish believers; hence suspect indeed! However, they were prepared to search, and they found Jesus. Truly spiritual people have this yearning for God and his world, however they describe it, and this should also characterise us.

At times we may face discouragement, and two prophets stand out with something to teach us from their weaknesses as well as their strengths – Jonah and Elijah. When Jonah eventually went to Nineveh and preached against their wickedness, to his surprise, they repented. God will not necessarily use our Christian witness the way we expect. Then what I would call the Elijah complex is the Christian who feels he or she has to do it alone: 'I, only I, am left'.[17] Usually, we have only one part to play and there are, perhaps, a dozen other Christians involved in the complete story.

Our aim must be to uphold Jesus and all he stands for. We have to earn the right to speak out about our faith where and when people are talking about spirituality, not by our certainty and dogmatism (which often comes over as arrogance) but by our faith being transformed into action, by genuine concern for people and by having a good grasp of what it is that we believe.

Modern, western, 'first-world' spirituality has something of supermarket consumerism about it. 'I will take a vacuum-pack of New Age sensationalism, a carton from a Hindu ashram, a jar of Buddhist meditation and a tiny peck of Sufi Islam'. As Christians, we are also influenced by this way of thinking but we are not at liberty to pick and choose, to make our own DIY religion. We are bound to the ground of our being by our biblical faith. Many non-Christians have a great feeling of relief that we, Christians, do have certainties in life, that we do have a reason for the hope that we have.[18]

As Christians, we must go to the place where people are. If those seeking foundations for life are talking about spirituality, we should be there even though, at times, we may find this frustrating and uncomfortable. What we say has to be relevant for the present. Just thinking of some of the words sung in church or spoken from the pulpit makes one cringe. Would your colleagues accept them? Probably they would not even understand what was being talked about. The New Testament writers were extremely good at giving examples from everyday life to clarify their point; for example, 'redemption', a 'shield of faith', or 'meat dedicated to idols'. Unfortunately, Christians sometimes still use first century imagery, which is lost on present-day hearers. It is essential that we learn to talk about the timeless truths of the gospel using language and concepts that people can understand and relate to.

We need to listen. Then we can try to find what our friend's spirituality says about Jesus Christ and show him or her how this is relevant in this particular situation. We must start from the truth they know and lead them on to the truth they don't yet know, but we can only do this if we are there at the place of discussion!

Andrew Sims is emeritus professor of psychiatry at Leeds University

Religion

• Community focussed
• Observable, measurable, objective
• Formal, orthodox, organised
• Behaviour orientated, outward practices
• Authoritarian in terms of behaviours
• Doctrine separating good from evil

Spirituality

• Individualistic
• Less visible and measurable, more subjective
• Less formal, less orthodox, less systematic
• Emotionally orientated, inward directed
• Not authoritarian, little accountability
• Unifying, not doctrine orientated