Q: What is behavioral medicine?
A: Most of the work that we do is try and investigate how psychological factors like depression or hostility or anxiety contribute to the development and maintenance of heart disease. That's the work I do most of the time. Other people in our group here in behavioral medicine work in the areas of cancer, neonatal development, fetal development.Q: There have been a lot of studies, especially lately, that appear to show an association between religion and healing. How do you sum up the findings and the validity of the findings so far?
A: Most of them are extremely weak and inconclusive. There are a few solid studies. But we're by no means able to conclude conclusively that there's a causal association between religious involvement and better health. Actually, we can say very little at the moment. Most of the studies that have appeared in the media are extremely weak methodologically, and we can draw very few conclusions about causal relationships between religious involvement and health. We simply don't know enough.
Q: Is there an association but no proof?
A: No. In most cases I'm not even sure that we can say there's an association. The studies are so weak. There are some better studies, but by and large, we're not even sure whether there's a solid association, let alone a causal one.
Q: What is the matter with the studies?
A: Many of them use very small samples. They pick and choose the data that they want to present and ignore other data. There's a problem in the medical literature, or a methodological issue in the medical literature called the problem with multiple comparisons. If you continue to test and test and test and test this hypothesis and that hypothesis, you keep fishing through a data set, eventually you'll find something that reached statistical significance. And then you say, "Aha! There it is." But that's methodologically inappropriate. You have to specifically pick one hypothesis or two hypotheses, test those, and let the chips fall where they may.
Q: What can you say and not say about the studies that appear to show some kind of relationship between religion and health and healing?
A: Most of the studies are methodologically inadequate and don't permit us to say anything. The few that are adequate don't permit us to make any causal attributions. We can't say for sure that religious involvement causes better health. We may be able to say that there's an association but we don't understand it.
Q: The assertion that there is a strong connection between religious life and good mental health and that good mental health contributes to and causes better physical health -- can you comment on that?
A: I really don't know about the mental health literature to speak definitively about it. Most of the work that we've done has been in examining relationships between religious involvement and physical health. My guess is, though, that the literature on mental health is no better than the literature on physical health.
Q: Is it fair to say that, except for you and some of your colleagues, there's been surprisingly little published criticism of these studies?
A: Yeah, I think that's fair to say. There are other critics. There are a number of other people around the country. But there are far more proponents of the position than there are critics of it.
Q: Why is that?
A: I don't know. I think there probably are any number of reasons, actually. Religious involvement throughout history waxes and wanes. There are periods of rising interest in religious involvement [and] declining interests. I think at the moment we're in a period of rising interest. That's one of the reasons why there's so much research at the moment. There are other reasons as well. I think there's been some very active foundation support for research in this area that has raised the level of awareness of it. And so there are many more people who are interested in promoting the idea than criticizing it.
Q: Much of the research says the combination of strong religious faith and a strong and supportive religious community is what contributes to healing. But I'm wondering, and I expect you wonder, too, whether a strong belief in anything and a strong community of any nature would get the same effect?
A: In the first place, I think there's actually relatively little research that points in the direction you suggest. But if it were true, I don't think it any more true of religious involvement than it is of any other significant involvement in a community organization. I think if, in fact, there are relationships between religious involvement -- religious attendance, for example, at services -- and health, it's largely attributable to maintaining an involvement in social engagement, which can be implemented in any number of ways.
Q: Being in a service club or bowling league might be just as helpful? Speak to this argument that strong faith plus strong religious community equals better health.
A: If in fact it's true, it's very likely true because it's one kind of social engagement. I think there is a fair amount of evidence to suggest that social support and engagement in society is good for one's health. There are many ways in which you could be engaged that could promote health. Certainly going to church is one. But being involved in social organizations, community organizations, libraries, political organizations -- all of those probably have the same kinds of benefits.
Q: Can a strong religious faith sometimes do harm for a very sick person? Can it lead to an argument with God that would, in turn, lead to a lot of anger and stress that are not good for healing?
A: Let me give you an example. I tend to shy away from anecdotes, but this is an anecdote that really drives home the point that making the assertions about the health benefits of religion can be harmful as well as helpful. At the very beginnings of my career in behavioral medicine as a researcher, I was conducting a study that involved interviewing women awaiting the results of gynecologic biopsies. I was interviewing a young woman in a semiprivate room in a New York hospital. Another woman in the hospital was also awaiting the results of her biopsy. And while I was interviewing the patient, I was seeing that the results for the biopsy for the other woman came back. She was surrounded by her family and friends, and the results were negative. And her father exclaimed, to no one in particular, "We're good people. We deserve this." Now that's a perfectly reasonable thing for the father of a potentially ill young woman to say. But what was the woman I was interviewing supposed to say to herself when her biopsy came back positive? Was she supposed to say, "I'm a bad person; that's why I got cancer. I've been insufficiently devout, insufficiently faithful. That's why I got cancer"? It's bad enough to be sick; it's worse still to be gravely ill. But to add to that the burden of remorse or guilt over some supposed failure of devotion is simply unconscionable. But that's what you get if you start making assertions about the relationships between religious faith and healing. For those people who don't get better, what are they supposed to say to themselves?
Q: And what about the argument that religious faith can do harm, because somebody says, "Why me, God?"
A: If you assume that religious faith is associated with health benefits, then you have to assume the opposite -- that failure of devotion is associated with recurrent illness. And that leads people to ask those questions: Why me? Why am I being punished? It's a terrible thing. You know, it's bad enough to be sick. It's terrible to add to that the burden of remorse or guilt over some supposed failure.
Q: Many of the people who have written about this say that the research is far enough along so that doctors should be much more sensitive than most of them are to a patient's spiritual and religious life. They should take a spiritual history, for instance, of the patient.
A: Right. There are so many reasons why that's a bad idea we don't have enough time to discuss them. But in the first place, there are any number of studies now that indicate that for the treatment of chronic illness or prevention of illness, physicians already don't have enough time in the day to deal with those documented relationships between risk factors and the development of disease. There was a study published two or three years ago in THE AMERICAN JOURNAL OF PUBLIC HEALTH that indicated that if doctors followed all of the recommendations of the U.S. Preventive Services Task Force, they would spend 10.4 hours a day doing nothing else. Now I am the first to admit that physicians have to know things that are important about their patients and, in the course of taking a history, they have to ask questions about religion and spirituality in the same way that they ask questions about work, family, hobbies, etc. You ask those questions and then you move on. But you don't involve yourself in extensive inquiries about religion and spirituality at the expense of other, more demonstrably important things.
Q: And what about a doctor praying with a patient if the patient wants it?
A: Well, how do you know the patient wants it in the first place? If patients want prayer, then what physicians ought to do is, in a very sensitive way, refer them to local clergy or to health care chaplains, or they can sit by silently and allow the patient to pray. But getting physicians involved religiously in the context of a clinical intervention is a very bad idea, because it raises all sorts of problems with religious interference and interferes with freedom of religion.
Q: So doctors shouldn't do it?
A: No, they should not do it. It sets up expectations between the patient and the physician that can be detrimental. It can be religiously manipulative or even coercive. If patients have religious concerns, physicians ought to do with those patients what they do with all other patients for whom they lack expertise -- they should refer to specialists. If you see an internist and you have a problem with your heart, the internist is going to refer you to a cardiologist because he or she lacks the expertise in cardiology. The same is true with physicians who have patients with spiritual or religious concerns. They don't have training in those matters.
Q: Medical schools now, almost all of them, are offering some kind of training in religion and spirituality.
A: That's true only insofar as you believe that one or two mentions of religion and spirituality over the course of a four-year curriculum constitute training. There's hardly any substantive training, certainly nothing that compares to the kind of training that clergy receive. What physicians who have patients with spiritual concerns ought to do is refer to the appropriate specialists -- heath care chaplains, local clergy. That's what they ought to do.
Q: What if the doctor is a very religious person? Why not pray with patients?
A: Because the patient is there for a medical reason, and the physician-patient relationship is very special. The relationship is not a symmetrical one. The physician is the expert; the patient receives the physician's advice and recommendations and is expected to follow them. And that's perfectly appropriate when the recommendations are medically derived, when they're related to the physician's medical expertise. But when physicians depart from their medical expertise to make recommendations about other matters, the bond between the physician and patient should be severed. We don't expect physicians to make recommendations about financial matters, even though they may be very proficient in financial matters and, as a class of people in the U.S., [they] are extremely well off compared to others.
