“Even in the best studies, the evidence of an association between religion, spirituality, and health is weak and inconsistent,”1 conclude R. P. Sloan and his coauthors in an important article published in one of the world’s most prestigious medical journals, The Lancet. The authors present their findings in this 1999 article as reflecting a “comprehensive…review of the empirical evidence.”2 Although not restricted to Christianity, the authors preferentially target Christian belief and practice, with a focus on its effects on physical disease, about which they make the following claims.
First, research that appears to show a positive relationship between religion and health is hopelessly confounded by behavioral differences between those involved in spiritual or religious practice and those who are not. The claim here is that how religious persons behave is what contributes to their health, not their religious commitment per se. So if a sample of religious believers is healthier than those who are areligious, it is because the former, more so than the latter, tend not to smoke cigarettes or use illicit drugs, tend not to drink alcohol to excess, tend not to engage in risky sexual behaviors, and so on. Nothing concerning their specificallyreligious behaviors contributes to their health.
Second, the authors highlight conflicting studies. Whereas one study might suggest that religion improves health outcomes, another study might suggest that it does not, and this apparent inconsistency is good reason to dismiss whatever positive studies there are.
Third, the authors conclude that even if there were strong evidence for a positive link between religion and health, medical professionals risk significant ethical problems in breaching the “wall of separation” between faith and medical practice. They state, “When doctors depart from areas of established expertise to promote a nonmedical agenda, they abuse their status as professionals. Thus, we question inquiries into a patient’s spiritual life in the service of making recommendations that link religious practice with better health outcomes.”3 They go on to say that religion, like marital status and socioeconomic status, which have clear associations with various health variables, is a personal, private matter, “not the business of medicine, even if [it has] health implications.”4 Gesturing in the direction of the ethical admonition that physicians, first, “do no harm,” the authors raise concerns about the possibility of health care professionalsdoing harm to patients by linking better health outcomes to religious practices, in virtue of their precipitating guilt in patients who might come to believe that their health problems are secondary to their moral failures.
A REBUTTAL TO SKEPTICS
That same year, H. G. Koenig and his coauthors5 published a response to the Lancet article, pointing out its multiple shortcomings, including the important observation that although the article promoted itself as a comprehensive review of the research literature on the link between physical health and religion, it was, in fact, highly selective. Only 24 of approximately 325 research studies concerning that link—and none of the approximately 900 research studies that have examined the link between religion and mental health—were reviewed. Although theLancet article makes no pretense to reviewing the link between religious belief and practice and mental health, this omission on their part “is relevant because one of the strongest rationales for religion’s effects on physical health lies in its connection with psychological and social functioning….Thus the studies chosen [by Sloan et al.] for the review were selective from the standpoint of omitted evidence and also because they relied on a narrow conception of health.”6
The value of examining this pair of articles fifteen years after their publication lies in appreciating Sloan et al.’s missteps, as pointed out by Koenig et al.—missteps that tend to resurface in later articles critical of research into the health-promoting value of various religious beliefs and practices. Specifically, Koenig et al. make the following counterpoints.
First, rather than confounding research into the relationship between religion and health, behavioral differences between those with and those without religious commitments explain, at least in part, the means by which those with religious commitments are, on average, healthier. One’s being chaste or one’s not using alcohol to excess—behaviors often motived by one’s religious faith—are mechanisms by which one’s physical health is mediated, rather than constituting a behavioral difference that is unrelated to one’s peculiarly religious form of life.
Second, studies with differing outcomes that are investigating the same or similar phenomena give one no reason to dismiss the positive studies with which these other studies conflict. It is, for example, the rule in psychopharmacological research that when multiple studies of psychiatric medications are undertaken, some studies are negative and some positive. No one suggests that this gives us good reason to dismiss all such studies. In fact, the U.S. Food and Drug Administration (FDA) requires, in most instances, only two well-conducted (“registration”) studies in order for a psychiatric medication to be approved. It is estimated, for example, that up to half of antidepressant medication registration studies are negative or inadequate. Only in rare cases is every well-conceived study of a psychiatric medication positive. There are multiple reasons why negative or inadequate medication studies occur with medications that, in fact, are judged, given the totality of evidence, to be effective. In such cases, the nonpositive studies are dismissed, and the positive studies are believed to reflect the true effects of the medication under study.7
Furthermore, Koenig et al. note that the very notion of “inconsistency” in this domain is often misshapen, comparing apples with oranges. They explain that “the charge of inconsistency…should be applied only when near identical study designs yield different results, not when studies of very different populations using different sampling techniques… find that different dimensions of religiousness are relevant to different health outcomes.”8
Third, it is pointed out that “religion is not a single homogenous construct where different religious measures all assess the same thing. The many aspects of religion… include public ritual observances, private devotional practices, as well as attitudes, beliefs, and feelings.” The authors go on to explain that “the different dimensions very likely have different pathways in their effects on health.”9 I would add that Sloan et al. speak of faith and religion in a manner that muddies, rather than clarifies, the myriad differences between various religious and spiritual beliefs and practices, the degrees of belief and practice involved, and even what counts as a religious or spiritual context. For example, they cite several studies that examine generically characterized “religious behaviors and experiences,” “religiousness,” “faith,” and frequency of attendance at “religious services,” without any attempt to isolate those characteristics of the lives of religious believers that reflect a genuine love for the Christ.10
Fourth, Koenig et al. point out that patients who feel guilty, have a sense of moral failure, or feel they lack sufficient faith as a result of becoming ill are in a position relevantly similar to those who feel guilty or have a sense of moral failure after developing an illness related to behaviorslinked to poor health that they failed to alter; for example, smoking cigarettes (leading to lung cancer or emphysema), eating an unhealthy diet and not exercising (leading to obesity, diabetes, and heart disease), or having extramarital sex (leading to sexually transmitted diseases). One might, with similar force, claim that one’s smoking habits, diet, and sexual life are personal, private matters that are not the business of medicine, despite their having health implications, and that medical professionals are abusing their power and harming their patients when they encroach on these areas of their patients’ lives and instill this sense of guilt, shame, and self-blame.
CHRISTIANITY’S HARM 2.0
Fast-forward fifteen years. This theme of doing harm to others, particularly as it applies to Christianity, has been further advanced in a noteworthy fashion by human development and family studies specialist Marlene Winell (the daughter of Pentecostal missionaries) and psychologist Valerie Tarico in their article, “The Crazy-Making in Christianity: A Look at Real Psychological Harm,” anthologized in a collection of essays by atheist authors.11 Winell and Tarico make some of the same mistakes as Sloan et al. and several more.
No Clear Definition of Christianity
Perhaps their most egregious and central error is to provide no clear idea of what, precisely, they mean by “Christianity.” To illustrate the problem, consider an analogous situation. Suppose that one were to say that persons who practice medicine harm their patients, both physically and emotionally, and that the medical profession is “crazy-making.” Is that true? Well, in one sense it is. As a psychiatrist who works in both the forensic and clinical arenas, I am aware of multiple medical practitioners who have harmed their patients emotionally, intentionally (e.g., by having sex with their patients) and unintentionally (e.g., by making serious medical mistakes). Just as some persons who practice medicine harm their patients, intentionally or unintentionally, so too some persons who “practice Christianity” (in Winell and Tarico’s sense) harm others.
Now, some persons who practice medicine are not licensed to practice medicine. That subset of medical practitioners parallels those persons who “practice Christianity” but who are not Christians (i.e., who are not regenerate followers of Jesus), but who claim to be. According to psychiatrist M. Scott Peck, the best place to find such impostors of true Christianity is, not surprisingly, in church pews where their disguise is most effective.12 Perhaps we should exclude these groups of medical and Christian impostors from our discussion.13
The Church and “Complications”
But what about licensed physicians? Do they sometimes harm their patients, either intentionally or unintentionally? Yes. Sometimes they intentionally stray beyond the bounds of established practice (the “standard of care”) and make medical mistakes. Other times, they might not be experienced in a certain procedure and, unintentionally, err in their practice, resulting in harm to their patients. Correlatively, might some authentic Christians (perhaps because they are young in their faith) unintentionally transgress the bounds of historical Christianity in belief or practice? Or might some of these Christians intentionally stray beyond the bounds of biblical teaching and historical Christianity, but with no intention of harming anyone? Or might some Christians sin by intentionally harming others (e.g., by assaulting them, as licensed physicians sometimes do)? Yes, on all counts. Genuine Christians (not unlike genuine physicians) are not immune to making mistakes in Christian practice or belief, to transgressing traditional Christian boundaries, or even to committing acts of violence toward others—insofar as being a Christian does not make one wholly immune to committing even egregious acts of sin. Did not even Christ teach, “It is not the healthy who need a doctor, but the sick”? After all, Jesus did not come “to call the righteous, but sinners to repentance” (Luke 5:31, 32 NIV).
Reality in a Fallen World. Now, importantly, genuine physicians, even if they neither assault their patients, act outside of the standard of care, nor make medical errors, can still sometimes harm their patients. Sometimes, for example, a surgery is performed without any deviation from excellent medical practice, and the result is a complication that can lead to physical or emotional harm. Similarly, a course of psychotherapy that is performed without any deviation from excellent psychotherapeutic technique can result in a complication involving physical harm (e.g., by way of self-injurious behavior, even to the point of suicide) or emotional harm. In fact, I warn all of my patients with whom I conduct intensive psychotherapy that one risk of this undertaking is that they might react to standard psychodynamic psychotherapeutic technique in a negative, even catastrophic, manner.
Similarly, even when limiting our discussion to genuine Christians who conduct themselves as genuine Christians ought to conduct themselves, there might be instances in which those toward whom they are acting, or they themselves, will respond quite negatively, and be harmed emotionally. Examples abound, but none is as powerful as the example of Jesus’ own life, during which He, who was free from all sin, suffered emotionally in the garden of Gethsemane, and suffered both physically and emotionally on the cross, while living the paradigmatic Christian life. There is also a long list of Christian martyrs who followed Jesus to their deaths. In addition, as anyone can tell you (especially those with children), when you set limits on peoplefor their good, they sometimes respond emotionally quite negatively. Anyone with a moral code, who cares for others, and who attempts to guide others (who resist this guidance) in the direction of good has experienced the negative emotional reactions that can accompany such a clash of wills.
By What Measure? The standard, then, in medicine and in Christianity, is to be without reproach. But even then negative outcomes are unavoidable. Still, it is the standard against which Winell and Tarico’s efforts should be aimed, rather than against the myriad substandardexamples that they invoke. Their essay would be much more effective if it took Christianity as practiced in a manner that, as far as is possible for us, matches the example of Jesus, and compared that to some comparable standard of secularism. Instead, they highlight multiple episodes of religious malpractice—examples of people behaving contrary to the teachings of Christ and biblical Christianity—and pretend that this malpractice is the core of the Christian life. There are plenty of similar instances of malpractice among non-Christians (including atheists) and among physicians who (mal)practice medicine. But no one should, for a moment, accept any of these instances of malformed practice as that which defines or centrally characterizes medicine, Christianity, or, for that matter, atheism.
Winell and Tarico state, for example, that “Christian beliefs and Christian living can…[set] up multigenerational patterns of abuse, trauma, and self-abuse….[and] can stunt child development,” with females being at particular risk.14 They aim to provide a picture of “what religious trauma looks like, and how former believers can reclaim their lives and health.”15 Still, these authors point out that “the best research available, taken together, shows a modest positive correlation between religious involvement and mental health….with some studies showing positive associations, some showing negative associations, and some showing none at all. This is likely due to the wide variety of ways in which religious involvement and mental health are measured, but also to the enormous variations in religion itself.”16 One wonders whether these authors can also point to even a modest positive correlation between purely secular practice and mental health, whether correlational or not.
Religion, Not Christianity
Curiously, the allusion to there being apparently inconsistent studies in this domain is attributed by the authors, in part, to enormous variations in religion, not specifically to Christianity. In multiple places in their essay, Winell and Tarico move with relative ease from discussing Christianity to discussing religion, in a manner that is, well, “crazy-making.” The “enormous variation” in studies involving religion to which they point is nowhere remedied in their essay in virtue of this mixing of Christianity (very broadly construed) with religion (even more broadly construed). For example, according to Winell and Tarico, in a fit of recklessness, “The purveyors of religion insist that their product is so powerful it can transform a life, but somehow, magically, it has no risks.”17 (Really? Tell this to the martyrs.) They go on to say, using a medical analogy of their own, that, “in reality, when a medicine is powerful, it usually has the potential to be toxic, especially in the wrong combination or at the wrong dose. And religion is powerful medicine”18—as noted, even in the right combination and at the right dose. The point is not whether living the Christian life, or the atheist life, can cause harm, even when lived to the very standard of that form of life—there are, after all, even some things that atheists are willing to die for—but which of these two forms of life conforms to reality, lives the truth, accords with our nature, and in its culmination fulfills our purpose, providing genuine happiness and flourishing, allowing us to rest in a communion of deep and abiding love.
Christianity Selectively Defined and Judged
To their credit, Winell and Tarico characterize Christianity in general as “not just a religion. It is a broad, encompassing lens through which believers experience the world,”19 and they attempt to narrow the universe of religious discourse under study to certain expressions of “evangelical and fundamentalist” Christianity. Unfortunately, their effort in this latter regard is profoundly misshapen insofar as they characterize this subset of Christianity as being based on, among other things, “a literal interpretation of the Bible,”20 blithely unaware that no Christian church (or Christian believer) literally takes the Bible “literally.” When Jesus said that He is the vine and we are the branches (John 15:5), we are not meant to understand by this that He, and we, are plants.
The authors further characterize the churches under scrutiny—those involving “toxic religion”21—as those that require conformity for membership, teach that humans need salvation, and focus on the spiritual world as superior to the natural world.22 But does not any organization (or any civil society, for that matter) require some degree of conformity for membership? (Those who do not conform to many of our society’s laws, for example, are incarcerated, removed from membership in civil society.) Moreover, it is unclear which authentically Christian churches are being excluded by the authors in virtue of their stating that the churches under scrutiny view humans as needing salvation. What, pray tell, is the alternative—teaching that some do not need salvation and should be abandoned to die in their sins? The question again arises as to which form of life conforms to reality and lives the truth. And this matter of “focusing on the spiritual world” is also puzzling. Our ultimate goal as human beings is to experience the divine happiness that results from knowing and loving God and sharing in His life in community with others who know and love God forever. How can Christians possibly attain that end withoutfocusing on God, who is Spirit (John 4:24)?
RELIGIOUS TRAUMA SYNDROME
Perhaps the authors’ most distinctive approach to the mental health of religious believers involves their discussion of that “uniquely mind-twisting”23 emotional trauma in religious contexts that can result in what Winell terms “Religious Trauma Syndrome” (RTS). The authors contend that RTS is “a recognizable set of symptoms experienced as a result of prolonged exposure to a toxic religious environment and/or the trauma of leaving the religion,” which is “akin to Complex PTSD [Posttraumatic Stress Disorder]…a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma with lack or loss of control, disempowerment, and in the context of either captivity or entrapment.”24 The authors go on to suggest that “breaking out of a restrictive, mind-controlling religion can be liberating: certain problems end, such as trying to twist one’s thinking to believe irrational doctrines, and conforming to repressive codes of behavior.”25 Leaving one’s religion can also result in major emotional and cognitive disruptions, alienation from family and friends, feelings of betrayal, and multiple other negative social, behavioral, physical, and psychological effects akin to those long-described by “exit counselors” and “deprogrammers” of persons enmeshed in religious cults, including those groups that promote themselves as Christian but have deviated significantly from the tenets of Christian orthodoxy.26
Might there be some utility in thinking about certain emotional traumata through the lens of RTS? Yes, there might; but there is also a worry. Although there are clearly distinctive mental health issues that arise in some of those toxic religious contexts described by Winell and Tarico, there is in their approach both a contextual myopia and a recklessness with accuracy that detracts from some of their otherwise relevant points. The authors seem blind to the fact that there are also many individuals who have been traumatized in similar ways in virtue of breaking out of, or being under the domination of, myriad areligious contexts.
I have known multiple individuals who have lived under the oppression of secular and various cultural regimes in which they experienced similar traumas, and from which they broke free by way of Christian conversion. The hegemony of political and cultural secularism, for example, as found in many cities and institutions in this country (academic, governmental, religious, etc.), with its strangulation of free speech and thought, its relentless efforts at indoctrination, its irrational obeisance to a purposeless universe, and its forceful freedom-dissolving pressure to conform to ways of life that are detached from reality at its core, is experienced by individuals, appropriately, as traumatizing to their nature as human beings. And their leaving these contexts has resulted in myriad emotional and cognitive disruptions, including alienation from family and friends, and feelings of betrayal. Might Winell and Tarico be comfortable with an RTS diagnosis for those who leave the oppressive and relatively meaningless life of one brought up in the Unitarian Church, for example, and who become Baptists or Catholics, finally freed from the shackles of Unitarianism, but no longer accepted by their Unitarian friends and family?
What about “Political Trauma Syndrome” or “Cultural Trauma Syndrome”? And what about “Educational Trauma Syndrome” (symptoms of which might characterize many who have fled the toxic, stifling environs of government schools and have embraced the freedoms found in homeschooling)? There is, in this light, a selectivity in the authors’ work that is reminiscent of what we saw earlier in the Lancet article.
Finally, again echoing Sloan et al., the authors frequently demonstrate recklessness with the truth. According to Winell and Tarico, mental health professionals’ training focuses on thebenefits of religious and spiritual factors on mental health, not its harms.27 In reality, however, the long history of the mental health profession’s attitude regarding religious belief has been largely adversarial, focusing on explaining away the contents of religious belief, emphasizing its “illusory” and defensive aspects, and denigrating its teachings regarding sexuality among other things.28
Winell and Tarico assert that secular science has abandoned mind–body dualism to which Christianity still clings.29 Multiple prominent secular neuroscientists, however, were and are mind–body dualists, including neurosurgeon Wilder Penfield,30 who was a student of neuroscientist and Nobel laureate Sir Charles Sherrington, also a dualist. The authors also falsely assert that our understanding of humans as “animals” is “a new approach to life,”31when, in fact, Aristotle, for example, categorized humans as “rational animals,” and no Christian I know would deny that humans are part of the animal kingdom.
Furthermore, Winell and Tarico fallaciously assert that the Bible (without providing any citations) sanctions misogynist acts, including rape, forced marriage, honor killings, and human trafficking, adding, in a particularly egregious lapse of reason, that “the set of rules that govern a woman’s worth and treatment are property laws, not person rights.”32 The clear biblical teaching, however, is that men and women equally reflect the image of God (Gen. 1:26– 27); that, in Christ, men and women are one (Gal. 3:28); and that husbands are to love their wives as Christ loved the church and gave Himself up for her (Eph. 5:25)—statements that in no way reflect “property laws.”33
Most strangely, Winell and Tarico forward the assertion that persons with supernatural beliefs do not seek to be fully alive in the here and now.34 The reality, of course, is that knowing God in Christ in a communion of deep and abiding love is an incomparable good such that followers of the Lord Jesus seek to engage fully here and now the life and work of the kingdom of God, even as they daily pray, “Your kingdom come, your will be done, on earth as it is in heaven” (Matt. 6:10 ESV). Christ Himself said that He came to give us life in abundance (John 10:10), both now and forever, “a truth to which,” in Plato’s words, the authors’ “folly makes them utterly blind.”35
A. A. Howsepian, MD, PhD, is an assistant professor of psychiatry in the University of California, San Francisco–Fresno Medical Education Program and has a private practice primarily in forensic psychiatry.