Religion and Spirituality in Psychiatry

196 Harold G. KoenigIn some Eastern cultures (Japan and some areasof China), suicide may be viewed as an honorableact in certain rare circumstances (after shamefuldeeds or in service to country), but it is not condonedto avoid or escape from pain and suffering.Within Judeo-Christian faith traditions, tokill oneself is equivalent to murder, for one of theTen Commandments is “Thou shalt not kill,” andthere is no distinction made between killing one’sself or killing others. Such prohibitions are powerfuldeterrents to the sequence of psychologicalevents that eventually lead to successful suicide.Religious and spiritual beliefs often help peopleto cope with the pain and suffering that leadto suicidal thinking, and thereby convey hopeand meaning that can prevent suicide. Religiousinvolvement can also surround the suicidal personwith a community of people who can supportthe person and help him or her bear theemotional burden. “Am I my brother’s keeper?”asked Cain in Genesis. God’s answer, “You betyou are.” At the heart of some faith communities(although not all) is the care that membersdemonstrate toward one another. This is the idealthat the Christian scriptures (and the scripturesof other world religions) emphasize. “Whoeverdoes not love does not know God, because Godis love” (1 John 4:8, NIV).Plenty of research supports the claim that religiousinvolvement can prevent suicide in thosewith or without medical illness. People withstrong religious beliefs, particularly if involvedin a supportive religious community, have fewerthoughts about suicide, have more negativeattitudes toward suicide, and commit suicideless often than those who are not religious. In areview of sixty-eight studies that examined therelationship between suicide and religion, fiftyseven(84 percent) found that religious personswere more negative about suicide, had fewerthoughts about it, attempted it less, and were lesslikely to complete suicide. In these studies religiousnesswas measured in many different ways:from frequency of religious activities to degreeof personal religiousness to regional rates of religiousbook publication. Countries of the worldthat publish fewer books on religion have highersuicide rates than countries that publish morereligious books.(11)Critics say that areas of the world that are morereligious often have stronger cultural taboos aboutcommitting suicide, which then affect whetheror not cases of suicide are reported. Muslims,for example, strongly condemn suicide, whereasmembers of Eastern religious traditions such asBuddhists, Hindus, Chinese, and Japanese religionsare more tolerant (with Christians and Jewsfalling in between, depending on how conservativetheir beliefs are).(12, 13)More recent studies on religion and suicideinclude subjects of different ages across the lifespan and from various ethnic groups. Because suiciderates are greatest at the age extremes (adolescents/teenagersand older adults), studies in thesepopulations are particularly relevant. Greeningand Stoppelbein examined religiousness and suicidalattitudes in 1,098 Caucasian and African-American adolescents, asking them to rate thelikelihood that they would ever commit suicide.(14) Investigators controlled analyses for depressionseverity, hopelessness, social support, and styleof causal attribution. Of all these characteristics,religious orthodoxy (commitment to core beliefs)was the single strongest predictor of negative attitudestoward suicide. Furthermore, while severityof depression predicted a greater self-reportedfuture likelihood of committing suicide, greaterreligious orthodoxy reduced the likelihood ofdepressed adolescents saying that they would everdie by suicide (that is, religious orthodoxy moderatedthe effect of depression on suicide).The same pattern appears to be true in olderadults, where the suicide rate is higher than anyother population group. In a study of 835 urbanlow-income African-Americans, with an averageage of 73 years, Cook and colleagues examined predictorsof active and passive suicidal ideation.(15)Passive suicidal ideation is a desire to die or wishto be dead, but no active plans or intentions to endlife. Active suicidal ideation involves more seriousplans on how to commit suicide and active desire toharm self. Of the multiple characteristics measured(anxiety, social dysfunction, somatic symptoms,low social support, absence of a confidante, older