![[Photo of Dr. Koenig]](koenig.gif)
Harold G. Koenig, M.D., M.H.Sc., received his training in both geriatric medicine and geriatric psychiatry at the Duke University Medical Center. He is currently on the faculty as an Assistant Professor of Psychiatry and of Internal Medicine. Dr. Koenig also serves as Director of Psychiatric Services at Duke's Geriatric Evaluation and Treatment (GET) clinic and is the Director of Duke's Program on Religion, Aging and Health within the Center for Aging. Most of his research involves depression among the hospitalized, medically-ill elderly.
Dr. Koenig explains that while his own faith has contributed to his interest in the effects of religion on mental health, his is a case of faith as servant of science, and not one of beliefs driving the data; the results of his systematic studies of the effects of religion on mental health have often been surprising, and have served in many instances to strengthen his beliefs. Teresa Hsu, a Trinity senior, spoke with Dr. Koenig about his work and about what an understanding of religion can offer the science of psychiatry.
TH: What are some difficulties you've faced in trying to have both a faith and a career?
HK: Psychiatry has a very different way of explaining phenomena both in the world and also in the human mind than does religion. Religion operates on a different framework than psychiatry does. Psychiatry tends to explain psychological states and behaviors in terms of psychological principles, dynamic factors, the unconscious, and so forth. Religion explains these in a different way: in terms of spiritual forces, in addition to psychological forces. In psychiatry, everything is explained as being due to psychological or biological forces; the spiritual part of man is discounted and ignored. On the other hand, many of my religious acquaintances discount the psychological forces and biological aspects of the human mind. And so, as I interact with persons from these different perspectives, there is sometimes friction: one group is operating on one framework and the other on a different framework.
TH: And where do you place yourself?
HK: Pretty much in the middle, trying to integrate the two--which I think is very possible. But it does take a great deal of open-mindedness on both sides of the issue. Open-mindedness in terms of my faith, and in terms of my rigorous, scientific way of approaching the human mind.
TH: Does your faith ever serve as a stumbling block in your career?
HK: I don't think so. If anything, it serves to broaden the way I look at issues, especially in psychiatry and psychology. I think it enhances my ability to consider a wider range of social-psychological factors in my research. One of the ways my faith has enabled me to look at issues in a different way is by leading me to consider the possible impact of religion on life satisfaction and well-being in later life. I think without my faith, it would have been difficult to understand what it means when older patients tell me they're praying over something, reading the Bible concerning a situation, or putting the situation in God's hands. A clinician without a religious background could easily overlook this.
TH: And that's one example in which it has served to broaden your view.
HK: Exactly. Because it enables me to think, "Ah, people say they find help in religion. Let's look at this now; let's include religious faith among other variables in this research, along with social support, finances, personality, and biological factors." It's helped me realize that religion may be another factor that influences the mental state just as these other factors do. My faith has broadened my ability to consider not only biological and psychological factors but also the spiritual forces involved in how people operate and how they explain the world around them. I think a person's religion can also influence whether or not he or she seeks health care, as well as the relationship a patient has with his or her doctor. This area has been completely ignored in health care research, yet it crops up in many different situations. You find people from fundamentalist groups not seeking psychiatric services, or stopping their medications, or relying entirely on faith healing; on the other hand, you also find the doctor neglecting any impact that a person's faith can have. The result is a situation where people are not getting the help they really need--a combination of spiritual, psychological, and medical therapies. So patients end up getting piecemeal treatment, in that they either get only spiritual and religious help from the clergy (who may ignore or discredit all the potentially helpful advances in science, psychology, and medicine) or patients are given only medical and psychological treatment and their faith is ignored. Consequently patients are not getting the holistic treatment that I think would maximize their use of medical services and their response to those services.
TH: Do you discuss these issues with your non-religious colleagues, and if so, how do they react?
HK: I haven't discussed it a lot, mainly because there hasn't been a lot of interest in this topic. That is changing rapidly, however. My colleagues and I in the Center for Aging have published four articles in major psychiatric journals over the past two years: the American Journal of Psychiatry and Hospital and Community Psychiatry. This research has recently been summarized in the book Aging and God (Haworth Press.) We have found greater well-being, lower rates of depression, less anxiety, and less incidence of alcoholism among persons who rely heavily on their religious faith to cope with adversity. This is particularly true among older persons who are disabled and ill. Lower blood pressure, fewer strokes, and lower rates of cancer have also been found among those who frequently attend church. I think the attitude toward religion held by mental health professionals is going to be changing, because there are a number of investigators in other institutions who are now doing this type of research and are finding similar results. Here at Duke we have been trying to demonstrate what is clinically obvious: that religion is of help to persons with health problems, especially when they get older. I'm hoping this research will stimulate discussion among my colleagues here at Duke as well as on the national scene.
TH: So it sounds like the role of your faith in your life is more that of giving you added understanding in your research.
HK: From a professional standpoint, yes. Religion helps me to broaden my perspective in both research and clinical care. My professional life, however, is separate from my personal life, as it needs to be. If I were to mix the two, it would bias me to the point that I would be unable to objectively deal with patients who have a wide range of beliefs. I try not to let my personal beliefs cloud my judgment in either research or clinical care, in order to remain as objective as a scientist and clinician needs to be.
TH: Do you think that a lot of psychiatrists are able to do that?
HK: I think that one's beliefs will affect one's therapy, especially in psychiatry. Even if you claim not to have any religious beliefs, that itself is a belief system. And you're always going to be subtly transferring values to your patients, regardless of what your conscious intentions are. Psychiatry is not a valueless type of therapy. We are always influencing patients by our values. If someone is a Christian psychiatrist, he or she is going to influence patients one way, and if he or she's an agnostic, there will be a different influence. It's virtually impossible to avoid this, because the work that we do is concerned with trying to help people change and convince them of a better way to live and behave towards others. Psychiatrists try to provide patients with an outlook on life that will make them feel better about themselves and those around them. It's very difficult to do that without transferring some of your personal values, even though psychotherapy is supposed to be value-free.
The therapist makes every effort not to put his or her own values on the patient, because each person is on his or her own individual quest for meaning, purpose, and happiness in life. As I see it, the role of the psychiatrist is to facilitate that quest and to help the patient move along his or her own chosen path; and if the patient gets stuck, particularly if stuck in a mental illness, it is the psychiatrist's job to free him or her so that he or she can resume the journey in life to seek pleasure as well as to seek meaning and a greater purpose in living. I think that most psychiatrists would agree with that, though each might have a different idea of how best to accomplish it.
TH: Have you ever given clinical advice to a patient that was based on your faith? For example, have you every suggested that a patient try praying?
HK: I have done that with patients who have come to me clearly because of my Christian beliefs. In these cases, where it is well recognized that this is what the patient wants, then I will use the person's faith as a tool to help free him or her from whatever psychological impediments he or she has. I will not do that with someone who comes to me and seeks a secular therapy; I might mention that some persons have found religion helpful to them, but in no way do I push it--that would be unprofessional and unethical.
TH: Moving from a professional to a personal standpoint, how does your faith help you to be a better clinician or deal with internal conflicts you may have?
HK: Because my area of research is geriatric psychiatry, I frequently deal with people who are getting older, usually persons having problems with both physical and mental health. I spend most of my time in the hospital on the medical wards with patients who are sick, who are facing life-threatening illnesses, and typically, who are dying. My faith helps me to feel more comfortable dealing with these issues. I feel especially comfortable dealing with issues related to depression and mental illness because I really believe that there's hope for these people. My faith gives me a hopefulness, which I can oftentimes transfer to my patients who are not always very hopeful. These patients often see themselves as in a vicious cycle. A lot of the time a patient, when he or she has lost hope, will borrow hope from the therapist in order to continue on. My faith gives me a very positive attitude towards the future and a sense of purpose and meaning in life that enables me to better deal with patients and to deal with issues surrounding death--which is often difficult even for doctors. One of the reasons why there aren't a lot of physicians specializing in geriatrics or geriatric psychiatry is that many patients will die while you're working with them. This threatens the security of someone who has been in denial of his or her own mortality. As a Christian, I don't need to deny my mortality. It fits into my world view and it enables me to better deal with these issues with patients. I do not shy away from talking about death with patients, and I actually enjoy working with those in their last days of life. So for me, especially, in geriatrics, my faith has been really helpful in my work.
TH: If you're familiar with other religions, do you think there's a difference between the way Christianity helps both the clinician and the patient and the ways other forms of spirituality might do the same?
HK: Well, I'm only really familiar with the Christian faith, so it's hard for me to generalize and say that other religions might have the same effects. Most of the research has only been done with people belonging to the Judeo-Christian religious tradition. There has not been a lot of systematic research done on the mental health effects of Mohammedanism, Buddhism, Taoism, Shintoism, or other major world religions. Part of the problem is that, even in the United States, there's not much money for such research. But in other countries, there's certainly not. And you can't really study people in a religious tradition outside of the area or country where that tradition is dominant; for instance, it would be hard to study Buddhists or Muslims in the United States and compare them to Christians, because they're out of their natural environment. You'd have to study them in their natural environments in order to look at the association with mental health: for example, Buddhists in China. People who come out of their native land and maintain their religious tradition in a foreign land are often quite different in their psychological makeup and life experiences. They're a unique group, and they suffer higher stresses resulting from a lot of factors that don't affect natives. So it's difficult to generalize from an atypical group to the health effects of a particular religion in general.
There are, however, certain aspects of Christianity that increase the likelihood that it will be related to mental health. In particular, there is a focus on a personal relationship with a Supreme Being who is not just a distant kind of god who's out there and not interested. Christians believe in a personal God who cares about people, who has a purpose and a plan for every individual, and who is concerned about suffering and really wants the best for every person. That's really something unique; there's no other religion I am aware of with this belief--that there is a personal God that's separate from Creation who is really interested in every individual person and wants to interact with and be involved in people's lives. Knowing this provides people with the sense that they're not alone, that there's somebody on their side. Again, it's not been studied systematically, but I think that there is something unique about the Judeo-Christian belief system that enables it to have a particularly positive effect on mental health.
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