A Bio-Psycho-Socio-Spiritual Model of Health and Disease

The bio-psycho-social (BPS) model of health and disease, first proposed by Engel (1977) includes different dimensions of health and illness such as biological (e.g. cancer, heart attack), psycho-social (e.g. depressive/anxiety disorders) and socioeconomic (e.g. financial problems, divorce). Following the basic idea of this model, it is proposed that there is an ongoing interaction between these dimensions within the process of health and disease (Engel 1981). Although to date, the bio-psychosocial model has been established on a theoretical level, there is still a lack of empirical research on this topic (Ghaemi 2009). In addition, after the evaluation of the relevant literature in this area, it can be concluded that the BPS model - though comprehensive in principle - disregards a variety of facets that might also become crucial in relation to physiological and psychological aspects of health and disease. In particular, the BPS model does not consider a spiritual dimension or religious/ spiritual belief processes explicitly, which elsewhere has been documented as being important for health and subjective well-being (Mohr et al. 2006; Hill and Pargament 2008; Miller and Thoresen 2003). In response to this, it has to be clarified that in this chapter I focus on religious/spiritual belief processes, which have been discussed as being one possible kind of various belief processes, or so-called creditions (Angel 2013; Seitz and Angel 2015). Furthermore, there has been extensive research on whether religiosity/spirituality is an independent factor relative to those usually included in the BPS model. There have also been some attempts in personality research to enhance the “Big Five” model (Extraversion, Neuroticism, Agreeableness, Conscientiousness and Openness to Experience) by means of a sixth dimension, Spiritual Transcendence (Piedmont 2004; Saroglou 2002, 2009).

Furthermore, there is still no consensus on the questions, “How can spirituality/ religiosity be best described?” or “What exactly can be understood by proclaiming a religious/spiritual belief system?” For more than 100 years, these questions have been a key problem for scholars coming from various disciplines who have tried to define religion or spirituality as an object of interest (James 1985; Pargament 1999; Wulff 1997; Zinnbauer et al. 1997), and there is still ongoing debate in the field. It is broadly accepted, at least, that both religiosity and spirituality relate to the realm of transcendence (as opposed to immanent).

In addition, there is still no consensus on the issues of how to define religion or spirituality, or what exactly should be understood by proclaiming a religious/spiri- tual belief system. It is broadly accepted that what is “religious” or “spiritual” to someone can vary greatly. However, scholars have recently tended to use the word “religion” as a complex cultural concept to refer to known faith traditions and institutions, whereas “spirituality” tends to be used in reference to individual life orientations, higher principles, purposes, and values, whether stated in other-worldly terms or not. Some regard a special thing or being as sacred, others emphasize whatever provides meaning in life. Thus, although religion has typically been described in terms of institutions and traditions, spirituality has been conceptualised as a broader construct, without confessional bonds. Religious/spiritual belief processes as a kind of meaning based coping strategy, for instance, have been found to play an important role in the process of dealing with a serious disease (Rosmarin et al. 2013; Folkman and Moskowitz 2004).

The spiritual dimension of human perception has also attracted a lot of interest from psychology and, in particular, psychoanalysis over its history. Beginning with Freud (1927), who became most famous because of his highly critical appraisal of religion, religious/spiritual beliefs have been addressed by highly established authors such as Erik Erikson, Donald W. Winnicott or Heinz Kohut, to name but a few (Kernberg 2000). More recently, Ana Maria Rizzuto (Rizzuto 1998) asked her self ‘Why did Freud reject God?’ and succeeded in giving an adequate answer from the very perspective of a psychoanalyst. Additionally, Shafranske (2009) proposed a psychodynamically-oriented psychotherapeutic approach: how to integrate the spiritual dimension into the therapeutic practice. Furthermore, religious/spiritual beliefs have also been discussed from an evolutionary-psychodynamic perspective, as being linked to different kinds of attachment styles (Kirkpatrick 1999).

In general, there is a large amount of research emphasising the beneficial effects of religiosity and spirituality on mental health and/or subjective well-being,; thus, religious/spiritual belief systems have also been found to play an important role in clinical settings (Smith et al. 2003; Miller and Thoresen 2003; Hook et al. 2010). There is substantial evidence for religiosity and spirituality being an efficient suicide buffer, especially among psychiatric patients, as Dervic et al. (2014) demonstrated that religious affiliation was substantially associated with less suicidal behaviour in depressed inpatients. After other factors were controlled, it was found that greater moral objections to suicide and lower aggression level in religiously affiliated subjects might function like protective factors against suicide attempts. This finding is in line with our own results consistently showing that an affiliation with a religious community was negatively related to suicide attempts or suicidal ideation (Unterrainer 2010).

Furthermore, there is also substantial evidence for a negative association between religiosity/spirituality and nearly all kinds of addictive diseases (Unterrainer et al. 2013, 2012a; Galanter et al. 2007). In a study by Kendler et al. (2003), different kinds of functional and dysfunctional religious/spiritual beliefs were found to be related to lifetime substance abuse disorders. Moreover, an extensive meta-analytical review of 263 papers supports this negative correlation between positive kinds of religious/spiritual beliefs and addictive disorders (Cook 2004). Although religion and spirituality are positively related with nearly every indicator of mental health (Dein et al. 2012), the working mechanisms behind these findings remain unexplained; this poses a challenge to neuroscientific brain research (Newberg and d’Aquili 2000; Fenwick 1996). Additionally, Sloan et al. (1999) criticised what they called a sometimes hasty over-interpretation of the positive connection between religiosity/spirituality and mental health. Additionally, as noted by Koenig (2008), there is still no clear conceptualisation of spirituality in the literature since parameters of subjective well-being are often mixed up with parameters of religiosity and spirituality. If this is so, then why does it still make sense to consider the religious/ spiritual dimension as an important topic in clinical and health research?

As described by Ernest Becker (2007; McGregor et al. 1998) in The Denial of Death (1973), as human beings we confront our own mortality every second of our lives. Accordingly, religion and spirituality could be taken as an important means to transcend this kind of existential fear or dilemma of mortality through the facilitation of a feeling of heroism and, therefore, being part of something eternal. Along the lines of thought of Ernest Becker, mental illness is extrapolated as a failing in one’s hero system(s) such as in depression. Depressed individuals are being consistently reminded of their mortality, resulting in a feeling of insignificance, without having any resources to counter-balance these feelings (Mikulincer and Florian 2000). Within this picture, schizophrenia might be taken as a step beyond depression, in which one’s identity is falling apart, making it impossible to engender sufficient defence mechanisms against mortality. Thus, people diagnosed with a psychosis have to create their own reality or inner world in which they can continue to exist as heroes. However, as Julian Jaynes (1976:431) noted, we have to be careful in expanding our theories, especially in the field of schizophrenia research, as ‘recent decades have watched with gratitude a strong and accelerating improvement in the way this illness [schizophrenia] is treated. But this has come about not under the banners of new and sometimes flamboyant theories... but rather in down-to- earth practical aspects of day-to-day therapy’.