Throughout human history, traces of discussions around the mind-body-spirit triad can be found. In fact, consistent reference to this triad can be noted in Indigenous, ancient Sanātan Dharma (endonym used to refer to Hinduism), and other religious and cultural traditions, customs, teachings, and practices. When people focus on Eurocentric philosophical discourse, however, they often turn their attention to Rene Descartes (1637), credited for “discovering the mind-body dualism.” Although he does not speak directly about the soul or spirit, Descartes explains that the mind and body are two separate entities—that the mind is immaterial and can exist outside of the body, and that the body itself cannot think. The divide between spirituality/religion and mental health was further widened in the late nineteenth century when neurologist Jean Charcot and his student Sigmund Freud associated religion with hysteria or neurosis.
These philosophical assumptions are interesting in contextualizing the intersection between spirituality/religion and mental health. In contrast, the World Health Organization (WHO) conceptualizes mental health as a state of well-being in which the individual realizes his or her abilities, and can cope with the normal stresses of life, work productively, and contribute to his or her community. This definition is more realistic and relevant today as it focuses on one’s capacities, function, and productivity. More importantly, well-being is considered a pillar of mental health and focuses on an individual’s coping capacity to promote social participation. The WHO definition also implicitly presents mental health as a continuum for each individual that has ups and downs.
As it stands, the current health-care system is geared toward alleviating visible disabilities where possible and maximizing function
The disabilities associated with mental health are defined and treated differently across geographical locations. In the West, these conceptualizations have affected how physicians provide care. A great deal of focus in clinical training in medicine is to arrive at a diagnosis through patients’ past and present medical and social history, physical examination, and laboratory or other diagnostic tests. A physical exam is a stepwise approach of inspection (looking at a part or whole body for visible signs), palpation (feeling the area or body part with hand or fingers), percussion (tapping on the body), and auscultation (listening using a stethoscope). In fact, these skills specifically are hammered into medical trainees from day one. These techniques are meant to look for visible disease manifestations. But how does one look for something that does not have visible manifestations? Can physicians continue to use these same methods to assess mental health conditions, which unlike physical ailments, are frequently non-apparent.
Though the history-taking component of a medical exam can give us some insights into a person’s mental health, most of the clinical examination is targeted to “see” issues or dysfunction. Often no noticeable abnormalities or dysfunctions are noted by a physician during their clinical encounter with a person experiencing mental health issues. As it stands, the current health-care system is geared toward alleviating visible disabilities where possible and maximizing function. The current diagnostic and treatment approach works well when physical impairments are isolated and a return to pre-disease health is a realistic outcome. However, the same approach is limiting when treating people with mental health issues.
An extension of clinical care involves focusing on neurochemical imbalances in a specific brain region. With advanced knowledge and technological capabilities, physicians are able to observe how different parts of the brain work and, from there, see if there are issues concerning the functioning of various neurochemicals or brain pathways. If, after testing, there are observable problems that seem to deviate from “normality,” then we can develop and prescribe medications to address the specific issue. Though medications can improve the neurochemical imbalance in the brain, it’s not certain whether these medications should be taken forever, or what the de-prescription strategies are. This approach also completely disregards the fact that not all mental issues arise from neurochemical imbalances or damaged parts of the brain. A possible drawback of medical management could be an overreliance on medications and assuming medications as a cure instead of addressing the root cause of the mental condition in the first place.
From a clinician’s perspective, with limited time and a long waiting list, it is much easier to tackle the more concrete or tangible issues. In Canada, for example, an appointment with a family physician lasts 10-15 minutes on average. This is barely enough time for physicians to sufficiently obtain history, conduct examinations, and order or review laboratory or diagnostic tests. Given the constraints, it is often easier to refer patients to specialized psychiatric care, which adds to long waiting periods and could be detrimental for patients who need more immediate help. The lost opportunity to intervene during the first contact with the family physician could result from insufficient time allocated in the fee-for-service publicly funded health-care system as in Canada. This burdens an already strained system due to a mismatch between limited specialized mental health service providers and the large number of people needing these services. With this in mind, most patients seeking mental health support would benefit from access to social workers, psychologists, or therapists who can provide more sustainable, lasting, and meaningful care to patients. These services are often not covered by public health-care systems or private insurance, thereby costing health-care systems and economies enormous losses due to lost wages and productivity for the patients, their families, and society, by extension.
Most physicians recognize the benefits of spirituality/religion to a person’s overall well-being
In socialized health-care systems, one critical question centers on which health-care services should be covered through public funds. Who decides what is covered—the government or society? Society values certain health services more than others as it is relatively easy for the general public to imagine quality of life after losing a leg or sight. Comparatively, it is much harder for same general public to imagine the extent of impairments for those living with a non-apparent disability, such as those arising from mental health issues. In this case, can people solely rely on society to make this judgment? Given what we know about health, it is impossible to consider physical and mental health as independent as once thought. Moreover, it is well recognized that a person receiving treatment for mental health disorders would benefit from a multidisciplinary team of health-care professionals, which still leaves out the spiritual/religious well-being of the person.
The concept of spirituality/religion has started to enter modern evidence-based health care for some time now. Most physicians recognize the benefits of spirituality/religion to a person’s overall well-being. The first reference to any spiritual/religious in health care is in the fourth edition (1994) of the Psychiatric Diagnostic and Statistical Manual (DSM), labeled as “Religious or Spiritual Problem” (Code V62.89). This label continues to appear in the subsequent iterations of the DSM under various headings. Spirituality/religion is reflected here as a mental disorder problem suggesting a lack of acceptance from the Western medical community towards the role of spirituality/religion in mental well-being. The pervasive, not negative, attitude is likely to hamper people trying to use spiritual/religious beliefs to support their mental health and well-being. While medication will work whether or not one believes in spiritual/religious well-being, having additional support can help individuals maximize their health and well-being and desire to continue and engage in care and treatment.
Spirituality/religion are assets that offer opportunities for a person to develop coping skills against maladaptive behaviors; contribute to the well-being of their community; establish a set of principles and values that help an individual navigate their life course and manage stressors and distress; and provide a sense of purpose, peace, and self-control. It is interesting to highlight that some mental health conditions, such as substance abuse or depression, have been associated with a lack of spiritual space in one’s life. Additionally, studies suggest a positive impact of including spiritual/religious context in treating depression, suicide, anxiety, psychotic disorders, and substance abuse. Several therapies, such as spiritually focused therapy groups, religious cognitive behavioral therapy, and spiritually augmented cognitive behavior therapy, have shown the positive impact of including a spiritual/religious component. Evidence-based medicine alone, without the other support of spirituality/religion, is incomplete in caring for patients and communities. There is a need to develop health systems that merge the best of two worlds and are centered on qualities and values such as integrity, justice, kindness, and cooperation.
Attention to mental health and well-being is increasingly reported worldwide, and influential people including celebrities share their experiences and support for various mental health causes. Mental health services are integral to schools, universities, and workplaces. While such affirmative action is necessary, it is not sufficient enough to improve mental health services and incorporate spirituality/religiosity into multidisciplinary assessment and treatment. There is a need for therapists/psychiatrists to be aware of the spiritual/religious beliefs and conditions of their patients. Within psychiatry, there has been recognition and research between spiritual/religious beliefs and mental health.
If one were to envision an ideal care model, it would be an amalgamation of evidence-based medicine coupled with spiritual/religious well-being toward living a fulfilling life whether or not one has a curable or incurable health condition. This would need to dismantle the current health-care system and institutions and go back to the drawing board to design health care that matches the needs of the people with services that match those needs. Physicians may need to have uncomfortable discussions surrounding spirituality/religion and embrace the uncertainty and abstractness aspect of these constructs.