Religion and Spirituality in Psychiatry

238 Sylvia Mohr and Philippe Huguelet3.7. Support from the ReligiousCommunitySupport from the religious community is foundedon two dimensions: first, the social support thatmembers of the religious congregation mayoffer, just like any other social network, and second,specifically religious support. The religiouscommunity may assist the patient at severallevels (material, emotional, and informational).Moreover, many religions emphasize the importanceof helping others, which may encouragethe patient in a role of assisting others. Thisattitude is especially relevant to self-esteem andrecovery. However, patients may also feel thattheir religious communities reject or judge them.They may be disappointed or angry with theirreligious communities. This potential negativeaspect must also be elicited and elaborated, likeother conflicts in relationships.3.8. Subjective Importance of ReligionAt this point in the interview, the clinician hasalready learned about the patient’s spiritual beliefs.To gain a better understanding of the salience ofspirituality and religiousness in the patient’s life,the clinician must accommodate the patient’s spiritualand religious language. For example, if thepatient believes in God, the clinician will replace“your religious or spiritual beliefs” by “your beliefin God” and ask, “In general, how important isyour belief in God in your day-to-day life?” Giventhe variety and looseness of the concepts of spiritualityand religiousness, appropriate language isessential. To help the patient express the salienceof his or her spiritual beliefs, the clinician maysuggest anchored points of importance, such as“not at all,” “a little,” “some,” “very,” or “essential.”By providing support, spiritual or religious beliefsmay bring hope, acceptance, joy, and meaning tolife. But religious beliefs may also be a source ofsuffering and despair.At this point in the interview, the clinicianshould be aware of the patient’s religious preference,his or her spiritual beliefs and practices,major changes in his or her spiritual history, andthe salience of spirituality and religiousness inhis or her life. But to what extent is this relevantto clinical outcome and care?For the assessment of spirituality and religiosity,Huber (33) has pointed out the keyconcept of centrality. Centrality describes thehierarchical status of religion in personality.The more central the religion is, the more it caninfluence the person’s experience and behavior.When religion is central, it has a powerfulinfluence on every domain of life (health and illness,family, career, sexuality, politics, and otherbeliefs and behaviors). When religion is subordinateor peripheral, it influences fewer areas. Atthis point, the clinician can readily identify thepatients for whom religion is marginal in theirlife, that is, for whom religion has never beenimportant and who currently have no or fewreligious practices.Case ExampleAs an example of low centrality, a45- year-old man with paranoid schizophreniareported, “I am a Catholic. I haven’t goneto church since I was a teenager because Iam not interested. I believe in God; this givesme hope for an afterlife. I don’t think aboutit in my daily life or use it to help me.”For patients with low centrality, the spiritualassessment should end at this point for tworeasons. First, assessment of these areas is notneeded because there is no apparent relationshipbetween religion and their psychiatric condition.Second, the clinician must respect every kind ofspiritual stance, including a professed absence ofbelief. Addressing religious coping with patientswith low religiosity could send the ill-fated messagethat they are missing something, and thus beharmful. Excessively concentrating on religionin this case may be the counterpart of the dismissivemessage about spirituality that is so frequentlysent when the issue is not addressed withpatients for whom it is central. The prevalence oflow centrality varies according to area, cohort,and population studied. In Germany, one studyfound that religion was marginal for 26 percent