International Center for the Integration of Health and Spirituality 2003 Conference Keynote Address: "Overview of the Relationship Between Spiritualit

I think introducing this area by giving you a little bit of a historical perspective on the topic is important to understand that religion and mental health, although separated for so many years, them coming together now is not something entirely new. In fact, their being apart over the last 100 years is really what is new.

In the first century in western Europe, there was no treatment, basically, for the mentally ill. They were kept away from the population because the people didn't want the mentally ill to be scaring the people in the general population, so they were kept in dungeons and in dark cells. So that was the form of treatment: there was no treatment.

Then, in the fifth century, one of the first hospitals for the treatment of the mentally ill, specifically mentally ill, was established in Jerusalem and, of course, was run by monks.

In the sixth century, monasteries throughout western Europe brought in the mentally ill to provide care for them. This is particularly true in Spain.

In the twelfth century in Belgium, the mentally ill were brought into the houses of many of the devoutly religious people. So they were actually included in family life. Of course, there were religious reasons that they brought in these mentally ill who otherwise would have been oftentimes living on the streets.

In the fifteenth century, however, the Church began to persecute the mentally ill probably with the intention of trying to maintain a faith that was pure and that was not heretical but also the issue of this demon possession. The idea that people were possessed by demons and that the demons had to be exorcised. If they weren't successful, then the person would be burned or beheaded, whatever. So this was the witch hunts.

Also in the fifteenth century, there was a fellow by the name of St. John of God. Interesting story. He was in Spain. I believe he was a book salesman. What he did was, he was in his 40s and he had a spiritual experience that changed his life. He had a dramatic conversion experience. Then he went into the mental hospital.

Apparently, it destabilized whatever it was that was going on in his mind and he became psychotic, and he ended up in a mental hospital. He stayed there for several weeks and then came out and was living on the streets.

Then someone allowed him to live in, actually, the little area in front of his house that was covered by a roof. He lived there and he brought in other people to sleep with him on the streets, other mentally ill people. He brought them into his little area there that he had to sleep.

Eventually, that grew into an actual hospital. Then, this kind of a hospital that brought in the mentally ill into their midst, this entire order came up, the order of St. John of God. This, even today, still has literally hundreds of different hospitals around the world that bring in and care for the mentally ill.

The eighteenth century moral treatment is the whole beginning of American psychiatry. You don't hear much of this in the literature, particularly with regard to psychiatry, that American psychiatry had its origins in what is called a moral treatment.

The first psychiatric hospitals in the United States were built by the Quakers bring moral treatment over from Europe. The first one was Friends Asylum in Philadelphia, the Friends Asylum. Then the Hartford Retreat and the Worcester Retreat were all modeled after Friends Asylum.

What we don't realize, though, is that the founders of the American Psychiatric Association and the "American Journal of Psychiatry" were the superintendents of these institutions. They included chaplains and ministers very much as part of the treatment team of the mentally ill. In fact, these ministers lived on the grounds of the mental institutions and provided not only services for the patients but also provided some spiritual care.

A lot of this was documented, in fact, in the "American Journal of Psychiatry" in, I think it was 1998, in an article that was published there.

Now, of course, over the next 100 years, that was all to change with Freud's influences on modern psychiatry. Since the late 1800s, psychiatry, psychology, and religion have been very separate.

However, in the twenty-first century, things are changing. This includes the training in psychiatry and psychology as well as research and the volume of research.

Now, I would like to get this part of it out of the way. We do know that religion does have negative effects in individual cases on people's mental health. It is unclear whether or not it is the mentally ill person or emotionally ill person that then globs onto religion or whether it is the religion that actually makes a person neurotic or mentally ill. That is up to question.

I think for a long time mental health professionals assumed that it was the religion that was making people unstable, neurotic, mentally ill, rather than vice versa, the mentally ill person seeking comfort and health, globbing onto religion.

However, religion can be used to justify hatred, aggression, and prejudice. That we see at some level all over the place and in every religion. It can be used to gain power and control over others. It can be used to foster rigid thinking, obsessive practices. It can foster anxiety, fear, excessive guilt. It may be used to deny the facts in a kind of magical, unrealistic way. It can be used defensively to avoid addressing issues common in the thought content of psychotic persons. It can interfere with mental health care. People may feel that they have been healed of their bipolar disorder, is probably the best example, and they will stop their lithium.

It can foster negative attitudes towards mental health professionals. Given the negative attitudes of mental health professionals towards religion, many religious groups have also discouraged people in their congregations from seeking psychological or psychiatric care.

It can delay diagnosis and effective treatment. People may be treated locally, say, within a church setting by counselors or by a minister and they may have a severe depression that may worsen. They may commit suicide. That happens.

Now, let's take a look at some of the definitions here. Spirituality versus religion. Now, not everybody agrees with me on this. So if you all think differently on this, you have plenty of other company nationally, but since I'm giving this talk, I'm going to give you my view of the situation.

Spirituality is popular, religion is not. However, for researchers, spirituality tends to be very diffuse. It can be almost unique to every different person. So, how do you actually measure a construct and then correlate it with different mental health outcomes, that is diffuse, that includes mental health as part of its definition? How do you do that?

I usually speak in terms of religion, not spirituality because I can measure religion: religious beliefs, religious practices, religious activities. However, I use a broad definition of "religion" when I talk about it. I don't mean just going to church with "religion" or institutionalized religion.

Religion, as I talk about it, includes personal religious beliefs, personal commitment, practices, prayer, devotional reading, faith community involvement, attending services, practicing the rituals, group religious activities, volunteering for religious reasons.

This is very important here. Religion may impact but does not necessarily include forgiveness, meaning and purpose, sense of connectedness, or sense of peace, wonder, beauty, and awe that oftentimes is folded into the term "spirituality." When you include all of these other things in your spiritual predictor variable, you create a circular type of reasoning here. If you define spirituality as being able to forgive, as meaning and purpose in life, all of those things are naturally connected with mental health.

There have long been very strong correlations between those factors and mental health. They are almost kind of pseudonyms for mental health variables. Therefore, if you include that as part of your definition of spirituality, what are you really measuring then when you are looking at the correlation between spirituality and mental health?

So, I encourage you not to include these things as part of your predictor variable, part of your spiritual variable, but rather look at the correlation between religion or spirituality and forgiveness, meaning and purpose, et cetera.

Again, this is my view on it. Many of you may have good reasons not to do this, but this is what I would suggest, to keep things more pure and to avoid the circular type of reasoning.

Now, let's look a little bit at the research prior to the year 2000. This is summarized here. It is in the "Handbook of Religion and Health." If you look at purpose and meaning in life, you can see that of the 16 total studies in the literature, 15 find that the religious person has greater purpose and meaning in life.

Now, this is important to establish this connection, to look at it scientifically, to measure one and then correlate it with the other because many atheists and agnostics would say, hey, I have purpose and meaning in life, why should purpose and meaning be part of the definition of religion and spirituality? So, it is important to establish then the connections between purpose and meaning in life and religious practices or beliefs.

Well-being, hope, and optimism. Of the 114 studies that have looked at this in the last 100 years, we find that 91 find a connection. Greater hope, greater optimism, greater well-being. Social support in virtually all of the studies. Marital satisfaction and stability in 80 or 90 percent of studies. Depression and its recovery, two-thirds of studies. Suicide, again, 80 to 90 percent. Anxiety and fear, about 50 percent.

Now, why is that? Why are there fewer studies showing this correlation for anxiety and fear? Part of it has to do with the fact that fear and anxiety are powerful motivators for people to become religious. Think of September 11th. Think of since the war began. How has the U.S. population reacted?

After September 11th, given the fear and uncertainty, nine out of 10 Americans turned to religion as a way of coping. This was reported in the "New England Journal of Medicine" the week after September 11th, that there were really no other coping behaviors more common than Americans turning to religion, 90 percent of the population. This was a national sample.

About two or three weeks ago, the Gallup organization released findings from early March of 2003. Weekly church attendance had risen about 10 percent, with 49 percent weekly church attendance, 49 percent based on a national Gallup poll.

So the idea here is that anxiety and fear motivate people towards religion, but don't always reduce the anxiety and fear immediately. Therefore, when you look at cross-sectional studies, which most of those studies are, you find sometimes religion and anxiety are positively correlated because it is the anxiety that caused people to turn.

Substance abuse, a lot of research on that. Delinquency, quite a bit.

In summary, of the 724 quantitative studies that we could identify in the previous 100 years, 478 find a statistically significant positive correlation with the religious variable.

Now, what about since the year 2000? Since 2000. We have been talking about prior to the year 2000. Now let's look at since 2000.

Now, there is a growing interest in this field. Entire issues of many journals have been devoted just to religion and mental health. The entire issue. Now, prior to about 1990, I don't think this ever occurred before, that you had an entire issue of a secular journal devoted to papers on religion, spirituality, and mental health.

This only includes about 70 percent of the journals. There have been several journals since I developed this slide that have actually come out with entire issues on the topic. These are secular journals.

Now, growing amount of research. If you remember nothing else, nothing else of what I say, I want you to look at this. Look at this right here. I want you to start down here.

You can do this yourself, and I encourage you to do this. Go into "Psychlit," which is the largest on-line database for research studies in psychology and psychiatry. Go into the "Psychlit" database and simply put in the word "religion." Search for it, focus it down, and then see how many studies you get, but restrict the year to 1980 to 1982, down here. Then take the word "spirituality," put it in "Psychlit," run it, focus it on the articles, and see what you get out, again focusing on just 1980 to 1982.

What you find is you will find 101 articles on religion and zero on spirituality because spirituality, there was no such term in 1980 to 1982 in the scientific world. It didn't really come about until 1990.

Now, at that time, 1980 to 1982, there were 406 articles on social support. So therefore, the ratio of articles on religion or spirituality to social support was 25 percent.

Now, simply move up in time and let's look at 2000 to 2002. This time do exactly the same thing, but restrict your time period between 2000 and 2002. What do you find? You find 410 on religion and 821 on spirituality. You now have 1108 articles instead of 101 articles for the same period of time. Now, what does this suggest?

Now, more important, look at the number of articles published on social support during that time, 1590. Now look at the ratio. It's no longer 25 percent, it's now 70 percent.

I encourage you to do this. I think there is no better evidence that this area is growing rapidly within the mainline academic community than if you just look at the literature out there.

Now, there are also a growing number of posters and presentations and dissertation abstracts. If you just go to APA or you go to the American Psychiatric Association meetings, American Psychological Association. Look at the abstracts that are being presented. There are a lot more on religion and spirituality than there were 10 to 20 years ago.

Qualitative research, in addition to quantitative studies, have been coming out in this area, particularly in women, AIDS, African Americans, caregivers, and those who are stressed. These are very important populations to be looking at religion and spirituality because it appears to be in stressed populations that you see these effects emerging.

Now, I am just going to give you kind of a very brief overview on some of the recent studies that have been out. This is very quick. I don't want to take much time on this, but I think it is interesting.

I have divided them up. They are all since 2000. I have divided them up by different conditions, one being adaptation, a section on depression, substance abuse, et cetera. Let's just look at some of these.

Matthews — not Dale Matthews, another Matthews — clinical trial with intercessory prayer. Patients who expected to receive intercessory prayer felt significantly better than those who expected to receive positive visualization. So the expectation that one is going to receive prayer seemed to help the well-being of these patients.

Dale Matthews, by the way, also found in his study of rheumatoid arthritis patients that patients who thought they were being prayed for in the double-blind part of the intercessory prayer experiment did better than those who didn't think they were being prayed for, whether or not they were actually being prayed for. So thinking that you are being prayed for seems to make a difference.

Here is a study of caregivers of patients with schizophrenia. Strength of religious beliefs predict greater well-being. Now, this kind of confirms what Peter Rabins at Hopkins found in his longitudinal study of caregivers of Alzheimers and cancer patients, that the more religious the caregiver was, the faster the emotional adaptation.

Now, although many of these studies find a positive correlation here that I am going over, my intention when I did this literature review, which was fairly rapidly, was not to just find the positive studies.

I tried to put up here the most recent studies that were quantitative that were published in the literature. So this should be fairly representative, although there is probably some bias in selecting out some of these articles. It is, I think, fairly representative of the research that is out there, perhaps a little bit biased on the positive side, but not a great deal.

Here is one in the "Journal of Adult Development," 195 adults with recent vision loss. Spirituality buffered the effects of negative life events experiencing impact in control ratings. So again, in a stressed population you see this effect.

Three-hundred nineteen psychology undergraduates getting the NEO Personality Inventory and these other scales. These spirituality scales correlated with extroversion, agreeableness, and conscientiousness.

Here is one in England: 179 adults. Again, spirituality related to extroversion. Extroversion on, this time, a different personality scale.

This is one of 230 low-income women with HIV and AIDS. Spirituality significantly correlated with adjustment. Once again, you have these stressed, oftentimes medically ill populations where you see these effects coming out.

Let's look at depression. A study in Canada by Dr. Baetz. She is in the audience here. I hope you all get to meet her. She is doing a series of studies in Canada. This one is one of, I think, four or five studies she has recently done, 88 psychiatric inpatients. The more frequent worship attendance, the less severe depression, the shorter length of stay, the higher satisfaction with life.

Here is 156 spouses of lung cancer patients. Again, the caregivers. Curvilinear relationship between religious coping and depression. Those who had moderate religious coping had higher depression. Moderates had higher depression than those who had either high religious coping or did not use it at all.

So if you were atheistic and you were absolutely positive that God didn't exist, you coped relatively well. If you were absolutely positive that God did exist, you coped pretty well, too, but if you were kind of in the middle and weren't sure whether or not he existed, or she existed, then that's when you had more depression, at least among the spouses of these lung cancer patients. It is the uncertainty, the uncertainty.

Here is an interesting study of 227 Iranian and 220 U.S. college students. Intrinsic religiosity in both samples correlated with greater adjustment, less depression, less anxiety, less perceived stress, and greater self-esteem. The opposite was found for extrinsic religiosity.

Again, in the "British Medical Journal," 135 relatives and friends of terminally ill patients, spiritual belief predicting faster resolution of grief symptoms, helping with the bereavement process.

Here is a study: 303 psychology students providing a significant moderating effect for both depression and anxiety, but more for depression than with anxiety. Again, because of that mixture with anxiety of turning to religion with depression, giving hope, giving meaning, giving purpose, et cetera.

Substance abuse. Let's look at a few here. Longitudinal analyses of 1,526 alcoholics. Alcoholics Anonymous significantly associated with abstinence and reductions in drinking intensity whether the person who attended AA was religious or atheistic. Clients unsure of god beliefs — see, again this uncertainty, unsure of their god beliefs — reported significantly higher drinking frequency. Atheists and agnostics were less likely to attend AA, but if they did, they did just as well as believers.

Four-hundred seventy-five youths, those involved in religious activities predicting probability of never using alcohol. Spirituality predicting never using marijuana or hard drugs. Forty-three HIV-positive injection drug users, independent of other predictors. Strength of perceived religious and spiritual support was a significant predictor of abstinence.

Another one: 252 in a treatment setting. Spiritual well-being predicting length of recovery and recovery barriers.

Now remember, the spiritual well-being scale has in it an existential well-being scale and a religious well-being scale. We're not too sure, if you're just looking at the total score, whether it's the existential well-being score that is actually predicting things. The existential well-being score is really a proxy for a mental health variable, like well-being.

Here are 236 recovering substance abusers. Religious faith and spirituality associated with increased coping, resilience to stress, greater optimism, more perceived social support, and lower anxiety.

So now, yes, there is probably a file-drawer phenomena, that many of these studies all seem to be positive. Those are the ones that tend to get published. The ones that you don't find any relationship probably end up not getting published.

Certainly, you would expect, if you found a negative relationship between religion and mental health, that that would get into the mental health literature, given the secular departments of psychology and sociology, but you don't find those relationships very often. You don't find the negative relationships between religion and mental health or substance abuse, et cetera.

Treatment application. This is 228 participants. Inclusion of spiritual process in counseling. Spiritual intervention perceived similarly to a cognitive behavioral intervention, regardless of the spirituality of the patient. So in this particular study, including the spiritual process in counseling, was fairly acceptable to patients, regardless of their spirituality.

Here is one from the "Journal of General Internal Medicine," a focus group with 22 seriously ill patients. The willingness to address religious and spiritual discussions, this time, was correlated with the physician-patient relationship, which means that patients didn't particularly want to discuss their intimate religious and spiritual beliefs with a physician they didn't know, but would rather do that with a physician that they had a relationship with, that they trusted.

These are very sensitive issues that people experience with regard to their religion and spirituality, and they wanted to have a connection with their doctor in particular that would be helpful if these issues were brought up.

Here are 95 parish nurses and 91 mental health nurses who were compared on spiritual issues. Both groups reported high spiritual perspective scores and similar interventions.

So apparently, at least in this study, parish nurses and mental health nurses were fairly similar in what they did with patients.

Here is a study in Canada, a study of 200 Canadian and 210 occupational therapists. Do we have any occupational therapists in the audience? Yes, one at least. Good. There is a lot of interest in occupational therapy. I'm excited about that.

Now, here is a study that patients have a preference for discussing spiritual and religious issues in counseling. So this summary is here to suggest that patients would be open to this.

Miscellaneous studies. These are interesting ones here. This is one looking at 340 community-residing and institutionalized elders. Personal meeting, religiosity, spirituality contributed more to well-being than did social resources, physical health, or negative life events. Isn't that interesting? These factors contributing more to well-being than these standard predictors of well-being and mental health.

Here is one looking at 254 students and psychotherapy outpatients' religious straying, feeling alienation from God, religious fear, religious guilt. This is the other side of the picture, when people feel like God is punishing them, has deserted them, doesn't love them.

This is work that Ken and I did at Duke — not this — but we did a study looking at survival after hospital discharge from Duke and found that those people with negative religious coping, like what these guys are describing here, was correlated significantly with death after discharge, independent of their physical health and their mental health. So this doesn't only have mental health applications, this has physical health applications as well.

Here are 76 African American and white primary care patients. Intrinsic spirituality, extremely important for depression care; three times more likely in African Americans than in whites. So in African Americans, in particular, religious and spiritual issues in treating depression should be very important.

Now, here is religious coping. The practices of 400 psychologists were assessed and correlated with their distress levels. No differences observed between religious and non-religious therapists. That's interesting.

So we have the question now: Is it the religious therapist that has more or less distress versus the non-religious therapist? At least, this study showed there was no difference.

In any case, more research needs to be done. There haven't been a lot of studies, and I think there needs to be, on, actually, the effects of the caregiver's spirituality, the mental health provider's spirituality, on their ability to relate to patients and on patient outcomes in therapy. Very little research on that.

Here is a good one. Two-hundred subjects underwent genetic subtyping and answered questions on a spiritual scale. The DRD4 gene and spiritual acceptance were significantly related. The gene may play a role in personality trait of spiritual acceptance. So therefore, someday we may be able to develop a pill to activate this gene in people to make them more spiritual.

Let's look a little bit, quickly, at the kinds of studies needed. Further qualitative studies, we need more studies that are qualitative in nature, that actually look at some of the mechanisms, try to explore how religion and how spirituality impact mental health and various aspects of mental health and mental disorder.

Second of all, we need more longitudinal studies on the outcome and the course of major mental disorders: schizophrenia, bipolar disorder, major depression. Very few longitudinal studies looking at those outcomes.

We need clinical trials using religious interventions. There have been a few studies, maybe five to 10 out there. They're not really well designed, but there are some studies out there that are clinical trials looking at religious interventions, mostly in religious patients. They should serve as models for more studies that need to be done looking at better samples.

The idea of clinical trials, where you look at a religious intervention in a patient with a mental disorder, I think it's important that we have more studies done like that because there are very few out there. That, of course, helps to determine the causality.

A lot of those earlier studies were cross-sectional or longitudinal. Cross-sectional studies don't provide any evidence for causality. Longitudinal ones provide some circumstantial evidence for causality, but no direct evidence because you need a clinical trial to establish that.

Program effectiveness. Evaluations need to be done. For example, faith-based delivery of mental health services. What difference does that make, if mental health services are delivered in a faith-based setting versus a secular setting? There are no clinical trials looking at that, and so we need to have program effectiveness studies done.

This is particularly important if the faith-based initiative might, in the future, grow from just the substance abuse area into the mental health area, as well, the faith-based and community initiative of our government.

Theologically-informed instrument development needs to be done, instruments designed specifically for different religions, instruments designed that are valid across religions. We need a combination of these specific for different religions, and also some valid across religions.

We need instruments that include an individual's historical exposure. A lot of times, these instruments only capture right now, as far as immediately, how spiritual or religious a person is. We need some evidence for the history because we know that that changes over the lifetime of an individual. People spiritually mature over a lifetime, and we need to get that exposure.

We don't really have any studies looking at the level of exposure to religion, spirituality, and mental or physical health outcomes. Instruments that tap activities and behaviors through monitoring, in other words, people wearing a device that they might be beeped every 10 minutes and say, what were you thinking about, what were you doing. See to what extent, how much of the time do people spend thinking about religion or spirituality in their lives rather than making them just do a retrospective report. It would be nice to be able to monitor that.

Studies addressing application and clinical practice, including impact of the health professional's spirituality on outcomes, as I said earlier.

This is the last slide before we have some time for questions.

This is kind of a summary of the talk. Lots of research showing connections with mental health, lots of research, but we are still only at the very edge of a field that is growing, that is emerging. We're at the very edge of it. There is a tremendous amount of research that needs to be done to define better what is going on and what these relationships are all about.

What I showed you here is, there is a lot of research being done now. There has been a lot of research that has been done, but a lot of it, like I said, is cross-sectional. A lot more research needs to be done in terms of these more sophisticated study designs, to give it some sense of what this means, and then how to apply it.

Amount of interest and research is rapidly growing in this area. More sophisticated measures of religion and spirituality and methods of studying religion and spirituality are needed, more longitudinal studies. Clinical trials are needed, especially of the impact and acceptability of religious and spiritual approaches to treatment.

Religion and spirituality are starting to become mainstream. This is now starting to become popular, believe it or not. Before, you couldn't get a study through the IRB or get NIH to fund a study on religion, but now, if you include religion or measuring spirituality, it's almost like, okay. This is kind of the trend now.

You really haven't done a complete grant unless you have included a couple of variables on this and kind of look at it. It's almost like social support was five years ago, where you almost had to look at social support if you were looking at some kind of mental health outcome. Now we are starting to get almost to the point where you need to be measuring a few religious variables, as well.

NIH is more receptive to this area. I think that the evidence is that there is growing receptivity within NIH. I think there is some concern about the review groups. Many of the review groups don't have people on them with experience in this area, or knowledge in this area, and therefore, people reviewing the grants may not be real familiar with the area.

So that is a concern that I think needs to be addressed within the study sections at NIH, that some experience gets included on those study sections.

Funding issues remain a challenge. There is no doubt about that. Getting any studies funded on religion and spirituality, although, like I said, growing interest in this area at NIH. NIH funds are not expanding this year, so that's an issue on getting more money. Therefore, a lot of times we will have to be piggybacking these religious variables on studies that we have funded through other means, through more conventional means, adding, say, a few questions on this and then looking at it along with what else you are looking at.

Question-and-Answer Session

DR. KOENIG: Let's open it up now for about six minutes worth of questions.

Yes?

QUESTION: Thank you. In substance abuse treatment, spirituality has played a mainstream role for 50 years. I even note the mainstream is like an aquifer. We don't talk about it outside the treatment facility. A clear distinction has long been made between religion and spirituality. What is your reaction to that, both to the fact that it has developed subrosa over the years and without any review in the literature, any testing, and to the question that a clear distinction between spirituality and religion has long been made in that field?

DR. KOENIG: Yes. AA was the first, really, that made in-roads into psychiatry, the first in-roads that religion/spirituality had in the field. There is no doubt about that.

Now, the way I talk, I would say it was religion within AA that was being utilized, the evidence of a higher power and the idea of turning over one's life, that one is unable to deal with this situation and having to turn over one's life to a higher power and then acting this out by providing support to one's neighbor, the other alcoholic, supporting that person in their recovery. These are very elemental religious principles.

That is the way I would call it. Some people would call it spiritual principles. So, to me, I think, whatever you call it, whether you call it spirituality or religion, it was the first in-roads.

In 1953, the "American Journal of Psychiatry" published a paper that talked about alcoholics and what were aspects among alcoholics who survived, who didn't die of their illness. This was even before AA, I think. I don't know when AA was developed. Was that before AA? 1936?

Before AA became real popular, 28 percent of recovery was due to religious conversion. Religious conversion — it said this in this "American Journal of Psychiatry" article — among the alcoholics. They said this before AA became more prominent, but there is no doubt that AA and the principles there in AA and all the substance abuse, whether it is alcohol, whether it is drugs, whether it is eating disorders, are all the same. The idea that these are powerful disorders that completely take over the person. The idea that this person literally becomes helpless in the face of this powerful addiction, and having them to counteract that by saying, I can't deal with this, admitting that, giving it up, and then living that out by caring for one's neighbor, so to speak, the "love God, love my neighbor" kind of idea, is instrumental, I think, in recovery.

Yes, sir?

QUESTION: I have a comment about the gene, the DRD4 gene. It is known in the nutritional literature, for example, that certain modifications like caloric restriction can activate a longevity gene. Maybe it is possible that religious practices or spiritual practices, meditation, prayer, can activate that gene.

DR. KOENIG: That is interesting. Studies need to be done. Very interesting. An activation of a spirituality gene.

QUESTION: Maybe there are other drugs that can do that.

DR. KOENIG: Maybe not. Maybe there are other practices that can be used. Excellent. Yes?

QUESTION: I really appreciate your historical perspective on the renewal of shifting around between negative and the positive view of religious effect. The ones we see the field moving on, we may see a more complex picture, I think, especially when we move from the mainstream religion to different perspectives when the people have different experiences with different religious beliefs under different conditions and in conjunction with different disciplines.

Do you think we will see a more complex picture, for instance, both ways, negative and positive impact of religion and spirituality? Mutual influence, I am talking about there is a likelihood that in some aspects religion will contribute a manifestation of mental illness. Also, at the same time, mentally ill patients will turn to religion and spirituality to seek comfort.

DR. KOENIG: Yes. I think that there is no doubt that the picture ahead will be complex as we look at many different religions and as we study them. However, I think that you would be surprised at what we will find, that some religions that might seem to us very destructive or very neurotic or very obsessive or very constrictive may turn out to be, for the people who choose those religions, very beneficial for them, depending on who chooses, who selects themselves into the religion.

So, as we also deal with cultural issues, things may be very different than we expected. So, I agree with you. It will be a complex picture ahead. There is no telling what we may find as we start to look very specifically into different religions and different cultures in their natural habitats as well.

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