Rethinking the relationship between psychiatry and spirituality

Over the past three decades, scholars have observed an alarming increase in “deaths of despair” in the United States, a term referring to deaths due to suicide, drug overdoses, and alcoholism (1). In May 2023, U.S. Surgeon General Dr. Vivek Murthy issued an advisory stating that the epidemic of loneliness and isolation is having a devastating effect on society’s mental and physical health (2). The use of the terms “hopelessness” and “loneliness” to describe the drivers of health outcomes is evidence of fundamental human needs for connection and meaning; needs that, if not met, can negatively impact health. Both connection and meaning are aspects of spirituality, defined as dynamic and essential aspects of humanity through which people seek ultimate meaning, purpose, and transcendence, experiencing relationships with self, family, others, community, society, nature, and the significant or sacred (3). Spiritual concerns arise frequently in psychiatric clinical practice because mental illness often causes distress that leads to isolation, hopelessness, and suicidal thoughts. Patients are plagued by existential questions such as, “Why did this happen to me?” and “What does it all mean?” Sometimes their concerns are more directly spiritual in nature: “If there is a God, why does he inflict this suffering on people?”

Psychiatry has adopted assessment and treatment models that rarely consider spirituality as either a need or a resource, despite evidence that patients with mental illness often turn to spirituality as a coping mechanism and that spirituality can have both positive and negative effects on people with mental illness (4). Recently, there has been increased recognition of the relationship between spirituality and health outcomes. In 2016, the World Psychiatric Association issued a position statement calling for the inclusion of spirituality and religion in clinical care (5). Also, a recent review of the evidence on spirituality and health outcomes recommended that health professionals recognize and consider the benefits of spiritual communities as part of efforts to improve well-being (3). In the context of public mental health services, spiritual needs have been considered through developing opportunities for people to foster meaningful connections with themselves, others, nature, or higher powers (6). The fields of hospice and palliative care are explicitly aware of the spiritual needs of patients approaching the end of life and, in contrast to psychiatry, that palliative care physicians should be able to perform comprehensive spiritual assessments and provide spiritual support ( 7 ).

In the psychiatric framework, we make a diagnosis and consider evidence-based treatments such as medications and psychotherapy, which are somewhat effective for some people, for some time. Those who do not benefit from these interventions will progress through the best treatment algorithms currently available, which often include multiple attempts to switch or add medications in combination with psychotherapy, when available. Evidence-based medicine in psychiatry relies on efforts to turn subjective experiences into objective indicators that can be scientifically measured and studied. This pursuit is important and necessary to fulfill our promise to the public to provide safe and effective treatments. As physicians and scientists, it is also our responsibility to recognize the limits of objectivity when it comes to our minds and the illnesses that inhabit them, and to value, without diminishing or minimizing, the importance of the subjective and intangible aspects of the human condition. The limitations of empirical knowledge and the legitimacy of subjective experiences, including mystical experiences, with the rise of psychedelic research, give psychiatry an opportunity to rethink its relationship to spirituality and the challenges and relief that spirituality brings to those who seek help.

In his book, The fantasy futureSigmund Freud wrote that “religion is a system of wishful thinking which denies reality.” (8) This position would have a far-reaching impact on how psychiatrists viewed religion and spirituality. Psychiatrists are the least religious members of the medical profession. (9) In his later writings, Civilization and its DiscontentsFreud describes a letter he received from his friend, the French poet Romain Rolland, in which the poet agreed with Freud’s position on religion but expressed concern about his denial of spiritual experiences. Freud writes of his friend’s description of spirituality:

“This is, he says, a peculiar feeling which he himself has always had, which has been confirmed by many others, and which probably exists in millions of people. It is a feeling which he likes to call ‘eternal’, a feeling without limits, without boundaries, ‘oceanic’ as it were (10).”

Nearly 100 years later, experiences like the infinite ocean and the associated feelings of awe, oneness with the divine, connection, and ineffability are now commonly assessed in clinical trials of psychedelics through measures such as the Mystical Experiences Questionnaire and the Altered States of Consciousness Questionnaire. Although an area of ​​active debate, there is evidence that these spiritual or mystical experiences play a large role in mediating the therapeutic effects of psychedelic drug treatments (11). A systematic review of 12 psychedelic therapy studies established a significant association between mystical experiences and therapeutic effects in 10 studies (12). While this may not be surprising given that psychedelics have been used in traditional spiritual practices for millennia, these findings from clinical trials provide evidence to support Rowland’s concern with Freud regarding the importance of spiritual experiences in mental health.

at a later date Civilization and its DiscontentsFreud acknowledges that “I cannot discover this ‘oceanic’ feeling in myself. Emotions are not easy to treat scientifically… My experience has not convinced me of the fundamental nature of such sensations. But that does not give me the right to deny that they do occur in other people (10).” We can acknowledge the inherent limitations of the field of psychoanalysis that Freud created with its apparent disdain for religion and lack of empirical understanding of the benefits of spiritual experiences. When we see patients with psychiatric disorders that were deemed treatment-resistant experience remarkable benefits from psilocybin-catalyzed transcendence, we are prompted to humbly ask what unmet needs underlie treatment resistance and to reexamine the role of spirituality and connection in the prevention, assessment, and treatment of psychiatric disorders. Not everyone with a psychiatric disorder will be a good candidate for treatment with psychedelic medicine, but everyone deserves treatment that takes into account the need and potential sources of connection, meaning, and transcendence.

Author contributions

KD: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.

Funding

The authors declare that they received no financial support for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims made in this article are those of the authors themselves and do not necessarily represent those of their institutions, publishers, editors, or reviewers. Products evaluated in this article, or claims made by their manufacturers, are not endorsed or approved by the publishers.

References