To Believe or Not to Believe: The Role of Faith in Treating Mental Illness and Preventing Suicide
Harold G. Koenig, M.D.
More and more research is showing a connection between religious beliefs and practices and better mental health (i.e., greater well-being, less alcohol or drug abuse, less depression, and less suicide).1, 2 Researchers are now utilizing this research gathered from observational studies to design and test religiously-integrated interventions for depression, anxiety, and post- traumatic stress disorder. I will briefly review some of that research here, then discuss the role that religious faith plays in the prevention of suicide, and finally describe a case that illustrates the complex interaction between faith and suicide.
First, how is faith utilized in the delivery of care and does it make a difference? There continues to be a deep divide between the attitudes of mental health professionals and those of patients regarding to the utilization of religious resources in therapy.3 While 55-74% of psychotherapy clients express a desire to discuss religious/spiritual issues during therapy,4, 5 resistance to doing so remains high among conventional therapists. Although there are many spiritually-integrated interventions now being proposed that utilize broad, non-specific approaches often based on Eastern philosophies and meditation techniques, only a few distinctively religious psychotherapies have been introduced into clinical practice. By religious psychotherapy, I mean therapy that utilizes a person’s religious faith (beliefs, practices, rituals, Holy Scriptures, and faith community involvement) in the treatment of a mental disorder.
Religiously-integrated cognitive behavioral therapy (RCBT) for depression appeared on the scene for the first time in 1992 with the work of Rebecca Propst and colleagues who compared religious vs. conventional CBT for depressed religious adults, a study that was published in the American Psychological Association’s flagship periodical, Journal of Consulting and Clinical Psychology.6 They found that 18 weekly sessions of RCBT resulted in faster improvement in depressive symptoms than conventional CBT, although the difference faded to non-significance by three months post-intervention (when depressive symptoms were low level for all participants). In a 2011 meta-analysis of 46 studies (3,290 participants) examining outcomes from religious accommodative therapies and non-religious spiritual therapies, Worthington and colleagues found that clients receiving religious accommodative therapies showed slightly greater improvement on psychological outcomes than those receiving secular psychotherapies.7
Are there certain parameters or constructs pertaining to a patient’s faith orientation or specific practices that are particularly effective? Regardless of technique, the therapeutic alliance that develops between therapist and client seems to be a dominant factor (as it is in secular therapies). We recently developed a version of religiously-integrated CBT8 and compared it to conventional CBT in 132 clients (88% Christian) with major depression and chronic medical illness. Five, manual-based, religiously-integrated therapies were developed, starting first with a Christian prototype9 and then developing Jewish, Muslim, Buddhist, and Hindu versions.10 The results of this randomized clinical trial indicated equal efficacy for both RCBT and CBT in reducing depressive symptoms, and RCBT was more effective than CBT in highly religious clients (who were also more adherent with RCBT).11 In that study, the therapeutic alliance developed more rapidly in those receiving RCBT, although conventional CBT soon caught up.12 Religiously-integrated forms of psychotherapy for anxiety in patients from non-Christian faith backgrounds have been developed… and found to be more effective than conventional treatments, but again only in those who are religious.13, 14 Thus, it appears that religiously-integrated psychotherapies are most effective in religious clients and may not be as useful in those who are less religious. We are now developing a religiously-integrated form of psychotherapy for “moral injury” in active duty U.S. soldiers and veterans with post- traumatic stress disorder (PTSD), many of whom are religious and having inner conflicts over what they experienced while serving in the military (which could be driving PTSD symptoms years later).15
With regard to suicide, there is now a vast amount of research published in peer- reviewed academic journals documenting that religious faith makes a difference in terms of suicidal thoughts, plans, attempts, and completed suicide. In our systematic review of the peer- reviewed literature published prior to 2010, we identified 141 quantitative studies that had examined relationships between religious involvement and suicidal thoughts, attempts, or completed suicide. Of those, 106 (75%) reported significantly fewer suicidal tendencies in those who were more religious.16 Multiple studies published within the past 18 months confirm these findings across different populations and geographical areas.17, 18, 19, 20
Not all research, however, finds that religious belief has a protective effect on suicidal tendencies. This is particularly true for studies coming out of mainland China. In a psychological autopsy study of 392 suicides in people aged 15-34 compared to matched living controls from rural counties in China in 2008, religious involvement was significantly more common among young people who committed suicide compared to controls (28.8% vs. 16.8%), especially among men (24.8% vs. 9.9%). 21 When other predictors of suicide were controlled, though, the differences lost statistical significance.
In a more recent study, we examined suicidal thoughts, plans, and attempts in a population-based sample of 2,769 community-dwelling adults in far Western China (50% without any religious affiliation), a region where more than one-third of the population is Muslim.22 We also found that higher personal religiosity scores and total religiosity were correlated with more suicidal tendencies, but again this relationship disappeared after controlling for demographic characteristics. In secular countries like China (2.8% Christian), many turn to religion for comfort only after their lives become desperate. As a result, religiosity often becomes a marker for emotional distress. Also, historically, those needing mental health care in China typically sought help from the Church, which was their only option. Thus, the relationship between faith and suicide is not always simple.
My own beliefs were recently challenged in a case that made me realize how complex the situation may become when faith and yearnings to die occur in the setting of severe and protracted physical illness. Mr. Q was an elderly gentleman is his mid-80s who had a very successful and active career in business, many friends, a devoted wife, and several children who were incredibly involved in his life.23 Mr. Q’s latter years had not been kind to him. Very independent and physically vigorous throughout most of his life, things changed after he reached the age of 80. At that time, he developed chronic pain syndrome, problems with his bladder causing incontinence, recurrent infections, and multiple falls resulting from deconditioning. He spent most of his time in bed sleeping, as this seemed to give him peace and shut out the world of pain around him.
Mr. Q was referred to me after an Emergency Room visit following a fall, when he told the doctor that he wanted to die. My initial evaluation revealed a friendly, very intelligent, and competent, but chronically ill, older man who was articulate about his struggles and why he was tired of life. He was not particularly religious, but had been raised in the Church. I treated him with anti-depressants, anti-anxiety agents, and even anti-psychotics (since delirium from recurrent infections was a problem).
He started to get better with the drugs, and even began to engage in regular physical therapy, including pool exercises several times per week. Despite this, however, one new medical problem followed another. Sleep, appetite, and his relationships with family members all became affected by his deteriorating physical condition and the accompanied irritability. Since I could do little more medically, I told him every time I saw him that I was praying for him (and really did). I expressed to him that he was a warrior in a mighty battle, a soldier taking fire in the trenches (language he understood as a veteran), and the heavenly hosts were watching and cheering him on. Over time, our relationship strengthened and his wife told me that the highlight of his week was coming in to see me, when he always perked up. At home, she assured me, he was not doing so well.
After several months of treatment, he nonchalantly mentioned during a clinic visit that he had gotten baptized the week before and was, in fact, reading a book about the heroes of the Christian faith. I was thrilled beyond words, and he could tell. Mr. Q continued to improve emotionally and there was no longer talk of suicide.
A few weeks later, I received an e-mail from his wife. Mr. Q had just experienced a major stroke that left him unable to move his right side (he was right handed), speak clearly, or swallow. Nevertheless, he remained alert without significant cognitive impairment, completely aware of his new situation. To prevent him from dying and to provide fluids, food, and medication, the doctors inserted a feeding tube directly into his stomach and then transferred him to a nursing home for rehabilitation and long-term care. The stroke left him in a situation like my own father’s, who spent years in a nursing home in pain from multiple bed sores before finally dying as a result of an infected sore. I visited Mr. Q several times at the home, reading him Scripture (Psalm 139) and encouraging him that God was near and he was not alone. I guess I had become overinvolved, as he had developed into more of a friend than a patient.
Mr. Q’s wife e-mailed me after he had spent several weeks in the nursing home. She said he had decided to die and asked the doctors to withdraw his feeding tube. Given his suffering from chronic pain, total dependency, inability to speak or swallow, and without any real potential for improvement, I thought about how I should respond. I have always been opposed to suicide of any kind, and have written and published on this topic. What would I do, though, if I was destined to lie in bed for the rest of my life unable to move about independently, speak or eat or swallow, and in constant pain with only minimal relief? Would I, too, ask my doctor to pull the feeding tube and let me go naturally?
So, I went to visit him to discuss my thoughts. I encouraged him to have a serious talk with God and ask if He had any purpose left for his life (and try not to allow his own desires to influence God’s response). If God’s answer was: “Yes. I can still use you in this life to accomplish my will,” then I encouraged him to leave the feeding tube in and do the best he could. If the answer was “No,” then I would understand if he decided to withdraw the tube, refuse further feedings or treatments, and die a natural death.
Interestingly, a relative was in the room when we had this discussion. As a Christian, the relative reminded me that only God has the right to end a man’s life. I contended, saying that was easy for him to say since he wasn’t the guy lying in that bed, and told him that modern medicine had the power to keep people alive indefinitely, prolonging their suffering. He said that he understood, but what was important was not the technology keeping Mr. Q alive, but the decision in his mind to hasten his own death. The relative felt that such a decision was not consistent with what Christians believe. I acknowledged his point and thanked him for reminding me of that, but I still struggle with how I would respond if I was the one in that bed.
Whether or not Mr. Q had that conversation with God as I suggested, we will never know. I did learn a few days later, though, that he told his doctors he did not want any more feedings through the stomach tube. Several days later, I visited him at the nursing home for what I suspected would be the last time. When I arrived, he was close to death but had moments when he was lucid. During one of those moments, a relative told him to put his hand in God’s hand and let Him take him home. I encouraged that, too, and said, “I loved you as your doctor, and if I don’t see you again here, then I’ll see you on the other side.” Though barely conscious, he reached out his hand and I took it in mine to say goodbye. As I left the room, I saluted him, as a soldier in a battle I hope I will never have to fight.
Harold G. Koenig, M.D., is Professor of Psychiatry and Associate Professor of Medicine at Duke University Medical Center. He is also Adjunct Professor in the Department of Medicine at King Abdulaziz University, Jeddah, Saudi Arabia, and in the School of Public Health at Ningxia Medical University, Yinchuan, People’s Republic of China. In addition, Dr. Koenig is the director and founder of the Center for Spirituality, Theology and Health at Duke University (http://www.spiritualityandhealth.duke.edu/).