MichaelA.Norko,MD,MAR,*† DavidFreeman,MD,‡ JamesPhillips,MD,*WilliamHunter,MD,§ RichardLewis,MD,*andRamaswamyViswanathan,MD,DMSc||
RELIGIONASAPROTECTIVEFACTOR
Abstract: Thevastmajorityoftheworld'spopulationisaffiliatedwithareligiousbeliefstructure,andeachofthemajorfaithtraditions(initstrueform)is stronglyopposedtosuicide.Ampleliteraturesupportstheprotectiveeffectofreligiousaffiliationonsuiciderates.Proposedmechanismsforthisprotectiveeffect includeenhancedsocialnetworkandsocialintegration,thedegreeofreligious commitment,andthedegreetowhichaparticularreligiondisapprovesofsuicide. Wereviewthesociologicaldatafortheseeffectsandthegeneralobjectionstosuicideheldbythefaithtraditions.Weexplorehowcliniciansmayusesuchknowledgewithindividualpatients,includingroutinelytakingareligious/spiritual history.Theclinicianwhoisawareofthecommonthemesamongthefaithtraditionsinoppositiontosuicideisbetterpreparedtoaddressreligious/spiritualmatters,asappropriate,incrisissituations.Theclinicianwhounderstandsthe patient'sbeliefsystemisalsobetterpreparedtorequestconsultationwithreligiousprofessionalswhenindicated.
KeyWords: Suicide,religion,spirituality,faithtradition,protectiveeffect (JNervMentDis 2017;205:9 14)
Suicideisaglobalpublichealthconcern,withmorethan800,000 completedsuicidesperyear.In2012,suicidewasthe15thleading causeofdeathworldwide,accountingfor1.4%ofalldeaths,andwas thesecondleadingcauseofdeathamong15-to29-yearolds(World HealthOrganization,2016).IntheUnitedStates,suicidewasthe10th leadingcauseofdeathin2013,withover41,000suicides.For15-to 34-yearoldsintheUnitedStates,suicideisthesecondleadingcause ofdeath(CentersforDiseaseControlandPrevention,2015).ThesuiciderateintheUnitedStateshasincreased24%from1999to2014,increasingby2%peryearsince2006.Increaseshaveoccurredformen andwomenandinallagegroups(Curtinetal.,2016).
Whatistherelationofreligiontosuicide?Religionisanimportantpartoflifearoundtheworld.Eighty-fourpercentofthe worldpopulationisaffiliatedwithareligiousbeliefstructure(Pew ResearchForum,2012).ThreequartersoftheworldpopulationascribestoeithertheDharmicreligions(BuddhismandHinduism)or theAbrahamicreligions(Christianity,Islam,andJudaism).Broadly, eachofthesereligions,initstrueoraccurateteachings,isopposedto suicide;theyallconsiderlifetobeprecious.
Hence,itisimportanttostudyifandhowreligionprotects againstsuicide.Inthisarticle,wereviewtheliteratureonthesubject, explorepossiblemechanismsforsuchprotectiveeffects,anddiscuss theimplicationsforcliniciansandresearchers.
Manyauthorscitereligionasaprotectivefactoragainstsuicide (ColucciandMartin,2008;Dervicetal.,2004;GearingandLizardi, 2009;Koenig,2009;Wuetal.,2015).Inasystematicreviewofquantitativeresearchonreligion,spirituality,anddepression,Koenigetal. (2001)reportedthatthemajority(61%)ofstudiesreportedinverserelationshipsbetweenreligion/spiritualityanddepression,andveryfew (6%)reporteddirectcorrelativerelationships.
Althoughthisarticlefocuses onthepotentialmitigatingeffectsofreligiononsuicide,wenotethatreligiondoesnotalways havethiseffect.Forexample,Hinduculturalhistoryincludestheacceptanceofsati(theburning deathofawomanonherhusband'sfuneral pyre)(Bhugra,2005;Commission,1987).Suicideisarecognizedform ofpoliticalprotestinsomeBuddhistcountries(TibetandVietnam) (Worth,2011).Contemporarysuicidebombingsareperpetratedunder theguiseofreligioussalvation(Anees,2006).Itisalsoimportantto notethatsomeindividualsmayexperiencedissonancebetweentheir personalbeliefsandtheirfaithtraditionoforigin,andthiscanlead tofeelingsofanger,guilt,andshameandcanadverselyaffectmental health(Pargamentetal.,1998).Elaborationofthesetopicsisbeyond thescopeofthisarticle.
POSSIBLEMECHANISMSOFPROTECTION
Therearevariousmechanismsbywhichreligionmaybeprotectiveagainstsuicide.ThepreeminentsociologistÉmileDurkheimpromulgatedtheideathatreligionisamajorintegrating,cohesiveforce intraditionalsocieties(Durkheim,1951a),andhearguedthatthatforce isspecificallyprotectiveagainstsuicide(Durkheim,1951b).Although detailsofDurkheim'sstudyofsuicidehavebeenchallenged(seethe studybyColucciandMartin,2008,forexample),hisgeneralargument fortheprotectiveeffectofreligiousaffiliationisstillaccepted.Persons residinginnationswithrelativelyhighlevelsofreligiosity,associated withoneofthefourmajorfaiths(Buddhism,Christianity,Hinduism, andIslam),arefoundtohavelowerratesofacceptabilityofsuicide (StackandKposowa,2011).Observedsuicideratesarehigherincountrieswherereligiousbeliefsarenotactivelypromotedbythestateand lowerincountrieswheretheyare(NeelemanandLewis,1999).van Tubergenetal.(2005)alsonotedthattheprotectiveinfluenceofreligiousgroupsaffectsthecommunityasawholeandnotjustmembers ofparticularreligiousaffiliations.
*DepartmentofPsychiatry,YaleUniversitySchoolofMedicine,NewHaven; † ForensicServices,ConnecticutDepartmentofMentalHealthandAddiction Services,Hartford,CT; ‡MissionHealthSystem,Asheville,NC;§OVLClinic, SouthBeachPsychiatricCenter,StatenIsland;and||StateUniversityofNew YorkDownstateMedicalCenter,Brooklyn,NY.
SendreprintrequeststoMichaelA.Norko,MD,MAR.E mail:michael.norko@yale.edu.
TheauthorsaremembersofthePsychiatryandReligionCommitteeoftheGroupfor theAdvancementofPsychiatry,whichhasapprovedsubmissionofthis manuscriptasaGAPproduct.
Copyright©2016WoltersKluwerHealth,Inc.Allrightsreserved.
ISSN:0022-3018/17/20501 0009
Consistentwiththesefindings,researchershavenotedaprotectiveeffectofattendanceatchurches(KleimanandLiu,2014;Robins andFiske,2009;StackandLester,1991;VanderWeeleetal.,2016). Incontrast,privatereligiouspractices,suchasprayer,arenotprotective ofsuicide,providingevidencethattheprotectiveeffectismediatedby socialsupport(RobinsandFiske,2009)and/orthepositiveeffectsof socialnetworkingwithinreligiouscommunities(ColucciandMartin, 2008;Nelsonetal.,2012;PescosolidoandGeorgianna,1989).
Inadditiontotheprotectiveeffectofreligiousaffiliation,researchershavefoundthatparticularbeliefsmayalsobeprotective (StackandKposowa,2011;Starketal.,1983).Withabeliefinthe afterlife,forinstance,apersonwhosuffersmayendureadversity withoutbecominghopeless,whichisaprimeriskfactorforsuicide. Thereligiouslycommittedindividualmaynotseesuicideasan
option.Consistentwiththisfinding,lackofreligiousconvictionwas consideredariskfactorforsuicideinastudyof269completedsuicides,whencomparedwith269livingcontrols,inBangalore,India (Gururajetal.,2004).GreeningandStoppelbein(2002)alsonoted thegreaterinfluenceofcommitmenttocorereligiousbeliefs,compared withsocialsupport,inastudyofover1000African-Americanandwhite adolescents.Inastudyof25countries,religiouscommitmentwasnegativelycorrelatedwithsuicide,butonlyforwomen(Stack,1983).This mayberelatedtothefindingsfromarecentPewResearchCenter (2016)studyof192countriesthatwomenareoverallmorecommitted totheirreligiouspracticethanmen,withsomeexceptions.
ArecentstudybyVanderWeeleetal.(2016)foundthatweekly attendanceatreligiousserviceslowerssuicideriskfivefold(compared withnoattendanceatservices)inaprospectivelongitudinalstudyof nearly90,000femalenursesintheUnitedStates.Theresearcherscontrolledforsocialintegrationandfoundthatthisfactorhadnosignificant effectforthosewhoattendedservicesonceormoreperweek,although socialintegrationdidmediatesomeprotectiveeffectforthosewho attendedoccasionally.
Justassomereligiousideasprotectagainstsuicidethrough toleranceofsuffering,othersspecificallydisapproveofsuicide (Vijayakumar,2002).Moralobjectionstosuicide( e.g., “mybeliefs forbidit ” or “onlyGodhastherighttoendlife”)wereassociated withlowerlevelsofsuicide behavior(Dervicetal.,2004).In149depressedbipolarinpatients,ahigherscoreonthemoralorreligious objectionstosuicidesubscalewasassociatedwithfewersuicidalacts andmediatedtheprotectiveeffectsofreligiousaffiliationonsuicidal behavior(Dervicetal.,2011).In265depressedinpatients,thosewith lowmoralorreligiousobjectionstosuicidehadmorelifetimesuicide attempts,greaterdepressionseverity,morehopelessness,moreimpulsivity,lessanxiety,andfewerreasonsforlivingandwerelessoftenaffiliatedwithareligioustradition(Lizardietal.,2008).
Relatedtothisdiscussionofreligiousbeliefsisthefindingin copingstudiesthatmanypeopleusereligiouscopingeffectivelytodeal withstressandemotionaldistress,includingthoseexperiencingpsychiatricdisorders(Hefti,2011;Koenigetal.,1988;Pargamentetal.,1990; Pargamentetal.,1998).Thismay,ofcourse,beanotherpossible mechanismoftheprotectiveeffectofreligiononsuicide.Inemphasizingthepositiveeffectsofreligiousbeliefs,however,weshouldnote thatPargamentetal.(1998)foundthatbeliefinGod'spunishment,angeratGod,religiousdoubts,andconflictswithchurchteachingswere associatedwithpoorermentalhealthoutcomes.
MAJORRELIGIONS'ATTITUDESTOWARDSUICIDE
Inthecareofreligiouslyaffiliatedpatientswithsuicidalthoughts orbehaviors,anunderstandingofthetenetsoftheirreligionsmaybe useful.Inthefollowingparagraphs,wemakeanefforttoreflectcommonlyheldbeliefsamongmembersofvariousfaithtraditions.
Islam
TheKoranstrictlyprohibitssuicide.(Italsoforbidsalcohol,a well-knownriskfactorforsuicide.)Surah4,verse29,states, “Anddo notkillyourselves[oroneanother].” Thereisalsothenotionthatthe humanbodyisagiftfromGodtobenurturedandprotected.Forexample, “… Manisnotauthorizedtokillhimself.[The]humanbodyis aconstructionmadebyAllah.Hewhohasbuiltthatstructurewillpull itdown” (Dikmen,2008).Suicidemaybeseenasanunforgivablesin, andmanyMuslimsarefearfuloftheconsequencesofsuicidalbehavior. AmongthesayingsoftheprophetMuhammad(Hadith)aremanyexamplesoftherepetitionoftheactofsuicideoccurringintheafterlife aspunishment.Forexample, “whoevercommitssuicidewithsomething,willbepunishedwiththesamethinginthe(Hell)Fire” (Sahih Al-Bukhari).BurialinaMuslimgraveyardmaynotbepermittedfor thosewhocommitsuicide(SarfrazandCastle,2002).Withinthe
religion,thereissomedebateoverwhetherdeathbysuicidealways leadstocondemnationtohell,becauseIslamalsoteachesthatsevere mentalillnessmaydepriveanindividualoftheclearmindrequired forresponsibilityforsuchdecisions(Abou-Allaban,2004).Research intoIslam'sprotectiveeffectislimited,inpartbecauseMuslimcountriesdonotsendsuicidedatatotheWorldHealthOrganization (SarfrazandCastle,2002;ShahandChandia,2010).Therearesome studies,though,demonstratingthatcountrieswithlargeMuslimpopulationshavelowersuiciderates(ShahandChandia,2010,Simpsonand Conklin,1989).MuslimsinWesterncountrieshaveahigherriskofsuicidethanthoselivingintraditionalIslamiccountries(Hedayat-Diba, 1999).TheremayalsobesomeindicationofanincreasingtrendinsuicidesinIslamiccountries(GearingandLizardi,2009;Sarfrazand Castle,2002).Littleisknownempiricallyaboutpossibledifferencesin suicideratesbetweenvariousIslamicsects(GearingandLizardi,2009).
Hinduism
Hinduismisnotacreedalreligionandbehaviorisemphasized overbeliefs(Flood,1996).ScriptureisnotasfoundationaltoHinduism asitistotheAbrahamicfaiths,andtherearemanydiversesectswith theirownparticularteachings.AlthoughHinduscripturesaresomewhatambivalentonthesubjectofintentionaldeath(Ineichen,1998), Hinduteachersstronglycondemnsuicideasthedestructionofasacred life.Eachbeinghasapurposeinlife,includingvariousexperiencesand opportunitiesforlearningandspiritualprogress.Toleavelifeintentionallybeforethatworkiscompletedistofacethesameworkagainin moredifficultcircumstances(IntegralYogaofSriAurobindo&The Mother,2011).Despitetheseadmonitions,thesuiciderateinIndiais highat22.0per100,000populationperyear(Pateletal.,2012)comparedwith13.0per100,000intheUnitedStates,forexample(Curtin etal.,2016).InIndia,80%ofthepopulationisHindu(Government ofIndia,2011).OnestudyofUKresidentsfoundthatHinduswereless likelytohavemoralobjectionstosuicidethanMuslims,althoughthere werenosignificantdifferencesinsuicidalthoughts,plans,orbehavior (KamalandLowenthal,2002).InseveralotherstudiesoutsidetheIndiansubcontinent,Hindushavealsobeenfoundtohavehigherrates ofsuicidethanMuslims(GearingandLizardi,2009).
Judaism
TheJewishfaithplacesgreatvalueonthepreservationoflife, andsuicideisaviolationofthisprinciple.Althoughprohibition againstsuicideisnotspecificallyrecordedintheTalmud,thepostTalmudictractateEvelRabbatiservesastheacceptedprohibition ofsuicide.Judaismfocusesonlifefromathis-worldlyperspective ratherthanonafuturelife(lifetocome)perspective(Millerand Lovinger,2000).ThepurposeofhumanlifeistoparticipateinGod's planforcreation(KaplanandSchoeneberg,1988). “Jewishreligious teachingtendsnottostressdeathandtheroleofthedead,inconsonancewithMoses'admonition,towardtheendofhislife, ‘ Ihaveput beforeyoulifeanddeath,blessingandcurse.Chooselife ’ (Deuteronomy30:19)” (Abramovitch,1987,p.132).Anindividualwho commitssuicide “givesuptheopportunitytocontinuetoaccomplish gooddeedsandhelpothers,andhaswillinglydestroyedthesoulthat Godgavehimorher ” (Leach,2006,p.67).Suicideisnotconsidered anescapefromtheproblemsofreality,anditresultsinaworseconditioninwhichtherearenofurtheropportunitiestoresolvetheproblems(Lizardietal.,2008).Apersonwhodiesbysuicidemaybe prohibitedfrommourningritesandfullburialrites(Baileyand Stein,1995;KaplanandSchoeneberg,1988).AUSstudyfound lowerlevelsofsuicidalbehaviorinstateswithhigherJewishpopulations(BaileyandStein,1995).Severalstudieshavefoundlowerrates amongJewscomparedwiththegeneralpopulationandgroupsof Christians(GearingandLizardi,2009;SimpsonandConklin,1989).
Thereismuchdiversityinbeliefsandcustomspracticedby Buddhists.Buddhistpracticeisfocusedonthereliefofhumansuffering.Suicideisseenasaformofsufferingthatresultsfromadesirefornonexistence.Buddhistsholdthathumanlifehasvalue, becausethebirthofahumanbeingistheculminationofthatindividual'seffortthroughmanypreviouscyclesofbirth(thoughnotall practitionersbelieveinarebirthcycle)andasteponthewaytoenlightenment.Deathbysuicideisnotseenastheendofsuffering (DisayavanishandDisayavanish,2007).InBuddhism,suicideis seentopromoteratherthanprotectagainstsuffering. “Apersonwho optsfordeathbelievingittobeasolutiontosufferinghasfundamentallymisunderstoodtheFirstNobleTruth,” thatis,thatlifeissuffering (Keown,1996,p.31).Despitesuchadmonitions,Buddhistcountries havearelativelyhighersuiciderate(BertoloteandFleischmann, 2002).AlthoughsomeBuddhistscripturesprovideexonerationforrare suicidesbyenlightenedindividuals(Attwood,2004;Keown,1996), thisdoesnotlikelyexplainthesedata.PerhapsAttwood(2004)iscorrectinhisrecognitionthatBuddhistethics “maywellbeuselessinthe faceofextremesuffering.”
Christianity
SuicideisstrictlyforbiddenasanactcontrarytoGod'splanfor anindividual'slife.Inthefifthcentury,Augustine(1950)clearlydenouncedsuicideasaformofhomicide,inwhichtheactordespairsof God'smercy.Inthepast,suicidewasgenerallyregardedasanunpardonablesin,whichresultsintheindividualgoingtohellafterdeath. However,thelastcondemnationofsuicidebythepopewasinthe 1940s,andthestancehassoftenedovertime,becausetheCatholic Churchismorelikelytoconsidercontextualfactorsofdeathbysuicide. “Gravepsychologicaldisturbances,anguish,orgravefearofhardship, suffering,ortorturecandiminishtheresponsibilityoftheonecommittingsuicide.” TheCatholicChurchalsoholdsthat “weshouldnotdespairoftheeternalsalvationofpersonswhohavetakentheirown lives ” because “Godcanprovidetheopportunityforsalutaryrepentance ” (Catechism,1994,#2282 2283).AlthoughJoubert(1995) foundthatstateswithhigherpercentagesofCatholicshadlower ratesofsuicide,StackandLester(1991)foundnocorrelationbetween Catholicismperseandsuicidalideation,butCatholicismwasassociatedwiththeprotectivefactorofgreaterchurchattendance.Protestantism'sprotectiveeffectisdifficulttoassessgivenitsdiversity,although moreconservativedenominationshavebeenfoundtohavelowersuicidalideation(StackandWasserman,1992).Inonestudy,Catholicism andevangelicalChristianitywereassociatedwithlowerratesofsuicide intheUnitedStates,withgreaterprotectiveinfluencefromCatholicism (PescosolidoandGeorgianna,1989).Otherstudieshavenotfounddenominationtobeimportant(Dervicetal.,2004).
CLINICALUSEOFRELIGION'SPROTECTIVEEFFECTS
Eachofthemajorworldreligionsisopposedtosuicide.However,notalladherentstoaparticulartraditionwillholdallofthesebeliefsorholdtheminthesameway.Notonlymayteachingsvarywithin thebroadtradition,butalsoindividualswill,ofcourse,havetheirown understandingsorinterpretationsofvariousteachings.Itisimportant, therefore,foracliniciannottomakeassumptionsaboutindividuals' personalbeliefsaboutsuicidebasedsolelyontheirprofessedfaithtradition.Furthermore,approximately15%oftheworld'spopulationdoes notespouseareligionorfaithtradition(Keller,2000)andthuswould notbenefitfromareligion'sprotectivefactorsperse.However,itisalso importanttoassesspatients'spiritualorhumanisticbeliefsthatmay amelioratetheriskofsuicide.
Aparticularunderstandingofasuicidalpatient'sreligiousor spiritualbeliefsaboutsuicidemayassistinpersonalizedcareof thepatient.Thisincludestakingareligious/spiritualhistoryto
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understandthewaysthatspiritualityandreligionrelatetoapatient's well-being(GearingandLizardi,2009;JosephsonandWiesner, 2004),andhowthepatient'sbeliefsinformviewsonsuicide (Koenig,2016;Rickgarn,1990).Doesthepatientviewhis/herreligionascondemning,permitting,orneutralonsuicide?Doesthepatient'sunderstandingofthefaithtraditionpromotesuicideasa responsetoshame,acceptitinextenuatingcircumstances,orprotect thebelieverfromhopelessness?Aretherewaysinwhichtheindividual'sreligiousbeliefsareleadingtoincreaseddistress,guilt,ordecreasedself-worth(KoenigandLarson,2001;Pargamentetal., 1998)?Doesthepatientusehis/herprofessedreligiousbeliefsasresistancetotherapy(Barnhouse,1986)?
Takingareligioushistorycommunicatesopennesstoapatient'suniquespiritualexperienceanddevelopsasharedvocabulary withwhichtoframelifeevents.Therearesomesimpleinstruments availabletoguidetheclinicianintakingareligious/spiritualhistory. Forexample,seethestudybyPuchalski(2006)fortheFICAinstrument, AnandarajahandHight(2001)fortheHOPEinstrument,orKingand Koenig(2009,Table2)forasimplesetofquestions.Josephsonand Wiesner(2004,pp.26 27)providedanin-depthinterviewguide.
Mostsuicideassessmentinstrumentsdonotincludetheprotectivefactorofreligion(KehoeandGutheil,1994).Therearesomeexceptions,however.TheBeckScaleforSuicideIdeation(Becketal., 1979)containstheitem “deterrentstoactiveattempt(e.g.,family,religion,irreversibility),” TheColumbiaSuicideSeverityRatingScaleasks thesamequestion, “Aretherethings anyoneoranything(e.g.,family, religion,painofdeath) thatstoppedyoufromwantingtodieoracting onthoughtsofcommittingsuicide?” (Posneretal.,2009).TheReason forLivingScale(Linehan,1996)containsaMoralObjectionstoSuicidesubscale,consistingoffourstatements: “IbelieveonlyGodhas therighttoendalife;myreligiousbeliefsforbidit;Iamafraidofgoing tohell;Iconsideritmorallywrong” (Linehanetal.,1983,p.279).
Ahelpfulresourceaboutreligious/spiritualinterventionsin mentalhealthcareistheAmericanPsychiatricAssociation'sResource DocumentonReligious/SpiritualCommitmentsandPsychiatricPractice(AmericanPsychiatricAssociation,2006).Theseguidelinesadvise psychiatriststomaintainrespectfortheirpatients'beliefsandvalues,to avoidimposingtheirownreligiousorspiritualvaluesontheirpatients, andtoseetheirpatients'religious/spiritualidealsaspartoftheprocess ofrecovery.Italsooffersanappendixwithexamplesofproblemsthat canariseindealingwithreligious/spiritualissuesinmentalhealthtreatment,whichserveasausefulcaution.
Eveniftheclinicianisopentosuchexploration,theresulting discussionsmaybecometechnicallycomplexfromareligiousperspective,inwhichcaseconsultationwithchaplainsorreferraltoclergyare appropriateandprudentresponses(Larsonetal.,1988,2000;Thieland Robinson,1997;WaldfogelandMeadows,1996).Somepatientswill haveunrealisticexpectationsorinaccurateknowledgeofthetenetsof theirfaithtradition,whichmaycausethemexcessiveguilt,anxiety,or shame,forexample.Clergyreferralcanbeaneffectivewaytohelpwith suchconfusion(AndersonandYoung,1988).
Somepatientsmayfeelguiltyabouttheirsuicidalideation,given theirprofessedfaithtradition,andmaybeambivalentaboutorrejecting ofclergyreferral.Itmaybeusefulinsuchsituationstoconsiderthe transferencepotentialsofthematchornonmatchofthepatient'sand therapist'sfaithtraditionsorlackthereof(AbernethyandLancia, 1998;Josephson,2004;Peteet,2004).Apatientofthesamefaithtraditionasthetherapistmaybemorelikelytotrustthetherapist,butmay alsoexpectlessconfrontationthanwillorshouldbereceived,orbe ashamedtosharehisorhermoralfailings.Sessionsmaybecomeunproductiveiftheyrecallthepatient'searlierreligiousstrugglesornegativereligiousexperiences.Apatientofadifferentfaithtraditionmay feelthatthetherapistissaferandmoreobjective,butmayalsobeconcernedthatcherishedvalueswillbeunderminedorthathe/sheisnot understoodorpermittedtodiscussreligiousorspiritualmattersfreely.
Countertransferencepotentialswithmatchingtraditionsmayinclude thefollowing:oppositionalresponsestothepatientbasedonthe therapist'sexperienceswithreligiousauthorityfigures,attemptsto “enlighten ” thepatientaboutreligiousmatters,avoidanceofneeded confrontation,andoverlypositiveorhostilereactionstothepatient. Innonmatchsituations,therapistsmayrecoilfrompatients'expressed religiousbeliefsorbeimmobilizedbythepowerofthosebeliefs.The therapistmaydesiretodivertthepatientfromhisorherreligiousbeliefs oravoidexploringthemduetolackofconfidenceindealingwiththem (AbernethyandLancia,1998;Josephson,2004;Peteet,2004).
Peteet(2004,p.57)advisesthattherapistsseekinformedconsent ofthepatientwhenaddressingtransparencyaboutthetherapist'sworld view.Hesuggeststhefollowingquestion: “IfIexplorefurtheryourspiritualconcerns(ortellyoumyownreligiousidentification,joinyouin prayer,orsuggestachurchforyoutotry),howwillthisapproachhelp withourworkofgettingyoubetter?” Ifthetherapistcomestoconclude thatnegativetransferenceorcountertransferenceisinhibitingthetherapy,particularlyinasituationofworseningdepressionwithsuicidality, considerationmightbegiventoconsultationwithand/orreferraltoa colleaguesituateddifferentlyinthematch/nonmatchdimension.It mayalsobeworthpostponingtheexplorationofmattersoffaithduring periodsofoverwhelmingdepression perhapsencouragingthepatient'stemporaryindulgencewhenhe/shewishestocontinuetoexplore suchcontent untilfurtherstabilizationcanbeachieved.
AbernethyandLancia(1998)describedtwocasesillustratingextensivelythecomplexitiesoftheclinician'seffortstoexplorereligious themesinpsychotherapy.Eachofthecasesinvolvedtwoseparate coursesoftreatment,asthetransferenceandcountertransferencedimensionsevolved.Peteet(2004)providesclinicalscenariosinvolving religiousthemesanddiscussesthepossiblewaysinwhichtherapists mightaddressthem,includingaddressingonlythepsychologicaldimensions,addressingthereligiousdimensionsdirectly,andworking withanoutsidereligiousresource.Josephson(2004)usesmultiplecase examplestoillustratehowreligious/spiritualfactorscanbeincorporatedintotheoverallclinicalformulationandtreatmentplan.
Thereareseveralempiricalstudiesdemonstratingthatincludingreligiouscontentintherapywithreligiouspatientsleadstoquickeror greaterimprovementinsymptomsfordepressedoranxiouspatients (AzharandVarma,1995;Azharetal.,1994;Ebrahimietal.,2014; Propstetal.,1992).VanderWeeleetal.(2016,p.E7)suggestthat “alreadyreligious” patientsmightbeencouragedtoattendservices “asa formofmeaningfulsocialparticipation.” Coupledwiththeresearchfindingsonreligiouscopingnotedabove,theseresultssuggestthepossibilitythatincorporatingreligiouscontentintherapywith religiouspatientsmayhaveanameliorativeeffectonsuicidepotential.However,toourknowledge,researchershavenotspecificallytestedthishypothesisempirically.
incorporatingreligiousthemesintherapy.Thechallengeforresearchers istocarryouttheneededempiricalinvestigations.
Thechallengeforcliniciansistomakeuseofavailableknowledgeineffortstotapintotheknownbenefitsaffordedbyreligionin treatmentofthereligiouspatient,perhapsdespitetheirpersonalviews aboutreligion.Infact,Propstetal.(1992)foundthatnonreligioustherapistsconductingreligiouslythemedcognitivebehavioraltherapywith religiouspatientshadthebestoutcomes.
CONCLUSIONS
Heftietal.(2011)notedthat “religiositycanbeconceptualized asapersonalresourceforreligiouslyorientedpatientsand theactivationofthisresourcemaysupporttherapeuticprocessesandimprove healthoutcomes” (p.620).Giventheavailabledata,itmakes good senseforclinicianstoroutinelytakeareligion/spiritualityhistory, whichmayatleastopenthedoortoproductivediscussionsorreferrals.Understandingapatient'svaluesandbeliefs beforetheoccasionofacrisis preparesthecliniciantoaddressthosebeliefsinthe contextofincreasingdepressionandsuicidality.Reexaminationof thepatient'sbeliefsatsuchtimes,possiblywithconsultationfrom appropriateclergyoraknowledgeablecolleague,mayhelpstrengthen protectivebeliefsandchallengeandamelioratebeliefscausingnegative self-appraisals.Evenifnosuchcrisisoccurs,thereligion/spirituality historygivesthepatientpermissiontoraisemattersintherapy, whichotherwisemightgounaddressed,representingmissedopportunitiesforthecliniciantoassistinsignificantdimensionsofthepatient'spersonalgrowth.
ACKNOWLEDGMENTS
Theauthorsaregratefultothesecolleaguesfortheirreviewof thefaithtraditionsectionsofthisarticle:NeilAggarwal,MD,MBA; MartaDabis,MSMBA;OmarSultanHaque,MD,PhD;Velandy Manohar,MD;SabitaRathi,MD;andRabbiHeschSommer,DMin. DrNorkoacknowledgesthesalarysupportoftheConnecticutDepartmentofMentalHealthandAddictionServices.
DISCLOSURE
Theauthorsdeclarenoconflictofinterest.
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DISCUSSION
Allmajorfaithtraditions(whenproperlyinterpreted)haveanegativeattitudetowardsuicide,withseveralcommonthemesthatcliniciansmightraisewithappropriatepatientstogoodeffect.Littleis knownaboutsuicideriskandatheism/agnosticism;researchisneeded toexaminewhetherthecoherentadoptionoftheseworldviews,orbelongingtoacommunityofsimilarlymindedpeople,mayalsobeprotective(Nelsonetal.,2012).
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