Toward an Integration of Spirituality and Religiousness Into the Psychosocial Dimension of Schizophrenia

Biological, social, and psychological factors are thought to account for schizophrenia and to mediate the effects of various treatments. Any effort to understand the great heterogeneity of outcomes in schizophrenia must integrate subjectivity and the experience gained from psychiatric research and clinics (1) . For many years, studies of religion and schizophrenia mainly focused on religious delusions and hallucinations with religious content. Recently, however, the role of religion as a coping mechanism and in the recovery process of patients with schizophrenia has begun to receive growing interest (2) . High prevalences of religiosity in patients with psychosis have been reported in North America (3 – 4) and Europe (5 – 6) . The role of spirituality as a resource for finding meaning and hope in suffering has also been identified as a key component in the process of psychological recovery (7 – 10) . Clinicians are rarely aware of the importance of religion for patients (11) , even if spirituality needs to be integrated into patient care (12) . This task is particularly difficult when dealing with schizophrenia, since religion may be a manifestation of psychosis as well as a coping behavior that patients use to help them deal with symptoms.

Given religion’s importance for many patients, it should be integrated into the biopsychosocial model of schizophrenia in order to achieve a whole-person approach to treatment. To our knowledge, no systematic studies have explored religion as a mediating variable in the process of coping with psychotic illness. By “religion” we mean both spirituality, which is concerned with the transcendent, addressing the ultimate questions about life’s meaning, and religiousness, which refers to specific behavioral, social, doctrinal, and denominational characteristics. In a cohort of outpatients suffering from psychotic disorders, we systematically investigated the positive and negative roles of religion in coping with psychosis and other aspects of patients’ lives. Relationships between religious coping and clinical variables were also assessed.

Method

Study Design

The study design and procedure have been described in detail elsewhere (11) . Participants were outpatients 18 to 65 years of age who were being treated in one of Geneva’s four psychiatric outpatient facilities and met ICD-10 diagnostic criteria for schizophrenia or another nonaffective psychosis. Diagnoses were verified by a review of patients’ charts. Patients whose clinical condition prevented them from participating in the interviews were excluded. In each clinic, about 200 patients were eligible for the study. To balance feasibility and generalizability, we planned to recruit about 120 patients. Psychiatrists in the four outpatient clinics were provided with information about the study. Each clinician was asked to present the study to the next five patients on their schedule in order to control for selection bias, such as selection of patients according to religious characteristics. One of the authors (S.M.) then met 103 patients for an audiotaped interview; three patients refused to participate. To control for interviewer bias, a second author (L.B.) met an additional 15 patients. The study was approved by the ethical committee of the University Hospital of Geneva. All participants received detailed information about the study and gave written consent.

Measures

Demographic data were collected, and the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression (CGI) were administered. Psychosocial adaptation was evaluated with axis V of DSM-IV. Subjective quality of life was assessed with a visual analog scale.

No validated questionnaire exists for surveying religion and religious coping among psychotic patients. In this population, measures of religiosity may exhibit factorial patterns different from those in nonpsychiatric populations (13) . Moreover, as Wulff (14) pointed out, no questionnaire could be adapted to every kind of religious belief and practice. For those patients whose spirituality and religiousness may also be mixed with their psychopathology, the most appropriate evaluation method is the clinical interview, which allows clinicians to adapt their language to the beliefs of the individual patient. We developed a semistructured interview inspired by several scales or questionnaires, including the Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research (15) , the Duke Religion Index (16) , and a questionnaire on spiritual and religious adjustment to life events (17) . The interview was designed to explore patients’ spiritual and religious history, beliefs, and private and communal religious activities; the importance of religion in patients’ daily lives; the importance of religion as a means of coping with their illness and its consequences; the synergy or incompatibility of religion with somatic and psychiatric care; and patients’ ease in speaking about religion. Our clinical grid proved to be applicable to a broad diversity of religious beliefs, even pathological ones, with high interjudge reliability and construct validity. In addition to the structured interview, we used a visual analog scale with 5 anchored points to obtain self-report measures on the salience of religiousness (i.e., the frequency of religious activities and the subjective importance of religion in daily life), religious coping, and synergy with psychiatric care. The duration of the interview was about 45 minutes. All interviews were audiotaped. A comparison of the sets of the two different interviewers yielded equivalent distributions for each individual religious variable.

The subjective importance of religion for the patient was also assessed by the two clinicians, in terms of its centrality (18) . The concept of centrality ascribes a hierarchical status to religion as regards personality. The more central religion is, the more it can influence the person’s experience and behavior. Interrater reliability was high for centrality (Kendall’s tau b rank correlation=0.78, two-tailed p<0.001).

In addition to this quantitative estimate, a qualitative content analysis of all interview transcripts was conducted by two authors (S.M. and L.B.) to obtain a comprehensive view of religious coping strategies. This analysis showed that patients could be separated into three groups reflecting their coping strategies at a psychological level (i.e., coping with existential and symptomatic issues): those with positive coping, those with negative coping, and those with no religious coping. Patients were placed in the positive coping group if their religion provided them with a positive sense of self or a spiritual sense of their illness that helped them accept it and mobilize their religious resources to cope. With this form of religious coping, symptom severity was decreased and social relationships were improved. Patients were placed in the negative coping group if their religion contributed to a negative sense of self, in terms of despair and suffering or a spiritual sense of the illness inducing fear, anger, or guilt. With this form of religious coping, symptom severity and social isolation increased. Patients were placed in the no religious coping group if they had absolutely no spiritual beliefs or religious practices or if their religion was not mobilized to cope with their illness in any way. With these criteria in mind, one of the authors (L.B.) independently classified the patients into the three groups. Interrater reliability was high (kappa=0.86). Disagreement occurred only in cases of inconsistent relationships between religion and schizophrenia—for example, a patient with positive coping at the psychological level but negative coping for psychiatric treatment. The positive and negative coping groups compared in terms of social integration, comorbidity, and psychiatric treatment.

Statistical Analysis

Data were analyzed with SPSS version 11 (SPSS, Inc., Chicago, 2001). Distribution-free univariate statistics were used for comparisons of the variable distributions between groups (chi-square, Wilcoxon rank test, Kruskal-Wallis test). Kendall’s tau b rank correlations were used to assess relationships between religion and clinical variables.

Results

Table 1 summarizes the sample’s demographic and clinical characteristics. The majority of the patients were Christian (61%); 9% came from other traditional religions (Judaism, Islam, and Buddhism), 12% from minority religious movements (for example, esoterism, spiritism, Christian Science, Scientology, or UFOlogy), and 18% had no religious affiliation. Fifty-six percent reported that they never participated in religious practices with other people, 14% did so occasionally, and 30% did so at least once a month. Twenty percent felt they received great support from their religious community and 10% some support. Twenty-four percent reported that they never engaged in any religious practices alone, 14% that they occasionally did so, 10% that they did so every week, and 52% that they did so every day. Religion was important in the lives of 85% of the patients and was absent from or of no importance in the lives of 15%. For nearly half the patients (45%), religion was the most important element in their lives; 78% rated it as being important to essential in day-to-day life, 67% in giving meaning to their lives, 59% in giving meaning to their illness, 60% in helping them cope with their illness, 52% in helping them gain control of their illness, and 63% in giving them comfort. Some patients perceived an antagonism between their religion and medication (12%) or supportive therapy (10%). Most patients (80%) felt at ease in talking about religion with psychiatrists.

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Table 2 summarizes the influence of religion on various psychological, social, and clinical variables for each of the three coping categories.

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Positive Effects of Religious Coping

Religion was used as a positive way of coping by 71% of patients and as a negative way of coping by 14% of patients. At a psychological level, religion gave these patients a positive sense of self, in terms of hope, comfort, meaning of life, enjoyment of life, love, compassion, self-respect, self-confidence, and so on. For two-thirds of these patients, religion gave meaning to their illness, mainly through positive religious connotations (a grace, a gift, God’s test in order to grow in spiritual life, a spiritual acceptance of suffering, and the like), and less frequently with negative connotations (the devil, demons, God’s punishment, and the like). However, even if those meanings were negative in religious terms, they were positive in psychological terms by fostering an acceptance of the illness or a mobilization of religious resources to cope with the symptoms. For example, one patient said, “I think my illness is God’s punishment for my sins; it gives meaning to what happened to me, so it is less unjust” (30-year-old woman with paranoid schizophrenia). Another said, “I believe that my hallucinations and delusions are due to bad spirits; this gives me an explanation that helps me to lessen my fear and distress, and to stay calm” (30-year-old woman with paranoid schizophrenia). For three-quarters of this coping group, religious coping had a positive impact on positive symptoms (by lessening the emotional or behavioral reactions to delusions and hallucinations, by reducing aggressive behavior, or both), as well as on negative and general symptoms. Two patients who suffered from delusions of persecution expressed this clearly. One said, “I always have a Bible with me. When I feel I am in danger, I read it and I feel I am protected. It helps me to control my violent actions” (26-year-old man with paranoid schizophrenia). The other said, “If you say that God is love, you try to learn to love people. This allows me to distance myself from my problems relating to people, to welcome people” (40-year-old woman with paranoid schizophrenia). A patient who had delusions of control said, “For some time every day, I feel that other people can control me from a distance and that they can do anything they want with me. However, I do not feel anxious like I did before. The Buddhist monk told me it was only my imagination, and he teaches me how to meditate. In this way, I distance myself from this idea of control; I tell myself that it is just a symptom of an illness, that there is nothing true about it and it has no meaning” (20-year-old man with paranoid schizophrenia). A patient who suffered from auditory hallucinations said, “If you tell yourself that you have an eternal life ahead of you, you know that the voices will end, that they are not eternal. Consequently, voices are nothing in fact when they will not always be there” (25-year-old man with paranoid schizophrenia).

Religion may also help in reducing anxiety, depression, and negative symptoms, as illustrated in the following quotations. “I am anxious about meeting people, so beforehand I pray that everything will be OK. Then I am confident in the situation” (50-year-old man with paranoid schizophrenia). “I have no motivation to do anything, so I pray; I offer my suffering to Jesus. This gives me strength and comfort to do things” (60-year-old woman with schizoaffective disorder). “When I feel despair, prayer helps me find peace, strength, and comfort” (49-year-old woman with undifferentiated schizophrenia). “I am spiritual in my heart. My way of meditating is to sing. Breath and spirit are linked. When I sing, I do not feel as depressed, and I am more enthusiastic about doing things” (44-year-old man with paranoid schizophrenia).

At the social level, religion can provide guidelines for interpersonal behavior, leading to reduced aggression and improved social relationships. One patient said, “Believing in Jesus helps me to control my actions. It means not beating my fellow man when he upsets me!” (31-year-old man with paranoid schizophrenia). Another said, “It is difficult for me to communicate with people. I read the Bible and I meditate about love, peace, and forgiveness, and it helps me in my day-to-day relationships with others” (36-year-old man with paranoid schizophrenia).

Despite the subjective importance of religion, only one-third of the patients in the positive coping group actually received social support from a religious community. Some did not receive any support from their communities because of their symptoms, even though they engaged regularly in religious practices, as illustrated in the following quotations. “I’ve gone to church every Sunday since childhood; I listen to the sermon; I do not speak to anyone” (50-year-old man with paranoid schizophrenia). “I am angry with my brothers in Christ because they did not help me at all. Religious teaching helps me, but I haven’t found any warmth in relationships with people. On the contrary, I feel persecuted by them” (31-year-old man with paranoid schizophrenia). “I go to the synagogue every day. I do not tell my friends about my problems, so they cannot stand me” (29-year-old man with paranoid schizophrenia). More often, symptoms hindered religious patients from practicing in their religious communities: “I lived in a religious community for 2 years. Now, I pray alone every day. It is too difficult for me to go to church. When I go to the service, I see dirty things and I feel the devil taking my hand” (48-year-old woman with paranoid schizophrenia). “For 2 years now, I’ve felt so indifferent, without any motivation, that I have given up my involvement in my church. I feel guilty that I’m not involved like other people” (60-year-old woman with schizoaffective disorder).

However, for some patients, religious communities provided precious social support. One patient said, “I am a single woman; I have a lot of problems. At church, I meet a lot of people. It comforts me. I participate in every church activity: the service on Sunday, the intercession prayer group, and I sing in the choir. The pastor and church members pray for me” (39-year-old woman with paranoid schizophrenia).

Religion may play positive and negative roles in the comorbidity that is frequently associated with schizophrenia. Religion may protect against suicide attempts. As one patient said, “When I feel such despair that I want to jump out the window, I think about God. This helps me to live, even if life is so hard sometimes” (41-year-old man with paranoid schizophrenia). However, religion may be a risk factor, even for patients with positive religious coping. As another patient said, “Spirituality is essential in my life; I know that there is life after death. Once, I took medication to die in order to experience death and know what it is like afterward” (36-year-old man with schizoaffective disorder). Religion provided guidelines for some patients that protected them from substance abuse. It may even have oriented them toward a life free of toxic substances. “I felt bad. I smoked a lot of hashish every day. Once I had a religious conversion after a mystical revelation that the way I was behaving was not what God wanted for me” (34-year-old man with paranoid schizophrenia).

Religion may also play a role in decreasing or increasing adherence to psychiatric treatment. Some patients felt that a contradiction existed between religion and psychiatric care. “Psychiatrists say that my mind is disorganized. Medication helps me with that. But I want God to organize my mind. I need a miracle in my life” (26-year-old man with paranoid schizophrenia). On the other hand, psychiatric care may be integrated into religious beliefs when patients give God credit for its existence: “God has provided psychiatrists and medication to heal patients. First I trust God; then, thanks to God, I trust people. It is a great relief for me to be able to trust” (47-year-old man with schizoaffective disorder). Naturally, such beliefs depended mainly on the individuals rather than on the religious community. Indeed, the two patients quoted here were both highly involved in Pentecostal churches.

In some patients’ lives, religious leaders played a key role in the integration of psychiatric care and religious beliefs. One patient described his experience as follows: “Two years ago, I began to hear voices of demons; I believed I was Jesus Christ. I met an exorcist priest. He told me that I could not be Jesus Christ and he taught me the gospel. I met him every week. The voices told me not to take any medication. He told me not to listen to them, that demons are liars. He told me that the medication could help me. Since then, I’ve agreed to take it” (24-year-old man with paranoid schizophrenia).

Negative Effects of Religious Coping

Fourteen percent of patients reported negative effects of religious coping. For these patients, religion was a source of despair and suffering. Four patients felt despair after failure of the spiritual healing they had sought. As one patient said, “I did not get any comfort from psychiatry. So I turned to Christian Science, which has healed many people. Prayer is an assertion that healing is already there and to see it. I tried for years. It comforted me when it was new, but I did not succeed, so they told me that I was a negative person and a bad influence on others. I was not worth their attention. Since then, I’ve drunk alcohol” (41-year-old woman with hebephrenic schizophrenia). Others used religion to cope, but with a negative outcome. As an example: “I suffer from being so isolated. I was not a believer, but I went to church in order to meet people. But when I read the Bible, it disturbs me. I begin to think I have behaved wickedly and then I believe I am the devil” (47-year-old man with schizoaffective disorder). Although religion was meaningful for these patients, it always carried negative religious connotations. In some cases, religious coping increased delusions, depression, suicide risk, and substance use. Only one patient with negative coping found community support, but this led to a loss of faith and an increase in his adherence to medication: “I went to church to be healed and to meet a woman. I believed Jesus would help me, but this is a lie. More problems came, like a curse. Evil has the power on Earth. God is a cruel God. I want to die because I suffer too much. It is not Jesus who helps me, but people. At least medication helps me for anxiety” (43-year-old man with paranoid schizophrenia).

Clinical Correlates of Coping Type

At the time of the study, 16 of the patients with positive and negative religious coping presented religious beliefs mixed with their delusions or hallucinations. At a psychological level, they experienced religion as either negative (six patients) or positive (10 patients). However, none of these patients actually participated in community religious practices. The following example comes from a patient for whom religion was negative: “I am transparent; everybody knows my thoughts and feelings and sees my dreams. God wants to kill my soul. Everyone knows about God arranging my murder; they speak about it on the TV and the radio. I’ve tried to kill myself twice, but now I do not need to anymore since God will kill me” (34-year-old man with paranoid schizophrenia). For a patient who experienced auditory hallucinations and delusions, religion was positive: “I do not know if I am participating in religious practices with other people when I hear people who tell me to pray. I wonder if they are from a sect that is persecuting me. So I began to pray; I feel more peaceful and confident now. I have the impression that I can manage the voices. Prayer comforts me; it gives me guidelines for my relationships with others, to be nice and not to lie” (37-year-old woman with paranoid schizophrenia).

No differences in demographic variables were observed between the three coping groups. On clinical variables, the no religious coping group was more likely than the other two groups to be regular substance users (47% versus 19%; χ ² =6.18, df=2, p<0.05) and had more negative symptoms (median score=16 versus 10; Kruskal-Wallis test=7.92, df=2, p<0.02). Duration of illness was greater in patients with negative religious coping (median=17 years versus 12 years; Kruskal-Wallis test=8.24, df=2, p<0.02), and patients in this group were not as happy as the others (20% versus 47%; Kruskal-Wallis test=5.92, df=2, p<0.05). No differences were observed between the three groups on any other clinical characteristics. Table 3 lists the statistically significant correlations between religious measures and clinical characteristics.

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Discussion

Our study confirms the high prevalence of religious coping among patients suffering from psychosis, as others have found in comparable populations (3 – 6) . Patients consider spirituality to be more important in their everyday lives than does the general population, but they participate in community religious activities less often (11) . Religion has been shown to play a role for patients suffering from depression, anxiety disorders, and substance use disorders as well as patients who have attempted suicide (19) . Our study elicits religion’s role in these symptoms and comorbidities, as well as in quality of life, in a sample of psychotic patients. Moreover, our study illuminates the mechanisms by which positive religious coping helps patients deal with positive psychotic symptoms, namely, by reducing distress, anxiety, and nonadaptive behaviors associated with delusions and hallucinations. To our knowledge, religion’s role and the mechanisms by which it exerts an effect have not previously been studied in a sample of patients with psychosis. In spite of their illness, almost half of the patients felt happy. Negative religious coping appeared to increase despair, whereas for the positive religious coping group, relying on spirituality to deal with the chronicity of their illness seemed to increase happiness.

The content analysis elicited several factors that may explain the salience of religion in patients’ lives: coping, healing, and psychopathology. According to patients’ own statements, their illness may affect their religion. To deal with their illness and its social consequences, more than half of the patients relied on religious resources to cope (54%). According to Pargament and Brant (20) , in contrast with secular methods of coping, religion seems to offer a response to the feeling of insufficiency. When other sources of support are lacking, spiritual support makes explanations possible when no other explanations seem convincing, brings a sense of control through the sacred when life seems out of control, and provides new objects of significance when old ones are no longer compelling. These factors may contribute to the high prevalence of religious coping in schizophrenia, a disorder associated with impairment in multiple domains of functioning that often remains chronic and disabling.

Other patients, in despair because of the chronic aspect of their illness, turned to religion to be healed (5%). Positive psychotic symptoms alone increased the salience of religion for 26% of the patients. Fifteen percent of the patients presented religious beliefs mixed with their positive psychotic symptoms. Moreover, 11% of patients who had experienced delusions or hallucinations with religious content in the past explained how these symptoms had stimulated religious coping. As one patient related, “My illness opened my mind to spirituality. I do not talk about it to psychiatrists since they do not believe it. Before I received medication, I heard voices. Once I took refuge in a church; I prayed to the Virgin Mary and the voices fell silent. Since that day, she has protected me. Sometimes she appears to me; it is not a hallucination” (42-year-old man with hebephrenic schizophrenia). As anthropologists have shown, many people believe in the existence of supernatural powers and the possibility of communicating with them (21) ; in this context, religion is particularly compelling as a source of meaning for experiences as strange as hallucinations and delusions. Psychopathology may affect religion in the opposite direction as well. Indeed, our analyses suggest that negative symptoms and substance use may have hindered the development of healthy spirituality.

Whatever the reason for the increased spirituality in patients’ lives, religion may play a positive or a negative role. It was positive for 90% of the patients in our sample who turned to religion to cope, for 33% of those who turned to religion to be healed, and for 80% of those who turned to religion as a result of their positive psychotic symptoms.

Our study also indicates some ways in which religion may affect the illness, substance use, suicide attempts, and treatment adherence. However, religious coping is not always positive. Aside from patients whose religion intensified their suffering at an individual level, in some cases positive religious coping that was helpful for the self or for symptoms sometimes also led to a refusal of psychiatric treatment and an increased risk of suicide attempt.

Different patterns of relationships between current religion and clinical variables emerged according to the importance and the role of religion (positive, negative, or no role). However, the main limitation of our study is that these relations are cross-sectional, and correlations are not an index of causality. Longitudinal studies are needed to evaluate the efficacy of religious coping. Also, religion is culturally bounded, and investigation into other aspects of our patients’ lives is necessary before any generalizations can be made. Further studies that include use of a structured instrument to verify the accuracy of diagnoses are also needed to make comparisons across the spectrum of psychosis and to extend these comparisons to other psychiatric disorders. Given the importance of religion, its role as well as the clinical interventions employed and their outcomes should be systematically investigated for each patient.

Despite highly developed religiosity, few patients were involved in their religious communities. Moreover, in our population, no patients whose religious beliefs were currently mixed with their delusions or hallucinations were in contact with individuals from religious communities. Collaboration with religious persons could be a unique resource in the lives of individuals for whom religion is of primary importance. In comparison with surgical patients, psychiatric patients are more likely to have unmet spiritual needs (22) .

The focus on the pathological side of religion—religious delusions—has inadvertently contributed to the stigmatization of religion for people with schizophrenia. Our study establishes a balance between both of these aspects or functions of religion, which can have a positive or negative impact on patients’ lives. Religion is neither a strictly personal matter nor a strictly cultural one. From this perspective, spirituality should be integrated into the biopsychosocial model. Our results indicate that the complexity of the relationship between religion and illness requires great sensitivity to each unique story.