Brief report
A test of faith in God and treatment: The relationship of belief in God to psychiatric treatment outcomes

https://doi.org/10.1016/j.jad.2012.08.030Get rights and content

Abstract

Background

Belief in God is very common and tied to mental health/illness in the general population, yet its relevance to psychiatric patients has not been adequately studied. We examined relationships between belief in God and treatment outcomes, and identified mediating mechanisms.

Methods

We conducted a prospective study with n=159 patients in a day-treatment program at an academic psychiatric hospital. Belief in God, treatment credibility/expectancy, emotion regulation and congregational support were assessed prior to treatment. Primary outcomes were treatment response as well as degree of reduction in depression over treatment. Secondary outcomes were improvements in psychological well-being and reduction in self-harm.

Results

Belief in God was significantly higher among treatment responders than non-responders F(1,114)=4.81, p<.05. Higher levels of belief were also associated with greater reductions in depression (r=.21, p<.05) and self-harm (r=.24, p<.01), and greater improvements in psychological well-being (r=.19, p<.05) over course of treatment. Belief remained correlated with changes in depression and self-harm after controlling for age and gender. Perceived treatment credibility/expectancy, but not emotional regulation or community support, mediated relationships between belief in God and reductions in depression. No variables mediated relationships to other outcomes. Religious affiliation was also associated with treatment credibility/expectancy but not treatment outcomes.

Conclusions

Belief in God, but not religious affiliation, was associated with better treatment outcomes. With respect to depression, this relationship was mediated by belief in the credibility of treatment and expectations for treatment gains.

Introduction

In the modern era, spirituality and religion continue to play an important role across cultures globally. This is particularly the case in the United States where 93% of the population holds belief in God or a Higher Power (Gallup, 2011) and the words “In God We Trust” appear on every bill and coin produced by the U.S. Mint. It is therefore not surprising that this important domain can have both a positive and negative effect on mental health. On the one hand, spiritual/religions involvement can buffer against depression, hopelessness, self-injury and suicidality (Miller et al., 2012, Murphy et al., 2000, Rasic et al., 2009), facilitate regulation of negative emotions (McCullough and Willoughby, 2009) and serve as a resource during times of distress (Pargament et al., 2000). On the other hand, spiritual struggles such as anger at God or religious guilt can exacerbate (McConnel et al., 2006) or even facilitate the development of psychiatric symptoms (Pirutinsky et al., 2011). What is surprising, however, is that although the number of studies in this area has grown over the past two decades (Hill and Pargament, 2003) virtually all research has been conducted within the general population or within specific religious communities (Koenig, 2009). Moreover, the handful of studies conducted within clinical psychiatric samples have been essentially descriptive in nature (e.g., assessing the prevalence of church attendance) and failed to examine mediators by which specific facets of spirituality may proximally and functionally connect to specific symptoms or outcomes (Rosmarin et al., 2011). In light of the importance of this domain, its central relevance to political, economic and other trends, and research suggesting links to mental health/illness in the general population, a closer look at the clinical psychiatric relevance of spirituality – beyond the perfunctory appraisal of religious affiliation during a standard psychiatric assessment – is warranted.

One recent study in a clinical sample found that self-rated importance of religion at baseline (measured by a single-item) was associated with improved treatment outcomes in outpatient care for panic disorder (Bowen et al., 2006). Specifically, patients who rated religion as “very important” demonstrated greater reductions in anxiety and stress, though not depression, over the course of Cognitive Behavioral Treatment (CBT). Findings were significant at 6- and 12-month follow-up and remained after controlling for pre-treatment levels of self-esteem, interpersonal functioning, mastery, perceived stress, and depression. This interesting result points to the potential clinical importance of patients’ spiritual involvement in psychiatric treatment outcomes. However, this finding has yet to be replicated. Further, and more importantly, it remains unclear how and why spirituality might be tied to better mental health treatment outcomes.

One possibility is that belief or faith in God can generalize to belief or faith in psychiatric treatments. It is known that treatment credibility – how believable and logical a treatment is perceived to be – and treatment expectancy – patient expectations to experience treatment gains – are robust predictors of treatment success in psychosocial interventions (Newman and Fisher, 2010). Among other things, these factors improve the therapeutic alliance, as well as patient motivation and compliance with treatment (Goossens et al., 2005). It is thus theoretically plausible that the general cognitive framework of faith in a God or Higher Power may impact treatment outcomes by facilitating greater faith in treatment (i.e., enhancing treatment credibility and expectancy) in the course of psychiatric care. More broadly, the tendency or proclivity to have faith in conventional social constructs could generalize across both religious faith and faith in medicine (and perhaps faith in conventional economic and political constructs as well). Thus, the general attribute of faith could be related to both spiritual and medical domains, whereas mechanistically, faith in treatment could mediate enhanced treatment response by individuals with spiritual beliefs. Another possibility is that spiritual belief may serve as an internal resource to support emotion regulation, which has been postulated to lie at the heart of mood and affective disorders (Goldin et al., 2008). Specifically, belief in God or a Higher Power may facilitate cognitive reappraisal – the ability to change one's thinking about emotionally charged situations (Gross, 1998) – and/or the ability to experience negative emotions without suppression (Gross, 2002). However, it is also possible that any positive effect of belief in God on treatment outcomes is simply an artifact of religious social systems that provide congregational support.

We therefore prospectively assessed for belief in God in an acute partial hospital psychiatric setting, and examined its relationship to treatment outcomes. We further assessed for possible mediating mechanisms of this relationship—namely, treatment credibility/expectancy, emotion regulation, and congregational support. We hypothesized that belief in God would be associated with better treatment outcomes. We further hypothesized that spiritual belief would correlate with treatment credibility/expectancy, use of emotion regulation and religious social support, and that any observed relationships between spiritual belief and treatment outcomes would be jointly mediated by these factors.

Section snippets

Procedure and participants

One-hundred and fifty-nine patients were recruited from an acute Cognitive Behavioral Therapy partial hospital program (day treatment) at McLean Hospital, over a period of one year (November, 2010 to October, 2011). Patients were approached in the common area of the program to participate in “a research study” and less than 5% refused for a variety of reasons (e.g., symptom severity, lack of interest in research). Only two participants refused to complete the study following informed consent,

Results

Demographics were uncorrelated with treatment change scores, but it was observed that belief in God was associated with both age (r=.25, p<.001) and female gender (r=.22, p<.01). Neither belief nor religious affiliation was associated with any pre-treatment symptom levels (rs ranging from −.09 to .07, ns).

With regard to primary treatment outcomes, belief in God was significantly higher among treatment responders than non-responders F(1,114)=4.81, p<.05, and linearly associated with greater

Discussion

Despite the prevalence and importance of spirituality and considerable literature tying this domain to mental health and illness in the general population, academic medicine in general, and psychiatry in particular, has been slow to study this subject matter within patient samples. Consequently, much remains unknown about the relevance of spiritual factors to patient care, and any mechanisms by which it may impact healthcare and outcomes. In this study, we sought to replicate and extend

Role of funding source

The opinions expressed in this manuscript do not necessarily reflect those of The Gertrude B. Nielsen Charitable Trust. All information presented is based on generally accepted scientific principals and methods, and does not promote any commercial or other interest that may be aligned with its funding source.

Conflict of interest

The authors have no conflicts of interest to disclose. David H. Rosmarin, Ph.D. had full access to all the data in this study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Acknowledgment

Funding for this study was provided by the Gertrude B. Nielsen Charitable Trust. The authors wish to thank Philip Levendusky, Ph.D., ABPP for his mentorship.

References (28)

  • M.E. Goossens et al.

    Treatment expectancy affects the outcome of cognitive-behavioral interventions in chronic pain

    Clinical Journal of Pain

    (2005)
  • J. Gross

    Emotion regulation: affective, cognitive, and social consequences

    Psychophysiology

    (2002)
  • J.J. Gross

    Antecedent- and response-focused emotion regulation: divergent consequences for experience, expression, and physiology

    Journal of Personality and Social Psychology

    (1998)
  • J.J. Gross et al.

    Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being

    Journal of Personality and Social Psychology

    (2003)
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    Author note: The authors have no conflicts of interest to disclose. David H. Rosmarin, Ph.D. had full access to all the data in this study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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