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REVIEW ARTICLE

Varieties of Religious (Non)Affiliation A Primer for Mental Health Practitioners on the “Spiritual but Not Religious” and the “Nones” David Saunders, MD, PhD,* Michael Norko, MD, MA,†‡ Brian Fallon, MD, MPH,§ James Phillips, MD,† Jenifer Nields, MD,† Salman Majeed, MD,|| Joseph Merlino, MD, MPA,¶ and Fayez El-Gabalawi, MD# Downloaded from https://journals.lww.com/jonmd by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3yRlXg5VZA8ta0m8jqCQrWKcnwU3d+xN1ogMF0kfT5QY= on 04/17/2020

Abstract: Given changing demographics of religiosity and spirituality, this article aims to help clinicians understand contemporary trends in patient religious and spiritual orientation. It first identifies and describes the evolving varieties of religio-spiritual orientation and affiliation, as identified in survey studies. Particular attention is given to the examination of those who identify as spiritual but not religious (SBNR) and None (i.e., no religious affiliation), which is important to mental health practice because many patients now identify as SBNR or None. Next, empirical data are considered, including what the literature reveals regarding mental health outcomes and SBNRs and Nones. We conclude with a summary of the main points and five recommendations that mental health practitioners and researchers need to consider regarding this increasingly large portion of the population. Key Words: Religion, spirituality, spiritual but not religious, Nones (J Nerv Ment Dis 2020;208: 424–430)

wo segments of the American religious landscape are undergoing precipitous growth: “Nones,” or the religiously unaffiliated, and the “spiritual but not religious.” As of 2019, Nones represent 23.1% of the American population—an order of magnitude increase from the 1950s, and up from 22.8% only 2 years ago (Jenkins, 2019). The spiritual but not religious (SBNR) account for 27% of the US population, an almost 150% increase from 2012, despite not existing as a category of orientation in the 1950s (Lipka and Gecewicz, 2017). The following article concerns these two partially overlapping subgroups within the American religious landscape, that is, the religious practices and beliefs endorsed by residents of the United States. “None” refers, quite simply, to the checking of a box by a survey respondent—“None”—in response to the question, “What is your present religion, if any?” (Pew Research Center, 2015). This group has collectively come to be referred to as the “Nones.” While more than a third of Nones identify as “spiritual” (Drescher, 2012), their defining feature is nevertheless nonaffiliation with religious institutions (see Fig. 1). Slightly more difficult to define are the SBNR. Although the terms spirituality and religiosity once referred to more closely related phenomena, they have become increasingly distinct due to any number

*Yale Child Study Center; †Department of Psychiatry, Yale School of Medicine, New Haven; ‡CT Department of Mental Health and Addiction Services, Hartford, Connecticut; §Columbia University Department of Psychiatry, New York, New York; ||Penn State Hershey Medical Center, Department of Psychiatry, Hershey, Pennsylvania; ¶State University of New York-Downstate Department of Psychiatry and Behavioral Sciences, Brooklyn, New York; and #Department of Psychiatry and Human Behavior, Thomas Jefferson University, Philadelphia, Pennsylvania. Send reprint requests to David Saunders, MD, PhD, 160 Theodore Fremd Ave, Apt A8, Rye, NY 10580. E‐mail: david.saunders@yale.edu. All authors are members of the Psychiatry and Religion Committee of the Group for the Advancement of Psychiatry, which has approved submission of this manuscript as a GAP product. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/20/20805–0424 DOI: 10.1097/NMD.0000000000001141

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of political, religious, and cultural forces (Fuller, 2001; Mercadante, 2014). One sequela of the untethering of religiosity and spirituality is the birth of this new term on the spectrum of religio-spiritual orientation, SBNR (Ammerman, 2013; Fuller, 2001; Kenneson, 2015; Mercadante, 2014; Saucier and Skrzypińska, 2006). Interestingly, almost two-thirds of people who identify as SBNR still acknowledge a religious affiliation (box C in Fig. 1), Protestant in about half of those individuals, and Catholic in about one quarter (Lipka and Gecewicz, 2017; Pew Research Center, 2012). The literature does not help clarify this survey finding. The question addressed in this article is why mental health practitioners should care about the demographics and religious practices of SBNRs and Nones. The answer is threefold. First, the data clearly indicate that many of our patients will identify as either Nones or SBNRs. There are 57.5 million Nones and 68.1 million SBNRs in America— 23.1% and 27% of the US adult population, respectively (Lipka and Gecewicz, 2017), with some identifying as both a None and an SBNR (box C′ in Fig. 1), and others identifying as one or the other (None in box A′ and SBNR in box C in Fig. 1). Second, SBNRs and Nones are drawn from all sexes, age ranges, ethnicities, income-ranges, and multiple political orientations (Pew Research Center, 2012). Regardless of practice location or population, clinicians are therefore bound to encounter Nones and SBNRs in mental health practice. Third, surveys indicate that many individuals—the exact percentage depends on the clinical context—would prefer to have spirituality and/or religiosity considered in their care (McCord et al., 2004). Unfortunately, data indicate that most doctors never inquire about patients' religiosity/ spirituality or only rarely do so (Curlin et al., 2006). Whether via an informal spiritual assessment or by using a range of established formal methods for conducting assessments of religio-spiritual orientation (Saguil and Phelps, 2012), such as the FICA Spiritual History Tool (Puchalski and Romer, 2000) and the HOPE Questions (Anandarajah and Hight, 2001), knowing about patients' supports, belief systems, and helpful practices, including whether they identify as a None or an SBNR, can help a clinician better understand them, how they manage their lives, and aid in times of crisis when they might need reminders about using their religious or spiritual supports. Given that religious/spiritual orientation has been shown to impact mental illness and well-being (Dein et al., 2012; Gonçalves et al., 2015; Koenig, 2015, 2012; Unterrainer et al., 2014; Weber and Pargament, 2014), it makes good sense for mental health practitioners to pay attention to mental health considerations in this growing segment of the population, a case that we argue throughout the course of the article. Unfortunately, although an extensive body of research offers insight into the effects of conventional religiosity and/or spirituality on mental well-being (Dein et al., 2012; Koenig, 2015, 2012; Unterrainer et al., 2014; Weber and Pargament, 2014), little has been written about the mental health of SBNRs or Nones, a rapidly expanding segment of the population. To address this shortcoming, the objectives of the article are fivefold: first and foremost, to offer clinicians a nuanced and up-todate understanding on trends in religiosity and spirituality in the general