Mitigating the Impact of the Closure of Religious Centres due to the COVID-19 Pandemic on Patients with Mental Illness

Dr Abdulazeez Towobola, Consultant Psychiatrist

Abstract

Religious and spiritual centres namely churches, temples, mosques, synagogues, and others, provide immense resources to patients living with mental illness. Studies have established that patients use spirituality and religion for coping, while attaining a sense of purpose and meaning. Many spiritual and religious activities are communal and occur on the premises of these centres, providing social outlets to patients. The COVID-19 pandemic has led to an unprecedented widespread disruption of services including closure of religious centres. This paper reviews the likely impact of social isolation and other effects due to the closure of religious centres on patients with mental illness, and how this can be mitigated.

Introduction

The World Health Organization (WHO) defines Mental Health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community [1]. Many studies have shown the link between well-being and spirituality and religion, and have demonstrated how religious groups provide support towards recovery and rehabilitation of patients with mental illness, to aid mental health systems [2, 3]. Whilst some researchers say it is difficult to distinguish between spirituality and religion [4], Cook [5] has defined spirituality as a distinctive, potentially creative, and universal dimension of human experience arising both within the inner subjective awareness of individuals and within communities, social groups, and traditions. It may be experienced as a relationship with that which is intimately “inner”, immanent and personal, within the self and others, and/or as a relationship with that which is wholly “other”, transcendent and beyond the self. It is experienced as being of fundamental or ultimate importance and is thus concerned with matters of meaning and purpose in life, truth, and values.

Social (physical) distancing measures introduced to curtail the spread of the COVID-19 pandemic, ranging from mandatory quarantine to voluntary self-isolation and including restrictions on many activities outwith our immediate household, have the potential to put the mental health of many people in general, and vulnerable patients with mental illness in particular, at risk [6]. In particular, the curtailment of meetings and acts of worship for many religious groups (at least where these involve meeting in person) mean that patients with mental illness may be unable to participate in these. In this paper, the mechanisms through which spirituality and religion influence mental health, and the possible impact of the COVID-19 pandemic on these are briefly discussed, before steps that have been taken to mitigate these are reviewed.

Mechanisms through which spirituality and religion influence mental health

Research has identified five main mechanisms through which spirituality and religion influence mental health, namely: a) coping styles, b) locus of control and attribution, c) social support and social networks, d) physiological mechanisms, and e) architecture and the built environment [7]. A brief description of each of these mechanisms is provided in Table 1. Whilst some of these mechanisms are largely either individual or concern the relationship between the individual and God (coping style, locus of control and attribution, physiological mechanisms), others depend on the community aspect of spiritual and religious networks (social support and social networks) or physical location (architecture and the built environment).

MechanismDescription
Coping stylesA collaborative coping style where an individual collaborates with God in problem solving was associated in studies with greater involvement in recovery-enhancing activities [8].
Locus of control and attributionSpiritual or religious beliefs such as belief in an all-powerful and all-controlling God may help individuals to reframe or reinterpret uncontrollable events, thus making them more meaningful and less stressful [4].

This optimistic attributional style [9] and internal locus of control (through relating to God) are usually associated with better health outcomes [10].
Social support and social networksSpiritual and religious networks can provide stability over time and a valuable source of support in terms of self-esteem, information, companionship, and practical help in coping with stress [11].

Hospital chaplains [12], local religious leaders and clergy have a role in promoting the mental health of those in their localities [13], and this, in addition to the support from other members of religious congregations, is considered to be a key mediator between spirituality and mental health [14].
Physiological mechanismsEncouragement of positive emotions such as hope, contentment, love and forgiveness by spiritual traditions while discouraging negative emotions like anger or fear, help to modulate the neural pathways that connect to the endocrine and immune systems [9].

Mindfulness meditation training was shown to alter brain network functional connectivity patterns and reduce Interleukin-6, an inflammatory marker, compared to relaxation training, thus explaining the improvements in inflammation [15].
Architecture and the built environmentThe artistic grandeur of many historical [16, 17] and modern religious buildings are considered to have therapeutic power as many people find solace in the significance of churches, temples, and mosques [18, 19].

The sense of connectedness within these spaces, to other people, to oneself (immanence) or to God or other (transcendence), is a key factor that underpins many expressions of spirituality [7].

Table 1: Mechanisms through which spirituality and religion influence mental health

Impact of the COVID-19 pandemic
Following guidance by the UK government in 16th March 2020 to limit non-essential contact with others, many acts of worship and other meetings by religious groups were suspended. The Muslim Council of Britain called for ‘the suspension of all congregational activities at UK mosques and Islamic centres’ on that day [20] whilst the Church of England suspended all services [21] and the Chief Rabbi ordered the closure of all synagogues affiliated with the United Synagogue [22] the following day. This unprecedented widespread disruption of services, closure of religious centres [23] and limitation of access to chaplaincy services will invariably impact the mechanisms by which spirituality and religion impact mental health, with a potential to have a negative effect on patients. These changes likely impact some mechanisms (social support and social network, architecture and the built environment) more directly than others; however, it is likely that loss of these mechanisms may also impact other mechanisms (for example through patients finding it harder to ‘collaborate with God in problem solving’ without the support of others in their faith community).

Psychological impact of social isolation
The psychological impact of social isolation has been studied and documented previously. Trauma-related mental health disorders, including PTSD, were found to be at least four times higher in children and parents quarantined for the 2009 influenza A (H1N1) pandemic in the US [24]. Restriction of movement, loss of social connections and employment, loss of financial income, fear of contagion, or concern about lack of access to basic needs such as medicines, food, or water can potentially lead to anxiety, low mood, stress, fear, frustration, and boredom, and reduced psycho-social functioning [6]. Loneliness is a psychological manifestation of social isolation which studies have found to be associated with premature death at rates comparable to obesity and smoking[25, 26]. The elderly, people with pre-existing mental illness and people with learning difficulties have been identified as being at increased risk of psychological harm due to social isolation [27]. It is therefore very important to consider ways in which the impact of the closure of religious centres can be mitigated.

Mitigating the impact of closure of religious centres

Identification of needs
Many studies advocate asking service users about their spiritual and religious needs upon entry to the service and throughout their care and treatment [7]. Identification of those at increased risk from the COVID-19 lockdown amongst patients with mental illness by primary and secondary-care doctors, other health workers, carers and chaplains is important in order to provide prompt psychological support to improve patient outcomes [28, 29]. Increased alertness is necessary when the risk of mental illness is further complicated by other risks including older people living alone or in care homes, learning and communication disabilities, recent bereavement, illness or hospitalisation, domestic abuse, unemployment or loss of income, alcohol and substance misuse, those in quarantine or self- isolation (shielding) due to serious physical health conditions, those with caring responsibilities, young people (due to closure of schools and sports facilities) and refugees/migrants [27].

As some patients may not openly report psychological symptoms or needs, using our clinical judgment, prior knowledge of the patient, and individual risk factors will help in identifying those who require intervention [6]. Starting with open-ended questions, clinicians are encouraged to use validated screening questions such as Patient Health Questionnaire-4 (PHQ-4) screening questions for anxiety and depression [30], UCLA Loneliness Scale [31] for severe loneliness and HOPE questions (See Table 2 and 3) to identify spiritual needs [32].

Alternative approaches
There is strong evidence that remote telephone or video consultations are acceptable, safe, and effective [33] and in addition to social prescribing [34], they form the strategies recommended to reduce psychological harm during the pandemic [6]. The Church of England validates the challenges of providing remote pastoral care particularly in the context of supporting the bereaved (many of who have been socially and physically distanced from their relatives who died from COVID-19) or isolated church members. They also encouraged the holding of services electronically with many churches implementing regular online services with community aspects maintained through the use of comments sections and Zoom meetings. Many other church activities have also gone ahead using digital means while churches continue to provide previously established services such as running local volunteering schemes, foodbanks, and care of the homeless. The Church of England recommends maintaining wellbeing by ‘rootedness in God, relationship with oneself and other creatures of the world, and maintaining rhythms (routine)’ [35].

Studies show that the impact of quarantine can be mitigated by making the quarantine or lockdown ‘as short as possible’, providing adequate and clear communication, ensuring basic supplies (such as food, water, and medical supplies) and reinforcing the sense of altruism [27], which spirituality or religiosity supports. Acknowledging the benefits of places of worship on spirituality and mental health, the UK Government agreed to ease the lockdown from the 15th of June 2020, to allow individual prayers in places of worship, however communal worship remained prohibited until 4th July 2020 [36, 37]. Putting safety first, particularly with many of its adherents belonging to the Black and Ethnic Minority (BAME) communities who are disproportionately impacted by the coronavirus infection, the Muslim Council of Britain (MCB) has taken a very cautious and gradual approach to re-opening the mosques for congregational prayers [38]. They have arranged a weekend ‘Visit My Mosque Day Digital’, with mosques across Britain offering live virtual tours to members of the public to showcase the support Imams and mosque leaders are providing to their local communities during lockdown, in terms of ‘opening up as foodbanks, delivering hot meals to those in need and supporting their local hospitals with food donations’ [39].
The Westminster Synagogue website provides information on offering Shabbat Services and educational classes over Zoom and how adherents of the faith can get involved during the COVID-19 lockdown while making their festivals meaningful [40]. BAPS Swaminarayan Sanstha (BAPS) in the UK, with their headquarters at the Neasden Temple in London, have highlighted their relief work in providing health awareness videos and presentations in English and Gujarati, telephone support, delivery of food and basic amenities, using over 1000 volunteers across the UK [41].

Discussion

The impact of the closure of spiritual and religious centres or spaces, and restricted access to chaplains and clergy due to the COVID-19 pandemic have a potential to worsen the mental health of patients significantly by interfering with the mechanisms through which spirituality influences mental health. Meeting the spiritual or religious needs of patients in these times is challenging, however individuals and religious leaders have been resourceful and creative in facing the challenges, using evidence-based approaches to mitigate the impact of social isolation. Identifying those at risk promptly is important so that they can be linked to resources to meet their spiritual needs.

The past few months have been a period of substantial innovation across religious groups with many novel ways of worshipping and meeting together having been explored and developed. Approaches such as online services make it easier for some to try a religious gathering for the first time; however, others may struggle to join (for example due to a poor internet connection or poor technological literacy) and it is not clear how the move online affects how people are welcomed into the community (it is easier to remain anonymous on the internet than in a church building).

Further research is needed on the impact that the current restrictions have had on patients’ mental health. In addition, research should consider ways in which the limitations of the current approaches can be addressed, for example how new members can be better welcomed to a community in an online setting. Finally, it should be investigated whether these new approaches to congregational meetings could be used to help engage patients who have previously been unable to do so (e.g. inpatients, those who are housebound) with the benefits of religion and spirituality.

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