M Z AZHAR, Associate Professor, Psychotherapy Clinic ,Hospital USM, School of Medical Sciences,
University Science Malaysia, Kubang Kerian,16150 Kota Bharu, MALAYSIA

Psychotherapy  is commonly used for the treatment of anxiety  and depression.  Biofeedback,  relaxation and medication  are  useful adjuncts  to  psychotherapy  and have been shown  to  reduce  the physiological as well as the psychological components of  anxiety in  normal populations. Research in meditation has  been  largely limited to non psychiatric populations. The therapeutic effect of the  religious  teachings and beliefs and the  tendency  of  most people to fall back on religion for mental peace is well known. Galanter  et al (1) described a case where  the  psychiatrist used citations from the New Testament to being about an  improvement in a Christian patient. The religious issues in psychotherapy  have  been reported in several studies. Galanter et al (1)  in  a survey  of  psychiatrist  members of the  Christian  Medical  and Dental  society found that their attitudes towards  patients  and their  problems were influenced by their beliefs.  Questionnaires were sent to 260 members, and usable responses were received from 193 of them. The subjects were asked about demographic and  practice  variables, "born again" religious experiences  group  cohesion, and beliefs about using the Bible and prayer in  treatment. The  respondents  were  somewhat more  religious  than  Americans overall.  Nearly  all reported having been  "born  again,"  after which  they  generally experienced a decrease in  emotional  distress.  There  was a significant difference in  the  respondents' affiliate  feelings toward psychiatrists in the Christian  Psychiatry movement and other psychiatrists. For acute schizophrenic or manic episodes, the respondents considered psychotropic  medication the most effective treatment, but they rated the Bible and prayer  more highly for suicidal intent, grief  reaction,  sociopathy, and alcoholism. Whether or not a patient was "committed to Christian  beliefs" made a significant difference in whether  the respondents  would recommend prayer to the patient as  treatment. About  one-half  said they would  discourage  strongly  religious patients  from an abortion, homosexual acts, or  premarital  sex, and  about  one-third said they would discourage  other  patients from  these activities. The study suggested a need for more  sensitivity to religious issues by psychiatrists. It remains important  to  evaluate ways in which a religious  perspective  can  be related  to clinical practice and what benefits and problems  may derive from such a relationship.

However, there are no controlled studies to prove the superiority of  these  techniques. A recent study by Kabat Zinn et  al (2)  showed that a group medication training program can effectively reduce symptoms of anxiety and panic with generalized anxiety disorders, panic disorder or panic disorder with agoraphobia. Working with a group  of  patients who were inherently religious, it  was  found that  the addition of a meditation based program seems  to  improve anxiety symptoms even among the very anxious patients.

Psychotherapy has been used in patients with depression in  addition  to  antidepressant drugs.Psychotherapy  seeks  to  relieve suffering caused by psychological stresses arising from a variety of  sources.  Stresses  includes the  persons  introduction  with others  as well as features of the human condition such as  death and  spirits.  These  are also the domain of  religion.  As  such psychotherapy  is a socio-cultural institution and  their  issues will play a major role in the mode and outcome of  psychotherapy. It is with this in mind that we began to look at ways of incorporating these issues in psychotherapy of patients in Malaysia.  We had to look for something that the patients will be familiar with
and  can  identity with. If this happens than even  the  patients families will encourage them to be compliant with the therapy.

Csordas  (3) described a form of psychotherapy that worked for  a certain group of individuals through involvement of socio-cultural perspectives.  He  describes Catholic  charismatic  healing  that seems to have good outcome. The distinguishing feature he says is that the healers accept the reality of evil spirits as components of a therapeutic system, manifest themselves as normal mental  or emotional  states  that are out of control. They  view  religious healing  and naturalistic psychotherapy as complimentary.  Koltko (4) states that ideally, psychotherapists should be  able to take into  account  the  impact on therapy of  religious  beliefs  and practices,  especially those that play powerful roles in the  patients  lives.  This is very true in our patients  as  those  who underwent  psychotherapy  with  the  beliefs  being  incorporated improved  faster.

A therapist should understand  that  religious beliefs  and  values  held by a community of  persons  have  been present for much longer than the therapist particular therapeutic orientation  because  they have had adaptive value. As  such therapist  should  not challenge or attempt to  change  them  and instead  use  them in therapy. Highly  religious  patients  become dissonant when their action do not match their values. It is  easy to  look at the values and analyze why his behavior is  different from the values rather than explain it in term of "sexual  deprivation or other conflicts.

Our experience with religious psychotherapy in Malaysia has  been very encouraging. In a study using control, 32 depressed patients (DSM  III R diagnosis) had significantly more  rapid  improvement then  their  controls (5). This means better  acceptance  of  the therapy them the secular psychotherapy used in the control group.

In another study of 30 bereaved patients also using controls, the 15 patients showed consistently significant improvement as  compared to  the  control  group at the end of 6 months  (6).  This  again indicate  that highly religious patients with grief and  bereavement  tend to improve faster with religious psychotherapy.  Using anxiety  patients referred to the psychotherapy clinic,  we  again compared the groups and found that those given religious  psychotherapy  in addition to supportive psychotherapy and  neuroleptic drug showed significant more rapid improvements in anxiety  symptoms  than those who received supportive psychotherapy and  drugs only (7).

It does seem to show that religious patients may require a different form of psychotherapy. In our  patients the religious  teaching  we practiced was different from the concept of Csordas  (3). One  hypothesis is that an individual will experience  dissonance with  resultant  guilt, anxiety or alienation if  the  individual acts  contrary to personal values. If unresolved, these  feelings may manifest  as mental illness. Values are ideals that have been learned  from childhood through parents and later on become  more defined as one picks up ideal from other sources such as teachers and religious teachers or preachers. Clear values are relevant to mental health because if intentions and actions are in accordance with the personal value system, there is no conflict. Self esteem is reinforced, there  is satisfaction in chosen endeavors,  there is  harmony with the environment. But if actions are contrary  to personal values, there is dissonance, self esteem is lowered  and there  may  be feelings of shame, guilt or anxiety. In  this  hypothesis,  the  conflict  between the actions  and  the  personal values  is  understandable i.e., there is no need to  look  for  a conflict,  it is there. What is required is to have a  relook  at the  personal  value  system, to analyze and  understand  it  and ultimately to modify or change it to suit the environment, social situation  and  personal  ideal. As such it is  not  a  "conflict search" but a "value search" into finding an alternative,  usually,  more positive way of developing a value system for  the  patient.

Koltko (4)  emphasizes that therapists should keep in mind  that  the religious  beliefs and values held by a person have been  existing for  a much longer period than the therapist's particular  therapeutic orientation. Hence the therapist should not lightly  challenge or attempt to change them. Psychotherapists should be  able to take into account the impact of religious beliefs and practices  on therapy, especially those that plays a powerful role in  a patient's life.

Praying has been used as a method in our study patients. It is  a form of meditation. It promotes relaxation and thereby a  general sense of well being, through physiological changes beneficial  to overtly tense people. More specifically, medication exercises may facilitate  conscious access to hitherto  inaccessible  memories,
thoughts and feelings, thereby increasing the patient's   ability to alter them in a therapeutic direction. Some forms of religious meditation  have  features in common with  relaxation  techniques used as adjuncts to psychotherapy.

The  above studies highlight an important point. Use of  religion along  with the scientific psychotherapy has an additive  effect. It  is  more  acceptable to the patient and the  family  and  the patients'  compliance is also increased. Moreover,  the  patients are spared of traditional healers. Finally, although our  experience  shows that the end point may be the same  with  non-religious oriented psychotherapy, nonetheless the morbidity period is definitely shortened with the early improvement in the symptoms.

PERSIKOL will continue to be actively involved in research and promotion of religious aspects of psychotherapy.
 

References

1.Galanter M,Larson D,Rubenstone E., Christian psychiatry - The impact of evangelical belief on clinical
practice. Am J Psychiatry 1991;148:90-95

2. Kabat-Zinn J,Massion AO,Kristeller J,et al., Effectiveness of a meditation based stress reduction
program in the treatment of anxiety disorders. Am J Psychiatry 1991;149:936-943

3. Csordas T.J., The psychotherapy analogy and charismatic  healing,. Psychotherapy 1990;27:79-90

4. Koltko M.E., Religious beliefs affect psychotherapy: The example of  Mormonism. Psychotherapy 1990; 27:132-139

5.Azhar M.Z., Varma S.L., Religious psychotherapy in  depressive patients. Psychotherapy and
Psychosomatics 1995; 63:165-168

6. Azhar M.Z., Varma S.L., Religious psychotherapy as  management of bereavement. Acta Psychiatrica  Scandinavica  1995;91:233-235

7.  Azhar M.Z., Varma S.L., Dharap A.S., Religious  psychotherapy in  anxiety  disorder patients.
Acta  Psychiatrica  Scandinavica 1994;90:1-3.