Spirituality in Mental Health Care in Brazil: Reflections on Bioethics Informed by Empirical Evidence

Abstract

Spirituality and religiosity (S/R) are significant dimensions in mental health care and provide an important foundation for spiritual care, particularly in sociocultural contexts where religious beliefs are deeply embedded in personal and collective life. This study investigates the role of S/R in the treatment of psychiatric patients hospitalized in a private mental health clinic in southern Brazil. Using validated instruments—the Centrality of Religiosity Scale (CRS-10BR), the Brief-RCOPE-14, and the Inventory of Attachment to God (IAD-Br)—the study assessed religious centrality, coping strategies, and attachment styles to God among 100 participants. Based on CRS parameters, the sample was classified as predominantly “religious.” The findings revealed that most patients identified with some form of religion or belief in God, reported moderate to high levels of positive religious coping, and predominantly exhibited secure attachment patterns. Statistically significant correlations were observed between higher religiosity, greater use of positive coping strategies, and lower avoidance in the relationship with God. Despite these findings, spiritual and religious aspects were rarely addressed in clinical interactions. The findings are discussed through the lens of clinical bioethics, emphasizing the ethical relevance of spirituality and religiosity in psychiatric care and highlighting the relevance of developing practical approaches to spiritual care within a whole-person, patient-centered model.

1. Introduction

Spirituality and religiosity (S/R) have been increasingly recognized as relevant dimensions in the field of mental health. Studies indicate that these experiences can influence both the onset and management of mental disorders, contributing to psychological well-being and the construction of meaning in the face of suffering (Pargament 1997; Koenig 2009; Hefti 2013; Koenig et al. 2012; Miller et al. 2012).

The Brazilian population, currently over 203 million inhabitants according to the most recent national census (IBGE 2023), is considered “highly religious” (Huber and Huber 2012; Esperandio et al. 2019). The latest census data (IBGE 2023) indicate a decline in Catholic affiliation (56.7%) and increases in Evangelical affiliation (26.9%), Afro-Brazilian religions (1.05%), and the number of individuals reporting no religion (9.3%). Regarding the latter category, a recent study indicates that some individuals do not identify with any specific religion yet still report cultivating a personal spirituality or religiosity (Esperandio et al. 2025). This pattern may suggest a possible shift in societal understanding regarding the meanings of spirituality and religiosity in Brazil, particularly in how they are perceived and used as resources.

Despite their relevance, S/R are often overlooked in clinical settings—whether due to limited training, lack of knowledge, or ethical concerns among healthcare professionals. In the Brazilian context, this gap is particularly paradoxical given the high percentage of individuals who identify as religious and the cultural centrality of faith across different social groups (Brasil 2010).

This article investigates how aspects of S/R manifest in the experience of patients hospitalized at a psychiatric clinic in southern Brazil. The findings are examined through the lens of clinical bioethics, which provides a framework for reflecting on how spiritual and religious dimensions can be ethically integrated into mental health care.

Before proceeding, it is necessary to clarify the concepts of spirituality and religiosity adopted in this study. Although they are distinct constructs, the term spirituality is often used interchangeably with religiosity. Different countries and cultures may hold their own concepts, perceptions, and perspectives regarding these dimensions (Puchalski et al. 2014; Curcio and Moreira-Almeida 2019). The definitions adopted here are consistent with the international consensus (Puchalski et al. 2014, p. 646), according to which:

spirituality is a dynamic and intrinsic aspect of humanity through which individuals seek meaning, purpose, and transcendence, and experience their relationships with themselves, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices.

Religiosity, in turn, refers to the way in which individuals live out their beliefs, practices, and ethical-moral values associated with an institutional religion. Religiosity can thus be understood as one expression of spirituality. Considering the relationship between these two terms, this study adopts the combined expression of spirituality/religiosity (S/R) to refer to the spiritual dimension, as it more accurately reflects the focus of the present research.

Regarding research on spirituality and mental health, in Brazil this topic has expanded in recent years, reflecting the broader development of this field and the growing accumulation of empirical evidence within psychiatry and psychology (Lucchetti et al. 2021; Koenig 2009). Empirical studies indicate that spiritual and religious dimensions are highly prevalent and are consistently associated with mental health outcomes, especially in contexts of psychological distress (Lucchetti et al. 2021). For example, Mosqueiro et al. (2021) pointed out that attendance and personal beliefs may be associated with lower levels of depressive symptoms and improved coping among psychiatric patients.

In other countries, evidence from prospective studies with psychotic patients suggests that positive religious coping may contribute to reductions in depressive and anxiety symptoms, while negative coping has been associated with greater suicidality and more pronounced affective distress (Rosmarin et al. 2013; Doering et al. 1998).

At the same time, studies have emphasized the complexity and ambivalence of spiritual experiences. While spirituality may serve as a source of meaning, resilience, and emotional support, it may also be associated with distress, conflict, or maladaptive coping, particularly in cases involving negative religious coping or problematic interpretations of suffering (Pargament and Feuille 2011; Lucchetti et al. 2021). These findings highlight the importance of approaching spirituality in mental health care with both sensitivity and critical awareness, recognizing its potential benefits as well as its possible risks.

2. Materials and Methods

This is a quantitative, descriptive, cross-sectional study conducted with inpatients at a private psychiatric clinic located in a large city in southern Brazil. The clinic, specialized in psychiatric care, offers a full range of treatment modalities and operates with a multidisciplinary team. It also serves as a teaching hospital, integrating clinical care with training in psychiatry. The study aimed to assess three key aspects of spirituality/religiosity (S/R): centrality of religiosity, spiritual/religious coping (SRC) strategies, and attachment to God. These dimensions were assessed using validated instruments, selected for their ability to capture distinct yet complementary aspects of S/R, including beliefs, practices, coping strategies, and relational dynamics.

Data collection took place between December 2018 and July 2019, with a sample of 100 patients. Participants were invited to take part voluntarily by signing an informed consent statement. The clinic’s healthcare team assisted in selecting patients eligible to participate in the study. Inclusion criteria included being over 18 years of age, not experiencing a psychotic episode, and having no comorbidities that could interfere with comprehension of the questionnaires. The instruments used were:

(1)

Centrality of Religiosity Scale (CRS-10BR):

Comprising 10 items, this scale measures five core dimensions of religious life: (1) Intellectual: how often the person reflects on religious issues; (2) Ideological: belief in the existence and nature of a transcendent reality; (3) Public Practice: frequency of participation in collective religious rituals or services; (4) Private Practice: intensity of private religious practices, such as prayer or meditation; (5) Religious Experience: emotional intensity of subjective experiences involving the sacred. The Brazilian version was validated by Esperandio et al. (2019). The scale is based on two main premises: (1) the overall intensity across these five dimensions provides an estimate of the frequency and strength of personal religious system activation; and (2) the degree of activation reflects the centrality of religiosity in the individual’s psychosocial organization (Huber and Huber 2012). Based on the CRS score, individuals are categorized according to the degree to which their personal religious construct-system occupies a central position within their cognitive and emotional architecture, distinguishing between Highly Religious, Religious, and Non-Religious profiles.

(2)

Brief-RCOPE-14:

The Brief RCOPE Scale is a 14-item measure of religious coping with stress created by Pargament and Feuille (2011), and it is divided into two subscales, each consisting of seven items, which identify clusters of positive (e.g., seeking spiritual comfort, forgiveness, benevolent religious reappraisal) and negative religious coping methods (e.g., spiritual discontent, feelings of punishment or abandonment by God). The Brazilian validation was conducted by Esperandio et al. (2018).

(3)

Inventory of Attachment to God (IAD-Br):

This scale evaluates the individual’s attachment style toward a personal God, based on two dimensions: Anxiety over Abandonment (worry about being rejected or abandoned by God) and Avoidance of Intimacy (difficulty in trusting or connecting with God) (Beck and McDonald 2004). Based on these dimensions, attachment styles are classified as: secure (low anxiety and low avoidance), anxious (high anxiety, low avoidance), avoidant (low anxiety, high avoidance), and anxious-avoidant (high anxiety and high avoidance). The instrument was validated in Brazil by August et al. (2018).

In addition to these instruments, a sociodemographic questionnaire was administered to collect data on education, marital status, religious affiliation, belief in God, and attitudes toward discussing S/R in the clinical context.

Statistical analyses were performed using Jamovi (v.1.2), R (v.3.6), and SPSS (v.22). Categorical variables were presented as absolute and relative frequencies; numerical variables were expressed as means and standard deviations. Internal consistency was measured using Cronbach’s alpha, with satisfactory results for all instruments (CRS = 0.826; Brief-RCOPE-14 = 0.808; IAD-Br = 0.716). Correlations between variables were assessed using Pearson’s correlation coefficient. A significance level of 5% (p < 0.05) was adopted.

The study was approved by the local Research Ethics Committee in accordance with the principles of the Declaration of Helsinki. Informed consent was obtained from all subjects involved in the study.

3. Results

Data were collected cross-sectionally from 100 patients admitted to a private psychiatric clinic.

3.1. Sociodemographic and Clinical Profile

The sociodemographic and clinical characteristics of the sample are presented in

Table 1. Sociodemographic and clinical characteristics of participants (n = 100).

Variable	n (%)
Sex
Men	45 (45%)
Women	55 (55%)
Marital status
Married/stable union	39 (39%)
Separated/divorced	23 (23%)
Single	37 (37%)
Widowed	1 (1%)
Employment status
Employed	89 (89%)
Not employed	7 (7%)
Retired	4 (4%)
Educational level
Elementary school	10 (10%)
High school	35 (35%)
Bachelor’s degree	38 (38%)
Master’s degree	17 (17%)
Psychiatric diagnoses
Depressive disorder	28 (28%)
Bipolar affective disorder	25 (25%)
Alcohol use disorder	18 (18%)
Cocaine use disorder	8 (8%)
Other psychoactive substance use	13 (13%)
Other diagnoses	8 (8%)

. The sample was predominantly composed of women, with a mean age of 40.3 years (SD = 13.0). Participants showed diverse marital statuses and educational backgrounds, with more than half having completed or currently enrolled in higher education. In terms of employment status, most participants were employed, with smaller proportions classified as not employed or retired. Clinically, the sample was primarily composed of patients with mood disorders and disorders related to psychoactive substance use, reflecting the typical profile of a psychiatric inpatient population. The remaining 8% included schizophrenia, personality disorders, and somatoform disorders. The average length of hospitalization was 14.7 days (SD = ±15.9).

3.2. Spiritual and Religious Aspects

Most participants (76%) reported belonging to a religion. The most frequent groups were Catholics (25%), Evangelicals (21%)—including Pentecostal, Neo-Pentecostal, and Protestant—and individuals with multiple religious affiliations (20%). Another 17% believed in God but were not affiliated with any institutional religion, while 5% identified as non-believers.

Only 16% reported that a healthcare professional addressed spiritual or religious issues during treatment. On the other hand, 25% expressed interest in discussing such issues with the clinical team, and 31% spontaneously brought them up in the therapeutic setting.

3.3. Centrality of Religiosity

The mean score on the Centrality of Religiosity Scale (CRS-10BR) was 3.90 (SD = ±0.84), classifying the sample as “religious.” The highest-scoring dimensions were private practice (M = 4.54) and ideology (M = 4.38), as shown in

Table 2. Mean scores by CRS dimension (n = 100).

Dimension	Mean (SD)
Public practice	3.37 (±1.30)
Intellectual	3.48 (±1.15)
Religious experience	3.71 (±1.30)
Ideology	4.38 (±0.97)
Private practice	4.54 (±0.90)

.

3.4. Brief RCOPE-14

Positive religious coping had a moderate average (M = 3.44; SD = ±1.26), classified as high in 33% of cases and very high in 24%. Negative religious coping had a low average (M = 2.12; SD = ±1.06), reported as nonexistent in 37% and low in 32% of the participants. According to the Pearson correlation coefficient, there was a statistically significant positive correlation between positive CRS strategies and centrality of religiosity, as presented in

Table 3. Correlations between religiosity, religious coping strategies, and attachment to God (n = 100).

Variables	r	p
Positive religious coping × Centrality of religiosity	0.461 *	<0.001
Negative religious coping × Centrality of religiosity	−0.059	0.229
Positive religious coping × Avoidance of intimacy with God	−0.504 *	<0.001
Positive religious coping × Anxiety over abandonment by God	0.052	0.290
Negative religious coping × Avoidance of intimacy with God	0.120	0.014
Negative religious coping × Anxiety over abandonment by God	0.669 *	<0.001
Centrality of religiosity × Anxiety over abandonment by God	−0.074	0.084
Centrality of religiosity × Avoidance of intimacy with God	−0.481 *	<0.001

Note. Positive r values indicate direct associations; negative r values indicate inverse associations. * p < 0.001.

. In other words, participants with higher levels of S/R, as measured by the CRS, exhibited higher levels of positive religious coping methods.

3.5. Attachment to God Styles and Variable Correlations

Most participants exhibited a secure attachment to God (57%), followed by avoidant (29%), anxious (9%), and anxious-avoidant styles (5%). The mean score for “anxiety over abandonment” was 2.71 (SD = ±1.20), and for “avoidance of intimacy” it was 3.20 (SD = ±1.52).

Correlation analyses (Table 3) revealed statistically significant relationships between religiosity, religious coping strategies, and dimensions of attachment to God. According to the Pearson correlation coefficient, a statistically significant negative correlation was observed between positive religious coping methods and the degree of avoidance of intimacy with God. A similar pattern was found for the association between avoidance and centrality of religiosity. In turn, negative religious coping was positively correlated with higher levels of anxiety over abandonment by God.

4. Discussion

The findings of this study highlight the central role that spirituality and religiosity (S/R) play in the lives of many patients undergoing psychiatric treatment. The average score on the Centrality of Religiosity Scale classified the sample as predominantly religious, with the highest scores in the private practice and ideology dimensions. This suggests that many patients maintain a more personal and reflective spiritual experience, rather than a collective or institutional one—a pattern consistent with other studies in Brazilian contexts.

Despite this centrality, only a minority of patients reported having been asked about spiritual or religious issues by healthcare professionals. This gap reflects a mismatch between patients’ subjective experiences and current clinical practices, reinforcing previous findings about the lack of training and openness among professionals when dealing with this dimension (Curcio and Moreira-Almeida 2019). It may also be related to multiple factors, including limited professional training, institutional priorities, and ethical concerns regarding the integration of spirituality into clinical care.

With regard to coping strategies, there was a significant prevalence of positive spiritual/religious coping, and a low incidence of negative coping. A positive correlation was found between religious centrality and positive coping, reinforcing the hypothesis that individuals with a more central religious orientation tend to mobilize more constructive spiritual resources when facing suffering. It is important to note, however, that these findings indicate associations rather than causal relationships. These findings are in line with research linking positive coping with reduced symptoms of anxiety, hopelessness, and suicidal ideation in patients with mental disorders (Pargament 1997; Koenig et al. 1998).

The observed correlations between the dimensions of attachment to God and other variables revealed another key aspect. Individuals with higher levels of avoidance of intimacy with God showed lower positive coping scores and lower religious centrality. Conversely, those with high anxiety over abandonment by God were more likely to use negative coping strategies. These findings are consistent with the religion-as-attachment model, which proposes that the aspects of religion most strongly associated with mental health are those that express attachment components—particularly the experience of God as a secure base and safe haven (Granqvist 2014; Kirkpatrick 2005). In contexts of heightened attachment activation, such as psychiatric hospitalization, the capacity to perceive God as emotionally available and protective may facilitate adaptive coping, whereas insecure attachment patterns—marked by avoidance or anxiety—may limit access to these regulatory functions and increase vulnerability to spiritual distress. Thus, our findings reinforce the view that it is not religiosity per se, but the attachment-related quality of one’s perceived relationship with God—especially its ability to function as a secure base and safe haven—that appears most relevant to mental health outcomes (Granqvist 2014).

These findings point to the relevance of considering religious attachment styles as clinically significant variables. Patients with insecure spiritual bonds—anxious, avoidant, or ambivalent—may experience religion as a source of ambiguity or distress, which requires a sensitive and well-informed clinical approach. Neglecting this dimension can lead to misinterpretation, patient withdrawal, or resistance to treatment (Exline and Rose 2012).

From a bioethics perspective, these results point to the importance of integrating the spiritual dimension into clinical practice in a respectful and non-intrusive way. This means recognizing the moral autonomy of the patient, avoiding judgment, and offering a safe space for spiritual beliefs to be expressed, reflected upon, and—when appropriate—used therapeutically (Gracia 2010; Leget 2013).

It is important to clarify that integrating S/R into mental health care does not mean promoting proselytism or using spirituality instrumentally. Rather, it reflects a commitment to whole-person care, which honors the complexity of human experience. As Puchalski et al. (2014) argue, spirituality should be viewed as a core element in person-centered care, alongside biological, psychological, social, existential, and spiritual dimensions.

4.1. Implications for Bioethics in Mental Health Care

The empirical findings—especially the gap between patients’ spiritual experiences and clinical practice—provide a concrete basis for bioethical reflection on how forms of spiritual care may be ethically integrated into mental health care in response to patients’ spiritual and religious needs. From a broader bioethical perspective, understood as a field that reflects on the ethical dimensions of life in its multiple expressions, the strong presence of spiritual and religious content in the lives of patients with mental health conditions suggests the relevance of reconsidering traditional models of care. As shown in this study, S/R not only influences how individuals cope with illness but also shapes their value systems, moral reasoning, and healthcare decisions.

In this context, the complexity of these findings calls for a broader bioethical approach capable of integrating multiple dimensions of human experience. Integrative bioethics can thus be understood not as a prescriptive framework, but as an approach that emphasizes the need to consider multiple dimensions of human experience—including spiritual and existential aspects—in ethically sensitive clinical practice. Such a perspective allows bioethics to function as a bridge between clinical knowledge and the lived, meaning-making dimensions of patients’ experiences. Studies indicate that although patients draw on spiritual values in health decisions, they refrain from sharing this with clinicians due to fear of being judged or misunderstood. The absence of a legitimate space to explore these issues can weaken the therapeutic alliance or even compromise informed, value-aligned decision-making (Koenig et al. 2012; Balboni et al. 2022).

While this broader perspective provides an important framework, it is also relevant to consider how more traditional bioethical approaches—such as principlism—contribute to this discussion. For instance, the principle of beneficence calls on healthcare professionals to promote the patient’s well-being, which includes acknowledging meaningful sources of comfort and resilience—such as positive religious coping. While this principle offers an important ethical orientation, it may not fully capture the depth of patients’ spiritual experiences, and ignoring this dimension can hinder therapeutic outcomes, especially in a country like Brazil, where religiosity is widespread (Brasil 2010).

The principle of justice highlights the importance of equitable treatment, regardless of patients’ religious profile, and supports care that is responsive to their broader context. However, a more comprehensive bioethical lens invites us to move beyond distributive concerns alone. This involves recognizing the cultural and social determinants that influence both health access and spiritual expression. Understanding S/R as a clinically and ethically relevant factor allows for more culturally responsive care, particularly for vulnerable populations (Rodríguez-Yunta 2016).

Although principlism in bioethics offers important ethical guidance, it may not fully capture the relational and experiential dimensions highlighted by the present findings. For this reason, the bioethical framework adopted here moves beyond strictly normative or deontological paradigms and is grounded in care ethics (Jounou and Tronto 2024; Leget 2013; Vries and Leget 2012). From this standpoint, attentiveness to patients’ spiritual and religious experiences becomes an essential dimension of ethically responsive care. Such an approach emphasizes attentiveness to the unique narratives and moral worlds of patients. Within this perspective, ethically integrating S/R into clinical care entails not merely tolerating religious content in healthcare settings, but fostering spaces for attentive listening, validation, and, when appropriate, therapeutic engagement. These practices demand not only technical expertise but also ethical and relational competence. Clinicians should therefore be adequately trained to navigate religious diversity with sensitivity, avoiding imposition while safeguarding the patient’s dignity and worldview.

These empirical findings also offer relevant insights for pastoral, theological, and spiritual care practices. By highlighting both the supportive and potentially distressing roles of spirituality and religiosity in the lives of patients with mental health conditions, this study underscores the need for spiritually sensitive approaches that are attentive to individual experiences, coping styles, and relational dynamics. For pastoral agents, theologians, and spiritual care providers, this implies the importance of engaging patients’ spiritual narratives with discernment, avoiding both neglect and uncritical affirmation. Such engagement may contribute to more ethically grounded and contextually responsive forms of spiritual support within mental health care settings.

4.2. Study Limitations and Future Research Directions

This study presents several limitations that should be considered when interpreting the findings. First, it involved a non-probabilistic sample drawn from a single private mental health clinic located in southern Brazil, which limits the generalizability of the results to other regional, institutional, or sociocultural contexts. The study does not aim to represent the Brazilian population as a whole, but rather to explore patterns within a specific clinical context. Furthermore, the participant profile may reflect characteristics specific to individuals with access to private mental health services, such as higher levels of education or socioeconomic status not representative of the broader population. In addition, no direct measures of socioeconomic status (e.g., income) were collected, which limits a more detailed characterization of the participants’ social context. Although employment status was assessed, it does not fully capture the complexity of socioeconomic conditions.

While the data were collected between 2018 and 2019, spirituality and religiosity remain highly relevant dimensions in the Brazilian context, as indicated by national demographic data. However, it is possible that clinical practices and patient expectations have evolved over time, which highlights the importance of conducting updated and longitudinal studies in this field.

Another important limitation concerns the study’s cross-sectional design, which enables the identification of statistical associations between variables but does not allow for causal inferences. The involvement of clinical staff in the selection of participants may have introduced a degree of selection bias. Additionally, the data were collected through self-report instruments, which may have been influenced by memory biases or social desirability—particularly in relation to sensitive issues such as faith, guilt, or feelings of divine abandonment.

Moreover, although the instruments used were validated and widely applied, they are based on a theoretical framework centered on a theistic Christian model. This may have limited the ability to capture the spiritual experiences of patients from other religious traditions or of those unaffiliated with institutional religion, such as Buddhists, spiritualists, or individuals who identify as “spiritual but not religious.”

Given these limitations, future research is encouraged to: (1) Conduct studies with larger and more diverse samples, including public institutions, different regions of Brazil, and more socially vulnerable populations; (2) Utilize longitudinal designs to assess changes in spiritual dimensions over time and during treatment; (3) Incorporate qualitative or mixed-method approaches to explore in greater depth the meanings attributed to spiritual/religious experiences; (4) Develop and validate instruments that reflect a broader range of spiritual worldviews, sensitive to Brazil’s religious and cultural diversity.

Such advancements may contribute to the development of a more robust and ethically grounded field of integration between spirituality, mental health, and clinical bioethics—one that is responsive to the complexity and pluralism of Brazilian reality. Future studies could also explore the perspectives of healthcare professionals to better understand the barriers and facilitators involved in addressing S/R in clinical practice.

5. Conclusions

This study examined how spirituality and religiosity manifest in the experiences of patients hospitalized in a private mental health clinic in southern Brazil, focusing on centrality of religiosity, spiritual/religious coping strategies, and attachment to God. The findings indicate a significant presence of the spiritual dimension in patients’ lives, as well as its association with positive coping strategies and more secure patterns of attachment to God. At the same time, the results also suggest that spirituality is not uniformly beneficial and may, in some cases, be associated with distress.

Nevertheless, a low level of integration of these aspects was observed in clinical practice, revealing a mismatch between patients’ subjective experiences and the model of care offered. This gap points to the importance of better preparing mental health professionals to adopt approaches that recognize S/R as a legitimate part of the individual’s identity and psychological suffering.

The evidence presented also supports the relevance of addressing S/R from a clinical bioethics perspective, which may offer a useful framework for ethical, pluralistic, sensitive, and person-centered care. Respect for autonomy, diversity, and the complexity of spiritual experience can be understood as important elements of truly humanized mental health care.

In conclusion, the findings of this study suggest that the strong presence of spiritual and religious dimensions in patients’ lives may warrant greater attention in mental health care. Ethically and contextually integrating spirituality into clinical practice may help inform the development of forms of spiritual care that are attentive to patients’ values, beliefs, and existential concerns. These efforts may benefit from a closer dialogue between theology and clinical bioethics, both in the development of spiritually sensitive care practices and in the preparation of professionals, such as chaplains or spiritual care providers, capable of offering appropriate spiritual support within mental health settings.

This approach may provide a relevant perspective toward more comprehensive, effective, and respectful care in the Brazilian mental health context. It is hoped that this research will help expand the dialogue between spirituality, mental health, and bioethics, and inspire further studies and clinical practices that are more attuned to this essential dimension of human experience.