Philosophical aspects of faith and therapy

The Oxford English Dictionary defines faith as confidence, reliance or trust in another person or thing. Faith is also belief derived from testimony or authority, rather than empirical evidence, and this includes believing in religious tenets as truths. Originally, use of the word was exclusively religious, and that origin still colours its meaning. In the research literature, ‘faith’ is conflated with ‘spirituality’ or ‘religiosity’, particularly when discussing its behavioural correlates. So, while it relates to the dimension whose poles are credulity and scepticism, it also suggests a degree of awareness of something numinous, or possibly sacred, which both colours and justifies beliefs held through it. Despite its origins, faith is not now synonymous with religion, especially organised religions, which combine faith with many types of reasoning, including empirical scientific reasoning if the topic is deemed appropriate. Although many, if not all, societies have a deep-seated belief that correct faith can promote healing, the justification of therapies by referring to faith's foundations of belief, spiritual acceptance and authority are fundamentally opposed to empirical scientific method as conventionally understood. Faith-based therapies therefore require a philosophical justification applicable to both faith and science, if they are to be employed within modern medicine: three such justifications are possible.

The first, that faith-informed therapies are justified by their demonstrated efficacy, is discussed in detail below. However, this can only be a contingent justification for their inclusion, and it reduces faith to a therapeutic characteristic, which does not capture its nature.

The second, that we should be guided by patient preference, including faith preference, is currently the most generally accepted justification for them. However, we shall see that this is not necessarily easy to implement for all faith-related ideas and beliefs, and it also redefines faith in an inimical fashion, this time as merely something to satisfy patients’ wishes, albeit there are separate ethical arguments for routine inclusion of such qualities to encompass patient diversity.

A better alternative to these is the doctrine of double effect, that a single intervention may have two (or more) consequences of varying desirability. This is most commonly discussed in relation to end-of-life decisions. It is relevant here because a faith-informed approach might improve the quality of treatment of the patient, but also either modify their faith, or require the practitioner to adopt faith-informed values that are not shared, while non-therapeutic aspects of faith might provide sufficient alternative benefit to compensate for a therapeutically suboptimal treatment. The doctrine of double effect presumes that the intervention being considered is beneficial in some way: it thus attaches an empirical qualifier to faith when included in a treatment, rather than redefining the concept of faith away.

The psychology of faith

Since the late 19th century, the ‘lexical hypothesis’ has suggested that humanity's most important individual differences might be encoded as single words, and analysis of such descriptive words has enabled the construction of reliable and valid dimensions to account for individual differences and underpin their variable expression: traits. Psychoanalysts have long considered faith to be a trait. As a trait, it follows that its intensity in individuals is amenable to study by questionnaire, and several well-validated questionnaires exist, although they largely address faith from a Christian standpoint. Consistent with this interpretation, faith has both genetic and environmental associations which predict its expression in individuals, although methodological problems make its precise function and significance hard to determine. I intend to rely on Hood's proposal that faith, as a trait, has value because it introduces cognitive biases that contribute to social cohesion (Reference HoodHood 2009). While some of this is a trivial implication of aspects of the definition, such as reliance on authority, Hood has adduced psychological evidence to extend this idea to our experience of the numinous and sacred aspects of faith. This proposal subsumes the other major empirically based alternatives, threat avoidance (Reference Miller and StarkMiller 2002) and power relationships (Reference Collett and LizardoCollett 2009), as both theories presume that faith leads to a more cohesive society, more tightly focused on achieving the intended goal. Psychological theories which focus on the existential value of faith, rather than its social value, such as terror management theory (Reference Vail, Rothschild and WeiseVail 2010), also explicitly include socially cohesive psychological processes such as attachment. Convergent validation for this view has been provided by social and ethological research (Reference Sosis and AlcortaSosis 2003), and a ‘sense of connectedness’ is central to spiritual experience (Reference de Jager Meezenbroek, Garssen and van den Bergde Jager Meezenbroek 2012). As a trait which fosters social cohesion, faith also requires a cultural context for proper expression, and is not captured by personality traits alone. It seems likely that good social cohesion significantly improves the quality of our lives, thus reinforcing and maintaining the faith we share with those around us.

From this approach to the components of faith and its consequences one can infer how the resulting bias influences both practitioners’ and patients’ preferences for therapy, and might compete with empirically based judgements. This is set out graphically in Fig. 1, which also adumbrates how some pathways to bias might be modified.

FIG 1 The expression and moderation of faith-based bias affecting practitioner judgement and practice.

Figure 1 assumes that the explicit goal of the practitioner is to improve the patient's quality of life but, as the arrows show, the practitioner will also be interested in the quality of their own life: not a bad thing here, as a patient improving will provide professional satisfaction. The practitioner should advise a therapy based on evidence (shown on the right of Fig. 1) but, like the patient, the practitioner will have a trait for faith, which will bias the practitioner towards making recommendations congruent with their own beliefs and their social network (shown inside and to the left of Fig. 1). This bias would need to be inhibited in the practitioner (though not normally in the patient), but practitioners are much less sensitive to their patients’ quality of life (shown by the dashed arrow) than they are to symptom reduction.

Faith-informed therapies in practice

There are currently three main routes by which faith-informed approaches are entering mental healthcare.

As described in the literature, mindfulness-based cognitive therapy (MBCT) is an entirely secular technique, closely allied to cognitive–behavioural therapy (CBT), with an empirical evidence base. No secret is made of the fact that it has been derived from Buddhist practice, although other religions (most obviously Hinduism, though Judaism, Islam and Christianity all have strong contemplative traditions) also practice mindfulness as part of their devotions. Many influential therapeutic practitioners of mindfulness are Buddhist, and consider it to be congruent with general healthcare ethics, rather than detachable from Buddhist practice. Courses involving mindfulness-based therapeutic techniques are taught in Buddhist centres, and university courses of mindfulness-based therapy include teaching Buddhism: both settings are seen as providing appropriate training. Some have extended the use of mindfulness to the inclusion of Buddhist psychology, and there is a plethora of books by mindfulness-oriented psychotherapists recommending a rapprochement with Buddhism.

Mindfulness has been taught without Buddhist background in effective psychotherapies targeted at borderline personality disorder, in particular dialectical behaviour therapy (DBT) (Reference LinehanLinehan 2014) and mentalisation-based treatment (MBT) (Reference Bateman, Bales and HutsebautBateman 2014). However, even here it has been theorised that the observed benefits result from a spiritual dimension that mindfulness has introduced (Reference Bennett, Shepherd and JancaBennett 2013).

Therapeutic prayer, mostly promoted by Christian and Moslem practitioners, has relied on a three-step religious engagement with patients. The first step is to assert that private prayer by the practitioner for the welfare of their patients is unexceptionable and an appropriate expression of compassion. The second is to argue that shared faith between practitioner and patient may be a help, rather than a hindrance, and may even be sought by patients, particularly from a religious minority. The third is an extension of the second, that joint prayer between practitioner and patient, or religious observance, may be an appropriate part of care (Reference KoenigKoenig 2008).

When faith-informed therapies are developed, a common approach is to construct therapies that combine religious and therapeutic elements within their delivery. Frequently, the therapeutic component is of known efficacy, and a secular version may be tested against a faith-informed version as part of the therapy's evaluation. Such approaches inform much of the research on the specific contribution that faith makes to therapeutic efficacy, which is discussed next.

Delivering faith-informed therapies

Consideration of the empirical evidence just reviewed in the light of the doctrine of double effect suggests that simply avoiding faith-related values in therapy (as adopted by the majority of practitioners) is not sufficient. Similarly, basing a choice on no more than congruence with patients’ beliefs and preferences may not be in their therapeutic interest.

If changing spiritual belief is seen as a risk, then there is insufficient evidence to suggest that faith-informed therapies, other than mindfulness for depression, provide sufficient additional benefit to justify such a risk being taken. However, if such change is not a concern, then the doctrine of double effect suggests that faith-informed therapies of equivalent effectiveness become an option for discussion with patients, and could be potentially valuable for those patients whose religious engagement exacerbates or mitigates their psychopathology.

Figure 2 shows as a flowchart a faith-sensitive decision-making process for therapy choice and monitoring derived from the research just discussed. The flowchart begins with the practitioner asking himself or herself a very simple assessment question: is faith important for this patient? Reference CookCook (2015) gives a range of approaches to assess this. Given the evidence discussed above, the practitioner should also assess whether the patient's faith and coping style is a support or a risk to recovery, by deciding, for example, whether faith informs anxious or depressive ruminations. As Fig. 2 shows, faith-informed therapy is non-controversially indicated when faith is important to the patient, the patient's faith-related coping style is helpful, and the faith-related beliefs and values of therapist and patient are shared. If a patient's faith-related coping style is unhelpful, then the choice lies between a secular alternative, or – rarely – a faith-informed therapy designed to maximise alternative benefit and challenge the unhelpful coping style while minimising risk.

FIG 2 Decision-making process for faith-informed therapy.

a. Such as a seriously harmful coping style or quality-of-life problem.

There could also be occasions when a faith-informed therapy is indicated, but made difficult through an irreconcilable difference between the patient's and the therapist's values. To manage these potential risks, Fig. 2 suggests that practitioners should, from the outset, have access to a reference group of mental healthcare professionals who have received anti-bias training. The classic ‘Delphi’ system remains the gold standard for such groups: a detailed discussion is beyond the scope of this article, but its key components are aggregated, anonymised responses and the opportunity for multiple iterations. Although anonymity would be hard to achieve, both of the other criteria have been greatly facilitated by electronic communication, which also avoids the need for the group to schedule meetings. The use of a reference group, and HRQoL as well as symptom-based routine outcome measures, extends the application of ‘spiritually conscious care’ (Reference Saunders, Miller and BrightSaunders 2010) and descriptions of expected competencies (Reference CookCook 2015) by deploying techniques and strategies that specifically address practitioner bias relating to their patients’ faith, once it is elicited. Although the process appears complex and potentially resource-intensive, in practice most cases will not require detailed group discussion, though the individual practitioner will need appropriate training in the faith-informed therapy chosen.

MCQs

Select the single best option for each question stem

1. 1 The most important reason to assess faith in patients is:

   1. a unresolved guidance about faith in therapy

   2. b avoidance of secular bias

   3. c salience for patients

   4. d maintenance of social cohesion

   5. e acceptability of mindfulness-based cognitive therapy.

2. 2 The biggest risk to patients in using faith-informed therapies arises from:

   1. a lack of efficacy

   2. b a negative religious coping style

   3. c conflict between therapist and patient

   4. d changing the patient's faith

   5. e impact on quality of life.

3. 3 The best reason for using faith-informed therapies is:

   1. a reliable evidence of efficacy

   2. b patient acceptability

   3. c positive change in symptomatology

   4. d improvements in health-related quality of life (HRQoL)

   5. e demonstration of therapist empathy.

4. 4 The doctrine of double effect is most helpful in making decisions about faith in therapy because:

   1. a it can be used in end-of-life care

   2. b it is inherently free from bias

   3. c it minimises risk to the patient

   4. d it recognises patient preferences

   5. e it explicitly values both faith and symptomatology separately.

5. 5 Therapists can improve their practice when encountering faith by:

   1. a making use of a skilled reference group in difficult circumstances

   2. b taking time over faith-related decisions

   3. c avoiding early compromise in situations where values seem to clash

   4. d explicitly considering both quality of life and symptom change as separable treatment goals

   5. e all of the above.

1

c

2

b

3

d

4

e

5

e