Religious Identity May Impact Suicide Risk

What are the two things you’re never supposed to discuss at the dinner table? Politics and religion. Despite most Americans identifying as religious and the United States being the most religious country of its kind—i.e., Western, Educated, Industrialized, Rich, and Democratic (WEIRD)—psychological science has avoided religion much like people do at holiday gatherings.

Many therapists and researchers alike either ignore religion or view it as irrelevant to their work. This is despite research showing that religion is a particularly salient aspect of identity, and many people want to incorporate their religious beliefs into treatment (Knox et al., 2005; Lindgren & Coursey, 1995).

Researchers have found that religious patients are more likely to complete cognitive behavioral therapy when their religious beliefs are integrated into the treatment (Koenig et al., 2015). In our partial hospital at McLean Hospital, we found that religious patients experienced greater improvements in treatment outcomes than non-religious patients (Rosmarin et al., 2013). Despite the potential benefit of religion in treatment and the preference of many patients, the role of religion in mental illness, particularly suicidality, is understudied.

Another “off-limits” topic in polite company is death. In the U.S., we live in a death-denying culture, as the late sociologist Ernest Becker once put it. From our funerary practices to our treatment of older adults, death is often treated as something to be avoided and ignored rather than accepted and addressed. The Cleveland Clinic reports that 10 percent of people experience death anxiety, a persistent state of worry, apprehension, and dread about death and dying (2022). Fear of death does not always become an anxiety disorder, however. Some fear of death may actually be a good thing as it might make people less likely to engage in risky behaviors and promote self-preservation.

In fact, fearing death too little is associated with suicidal behavior. The Interpersonal Psychological Theory of Suicidal Behavior (Joiner, 2005; Van Orden et al., 2010), a leading theory of suicide, suggests that fearlessness about death sometimes leads to a greater willingness to attempt suicide. How this plays out in real-time may be influenced by identity-related factors.

The relationship between suicide, fear of death, and religious identity is unclear. A conflict exists in the scientific literature surrounding these three factors. On the one hand, less fear of death has been shown to predict suicidal behavior. At the same time, religion has been associated with less fear of death and less willingness to engage in suicidal behaviors. Thus, it is possible that religious identity impacts the expected relationship between fear of death and suicidal behavior.

In a recent study, we wanted to learn about the relationship between religious identity and fear of death in psychiatric patients and how these things impact patients’ suicidality. We thought that religious patients would experience less fear of death and lower suicidality, despite less fear of death predicting higher suicidality in other studies. Because religion has been shown to be a protective factor against suicidality, we thought that religion might stand in between lower fear of death and increasing suicidality.

It might be helpful to visualize it like this: imagine that suicide is a waterfall at the end of a river. A suicidal person is a leaf floating on the river’s surface and the current is the fearlessness of death. For some non-religious patients, the river can freely carry the leaf off the waterfall. But, for some religious patients, religion acts like a dam blocking or slowing the flow of the river enough that the leaf might have time to change course, or simply float around in a circle.

We recently examined this research question in 155 adults attending McLean’s Behavioral Health Partial Hospital Program (Hart et al., 2024). Here is what we found:

• Religious and non-religious patients did not differ in the amount of fear of death they experienced, which is different from what we expected.
• In line with current theories of suicide, higher fear of death predicted lower suicidal ideation, but only in non-religious patients.

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Our findings suggest that religious identity is important to consider when treating suicidal patients. The Interpersonal Psychological Theory of Suicidal Behavior holds that fearlessness about death predicts increased suicidality, but this was not true for religious patients. It seems that the risk factor of the fearlessness of death is not a risk factor for religious patients. Identity-related factors, such as religious identity, may need to be incorporated into theories of suicide, as well as assessment and treatments. This means we may need to change our treatments to match people’s identities if they are going to be most effective. Given that over 70 percent of Americans identify as religious and religion is on the rise globally (Pew Research Center, 2017; Wall Street Journal, 2023), gaining a better understanding of how religion impacts patients’ experiences is critical to providing effective care.

Frances Grace Hart contributed to this article. Grace is a member of the Cognition and Affect Research and Education (CARE) Lab at McLean Hospital. Dr. Chloe Hudson also contributed. Dr. Hudson is an Assistant Professor at Virginia Tech University.