S P IR I TU A L I T Y A N D H EA L T H

The importance of spirituality in medicine and

its application to clinical practice
Russell D'Souza
Nothing in life is more wonderful than faith the one great
moving force which we can neither weigh in the balance nor
test in the crucible . . . Faith has always been an essential factor
in the practice of medicine . . . Not a psychologist but an
ordinary clinical physician concerned in making strong the
weak in mind and body, the whole subject is of interest to me.

William Osler1

hile spirituality is a concept globally acknowledged,2

there is no consensus on how to define it.3 Spirituality
can encompass belief in a higher being, the search for
meaning, and a sense of purpose and connectedness. Although
religiosity and spirituality are not synonymous, there can be a wide
overlap between them.4
In discussing spirituality, one is really discussing the ways in
which people fulfil what they hold to be the purpose of their lives.
Thus it is easy to understand why so many different definitions of
The Medical Journal of Australia ISSN: 0025spirituality
have been proposed.
729X 21 May 2007 186 10 S57-S59
Some
perceive human beings as having two realms of existence.
The Medical Journal of Australia 2007
The outer
realm consists of a persons interaction with the world.
www.mja.com.au
The inner
realm and
is his
or her interaction with the transcendental,
Spirituality
health
which may be a divine being or ideals hinted at through experiencing such feelings as awe, love, and appreciation of beauty. Most
people would hold that correct action in the outer realm consists
of justice and magnanimity, while the inner realm deals with
sincerity.5 These principles may arise from different contexts. For
example, in the monotheistic faiths one acts justly to know God,
whereas in Buddhism one acts justly to be released from suffering.6
But, despite differing beliefs, the concept of spirituality is fundamentally similar for most people.
History, mental illness and medicine
Mind, body and spirit are integrally connected. Western medicine,
unlike traditional Eastern systems, has dichotomised the body/
mind and soul/spirit.7
Historically, psychiatry has undergone major changes considered
by some to be revolutions. Medieval concepts of mental illness
stressed that individuals had free will and were responsible for their
actions mental illness came from sin and the resulting punishment from God. As sin was central to mental illness, religious
activity was believed to be central to cure.8 The first major revolution in psychiatry was in the 17th and 18th centuries, when the socalled Age of Enlightenment saw a move away from the realm of
religion to the science of mental health.8 Then, in the late 19th and
early 20th century, the work of Sigmund Freud heralded the age of
psychoanalysis.9 A third revolution, the age of deinstitutionalisation, came with the discovery of chlorpromazine in 1954. The drug
brought about significant improvement in the control of symptoms,
leading to the closing down of many asylums and the movement of
patients into the community.10 The latest age, which could be called
the age of empowerment and consumerism, began in the mid1990s and continues today. It is an age in which we are informed of
patients needs, including the spiritual and religious dimensions of
managing their mental illness.

ABSTRACT
Recent international and Australian surveys have shown that
there is a need to incorporate the spiritual and religious
dimension of patients into their management.
By keeping patients beliefs, spiritual/religious needs and
supports separate from their care, we are potentially ignoring
an important element that may be at the core of patients
coping and support systems and may be integral to their
wellbeing and recovery.
A consensus panel of the American College of Physicians has
suggested four simple questions that physicians could ask
patients when taking a spiritual history.
Doctors and clinicians should not prescribe religious beliefs
or activities or impose their religious or spiritual beliefs on
patients. The task of in-depth religious counselling of patients
is best done by trained clergy.
In considering the spiritual dimension of the patient, the
clinician is sending an important message that he or she is
concerned with the whole person. This enhances the patient
physician relationship and is likely to increase the therapeutic
impact of interventions.
Doctors, health care professionals and mental health
clinicians should be required to learn about the ways in which
religion and culture can influence patients needs and
recovery.
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The spiritual dimension of the patient

Medical training in the Western world has strongly revolved around
the more easily measured physical aspects of patients and their care.
Learning how to deal with the spiritual aspects of medical care is not
a typical part of medical school or college curricula, yet evidence is
emerging that it is something our patients want and expect us to do
as part of the care we provide.11-13 In patients interactions with
clinicians and medical practitioners, they do not cease to be human
beings with deep and wide-ranging needs. Indeed, it is in times of
illness, crisis and transition that life, death and other spiritual
matters may loom all the more strongly in a patients consciousness.
Recognising patients spiritual concerns could be seen as an essential
part of the patient-centred medicine that is increasingly thought to
be crucial for high-quality patient care.14
Integration of science and humanism for the
patients health
It can be difficult to avoid emphasising the idea that science and
humanism are on two opposing sides. It is an opposition that
translates easily into stereotypes science as cold and unfeeling,
and humanities as warm-hearted and well intentioned but less
scientific. But both sides can be united under the umbrella of
medical humanities, in a shared approach that deepens our
understanding of human health and wellbeing. An approach that

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calls on multiple perspectives biomedical, spiritual, philosophical and sociological can help clinicians develop insight into the
relationship between patients, doctors and the health care system,
thereby enhancing their capacity to cure, relieve and comfort
patients.15
Doctors and healing
Doctors and clinicians are healers through the caring relationships
they form with patients.16 Caring often requires calling on an
individuals inner strengths. These strengths, among others,
include spiritual resources that support integration or wholeness of
body, mind and spirit. By addressing the spiritual and religious
dimensions in patient care, clinicians can be truly holistic and
bring patients wellbeing to the forefront. Spiritual and or religious
care that is ethical and sensitive is an invaluable part of total
patient care.
Attending to the spiritual dimensions of the patient can provide
the physician with a more in-depth understanding of the patient
and his or her needs. We may thus use a variety of spiritually
informed therapeutic tools that can greatly facilitate the patients
coping ability, thus enhancing wellbeing and recovery.
Clinicians own religious or spiritual practices or non-practices
may affect their ability to function effectively in this area of clinical
practice. As doctors, we have been trained to be objective and to
keep our own beliefs and practices separate, but over time we have
strayed into keeping patients beliefs, spiritual/religious needs and
supports separate from their care. Thus, we are potentially ignoring an important element that may be at the core of patients
coping and support systems and may be integral to their wellbeing
and recovery which is what we have set out to achieve in the
first place.
Spirituality and religiosity for the patient
Patients want to be seen and treated as whole people, not simply as
diseases. A whole person has physical, emotional, social and
spiritual dimensions. Ignoring any of these leaves the patient
feeling incomplete and may even interfere with healing. For many
patients, spirituality is an important part of wholeness, and when
addressing psychosocial aspects in psychiatry this part of their
personhood cannot be ignored.
There is evidence that many seriously ill patients use religious
beliefs to cope with illness.17 Religious/spiritual involvement is a
widespread practice that predicts successful coping with physical
illness.18 Studies by Koenig et al suggest that high intrinsic
religiousness predicts more rapid remission in depression, especially in patients whose physical function is not improving.19 In a
meta-analysis of more than 850 studies examining the relationship
between religious involvement and various aspects of mental
health, a majority of studies showed that people experience better
mental health and adapt more successfully to stress if they are
religious.20 Another analysis of 350 studies found that religious
people are physically healthier, lead healthier lifestyles and require
fewer health services.21
However, religious practices should not replace psychiatric
treatments. This is because, while many people find that illness
spurs them to metaphysical questions and helps them rediscover
religion, no studies have shown that people who become religious
only in anticipation of health benefits will experience better health.
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Addressing patients spiritual needs

The issue of patients spiritual needs could potentially be
addressed at the levels of academia, training and practice. In
academia, relatively little attention has been paid to spirituality. In
medical training, except in texts on palliative care22 and in ethics
courses and seminars, spirituality is not directly considered, even
though spiritual considerations will be present whenever patients
rights and needs are discussed. Doctors, psychiatrists and mental
health clinicians should be required to learn about the ways in
which religion and culture can influence a patients needs.
What does all this mean for good clinical practice?
It may be beneficial to adapt existing therapies to patients spiritual
perspectives. There is evidence that cognitive therapies may be
more effective if they take patients religious beliefs into account.23
The spiritually augmented cognitive behavioural therapy developed by our team has been shown to be effective in randomised
controlled trials in patients who rated spirituality as important or
very important.24-27 This therapy was associated with improved
treatment adherence and higher satisfaction in the intervention
group than the control group in schizophrenic patients who had
recovered from psychosis.27,28 Patient-centred approaches, as a
whole, help to maintain patient dignity and to ensure that the
interventions offered are appropriate. These have resulted in
positive outcomes, including better compliance with medication
poor compliance being a major barrier to achieving desired
outcomes in psychiatry and greater patient overall satisfaction.26,27
What doctors and clinicians should consider
Doctors and clinicians should not prescribe religious beliefs or
activities for health reasons. They should not impose their religious
or spiritual beliefs on patients or initiate prayer without knowledge
of the patients religious background and whether the patient
would appreciate such activity. It is also not their role to provide
in-depth religious counselling to patients a task that is best
done by trained clergy.
Doctors and clinicians should acknowledge and respect the
spiritual lives of patients and always keep interventions patientcentred. Acknowledging the spiritual dimensions of patients
involves taking a spiritual history.29 This is not appropriate for
every patient, although for people with life-threatening illness, it
probably is. A consensus panel of the American College of
Physicians has suggested four simple questions that physicians
could ask patients:30
Is faith (religion, spirituality) important to you?
Has faith been important to you at other times in your life?
Do you have someone to talk to about religious matters?
Would you like to explore religious, spiritual matters with
someone?
Taking a spiritual history is often a powerful intervention in
itself.31 Religious and spiritual patients, whose beliefs often form
the core of their system of meaning, almost always appreciate a
doctors sensitivity to these issues. Doctors and clinicians can thus
send an important message that they are concerned with the whole
person, a message that enhances the doctorpatient relationship,
the cornerstone of good medical care, which may increase the
therapeutic impact of an intervention and move to achieve positive
wellbeing.27

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Our calling as doctors and clinicians is to cure sometimes,

relieve often, and comfort always.15 The comfort conveyed when
a doctor or clinician supports the core that gives the patients life
meaning and hope is what many patients say they want.11
Considering these issues and approaching questions of spirituality
and religiosity of patients will not only improve patient care,
doctorpatient relationships and patient wellbeing, but may well
come to be seen as the salvation of biomedicine.
Competing interests
None identified.

Author details
Russell D'Souza, MD, FAPA, MPM, Director of Clinical Trials and Bipolar
Program
Department of Clinical Trials, Northern Psychiatry Research Centre,
University of Melbourne, VIC.
Correspondence: rdsouza1@bigpond.net.au

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(Received 8 Oct 2006, accepted 19 Mar 2007)

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